National Council magazine 2009, Issue 2

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If we truly value an improved quality of life for all Americans, we can no longer afford to overlook prevention and early intervention in behavioral health. National Council Magazine profiles member programs in prevention–early intervention for mental and substance use disorders, examining a broad range of initiatives — public education, screening in primary care, school-based initiatives, suicide prevention, employee assistance programs, and more. The magazine also features the views of policy and clinical experts on why prevention-early intervention is critical as we attempt to piece the healthcare puzzle together.

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National Council magazine 2009, Issue 2

  1. 1. A quarterly publication from the National Council for Community Behavioral Healthcare 2009, Issue 2 nationalCouncil magazine sharIng Best PractIces In Mental health & addIctIons treatMent www.thenationalcouncil.org Prevention and Early Intervention for Mental & Addiction Disorders the time is right, Page 2 Mental health First aid, Page 14 geoffrey canada on his harlem Miracle, Page 20 It takes a community, Page 24 From the Field, Page 30
  2. 2. INSPIRED SOLUTIONS NEW DIRECTIONS COOL CONNECTIONS 40th National Mental Health and Addictions Conference & Expo March 15-17, 2010 Disney’s Coronado Springs Resort Florida Register and reserve your hotel now! Call for Papers open through Sept 15, 2009. www.TheNationalCouncil.org/Conference | 202.684.7457
  3. 3. PDF available at www.TheNationalCouncil.org nationalCouncil M A G A Z I N E PolIcY PersPectIVes 2 Prevention and Early Intervention: The Time is Right Editorial by Linda Rosenberg National Council Magazine, 2009, Issue 2 4 Point/Counterpoint: Prevention — What Does It Really Save? Media Excerpts Prevention and early Intervention for 6 IOM Report on Prevention and Carl Bell Interview Mental & addiction disorders Meena Dayak, Chris Loftis 10 Saving Jobs, Saving Public Dollars Mental illnesses and addiction disorders remain an Vidhya Alakeson unsolved mystery to many. Against the backdrop of stigma, 12 Call to Include Prevention in Healthcare Reform lack of access to quality care, and funding constraints, SAMHSA Core Consensus Principles prevention-early intervention remains the missing piece of the puzzle. It’s the piece that completes the equation of total care for those we serve and commitment to improve the communities we live in. Many community-based healthcare organizations have been operating model programs in prevention–early intervention p.14 for mental and substance use disorders with impressive outcomes. These programs reach a range of populations — children, youth, older adults, veterans, and persons already eVIdence-Based earlY InterVentIons diagnosed with one form of mental illness or addictions who 14 Mental Health First Aid Educates and Transforms Communities may be at risk for other disorders. The programs comprise Lea Ann Browning McNee, Susan Partain a broad range of initiatives—public education, screening in 20 Geoffrey Canada on His Harlem Miracle primary care, school-based initiatives, suicide prevention, Meena Dayak, Chris Loftis employee assistance programs, and more. This issue of 22 Nurse-Family Partnership: Effective and Affordable National Council Magazine profiles some of these model Peggy Hill programs and features the views of policy and clinical 24 It Takes a Community experts on why prevention-early intervention is important as William R. McFarlane, Donna Downing, Anita Ruff we attempt to piece the healthcare puzzle together. 26 A Long-term Approach to Early Psychosis Intervention Tamara Sale, Ryan Melton 29 SBIRT: Effective Interventions for Alcohol-Related Health Problems Maureen Fitzgerald FroM the FIeld 30 Getting a Head Start on Mental Health: Children’s Programs National Council Magazine is published quarterly by the National Council for Community Behavioral Healthcare, 36 Saving Our Future: Youth Substance Use and Suicide Prevention 1701 K Street, Suite 400, Washington, DC 20006. 44 Across the Spectrum: Working with Special Needs Populations www.TheNationalCouncil.org Editor-in-Chief: Meena Dayak targetIng hIgh-rIsK PoPulatIons Specialty Editor, Prevention and Early Intervention: Chris Loftis 50 HOPE for Homeless Youth and Families Editorial Associate: Nathan Sprenger Nisha Beharie, Mary McKay, Kosta Kalogerogiannis Editorial and advertising queries to 54 InSHAPE: Promoting Wellness, Saving Lives Communications@thenationalcouncil.org or Ken Jue interviewed by Laura Galbreath 202.684.7457, ext. 240.
  4. 4. Policy Perspectives ditorial Prevention and Early Intervention: The Time is Right linda rosenberg, MsW, President & CEO, National Council for Community Behavioral Healthcare E pic arguments are being waged regarding the pros and cons of disease prevention. However, few, if any, are offering serious insight as to how to address the host of mental health disorders estimated to affect 14 to 20 percent of America’s young people in any given year. A perfect storm is brewing, exacerbated by a troubled economy, rising unemployment, increasing bankruptcies and home foreclosures, and dwindling funds for programs. Dismal realities affect families and threaten the mental health of our nation’s youth. Saving money Passionate exchanges tout the medical benefits is important, however, and lives saved through the early detection of breast cancer, stroke, and heart disease, while the bottom line should include the stigma surrounding mental illness persists. safeguarding a quality of life. Workplace shootings, familicides, and the overdose live a “normal” life. deaths and suicides of notable celebrities prompt According to the March their wake. The Early Detection and Intervention for frequent news coverage, with discourse on preven- 2009 Institute of Medicine (IOM) report brief for the Prevention of Psychosis Program, a national ef- tion and early detection in an everyday setting tak- policymakers: Preventing Mental, Emotional, and fort launched by the Robert Wood Johnson Founda- ing a noticeable backseat. The public interprets the Behavioral Disorders Among Young People, Progress tion and spearheaded by program director, William message: the mentally ill aren’t safe to be around. and Possibilities, evidence-based approaches are R. McFarlane, MD, estimates the cost to society As a result, would-be-patients fly below the radar proving to prevent certain mental health disorders, to be higher than $10 million over the lifespan to avoid detection. Without the increased use of and limit risk factors, and are likely to be far more of a person who has schizophrenia. The National prevention strategies that are scientifically proven cost-effective at addressing mental, emotional, and Council supports early intervention, before costs to work, and a correspondingly swift uptick in early behavioral disorders (MEBs). escalate and the prospects of a happy, healthy life detection efforts and community awareness and Most MEB disorders erupt during childhood and disintegrate. The ensuing discussions beg the ques- education in national media, mental disorders con- adolescence. The IOM report suggests that the tion — just how much is an improved quality of life tinue to fester like an undetected cancer. “window of opportunity” when symptoms first ap- worth these days? The discussions regarding preventative healthcare pear, typically 2 to 4 years before the onset of the The National Council recognizes that the issue are more than politically fueled punditry about disorder, is the prime time when prevention strat- reaches beyond the bread and butter aspects of dollars and cents. Saving money is important, how- egies have the most impact. Persons with mental healthcare, and becomes muddled when editori- ever, the bottom line should include safeguarding health disorders have usually been identified only als sound the alarm of diagnosing millions with a quality of life. When it comes to mental health- after they dropped out of school, and shuffled a disease that requires treatment. An op-ed piece care, or lack thereof, individuals and their families through the criminal justice system, and multiple by David Harsanyi in The Denver Post insists that are hoping for anyone to throw them a lifeline, to hospitals, leaving extraordinary healthcare bills in expanding the definition of diseases such as dia- 4 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  5. 5. betes, high cholesterol, and osteoporosis, has already tion of Psychosis Program uses evidence-based in- needs to move from laboratory settings to real world placed millions more Americans at the swelling terventions that help youths succeed, without stigma, settings, and must be responsive to community so- healthcare trough. The idea that patients shouldn’t before they experience the negative effects of a fully cioeconomic needs, diversities, values, and goals. The be identified for having a disease, or the potential to developed mental illness. IOM report also cautions that funding should not sup- develop one, is a precarious one, especially for men- Geoffrey Canada’s Harlem Children’s Zone, launched port programs that lack empirical evidence, despite tal health. Sweeping mentally ill patients under the in 1970 as a community-based truancy prevention their popularity within communities. carpet has been going on for years and has hindered program, has grown to include diverse programs and Identifying children with risk factors: Screenings even the most ardent efforts of dedicated mental serve more than 10,000 youth. The proven results — in can be a helpful tool if parents and communities are health professionals. Harsanyi is blunt — end of life 2008, nearly all students in third and eighth grade in aware of the purposes and methods of screenings, care is costly, and free will overrides the patient’s de- HCZ charter schools outperformed the average New and have the ability to decline if they do not want cision to follow the doctors’ advice anyway. Part of the York student in math. their children included. But all families can learn to stigma plaguing mental illness is the notion that one be aware of warning signals for teen depression, for College Dreams, an alcohol and drug prevention pro- can simply “snap out of” depression, or that persons example, and to distinguish between signs of impend- gram in Oregon, has saved thousands of youth from “choose” to be mentally ill. ing psychosis, and teenage angst that falls within the school dropout, substance abuse, and delinquency. Chicago Tribune reporter Carla Johnson acknowledges The program is based on scientific evidence regarding norm of behaviors prompted by the transition from in her article, Disease Prevention Often Costs More the risk factors for substance abuse and the protec- children to teens to young adults. than it Saves, that disease prevention won’t neces- tive factors that lead to long-term success for children Speak up: Programs that work need media attention sarily save money, but that some efforts to prevent who are beset by multiple and severe life adversities. to thrive. Seek out members of the media, distribute illness are necessary. Johnson quotes Robert Gould, press releases, and invite the media and the public to Based on recommendations in the March 2009 IOM president of the nonprofit Partnership for Preven- “community education nights” that highlight preven- report described in further detail in this issue, the tion, saying that “Many of the services that don’t save tion and early intervention efforts that build strong, National Council offers the following suggestions to money, improve people’s lives at relatively low cost.” healthy communities and improve the quality of life. increase public awareness and education efforts, and A “pro-prevention” piece, More Attacks on Prevention to fortify the case for evidence-based research and Society can no longer afford to ignore the risk factors and Its Role in Health Reform That Make No Sense, the use of proven practices regarding prevention and for and the onset of mental illnesses and substance by Kenneth Thorpe in The Huffington Post, cautions early detection: use disorders. Ignoring prevention and early interven- against using “imprecise language” when it comes to Taking charge on a national level: The IOM report tion is issuing a personal invitation to cut a young life policy-making, and strongly supports effective preven- recommends that “the White House create an entity drastically short. tion programs that work simply “because they reach the right people at the right places with the right in- to lead toward a broad implementation of evidence- terventions.” Precisely steering back to that “window based prevention approaches and to direct research With more than 30 years of distinguished service in mental health policy, services, and system reform, Rosenberg is a leading of opportunity” and the value of a healthy mind and a on interventions.” Public goals must be set for pre- mental health expert. Under Rosenberg’s leadership since 2004, sound quality of life. venting specific disorders and promoting mental the National Council for Community Behavioral Healthcare has grown to 1,600 member organizations, employing 250,000 staff health, and funding must be provided to launch and To further illustrate what research reveals, this issue and serving 6 million adults and children in communities across improve evidence-based programs. the country. Prior to joining the National Council, Rosenberg was of National Council Magazine focuses on stories of the senior deputy commissioner for the New York State Office of early intervention success. Dovetail efforts: Many mental disorders have common Mental Health. In addition to responsibility for New York’s state- developmental pathways. Resources must be aligned run adult, child, and forensic hospitals, she tripled New York’s The National Council has helped to bring the ev- assertive community treatment capacity, expanded children’s between the departments of Education, Justice, and idence-based public education program, Mental community-based services, developed an extensive array of Health and Human Services. The National Institutes housing options for people with mental illnesses and addictions, Health First Aid to the U.S. The program has trained of Health should develop a comprehensive 10-year implemented a network of jail diversion programs including New more than 3,000 persons in its first year. Studies show York’s first mental health court, and promoted the adoption of plan to research ways to promote mental health and evidence-based practices and consumer and family programs. A that persons trained in what to do when someone is prevent mental disorders in young people. State and certified social worker, as well as a trained family therapist and experiencing a mental health crisis have a greater psychiatric rehabilitation practitioner, Rosenberg has held faculty local agencies should coordinate efforts and foster a likelihood of actually helping the person, and show appointments at a number of schools of social work, serves on multi-agency approach to ensure a comprehensive numerous agency and editorial boards, and writes and presents a decrease in attitudes that encourage stigma and developmental perspective. extensively on mental health and addictions issues including the misperceptions. impact of organizational and financing strategies on consumer Equality in research funding: At present, a great outcomes. The Early Detection and Intervention for the Preven- deal of research leans toward treatment. Research NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 5
  6. 6. Policy Perspectives Perspectives from General Healthcare Point/Counterpoint Prevention: What Does It Really Save? The Myth of Prevention Excerpts from an essay by Abraham Verghese in the Wall Street Journal, June 20, 2009 A doctor explains why it doesn’t pay to stay well. Decoding what works, what falls short in Obama’s plans to reform healthcare. M y wife tried to tell me the other day that she had just “saved” us money by buying on sale a couple of things for which we have no earthly use. She then pro- more in women (since their heart-attack risk is lower)—I don’t see the savings there. plan: despite being an admirer, I just don’t see how the president can pull off the reform he has in mind without cost cutting. I recently came on a phrase in an article in Or take the coronary calcium scans or heart scan, which ceeded to tote up all our “savings” from said purchases most authorities suggest is not a test to be done on the journal “Annals of Internal Medicine” about an axi- and gave me a figure that represented the money we people who have no symptoms, and which I think of as om of medical economics: a dollar spent on medical had generated, which we could now spend... she had the equivalent of the miracle glow-in-the-dark minnow care is a dollar of income for someone. I have been me going for a minute. lure advertised on late night informercials. It’s a money reciting this as a mantra ever since. It may be the single I mention this because I have similar problems with the maker, without any doubt, and some institutions actually most important fact about health care in America that way President Obama hopes to pay for the huge and advertise on billboards or in newspapers, luring you in you or I need to know. It means that all of us—doctors, costly health reform package he has in mind that will for this “cheap” and “painless” way to get a look at your hospitals, pharmacists, drug companies, nurses, home cover all Americans; he is counting on the “savings” that coronary arteries. If you take the test and find you have health agencies, and so many others—are drinking at will come as a result of investing in preventive care and no calcium on your coronaries, you have learned that... the same trough, which happens to hold $2.1 trillion, investing in the electronic medical record among other you have no calcium on your coronaries. If they do find or 16% of our GDP. But reform cannot happen without things. It’s a dangerous and probably an incorrect pro- calcium on your coronaries, then my friend, you have cutting costs, without turning people away from the jection. just bought yourself some major worry. You will want to trough and having them eat less. Prevention of a disease, we all assume, should save us know, What does this mean? Are my coronary arteries We may not like it, but the only way a government can money, right? An ounce of prevention...? Alas, if only narrowed to a trickle? Am I about to die? Is it nothing? control costs is by wielding great purchasing power to such aphorisms were true we’d hand out apples each Asking such questions almost inevitably leads to more get concessions on the price of drugs, physician fees, day and our problems would be over. tests: a stress test, an echocardiogram, a stress echo, a and hospital services; the only way they can control ad- cardiac catheterization, stents and even cardiac bypass ministrative costs is by providing a simplified service, If the prevention strategies we are talking about are be- operations—all because you opted for a “cheap” and yes, the Medicare model (with a 3% overhead), and not havioral things—eat better, lose weight, exercise more, “painless” test—if only you’d never seen that billboard. allowing private insurance to cherry-pick patients. smoke less, wear a seat belt—then they cost very little and they do save money by keeping people healthy. Poor McAllen, Texas. It happens to be the focus of a re- Contrary to what we might think, comparative studies cent “New Yorker” piece by Atul Gawande, a piece that show us that the U.S. when compared to other advanced But if your preventive strategy is medical, if it involves President Obama referred to in his speech to the AMA, countries, does not have a sicker population: We actual- us, if it consists of screening, finding medical conditions because health care costs in McAllen are twice that of ly use fewer prescription drugs, and we have shorter hos- early, shaking the bushes for high cholesterols, abnor- comparable cities while health outcomes are no dif- pital stays (though we manage to do a lot more imaging mal EKGs, or markers for prostate cancer such as PSA, ferent. The reasons are complex but probably because in those short stays—got to feed the MRI machines). The then more often than not you don’t save anything and good physicians are ordering lots of tests, calling in lots bottom line is that our healthcare is costly because it is you might generate more medical costs. Prevention is a of consultants, making good use of the equipment they costly, not because we deliver more care, better care, or good thing to do, but why equate it with saving mon- own and the imaging centers they might have a stake special care. Alas, a solution that does not address the ey when it won’t? Think about this: Discovering high in (and yes, they think they can be objective in order- cost of care, and negotiate new prices for the services cholesterol in a person who is feeling well, is really just ing an MRI or CAT scan that sends the patient to their offered will not work; a solution that does not put caps discovering a risk factor and not a disease; it predicts own facility); it has to do with hospitals competing with on spending and that instead projects cost-savings here that you have a greater chance of having a heart attack each other for the kinds of patients with conditions that and there also won’t cut it. Leaders have to make tough than someone with a normal cholesterol. Now you can are reimbursed well, and wooing patients, wooing high- and unpopular decisions, and if he is to be the first reduce the probability of a heart attack by swallowing a volume physicians (some of whom are invited to invest president to successfully accomplish reform there does statin, and it will make good sense for you personally, in the hospital) to make full use of their PET scan, their not seem to be much choice: cut costs. especially if you have other risk factors (male sex, smok- gamma knife, their robotic-surgery facility, their cancer ing, etc.) But if you are treating a population, keep in center, their birthing center. That was Atul Gawande’s Abraham Verghese is professor and senior associate chair for mind that you may have to treat several hundred people conclusion, and I would concur. the Theory and Practice of Medicine at Stanford University. He to prevent one heart attack. Using a statin costs about is the author of the novel “Cutting for Stone.” $150,000 for every year of life it saves in men, and even Which brings me to my problem with the president’s 6 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  7. 7. More Attacks on Prevention and Its Role in Health Reform That Make No Sense Excerpts from an article by Kenneth Thorpe and Lydia Ogden in The Huffington Post, June 26, 2009 wo recent newspaper pieces on prevention by Carla reduced absenteeism at work and school, and enhanced all of every Medicare dollar 96 cents of each and every one, T Johnson (Associated Press) and David Harsanyi (Denver quality of life. or more than $447 billion last year and 85 cents out of Post) repeat some long-standing misperceptions about Worksite health promotion programs, too, are effective at every dollar in Medicaid nearly $300 billion go to care for prevention. Because prevention is central to health reform, both primary and secondary prevention. A systematic re- chronic disease, most of which is preventable. In one year, it’s time to set the record straight. view of more than 50 studies meeting rigorous guidelines total, this amounts to approximately $1.7 trillion spent Both the articles suffer from baby-with-bathwater syn- for review by the U.S. Task Force on Community Preventive treating patients with one or more chronic diseases roughly drome, brought on by lumping all kinds of prevention into Services found strong evidence of WHP program effective- 75 percent of all U.S. health care spending. This is essen- one big pot. Imprecise language is dangerous, particularly ness in specific areas: reducing tobacco use, dietary fat tially a hidden tax on every taxpayer in America. Anyone who in the realm of policy-making. It leads to fuzzy thinking and consumption, high blood pressure, total serum cholesterol cares about long-term health spending, particularly govern- that produces bad policy. levels, and days absent from work due to illness or dis- ment health care spending, should support prevention. It’s ability, as well as improve other general measures of worker common sense. Research shows that scientifically sound prevention programs for both individuals and populations improve productivity. At Citibank, for example, a comprehensive Mr. Harsanyi’s argument that we should avoid prevention be- health and save money. Research also shows that ef- health management program showed a return on invest- cause “the longer people hang around, the longer they fective prevention programs are targeted. They work ment of $4.70 for every $1.00 in cost. A similar compre- utilize the healthcare system” and drive up costs is hardly because they reach the right people at the right time in the hensive program at Johnson & Johnson reduced health worth addressing. It’s a bizarre concept that a civilized so- right places with the right interventions. risks, including high cholesterol levels, cigarette smoking, ciety would let people die of preventable causes. And it’s and high blood pressure, and saved the company up to economically inaccurate. Obese and chronically ill Ameri- Prevention can be divided into three parts: Things we do $8.8 million annually. cans tend to live shorter lives, but chronic diseases and to avert disease (primary prevention), like vaccinations for obesity are linked to two-thirds of the growth in U.S. health children or the YMCA diabetes program mentioned in the As far as tertiary prevention goes, there’s evidence of effec- tiveness for that, too. Here’s one of the best: For nearly 25 spending since the mid-1980s. We’re not cutting any cor- article. Things we do to find and treat disease in its earliest ners in health care costs by allowing these people to meet stages (secondary prevention), like mammograms and co- years, senior researchers at the University of Pennsylvania have implemented a series of large, randomized controlled the Grim Reaper earlier. lon cancer screenings. And things we do to avoid complica- tions when people are already ill (tertiary prevention), like trials with high-risk elders. Their studies have demonstrated The other major point both Mr. Harsanyi and Ms. Johnson programs to help older people with multiple chronic condi- that comprehensive tertiary prevention focused particularly miss is the “how” of prevention. How are policymakers tions manage their care at home, like the PACE (Program on transitional care produces better health outcomes and proposing to increase effective prevention inside and out- of All-Inclusive Care for the Elderly) and similar initiatives. significant cost savings. Their most recent research showed side the health care system? Contrary to how their articles Dumping various interventions for various groups together a 56% reduction in readmissions and 65% fewer hospi- describe it, the idea isn’t to insert one-off prevention ef- and concluding prevention doesn’t save money is just plain tal days for patients in transitional care. At the 12-month forts into the existing system. Instead, Congress and the wrong. mark, average costs were $4,845 lower for these patients. president are proposing fundamental changes to the way If this model were scaled nationally with an investment of we deliver prevention, care, and treatment. That means Not all prevention programs work, many because they $25 billion over 10 years, savings could reach $100 billion improving community-based primary and secondary pre- aren’t grounded in science. Not all of them save money. over the same period. vention, strengthening primary care (primary and second- All medical interventions including secondary and tertiary ary prevention), and incentivizing providers and patients prevention cost money. Screening for common and costly The AP article’s Mrs. Jones is 55 years old, obese, and at risk for diabetes. Studies show that in 10 years, when she to better prevent and manage diseases (secondary and diseases, like diabetes, high blood pressure, and high tertiary prevention). In sum: A comprehensive prevention cholesterol, may actually raise spending in the short-term, turns 65 and enters Medicare, the government will spend $20,000-$40,000 more on Mrs. Jones’ health care than plan rather than scattershot, unconnected, and ineffective because people who need treatment will get it. But over the efforts. long-term, that treatment is likely to avert even more costly Mrs. Smith’s, who’s the same age but a normal weight. Over complications, and thereby avoid higher spending. 30% of the recent rise in Medicare spending in the last By preventing costly diseases or better managing them, we decade is associated with the persistent rise in obesity in can help contain our out-of-control health spending. We Many studies show well-designed prevention programs are the Medicare population. The increase in obesity-related can boost productivity. In our troubled economy, we need cost-saving. For example, a significant reduction in total chronic diseases among all Medicare beneficiaries and to do both. Even if it didn’t save money, preventing suffering health care spending is linked to community-based life- particularly among the most expensive 5% is a key factor when we can is the right thing to do. Research, common style interventions (primary prevention). Research shows driving growth in traditional fee-for-service (FFS) Medicare. sense, and ethics all tell us the same thing: An ounce of that savings range from a short-term return on investment Six medical conditions, all related to obesity — diabetes, (science-based) prevention is worth a pound of cure. of $1 for every $1 invested, rising to more than $6 over hypertension, hyperlipidemia, asthma, back problems, and the longer term. An investment of $10 per person per year co-morbid depression account for most of the recent rise Kenneth Thorpe, PhD, is the Robert W. Woodruff Professor and in community-based programs tackling physical inactivity, in spending in the Medicare population. Chair of the Department of Health Policy & Management in the poor nutrition, and smoking could yield more than $16 bil- Rollins School of Public Health of Emory University. He serves as lion in medical cost savings annually within 5 years. This is Chronic disease resulted in more than $987 billion in pri- the executive director of the Partnership to Fight Chronic Disease. a remarkable return of $5.60 for every dollar spent, with- vate spending most of it covered by private health insur- Lydia L. Ogden, MA, MPP, is the chief of staff for the Institute for out considering the additional gains in worker productivity, ance, which means higher premiums for everybody. Nearly Advanced Policy Solutions of the Center for Entitlement Reform at Emory University. NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 7
  8. 8. Policy Perspectives eatured interview dr. Carl Bell New IOM Report on Prevention Calls for Leadership, Collaboration, and Emphasis on Research Summary of the Institute of Medicine’s report “Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities” (2009) Based on report briefs and press release at www.bocyf.org T he federal government should make promotion of mental health in young people a national priority, says a new Institute of Medicine report, “Preventing Mental, Emotional, and Behavioral Dis- orders among Young People.” Mental, Emotional, and Behavioral (MEB) disorders which include depression, anxiety, conduct disorder, and substance abuse are about as likely as frac- tured limbs in children and adolescents; inevitable and not at all uncommon. Almost one in five young people have one or more MEB disorders. Many disorders have life-long effects that include high psychosocial and economic costs, not only for the young people, but also for their families, schools, and communities. Among adults, half of Preventing mental, emotional, and behavioral disorders all MEB disorders were first diagnosed by age 14 among young people may be one of the best investments a and three-fourths by age 24. The financial costs in society can make: The benefits include higher productivity, terms of treatment services and lost productivity lower treatment costs, less suffering and premature mortality, are estimated at $247 billion annually. MEB disor- and more cohesive families, as well as happier, better adjusted, ders also interfere with young people’s ability to ac- and more successful young people. complish developmental tasks, such as establishing healthy interpersonal relationships, succeeding in Early identification and intervention of MEB prob- billions of dollars by preventing or mitigating school, and making their way in the workforce. lems, before they warrant a formal diagnosis, of- disorders that would otherwise require expensive Clear windows of opportunity are available to fer the best opportunity to protect young people. treatment. prevent MEB disorders and related problems be- Such interventions can be integrated with routine Yet the nation’s approach has largely been to wait fore they occur. Risk factors are well established, healthcare and wellness promotion through policies to act until a disorder is well-established and has preventive interventions are available, and the and practices that target young people with specific already done considerable harm. All too often, op- first symptoms typically precede a disorder by 2 to risk factors; promote positive emotional develop- portunities are missed to use evidence-based ap- 4 years. And because mental health and physical ment; and build on family, school, and community proaches to prevent the occurrence of disorders, health problems are interwoven, improvements in resources. Making use of the evidence-based in- establish building blocks for healthy development, mental health also improve physical health. terventions already at hand could potentially save and limit the environmental exposures that increase 8 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  9. 9. risk — approaches that are likely to be far more cost-effective in addressing MEB disorders in the an Interview with carl Bell long run. Because risk factors tend to come in Meena dayak, Director of Marketing and Communications and chris loftis, Phd, Director of clusters and to be associated with more than one Practice Improvement for the National Council for Community Behavioral Healthcare spoke to disorder, a focus on prevention and wellness can Dr. Carl C. Bell, member of the IOM Committee that authored the report on preventing mental, have far-reaching benefits that extend beyond a emotional, and behavioral disorders. specific disorder. Research has shown that a number of programs are can you tell us about your role on the IoM sexual affections so they have triple the rate of HIC effective at preventing these problems and promot- committee? infection. There is evidence we can prevent children ing mental health. Meta-analyses and numerous I was on that committee because I’ve been a cli- who experience trauma from participating in these nician for 30 years. I do business I’m a CEO of a behaviors as adults. This report could fix 1/3 of randomized trials have demonstrated the value of: comprehensive mental health center on the south healthcare problem. >> Strengthening families by targeting problems side of Chicago and that gives a very different per- Then there is the issue of braided funding. If we such as substance use or aggressive behavior, spective. I am a researcher, usually in high-risk set- could get CDC, NIH, NIDA, SAMHSA, and NIMH all teaching effective parenting skills, improving tings, community psychiatry settings, urban poor, working on prevention in concert, we would get communication, and helping families deal with African-American, HIV, violence prevention, children somewhere with this. disruptions (such as divorce) or adversities exposed to violence, and trauma. And I have expe- (such as parental mental illness or poverty). rience translating academic efficacy and research- the IoM had published a report on preven- based science into real world settings. tion in 1994. how is this new 2009 report >> Strengthening individuals by building resilience an improvement? and skills and improving cognitive processes Is the delay from research to implementa- Science, tons and tons of science! This new report and behaviors. tion a translation or funding issue? shows you how to implement this science for differ- Both. They’re prevented from doing research with the ent socio-economic groups. We’re closer than we’ve >> Screening to identify individuals at risk for process. NIMH is charged with research and SAMH- ever been. some specific disorders, such as anxiety or de- SA is charged with overseeing programs. It’s difficult pression, and making simple interventions such to do research in a culture that is prevention defi- The other issue that is crystal clear is that now is as cognitive training or social supports easily cient, illness-based, and overly focused on tertiary the time! There are so many other things coming accessible. issues. And the bulk of what they are talking about together that make this possible. There’s a tremen- is treatment prevention and not primary prevention. dous amount of synergy between the brain science >> Promoting mental health in schools by offer- and the psycho-social science. The problem is that ing support to children encountering serious Money is of course a problem, too! There is ample we haven’t put them together yet, but now is the stresses; modifying the school environment to evidence in the report that says it’s likely that vio- time do it as the science has exploded. promote prosocial behavior; developing stu- lence can be prevented, drug abuse can be pre- dents’ skills at decision making, self-awareness, vented, post partum depression can be prevented, Is there anything from the IoM report that is and conducting relationships; and targeting vio- and depression in children can be prevented. But getting traction in the healthcare debate? lence, aggressive behavior, and substance use. how is it all funded? Obama knows about the report. The problem is, Obama’s infrastructure hasn’t been in place yet. >> Promoting mental health through health- What three recommendations from the re- There has been a bit of pushback on some aspects care and community settings by supporting port are likely to have the most impact? of the report because some don’t want the govern- programs that teach coping skills, and target The first one would be to have the White House ment intrusion in their lives–a fear of big brother. modifiable lifestyle factors that can affect be- create a cabinet level group to put prevention into It really takes presidential leadership to remind place in the U.S. A great example is how prevention people of our interdependence! havior and emotional health, such as sleep, diet, of violence against women has worked with presi- activity and physical fitness, sunshine and light, dential support. What can leaders of community health cen- and television viewing. We’ve learned that children who are traumatized ters take away from this report? The key to most of these approaches is to identify have twice the rates of cancer, twice the rates of If they want to stay in business, they need to change risks — biological, psychological, and social fac- heart disease, four times the rate of lung cancer, their business. We’re in a different world. And if they tors — may increase a child’s risk of MEB disorders. and twice the rates of liver disease because trauma don’t keep up with the times, they’re being unethical Some of these risks reside in specific characteris- causes children to eat, drink, smoke, and trade because the science is there. tics of the individual or family environment (such NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 9
  10. 10. Policy Perspectives as parental mental illness or substance abuse or shown that the program significantly reduces ag- many young people and their families. serious family disruptions), but they also include so- gressive and disruptive behavior during first grade. National leadership is necessary to make sys- cial stresses such as poverty, violence, lack of safe The one-year intervention also has benefits over the tematic prevention efforts a high priority in the schools, and lack of access to healthcare. Most risk long term, lowering the students’ risk of alcohol and healthcare system as well as an integral aspect of factors tend to come in clusters and are associated drug abuse, as well as rates of suicidal thoughts and the network of local, state, and federal programs with more than one disorder. attempts. And it significantly reduces the likelihood and systems that serve young people and families. Early symptoms typically occur two to four years that highly aggressive boys will be diagnosed with The IOM report makes several recommendations, before the onset of a full-blown disorder, creating antisocial personality disorder as adults. Research including:: a window of opportunity when preventive programs has shown that programs that focus on enhancing social and emotional skills can also improve stu- >> A White House-created leadership body to devel- might make a difference. And some programs have op an inter-departmental strategy that identifies shown effectiveness at preventing specific disorders dents’ academic performance. specific prevention goals, directs multiple fed- in at-risk groups. For example, the Clarke Cognitive- Other programs improve children’s mental health eral agency resources toward these goals, and Behavioral Prevention Intervention, which focuses and behavior by enhancing parenting skills. The provides guidance to state and local partners on helping adolescents at risk for depression learn Positive Parenting Program, for example, uses a (however, the report cautions that federal and to cope with stress, has prevented episodes of ma- range of approaches, from a television series on state agencies should not support programs that jor depression in several controlled experiments. how to handle common child-rearing problems to lack empirical evidence, even if they have commu- Other programs have demonstrated broader pre- in-person skills training for parents struggling to nity endorsement). ventive effects in populations of young people. Pro- handle children’s aggressiveness or lack of coop- eration. These methods have been shown to lower >> Develop state and local systems that support grams that can be offered in family or educational partnerships among families, schools, courts, settings show particular promise in promoting men- kids’ disruptive behaviors, a positive change that persisted one year later. health care providers, and local programs to tal health and addressing major risk factors. One create coordinated approaches that support example of an effective school-based program is The IOM report emphasizes the value of promoting healthy development. the Good Behavior Game, which divides elementary mental health and considering mental health within school classes into teams and reinforces desirable a developmental framework. The mental health re- >> Invest in prevention and promotion, including behaviors with rewards such as extra free time and search spectrum should include not just the preven- setting aside resources for evidence-based pre- other privileges. Studies have tion of MEB disorders, but also a focus on wellness vention in mental health service programs and the promotion of mental health. Good prevention investment in proven prevention approaches by and mental wellness promotion interventions are school systems. grounded in research on the interrelationships >> Workforce training, including development of among the principal milestones of healthy devel- prevention training standards and training pro- opment and the family, school, and community fac- grams across disciplines including health, edu- tors that are associated with them. cation, and social work. PolIcY IMPlIcatIons >> Long-term tracking of the prevalence and fre- Officials at the local, state, and federal levels all quency of MEB disorders. play a role in mental health promotion and the pre- >> Implementation and evaluation of screening with vention of MEB disorders. Many providers and agen- community involvement, parental support, valid cies are responsible for the care, protection, or sup- tools, and interventions to address identified port of young people: the child welfare, education, needs. and juvenile justice systems, as well as medical and >> Continued research on both the efficacy of new mental health care providers and community orga- prevention models and real-world effectiveness of nizations. Yet resources within these agencies are proven prevention and wellness promotion inter- scattered, not coordinated, and often do not effec- ventions. tively support prevention programs or policies. The result is a patchwork that does not perform as an >> Adaptation of research-based programs to cul- integrated system and fails to serve the needs of tural, linguistic, and socioeconomic subgroups. 10 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  11. 11. >> Public education, with mass media and the inter- evidence-based intervention is needed. net offering the opportunity to greatly expand the Economic analyses: Funding for prevention programs reach of specific messages about risk factors and is increasingly made in an environment of decreased available resources, to reduce stigma, and to de- resources. Evidence of the economic benefits of pre- liver some kinds of interventions. ventive interventions is a critical policy tool. Yet, many role oF research research designs do not include information about Research has exploded in recent decades on efforts the costs of an intervention against which a commu- to prevent MEB disorders. Findings include improved nity could weigh the benefits. Even fewer include cost- understanding of the origins of MEB disorders and effectiveness analyses. Guidelines for conducting this advances in methodological approaches that al- type of analysis, as well as incentives for researchers low causal inferences to be drawn from evaluations to conduct it, are necessary. of preventive interventions and to track effects over Copies of Preventing Mental, Emotional, and Behav- multiple years. Many interventions have been tested ioral Disorders Among Young People: Progress and in multiple randomized trials and show long-term Possibilities are available from the National Acad- reductions in MEB disorders and related problem be- emies Press; 202.334.3313 or 800.624.6242 or at haviors, such as aggression, high-risk sexual behavior, www.nap.edu. and substance use, as well as such positive outcomes as improved grades and higher self-esteem. to prevent mental and behavioral disorders and ways Carl C. Bell is president and CEO of the Community Mental Health to treat these problems, the report says; currently, the Council & Foundation, Inc. in Chicago. He is also the director Neuroscience research may lead to early identifica- balance is weighted toward research on treatment. of public and community psychiatry and a clinical professor of tion of specific young people at risk for MEB disorders psychiatry and public health, University of Illinois at Chicago. He and to the refinement of specific, targeted interven- coMMunItY releVance is a member and former chairman of the National Medical As- sociation’s Section on Psychiatry; a fellow of the American College tions. Related research has identified opportunities Interventions are unlikely to be implemented, or of Psychiatrists; a fellow of the American Psychiatric Association, to change environments in ways that might influence implemented with fidelity, if they are not respon- a founding member and past board chairman of the National Commission on Correctional Health Care. Dr. Bell has published the expression of specific genetic or biological pre- sive to community needs and priorities. Communi- more than 350 articles on mental health. dispositions, for both current generations and their ties often have substantial expertise and professional Meena Dayak has 15+ years of experience in marketing and offspring. wisdom but have developed approaches that are not public relations for nonprofit healthcare organizations. She leads supported by empirical evidence. Researchers and National Council efforts to help consumers and providers tell The report encourages more collaboration between a compelling story so that the world will recognize that mental communities need to develop partnerships to evalu- traditional prevention and wellness researchers with illnesses and addictions are treatable health conditions from ate interventions that have both a solid theoretical which people can recover and lead full lives. Prior to joining developmental neuroscientists in order to widen the the National Council, she managed marketing initiatives for grounding and are responsive to community needs. body of research focused on advancing health and healthcare standards and information programs at the United Increasing relevance to a community also calls for States Pharmacopeia. preventing disorders, rather than the more traditional consideration of such other issues. Chris Loftis offers practice improvement and legislative guidance emphasis of research focused on diagnosed disorders to the National Council’s more than 1,600 member organizations after they are well established and have done consid- Adaptation: The effectiveness of evidence-based in- that provide treatment and rehabilitation to individuals with men- erable harm. Greater collaboration between research terventions may be significantly facilitated or impeded tal illnesses and addiction disorders. Loftis has served as a policy analyst for the National Health Policy Forum in Washington, DC, a fields—specifically, the testing of hypotheses across by aspects of the ethnic, linguistic, and cultural envi- nonpartisan organization that provides health policy programming the disciplines—will yield both theoretical and practi- ronment in which they are implemented. Research is for senior staff in Congress and the executive agencies. He also cal advances in prevention. needed to identify the specific factors that influence has worked as a practitioner and researcher, and has completed advanced specialty training in pediatric neuropsychology. Loftis effectiveness and the adaptations that are needed to has a doctorate in clinical psychology with a specialization in neu- The IOM report also urges continued research to build serve different populations. ropsychology from the University of Florida and completed a clini- understanding of what interventions work for whom cal internship at the Kennedy Krieger Institute at Johns Hopkins and when, and how best to implement them. The Screening in conjunction with intervention: Screen- in Baltimore, MD, where he worked with children with traumatic ing can be done in a number of ways and for a variety injuries, developmental disabilities, and chronic illnesses. National Institutes of Health should develop a com- Nathan Sprenger, the National Council’s marketing and communi- prehensive 10-year plan to research ways to promote of risk and early symptoms. Community acceptance, cations associate, provided administrative and research support mental health and prevent MEB disorders in young parental endorsement, and the capacity to respond to for this article and interview. people. In addition, agencies and foundations should needs that are identified are critical to its value. Re- establish equality in research funding between ways search on the effectiveness of linking screening with NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 11
  12. 12. Policy Perspectives Saving Jobs, Saving Public Dollars: Intervening Before Disability Vidhya alakeson, Policy Analyst, Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services This article represents the views of the author and not those of the U.S. Department of Health and Human Services. J uan was a delivery driver, but his health prob- lems were putting him at risk of losing his job. His diabetes was poorly controlled and had caused Security Insurance, for people who are no longer able to work. These programs, in turn, act as gate- ways to health insurance — Medicare in the case of can remain in their jobs and do not apply for public disability programs. Two of the demonstration sites, Texas and Minnesota, focus on people with serious foot ulcers that made it difficult for him to walk. He SSDI and Medicaid for those who quality for SSI. This mental illnesses and people with chronic physical also had bipolar disorder, which was not being con- safety net is vital for people who are too disabled to health problems who also have a mental health trolled. When he joined the Working Well program in work. Once people qualify for Social Security, how- condition. The ingredients that make up the service Harris County, Texas, Juan worked with a case man- ever, they rarely move off it, despite strong evidence packages in Minnesota and Texas are similar: com- ager to get orthopedic shoes, to receive support in that many people with mental health problems want prehensive health insurance, including dental and developing a diabetic diet and exercise plan, and to to and can work. People with mental illnesses now vision services as well as behavioral health benefits; make an appointment with a psychiatrist to bring constitute the largest and most rapidly growing employment supports; and a “broker” who works his mental health condition under control. As a re- The Demonstration to Maintain Independence and Employment, sult, Juan was able to continue working full time as a delivery driver and received a raise for exceptional funded by CMS, is evaluating the impact of actively supporting people performance (Bohman, Stoner, & Chimera, 2009). with mental illnesses who are at risk of becoming too disabled to Working Well is part of the Demonstration to Main- work, so that they can remain in their jobs. The intervention is proving tain Independence and Employment, which is funded to be effective in improving clients’ access to healthcare services, by the Centers for Medicare and Medicaid Services. health and functional status, job stability, and earnings. The DMIE is one of the federal initiatives currently evaluating the impact of earlier intervention for group of Social Security disability beneficiaries, and with participants to help them keep their jobs. The people with mental illnesses (earlier interventions every year only 1 percent of people who qualify for broker’s role is broad; it can range from helping a in the context of this article refer to interventions SSDI on the basis of a mental illness leave the rolls participant get an appointment with a psychiatrist prior to application for Social Security Benefits but and return to work. to finding him or her a place to live to organizing do not include first onset interventions). The DMIE represents a break with existing policy. child care (Gimm & Weathers, 2007). Current federal policy provides support, through So- Its purpose is to actively support people who are at Early results are promising. In Minnesota, the DMIE cial Security Disability Insurance and Supplemental risk of becoming too disabled to work, so that they intervention is proving to be effective in improving 12 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  13. 13. clients’ access to healthcare services, health and Providing integrated behavioral healthcare and supported functional status, job stability, and earnings. It has employment to a third of Social Security applicants with also reduced the number of applications for SSDI mental health conditions to help them return to work and stay off (Linkins & Brya, 2009). Analysis indicates that earlier interventions, such as the DMIE, could make sound the disability rolls could save the government $48 million in financial sense for the federal government as well as providing all the necessary services. for clients. A new study by Drake, Skinner, Bond, and back into work, following the principle that economic on qualifying for disability benefits. Goldman (2009) concluded that providing integrated self-sufficiency is in the best interest of their families. behavioral healthcare and supported employment The Social Security Administration is currently working Vidhya Alakeson is a policy analyst in the Office of the Assistant to a third of Social Security applicants with mental Secretary for Planning and Evaluation at the Department of with the Administration for Children and Families to health conditions to help them return to work and Health and Human Services where she leads work on mental look in greater depth at the movement of beneficia- health and disabilities. Prior to taking up this position in 2008, stay off the disability rolls could save the government she was a Harkness Fellow in Healthcare Policy based at HHS ries between TANF and SSI. $48 million in providing all the necessary services. and supported by the Commonwealth Fund in New York. Prior Drake et al. (2009) concluded their analysis of the to working in the US, Vidhya worked for the UK Government and One of the challenges of adopting a more comprehen- in several leading UK think tanks conducting policy research in potential savings from earlier intervention with sev- the areas of health, human services, and education. She has a sive approach to earlier intervention is the absence eral policy proposals. First, they suggested that states first class degree from Oxford University and a masters from the of strong evidence as to how to effectively support London School of Economics. provide supported employment and mental health people before they become Social Security beneficia- services early in the course of mental illness. Initia- REfEREncES ries. DMIE is one federal effort to address this evi- Bohman, T., Stoner, D., & Chimera, D. (2009, April). Working Well: tives such as the DMIE and RAISE are testing that Preliminary findings. Paper presented at the Centers for Medicare dence gap; the Recovery After an Initial Schizophrenia approach. Second, they suggested that health insur- and Medicaid Services MIG/DMIE Employment Summit, San Episode program is another. RAISE is a major new Francisco. ance be delinked from disability status. The two rec- initiative from the National Institute for Mental Health Drake, R. E., Skinner, J. S., Bond, G. R., & Goldman, H. H. (2009). ommendations are intimately connected. For people Social Security and mental illness: Reducing disability with sup- that will be launched this summer. For most people, with any kind of chronic condition, including a men- ported employment. Health Affairs,28, 761−770. the first onset of schizophrenia occurs in adolescence tal illness, access to healthcare is vital. The only way Gimm, G., & Weathers, B. (2007). What is the Demonstration or early adulthood. Emerging evidence suggests that to Maintain Independence and Employment (DMIE) and who is some people can access healthcare is to qualify for participating? Princeton, NJ: Mathematica Policy Research. intervening at this point can reduce the likelihood disability benefits. Fear of losing healthcare then be- Linkins, K., & Brya, J. (2009, April). MN DMIE: The role of that a patient will develop full-blown schizophrenia, comes a major barrier to moving off benefits. In this personal navigation and employment supports in client outcomes. but researchers have not reached a consensus as to Paper presented at the CMS MIG/DMIE Employment Summit, San respect, current discussions around extending health Francisco. which early interventions work best. RAISE will test insurance to the uninsured are particularly important. Loprest, P., & Maag, E. (2009). Disabilities among TANF recipi- two sets of interventions to assess whether they can Earlier intervention will only take hold if patients have 6/5/09 4:40 NHIS, Washington, DC:1 Institute. 10706 VVA.mech2:magazine ad ents: Evidence from the PM Page Urban effectively prevent the development of the condition a route to accessing healthcare that does not depend and reduce long-term disability as a result of mental illness. Research has indicated other opportunities for earlier Veterans & Their Families: Health Care intervention to prevent long-term dependence on dis- ability programs. A recent study by the Urban Institute WHAT YOUR Provider SHOULD KNOW… showed that close to 14 percent of recipients of Tem- porary Assistance for Needy Families have an emotion- al or mental health problem (Loprest & Maag, 2009). States have to meet strict work participation criteria for the TANF population, and participation in mental health treatment does not qualify as work participa- tion. As a result, it is often in the state’s interest to try to move women with mental health problems and www.veteranshealth.org other disabilities onto SSI. A focus on earlier interven- tion, by contrast, would seek to address the mental A program of Vietnam Veterans of America health needs of women on TANF and support them NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 13
  14. 14. Policy Perspectives Call to Include Prevention in Healthcare Reform Excerpts from SAMHSA’s “A Framework for Discussion: Ensuring U.S. Health Reform Includes Prevention and Treatment of Mental and Substance Use Disorders: Core Consensus Principles for Reform from the Mental Health and Substance Abuse Community” at www.samhsa.gov/Healthreform/docs/HealthReformCoreConsensusPrinciples.pdf T he Substance Abuse and Mental Health Ser- vices Administration reached out to hundreds of stakeholder and consumer groups and dozens of than waiting until they become acute or chronic. The national plan should utilize a public health Our nation is crying out for a health system that makes prevention and model for prevention that organizes multiple com- treatment for mental and substance use nationally and internationally recognized experts in munity sectors to plan, implement, and evaluate the fields of mental health and addictions to solicit disorders a priority rather than an after- appropriate strategies and programs designed to insight and recommendations on the most critical thought, that considers the whole person change community norms and environments to issues related to mental and substance use dis- rather than physical symptoms alone, and promote healthy choices and behaviors. Universal orders facing the American population today, with screening tools should be used to detect medical that seeks to eliminate the stigma and an emphasis on identifying opportunities to ensure conditions including mental and substance use dis- fragmented systems that interfere with that imminent health reform efforts include preven- orders early and treat them at a low level of acuity. Americans’ ability to access necessary tion and treatment for these disorders. These approaches will slash billions of dollars from preventive and treatment services funda- With consistency and solidarity, mental health and annual healthcare costs and dramatically improve mental to achieving recovery and enabling substance abuse professionals, consumers, and the overall health of Americans. them to lead healthy and productive lives.” family members from every part of the country, every cultural and socioeconomic group, and every diag- nosis and condition spoke with a single voice: “Our 2 legislate universal coverage of health Insurance with Full Parity nation is crying out for a health system that makes prevention and treatment for mental and substance Equal treatment for people with serious mental illness and substance use disorders must mean 3 achieve Improved health and long-term Fiscal sustainability use disorders a priority rather than an afterthought, access to effective services and high-quality care. There is a substantial body of evidence to demon- that considers the whole person rather than physi- Children and adults with mental and substance use strate that providing adequate levels of mental and cal symptoms alone, and that seeks to eliminate disorders are medically vulnerable populations. substance use disorders prevention and treatment the stigma and fragmented systems that interfere Many will not access needed primary health care services as well as integrating these services with with Americans’ ability to access necessary preven- or comply with medical treatment without signifi- primary healthcare can improve outcomes; cut tive and treatment services fundamental to achiev- cant support. Mechanisms developed under health and/or control the growth of overall healthcare ing recovery and enabling them to lead healthy and reform to expand coverage for currently uninsured costs; lessen the rate, duration, and intensity of dis- productive lives.” populations must require compliance with the new ability of many illnesses; improve productivity; and parity law. Similarly, the discriminatory IMD exclu- control the size and growth of other social costs. Based on stakeholder input, SAMHSA has developed sion under Medicaid must be modified. By including information about preventing as well a set of NINE CORE CONSENSUS PRINCIPLES: as detecting mental and substance use disorders Achieving universal coverage will also help to pro- in primary healthcare, institutional, and community 1 articulate a national health and Wellness Plan for all americans Our nation needs a national health and wellness mote health equity and increase access by requiring that priority attention be given to populations dis- proportionately affected by chronic disease. Such settings, we create an environment that enables early, low-cost treatment, thereby avoiding escala- plan that provides for comprehensive, community- populations include racial and ethnic minorities, tion to expensive, urgent-care facilities; minimizing wide prevention, screening, health, and wellness groups with low socioeconomic status, residents impact to family members, workmates, and others; services from infancy through old age. The plan of rural areas, chronically unemployed populations, and reducing the likelihood of lasting adverse ef- should provide for public education, prevention, women, children, older adults, persons with multiple fects to the consumer. Further, this cultivates a early intervention, treatment, and recovery services, chronic conditions, persons with disabilities, and whole-health, person-centered approach that fos- and must be a holistic, standardized system that criminal and juvenile justice–involved populations. ters not only recovery but also resilience. 4 emphasizes promoting wellness and resilience, pre- Health reform must recognize the need for special- eradicate Fragmentation by requiring venting risky and unhealthy behaviors before they ized mental and substance use disorders services coordination and Integration of care for occur to avoid the onset of illness or drug use, and to enable these populations to benefit from health- Physical, Mental, and substance use conditions addressing symptoms when they first emerge rather care coverage. 14 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2

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