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In observance of May is Mental Health Month, we speak to David Shern, PhD, senior science advisor at Mental Health America, and a member of American Public Health Association’s Mental Health Section. This year’s theme is “Mind your Health.” Shern talks about the importance of mental and overall health and ways to protect and promote mental wellness. He is interviewed by APHA staff member Lavanya Gupta.
What is the role of behavioral health in overall health and wellbeing?
We’ve come to really appreciate over the last several years, particularly since the production of the global burden of disease that behavioral health conditions, and by that I mean mental illnesses and substance use conditions, are quite disabling. In fact, in the United States, behavioral conditions produce more burden of disease than any other disease class. The reason for that is that they have an early age of onset; the median age of onset for behavioral health conditions is 14. So these are conditions of adolescence; typically the symptoms have developed two years earlier than that. We have traditionally been very poor at recognizing and treating these conditions, so that increases the rate at which they develop into life-long, chronic illnesses. Since they occur so early in life, they have immediate impacts on a person’s academic achievement-they’re right in the late to middle high school years-which subsequently cause a decrease in their occupational achievement, which of course compromises socio-economic status, places people in situations where they’re more likely to be under toxic stress and strain from lack of resources and flexibility of resources. So the effects of behavioral health conditions on the overall public health and wellbeing are profound and lifelong.
That’s great. Are their effective technologies for preventing mental health and substance use conditions?
There are effective technologies for both preventing and treating mental health and substance use conditions. The Institute of Medicine, in 2009, did a comprehensive review of the state of prevention and promotion technologies for mental, emotional and behavioral disorders, and concluded that we have a range of highly effective and well-studied interventions for both the prevention and promotion of behavioral health. The universal prevention interventions-things like the Visiting Nurse Partnership, which has been very, very well studied and for which we have longitudinal data, actually indicating multi-generational improvements in terms of overall health and wellbeing, decreased reliance on public assistance, decreased use of drugs, and more importantly decreased rates of child abuse and neglect. The Good Behavior Game, which is a first grade intervention, has 13-year follow up data indicating significantly increased rates of high school graduation and college attendance, speaking to the life-long effects of getting a launch in life. The Seattle Social Development project has 20 –year longitudinal data showing a significant decrease in terms of a number of public health outcomes, including rates of mental health symptoms 20 years following the interventions. We argue that these prevention interventions are the equivalent of mental health vaccines, because their effects are so long-lasting and affect such important areas of social functioning, which in turn affect the overall public health and wellbeing of the population. Similarly, we have interventions for adolescents, young adults, older adults, all of which have an evidence-based [method], but most of which are not implemented to the degree to which they could or should be to realize their benefit. And finally, we have a wide variety of treatment interventions which have shown to be effective- both pharmacotherapy and skill based behavioral health learning therapy- which are available for people who do become ill.
I really like the term “vaccine” when it comes to primary interventions for mental health. It’s really important for us to keep in mind that any kind of mental health illness can be as severe as any other physical illness that could be prevented by a physical vaccine. So I think it’s a great way to show a parallel mental health and any other kind of ailment that could affect your physical health, so that’s great.
I agree, using that comparison does really seem to help. Particularly when you’ve got these long-range outcomes that you can predict the implementation of the interventions. And something else that I’ve been trying to do is to stop using the distinction between mental health and physical health because I think as we understand more and more about the brain and how it develops and how it is influenced by genetics and also very importantly the environments in which we live and grow, it turns out that this distinction is really not helpful or really not true. These are very much physical health conditions and they manifest themselves both in terms of thoughts and emotions and motor behaviors, which we think of as things that are directly controlled by the brain, but also in terms of endocrine changes and immunological changes. All these systems work together to either promote health or illness. It’s kind of a subtle change, but I think that the degree to which we start to think of illnesses together rather than trying to draw this distinction between mind and body, would really help us pull our thinking together about working with whole people in whole environments.
Absolutely. Can you tell us a little bit more about the promotion of mental health on a community or school-based level?
As I mentioned a little earlier, there are large number of evidence-based interventions, many of which are school-based; increasingly, others that are pre-school based. I think that there’s a lot that we can do in terms of partnering with the early childhood education movement that seems to have really strong bipartisan support in our country, which is certainly appropriate, given how important those early developmental year are for a person’s life course. Earlier I mentioned the Good Behavior Game is very well studied and understood. The Seattle Social Development Project, Visiting Nurse Partnership; there’s a program called The Incredible Years; there’s another one called the Positive Parenting Program (PPP), which actually works directly with parents through either schools or primary care practices to help support and train parents in effective child rearing techniques, as well as including treatment interventions. The PPP program, again, very well studied, has a public education component, which helps alert new parents to the fact that some of the things they may be experiencing could be helped by some parent support- the use of support groups and a structured curriculum. So again, I would refer people who are interested to the 2009 Institute of Medicine Report, which does a terrific job of summarizing these issues. We also have some work that we’ve done with a collaboration between Mental Health America and the National Association of State and Health Program Directors, which is on the NASMHPD website, where we summarize many of these interventions and try to put these prevention technologies in sort of the overall context of health human and social development.
That’s great. So we’ve talked about primary interventions and educating parents, and also having school-based education to promote mental health and mental health awareness. What are our greatest challenges in behavioral health that you’ve observed in your career?
With pretty much all areas of healthcare delivery, I think the biggest challenges we have are, number one- implementing these interventions with fidelity. We actually have a large number of investments in our country in types of preventive activities, but as with many, many areas of human development, they are scattered across several components of the government, both state/local and federal, and then across departments within governments. So departments of juvenile justice work with kids who have started to develop behavioral problems within the juvenile justice system. Education of course is key. Health care- medical care and primary care for kids are key. So it’s kind of a complicated problem which we have the opportunity to deliver evidence-based treatments across a broad range of settings, in the full spectrum of the government, but we don’t really have an organized way to make sure those interventions are delivered with fidelity to the original design. And a second, closely related challenge is that we do not, at this point in time, have an organized financing strategy to promote and support these interventions. So it can be difficult to pay for them. Because of the traditional distinction between general public health and mental health that has been the case for our country, in terms of how our mental health systems and public health systems have kind of developed separately in many, many instances, there isn’t a recognized funding stream for overall behavioral health, or one that is coordinated such that the activities that occur in the different parts of government could be better related to one another. So if I had to highlight the two major challenges, one is implementing with fidelity, the evidenced-based that we have, and the second is having a sustainable financing mechanism to both help guide strategically our investments in prevention, and provide the resources necessary to make sure that these evidence- based practices are delivered.
You bring up some excellent points. So David, I’d like to round this out by asking you to tell us a little more about what May is Mental Health Month is about, and what this year’s theme really captures.
May is Mental Health Month is an initiative that was started by Mental Health America when it was called the National Mental Health Association over 60 years ago. It’s to try to bring increased public awareness to the importance of mental health, and increasingly, addiction conditions- substance use conditions- on the overall health and wellbeing of the population. This year’s theme is “Mind Your Health,” and it resonates to many of the themes that we’ve talked about today, in terms of what we know, we can do personally, or as communities or as society, to try to promote the development of strong mental health and prevent the development of mental illnesses and substance use conditions. So on the Mental Health America website, there is a link to Mental Health Month, and a large number of educational materials that are available to download that deal with all the aspects of both the treatment and prevention of mental illnesses as well as substance use conditions, and additionally the promotion of good mental health like good general health. We think about having stamina and the ability to exercise without getting overly tired, the ability to respond to stressful situations and return to normal, and when we think about mental health, we need to think about it in the same way- that we can develop strong mental health which gives us increased resilience to deal with the adversities that we experience in life, to concentrate better, to be more productive, to be more emotionally well balanced. So it’s important that when we think about the overall health of our population, we think not only about preventing illness, which of course is critically important, but also promoting strength and well being, and those are some of the main themes for May is Mental Health Month this year.
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