Chapter 27 Behavioral Health in the Community

1. Chapter 27Behavioral Health in the Community

2. 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

3. 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

4. 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

5. 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

6. Question Is the following statement true or false? • The highest use of alcohol occurs in middle-aged adults.

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

8. 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

9. 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

10. 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

11. Question Is the following statement true or false? • Effect theory attempts to explain the rationale for an intervention.

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

13. 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

14. 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

15. 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

16. Community Level Interventions (cont.) • Mental health promotion • Anticipated outcomes • Risk-protective activities • Life-sustaining activities • Life-enhancing activities

17. Question Is the following statement true or false? • The CAGE questionnaire is a valid self-report tool to screen for substance use.

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

19. 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

20. Substance Use & Community-Level Interventions • Population-based screening programs • Governmental agencies as resources • Policy-based interventions • Mental health policy • Substance use policy

21. 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/index.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/