Behavioral Health:
Public Health Challenge
Public Health Opportunity
Pamela S. Hyde, J.D.
SAMHSA Administrator
New Orleans, LA • January 25, 2012
MAKING THE CASE
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BEHAVIORAL HEALTH: AMERICA’S #1 PUBLIC
HEALTH CHALLENGE
GLOBAL & DOMESTIC IMPACTS
CHANGING THE HEALTH CARE FIELD
BEHAVIORAL HEALTH IS ESSENTIAL TO
HEALTH
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By 2020, mental & substance use disorders (M/SUDs) will
surpass all physical diseases as a major cause of disability
worldwide
One-half of U.S. adults will develop at least one mental
illness in their lifetime
• U.S. 2006: M/SUDs were 3rd most costly health condition behind
heart conditions and injury-related disorders
• Mental illness and heart diseases alone account for almost 70
percent of lost output/productivity
BEHAVIORAL HEALTH IMPACTS
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 2+ million Americans report
mental/emotional disorders
as the primary cause of their
disability (per CDC)
 Depression is the most
disabling health condition
worldwide; SA is # 10
 M/SUDs: 24 percent of
pediatric primary care office
visits & almost ¼ of all adult
stays in community hospitals
12
10
8
6
4
2
0
Years Lost Due to Disability in Millions (High-Income Countries –
World Health Organization Data)
PREMATURE DEATH AND DISABILITY
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 People with M/SUDs are nearly 2x as likely as general population to die prematurely, often
of preventable or treatable causes
 BH conditions lead to more deaths than HIV, traffic accidents + breast cancer
 More deaths from
suicide than from HIV
or homicides
 Half the deaths
from tobacco use are
among persons with
M/SUDs
5,000 deaths each
year attributable to
underage drinking
CDC, National Vital Statistics Report, 2009
10 Leading Causes of Death, United States
2008, All Races, Both Sexes
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RANK
ALL AGES
1.
Heart Disease:
616,828
2.
Malignant Neoplasms:
565,469
3.
Chronic Low Respiratory Disease:
141,090
4.
Cerebro-vascular : 134,148
5.
Unintentional Injury: 121,902
6.
Alzheimer's Disease:
82,435
7.
Diabetes Mellitus:
70,553
8.
Influenza & Pneumonia:
56,284
9.
Nephritis:
48,237
10.
Suicide:
36,035
WISQARSTM
Produced By: Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC
Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System
TOUGH REALITIES
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AGE 14-17
AGE 18 AND ↑
HAD SERIOUS THOUGHTS OF SUICIDE
2.9 million, 13.8%
(2009)
8.7 million, 3.7%
(2010)
MADE A PLAN
2.3 million, 10.9%
(2009)
2.5 million, 1.0%
(2010)
ATTEMPTED SUICIDE
1.3 million, 6.3%
(2009)
1.1 million, 0.5%
(2010)
DIED BY SUICIDE
>1,000 (2008)
>35,000 (2008)
MISSED OPPORTUNITIES = LIVES LOST
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77 percent of individuals who die by
suicide had visited their primary
care doctor within the year
45 percent had visited
their primary care
doctor within the month
18 percent of elderly patients visited their primary
care doctor on same day as their suicide
THE QUESTION OF SUICIDE WAS
SELDOM RAISED…
DAILY DISASTER OF UNPREVENTED AND
UNTREATED M/SUDs
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Any MI:
45.9 million
SUD:
22.1 million
Diabetes:
25.8 million
Heart Disease:
81.1 million
Hypertension:
74.5 million
39.2 %
receiving
treatment
11.2 %
receiving
treatment
84 %
receiving
treatment
74.6 %
receiving
screenings
70.4%
receiving
treatment
CHRONIC DISEASES: GLOBAL IMPACT
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World Economic Forum:
Global economic impact of 5 diseases could
reach $47 trillion over the next 20 years
MH will account for $16 trillion – a third of cost
Cancer
Diabetes
Mental
Illness
Heart
Disease
Respiratory
Disease
ECONOMIC IMPACT ON AMERICA
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Estimated total societal
cost of substance abuse
in the U.S. is $510.8
billion per year
Mental disorders:
~$94 billion in lost
productivity costs
per year
THE
ECONOMY
Alcohol and drug abuse
& dependence: ~ $263
billion in lost
productivity costs per
year
Economic costs of
mental, emotional,
and behavioral
disorders among
youth ~ $247 billion
IMPACT ON PHYSICAL HEALTH
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 MH problems increase risk for physical
health problems & SUDs increase risk for
chronic disease, sexually transmitted
diseases, HIV/AIDS, and mental illness
 Adults with SMI have shortened life spans
and high co-morbidities
•
•
69 percent report at least one medical disorder
83 percent are overweight or obese
 Cost of treating common diseases higher
when a patient has untreated BH problems
•
•
•
Hypertension – 2x the cost
Coronary heart disease – 3x the cost
Diabetes – 4x the cost
 M/SUDs rank among top 5 diagnoses
associated with 30-day readmission; one
in five of all Medicaid readmissions
•
•
12.4 percent for MD
9.3 percent for SUD
Individual Costs of Diabetes Treatment for
Patients Per Year
$300,000,000
$250,000,000
$200,000,000
$150,000,000
$100,000,000
$50,000,000
$0
With behavioral health With diabetes alone
problems and diabetes
IN LOUISIANA…..
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 Of persons 12 or older in LA:
•
•
•
7.2% (259,000) used an illicit drug in the past month, vs.
8.4% nationally
2.9% (105,000) abused or were dependent on illicit
drugs, vs 2.8% nationally
7.0% (253,000) abused or were dependent on alcohol,
vs 7.4% nationally
 Of persons 18 or older in LA:
•
•
•
19.7% had any form of mental illness, equal with the
national average
4.8% had serious mental illness, vs. 4.6% nationally
3.1% had thoughts of suicide, vs. 3.7% nationally
 Providers
•
•
163 total SA treatment facilities, 119 were outpatient
158 total MH facilities, 78 were outpatient
Based on 2008 to 2009 National Survey on Drug Use and Health
(NSDUH) data.
IMPACT OF TRAUMA
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 Childhood trauma is extensive
•
•
•
> 6 in 10 U.S. youth have been exposed to violence within the past year
Nearly 1 in 10 injured
695,000 children were victims of maltreatment in 2010
Adverse childhood experiences (ACEs) are associated with MI,
suicidality, substance abuse, and physical illnesses
•
•
ACEs = physical, emotional, and sexual abuse; family dysfunction, disasters and
their aftermath, poverty, domestic violence, events leading to involvement with
criminal justice or child welfare systems, neighborhood disorganization
Potentially explain 32.4 percent of M/SUDs in adulthood
Brain impacts: chronic acute stress in early childhood can lead to:
•
•
•
Future health problems (including depression & other BH problems)
Damage to hippocampus
Smaller physical size of developing brain
PREVENTION WORKS
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2009 IOM Report Preventing Mental, Emotional, and
Behavioral Disorders among Young People: Progress &
Possibilities
• Half of all adult mental, emotional and behavioral (MEB) disorders
were first diagnosed by age 14 and three-fourths by age 24
• MEB disorders among youth as commonplace as a fractured limb
• Individual, family and community risk and protective factors can
be addressed and are effective
• Common, early, consistent, multi-sector, continuous, communitybased public health approaches work
• Environmental, policy, culture and individual approaches work
TRAUMA & JUSTICE:
Homelessness
~ 46 percent of people who are homeless have a mental
illness; 64 percent have an alcohol or substance use
disorder
Among inmates who had MH problems, 13 percent of
state prisoners and 17 percent of jail inmates said they
were homeless in the year before their incarceration
Providing housing for persons with mental illnesses who
are homeless reduces criminal justice involvement by 38
percent (jail days) and 84 percent (prison days)
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TRAUMA & JUSTICE:
Jail Diversion
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> Half of all inmates have MH problem; 6 in 10 have SA
problem; one-third have both
When done right, jail diversion works:
● Divertees use less alcohol and drugs (53 percent at 6 months)
● Have fewer arrests after diversion compared to 12 months
before (2.3 vs. 1.1)
● Fewer jail days (52 vs. 35)
Meets community needs: 3 out of 4 SAMHSA jail
diversion programs keep operating after federal funding
ends
IN AN ENVIRONMENT OF CHANGE
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Federal
Domestic
Spending
EMERGING
SCIENCE
State
Budget
Declines
Health Reform
THE UNINSURED
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 Uninsured population – 37.9 M (<400% FPL)
• 18 M Medicaid eligible
• 19.9 M Health exchange eligible
• 11.02 M (29 percent) have behavioral health conditions
 Among Medicaid eligible population (133% FPL & below)
• 7.0 percent with a serious mental illness
• 14.2 percent with a substance use disorder
 Among exchange eligible population (134% - 399% FPL)
• 6.0 percent with a serious mental illness
• 14.6 percent with a substance use disorder
HEALTH REFORM: AFFORDABLE
CARE ACT
 Major drivers
•
•
•
•
More people will have insurance coverage
Medicaid will play a bigger role
Focus on primary care and coordination with specialty care
Major emphasis on home and community based services
and less reliance on institutional care
• Rethink what is offered as a benefit
• Outcomes: improving the experience of care, improving the
health of the population and reducing costs
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HEALTH REFORM: AFFORDABLE
CARE ACT
 Dual disorders the expectation, not the exception
•
•
•
50 percent Medicaid beneficiaries w/ disabilities also have psychiatric
illness
Annual Medicaid per capita health costs three to four times higher for
disabled beneficiaries with co-occurring BH condition
Dual eligibles represent 40 percent Medicaid spending
 Risk-based comprehensive managed care
•
•
66 percent Medicaid beneficiaries enrolled now
80 percent predicted for 2014
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WHAT’S NEXT?
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 Medicaid expansion & health exchanges – 1/1/14
 Simplified Medicaid eligibility
 Enrollment
 Essential health benefits (state choices)
 More primary/behavioral health integration
 Increasing parity
BEHAVIORAL HEALTH –
Public Health or Social Problem?
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Public
Health
Social
Problem
TRAGEDIES
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Grand Rapids, MI
2011 – 8 Lost
Tucson, AZ
2011 – 6 Lost
Virginia Tech, VA
2007 - 33 Lost
Red Lake Band of Chippewa,
MN, 2005 – 10 Lost
Asher Brown
2010 – 1 Lost
13 yrs old
West Nickle Mines School, PA
2007 – 6 Lost
Columbine High School, TX
1999 - 15 Lost
FROM EVENTS TO ASSUMPTIONS
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Individual Blame
• Misunderstanding
• Prejudice
• Discrimination
• Moral judgment
• Social exclusion
LEADING TO
INSUFFICIENT RESPONSES
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Increased
Security &
Police
Protection
Tightened
Background
Checks &
Access to
Weapons
Legal
Control of
Perpetrators
& Their
Treatment
More Jail
Cells &
Homeless
Shelters & JJ
Facilities
Institutional
/System/
Provider
Oversight
WHAT AMERICANS KNOW
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Most Know or Are Taught:
• Basic First Aid and CPR for physical health crisis
• Universal sign for choking; facial expressions of
physical pain; basic terminology to recognize blood
and other physical symptoms of illness and injury
• Basic nutrition and physical health care
requirements
• Where to go or who to call in an emergency
WHAT AMERICANS DON’T KNOW
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Most Do Not Know and Are Not Taught:
• Signs of suicide, addiction or mental illness or what to
do about them or how to find help for self or others
• Relationship of behavioral health to individual or
community health or to health care costs
• Relationship of early childhood trauma to adult
physical and mental/substance use disorders
SO, HOW DO WE CREATE . . .
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A national dialogue on the role of BH in public life
With a public health approach that:
• Engages everyone – general public, elected officials,
schools, parents, community coalitions, churches, health
professionals, researchers, persons directly affected by
mental illness/addiction & their families
• Is based on data, facts, science, common
understandings/messages
• Is focused on prevention (healthy communities)
• Is committed to the health of everyone (social inclusion)
HELP US CHANGE THE CONVERSATION!
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