The Reality of Recovery, Social Inclusion and Wellness

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The Reality of Recovery, Social Inclusion and
Wellness

• David L. Shern, Ph.D.
• President/CEO Mental Health America
• Inaugural Behavioral Health Collaborative
  Conference
• A Place in the Community and Beyond
• December 2, 2008
• Albuquerque, New Mexico

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Outline of the Presentation

• What Brings Me Here Today?
• Mental Health America at its Centennial
• Enduring Problems in the Publics Mental Health
• Mental Health Americas Strategy
• Call to Action

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The Difference Between Knowing and Doing Can Be
Fatal David Satcher, M.D. Former Surgeon
General
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Mental Health America

• Founded in 1909 by Clifford Beers, William James,
  Adolph Meyers and other national leaders as the
• National Committee on Mental Hygiene
• Celebrating our Centennial in 2009
• Opportunity to look back and look forward
• Design the Next Century of Mental Health in the US

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Beers Description of His Treatment in
Connecticut Public and Private Hospitals Call for
Reforms in Hospital Treatment
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Scientific Psychiatry as Mental Hygiene

• In addition to Hospital Reform
• Expanding Role of Psychiatry
• Outside of Custodial Institutions
• To Include the Prevention of Mental Illness
• Attempts to Emulate Scientific Advances in Other
  Areas of Medicine and Public Health
• Collection of Epidemiological Data
• Rational Decision Making
• Mental Hygiene Concept
• Vaguely Defined
• Little Science to Inform Action

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Then and Now

• Scientific Knowledge Base has Expanded
  Dramatically
• Rehabilitation
• Treatment
• Prevention
• Continuing Serious Challenges in Designing
  Effective/Responsive Systems that Utilize Science
  
• Effectively Support Good Practices
• Results in Extensive Loss of Life and
  Productivity

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The Recovery Story

• George Brooks Vermont State Hospital
• Challenged to Close the Hospitals Most Back
  Ward Patients
• Asked the Hospital Residents What They Needed
• Designed a Programs of Skills and Supports to
  Meet Their Self Identified Needs
• Courtney Harding Followed-up 30 Years Later
• Found the Majority to be either Fully or Largely
  Recovered

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Percentage of Persons with Schizophrenia Who
Largely or Fully Recovered

• Contrary to Conventional Wisdom People with
  Schizophrenia Can Recover
• Rosalyn Carter we now know that recovery is
  possible for any individual with a mental illness

From Knight (2003)
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Our Challenge

• Close the Gap Between Our Considerable Scientific
  Knowledge Base and What is Routinely Available
  in Ordinary Care

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We Should be Outraged at the Pathetic State of
Mental Health in the United States?
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U.S. Has Highest Rates of Mental Illness

• U.S. has the highest prevalence rates (26) in
  the world in a comparison of 14 developing and
  developed countries. (JAMA, 2004)
• For U.S.-born Mexican-Americans, the lifetime
  risk of being diagnosed with any mental disorder
  was similar to that for non-Hispanic whites --
  48.1 percent, or almost one in two people. But
  for new immigrants and Mexican nationals, the
  rate was only 24.9 percent. (MAPPS, 1998)
• After 13 years in residence Mexican immigrants
  rates equal those of other Angeleans.

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People Are Still Not Getting the Help They Need

• While approximately 80 percent of all people in
  the U.S. with a mental disorder eventually seek
  treatment at some point in their lives,
• the median delay across all disorders is nearly a
  decade. (NCS-R, 2005)
• less than one-third of people who seek help
  receive minimally adequate care. (NCS-R, 2005)

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The Impact of Behavioral Disorders
IllustratedSuicide is the Leading Cause of
Violent Deaths Worldwide(World Health
Organization, 2002)
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In the United States

• A Person takes His/Her Life Approximately Every
  16 Minutes

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Taking Lives

• Persons with Severe Mental Illnesses Served in
  Public Systems are Dying 25 Years Early
• Weve Known about this Phenomena since at least
  1934
• 66 Papers Published between 1934-1996
• Why Havent We Addressed This Problem?

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Increased Risk of Early Death for People with
Schizophrenia 38 Studies

• Causes of Death
• All Causes 2.58
• Natural Causes 2.41
• Unnatural Causes 7.50
• Cardiovascular 1.79
• Digestive 2.38
• Infectious 4.29
• Respiratory 3.19
• Suicide 12.86
• Has Worsened in Recent Decades

Saha, et al 2007
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Consequence of Untreated Mental Illness

• Depressed children are more likely to perform
  poorly in the classroom, engage in aggressive
  behavior, and have poor peer and teacher
  relationships
• Children with depression and anxiety disorders
  are
• more likely to miss school and subsequently drop
  out
• Abuse drugs and alcohol
• Children with anxiety disorders are more likely
  to have poorer occupational attainment

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Our Case

• The United States has the Most Expensive Health
  Care System in the World that produces Poor to
  Mediocre Health Outcomes
• Lack of Attention to Behavioral Factors is
  Fundamental to Improving these Outcomes

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Very Expensive Poor Outcomes

• U.S. citizens spent 5,267 per capita for
  health care in 200253 percent more than any
  other country. (Health Affairs, 2005)
• U.S. ranks 42nd for life expectancy down from
  11th in 1987 (Census Bureau, National Center for
  Health Statistics, 2007)
• U.S. ranks an average of 12th among 13
  industrialized nations for 16 health indicators,
  including
• 13th for low birth weight percentages
• 13th for neonatal mortality and infant
  mortality overall
• 11th for post-neonatal mortality
• 13th for years of potential life lost
  (excluding external causes)
• 10th for life expectancy at 15 years for
  females, 12th for males
• 10th for life expectancy at 40 years for
  females, 9th for males
• 7th for life expectancy at 65 years for
  females, 7th for males
• 3rd for life expectancy at 80 years for
  females, 3rd for males
• (JAMA, 2000)

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The Impact of Behavioral Disorders
IllustratedThe Disability Impact of Mental
Illness
Illness Related Disability--United States,
Canada, and Western Europe, 2000 (World Health
Organization, 2001)
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We Should be Outraged
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In Contrast to 1909

• Our Science Base is Considerable in
• Prevention
• Treatment
• Rehabilitation
• Our Challenge is Generating the Political Will to
  Make it Happen

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Preventative Interventions

• IOM Report in Early 2009
• Summarizing the State of Prevention Science for
  Mental Health and Substance Use Conditions
• Likely to Conclude
• Strong Science Base
• Challenges in Implementation and Political Will

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EXAMPLE Seattle Social Development Project
Proportion Who Met Criteria for GAD, social
phobia, MDE, or PTSD diagnosis at ages 24 and 27.
Hawkins, J. D., Kosterman, R., Catalano, R. F.,
Hill, K. G., Abbott, R. D. (in press). Effects
of social development intervention in childhood
fifteen years later. Archives of Pediatrics and
Adolescent Medicine
plt .05
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Early Identification and Intervention Programs

• Columbia University TeenScreen Program
• Computer Based Screening
• Immediate Clinical Re-Assessment for Positive
  Screens
• Case Management Services to Link Children and
  Families to Desired Care
• Well Developed Implementation Protocol

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Preventing Onset of Psychosis

• Evidence Indicates that the Longer the Duration
  of Untreated Psychosis, the Poorer the Prognosis
• Average Time between Psychotic Symptom Onset and
  Treatment is Over One Year
• Need to Identify Accurately and Intervene Early

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Prevention of Psychosis - Early Results

• Pooling Several International Studies McFarlane
  Reports One Year Rates of Conversion to Psychosis
  for Individuals at Risk
• 10 for Individuals Receiving Experimental Tx
• 34 for Persons in Control Conditions
• Interventions that Employ Evidence Based Family
  and Rehabilitative Interventions have
• Better Retention Rates
• Better Patient Functioning
• Better Family Well Being

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Evidence Based Treatment Programs for Adults

• Collaborative Care for the Treatment of
  Depression
• Cognitive Behavioral Therapy
• Interpersonal Therapy
• Pharmacotherapies
• Assertive Community Treatment
• Supported Housing
• Supported Employment
• Integrated Treatment for Co-Occurring Severe
  Mental Illness and Substance Abuse

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Supported Employment Interventions

• Meaningful, Competitive Employment Often Primary
  Consumer Goal
• Employment Rates in the Public System Typically
  Around 10
• Supported Employment
• Focuses on Competitive Employment
• Eligibility based on Consumer Choice
• Rapid Job Search
• Integration of Mental Health and Employment
  Services
• Consumer Preference in Job Choice
• Individualized Job Supports
• Personalized Benefits Counseling

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Bond, et al (in press)
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Mental Health Americas Approach

• In 2006 renamed the Organization from the
  National Mental Health Association to Mental
  Health America
• Emphasis on the Centrality of Mental Health to
  Overall Health and Social Well Being
• Position Issues to Increase Appeal to Broader
  Audiences
• Business
• Education
• General Health Care
• General Public
• Explicit Use of a Wellness/Public Health
  Framework rather than Focusing Singularly on
  Disease and Disability

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Mental Health Americas Approach

• US has the Most Expensive Health Care System in
  the World with Poor Outcomes
• Chronic Illnesses Account for 75 of Health Care
  Expenditures
• We do not Effectively Prevent or Treat Chronic
  Illnesses
• MHSA Conditions are the Most Chronic Conditions
• Controlling Health Care Costs and Improving
  Population Health Status will Require Effective
  Treatment of MHSA Conditions.

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Wellness Concept

• Activities to Promote Health, Social
  Participation and Life Satisfaction.
• Provides a Platform that is Relevant across the
  Full Spectrum of Health, Illness and Disability
• Specific Strategies Crafted to Respond to
  Individuals Preferences, Health Status,
  Environment and Needs

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Taxonomy of Preventive/Wellness Interventions

• Increase Personal Strengths and Skills
• Increase Environmental Supports and Buffers
• Reduce Exposure to Traumatic Life Events
• Inequities in Opportunities for Full
  Participation Result in Trauma
• Poverty
• Social Exclusion/Discrimination
• Community Based and Governed

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Disability None Signs and Symptoms
None Co-morbid Health Conditions None
What to do?Strategies to Maintain Health and
Functioning. Strengthen Skills and Supports to
Increase Resilience. Reduce Environmental Trauma
to Prevent Injury.
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Disability Severe gt Work, Home,
Interpersonal Signs and Symptoms Severe gt
Frequent, troubling hallucinations Co-morbid
Health Conditions None
What to do?Wellness strategy likely to involve
intensive treatment to reduce psychiatric
symptoms, rehabilitation services and supports to
improve functioning at work and home. Wellness
interventions including group supported
activities to stop smoking, get daily exercise,
aggressively manage weight.
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What to do?Wellness strategy likely to involve
intensive treatment to reduce psychiatric
symptoms, rehabilitation services and supports to
improve functioning at work and home as well as
integrated general health care to aggressively
manage other chronic conditions. APA/ADA
diabetes Protocol, Medications/Exercise to mange
hypertension, medication/physical therapy and
supports for arthritis.

• Disability Severe
• gt Work, Home, Interpersonal
• Signs and Symptoms Severe
• gt Frequent, troubling hallucinations
• Co-morbid Health Conditions Three
• gt Diabetes
• gt Hypertension
• gt Arthritis

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Julius Richmond

• Scholar, Surgeon General, Leader in Health
• Change Requires Three Elements
• Science
• Ability to Implement
• Political Will

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What You Can Do

• Generate the Political Will
• Join Mental Health America in its Movement
• Sign up at http//takeaction.mentalhealthamerica.n
  et.
• Give me your card or get a card from me and send
  me an email.