Why are we here today 1 in 10 Americans 1 in 5 families 1 in 7 workers 1 in 20 newborns 35% of ALL school children 1 in 8 veterans 1 in 2 homeless 1 i

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1 Why Behavioral Health is Important Steve Hornberger, MSW Long Term Quality Alliance June 5, 2012 Washington, DC

2 Why are we here today 1 in 10 Americans 1 in 5 families 1 in 7 workers 1 in 20 newborns 35% of ALL school children 1 in 8 veterans 1 in 2 homeless 1 in 4 elderly 80% of those in jail 60% of families in children and youth services

3 Prevalence In 2010, 23.1 million people aged 12 or older needed treatment for an AOD problem. Of those, only 2.6 million received any treatment.

4 The Gaps Of the 20.5 million who needed treatment but did not receive it, only 1.2 million (5.0%) felt they needed it (denial gap) Of that 1.2 million, 373,636 (34.8%) said they made an effort but were unable to get it (treatment gap) 826,364 (65.2%) reported making no effort (motivation gap).

5 Why are we here today In 2005, federal, state and local government spending as a result of substance abuse and addiction was a least $467.7 billion or 10.7 % of their combined $4.4 trillion budget. For each dollar of the $467.7 billion spent, 95.6 cents went to shoveling up the wreckage and only 95.6 cents went to shoveling up the wreckage 1.9 cents on prevention and treatment, 0.4 cents on research, 1.4 cents on taxation or regulation and 0.7 cents on interdiction.

6 RECOVERY

7 What does the science say Millions of Americans today receive health care for mental health or substance use problems and illnesses. These conditions combined are the leading cause of disability and death among women and the second highest among men. Institute of Medicine, 2006 Treatment is effective: When given a continuum of care, relapse rates for the treatment of alcohol, opioids, and cocaine are less than those for hypertension and asthma and are equivalent to those of diabetes (all of which are also chronic illnesses). Compliance to addiction treatment is greater than compliance rates for treatment of hypertension and asthma. O Brien and McLellan, 1996

8 What does science say 2 Treatment is Effective and Sustainable Addictions treatment has resulted in: 67% reduction in weekly cocaine use, 65% reduction in weekly heroin use, 52% decrease in heavy alcohol use, 61% reduction in illegal activity, and 46% decrease in suicidal ideation one year 46% decrease in suicidal ideation one year post treatment. These outcomes are generally stable for the same clients five years post treatment.

9 Continuing Care is Cost Effective A recent study of a lifetime simulation model (multiple episodes of treatment over a lifetime) shows that for every $1 spent on treatment (chronic care provided in a continuum of care) society accrues $37.72 in benefits. Zarkin et al., 2005

10 Addiction and Chronic Care Compliance Relapse Rate Addiction/Chronic Illness Rate (%) (%) Alcohol Opioid Cocaine 30 Nicotine 30 Insulin Dependent Diabetes Medication <50 Diet and Foot Care <50 Hypertension Medication Diet Medication <30 Diet < < < < < Asthma Medication <

11 SAMHSA s new working definition A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential Health: overcoming or managing one s disease(s), e.g., abstaining from use if one has an addiction problem and for everyone in recovery making informed, healthy choices that support physical and emotional wellbeing; Home: a stable and safe place to live; Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society; Community: relationships and social networks that provide support, friendship, love, and hope.

12 Recovery oriented systems of care Recovery-Oriented Systems of Care shifts the question from How do we get the client into treatment? to How do we support the process of recovery within the person s life and environment?

13 Recovery and Resilience Oriented System of Care

14 Resources Center for Integrative Health Solutions ACMHA: The College for Behavioral Health Leadership

15 CONTACT INFORMATION Ron Manderscheid, Ph.D National Association of County Behavioral Health and Developmental Directors Steve Hornberger, MSW LTG Associates, Inc

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17 THE HEARTS AND MINDS OF AMERICA: Advancing Health - Improving Lives Pamela S. Hyde, J.D. SAMHSA Administrator NCCBH 42 nd National Council Mental Health & Addictions Conference Chicago, IL April 17, 2012

18 THE HEALTH OF AMERICA S HEARTS AND MINDS 3

19 10 Leading Causes of Death, United States 2008, All Races, Both Sexes 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 4

20 Million Hearts A national initiative to prevent 1 million heart attacks and strokes over five years Remember Your ABCS A Appropriate Aspirin Therapy B Blood Pressure Control C Cholesterol Management S Smoking Cessation 5

21 BH PROBLEMS COMMON & OFTEN CO- OCCUR w/ PHYSICAL HEALTH PROBLEMS ½ of Americans will meet criteria for mental illness at some point in their lives 7 percent of the adult population (34 million people), have co-morbid mental and physical conditions within a given year 6

22 BH PROBLEMS ALSO COMMON IN HIGH NEED MEDICAL POPULATIONS Rates of cardiovascular disease, diabetes, and pulmonary disease are substantially higher among disabled individuals in Medicaid with psychiatric conditions 12-month prevalence of depression is ~ 5 percent among people without chronic medical conditions, 8 percent among people with one condition, 10 percent among people with two conditions, and 12 percent among people with three or more conditions People with asthma are 2.3 X more likely to screen positive for depression 52 percent of disabled individuals with dual-eligibility for Medicare and Medicaid have a psychiatric illness Dual-eligibiles account for 39 percent of Medicaid expenditures 7

23 CO-MORBIDITIES Psychiatric disorders were among 7 of the top ten most frequent co-morbid triads in the most expensive 5 percent of Medicaid beneficiaries with disabilities 8 Most common triad was co-morbid psychiatric conditions, cardiovascular disease, and central nervous system disorders 9.5 percent of all beneficiaries 24 percent of most expensive group

24 CO-MORBIDITY CHALLENGES 9 Adults who had any mental illness, serious mental illness, or major depressive episodes in the past year had increased rates of hypertension, asthma, diabetes, heart disease, and stroke (new NSDUH analysis, ) Most psychiatric medications, particularly anti-psychotic medications, can cause weight gain, obesity and type 2 diabetes, all of which impact mental conditions such as major depression Major depression is a risk factor for developing medical conditions such as cardiovascular disease (CVD) ; Persons reporting CVD have 1.43 x elevated risk of lifetime anxiety disorder

25 BH IMPACTS PHYSICAL HEALTH MH problems increase risk for physical health problems & SUDs increase risk for chronic disease, sexually transmitted diseases, HIV/AIDS, and mental illness Cost of treating common diseases is higher when a patient has untreated BH problems 24 percent of pediatric primary care office visits and ¼ of all adult stays in community hospitals involve M/SUDs M/SUDs rank among top 5 diagnoses associated with 30-day readmission, accounting for about one in five of all Medicaid readmissions (12.4 percent for MD and 9.3 percent for SUD) Individual Costs of Diabetes Treatment for Patients Per Year $300,000,000 $250,000,000 $200,000,000 $150,000,000 $100,000,000 $50,000,000 $0 With behavioral health problems and diabetes With diabetes alone 10

26 WHY WORSE PHYSICAL HEALTH FOR PERSONS WITH BH CONDITIONS? BH problems are associated w/ increased rates of smoking and deficits in diet & exercise People with M/SUD are less likely to receive preventive services (immunizations, cancer screenings, smoking cessation counseling) & receive worse quality of care across a range of services 11

27 PREMATURE DEATH AND DISABILITY People with M/SUDs are nearly 2x as likely as general population to die prematurely, (8.2 years younger) often of preventable or treatable causes (95.4 percent medical causes) BH conditions lead to more deaths than HIV, traffic accidents + breast cancer combined More deaths from suicide than from HIV or homicides Half the deaths from tobacco use are among persons with M/SUDs CDC, National Vital Statistics Report,

28 BH-RELATED DISABILITY According to the CDC, more than 2 million Americans report mental/emotional disorders as the primary cause of their disability Depression is the most disabling health condition worldwide; & SA is # 10 Years Lost Due to Disability in Millions (High-Income Countries World Health Organization Data) 13

29 STEEP HUMAN AND ECONOMIC COSTS 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 14

30 BH PROBLEMS = HIGHER MEDICAL COSTS Co-morbid depression or anxiety increase physical and mental health care expenditures > 80 percent of this increase occurs in physical health expenditures Average monthly expenditure for a person with a chronic disease and depression is $560 dollars more than for a person without depression Discrepancy for people with and without co-morbid anxiety is $710 A HMO claims analysis found that general medical costs were 40 percent higher for people treated with bipolar disorder than those without it 15

31 PUBLIC PERCEPTION OF VALUE Public is less willing to pay to avoid mental illnesses compared to paying for treatment of medical conditions, even when mental illnesses (including SUDs) are recognized as burdensome (NICHD, 2011) Public willing to pay 40 percent less than what they would pay to avoid medical illnesses 16 Mental illnesses account for 15.4 percent of total burden of disease (WHO), yet mental health expenditures in U.S. account for only 6.2 percent

32 BEHAVIORAL HEALTH AFFECTS EVERYONE ~Half of Americans will meet criteria for mental illness at some point 17 > Half of Americans know someone in recovery from substance use problem Positive emotional health helps maintain physical health; engage productively w/ families, employers, friends; & respond to adversity w/ resilience and hope 66 percent believe treatment and support can help people with mental illness lead normal lives 20 percent feel people with mental illness are dangerous to others Two-thirds believe addiction can be prevented 75 percent believe recovery from addiction is possible 20 percent would think less of a friend/relative in recovery from an addiction 30 percent would think less of a person with a current addiction

33 TREATMENT WORKS, BUT INACCESSIBLE FOR MANY Like many other illnesses, most people recover from M/SUDs 88 percent of individuals diagnosed with depression recover within 5 years 18 Any MI: 45.1 million SUD: 22.1 million Diabetes: 25.8 million Heart Disease: 81.1 million Hypertension: 74.5 million 37.8 % receiving treatment 11.2 % receiving treatment 84 % receiving treatment 74.6 % receiving screenings 70.4% receiving treatment

34 BH IS COMMUNITY HEALTH Adults with mental disorders experience high rates of unemployment and disability Unemployment rates are 3 to 5 times higher for people with mental disorders 44 percent of children in special education w/ emotional disturbances drop out of school highest of any category of disability Substance use reduces ability to parent and work; increases chances of involvement in criminal justice system 1/2 of all incarcerated people have MH problems; 60 percent have substance use problems; 1/3 have both 19

35 BEHAVIORAL HEALTH AS SOCIAL PROBLEM Public dialogue about behavioral health is in a social problem context rather than a public health context Homelessness Crime/jails Child welfare problems School performance or youth behavior problems Provider/system/institutional/government failures Public tragedies 20 Public (and public officials) often misunderstand, blame, discriminate, make moral judgments, exclude Ambivalence about worth of individuals affected and about the investment in prevention/treatment/recovery Ambivalence about ability to impact problems

36 LEADING TO INSUFFICIENT RESPONSES 21 Increased Security & Police Protection Tightened Background Checks & Access to Weapons Legal Control of Perpetrators & Their Treatment More Jail Cells, Shelters, Juvenile Just ice Facilities Institutional System Provider Oversight

37 BEHAVIORAL HEALTH FIELD S MESSAGES 22 Multiple and inconsistent messages Disease; disability; chronic medical condition; social reaction to difference; brain/genetic or environmental; treat the same as physical conditions; treat with a different psychosocial approach Substance abuse and mental illness stem from the same causes and often co-exist; or they are completely different fields and different diseases/conditions Behavioral health is and should be extraordinary; or should be the same as any other health condition

38 A PUBLIC HEALTH MODEL FOR BEHAVIORAL HEALTH Universal Focus on Population and Individual Health Health of any affects health of all social inclusion Prevention First Aim Is Healthy Individuals; Healthy Communities Preparation and activities to promote emotional health development and wellness, prevent disease/disorder, and react quickly and effectively to conditions that impact health 23

39 A PUBLIC HEALTH MODEL... Data & Information Driven To Track and Improve Population-Based Health Status and Quality of Care/Life What drives health? What causes disease/disorder? What works to prevent, treat and support recovery evidence-based approaches? Policies Affecting the Environment In Which Health or Disease Occurs Laws, regulations, rules, norms, culture, conditions, expectations re individual and collective behavior for self and toward others 24

40 A PUBLIC HEALTH MODEL Structures Creating & Supporting Government and Community Infrastructure and Capacity Departments, boards, committees, councils, commissions, coalitions, schools, universities Access Assuring availability of right services when individuals, families, community need them Prevention, treatment and recovery supports Adequate, trained, and culturally capable workforce

41 COMPARE... Physical Health What It Takes Nutrition Exercise Rest Good Genes Behavioral Health What It Takes Understanding/managing emotions Managing stress Positive social relationships Hope Spirituality 26 Reducing Risks Hand-washing Covering cough Protecting v food-borne illnesses Getting immunizations Taking universal precautions Avoiding unprotected sex Reducing Risks Trauma Chronic stress, esp. in childhood Non-supportive or destructive relationships Uninformed parenting No or limited skills

42 COMPARE... Physical Health Recognizing Signs Temperature Cough Fever Pain Avoiding Behaviors That Increase Risks Behavioral Health Recognizing Signs Suicidal thinking Depression and anxiety Post-traumatic stress Substance abuse Underage drinking or inappropriate amounts in adults Knowing When & How To Get Help Early detection tests/screening Stop the bleeding and pain Save life first Knowing When & How to Get Help Early detection screening/brief interventions Stop emotional pain Keep safe for individual and for community 27

43 SAMHSA S VISION A Nation That Acts On the Knowledge That: Behavioral health is essential to health Prevention works Treatment is effective People recover 28 A Nation/Community Free of Substance Abuse and Mental Illness and Fully Capable of Addressing Behavioral Health Issues That Arise From Events or Physical Conditions

44 THERE IS NO HEALTH WITHOUT BEHAVIORAL HEALTH! Heal the soul and the body will follow. Stevenson Kuartei, Minister of Health, Republic of Palau 29

45 MENTAL & SUBSTANCE USE DISORDERS CAN BE PREVENTED Product of biological, environmental and social factors Experiences trigger or exacerbate BH problems Trauma, adverse childhood experiences, disasters and their aftermath, poverty, domestic violence, involvement with the criminal justice or child welfare systems, neighborhood disorganization and family conflict Addressing risk factors is effective in reducing likelihood of M/suds Individual, family and community risk and protective factors Brain impacts chronic acute stress in early childhood can lead to: Future health problems (including depression and other BH problems) Damage to hippocampus Smaller physical size of developing brain 30

46 EARLY INTERVENTION REDUCES IMPACT 1/2 of all lifetime cases of mental illness begin by age 14; 3/4 by age On average, > 6 years from onset of symptoms of M/SUDs to treatment Effective multi-sectoral interventions & treatments exist Need treatment & support earlier Screening Brief interventions Coordinated referrals

47 A BOLDER VISION? Can we imagine: A generation without one new case of traumarelated mental or substance use disorder? A generation without a death by suicide? A generation without one person being jailed or living without a home because they have an addiction or mental illness? A generation without one youth being bullied or rejected because they are LGBT? A generation in which no one in recovery struggles to find a job? 32

48 Reinhold Niebuhr Nothing that is worth doing can be achieved in a lifetime; therefore we must be saved by hope. 33

49 34 Nothing that is true or beautiful or good makes complete sense in any immediate context of history; therefore we must be saved by faith.

50 Nothing we do, however virtuous, can be accomplished alone; therefore we must be saved by love. 35