Behavioral Health: Public Health Challenge Public Health Opportunity. Pamela S. Hyde, J.D. SAMHSA Administrator

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2 Behavioral Health: Public Health Challenge Public Health Opportunity Pamela S. Hyde, J.D. SAMHSA Administrator New Orleans, LA January 25, 2012

3 MAKING THE CASE 3 BEHAVIORAL HEALTH: AMERICA S #1 PUBLIC HEALTH CHALLENGE GLOBAL & DOMESTIC IMPACTS CHANGING THE HEALTH CARE FIELD

4 BEHAVIORAL HEALTH IS ESSENTIAL TO HEALTH By 2020, mental & substance use disorders (M/SUDs) will surpass all physical diseases as a major cause of disability worldwide One-half of U.S. adults will develop at least one mental illness in their lifetime U.S. 2006: M/SUDs were 3 rd most costly health condition behind heart conditions and injury-related disorders Mental illness and heart diseases alone account for almost 70 percent of lost output/productivity 4

5 BEHAVIORAL HEALTH IMPACTS 5 2+ million Americans report mental/emotional disorders as the primary cause of their disability (per CDC) Depression is the most disabling health condition worldwide; SA is # 10 M/SUDs: 24 percent of pediatric primary care office visits & almost ¼ of all adult stays in community hospitals Years Lost Due to Disability in Millions (High-Income Countries World Health Organization Data)

PREMATURE DEATH AND DISABILITY People with M/SUDs are nearly 2x as likely as general population to die prematurely, often of preventable or treatable causes BH conditions lead to more deaths than

6 PREMATURE DEATH AND DISABILITY People with M/SUDs are nearly 2x as likely as general population to die prematurely, often of preventable or treatable causes BH conditions lead to more deaths than HIV, traffic accidents + breast cancer More deaths from suicide than from HIV or homicides Half the deaths from tobacco use are among persons with M/SUDs 5,000 deaths each year attributable to underage drinking 6 CDC, National Vital Statistics Report, 2009

10 Leading Causes of Death, United States 2008, All Races, Both Sexes 7 RANK ALL AGES 1. Heart Disease: 616,828 2. Malignant Neoplasms: 565,469 3. Chronic Low Respiratory Disease: 141,090 4.

7 10 Leading Causes of Death, United States 2008, All Races, Both Sexes 7 RANK ALL AGES 1. Heart Disease: 616, Malignant Neoplasms: 565, Chronic Low Respiratory Disease: 141, Cerebro-vascular : 134, Unintentional Injury: 121, Alzheimer's Disease: 82, Diabetes Mellitus: 70, Influenza & Pneumonia: 56, Nephritis: 48, Suicide: 36,035 WISQARS TM Produced By: Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System

TOUGH REALITIES 8 AGE 14-17 AGE 18 AND HAD SERIOUS THOUGHTS OF SUICIDE 2.9 million, 13.8% (2009) 8.7 million, 3.7% (2010) MADE A PLAN 2.

8 TOUGH REALITIES 8 AGE AGE 18 AND HAD SERIOUS THOUGHTS OF SUICIDE 2.9 million, 13.8% (2009) 8.7 million, 3.7% (2010) MADE A PLAN 2.3 million, 10.9% (2009) 2.5 million, 1.0% (2010) ATTEMPTED SUICIDE 1.3 million, 6.3% (2009) 1.1 million, 0.5% (2010) DIED BY SUICIDE >1,000 (2008) >35,000 (2008)

SELDOM RAISED 45 percent had visited their primary care doctor within the month 18

9 MISSED OPPORTUNITIES = LIVES LOST 77 percent of individuals who die by suicide had visited their primary care doctor within the year 9 THE QUESTION OF SUICIDE WAS SELDOM RAISED 45 percent had visited their primary care doctor within the month 18 percent of elderly patients visited their primary care doctor on same day as their suicide

DAILY DISASTER OF UNPREVENTED AND UNTREATED M/SUDs

10 DAILY DISASTER OF UNPREVENTED AND UNTREATED M/SUDs 10 Any MI: 45.9 million SUD: 22.1 million Diabetes: 25.8 million Heart Disease: 81.1 million Hypertension: 74.5 million 39.2 % receiving treatment 11.2 % receiving treatment 84 % receiving treatment 74.6 % receiving screenings 70.4% receiving treatment

11 CHRONIC DISEASES: GLOBAL IMPACT 11 World Economic Forum: Global economic impact of 5 diseases could reach $47 trillion over the next 20 years MH will account for $16 trillion a third of cost Cancer Diabetes Mental Illness Heart Disease Respiratory Disease

12 ECONOMIC IMPACT ON AMERICA 12 Estimated total societal cost of substance abuse in the U.S. is $510.8 billion per year Mental disorders: ~$94 billion in lost productivity costs per year THE ECONOMY Economic costs of mental, emotional, and behavioral disorders among youth ~ $247 billion Alcohol and drug abuse & dependence: ~ $263 billion in lost productivity costs per year

13 IMPACT ON PHYSICAL HEALTH 13 MH problems increase risk for physical health problems & SUDs increase risk for chronic disease, sexually transmitted diseases, HIV/AIDS, and mental illness Adults with SMI have shortened life spans and high co-morbidities 69 percent report at least one medical disorder 83 percent are overweight or obese Cost of treating common diseases higher when a patient has untreated BH problems Hypertension 2x the cost Coronary heart disease 3x the cost Diabetes 4x the cost M/SUDs rank among top 5 diagnoses associated with 30-day readmission; one in five of all Medicaid readmissions 12.4 percent for MD 9.3 percent for SUD $300,000,000 $250,000,000 $200,000,000 $150,000,000 $100,000,000 $50,000,000 $0 Individual Costs of Diabetes Treatment for Patients Per Year With behavioral health problems and diabetes With diabetes alone

IN LOUISIANA.. 14 Of persons 12 or older in LA: 7.2% (259,000) used an illicit drug in the past month, vs. 8.4% nationally 2.9% (105,000) abused or were dependent on illicit drugs, vs 2.

14 IN LOUISIANA.. 14 Of persons 12 or older in LA: 7.2% (259,000) used an illicit drug in the past month, vs. 8.4% nationally 2.9% (105,000) abused or were dependent on illicit drugs, vs 2.8% nationally 7.0% (253,000) abused or were dependent on alcohol, vs 7.4% nationally Of persons 18 or older in LA: 19.7% had any form of mental illness, equal with the national average 4.8% had serious mental illness, vs. 4.6% nationally 3.1% had thoughts of suicide, vs. 3.7% nationally Providers 163 total SA treatment facilities, 119 were outpatient 158 total MH facilities, 78 were outpatient Based on 2008 to 2009 National Survey on Drug Use and Health (NSDUH) data.

15 IMPACT OF TRAUMA Childhood trauma is extensive > 6 in 10 U.S. youth have been exposed to violence within the past year Nearly 1 in 10 injured 695,000 children were victims of maltreatment in Adverse childhood experiences (ACEs) are associated with MI, suicidality, substance abuse, and physical illnesses ACEs = physical, emotional, and sexual abuse; family dysfunction, disasters and their aftermath, poverty, domestic violence, events leading to involvement with criminal justice or child welfare systems, neighborhood disorganization Potentially explain 32.4 percent of M/SUDs in adulthood Brain impacts: chronic acute stress in early childhood can lead to: Future health problems (including depression & other BH problems) Damage to hippocampus Smaller physical size of developing brain

16 PREVENTION WORKS 2009 IOM Report Preventing Mental, Emotional, and Behavioral Disorders among Young People: Progress & Possibilities Half of all adult mental, emotional and behavioral (MEB) disorders were first diagnosed by age 14 and three-fourths by age 24 MEB disorders among youth as commonplace as a fractured limb Individual, family and community risk and protective factors can be addressed and are effective Common, early, consistent, multi-sector, continuous, communitybased public health approaches work Environmental, policy, culture and individual approaches work 16

17 TRAUMA & JUSTICE: Homelessness 17 ~ 46 percent of people who are homeless have a mental illness; 64 percent have an alcohol or substance use disorder Among inmates who had MH problems, 13 percent of state prisoners and 17 percent of jail inmates said they were homeless in the year before their incarceration Providing housing for persons with mental illnesses who are homeless reduces criminal justice involvement by 38 percent (jail days) and 84 percent (prison days)

18 TRAUMA & JUSTICE: Jail Diversion 18 > Half of all inmates have MH problem; 6 in 10 have SA problem; one-third have both When done right, jail diversion works: Divertees use less alcohol and drugs (53 percent at 6 months) Have fewer arrests after diversion compared to 12 months before (2.3 vs. 1.1) Fewer jail days (52 vs. 35) Meets community needs: 3 out of 4 SAMHSA jail diversion programs keep operating after federal funding ends

19 IN AN ENVIRONMENT OF CHANGE 19 Federal Domestic Spending EMERGING SCIENCE State Budget Declines Health Reform

20 THE UNINSURED Uninsured population 37.9 M (<400% FPL) 18 M Medicaid eligible 19.9 M Health exchange eligible M (29 percent) have behavioral health conditions 20 Among Medicaid eligible population (133% FPL & below) 7.0 percent with a serious mental illness 14.2 percent with a substance use disorder Among exchange eligible population (134% - 399% FPL) 6.0 percent with a serious mental illness 14.6 percent with a substance use disorder

21 HEALTH REFORM: AFFORDABLE CARE ACT 21 Major drivers More people will have insurance coverage Medicaid will play a bigger role Focus on primary care and coordination with specialty care Major emphasis on home and community based services and less reliance on institutional care Rethink what is offered as a benefit Outcomes: improving the experience of care, improving the health of the population and reducing costs

22 HEALTH REFORM: AFFORDABLE CARE ACT 22 Dual disorders the expectation, not the exception 50 percent Medicaid beneficiaries w/ disabilities also have psychiatric illness Annual Medicaid per capita health costs three to four times higher for disabled beneficiaries with co-occurring BH condition Dual eligibles represent 40 percent Medicaid spending Risk-based comprehensive managed care 66 percent Medicaid beneficiaries enrolled now 80 percent predicted for 2014

23 WHAT S NEXT? 23 Medicaid expansion & health exchanges 1/1/14 Simplified Medicaid eligibility Enrollment Essential health benefits (state choices) More primary/behavioral health integration Increasing parity

24 BEHAVIORAL HEALTH Public Health or Social Problem? 24 Public Health Social Problem

25 TRAGEDIES 25 Grand Rapids, MI Lost Tucson, AZ Lost Asher Brown Lost 13 yrs old Virginia Tech, VA Lost West Nickle Mines School, PA Lost Red Lake Band of Chippewa, MN, Lost Columbine High School, TX Lost

26 FROM EVENTS TO ASSUMPTIONS 26 Individual Blame Misunderstanding Prejudice Discrimination Moral judgment Social exclusion

Control of Perpetrators & Their Treatment More Jail Cells &

27 LEADING TO INSUFFICIENT RESPONSES 27 Increased Security & Police Protection Tightened Background Checks & Access to Weapons Legal Control of Perpetrators & Their Treatment More Jail Cells & Homeless Shelters & JJ Facilities Institutional /System/ Provider Oversight

28 WHAT AMERICANS KNOW 28 Most Know or Are Taught: Basic First Aid and CPR for physical health crisis Universal sign for choking; facial expressions of physical pain; basic terminology to recognize blood and other physical symptoms of illness and injury Basic nutrition and physical health care requirements Where to go or who to call in an emergency

29 WHAT AMERICANS DON T KNOW 29 Most Do Not Know and Are Not Taught: Signs of suicide, addiction or mental illness or what to do about them or how to find help for self or others Relationship of behavioral health to individual or community health or to health care costs Relationship of early childhood trauma to adult physical and mental/substance use disorders

30 SO, HOW DO WE CREATE... A national dialogue on the role of BH in public life With a public health approach that: Engages everyone general public, elected officials, schools, parents, community coalitions, churches, health professionals, researchers, persons directly affected by mental illness/addiction & their families Is based on data, facts, science, common understandings/messages Is focused on prevention (healthy communities) Is committed to the health of everyone (social inclusion) 30

31 HELP US CHANGE THE CONVERSATION! 31

Behavioral Health: Public Health Challenge Public Health Opportunity. Pamela S. Hyde, J.D. SAMHSA Administrator

Behavioral Health: Public Health Challenge Public Health Opportunity Pamela S. Hyde, J.D. SAMHSA Administrator American Public Health Association 139 th Annual Meeting and Exposition Washington, DC October