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Chapter 27
Behavioral Health in the Community
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Mental Health in Transition: Key
Documents
• Healthy People 2010 (see Table 27.1)
• National Health Promotion and Disease Prevention
Objectives
• Report of the Surgeon General on Mental Health
• New Freedom Initiative – three impediments to provision
of quality mental health care:
– Stigma
– Unfair treatment limitations and financial
requirements
– Fragmented mental health service delivery system
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Incidence and Prevalence
• Global problem
• Mental illness accounts for >15% of mortality
worldwide (WHO, 2007)
• Higher rates in poor, poorly educated, and
unemployed
• Many are homeless and go untreated
• Age affects the pattern of mental illness in a
community
• Gender differences in prevalence of certain mental
disorders
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Substance Use and the CHN
• Continuum including abstinence, low-risk use,
risk/hazardous use, harmful use and dependence
(see Fig. 27.1)
• CHN needs basic understanding of issues related to
specific substance; clear idea of desired outcomes
related to treatment or prevention program
– Trends of substance use across different
populations and communities
– Differences between legal and illegal substance
use
– Consequences of substance use on community
– Substance use from environmental perspective
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Prevalence of Substance Use and Use
Disorders
• Alcohol: highest incidence of use in young adults (1825 yrs)
• Tobacco: decline over past decade but not consistent
across age groups and genders
• Marijuana: most frequently reported illicit drug
• Cocaine: majority are males 18 to 25 yrs of age
• Heroin: most >18 yrs and male
• Meth, Ecstasy, and PCP
• Prescription drugs: across all age groups; rise in
college students
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement true or false?
• The highest use of alcohol occurs in middle-aged
adults.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• False
– Young adults, ages 18 to 25 years, are the group
with the highest use of alcohol.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Theoretical Frameworks
• Process theory: identify resources and structure
needed to develop, implement, and evaluate
• Effect theory: provides rationale for why
intervention will work
– Determinant theory
– Intervention theory
– Impact theory
– Outcome theory
• Public health prevention theory: level of prevention
for program focus, type of intervention to use, and
target population
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Determinants of Mental Health
• Complex
• Numerous factors such as genetics, environment,
societal frame of reference and context
• Cultural beliefs
• Expectations, standards, legal parameters
• Process of adaptation as a source of stress
– Individual’s perception of stress
– Subsequent response
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Determinants of Substance Use Disorders
• Nature vs. nurture
• Genetics plays a major role in development of
alcohol dependence
• Individual factors (associated with AUDs): high
antisocial behavior, high impulsivity, major
depression, social anxiety problems, history of
childhood sexual abuse, hyperactivity, attention
problems, seminal events
• Environmental factors: influence of peers, lower
socioeconomic status, partner use, substance use by
family members
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement true or false?
• Effect theory attempts to explain the rationale for an
intervention.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• True
– Effect theory provides a rationale for why an
intervention will work.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Screening and Brief Intervention
• Routine screening
– Brief Psychiatric Rating Scale (BPRS; see Fig.
27.7)
– Beck Depression Scale
– Montgomery Ashberg Depression Rating Scale
(MADRS)
• Screening for depression: Center for Epidemiologic
Studies Depression Scale (CESD; see Fig. 27.8) and
shorter version, the CESD-10
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Screening for Substance Use and SUDs
• Three levels: screening for actual consumption, screening
for at-risk drinking, and screening for SUDs
• Level of risk: based on level of consumption
• Screening instruments
– Self-report: Michigan Alcoholism Screening Test
(MAST); Drug Abuse Screening Test; CAGE
questionnaire; Drug Use Screening Inventory (DUSI)
– Biological screens: urine, blood, hair, saliva, breath,
and meconium
• Positive screen: possible brief intervention
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Community-Level Interventions
• Community assessment and focus of intervention
• Level of prevention
• Mental health community interventions
– Integrative health assessment
– Factors include treatment history; personal life
stressors; disturbances in sleep, appetite, or
energy level without a rational explanation;
complaints of chronic pain; history of abuse,
trauma, substance use, and family history of
mental illness
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Community Level Interventions (cont.)
• Mental health promotion
– Anticipated outcomes
– Risk-protective activities
– Life-sustaining activities
– Life-enhancing activities
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement true or false?
• The CAGE questionnaire is a valid self-report tool to
screen for substance use.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• True
– Self-report tools such as the CAGE questionnaire
are reliable and valid tools that can be used to
screen for substance use.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
CHN & Community-Level Interventions
• Multifaceted role
– Ability to access and use epidemiologic data
– Advocacy: increase client access to services,
reduce stigma, and promote improved public
understanding & improved services in community
mental health; political involvement
– Education
– Case management, case-finding, referral
– Collaboration
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Substance Use & Community-Level
Interventions
• Population-based screening programs
• Governmental agencies as resources
• Policy-based interventions
• Mental health policy
• Substance use policy
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Internet Resources
• Al-Anon Family Group Headquarters, Inc.: http://www.alanon.org/index.html
• Mothers Against Drunk Driving (MADD):
http://www.madd.org/
• National Alcohol Screening Day:
http://www.mentalhealthscreening.org/events/nasd/inde
x.aspx
• National Institute on Alcohol Abuse and Alcoholism
(NIAAA): http://www.niaaa.nih.gov/
• National Institute of Mental Health:
http://www.nimh.nih.gov
• Substance Abuse and Mental Health Administration
(SAMHSA): http://www.samhsa.gov/
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins