Caribbean Exploratory Research Center

1. Caribbean Exploratory Research Center 3rd Annual Health Disparities Institute Marriott Frenchman’s Reef St. Thomas, USVI October 21-22, 2010

2. Mental Health and Substance Abuse in the United States Virgin Islands October 21, 2010 JM Valmond, MS, MPH, University of Texas School of Public Health, Houston, Texas G Callwood, PhD, RN, Caribbean Exploratory Research Center, University of the Virgin Islands (UVI), St. Thomas, USVI

3. Objectives At the end of this presentation participants will be able to: 1.  Describe the mental health and substance abuse system of care in the United States Virgin Islands (USVI) 2.  Discuss issues and challenges impacting the mental health and substance abuse system of care in the USVI population 3. Explore strategies and opportunities to strengthen the mental health and substance abuse system of care for all segments of the USVI population

4. Background • The U.S. Virgin Islands are an unincorporated territory of the United States • Residents are U.S. citizens, but do not vote in U.S. presidential elections. • Population 111, 470 (2005 estimates, 2005 VI Household Income & Expenditure Survey) residing on the four main islands of St. Croix, St. Thomas, St. John and Water Island. • 76.2% Black, 13.1% White, 1.1% Asian American and 6.1% Other (2000 U.S. Census). • 47.6% Male, 52.4% female (2000 US Census)

5. Background (cont’d) • 33.2% report they are foreign born, of which the majority (92.2%) are from the Caribbean • 21.2% report race as Hispanic/Latino for St. Croix, 7.3% for St. Thomas • Of population 5 and older, 25.3% speak language other than English at home; for St. Croix and St. Thomas, the language most spoken is Spanish • Families living below the poverty level in 1999 was 28.7%, with St. Croix at 34.8%, St. Thomas at 23% and St. John at 14.8% 2000 US Census

6. USVI Public Health System Context/framework • US Department of Health and Human Services • “Achieving the Promise: Transforming Mental Health Care in America”-Commission on Mental Health (2003) • Healthy People 2010/2020 • Substance Abuse and Mental Health Services Administration (SAMHSA) • USVI Department of Health (DOH) • USVI Healthy People 2010/2020 • Division of Mental Health, Alcoholism and Drug Dependency Services

7. VI Healthy People 2010

8. VI Healthy People 2010

9. Mental Health and Substance Abuse System of Care in the USVI Professional Boards Virgin Islands Mental Health Planning & Advisory Council

10. USVI Department of Health (DOH) • Legal authority set forth in Virgin Islands Code, Titles 3 and 19; • Functions as both the state regulatory agency and the territorial public health agency for the U.S. Virgin Islands. • Responsible for regulation of health care providers and facilities, policy development and planning, as well as vital statistics for the population. • Direct responsibility for conducting programs of health promotion, protection and preventive medicine

11. USVI DOH (cont’d) • Organized into two major divisions – Public Health Services and Health Promotion & Statistics. • Unlike state health departments on the U.S. mainland the DOH provides health services in its community health centers territory wide. • Boards license and regulate health care professionals. • Employs over 600 • Budget of $ 73,931,617 million includes $36,187,883 in Federal Funds (Governor’s Budget, FY 2011)

12. Division of Mental Health, Alcoholism and Drug Dependency Services (DMHADDS) • Division within Public Health Services charged with establishing and administering programs designed to offer prevention and treatment intervention in the areas of substance abuse prevention, substance abuse treatment, mental health and residential services. • Goals: • To provide comprehensive prevention and treatment intervention services to clients, including children, who have mental challenges and who abuse substances ; • To foster self-management and wellness behavior that would promote and sustain recovery Source: DMHADDS

13. Division of Mental Health, Alcoholism and Drug Dependency Services (DMHADDS) Service sites: • St. Thomas St. Thomas Mental Health Clinic, Charlotte Amalie • St. Croix Christiansted Community Mental Health Clinic Frederiksted Mental Health Clinic • St. John Morris F. DeCastro Clinic, Cruz bay, St. John

14. Division of Mental Health, Alcoholism and Drug Dependency Services (DMHADDS) Clients served (FY 2009) • Served 667 clients in 4 clinics; 21 in methadone program (available on St. Croix only) • 264 seen in St. Thomas-St. john; 403 in St. Croix district • 51% female; 49% male • 71 % report non-Hispanic, and 17% Hispanic, 12% other • Approximately 16% under the age of 18 • Prevention services on St. Croix reached in excess of 800 youth with evidenced-based outreach programs • Schizophrenia, bi-polar disorder most frequent diagnoses seen in mental health clinics DMHADDS Reports

15. Division of Mental Health, Alcoholism and Drug Dependency Services Prevention/primary care services (Community Health Clinics): • Case management (1 case manager on St. Thomas, 4 on St. Croix to serve its two clinics, and none on St. John) • Crisis intervention • Individual, family, child, and group counseling • Medication management • Psychological testing and evaluation

16. Division of Mental Health, Alcoholism and Drug Dependency Services Prevention/primary care services (Community Health Clinics) (cont’d) • consultation • court reports • referrals (e.g.. HIV/STD/TB clinic, MH clinic, GYN, AA, NA) • evaluations for emergency commitments; • Opiate Treatment Program ( aka the Methadone Treatment Program)-screening, daily medication and group counseling

17. Division of Mental Health, Alcoholism and Drug Dependency Services • Long-term Residential Services • Eldra Schulterbrandt Residential Long-term Care Facility, St. Thomas-29 beds • New residential facility due to open (32-bed), St. Thomas, adjacent to Eldra Schulterbrandt Facility • Off-island placements Outreach Programs • School-based prevention programs • Presentations to work sites/other organizations by request • Community outreach services

18. Acute Care Two public hospitals provide acute inpatient mental health services • Juan F Luis Hospital-Psychiatric Unit, St. Croix • 8-bed unit, with average census of 1-3 • Top 5 conditions: chronic schizophrenia, bipolar disorder(manic phase), drug-abusers, suicides and situational depressed (possible bipolar) • Staffing of 2 Psychiatrists, 1 Psychologist, 6 RN (1 Certified Psych), 2 LPN, 4 CNA • Roy Lester Schneider Hospital and Medical Center-Neurological-Behavioral Unit, St. Thomas • 21-bed unit, with average census of 8-10 • Top 3 conditions: schizophrenia, bipolar, suicide

19. Other government agencies: • Department of Human Services (DHS)-Virgin Islands Behavioral Service/Youth Rehabilitation Center-residential treatment/programs for troubled youth • Department of Education (VIDOE)-referral of students by school counselors • Department of Justice (DOJ)-Residential Substance Abuse Treatment Program (RSAT) for inmates/referrals and court-orders • VI Department of Public Safety (VIDPS)-forensic psychology/data on substance related vehicular accidents/first responders/intervention with mentally ill and homeless

20. Private sector providers/services • Psychiatrists • Psychologists • Counselors/Counseling services • Psychotherapy • Residential services for adolescents-Seaview, St. Thomas

21. Community Based/non-profit organizations Programs/services: • St. Croix Unity Coalition- community substance abuse prevention • Council On Alcoholism and Drug Dependence (COAST)- community substance abuse prevention, St. Thomas • St. Croix Mission Outreach-residential and outpatient treatment, continuing care support groups, rental/utility/food assistance, care management for homeless and addicted • Ten Thousand Helpers of St. Croix-homeless center, biennial mental health conference, youth programs, hope and recovery for mentally ill • The Village Virgin Islands Partners in Recovery-halfway house, women’s after care, outpatient, EAP, Solutions Improvisation, Partners in Parenting for both mentally ill and substance abuse clients • Clear Blue Sky-clubhouse for mentally ill rejoining the community • Karen’s House-assisted living facility • Kidscope/Family Resource Center • Al-anon • Alcoholics Anonymous (AA) • Narcotics Anonymous (NA) • A.R.C.H-Better Choices for a Better Future (youth prevention programs)

22. Community Based/non-profit organizations Advocacy • Disability Rights Center of the USVI (legal rights/advocates for persons with disabilities, including mentally ill) • The Virgin Islands Alliance for Mental Health Consumers/Survivors, Inc. • The Virgin Islands Alliance for the Mentally Ill, Inc. • Ten Thousand Helpers of St. Croix, Inc. • Clear Blue Sky

23. DOH Public Health System Strengths Service Delivery/access: • Services provided in community health clinics allow for better access and care coordination • System of care involves the consumer or family in developing and implementing treatment plans • Services provided regardless of ability to pay • Committed staff, some trained in the recovery model of care (best practice model) • St. Croix prevention staff utilize CSAP six strategies for effective prevention and outreach Site visit Report

24. Issues and Challenges Impacting the Mental Health and Substance Abuse System of Care in the USVI • Alcohol remains the most commonly used substance among high school youth and adults • On average, 35% (compared to 48% for mainland US) reported use in the past 30 days (YRBS), with Hispanic males in grades 11 and 12 being most at risk (VIP SIG Needs Assessment Report, 2006) • Adult rates are similar to US mainland rates, around 46% compared to just over 50% for US • Schizophrenia seems to be the most commonly seen mental illness at USVI (RLS/JFL staff interviews) inpatient facilities • Suicide seems to be on the rise • Mentally ill homeless VIP-SIG Grant: Prevention Needs Assessment (2006)

25. Issues and Challenges Impacting the Mental Health and Substance Abuse System of Care in the USVI Public health sector: • Limited to no reliable data • Only basic services provided on a regular basis for adults with Severe Mental Illness (SMI) • Limited community-based, supportive services for children with Severe Emotional Disorder (SED). • Insufficient case management and outreach services • No recovery elements due largely to lack of resources needed to implement • 2009 Site Visit Report, Community Mental Health Block Grant Monitoring

26. Issues and Challenges Impacting the Mental Health and Substance Abuse System of Care in the USVI Public health sector (cont’d): • Difficult access to certain services due to cost and time constraints for inter-island travel • Levels of service different by island • Waiting lists for basic services • Staff shortages-psychiatrists, mental health staff at all levels, social workers • No cultural competency training program for service providers or mandated services for diverse sub-populations

27. Issues and Challenges Impacting the Mental Health and Substance Abuse System of Care in the USVI • Public Health Sector Funding • Total funding declined from 2007($8,568,163) to 2009 ($6,270,767) • Local funding increased ($4,822,166-$5,365,722) slightly; • Federal funds of $1,690,472 (FY 2011 Budget projections) • Medicaid not significant source of revenue due to Federal cap on Medicaid Title XIX programs

28. Issues and Challenges Impacting the Mental Health and Substance Abuse System of Care in the USVI Issues related to overall system of care: • Limited meaningful data for system oversight, planning and evaluation • Fragmented system of care • Lack of transitional programs from acute care to outpatient services and related support services • Serious gaps in services/continuum of services, to include suicide prevention and services for homeless mentally ill • Staffing (shortages, non-competitive salaries, professional development) • Dwindling funding for mental health and substance abuse 2009 Site visit report

29. Issues and Challenges Impacting the Mental Health and Substance Abuse System of Care in the USVI Challenges Transforming mental health care in the US Virgin Islands • Building capacity in the health care system, to include surveillance and dissemination of meaningful data for program planning and resource allocation • Building capacity in the community, to include trained staff and providers at all levels in the continuum of care • Making the service delivery system recovery oriented • Increased advocacy

30. Strategies and opportunities to strengthen the system of care for all segments of the population • Infrastructure for ongoing data collection, analysis and dissemination • A strategic plan focused on recovery and resilience throughout the life stages • Improved service delivery for children and adolescents • Stronger advocacy

31. Strategies and opportunities to strengthen the system of care for all segments of the population Data Infrastructure • Required to enhance capacity for data collection and management • Work with DOE and CDC to resume Youth Risk Behavior Surveillance (YRBS) in middle school and high schools • Increase utilization of Behavior Risk Factor Surveillance System (BRFSS) data 2007 Virgin Islands Epidemiological Profile

32. Strategies and opportunities to strengthen the system of care for all segments of the population Data Infrastructure (continued) • Develop and implement comprehensive surveillance system, to include data from the private sector, hospitals and related agencies provided services to the population • Conduct regular consumer surveys 2007 Virgin Islands Epidemiological Profile

33. Strategies and opportunities to strengthen the system of care for all segments of the population Strategic Plan: • Needs assessment to determine services for mental health and substance abuse prevention and treatment, to include the mentally ill homeless and dual-diagnoses (2000/2006) • Comprehensive evaluation to identify gaps in service delivery, such as coordination of discharge planning with the hospitals and transitional services to ensure continuity of care to reduce recidivism and promote recovery

34. Strategies and opportunities to strengthen the system of care for all segments of the population Strategic Plan (continued): • Increased outreach activities to promote services in the least restrictive setting and to provide support clients in their own environment • Include recovery and support services, such as housing, vocational rehabilitation, employment, and peer support for clients, to foster self-management and wellness

35. Strategies and opportunities to strengthen the system of care for all segments of the population Improved service for children and adolescents • Comprehensive, reliable needs assessment for children and adolescent mental health and substance abuse services • Strategic plan for children and adolescent services, to include suicide prevention and care, as well services across the continuum of care and use of technology to increase access • Trained staff at all levels • Increased screening for mental illness and substance abuse • Improved coordination with school counselors for prevention, early identification and treatment

36. Strategies and opportunities to strengthen the system of care for all segments of the population Advocacy: • Consent decree requires development of a 5-year plan • The plan should include Evidence-Based Practices (EBPs) (such as Assertive Community Treatment, Supported Employment, Supportive Housing, Cognitive Behavioral Therapy, Multisystemic Therapy, and Functional Family Therapy) • Promote consumer-and family-run organizations, peer assistance, recovery support, and self-directed care • Six goals set forth in “Achieving the Promise: Transforming Mental Health Care in America” can guide development of local goals

37. Strategies and opportunities to strengthen the system of care for all segments of the population Department of Human Services (DHS): • Initiative to develop a strategic plan for intergovernmental youth services systems • Comprehensive strategic plan to engage key stakeholders in the mental health, juvenile justice, and educational systems in implementing a coordinated and seamless network of services for children, adolescents and their families 2009 Site Visit Report

38. References Arria, AM and Anthony, JC (2000) Final Report: Alcohol and Other Drug-Related Health Needs of Adults Living in the USVI. USVI DOH Division of Mental Health, Alcoholism and Drug Dependency Services; 57pp Disability Rights Center of the Virgin Islands (2008) Working Toward An Effective Mental Health Care System In The United States Virgin Islands; 26pp http://www.governordejongh.com/budget/fy2010/FY2010-Executive-Budget.pdf. FY 2011 Executive Budget. Government of the USVI, Department of Health: Office of Minority Health (2003) Healthy Virgin Islands 2010: Improving Health for All; 124pp. Government of the USVI, Department Of Health: Division Of Mental Health, Alcoholism And Drug Dependency Services (2009) Community Mental Health Services Block Grant Monitoring Report September 22–25; Government of the USVI, Department of Health (2007) Virgin Islands Epidemiological Profile. 67 pp Pacific Institute For Research and Evaluation (2008) Summary of findings from the 2007 Virgin Islands Youth Risk Behavior Survey. USVI DOH Division of Mental Health, Alcoholism and Drug Dependency Services ; 62pp President’s Commission on Mental Health (2003) Final Report: Achieving the Promise: Transforming Mental Health Care in America. http://www.census.gov/census2000/pdf/usvifullprofile.pdf. US Census www.cia.gov/library/publications/the-worldfactbook. Virgin Islands University of the Virgin Islands. 2005 Household, Income and Expenditure Survey Pacific Institute For Research and Evaluation/Virgin Islands Prevention-State Incentive Grant (2006) Prevention Needs Assessment; A summary of social and health indicators related to adolescent substance abuse use in the Virgin Islands

39. Acknowledgements • Gloria Callwood, PhD, RN, Director-Caribbean Exploratory Research Center (CERC) • Doris Hepburn, MA, Director, Mental Health, Alcoholism and Substance Abuse and her staff • Najib Malik, RNC, Head Nurse, Psychiatric Ward, Juan F Luis Hospital, St. Croix, USVI • Desiree Bertrand, MSN, RN, Research Coordinator, CERC/Faculty (part-time), UVI, St. Croix, USVI • Jaslene Williams, MSW, Consultant/ARCH Institute • Noreen Michael, PhD, former Director-Health Statistics/Chief of Staff-UVI President • Theresa Byrd, DrPH, RN, Associate Professor for Health Promotion and Behavioral Sciences, UT School of Public Health, Houston, TX

40. Mental Health and Substance Abuse in the United States Virgin Islands Thank you!