Category Archives: Mental Health
Behavioral health was a frequent topic at this year’s Preparedness Summit in Atlanta for both presenters and attendees, who focus on helping people cope with stress during a disaster as well as on mental health conditions which can be exacerbated by the stress of an emergency. Thomas Bornemann, EdD, has been the director of mental health programs at the Carter Center in Atlanta since 2002. The Carter Center is the philanthropic foundation of former president Jimmy Carter and his wife, and focuses primarily on peace and health initiatives globally and in the United States.
NewPublicHealth spoke with Bornemann about the Center’s mental health programs and challenges that lie ahead. We spoke with Bornemann several days before the shooting this week at Fort Hood.
NewPublicHealth: What are the key mental health projects underway at the Carter Center?
Thomas Bornemann: We’re involved in a number of issues at the local level, national level and globally. One of our major global programs is a program in Liberia, West Africa, where we’ve been working on scaling up services in this post-conflict, low-income country. We are in our fourth year of five, and we’re providing three services: We’re training mental health workers because their mental health system was decimated after the war; we have helped them develop a national mental health policy plan and a national mental health law that will go to the legislature for approval this year we hope; and we’ve been working on the issues of stigma and discrimination against people with mental illnesses and helping to develop support for family caregivers who provide the lion’s share of the care.
In the United States we’ve been working for years on Mrs. Carter’s number one healthy policy priority, which has been the implementation of mental health parity legislation which passed in 2008. The U.S. Department of Health and Human Services has been working on final regulations since then which spell out the terms and conditions of parity. We’ve been working on monitoring that through the years, and we were very proud that in November Secretary Kathleen Sebelius came here to announce the release of the regulations out of respect for Mrs. Carter’s long commitment to parity legislation. We’ll continue to monitor the parity efforts as they become implemented through the Affordable Care Act.
HHS: Common Sports Injuries Mean High Costs for People Without Insurance
The ASPE Office of Health Policy, part of the U.S. Department of Health and Human Services (HHS), has released a new issue brief analyzing the incidence and average health care charges associated with common sports injuries. The injuries range from minor sprains and strains to more serious injuries such as broken bones and concussions, where direct medical bills can be significant, placing an especially heavy burden on people without health insurance. Such individuals could be made to pay not just out-of-pocket costs, but also providers’ full stated charges. Breaking down health care costs by age and sometimes gender, the brief found, for example, that the average cost to fix a leg fracture for a person 10-19 years old was $4,689 and for those ages 25-40 was $3,403. Read more on injury prevention.
CDC: Drexel Meningitis Death Linked to Princeton Outbreak
Researchers at the U.S. Centers for Disease Control and Prevention have confirmed through “genetic fingerprinting” that a Drexel University student who died March 10 from meningitis died from the same serogroup B meningococcal strain that previously caused an outbreak at Princeton University. Health department officials confirmed that the Drexel student had been in close contact with Princeton students a week before becoming ill, indicating that the strain may still be present in the Princeton University community. Health officials have already administered antibiotic prophylaxis to prevent additional cases of meningococcal disease in people who had been close to the Drexel student. No new cases have since been reported. Read more on infectious diseases.
Study: ICU Survivors Face Heightened Risk for Mental Health Problems
Critically ill people who survive a stay in a hospital intensive care unit (ICU) are at heightened risk for mental health problems such as depression and anxiety in the following months, according to a new study in the Journal of the American Medical Association. Examining the records of more than 24,000 Danish ICU patients, researchers found that in the three months post-discharge that about 0.5 percent had a new diagnosis—which was 22 times higher than the rate in the general population. Approximately 13 percent received a new prescription for a psychiatric medication, including antidepressants and drugs for anxiety and insomnia, during that period. Researchers said the findings indicate that as doctors become better at saving the lives of critically ill patients, more people will also be at risk for problems beyond their physical health. Read more on mental health.
A recent report from the Institute of Medicine found that young athletes in the United States face a "culture of resistance" to reporting when they might have a concussion and to complying with treatment decisions. That culture can result in students heading back to school too quickly—when they should be resting their brains to prevent short- and long-term complications.
"The findings of our report justify the concerns about sports concussions in young people," said Robert Graham, chair of the committee and director of the national program office for Aligning Forces for Quality, at George Washington University, Washington, D.C. (Aligning Forces is a program of the Robert Wood Johnson Foundation.) "However,” says Graham, “there are numerous areas in which we need more and better data. Until we have that information, we urge parents, schools, athletic departments, and the public to examine carefully what we do know, as with any decision regarding risk, so they can make more informed decisions about young athletes playing sports."
Recently, Righttime Medical Care, a chain of urgent care centers in Maryland, opened a number of HeadFirst sports injury and concussion centers in the state, staffed with health professionals who can assess injuries for concussions as well as evaluate students for return to play—in consolation with a team of experts who work with HeadFirst staff. HeadFirst will this year be presenting and publishing data on the more than 10,000 youth it has examined and treated for concussion in just the past two years.
NewPublicHealth recently spoke with Robert Graw, MD, head of Righttime and HeadFirst, about the need for better prevention, evaluation and treatment of concussions to prevent long-term health problems and disability.
NewPublicHealth: Why did Righttime add concussion care to the services provided?
Robert Graw: My son is an orthopedic surgeon and talked to me about the number of injuries he was seeing. We decided a few years ago that we’d learn as much as we could about preventing head injury and the consequences of head injury, and then promote that information through Righttime’s call center and through the visits that people made to our sites.
In the process of learning as much as we could we realized that the knowledge base of how people evaluate and manage concussions had changed drastically in the last five years as people have done more research. So, we then gathered together a group of consultant physicians and neuropsychologists to determine best practices. We met with them frequently, and then had them train our provider staff so that all of them became much more informed about what a concussion really is, the best way to evaluate them and the guidelines for management going forward.
Army, NIH Studies Look at Mental Health Risks, Resilience in U.S. Soldiers
JAMA Psychiatry has released a collection of three articles detailing the findings of a large-scale study of mental health risk and resilience in members of the U.S. Military. Among the findings of The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS):
- The rise in suicide deaths from 2004 to 2009 occurred not only in currently and previously deployed soldiers, but also among soldiers never deployed.
- Nearly half of soldiers who reported suicide attempts indicated their first attempt was prior to enlistment.
- Soldiers reported higher rates of certain mental disorders than civilians, including attention deficit hyperactivity disorder (ADHD), intermittent explosive disorder (recurrent episodes of extreme anger or violence), and substance use disorder.
“These studies provide knowledge on suicide risk and potentially protective factors in a military population that can also help us better understand how to prevent suicide in the public at large,” said National Institute of Mental Health (NIMH) Director Thomas R. Insel, M.D.
The emphasis on mental health in the military comes at the same time as a small group of Vietnam veterans has filed suit against the U.S. government, alleging they received other-than-honorable discharges for violations that the psychiatric community and Army now understand were attributable to post-traumatic stress. The veterans say the government has resisted their attempts to upgrade the discharges. Read more on mental health.
NIH: Allergy Prevalence Consistent Across U.S. Regions, Although Type Varies
Allergy prevalence of allergies is consistent across all regions of the United States in every demographic except for children age 5 years and younger, according to a new study from the U.S. National Institutes of Health (NIH). Researchers analyzed blood serum data from approximately 10,000 Americans between 2005 and 2006. “Before this study, if you would have asked 10 allergy specialists if allergy prevalence varied depending on where people live, all 10 of them would have said yes, because allergen exposures tend to be more common in certain regions of the U.S.,” said Darryl Zeldin, MD, scientific director of the National Institute of Environmental Health Sciences (NIEHS), part of NIH, in a release. “This study suggests that people prone to developing allergies are going to develop an allergy to whatever is in their environment. It’s what people become allergic to that differs.” The comprehensive study also examined and outlined risk factors that would make a person more likely to develop an allergy. Read more on the environment.
Study: SNAP for Just 6 Months Increases Kids’ Food Security Significantly
Children in households that participate in the Supplemental Nutrition Assistance Program (SNAP)—previously known as the Food Stamp Program—for just six months experience significant increases in their “food security,” according to a new study in the journal Pediatrics. Food insecurity—or lack of easy access—is tied to a range of health and developmental problems. The study concluded that “SNAP serves a vital role in improving the health and well-being of low-income children by increasing food security” and that “Future research is needed to determine whether specific groups of children experience differential improvements in food security.” SNAP provided assistance to approximately 47 million people in 2013, with about half of those children. Read more on nutrition.
With the passage of the Mental Health Parity Act and the implementation of the Affordable Care Act (ACA), behavioral health experts are pushing to improve the quality of that care so that people seeking help—some for the first time—receive evidence-based care that best suits their individual needs. As part of that conversation, the U.S. Senate Health, Education, Labor and Pension committee held a hearing this week on mental health treatment trends in the United States.
Sen. Tom Harkin (D-Iowa) the committee chair opened the hearing by “pointing to disturbing new trends [including]...significant increases in the prescribing of psychotropic medications, while the use of behavioral and psychological treatments among children and youth has increased only slightly, and has actually decreased among adults.”
According to committee research on recent use of psychotropic drugs, use of antipsychotic medications has increased eight-fold among children and five-fold among adolescents, and has doubled among adults between 1993 and 2009.
The key witness at the hearing was William Cooper, MD, MPH, a professor of pediatrics and health policy at the Vanderbilt University School of Medicine who conducts population-based studies of medication use in children. Cooper told the committee about a nine-year-old boy he treated for weight gain—which turned out to be a side effect of a psychotropic drug the child had been prescribed by a primary care provider given for disturbing the classroom. No mental illness diagnosis had been made for the child, and no mental illness was detected after evaluation at Vanderbilt.
Cooper said that in recent years the United States has seen a tremendous increase in the numbers of children diagnosed with mental health disorders.
“Whether this is a result of increased awareness, improved diagnosis, or other factors is not clearly understood,” said Cooper, who added that “while we must acknowledge that a part of the increase could be due to over-diagnosis, there is no disputing the fact that a large number of children and their families suffer significantly because of mental illness.”
Furthermore, added Cooper, given the fact that suicide is the second leading cause of death for children ages 12-17, “tragic consequences of childhood mental health disorders highlight our sense of urgency in addressing this important problem.”
Cooper added that treating mental health disorders can be challenging and that 50-75 percent of the care for children with mental health disorders occurs in primary care settings “making it critical that consultation and communication between primary care professionals and experts in mental health be enhanced.”
Significantly, Cooper told the panel that despite guidelines, much of the mental health care for children occurs in a manner “inconsistent with optimal practice,” including:
- Use of medications for diagnoses for which there is little evidence of benefit.
- Use of multiple medications at the same time, especially among particularly vulnerable children such as children in foster care, where a recent study found multiple psychiatric medications in up to 75 percent of children being treated.
- Use of medications alone without proven psychotherapies.
Cooper attributed the problems to several factors, among them:
- Many general practice doctors are unaware of current mental health treatment guidelines.
- Inadequate mental health resources to provide best treatments.
- Too few professionals with training in providing mental health care to children.
- Barriers to treatment, including cost or the need to travel long distances.
- Stigma associated with mental illness, which may reduce families’ willingness to acknowledge a mental health disorder and seek treatment.
The HELP committee plans to hold additional hearings to address mental health issues. Other attention to the issues addressed at the hearing include a recent meeting in Washington, D.C. among professionals who conduct psychiatric clinical trials. They stressed the need to involve patients and families more in trial design and access, as well as to work with trial designers on mental health needs not currently being met.
The Substance Abuse and Mental Health Services Administration, a federal agency, recently announced several new funding grants to help individual groups facing mental health concerns including:
- A grant program for residential treatment of pregnant and postpartum women.
- A grant program to expand and sustain comprehensive community mental health services for children and their families, in order to improve behavioral health outcomes for children and youth with serious emotional disturbances, as well as improve the health and well-being of their families.
- A grant program to provide tribal and urban American Indian and Alaskan Native communities with tools and resources to plan and design a holistic, community-based coordinated system of care approach to support mental health and wellness for children, youth and families.
Read more about mental health on NewPublicHealth.
New Study Shows Latinos of Different Origins Can Have Different Diseases, Risk Factors
A review of a recent study, the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) that enrolled about 16,415 Hispanic/Latino adults, finds diversity among Latinos not only in ancestry, culture and economic status, but also in prevalence of certain diseases, risk factors and lifestyle habits. The study was done among Latinos living in San Diego, Chicago, Miami, and the Bronx, N.Y., who self-identified with Central American, Cuban, Dominican, Mexican, Puerto Rican, or South American origins.
- The percentage of people who reported having asthma ranged from 7.4 (among those of Mexican ancestry) to 35.8 (among those of Puerto Rican ancestry).
- The percentage of individuals with hypertension ranged from 20.3 (South American) to 32.2 (Cuban).
- The percentage of people eating five or more servings of fruits/vegetables daily ranged from 19.2 (Puerto Rican origin) to 55.0 (Cuban origin). Also, men reported consuming more fruit and vegetables than women.
- Women reported a much lower consumption of sodium than men among all Hispanic groups represented in the study.
- About 1 in 3 individuals had pre-diabetes, also fairly evenly distributed among Hispanic groups.
- Only about half of individuals with diabetes among all Hispanic groups had it under control.
A second study among the same population will start in October 2014 to reassess certain health measurements and understand the relationship between the identified risk factors during the first visit and future disease in Hispanic populations. Read more on health disparities.
Study: Acetaminophen During Pregnancy Tied to Increased Risk for ADHD, HKDs in Kids
Children whose mothers used acetaminophen during pregnancy are at higher risk for developing attention-deficit/hyperactivity disorder (ADHD)–like behavioral problems or hyperkinetic disorders (HKDs), according to a new study in JAMA Pediatrics. Researchers analyzed data on 64,322 children and mothers enrolled in the Danish National Birth Cohort from 1996 to 2002, finding that approximately 56 percent of the mothers reported acetaminophen use during pregnancy. Their children were 37 percent more likely to be diagnosed with an HKD, 29 percent more likely to be prescribed ADHD medications and 13 percent more likely to exhibit ADHD-like behaviors at age 7. Approximately five to six percent of babies born today will develop ADHD symptoms at some point in their lives. Jorn Olsen, MD, one of the study's authors and a professor of epidemiology at UCLA and at Aarhus University in Denmark, noted that the risk was relatively modest, but that “for women who are pregnant and who have not taken these drugs, I think that the take-home message would be a lot of the use of these particular drugs during pregnancy is not really necessary," according to Reuters. Read more on maternal and infant health.
Stigma Remains Powerful Barrier Impeding Mental Health Care for Many
The stigma surrounding mental health continues to remain a very real and very serious barrier keeping many people from seeking the health care they need, according to a new study in the journal Psychological Medicine. The analysis, from researchers at King’s College London and funded in part by the U.S. National Institutes of Health, combined the results of 144 studies including more than 90,000 people from around the world. Approximately 25 percent of people are estimated to have mental health problems, but only 75 percent of those in the United States and Europe seek treatment; delays in treatment are linked to worse outcomes for many mental health disorders, such as psychosis, bipolar disorder, major depression and anxiety disorders. The study pointed specifically to “treatment stigma” (the stigma associated with using mental health services or receiving mental health treatment) and “internalized stigma” (shame, embarrassment) as the most significant barriers, as well as concerns about confidentiality, wanting to handle the problem by themselves and not believing they needed help. "We now have clear evidence that stigma has a toxic effect by preventing people seeking help for mental health problems,” said Professor Graham Thornicroft, from the college’s Institute of Psychiatry and the study’s lead author. “The profound reluctance to be ‘a mental health patient’ means people will put off seeing a doctor for months, years, or even at all, which in turn delays their recovery." Read more on mental health.
Cold Winter Raises Concerns about Energy Insecurity
A new brief by researchers at the Mailman School of Public Health at Columbia University looks at energy insecurity (EI), which is measured by the proportion of household energy expenditures relative to household income. EI tends to impact low-income families in part because they often live in older homes and apartments that haven’t been constructed to conserve heat.
Key findings of the brief include:
- More than half of families affected by economic EI are living in poverty (below 100 percent of the federal poverty level) and about one third are extremely poor.
- Approximately half of all households facing economic EI are black/African-American and about one-third are white.
- Geographically, the largest proportion (46 percent) of children in households with economic EI resides in the South.
- Over half of families with economic EI are renters; 41 percent are homeowners.
According to the Mailman researchers, the main safety net program for EI, the Low-Income Home Energy Assistance Program (LIHEAP), covers only a fraction of the overall need. Of the estimated 10-15 million homes eligible for benefits in 2012, 5.5 million received assistance for reasons such as lack of awareness by people who could benefit and program budget cuts. Read more on poverty.
Many Adults with Depression Symptoms Have Not Consulted a Professional
A new report by the Substance Abuse and Mental Health Services Administration (SAMHSA) finds that close to 40 percent of the 15 million American adults who experienced a major depressive episode in the past year did not talk to a counselor or health provider. A major depressive episode is defined as a period of at least two weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had at least four of seven additional symptoms reflecting the criteria as described in the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of the Mental Disorders (DSM-IV). “This report shows that too many Americans still needlessly suffer in silence instead of reaching out to providers for help in getting them on the road to recovery through effective treatment and supports,” said Paolo del Vecchio, the director of SAMHSA’s Center for Mental Health Services. “We are raising awareness about the hope for recovery from these conditions, helping communities identify their behavioral health needs, and increasing education about access to treatment for all Americans through the Affordable Care Act and the new parity protections for insurance coverage.” Read more about mental health.
EPA Proposes New Safety Measures to Protect Farm Workers from Pesticide Exposure
The U.S. Environmental Protection Agency (EPA) has announced proposed revisions to the Worker Protection Standard to protect the nation’s two million farm workers and their families from pesticide exposure. The EPA is proposing significant improvements to worker training regarding the safe usage of pesticides, including how to prevent and effectively treat pesticide exposure. Increased training and signage will inform farm workers about their protections under the law. The EPA has also proposed that children under 16 be legally barred from handling all pesticides, with an exemption for family farms. The revisions are based on more than a decade of extensive stakeholder input by federal and state partners and from across the agricultural community including farm workers, farmers and industry. Read more on the Environmental Protection Agency.
IOM Report: More Evidence-Based Practices Needed to Help Treat and Prevent Psychological Disorders among Service Members and Families
Between 2000 and 2011, almost 1 million service members or former service members were diagnosed with at least one psychological disorder either during or after deployment, according to recent research by the Institute of Medicine (IOM). As a follow up, the U.S. Department of Defense (DOD) asked the IOM to evaluate the department’s efforts to prevent psychological disorders among active-duty service members and their families. That report was recently released.
The report includes recommendations on how the DOD can improve care.
Finding 1: DOD has implemented numerous resilience and prevention programs for service members and their families, but it faces a number of challenges, including an insufficient evidence base to support its interventions and a lack of systematic evaluation and performance measures.
Recommendation 1: By targeting resources to develop the evidence base and disseminate that evidence, DOD’s prevention efforts can be both more effective and cost effective.
Finding 2: There is a need for DOD to improve approaches for identifying and intervening with service members and their members who may already have or may be at risk for developing a psychological disorder.
Recommendation 2: DOD should dedicate funding, staffing and logistical support for data analysis and evaluation to support performance monitoring of programs for accountability and continuous improvement.
Finding 3: Screening, assessment and treatment approaches for psychological health problems are not always implemented between and within the DOD and the U.S. Department of Veterans Affairs (VA) in a consistent manner or aligned with the evidence base, which threatens the delivery of high-quality care and hampers evaluation efforts.
- There are opportunities to improve processes of training and evaluating clinicians, including the incorporation of continuing education and supervision; standardized periodic evaluation; and a greater emphasis on coordination and interdisciplinarity.
- The DOD and VA should invest in research to determine the efficacy of treatments that do not have a strong evidence base.
- Both departments should conduct systematic assessments to determine whether screening and treatment interventions are being implemented according to clinical guidelines and departmental policy.
- Accessible inter-department data systems should be developed to assess treatment outcomes, variations among treatment facilities and barriers to the use of evidence-based treatment.
- Read the complete report.
- Read a NewPublicHealth interview with Jonathan Woodson, MD, Assistant Secretary of Defense for Health Affairs about the National Prevention Strategy.
- Learn more about the state of mental health in the military from this infographic from the American Psychiatric Association embedded below.
A recent essay by columnist Nicholas Kristof of The New York Times looked at a critical problem faced by jails across the country, which often double as behavioral health treatment centers. For many inmates, mental health problems have been the significant factor in committing a crime, with some even purposely flouting the law in the hopes of getting into jail where they can get free treatment. As a result, the United States has a national inmate population where half of all male inmates and three quarters of all female inmates have a behavioral health condition.
Solutions are beginning to emerge, though critical problems remain. At a recent health initiatives forum convened by the National Association of Counties and held in San Diego, county health officials talked about the promise of the Affordable Care Act, which will allow jail health specialists to help enroll inmates in coverage in advance of their discharge to help continue care—behavioral and physical—outside of jail.
Read the full column here.
>>Bonus Link: Read NewPublicHealth’s coverage of the recent NACo Health Initiatives Forum.
While behavioral and physical health have generally been separate entities in the United States, new rules under the Affordable Care Act are bringing them together—both to reduce costs and to integrate care in millions of people who face behavioral and physical health issues.
Experts at last week’s Healthy Communities Initiative forum, convened by the National Association of Counties (NACo), and this week’s AcademyHealth National Policy Conference, meeting in Washington D.C., presented strategies for combining the two. Some pilot projects are beginning. The pace is picking up largely because many people now covered under the states that have created Medicaid expansion have a range of behavioral and physical health needs. They will benefit from integration because the two are often connected—for example, diabetes has been linked to depression—and because connecting the two can reduce health care costs and reduce the number of provider visits a patient has to make.
“Behavioral health is a driving force in why people don’t get where they want to be,” said Donna Skoda, Assistant Health Commissioner of Summit County, Ohio, who spoke at the NACo forum.
Several public health officers at the forum presented ideas of what works in their communities, including:
- Hiring nurses to be care providers to assess both behavioral and physical health needs
- Retraining behavioral health specialists, including psychiatrists, to use blood pressure cuffs and other medical equipment
- Integrating patient files with information on mental and physical health baselines and changes
- Opting, when possible, to deliver care in physical health offices rather than counseling offices, since physical practitioner clinics already have devices needed such as scales
Presenters at the AcademyHealth policy conference stressed cost savings. For example, Washington state will participate in a federal demonstration project for beneficiaries dually eligible for Medicare and Medicaid. Under the demonstration, the health plans will be responsible for a full range of services—including mental health; chemical dependency; long-term services and supports; and medical care—under a single capped rate.
“Integrated care needs to be the rule, not the exception,” said Charlene Le Fauve, a deputy director of the National Institute of Mental Health.
Le Fauve said new technologies can be an important factor in delivering care including mobile devices and internet tools, which can be used at provider offices, clinics, and in homes if communities provide those services.
Other ideas being funded include training community workers for brief interventions which may be able to keep many people with mental illness out of both the emergency room and the hospital. Phone intervention is also being studied, said Le Fauve.