Chapter 27 Behavioral Health in the Community

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Mental Health in Transition: Key Documents

• Healthy People 2010 (see Table 27.1) • National Health Promotion and Disease Prevention Objectives • Report of the Surgeon General on Mental Health • New Freedom Initiative – three impediments to provision of quality mental health care: – Stigma – – Unfair treatment limitations and financial requirements Fragmented mental health service delivery system Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Incidence and Prevalence

• Global problem • Mental illness accounts for >15% of mortality worldwide (WHO, 2007) • Higher rates in poor, poorly educated, and unemployed • Many are homeless and go untreated • Age affects the pattern of mental illness in a community • Gender differences in prevalence of certain mental disorders Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Substance Use and the CHN

• Continuum including abstinence, low-risk use, risk/hazardous use, harmful use and dependence (see Fig. 27.1) • CHN needs basic understanding of issues related to specific substance; clear idea of desired outcomes related to treatment or prevention program – – Trends of substance use across different populations and communities Differences between legal and illegal substance use – Consequences of substance use on community – Substance use from environmental perspective Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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Prevalence of Substance Use and Use Disorders

Alcohol: highest incidence of use in young adults (18 25 yrs) • Tobacco: decline over past decade but not consistent across age groups and genders • Marijuana: most frequently reported illicit drug • Cocaine: majority are males 18 to 25 yrs of age • Heroin: most >18 yrs and male • Meth, Ecstasy, and PCP • Prescription drugs: across all age groups; rise in college students Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question

Is the following statement true or false?

• The highest use of alcohol occurs in middle-aged adults. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer

• False – Young adults, ages 18 to 25 years, are the group with the highest use of alcohol.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Theoretical Frameworks

• Process theory: identify resources and structure needed to develop, implement, and evaluate • Effect theory: provides rationale for why intervention will work – – Determinant theory Intervention theory – – Impact theory Outcome theory • Public health prevention theory: level of prevention for program focus, type of intervention to use, and target population Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Determinants of Mental Health

• Complex • Numerous factors such as genetics, environment, societal frame of reference and context • Cultural beliefs • Expectations, standards, legal parameters • Process of adaptation as a source of stress – – Individual’s perception of stress Subsequent response Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Determinants of Substance Use Disorders

• Nature vs. nurture • Genetics plays a major role in development of alcohol dependence • Individual factors (associated with AUDs): high antisocial behavior, high impulsivity, major depression, social anxiety problems, history of childhood sexual abuse, hyperactivity, attention problems, seminal events • Environmental factors: influence of peers, lower socioeconomic status, partner use, substance use by family members Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question

Is the following statement true or false?

• Effect theory attempts to explain the rationale for an intervention.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer

• True – Effect theory provides a rationale for why an intervention will work.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Screening and Brief Intervention

• Routine screening – – – Brief Psychiatric Rating Scale (BPRS; see Fig. 27.7) Beck Depression Scale Montgomery Ashberg Depression Rating Scale (MADRS) • Screening for depression: Center for Epidemiologic Studies Depression Scale (CESD; see Fig. 27.8) and shorter version, the CESD-10 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Screening for Substance Use and SUDs

• Three levels: screening for actual consumption, screening for at-risk drinking, and screening for SUDs • Level of risk: based on level of consumption • Screening instruments – – Self-report: Michigan Alcoholism Screening Test (MAST); Drug Abuse Screening Test; CAGE questionnaire; Drug Use Screening Inventory (DUSI) Biological screens: urine, blood, hair, saliva, breath, and meconium • Positive screen: possible brief intervention Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Community-Level Interventions

• Community assessment and focus of intervention • Level of prevention • Mental health community interventions – – Integrative health assessment Factors include treatment history; personal life stressors; disturbances in sleep, appetite, or energy level without a rational explanation; complaints of chronic pain; history of abuse, trauma, substance use, and family history of mental illness Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Community Level Interventions (cont.)

• Mental health promotion – Anticipated outcomes – – – Risk-protective activities Life-sustaining activities Life-enhancing activities Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question

Is the following statement true or false?

• The CAGE questionnaire is a valid self-report tool to screen for substance use.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer

• True – Self-report tools such as the CAGE questionnaire are reliable and valid tools that can be used to screen for substance use.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

CHN & Community-Level Interventions

• Multifaceted role – – – – – Ability to access and use epidemiologic data Advocacy: increase client access to services, reduce stigma, and promote improved public understanding & improved services in community mental health; political involvement Education Case management, case-finding, referral Collaboration Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Substance Use & Community-Level Interventions

• Population-based screening programs • Governmental agencies as resources • Policy-based interventions • Mental health policy • Substance use policy Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Internet Resources

• Al-Anon Family Group Headquarters, Inc.:

http://www.al anon.org/index.html

• Mothers Against Drunk Driving (MADD):

http://www.madd.org/

• National Alcohol Screening Day:

http://www.mentalhealthscreening.org/events/nasd/inde x.aspx

• National Institute on Alcohol Abuse and Alcoholism (NIAAA):

http://www.niaaa.nih.gov/

• National Institute of Mental Health:

http://www.nimh.nih.gov

• Substance Abuse and Mental Health Administration (SAMHSA):

http://www.samhsa.gov/

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins