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Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health

  • Date: Nov 18 2014
  • Policy Number: 201415

Key Words: Mental Behavioral Health, Health Care, Health Services, Social Determinants of Health

The behavioral health status of the US population is exceedingly poor, as reflected in high rates of diagnosable mental illnesses, substance use disorders, and degradation of human capital. The lifetime prevalence rate of any mental illness or substance abuse conditions is about 50%, nearly double the rate of other developed nations. Behavioral health is an essential component of overall health and well-being, and its currently compromised status requires an urgent and explicit public health response. This policy statement documents the critical public health problem represented by the poor behavioral health status of the US population, its disproportionate prevalence among vulnerable populations, and its persistently negative impact on human capital. Research on the social determinants of behavioral health, along with increasing acknowledgment of the evidence by policymakers, provides a basis for public health strategies to improve the nation’s behavioral health. Evidence-based approaches for improving behavioral health have been identified and represent a suite of strategies for increasing resilience and reducing levels of environmental trauma. This policy statement calls for systematic implementation of a broad public health strategy that integrates behavioral health promotion, prevention, and treatment to improve the behavioral health of the US population.      

Relationship to Existing APHA Policy Statements
A number of APHA policy statements address specific behavioral health issues, often within specific populations. This proposed policy statement addresses the problem of poor behavioral health in the US population in broad terms, promotes a general theory of the etiology and escalation of the problem, and recommends action steps toward a comprehensive approach to improving behavioral health. The following APHA policy statements address specific behavioral health issues:  
•    APHA Policy Statement 9604: Accountability in the Provision of Health and Welfare Services to Persons with Mental Illness
•    APHA Policy Statement 9701: For Nondiscriminatory Coverage of All Mental Health Treatment
•    APHA Policy Statement 200029: The Need for Mental Health and Substance Abuse Services for the Incarcerated Mentally Ill
•    APHA Policy Statement 200120: Support for Culturally and Linguistically Appropriate Services in Health and Mental Health Care
•    APHA Policy Statement 20079: Building a Public Health Infrastructure for Physical Activity Promotion
•    APHA Policy Statement 200911: Public Health’s Critical Role in Health Reform in the United States
•    APHA Policy Statement 201011: Reforming Primary Health Care: Support for the Health Care Home Model
•    APHA Policy Statement 201013: American Public Health Association Child Health Policy for the United States
•    APHA Policy Statement 201111: Prioritizing Noncommunicable Disease Prevention and Treatment in Global Health
•    APHA Policy Statement 201310: Solitary Confinement as a Public Health Issue
•    APHA Policy Statement 201311: Public Health Support for People Reentering Communities from Prisons and Jails
•    APHA Policy Statement 201312: Defining and Implementing a Public Health Response to Drug Use and Misuse

Problem Statement
A population’s behavioral health status affects numerous essential dimensions of a healthy society. In addition to the health care system, these dimensions include academic and occupational achievement, economic productivity, social welfare expenditures, public safety, and criminal justice systems. Good behavioral health enhances human capital and social structure; poor behavioral health erodes the population’s human capital and the functioning of its communities and institutions. Given the broad societal effects of behavioral health, it is imperative to address the problem of the poor behavioral health status of the US population and to identify and champion strategies that will dramatically improve behavioral health status and consequently the overall health and well-being of the nation. (While the focus of this policy is the improvement of behavioral health status in the United States, it is important to recognize the need for behavioral health promotion and treatment across the globe. Attention to the problem in the United States in this single policy is not intended to ignore or diminish an understanding of the worldwide need for reductions in stigma and increases in prevention and treatment of behavioral health problems.)

What is behavioral health? The concept of “behavioral health” expands the term “mental health” to include substance use, behaviors, habits, and external forces that contribute to mental or emotional well-being. Behavioral health is “a state of mental/emotional being and/or choices and actions that affect wellness. Behavioral health problems include substance abuse or misuse (i.e., alcohol and drug addictions), serious psychological distress, suicide, and mental and substance use disorders.”[1] Behavioral health status is an essential component of overall health and well-being and reflects the degree to which people’s thoughts, emotions, and actions enable them to fully participate in and enjoy the important functional roles in life. Mental illnesses and addictions reflect behavioral health disorders that negatively affect functioning and include both diagnosable mental illnesses and subclinical disturbances that impair full social participation.  

Behavioral health disorders (mental and emotional illnesses and addictions) account for nearly one third of the overall disease burden in the United States, eclipsing all other single health conditions.[2] The lifetime prevalence of any behavioral health disorder in the United States is approximately 50%, nearly double that of other industrialized and developing nations. While no comprehensive survey of global mental health is available, data from the World Mental Health Survey of 17 nations indicate that the United States has the highest prevalence of mental illnesses in the world and ranks second in the category of substance use.[3]

Driven by high prevalence, poor recognition of problems, historical patterns of insurance discrimination, and inadequate access to care, mental health and substance use disorders represent the most disabling of all health conditions. This disease burden is in part attributable to the early onset of these disorders.[4,5] Among individuals who will have a lifetime behavioral health diagnosis, the median age of onset is 14. However, significant symptoms of behavioral health disorders precede the point at which full diagnostic criteria are met by 2 years, and on average there is a 10-year delay in receiving treatment.[6]

Given their high prevalence, underdetection, and undertreatment, as well as the lack of an organized prevention structure, behavioral health disorders are associated with indicators of poor social functioning and overall health. The presence of a behavioral health disorder is also one of the most powerful predictors of academic failure.[7–9] As such, untreated depression and anxiety disorders place individuals at greater risk for the development of substance use and antisocial behaviors and, therefore, greater risk for limited academic and occupational achievement.

Consistent with these negative impacts, behavioral health disorders are associated with substantial expenses and lost employment opportunities. In 2009, the Institute of Medicine (IOM) estimated that mental, emotional, and behavioral disorders among children and young adults resulted in $247 billion in quantifiable costs.[10]

The problem of markedly poor behavioral health status is characteristic of the US population overall, but because of cultural and social contexts that influence behavioral health, there are disparities in behavioral health status and access to prevention and treatment services across subpopulations. The following are some examples of disproportional prevalence and impact:
•    While lifetime behavioral health disorder prevalence rates among adult women (56.5%) and men (58.4%) are similar, women have a higher prevalence of anxiety (36.4%) than men (25.4%), as well as a higher prevalence of mood (e.g., depression) disorders (24.9% among women and 17.4% among men). In contrast, rates of alcohol and nicotine abuse are higher among men (47.8%) than women (29.6%).[11]
•    About one fourth (20%–25%) of the homeless population suffers from some form of severe mental illness.[12]
•    Racial and ethnic minority populations bear a disproportionately high disability burden from mental disorders.[13]
•    Rates of substance use disorders among lesbian, gay, bisexual, and transgender populations may be 20% to 30% higher than those in the general population.[14]
•    People with behavioral health disorders are dramatically overrepresented in the juvenile justice and adult criminal justice systems, reflecting both the inadequacy of our public health response to individuals with these disorders and the adverse effects of criminal justice policies seeking to reduce rates of illegal substance use through mandatory sentencing.[15]

Such disparities that result from inadequate prevention and treatment are most concerning because they spotlight the ethical problem of accepting the status quo of poor behavioral health in the United States. The markedly poor behavioral health of individuals in these subpopulations compromises their right to good health.

Behavioral health disorders are also likely to co-occur with other chronic physical illnesses, such as asthma and cardiac disease. There is evidence, too, that the presence of depression may be a risk factor for the development of type 2 diabetes.[16,17] The Institute of Medicine’s Committee on Living Well with Chronic Disease identified nine “exemplar” conditions that have a “significant effect on the nation’s health and economy”; one third of these conditions were or included behavioral health disorders.[18] Three quarters of health care expenditures are attributable to the treatment of chronic illnesses. Given their early age of onset and poor rates of recognition and treatment, behavioral health conditions are arguably among the most chronic illnesses.

One of the most recent and striking findings about the impact of chronic mental illness is that people with severe mental health disorders who have been served in public mental health systems have an unadjusted life expectancy that is 25 years less than that of the general population, as well as an adjusted rate that reflects approximately 8 years of lost life relative to comparable individuals without a mental illness.[19] Many of the statistical adjustment factors (such as poverty) are themselves related to the development of mental health disorders, and therefore “correcting” for them often produces a more conservative estimate of excess mortality. For example, individuals with schizophrenia are at 12 times greater risk from death by suicide than the general population, and they experience the effects of chronic physical disorders (e.g., asthma, heart disease) and unhealthy lifestyle choices (e.g., smoking) earlier in their lives.[20]

Taken together, the effects of behavioral health disorders on the overall health and well-being of our country are of great concern. We have lacked an adequate and consistent public health response for several reasons. First, treatment of mental health and substance use disorders in the United States has been provided in segregated, fragmented, and underfunded care settings. Second, mental health and substance use disorders have historically been perceived and politically confused as social welfare rather than health problems. Finally, stigma and discrimination against people with behavioral health disorders have largely resulted from a misunderstanding that these disorders are moral weaknesses.

One result of an inadequate public health (and larger health system) response to behavioral health needs is the very low rate of treatment use; it is estimated that only 11% of individuals over the age of 12 who have a substance use disorder receive treatment.[21] Although access to mental health treatment is somewhat better than access to treatment for addictions, it is still poor within both the specialty and primary health care sectors.[22] While considerable science demonstrates the effectiveness of primary prevention interventions, these interventions have not been universally available. Furthermore, the interventions that are available are currently supported by a fragmented and disparate array of categorical funding across a number of human service sectors (health, behavioral health, education, social welfare, and juvenile justice agencies). No formal infrastructure exists to direct and evaluate the investments across these diverse service sectors and to coordinate and increase accountability for public health outcomes. Although it is now generally recognized that a majority of individuals with even the most severe mental health and/or substance use disorders can recover with appropriate treatment and support, current systems of care are inadequate to accomplish these ends.[23]

There have been fundamental advances in knowledge regarding the etiology of behavioral disorders, such that it is well accepted that behavioral health is “determined by socio-economic, biological and environmental factors.”[24] Specifically, there are significant genetic influences on mental health and substance use disorders, with heritability estimates ranging across populations and studies but consistently indicating an important heritable contribution to risk.[25–27] Particularly germane for the field of public health, it is also known that this genetic risk is differentially expressed in response to differing environmental variables, importantly including socioeconomic influences that either further predispose illness or compensate for genetic risk factors.[28,29] For example, in some instances specific genotypes in combination with environmental stress have been shown to increase the expression of depressive symptoms.[30–32] In the context of differential genetic risk, the effects of trauma and/or exposures to toxic and chronic stress have consistently been found to be related to the development of behavioral health and general health problems. The neurobiology of these interactions is increasingly well understood.[33,34] According to this developmental understanding of the etiology of behavioral health conditions, there is a self-reinforcing cycle in which genetic vulnerability combines with environmental and social-economic stress (broadly conceived to include both material and psychological components) to increase an individual’s allostatic load, that is, the price the body pays for persistent exposure to toxic stressors. The resulting persistent presence of stress hormones affects neural development, structure, and function, with broad-scale negative consequences for the development of neurological, endocrine, and immune systems; in other words, trauma and chronic stress can have an adverse impact on subsequent overall health and wellness, affecting both behavioral and general health.

Factors that are in constant interplay with genetics include social determinants of behavioral health, as acknowledged by the World Health Organization in its Mental Health Action Plan 2013–2020: “Determinants of mental health and mental disorders include not only individual attributes such as the ability to manage one’s thoughts, emotions, behaviours and interactions with others, but also social, cultural, economic, political and environmental factors such as national policies, social protection, living standards, working conditions and community social supports.”[35]

The recognition of social determinants of behavioral health is accordingly foundational to an overall strategy to prevent behavioral health disorders, especially among children and young adults, and subsequently to improve the behavioral health of the US population.[36] Social determinants such as poverty, which often results in frequent moves and changes in schools, limited health care, overcrowding, and unsafe environments, are acknowledged as potent risk factors for behavioral health disorders. Exposures to violence, social isolation, and discrimination are also sources of toxic stress and significantly contribute to the development and exacerbation of behavioral health disorders.

The findings of the Adverse Childhood Experiences (ACE) study document that exposure to toxic stress can result in long-term behavioral and general health problems.[37,38] In this study, supported by the Centers for Disease Control and Prevention, 17,000 insured, largely nonminority Kaiser Permanente HMO enrollees were asked to report whether they had experienced traumatic events in any of several domains, including childhood abuse (psychological, physical, and sexual) and household dysfunction (e.g., substance abuse, mental illness, imprisonment of a family member). The number of domains in which the person reported traumatic events was later used to calculate an ACE score that was subsequently associated with health status variables. Chronic depression, suicide attempts, and alcohol and other drug addictions, as well as other behaviors such as smoking and risky sexual behaviors, are all associated with elevated ACE scores. Similarly, elevated ACE scores are related to increased risk for liver disease, chronic obstructive pulmonary disease, and coronary artery disease. Individuals with an ACE score of 6 or higher die 20 years earlier on average than those with an ACE score of 0. In all likelihood, the effects of stress and trauma are mediated both by their direct neurobiological impact and by the associated increase in unhealthy behaviors.

The striking associations between increasing numbers of adverse childhood experiences and increased risks for a wide range of behavioral health and general health problems augment the already well-documented health impact of elevated stress. These increased secondary risks affect a substantial part of the population, since the prevalence rates of many adverse childhood experiences are also substantial. The implication for policy is to focus attention and effort on prevention of behavioral health disorders by systematically reducing risk factors associated with adverse experiences and increasing exposures to protective factors that may promote resilience against the negative consequences of traumatic exposures.[38]

Current knowledge includes an improved understanding of critical influences on behavioral health resulting from both individual developmental experiences and the effects of population-based social determinants such as income levels and prevalence of violence. What we now know calls urgently for implementation of a public health approach to behavioral health.[39,40] This approach should (1) target reductions in socially mediated stressors that place populations at risk of behavioral health disorders, (2) promote factors that protect populations from behavioral and other health disorders, and (3) complement and extend efforts by the National Center for Chronic Disease Prevention and Health Promotion that are designed to integrate mental health promotion and behavioral health prevention alongside chronic (physical) disease prevention.[41]

Proposed Recommendations
There is a substantial set of scientific findings about effective preventive and treatment interventions for behavioral health disorders. Most compelling are research findings with regard to children and young adults. In 2009, the Institute of Medicine summarized the state of the science in the prevention of mental, emotional, and behavioral disorders and health promotion among children and young adults.[42] The IOM committee concluded that the science base is sufficient for action and called for national leadership efforts to focus government investments in youth development. The committee further identified a number of empirically validated interventions, appropriate for individuals at differing developmental stages, that have been experimentally demonstrated to affect behavioral health outcomes by reducing risk factors and strengthening protective factors.

For example, the Nurse Family Partnership, in which trained public health nurses work with low-income mothers during their first pregnancy, has been shown to reduce levels of child maltreatment and improve long-term outcomes among both mothers and their children.[43] The Triple P intervention program, which integrates prevention and treatment, has been demonstrated (in an experimental trial in South Carolina) to reduce child abuse rates at the county level by nearly 30%.[44] Both of these interventions help reduce exposures to traumatic events, which are known to hamper healthy development.

Other evidence-based interventions targeted to youth seek to strengthen individual resiliency. For example, the Seattle Social Development Project promotes opportunities for children’s active participation in the classroom and family and reinforces efforts and accomplishments.[45] It involves teachers and adult caregivers in the intervention, which is implemented in the elementary grades. Fifteen-year follow-up data are available for 27-year-olds who have not received any systematic interventions since age 12. Data contrasting outcomes among adults trained in experimental versus control classrooms show significant effects of the intervention on socioeconomic status, social engagement, completion of an associate degree, rates of mental health symptoms and diagnosable mental illnesses, and lifetime rates of sexually transmitted diseases. Such interventions targeting children and youth show great promise for disrupting the self-reinforcing cycle that characterizes poor mental health and life outcomes.

In addition to interventions that target children and youth, effective interventions that promote positive behavioral health across the life span are available and should be included in the tool set proposed in a new public behavioral health strategy. Interventions that incorporate “strength-based” approaches and promote recovery from mental illness and addictions should be implemented. For example, community health workers who were trained as part of the REACH NOLA Mental Health Infrastructure and Training Project helped reduce disparities in treating depression and posttraumatic stress disorder in groups affected by the conditions in post-Katrina New Orleans.[46]

Prevention and interventions with regard to the behavioral health of older adults should be included in a comprehensive strategy of behavioral health promotion. Specifically, issues related to cognitive health among older adults can and should be addressed. The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study, a multisite randomized trial that involved ethnically diverse samples, demonstrated specific cognitive gains in daily living skills among participants in the experimental condition.[47]  

These interventions are representative of a suite of strategies for increasing resilience, reducing levels of environmental trauma, and promoting positive behavioral health.[48] Complementing interventions such as those described above, the adoption of a planning, execution, and evaluation framework is essential to achieve public health ends. The five-step “Strategic Prevention Framework” of the Substance Abuse and Mental Health Services Administration (SAMHSA) is one such approach to effectively helping communities identify needs and select and implement evidence-based interventions to ameliorate the negative effects of social determinants of health among both children and adults.[49] Congruent with this public health approach is the recent and current work of the American Psychological Association’s Task Force on Socioeconomic Status.[50] The public behavioral health strategy suggested here must integrate prevention, treatment, and rehabilitative efforts with primary care and human service systems involving educational, correctional, and social service components.[51,52]

Over the past decade, the critical role of behavioral health in achieving health and well-being has received formal recognition. In October 2008, with the support of groups including APHA, the American Psychological Association, and the American Psychiatric Association, the Mental Health Parity and Addiction Equity Act became law.[53] This legislation requires that group health insurance plans not impose limits on mental health or substance use disorder benefits that are any more restrictive than those applied to essentially all medical benefits. The Affordable Care Act (ACA)—which comprises two legislative acts passed in 2010, the Patient Protection and Affordable Care Act (Public Law 111-148) and the Health Care and Education Reconciliation Act (Public Law 111-152)—has since expanded federal parity protections for behavioral health into the individual and small group insurance markets.[54]

Another important component of recent health care reform included in the ACA is the National Prevention, Health Promotion and Public Health Council, created to better support preventive efforts and promote the integration of behavioral health and primary care.[55] Much work is currently under way to evaluate processes and outcomes of integrated primary and behavioral health care. The findings of this work should inform the evidence-based foundation of this general behavioral health strategy and further emphasize the importance of primary care for the recognition and treatment of behavioral health problems.[56] Relatedly, health homes, accountable care organizations, and other creative financing and organizational strategies aimed at particular populations and spawned by the ACA should further enhance these efforts at improving population health. Addressing behavioral health disorders will be critically important if such efforts are to succeed.

Potential public health interventions targeting social determinants need not be limited to large-scale efforts. Locally based interventions can address issues specific to communities through establishment of new programs or modifications of existing ones; they can also increase social capital, whether through social capital sources such as trust, reciprocity, and social networks or through social capital outcomes such as social support, social cohesion, and civic activities.[57,58] There is evidence that strengthening social networks, social support, and community assets on a local basis can translate to improved health outcomes within a community.[59,60]

Necessary to this integrated strategy is the establishment of an infrastructure to measure and manage investments across these diverse arenas and to coordinate and increase accountability for public health outcomes, an ideal role for public health. Such an enhanced public health agenda fully integrates behavioral health as a core component of overall health rather than the traditional approach of isolating behavioral health needs from overall public health efforts.[61]

Opposing Arguments/Evidence
This policy statement presents a vision for a public health agenda that would fully integrate behavioral health as a core component of general health. The literature does not offer opposing arguments as such, much less marshal evidence against the proposed direction. Indeed, this statement seeks to accelerate movement that is already under way, as illustrated in the evidence provided in the two preceding sections. Nonetheless, some resistance, if not necessarily opposition, can be anticipated once the policy statement is formally endorsed and acted upon. The reason, in part, is that it seeks to partially undo some unhelpful aspects of the centuries-old, tacit acceptance of the notion of mind-body dualism, established in the Western tradition most clearly through the writings of René Descartes and now firmly reified in institutions, in approaches to treatment, and in strategies for advocacy.[62] Advances in science and medicine presented increasingly direct challenges to dualist assumptions about the independence of behavioral and somatic health during the 20th century, but our systems and much of our practice and day-to-day thinking continue to hold the mental and the physical in separate spheres. To some degree, the policy statement advanced here could seem to affront these deeply ingrained structures.

The medical field has focused almost exclusively on the body side of the dichotomy, leaving behavioral health, by definition, on the mind side, in a functionally separate arena. The resulting separate development has yielded both advantages and disadvantages. The field of behavioral health has developed its own theory, policy, service systems, and funding streams, but the separation has also helped to reinforce stigma and disparities and has imposed limits on opportunities for full participation in relevant scientific advances. Against such limitations, recent emphasis has been placed on redefining mental and addictive disorders in physical terms, characterizing mental illnesses as brain disorders. This approach has potentially offered the opportunity for the field to gain legitimacy in the medical world, sidestep stigma by invoking similarity to forms of physical disability, and further reduce the risk of suspicion that mental disorders might be the result of bad parenting. One consequence of this approach, however, is that a strict interpretation of the brain disorder argument could seem to eliminate the role of what we currently understand as mental processes and seek solutions in strictly biological terms. While informed advocates of the brain disorder position typically see a nuanced picture, there may still be an overemphasis on the biological. Calls for “reconceptualizing disorders of the mind as disorders of the brain” could seem to offer a basis for subtle opposition to the public health position offered here by emphasizing that behavioral health disorders are “disorders of brain circuits likely caused by developmental processes shaped by a complex interplay of genetics and experience” and that “behavioral and cognitive manifestations that signify these as ‘mental’ illnesses may be late stages of processes that start early in development.”[63] In this view, the behavioral aspects are derivative or epiphenomena, and the real illness lies in the biological realm. An overly simplistic view of this perspective, particularly in light of the heritability of these disorders, could imply the biological inevitability of certain conditions, significantly downplaying the importance of environmental influences.

Too great an emphasis on the biological fails to recognize the formidable epidemiological research evidence demonstrating a more complex and holistic explanation for the causes and escalation of behavioral health disorders and could inadvertently perpetuate stigma by seeming to limit options for ultimate recovery.[64,65] This policy statement is based on an integrative theory that includes social determinants while fully recognizing the impact of genetic vulnerability and epigenetic effects. It integrates brain biology with environmental influences and therefore supports the physical substrates of mental health and substance use disorders while providing a more nuanced, developmental approach. The statement is thus based on a more comprehensive understanding of the etiology of behavioral health disorders in an effort to inform a more effective public health response.[66] At the same time, the integrative theory of etiology of behavioral health would suggest that prevention and treatment efforts be carefully designed and conducted to explicitly counter simplistic accusations of parental blame for the poor behavioral health of children. Social determinants of health include structural conditions such as poverty and parental skills and support. Improving these two influences should provide effective and evidence-based skills and support to parents and caregivers affected by stressors found in toxic environments that may predict multigenerational risk for poor health. Within this framework, both the behaviors of the parent and those of the offspring have important structural environmental determinants that are the target of public health interventions.

Finally, a public behavioral health approach based on an integrative theory of the relationship between behavioral health and overall health may also be resisted by behavioral health policymakers and other stakeholders who argue for the necessity of maintaining separation of behavioral and physical health promotion, prevention, and treatment. Historically, the behavioral health arena has struggled to receive recognition as a science-based field and to receive adequate public funding for promotion, prevention, and treatment. Sustaining a unique identity separate from other health concerns and efforts may be seen as the most effective way to protect the gains of legitimacy and funding. However, the model offered here places emphasis on behavioral health disorders as antecedents to later general health problems and, as such, should pose no threat to behavioral health’s claims of legitimacy. Indeed, this model should strengthen behavioral health claims of legitimacy, as intended through current federal efforts. SAMHSA has awarded Primary and Behavioral Health Care Integration Program grants since 2009 with the goal of improving the general health status of people with mental illnesses and addictions, and the SAMHSA-HRSA Center for Integrated Health Solutions provides technical assistance to health care facilities that are working toward this goal.[67,68] The strategy of separation reflects the history of the field’s development, and it may have been necessary at some earlier time and comported well with long-standing Western dualist assumptions. Given the state of the science, this strategy is antiquated; integration is being promoted by policymakers concerned with either behavioral health or chronic medical conditions, and Western medicine is becoming increasingly open to alternative understandings of the mind-body relationship.[69]

Action Steps
Therefore, APHA:
1.    Urges the US Department of Health and Human Services (DHHS), together with the Departments of Education, Labor, Housing and Urban Development, and Justice, to develop an integrated public health plan (i.e., one that integrates behavioral health needs into all aspects of planning, programming, and resource allocation) intended to ameliorate the negative effects of social determinants of health and promote positive behavioral health in the United States.
2.    Urges Congress and the president to increase investments in effectiveness, implementation, and dissemination research on promotion, prevention, and evidence-based treatment interventions related to behavioral health disorders.
3.    Urges SAMHSA to collaborate with public health, behavioral health, health, and social service agencies; groups that support professional and peer-support development; and consumers in conducting workforce analyses to strengthen workforce development and training.
4.    Urges Congress and the president to provide additional resources that will assist communities in implementing SAMHSA’s five-step Strategic Prevention Framework and help promote the development of effective and sustainable prevention programs for positive behavioral health.
5.    Urges DHHS to construct an integrated and multidisciplinary database of surveillance measures that can be used to expand analyses of the prevalence and outcomes of known toxic factors (e.g., trauma, poverty, and child abuse) that are associated with behavioral health disorders.
6.    Urges the Office of the Assistant Secretary of Health to collaborate with SAMHSA in promoting knowledge of SAMHSA’s Trauma Informed Care Initiative to promote positive behavioral health.
7.    Urges Healthy People State and Territorial Coordinators to mobilize community sectors (state and local governments, behavioral and other health care providers, the business community, and private philanthropy) to play informed and collaborative roles in efforts to achieve the Healthy People 2020 objectives related to behavioral health.
8.    Requests the Public Health Accreditation Board to regularly assess its standards and guidelines during the process of accreditation review to ensure that strategies for monitoring and reducing toxic stress and implementing effective treatment approaches include the promotion of positive behavioral health.
9.    Urges educational institutions, especially schools of public health, to teach the integrative theory of behavioral health disorder etiology described in this statement as a public health perspective on behavioral health and to enhance students’ knowledge and skills in designing, implementing, and evaluating evidenced-based interventions and strategies that promote positive behavioral health.
10.    Urges SAMHSA to build upon and increase public education efforts and social marketing campaigns to disseminate research-based information that citizens can use to manage stress, identify early signs and symptoms of behavioral health and addiction disorders, and locate information on needed assistance, including sources for workplace wellness and employee assistance programs.
11.    Urges all community sectors (state and local governments; behavioral health, health care, and social service providers; nonprofit organizations; the business community; and private philanthropy organizations) to help reduce stigma related to behavioral health disorders and increase prevention through media and wellness campaigns.

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