1. Behavioral Health in Health Care Reform: Why and How? Mike Hogan, Ph.D. Commissioner, NYS Office of MH Chair, Pres. NFC on Mental Health (2002-3)

2. Behavioral Health in Health Care Reform: Why and How? Why?: – –Mental health problems are a major concern in every health care sector: Mental health problems of children are the #1 kids’ health problem and shape physical health later in life Mental health problems are frequent in adults, and patients with mental illness present in every primary care, acute care, and chronic illness setting We have good evidence about integrating care, but we don’t do it Where is Integration Needed? What does Integration Require?

3. Behavioral Care is now an Essential Element of Child Health Care— Especially for Children at Risk Child mental health problems: –Are the most prevalent and costly health conditions for children; “the major chronic diseases of childhood” –Childhood is when mental health problems emerge— and when preventive e.g. non-pharmacologic treatments are often effective –Effective interventions exist but are scattered “oases” Nurse-Family Partnership Other intensive parent education/support programs: Positive Parenting Program (PPP), Incredible Years, ParentCorps Addressing child mental health problems prevents adult chronic illness!

4. The Adverse Childhood Experiences (ACE) Study (www.acestudy.org) Adverse Childhood Experiences* (ACEs) are very common ACEs are strong predictors of later health risks and disease This combination makes ACEs ‘the leading determinant of the health and social well-being of our nation’ * Psychological or physical abuse by parents; Sexual abuse; Household Dysfunction: Substance Abuse, Mental Illness, Mother Treated Violently, Imprisoned Household Member

5. Adverse Childhood Experiences Social, Emotional, & Cognitive Impairment Adoption of Health-risk Behaviors Disease, Disability Early Death The Influence of Adverse Childhood Experiences Throughout Life

6. Childhood Psychosocial Problems Drive Chronic Adult Illness

7. Behavioral Health Care is Integral in Health Care for Adults In acute medical care settings: –35% comorbidity of depression and other illnesses in pts with acute physical illness –Typically 30-40% increase in inpatient stay –Complications on discharge if not addressed Chronic illness care –Prevalence of depression alone: 30%+ –For patients with serious condition e.g. major depression: managing the mental illness is a prerequisite to successful chronic illness care Integration is the Exception, not the Rule

8. Integrated Care Requires more than Parity: Mental Health Trends Source: National Comorbidity Study and NCS-R (Kessler et al.) 1--Good news, but what happened? 2--Trends Since 2002: % with depression, adequate care: -2002: 36.9% -2003: 33.3% -2004: 31.7% (Harmon et al., 2009)

9. Integration of General and Behavioral Health Must be 2-Way: Massachusetts Study: Deaths from Heart Disease Among People with SMI vs. Overall 1998-2000 3.5 RR 4.9RR 2.2RR 1.5RR

10. What Does it Take for Adequate MH Care in Health Settings—and Vice Versa? Recommendations Parity is necessary, but insufficient Screening is necessary for detection –E.g. Preventive Services Task Force Recommendations In office based primary care, many practices can handle “simple” mental illness (mild depression, ADHD)…but –In high volume and complex care settings, adequate assessment and care require a mental health professional “on the floor” (e.g. “depression nurse”) –Similarly, in behavioral health settings, many practices can handle basic health care Measures of care (e.g. detection rates, provision of care meeting standards) are essential

11. This Time, Let’s Get it Done… RIGHT Thank You