1. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 27 Behavioral Health in the Community

2. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Mental Health in Transition: Key Documents Healthy People 2010 (see Table 27.1) National Health Promotion and Disease Prevention Objectives Report of the Surgeon General on Mental Health New Freedom Initiative – three impediments to provision of quality mental health care: –Stigma –Unfair treatment limitations and financial requirements –Fragmented mental health service delivery system

3. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Incidence and Prevalence Global problem Mental illness accounts for >15% of mortality worldwide (WHO, 2007) Higher rates in poor, poorly educated, and unemployed Many are homeless and go untreated Age affects the pattern of mental illness in a community Gender differences in prevalence of certain mental disorders

4. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Substance Use and the CHN Continuum including abstinence, low-risk use, risk/hazardous use, harmful use and dependence (see Fig. 27.1) CHN needs basic understanding of issues related to specific substance; clear idea of desired outcomes related to treatment or prevention program –Trends of substance use across different populations and communities –Differences between legal and illegal substance use –Consequences of substance use on community –Substance use from environmental perspective

5. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Prevalence of Substance Use and Use Disorders Alcohol: highest incidence of use in young adults (18- 25 yrs) Tobacco: decline over past decade but not consistent across age groups and genders Marijuana: most frequently reported illicit drug Cocaine: majority are males 18 to 25 yrs of age Heroin: most >18 yrs and male Meth, Ecstasy, and PCP Prescription drugs: across all age groups; rise in college students

6. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? The highest use of alcohol occurs in middle-aged adults.

7. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False –Young adults, ages 18 to 25 years, are the group with the highest use of alcohol.

8. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Theoretical Frameworks Process theory: identify resources and structure needed to develop, implement, and evaluate Effect theory: provides rationale for why intervention will work –Determinant theory –Intervention theory –Impact theory –Outcome theory Public health prevention theory: level of prevention for program focus, type of intervention to use, and target population

9. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Determinants of Mental Health Complex Numerous factors such as genetics, environment, societal frame of reference and context Cultural beliefs Expectations, standards, legal parameters Process of adaptation as a source of stress –Individual’s perception of stress –Subsequent response

10. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Determinants of Substance Use Disorders Nature vs. nurture Genetics plays a major role in development of alcohol dependence Individual factors (associated with AUDs): high antisocial behavior, high impulsivity, major depression, social anxiety problems, history of childhood sexual abuse, hyperactivity, attention problems, seminal events Environmental factors: influence of peers, lower socioeconomic status, partner use, substance use by family members

11. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Effect theory attempts to explain the rationale for an intervention.

12. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True –Effect theory provides a rationale for why an intervention will work.

13. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Screening and Brief Intervention Routine screening –Brief Psychiatric Rating Scale (BPRS; see Fig. 27.7) –Beck Depression Scale –Montgomery Ashberg Depression Rating Scale (MADRS) Screening for depression: Center for Epidemiologic Studies Depression Scale (CESD; see Fig. 27.8) and shorter version, the CESD-10

14. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Screening for Substance Use and SUDs Three levels: screening for actual consumption, screening for at-risk drinking, and screening for SUDs Level of risk: based on level of consumption Screening instruments –Self-report: Michigan Alcoholism Screening Test (MAST); Drug Abuse Screening Test; CAGE questionnaire; Drug Use Screening Inventory (DUSI) –Biological screens: urine, blood, hair, saliva, breath, and meconium Positive screen: possible brief intervention

15. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Community-Level Interventions Community assessment and focus of intervention Level of prevention Mental health community interventions –Integrative health assessment –Factors include treatment history; personal life stressors; disturbances in sleep, appetite, or energy level without a rational explanation; complaints of chronic pain; history of abuse, trauma, substance use, and family history of mental illness

16. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Community Level Interventions (cont.) Mental health promotion –Anticipated outcomes –Risk-protective activities –Life-sustaining activities –Life-enhancing activities

17. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? The CAGE questionnaire is a valid self-report tool to screen for substance use.

18. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True –Self-report tools such as the CAGE questionnaire are reliable and valid tools that can be used to screen for substance use.

19. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins CHN & Community-Level Interventions Multifaceted role –Ability to access and use epidemiologic data –Advocacy: increase client access to services, reduce stigma, and promote improved public understanding & improved services in community mental health; political involvement –Education –Case management, case-finding, referral –Collaboration

20. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Substance Use & Community-Level Interventions Population-based screening programs Governmental agencies as resources Policy-based interventions Mental health policy Substance use policy

21. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Internet Resources Al-Anon Family Group Headquarters, Inc.: http://www.al-anon.org/index.html http://www.al-anon.org/index.html Mothers Against Drunk Driving (MADD): http://www.madd.org/ http://www.madd.org/ National Alcohol Screening Day: http://www.mentalhealthscreening.org/events/nasd/inde x.aspx http://www.mentalhealthscreening.org/events/nasd/inde x.aspx National Institute on Alcohol Abuse and Alcoholism (NIAAA): http://www.niaaa.nih.gov/http://www.niaaa.nih.gov/ National Institute of Mental Health: http://www.nimh.nih.gov http://www.nimh.nih.gov Substance Abuse and Mental Health Administration (SAMHSA): http://www.samhsa.gov/http://www.samhsa.gov/