Friday, April 4, 2008

The view from SAMSHA: What do Children (and Adolescents) Need

This week, I was fortunate to have the opportunity to hear Terry Cline PhD talk at Judge Baker Children's Center, as the penultimate speaker in a series that I discovered much too late in the year.  The room was packed to hear this Judge Baker alumnus speak of the role of the Federal government in facilitating the care of children with mental health problems in America.
He has been at SAMHSA for 14 months, after several years as Commissioner of Health or Mental Health (or both) in Oklahoma. His roots, however, were in home based mental health services; he used to be at Cambridge Youth Guidance Center and his first job was providing home based therapy in Cambridge and Somerville. He remembered that his training didn’t prepare him for the level of violence that his clients would live with on a day to day basis and the impact of poverty on the lives of families. Every day, he would walk by 15  families who would have benefited from his service on the way to the home of one family that he was able to serve.  This experience has informed his career as he has risen through the ranks.

He feels that the health care system that we have now is unsustainable, and that the new system will be different. The opportunity now is to shape the health care system to include behavioral health as a key component.  He pointed out that the challenges are not new: most are familiar to folks in the system for 30 years.  Therein lies the challenge.  To quote 
David Satcher, "The gap between what we know and what we do in public health is lethal to Americans, if not the world”  

He made a view points about SAMHSA:
  • Vision: A life in the community for everyone.
  • Mission: Building resilience and promoting recovery using a public health approach.
He used the old story of the townspeople who exhausted themselves rescuing drowning people from  the stream, before that someone had the idea of going upstream and checking out what was going on.  He sees the problem as systemic: The health care system provides incentives and rewards for treating acute illness, and has led us to a crisis management system, especially in mental health and substance abuse.  He thinks that we need to focus on  Prevention as much as Treament, and to reemphasize Recovery (much along the lines of the Chronic Disease model)

He then sounded themes that we have heard in the context of Rosie D:
  • Need to emphasize the connection between primary care and behavioral health providers to maximize the effectiveness of our workforce, and to focus our interventions "upstream".
  • Neeed to bridge the scientific community and the "community care community" to bolster the evidence base, which is often lacking.
  • We need to integrate mental health services with the rest of the community that is caring for the child.
If we can integrate these services, we will succeed, by developing a public health approach that drives us toward the children. If we don’t do this, the system will fail.

He cited the data that is driving this push:
  • ACE study: Early trauma adversely impacts lots of adult outcomes.  Big time.
  • NASMHPD Study: Serious mental illness takes 25 years off your life.  Really.
  • ½ of mental illness starts by age 14.
  • ¾ of mental illness start by age 21
  • 1/10 of  American youth will have major depressive episodes.
  • In the US.  23 million people are in need of services and 2.5 million receive services.

What works:

System of care make a difference:  At the Federal level, the Children’s Mental Health Initiative has tripled expenditures, but it is still only a drop in most State budgets.  Kids involved in these demonstration initiative are referred in through schools and agencies throughout the country and show better behavior and fewer juvenile justice problem.  The Administration has asked for an increase of $12 million for next year.

There is an ambivalence about substance abuse: We value medications and at some level, attach social value to drug use.   Still, our current initiatives have led to a 24% decrease in use of illicit drugs over the past 5 years. (  MJ, methamphetamine, cigarettes, alcohol )

We are starting the conversation to change the norm:  “A Day in the Life of an Adolescent” is a report that apparently translates the rates into reality. On any given day,  8000 teens take their first drink, and 4300 using their first drug. Also, he pointed out that prescription drug abuse is growing. We still have work to do.

He is very excited by the publication of new report,
PROMOTION AND PREVENTION IN MENTAL HEALTH: Strengthening Parenting and promoting resiliency that he thinks will be very helpful in moving the discussion forward.
So, how do we engage in prevention, or "move upstream"?
1) We need to going out to the schools: Headstart,  Child welfare, schools-  all must be engaged in the discussion.
2) W need ncouraging screening within the system.  (As we are doing as part of the Rosie D remedy).  Now that the Federal government has approved codes for SBIRT, we need to encourage its use.  
3) We need to improve access to services through primary care.
4) We need to recognize our allies and work with HRSA and other parts of the Federal System.
5) Sees SBIRT screening as a good thing. Should be done in Emergency Room.
So, how do we encourage recovery?.  Some of that is mantaining the relationships that make this all possible.  SAMHSA has been advocating for the involvement of families and youth in the design and delivery of systems. 

He also sees many challenges before us:  
  • We need a national initiative to address ethnic disparities in mental health care. There is lots of great work out there, but it needs to be pulled together
  • 32,000 people across the country commit suicide each day.   This must change.
  • At least 1/3 of incarcerated people have mental illness.   How do we deal with this?
  • Many feel that it costs too much to treat mental illness. Untreated mental health conditions costs all of us.
Overall, he was upbeat, optimistic and sees the Federal government as a spark for change at the state and local level.  I did not hear much in the way of specifics that will break down the system-  he doesn't see the Federal government's role as telling those of us in the field what to do.  He did, however, send a clear message that, whichever administration is in power, mental health and substance abuse treatment will be seen as important issues that need local solutions.  Rosie D may give Massachusetts the opportunity to lead the way.

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