Many developed countries have had great success in controlling communicable diseases, thus increasing life expectancy, which creates a larger aging population living with non-communicable

CHAPTER 15

15.1 INTRODUCTION Although in some cases behavioral and psychiatric/mental are grouped under the same broad category, behavioral health problems are generally effectively treated on an outpatient basis with combination psychotherapy and pharmacotherapy (medications). Behavioral health professionals are licensed by the state in which they reside to practice, and they collaborate on the management of clients’ behavioral problems. These professionals include psychiatrists, psychologists, psychiatric nurse practitioners, social workers, family counselors, and drug/alcohol and mental health counselors (Parker, 2002). Such chronic problems as dementia and mental retardation are considered psychiatric/mental problems rather than behavioral.

There is a distinct interconnectedness between mental health and health in general. The WHO defines health as, “a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity” (WHO, 2001b, p. 1). Mental health on the other hand is defined as, “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stress of life, can work productively and fruitfully, and is able to make a contribution to his or her community … it is determined by socioeconomic and environmental factors and it is linked to behavior” (WHO, 2001a, p. 1; WHO 2010, p. 1). For example, people are generally resilient enough to spring back when they are stressed, or depressed and are therefore able to maintain their

baseline. However, when they lose their resiliency and remain stressed or depressed for long periods and are unable to cope, they become ill.

Globally, the prevalence of mental disorders is high (approximately 80 percent), yet few severely affected seek treatment (Demyttenaere, et al., 2004). Kleintjes, Lund, and Flisher (2010), in their analysis of mental health in children and adolescents across the four African countries studied, which included Ghana, found that stigma toward people with mental health problems was felt to contribute to active discrimination and the violation of the human rights of service users; whatever their age (p. 136). Respondents viewed this as significantly influencing their “willingness to disclose and seek help” (p. 136). The authors also found that “there is a low priority of mental health relative to other health programs; and there is a link between poverty and mental health” especially in regard to development of problems such as “stress, depression and anxiety” (p. 137).

To the extent that a persons’ mental health is intact, they are more capable of maintaining their physical and social well-being. If their physical health is poor, or severely threatened by disease and the ills of poverty, it can negatively impact their mental and behavioral health. Herrman, Saxena, and Moodie (2005) suggest that physical illness is detrimental to mental health just as poor mental health is detrimental to physical health. Perhaps the more complex the physical health problem, the more likely a behavioral health problem will emerge. The same can be said for social problems and pressures that may result in risky behavior that consequently results in physical, mental, or behavioral health problems.

15.2 BEHAVIORAL HEALTH When persons have diminished capacities—whether cognitive, emotional, attentional, interpersonal, motivational, or behavioral…that interferes with their enjoyment of life or adversely affects their interactions with society and the environment, they are considered to have a mental health disorder (Kirby, 2004, Report 1 p 68). Mental illnesses not only result in human suffering for the individuals experiencing the problem but it also affects their families, the healthcare system, the social system, the workplace, and society at large (IHE, p. 9). According to the WHO (2004) mental health problems present a global burden and in some countries it carries a stigma that impedes how communities address the problem. Further, not only are “mental health problems stigmatized in society globally, mental health is generally underfunded, and it presents a significant burden for countries throughout the world” (WHO, 2003, p. 18). The WHO also predicts that “by 2020 mental disorders will account for 15% of disability—adjusted life-years lost to illness” (p. 18).

Worthington and Rauch (2000) suggest that behavioral therapy consists of reconditioning patients’ behaviors or the associations they have between a stimulus and response. Behavioral health, in much of the world, is an all-inclusive term that refers to the management of community-based, emotional instabilities, as well as psychiatric mental health problems that do not require hospitalization. It includes a variety of problems that can be managed on an out-patient basis, and emphasizes changing behavior. For example, according to Worthington and Rauch, (2000, p. 1147), “anxiousness is a normal human, or behavioral response to stress. However, distinguishing it from pathologic anxiety and anxiety disorders often requires a systematic evaluation and a thorough understanding of the individual patient’s physical and psychological status. Unrecognized and untreated, anxiety disorders increase the cost of medical care and render patients vulnerable to further morbidity, including demoralization, hypochondriasis, depression, and varying degrees of disability. A comprehensive and empathic assessment of the anxious patient by the primary care physician permits a reasoned and often therapeutically effective approach to the difficult problems presented,” by introducing behavioral interventions at the earliest point of contact (the community).

15.3 PREVALENCE AND MANAGEMENT OF BEHAVIORAL HEALTH CARE IN INDUSTRIALIZED (DEVELOPED) COUNTRIES

Behavioral and Mental Health in the United States It has been well established, that access to delivery of high quality, affordable health care in the United States health delivery system is generally a problem (USDHHS, 2006; Long, Chang, Ibrahim, & Asch, 2004; Burroughs et al., 2002; Smedley, Stith, & Nelson, 2002: Exner et al., 2001). However, access to behavioral health care and services in the United States (U.S.) is an even greater challenge. It has obvious shortcomings. According to the CDC (2007), 1 in 2 Americans in the United States has a diagnosable mental disorder each year, including 44 million adults and 13.7 million children. Although 80–90% of mental disorders are treatable, of those with a diagnosable mental disorder, fewer than half of the adults actually get help and only one-third of children get help. The CDC also reports that in 1999, suicide was the 8th leading cause of death in the United States. In 2009, suicide dropped to the 10 th leading cause of death (CDC, 2010). However, since 1980 suicide has doubled among young African American males. Further, African Americans are more likely to experience a mental disorder than their European American counterparts, yet they are less likely to seek treatment. When they do seek treatment, they are more likely to receive inpatient care. Latino American women are more likely to suffer from depression than Latino men, and when Asian American/Pacific Islander females seek mental health care, they are more likely to be misdiagnosed as “problem free” (CDC, 2007). Finally, American

Indians/Alaskan Natives appear to suffer disproportionately from depression and substance abuse and they are overrepresented as hospitalized in-patients compared to European Americans (CDC, 2007).

The Public Health Act of 2000 defines the function of the National Institute of Mental Health (NIMH) and the Center for Mental Health Services (CMHS). The Children’s Health Act of 2000 authorized the Substance Abuse and Mental Health Services Administration (SAMHSA). Patients who have documented addiction to controlled substances qualify for governmental disability payments. There are 7.7 psychiatric hospital beds per 10,000 of the population, and 3.1 beds in psychiatric hospitals in the United States. There are also, according to the WHO, 13.7 psychiatrists per 100,000 in the population (WHO, 2005). Feldman, Bachman, Cuffel, Friesen, and McCabe (2003) assert that there are 14.2 psychiatrists per 100,000 population. Both are substantial numbers. There are also 6.5 psychiatric nurses, 31.1 psychologists, and 35.3 social workers (WHO, 2005). ( who.int/profiles_countries , 2005).

The National Health Reform Bill (the Obama Bill), although heavily pertaining to physical health, does encompass limited considerations for mental health. There are an array of social, psychological, and biological factors that determine a person’s mental health and stability. Any one of these determinants can threaten a person’s mental health. A good example of this is evidenced by the stressors of such things as poverty, violence, and poor working conditions (WHO, 2010, p 2). Laypersons often do not understand the distinction between behavioral health and mental health.

The essential levels of care covered by the United States’ healthcare insurance policies are similar to general healthcare coverage. Despite a move decades ago toward deinstitutionalization of mental health services, resulting in the closure of many long-term mental healthcare facilities across the country, few changes have occurred in the funding of mental health. Also, due to the lack of community-based mental health providers, access to community-based mental health services are somewhat limited.

In the United States, behavioral health covers an array of disorders such as alcohol and other mood altering substances abuse and dependence, anxiety, depression, chronic fatigue, chronic and/or nonmalignant pain, insomnia, obesity, sexual dysfunction, and phobias (Worthington & Rauch, 2000). Phobias, according to Worthington & Rauch (2000) are “irrational fears related to specific stimuli that often result in an anxiety response that interferes with some aspect of people’s ability to function” (p. 1148). Behavioral health also may include the management of people considered bipolar, relationship violence, and adolescent adjustment problems that could include bullying, which schools often fail to prevent and parents often feel helpless against.

The prevalence for many behavioral health problems are high, yet behavioral health provider availability in the United States is low. For example, anxiety disorders have an estimated lifetime prevalence of 25% in the general population, and account for frequent visits to the non-psychiatric provider (physicians and nurses in advanced practice roles such as NPs and CNs). “Evaluation and management of these patients are often challenging because they present with feelings of distress and concern about disease in the absence of objective evidence” (Worthington and Rauch, 2000, p. 1147). Goroll and Mulley (2000) suggest that, “patients with anxiety disorders are 50% more likely to be alcoholic; similarly, the prevalence of anxiety disorders is 50% higher in alcoholics” (p. 1149).

An important message from the AMA suggests that, “alcohol use and abuse is the major cause of preventable deaths associated with violence and motor vehicle accidents. Excessive alcohol intake strains personal relationships and may affect one’s ability to keep a job, and it results in serious health problems including damage to the liver and brain” (Ringold, 2005 p. 1).

The most recent available national prevalence data on alcohol abuse and dependence is from 2000 and 2001. These data suggest that the United States has a very high prevalence of alcohol abuse and dependence, approaching 8% or nearly 14 million adults. The rates of abuse and dependence among persons 18–29 is twice those for the nation as a whole and alcohol use among 12- to 17-year-olds has drastically increased (NIH, 2009, p.1; Hanna, 2000, p. 1169). The CDC (2007) reported that overall, 6 in 10 (61.2%) of U.S. adults were current drinkers in 2005–2007 (CDC, p. 1).

During 2006–2009, the National Institute on Alcohol Abuse and Alcoholism (NIH, 2009) obtained data on alcohol use from surveying 44,000 children between ages 12 and 14 across geographical and socioeconomic areas. Reportedly 5.9% of 12- to 14-year-olds admitted to using alcohol during the month prior to the survey. Almost all of these kids got the alcohol for free, 45% reported getting their alcohol from a parent or other family member or taking it from their home without permission (NIH, 2009). Additionally 5,000 youths and teens under the age of 21 die annually as a result of underage drinking. These deaths include deaths from falls, burns, and drowning. Young people who use and abuse alcohol are also more likely to perform poorly in school, and engage in risky sexual and drug taking behavior (NIH, 2009).

In 2000, the overall estimated alcohol related cost to society associated with lost productivity, crime, accidental deaths, and fire exceeded $165 billion. The estimated direct cost of alcohol treatment and medical consequences of using and abusing alcohol approached $20 billion. More than $15 billion is paid for medical care alone (Hanna, 2000, p. 1169).

Primary care physicians are uniquely positioned to detect and treat harmful patterns of alcohol use. They are also best positioned to prevent alcohol related disorders and a host of related medical and social problems. Screening for alcohol problems long before they become disabling and more difficult to manage should be a routine part of every primary care practice. Timely recognition and intervention is critical. Alcoholism encompasses two distinct conditions; alcohol abuse and alcohol dependence (Hanna, 2000) commonly referred to as alcohol addiction. When persons become addicted to alcohol it greatly impacts not only their lives but the lives of their families, their co-workers, and their community. Once addicted, long-term family counseling, the use of support groups, detoxification, and substitution therapy is often necessary.

Depression is a complex problem that presents clinically as a variety of psychological and physical complaints. It is often not diagnosed early, and sometimes goes undiagnosed. Although many persons become occasionally depressed for short periods they are generally resilient and spring back before long. When depression is unresolved, it is called clinical depression. At this point it requires intervention and follow up that often includes the use of antidepressant medications and professional counseling.

Access to mental health services in the United States is based largely on insurance provisions which vary among subscribers. There is coverage under Medicare and Medicaid for individuals who are considered poor. In most cases, out-patient psychiatric mental health and behavioral health services have limited insurance coverage. Also, there are so few community-based behavioral health providers in some geographic localities that services are not available, and existing programs are limited; others are even threatening to close. As a consequence, primary care providers are among the first to evaluate and treat persons with behavioral health problems. However, referrals to behavioral health providers are difficult to obtain, and when they can be made wait lists are very long.

Behavior health managed care companies have reported that major segments of the U.S. population lack access to clinicians who are capable of properly evaluating the indication for prescribing and monitoring psychotropic medications (Christian, Dower, & O’Neil, 2007). With 14.2 psychiatrists per 100,000 people in the United States, a declining number of psychiatric mental health nurse practitioners, and persistent treatment barriers, Feldman et al. (2003) predict there will be continued lack of access to treatment and fewer incentives for behavioral health providers to enter into community practice.

Healthy People 2010 and 2020 call for more mental health providers to treat individuals in need of behavioral health. According to the United States Department of Health and Human Services (USDHHS) many employers of large workforces have established the goal to improve delivery of

behavioral health care in general medical and mental health sectors (United States Department of Health and Human Services, 2007). The Substance Abuse and Mental Health Services Administration, the largest supporter of mental health grant opportunities for mental health innovation and demonstration programs recognizes the need for more community-based mental health research designed to assist providers in better responding to behavioral health needs at the community level. This organization actively advocates for increased numbers of mental health providers who are experienced in, and committed to, evidence-based practice to be community-based, rather than hospital-based (United States Department of Health and Human Services, 2007).

Although behavioral health is generally underfunded throughout the United States, some states are leading the way in behavioral health services to address the needs of children. One such state is New Mexico where access to behavioral health care and services for children and their families is a state priority. Bolson (2004) describes the New Mexico mental health system as one that utilizes state and federal funds to develop and maintain a statewide coordinated, comprehensive service delivery system that has three distinct characteristics. It is: flexible and designed to meet the needs of clients at the local level; inclusive of, and responsive to, the ethnic, cultural, racial, and socioeconomic diversity of the state; focused on results with clearly defined and measurable outcomes for the clients served (p. 4).

The Child Youth and Families Department (CYFD) of the Community Services Section of the Children’s Behavioral Health and Community Services Bureau is a very successful program. It disseminates an extensive, service delivery manual that fully describes and defines the standards and guidelines to be followed for children receiving behavioral health services. The CYFD’s goal is to improve and enhance the emotional, mental, and behavioral health of its children, youth, and families. Children are, without question, the clearly identified (service) population that includes youth up to age 21 (and their families) who have an open case file with one of three agencies that make formal referrals for services. These include, County Protective Services, the Juvenile Probation/Parole office, and the Tribal/Social Services. Children determined to be at risk for entry into CYFD’s Protective Services, Juvenile Justice System, and/or Tribal Social Services can also be referred for behavioral health services. According to Bolson (2004), specific contributing factors defining the population meeting the specific service categories include:

• Severe behavioral, emotional, neurobiological problems/disorders or at risk of developing such problems

• Intention/plan to hurt self or others as evidenced by written, verbal, and/or behavioral indicators

• Child or parent suicide attempt during the past year

• Substance abusing behaviors by child or their parents

• Multiple delinquent acts or law enforcement contacts by child

• Multiple school problems, including suspension or expulsion from school during the last year

• Homeless/runaway

• Child or parent with mental illness

• Parents who are incarcerated, involved with the criminal justice system, or on parole or probation

• Physical, sexual, emotional abuse or neglect of the child (current or known history)

• Multi-generational history of familial maltreatment, neglect

Smith and Sederer’s (2009) proposal of a “mental health home” is another interesting, yet feasible solution to addressing the needs of the homeless who have serious mental illness. As a consequence of their illness, the mentally ill homeless, failing to get access to care at the community level, are bounced from place to place. They often become incarcerated, and have repeated admissions to hospita

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