A Field Trip: Resident's Day at the State House.

Wow.  The Residents of the Massachusetts AAP organized a fantastic program for Residents Day at the State House, and I got to go.  We got to hear Jack Shonkoff talk to us about how science and policy interact;  John McDonaugh talk about politics; and watch a group of really energized residents go out and talk to their legislators.  Let me try to capture some of what they had to say:

Jack  was superb, talking about his transition from scientist to policy maker, describing his journey with his usual brilliance.  I took lots of notes, but his advice essentially could be summed up in three points;

• TEACH DON”T PREACH:  We have to close the gap between what we know and what we do, by being smarter about how we bring the science to the table.  Teachers know that they have to meet their students "inside their own heads"- that is the basis of adult learning theory.  He is working with a group called  The Frameworks Institute, which has developed a wonderful rubric for learning about the Frames that guide our thinking and finding language that communicates what we are trying to say.
  
• EXPLAIN DON”T COMPLAIN.  It is easy to complain-  by working on policy, we acknowledge that the boundaries of pediatrics need to extend beyond the audience, if we are going to make a difference for children.  He made a point that others made throughout the day;  we are at our most effective when we are knowledge brokers, working with advocates for the benefit of children.
  
• RELATE DON”T BERATE.  Politics is all about building relationships.  In particular, with folks that we sometimes think of as "not like us".  Almost everyone cares about children, but there are a wide range of beliefs around how that is best done.  (As most of us docs know from the practice of medicine)  We as pediatricians need new partners:  Change happens when we make the relationships happen.
  

There's more-  I will try to work it into the blog later.  Check out his stuff at Harvard: The Developing Child,  Jack is where we all need to be.

Taking the Long View: What is going on around the country?

My Academy has a couple of interesting things in it websites for those of us embroiled in mental health reform;  please keep in mind that we are actually doing pretty well.  The AAP has given awards to 10 Chapters for their efforts in changing the paradigm for children's mental health care in their states.  Check it out here!  Chapter efforts include building local networks of pediatricians and mental health providers, improving communication and coordination between statewide profession organizations, needs assessments in major urban centers, creating resource directories and promoting  “dialogues in mental health in primary care” meetings between pediatricians, family practitioners, child psychiatrists, and community mental health providers.  As I read through the list, I was impressed by the commitment of pediatricians to address this problem, and how the rest of the country is adopting many of the same techniques that we have used in Massachusetts to get us to the cusp of major system change.  Whenever I get frustrated at the pace of change in Massachusetts, I need to take a look around and realize how long it has take to get us to here.

Second, is a really interesting article from about 4 years ago that looked as mental health service utilization and mental health needs in 13 states from a parental perspective.  They showed that service utilization is not simply predication by need or demographics.  In California, the rich folks get more services than do the poor folks.  In Massachusetts, the opposite is true.  " In Alabama and Mississippi, as well as in the states with the lowest rates of unmet need (Colorado, Massachusetts, and Minnesota), the opposite is true: children from low-income families are much more likely to receive any mental health service than children from high-income families."  Despite Rosie D., Massachusetts frequently does mental health services better than the rest of the country.

Doesn't get us off of the hook.  But somehow, I find it comforting.

Save the Date and Watch PBS

Please come to the Worcester Mental Health Forum on May 2, 2008.   Also, note that on April 8, 2008, PBS will air another special: The Medicated Child.   I just read the transcript, and it looks worthwhile;  pointing out how little we know about how mental illness works in children.  Food was thought as we build the new system.

From the MCH Listserve

1. BRIEF PRESENTS NATIONAL DATA ON MEASURES OF ADOLESCENT MENTAL HEALTH

The Mental Health of Adolescents: A National Profile, 2008 highlights existing national data about adolescent mental health status, assesses shortcomings of current data, and offers recommendations to address these shortcomings. The brief, produced by the National Adolescent Health Information Center at the University of California, San Francisco, with support from the Maternal and Child Health Bureau, reviews definitions of mental health and describes methods for assessing mental health status. To describe the prevalence of mental health problems, the authors organize the findings as follows: global estimates of behavioral and emotional problems, estimates of specific disorders, suicide, and utilization of mental health services. A conclusion, national data sources cited in the brief, and references are provided.
The brief is intended for use by health professionals, policymakers, educators, and others in strengthening systems that monitor the mental and emotional health of young people at national, state, and local levels. The brief is available at Brief.

Couple that with this, from the Journal of Adolescent Health:

Mental health and substance abuse 

Trends in the six objectives in this area mostly show modest or no improvement. The suicide rate for younger and older adolescents remains essentially unchanged, as does the percentage of adolescents who report suicide attempts that require medical attention. Trends in the two substance use objectives—binge drinking and marijuana use—show fairly small decreases. The midcourse review shows modest improvement in the two remaining objectives: the proportion of children and adolescents with disabilities who are reported to be sad, unhappy, or depressed, and the proportion of children with mental health problems who receive treatment. If these trends continue, only the last objective will meet its 2010 target.

Must be Monday;  lots of work to do.

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.

I've been a little tired...: Thoughts after responding to an RFI

So, as it used to say on the top of the blog, the Worcester Mental Health Network's Response to the the EOHHS Request for Information went in at 1:30 PM EDT on April 1, 2008. 68 questions, many of which I couldn't answer, we considered, and discussed by our group, and I think that it is fair to say that the Central Massachusetts voice was heard. Also, I sang four concerts over the weekend, and by Tuesday night was pretty tired. I guess I took a breather on the blog after that. I was a little tired.

So what now?

I have a few things I want to post. I had the opportunity to heard the Administrator of SAMSHA talk on Wednesday, and I took copious noted that I should be posting later today. The Worcester Mental Health Network Steering Committee met on Wednesday, and formulated our action plan for the spring. I'll write some about that. And, I have some more patient stories that I hope can inform our efforts that I need to pull together. So, stay tuned.

Side comment: Gershwin is fun!

When not doctoring, I actually sing in the Providence Singers.  Take a look at this cool slideshow from our recent Concert.  One more chance to see us do Gershwin this week. 

The Providence Singers Take Gershwin on the Road