Teenage Girls Are Exposed to More Stressors that Increase Depression Risk

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"Adolescence is often a turbulent time, and it is marked by substantially increased rates of depressive symptoms, especially among girls. New research indicates that this gender difference may be the result of girls’ greater exposure to stressful interpersonal events, making them more likely to ruminate, and contributing to their risk of depression. The findings are published in Clinical Psychological Science, a journal of the Association for Psychological Science. This is a photo of a pensive looking girl sitting on steps.“These findings draw our focus to the important role of stress as a potential causal factor in the development of vulnerabilities to depression, particularly among girls, and could change the way that we target risk for adolescent depression,” says psychology researcher and lead author on the study, Jessica Hamilton of Temple University. “Although there is a range of other vulnerabilities that contribute to the emergence of girls’ higher rates of depression during adolescence, our study highlights an important malleable pathway that explains girls’ greater risk of depression.” Research has shown that cognitive vulnerabilities associated with depression, such as negative cognitive style and rumination, emerge during adolescence. Teens who tend to interpret events in negative ways (negative cognitive style) and who tend to focus on their depressed mood following such events (rumination) are at greater risk of depression. Hamilton, a doctoral student in the Mood and Cognition Laboratory of Lauren Alloy at Temple University, hypothesized that life stressors, especially those related to adolescents’ interpersonal relationships and that adolescents themselves contribute to (such as a fight with a family member or friend), would facilitate these vulnerabilities and, ultimately, increase teens’ risk of depression. The researchers examined data from 382 Caucasian and African American adolescents participating in an ongoing longitudinal study. The adolescents completed self-report measures evaluating cognitive vulnerabilities and depressive symptoms at an initial assessment, and then completed three follow-up assessments, each spaced about 7 months apart. As expected, teens who reported higher levels of interpersonal dependent stress showed higher levels of negative cognitive style and rumination at later assessments, even after the researchers took initial levels of the cognitive vulnerabilities, depressive symptoms, and sex into account. Girls tended to show more depressive symptoms at follow-up assessments than did boys — while boys’ symptoms seemed to decline from the initial assessment to follow-up, girls’ symptoms did not. Girls also were exposed to a greater number of interpersonal dependent stressors during that time, and analyses suggest that it is this exposure to stressors that maintained girls’ higher levels of rumination and, thus, their risk for depression over time. The researchers emphasize that the link is not driven by reactivity to stress — girls were not any more reactive to the stressors that they experienced than were boys. “Simply put, if boys and girls had been exposed to the same number of stressors, both would have been likely to develop rumination and negative cognitive styles,” Hamilton explains. Importantly, other types of stress — including interpersonal stress that is not dependent on the teen (such as a death in the family) and achievement-related stress — were not associated with later levels of rumination or negative cognitive style. “Parents, educators, and clinicians should understand that girls’ greater exposure to interpersonal stressors places them at risk for vulnerability to depression and ultimately, depression itself,” says Hamilton. “Thus, finding ways to reduce exposure to these stressors or developing more effective ways of responding to these stressors may be beneficial for adolescents, especially girls.” According to Hamilton, the next step will be to figure out why girls are exposed to more interpersonal stressors: “Is it something specific to adolescent female relationships? Is it the societal expectations for young adolescent girls or the way in which young girls are socialized that places them at risk for interpersonal stressors? These are questions to which we need to find answers!” Co-authors on the study include Jonathan P. Stange and Lauren B. Alloy of Temple University and Lyn Y. Abramson of the University of Wisconsin-Madison. This work was supported by NIMH Grants MH79369 and MH101168 to Lauren B. Alloy. Jonathan P. Stange was supported by National Research Service Award F31MH099761 from NIMH." For more information on mental health topics, please visit CEUs for MFTs

Linked Brain Centers Mature in Sync

Imaging Reveals Underlying Unity Between Brain Structure and Development

Long-term neuroimaging studies show for the first time that areas of the brain that are wired together structurally and functionally also tend to mature in tandem over the course of development. The finding adds a new dimension to a picture that is emerging of how structure, function, and development of the brain are intertwined ceus for mfts

Background

Studies of brain development have shown that growth across the brain is not steady and uniform; some areas mature more quickly than others. These studies to date have not, however, examined whether areas of the brain that are linked functionally also develop in a coordinated way. It’s a challenging question because the developmental changes in brain anatomy that can be detected by neuroimaging unfold very slowly. Also, tempos of anatomical change differ from person to person, so comparing brain dimensions in different individuals at the same age can be misleading. The only way to approach this question is to track patterns of growth in the same individuals over many years.

This Study

To address this question, Armin Raznahan and colleagues at NIMH took advantage of a dataset that is unique in the world, consisting of records of brain growth measured by magnetic resonance imaging (MRI) of individuals from childhood to young adulthood. They studied changes in thickness of the outer layer of the brain, the cortex. In order to look for correlated anatomical change in connected parts of the brain, these investigators used records of cortical thickness from 108 individuals from ages 9 to 22. They focused on a well-defined and documented brain circuit: the default mode network or DMN. The DMN, a network identified by functional brain imaging, consists of nodes, or centers, in the brain that are active when someone’s mind is at rest, but quiet when the mind is focused on a task. In addition to tracking growth in the DMN, the NIMH investigators also looked at patterns of growth on the right and left side of the brain. There are extensive neuronal connections between the right and left hemispheres of the brain. Activation tends to be symmetrical and simultaneous within analogous parts on either side of the brain.

Results showed that there was a marked correlation in the rates of cortical thickness change between different points within the DMN when compared with the average correlation among thousands of other points across the brain. A similar pattern was seen among points in a second “task positive” network that is active while someone is carrying out goal-directed tasks; rates of change in cortical thickness within this second network also showed a pattern of coordinated maturing. Parts of the cortex involved in the integration and processing of incoming information and responses—the association cortex—were most likely to show correlated anatomical change with broad areas of the cortex. Similar correlations in change were not seen among parts of the cortex involved primarily in sensory input.

Correlations in anatomical change were also apparent between analogous centers on the right and left side of the brain, paralleling the symmetry in activation of these areas. Finally, the investigators looked at an area of the cortex (the frontopolar cortex) for which previous work had shown differences in the rate of maturation between males and females. This study found the same difference between males and females in maturation rate in this area. In addition, there were differences between the sexes in the degree to which thickness change in this area showed coordination with that of other areas of the cortex.

The coloring in this MRI scan reflects the extent to which changes in various areas of the maturing cortex correlate with similar changes over time in the default mode network, a network in the brain that is active when a person is at rest. Red indicates the highest degree of correlation—blue is the lowest. (Colors indicate correlation with one “node” within the default mode network, indicated by a circle in the image.)

Source: Armin Raznahan, Child Psychiatry Branch, National Institute of Mental Health


Significance

Neuroscientists are increasingly viewing the brain in terms of the development and function of neural circuits. According to Dr. Raznahan, this approach represents a sea change compared to the earlier emphasis on studying individual brain areas. In addition to the work reported here, recent studies of gene expression (activity) patterns in the brain suggest that genes that have roles in laying down connections between functionally related areas are also especially active during development.

In a high percentage of cases of mental disorders, the first symptoms emerge during youth; this is one piece of evidence that mental illnesses are disorders of development. Research on the relationships between brain connectedness and structural maturation can help provide a basis for future studies of how disruptions in the laying down of neural circuits in the brain during development can shape the structure and function of the adult brain and set the stage for mental illness. The authors point out in their paper that disorders that disrupt functional connections might also alter structural brain development. Comparing how development unfolds in individuals with and without disorders of mental health can offer clues to causes and targets for therapies. Finally, the findings on sex differences reported here can lend insight into the types of behavior seen during adolescence, especially risk-taking.

Reference

Raznahan, A., Lerch, J.P., Lee, N., Greenstein, D., Wallace, G., Stockman, M., Clasen, L., Shaw, P., and Giedd, J. Patterns of coordinated anatomical change in human cortical development: a longitudinal neuroimaging study of maturational coupling. Neuron. 2011 Dec 8;72(5):873-84.

Caffeine No Substitute for a Nap to Enhance Memory: Equivalent of 2-3 Cups of Coffee Worsens Motor Learning and Word Recall

Hoping to improve your tennis serve? It's probably better to catch a few winks than load up on java after a lesson, results of a NIMH-supported study suggest. Caffeine impaired such motor learning and verbal memory, while an afternoon nap benefited all three types of learning tested by Sara Mednick, Ph.D., and colleagues at the University of California, San Diego. The researchers report on their findings in the November issue of Behavioural Brain Research. CEUs for MFTs
Background

Ninety percent of Americans use caffeine daily, some substituting it for sleep. While the stimulant enhances alertness and concentration, it's been unclear whether it also helps learning and memory. By contrast, daytime naps, like nighttime sleep, benefit both alertness and memory, Mednick and colleagues have shown in a series of studies.

In this first head-to-head day-time comparison, 61 participants trained in the morning on verbal memory, motor, and perceptual learning tasks. After lunch, one group napped (60-90 min), while two other groups listened to a book on tape and received a pill containing either the caffeine equivalent of a little less than a Tall Starbucks brewed coffee (200mg) or a placebo. Later in the afternoon, the three groups were tested to see how well they had learned the tasks.

Findings of This Study

The nap group performed significantly better on a finger tapping motor task and in recalling words, than the caffeine group. The nap group also trumped the other groups on a texture discrimination task of perceptual learning. The placebo group performed better than the caffeine group on all three tasks. Curiously, just thinking that the pill might contain caffeine — the placebo effect — helped as much as a nap on the motor task.

Significance

Evidence suggests that caffeine interferes with tasks that require processing explicit, as opposed to implicit, information - like recalling a specific word, versus remembering how to type or ride a bike. Studies show that consolidation of such explicit verbal memory during sleep depends on lowered levels of the chemical messenger acetylcholine in the brain's memory hub. Yet, by blocking activity of a natural sedative chemical, caffeine boosts acetylcholine in this hub.

"This increase in acetylcholine by caffeine may impair the consolidation process by blocking replay of new memories," proposes Mednick. "Consistent with this, we found that the greater the explicit component of each task, the worse the caffeine group performed."

What's Next?

"Such an impairment of performance runs counter to society's assumption that caffeine typically benefits cognitive performance," she notes. "Apparent improvements with caffeine might actually reflect a relief from withdrawal symptoms. Just as no medicinal alternative to a good night's rest has been discovered, so too caffeine, the most common pharmacological intervention for sleepiness, may not be an adequate substitute for the memory enhancements of daytime sleep, either."

Mednick and colleagues are using new pharmacological agents found to selectively enhance particular stages of nighttime sleep to see if they can enhance memory consolidation during daytime naps. Brain imaging will pinpoint effects on neural circuits. These studies of pharmacologically enhanced naps could lead to improved treatments for memory impairment in mental disorders, based on manipulations of sleep, say the researchers.

Reference
Mednick SC, Cai DJ, Kanady J, Drummond SP. Comparing the benefits of caffeine, naps and placebo on verbal, motor and perceptual memory. Behav Brain Res. 2008 Nov 3;193(1):79-86. Epub 2008 May 8. PMID: 18554731

Case-managed Care Improves Outcomes for Depressed Patients with Multiple Medical Conditions

Science Update • December 30, 2010

Case-managed Care Improves Outcomes for Depressed Patients with Multiple Medical Conditions
People with diabetes or heart disease plus depression fare better if their medical care is coordinated by a care manager who also educates patients about their condition and provides motivational support, compared to those who receive care from their primary care physician only, according to an NIMH-funded study published December 30, 2010, in the New England Journal of Medicine.

Background
Coexisting depression is common among patients with diabetes or heart disease, especially if their medical conditions are poorly controlled. Having depression puts these patients at higher risk for poor self-care and more medical complications, and a higher risk for death. Patients dealing with multiple chronic conditions also tend to incur higher medical costs.

Wayne Katon, M.D., of the University of Washington, and colleagues at Group Health Research Institute in Seattle developed a team-based intervention approach—TEAMcare—that aimed to improve medical outcomes and ease depression symptoms among these patients. They tested the intervention in a randomized controlled trial of 214 participants in 14 primary care clinics in Washington state. The participants all had poorly controlled diabetes and/or heart disease with coexisting depression.

Half of the patients were randomized to a 12-month trial of TEAMcare, in which a medically supervised nurse care manager coordinated their care with their primary care provider (PCP) and other medical professionals. The nurse care manager also helped patients set goals for controlling their medical conditions, provided motivation and education about taking their medications correctly, consulted with patients' PCPs about changes in medications recommended by supervisors, and encouraged better self-care. The other half of the participants received usual care, in which their PCP consulted with them about depression care and medical disease control, but they did not have a nurse care manager coordinating their care.

Results of the Study
Overall, patients in the TEAMcare intervention fared better than those in usual care. Symptoms of depression eased in the TEAMcare group more so than in the usual care group. Patients in the TEAMcare intervention also showed greater improvements in blood glucose levels, blood pressure and "bad" cholesterol levels, compared to patients in usual care. Patients in TEAMcare were also more likely to have their medications adjusted, indicating a desire to fine-tune their care to achieve better results. TEAMcare patients also reported greater satisfaction with their medical care and a higher quality of life.

Significance
Previous research suggests that patients who are more satisfied with their medical care tend to be more motivated to take better care of themselves and therefore have better outcomes. According to the researchers, TEAMcare offers a promising way of improving outcomes in patients with multiple medical illnesses and depression because it provides systematic patient support as well as assistance to PCPs.

The researchers also note that patients with multiple medical conditions tend to have high health care costs. The study results suggest that a proactive, coordinated intervention like TEAMcare may facilitate better, more efficient care of these patients in particular.

What's Next
TEAMcare was tested among a specific population enrolled in one health plan, using highly trained nurse care managers. Further study is needed to determine whether the approach can be cost-effectively applied to broader populations, and whether less experienced nurse care managers could be used without sacrificing quality of care.
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Reference
Katon WJ, Lin EHB, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M, McCulloch D. Multi-condition collaborative care for chronic illnesses and depression. New England Journal of Medicine. Dec. 30, 2010.

December is National Impaired Driving Prevention Month

December 2010

By presidential proclamation, December is National Impaired Driving Prevention Month. This month seems particularly suited to this observation because traffic fatalities that involve impaired drivers increase significantly during the Christmas and New Year’s holiday periods.[i] But impaired driving is a roadway hazard that exists throughout the year. In 2009, nearly 11,000 people were killed in crashes involving impaired drivers[ii]—or about one death every 49 minutes. As a Nation, as communities, and as individuals, we need to take stronger action to help ensure that our roads and those who drive on them remain safe throughout the holidays and every day.

In an average year, 30 million Americans drive drunk, and 10 million Americans drive drugged. SAMHSA’s new survey on impaired driving, State Estimates of Drunk and Drugged Driving, found that nationally 13.2 percent of all people aged 16 or older drove under the influence of alcohol and 4.3 percent drove under the influence of illicit drugs during the past year. Some States recorded rates of drunk driving higher than 20 percent.

Furthermore, rates of impaired driving differed dramatically by age. While 11.8 percent of people aged 26 and older drove drunk, 19.5 percent of people aged 16 to 25 drove drunk. While 2.8 percent of the older group drove drugged, 11.4 percent of younger drivers did so.

President Barack Obama has made combating drugged driving a priority of drug control and has set a national goal of reducing drugged driving prevalence by 10 percent by 2015. To help achieve this goal, SAMHSA is working with the Office of National Drug Control Policy and the National Institute of Drug Abuse to develop standard screening methods to help detect the presence of drugs among drivers. SAMHSA also is advancing its primary strategic initiative: to prevent substance abuse and mental illnesses by creating prevention-prepared communities that can reduce the likelihood of these often-related problems and their consequences.

In issuing his proclamation, President Obama asked all Americans “to recommit to preventing the loss of life by practicing safe driving practices and reminding others to be sober, drug free, and safe on the road.” Talk openly about this issue and set a good example for others, especially young people, by making “one for the road” a nonalcoholic beverage. For evidence-based approaches on preventing underage drinking, visit the Too Smart To Start and Stop Underage Drinking Portal of Federal Resources Web sites.

SAMHSA wishes a safe and healthy new year in 2011 to all.


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[i] National Highway Traffic Safety Administration. (2007). Fatalities related to alcohol-impaired driving during the Christmas and New Year’s Day holiday periods. Traffic Safety Facts. From

http://www-nrd.nhtsa.dot.gov/Pubs/810870.PDF (accessed December 16, 2010).

[ii] National Criminal Justice Reference Service, U.S. Department of Justice. (2010). Impaired driving. From http://www.ncjrs.gov/impaireddriving (accessed December 16, 2010).

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Holiday Suicides: Fact or Myth?

The idea that suicides occur more frequently during the holiday season is a long perpetuated myth. The Annenberg Public Policy Center has been tracking media reports on suicide since 2000. A recent analysis found that 40% of articles written during the 2008 holiday season perpetuated the myth.1

CDC’s National Center for Health Statistics reports that the suicide rate is, in fact, the lowest in December.1 The rate peaks in the spring and the fall. This pattern has not changed in recent years. The holiday suicide myth supports misinformation about suicide that might ultimately hamper prevention efforts. MFT Continuing Education http://www.aspirace.com
Suicide remains a major public health problem, one that occurs throughout the year. It is the 11th leading cause of death for all Americans. Each year, more than 33,000 people take their own lives.2 In addition, more than 376,000 are treated in emergency departments for self-inflicted injuries.2

CDC works to prevent suicidal behavior before it initially occurs. Some of CDC’s activities include:

1.monitoring suicidal behavior;
2.conducting research to identify the factors that put people at risk or protect them from suicide; and
3.developing and evaluating prevention programs.

Thanksgiving Day a Time for Reflection, Gratitude, Sharing

Washington — Thanksgiving Day in the United States is possibly the premier U.S. family celebration — typically celebrated at home or in a community setting and marked with a substantial feast. Thanksgiving provides an occasion for reunions of friends and families, and it affords Americans a shared opportunity to express gratitude for the freedoms they enjoy as well as food, shelter and other good things.

Many Americans also take time to prepare and serve meals to the needy at soup kitchens, churches and homeless shelters. Others donate to food drives or participate in charity fundraisers; in fact, hundreds of nonprofit groups throughout the country hold Thanksgiving Day charity races called “Turkey Trots.”

And on a more worldly note, Thanksgiving marks the beginning of the “holiday season” that continues through New Year’s Day. The Friday after Thanksgiving is one of the busiest shopping days of the year.

Every year, the president issues a proclamation designating the fourth Thursday in November (November 26 this year) a National Day of Thanksgiving. It is an official federal holiday, and virtually all government offices and schools — and most businesses — are closed.

“As Americans, we hail from every part of the world,” President Obama says in his proclamation. “While we observe traditions from every culture, Thanksgiving Day is a unique national tradition we all share. Its spirit binds us together as one people, each of us thankful for our common blessings.”

THE FIRST THANKSGIVING

A variant of the harvest festivals celebrated in many parts of the world, Thanksgiving is popularly traced to a 1621 feast shared by the English Pilgrims who founded the Plymouth Colony (located in present-day Massachusetts) and members of the Wampanoag Indian tribe.

The Pilgrims had arrived in 1620, crossing the Atlantic Ocean to separate themselves from the official Church of England and practice freely their particular form of Puritanism. Arriving at Plymouth Colony too late to grow many crops, and lacking fresh food, the Pilgrims suffered terribly during the winter of 1620-1621. Half the colony died from disease. The following spring, local Wampanoag Indians taught the colonists how to grow corn (maize) and other local crops, and also helped the newcomers master hunting and fishing. The Wampanoag were a people with a sophisticated society who had occupied the region for thousands of years, says the National Museum of the American Indian.

Because they harvested bountiful crops of corn, barley, beans and pumpkins the Pilgrims had much to be thankful for in the fall of 1621. The colonists and their Wampanoag benefactors — who brought deer to roast — held a harvest feast to express gratitude for God’s blessings. Although it is known that the colonists provided fowl for the feast, the rest of the menu remains an educated guess; the Pilgrims likely offered turkey, waterfowl and other wild game, seafood such as mussels, lobster and eels, vegetables, grapes and plums, and nuts.


Turkey, caribou, moose and whale meat are served at the Alaska Native Thanksgiving dinner at the Anchorage Friends Church in 2006President Obama’s proclamation recognizes “the contributions of Native Americans, who helped the early colonists survive their first harsh winter and continue to strengthen our Nation.” It is a reminder of the Native American role in the first American Thanksgiving, a feast held to thank the Indians for sharing their knowledge and skill. Without that help, the first Pilgrims likely would not have survived.

The legacy of giving thanks, particularly with a shared feast, has survived the centuries. Several U.S. presidents — starting with George Washington in 1789 — issued Thanksgiving proclamations, but it wasn’t until President Abraham Lincoln’s 1863 proclamation that Thanksgiving became an annual national holiday. He called for it to be celebrated on the last Thursday of November. It was in the dark days of the Civil War, but Lincoln said that difficult times made it even more appropriate for blessings to be "gratefully acknowledged as with one heart and one voice by the whole American people."

A 1941 congressional resolution moved it to the fourth Thursday to assure a longer post-Thanksgiving, pre-Christmas shopping season in years when there are five Thursdays in November.

Each year, the president also “pardons” a Thanksgiving turkey — actually two turkeys, since one is a backup in case the other decides to misbehave during the ceremony. The two fowl, spared from the oven, live out the rest of their lives at a children’s petting zoo.

TRADITIONS OF THANKSGIVING

Thanksgiving sees the most air and car travel of the year as families and friends try to reunite for the holiday. Many Americans enjoy a local Thanksgiving parade, or the annual Macy’s department store parade, televised live from New York City. Others watch televised American football. Overseas, U.S. troops are served a traditional Thanksgiving dinner.

Turkey with stuffing, mashed potatoes and gravy, sweet potatoes, cranberry sauce and pumpkin pie are staples of the Thanksgiving feast, although there are meat substitutes such as “tofurkey” (combining the words tofu and turkey), a loaf made from seitan (wheat protein) or tofu (soybean protein).

Thousands of charitable organizations serve hot Thanksgiving dinners to the needy — and to anyone who shows up — and millions of frozen turkeys are donated to families each year.

“As we gather once again among loved ones, let us also reach out to our neighbors and fellow citizens in need of a helping hand,” says President Obama. “This is a time for us to renew our bonds with one another.”

He also asks Americans to “pay tribute to our country's men and women in uniform who set an example of service that inspires us all. Let us be guided by the legacy of those who have fought for the freedoms for which we give thanks.”

Certification and Licensure Issues Related to the Treatment of Co-occurring Disorders

Certification and Licensure Issues Related to the Treatment of Co-occurring Disorders.SAMHSA’S Co-Occurring Center for Excellence (COCE)
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Overview• Purpose of licensure and certification for professionals is to protect the public and ensure that practitioners have meet standards for practice.• Purpose of licensure and accreditation of programs is to ensure that they meet state regulations and/or national operating standards and also protect the public.
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Licensure and Certification of Professionals – Key Definitions• Licensure: A license is a property right of an individual and as a property right a license is backed by the laws of the State in which it is granted. (Shimberg &Roederer, 1994) “…it is illegal for a person to practice a profession without meeting standards imposed by the State.” (Schoon & Smith, 2000)
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Licensure and Certification of Professionals - Key Definitions• Certification: A process established by a private sector body that defines standards for professional practice. It may prohibit the use of a title or designation but often does not restrict someone from practicing a profession. (Schoon & Smith 2000)
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Licensure and Certification of Professionals – Key Definitions• Difference between licensure and certification is that certification is voluntary, not overseen by a governmental body and usually does not prohibit someone from practicing• Some states use the term “certified to indicate a license-e.g. “certified independent social worker” instead of “licensed independent social worker
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Purpose of Licensure and Certification• Provides assurance that practitioners– have met standards of practice – Can perform scope of practice established for the profession– Have demonstrated knowledge and skill to practice• Provides protection from incompetent and unscrupulous professionals
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Current Scopes of Practice and Core Competencies• Scopes of Practice for social workers, psychologists and psychiatrists include assessment, diagnosis, treatment of mental, emotional and behavioral disorders • The scopes of practice for psychiatrists, psychologists, social workers, mental health counselors, and marriage and family therapists also include addiction treatment • However, pre-service education for these disciplines contains little content on addictions
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Specialty Credentials• Specialty credentials in addictions exist for psychiatrists, psychologists, social workers and licensed professional counselors• Fewer than 7 percent of practitioners hold these national credentials (Harwood, et al, in press)• Some States (e.g.CT, IL, PA) have developed or are in the process of developing specialty credentials in COD but they are generally for addiction counselors
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Specialty Credentials Requirements• Mental Health Practitioners need to know the Transdisciplinary Foundations as described in the Addiction Counseling Competencies (CSAT 1998)– Understanding Addictions (models & theories; behavioral, psychological, physical health and social effects of psychoactive substances)– Treatment knowledge (continuum of care; importance of social, family and other support systems; understanding and application of research; interdisciplinary approach to treatment– Application to Practice (Understanding of diagnostic and placement criteria; understanding of variety of helping strategies– Professional Readiness (Understanding of diverse cultures; disabilities
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Specialty Credentials• For addiction counselors providing COD treatment the domains that have been identified include:– Assessment/evaluation/diagnosis– Clinical Competence– Case Management– Pharmacology and medical issues– Systems Integration– Professional Responsibility (IAODAPCA 2002)
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Benefits and Risks Related to Specialty Credentials• Enhance competencies of practitioners in providing services to clients with COD • Integrates COD services into practice• Specialty credentials are voluntary and not required for those providing COD services• Lack of pre-service education in COD may preclude effective screening, assessment, intervention and referrals for COD clients
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Elements of a COD Certification• Need comprehensive understanding of substance abuse & mental disorders– Remission– Recovery– Resilience• Competencies should include integrated assessment, engagement, integrated treatment planning and treatment, and long term integrated treatment methods (CSAT 2005)
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Benefits and Risks of a COD Credential• Currently a specialty credential for COD practice exists mainly for substance abuse professionals in several states• Other disciplines have an addiction certification• Advantage of developing a national COD credential is the creation of a scope of practice and competencies specifically designed for working with COD clients• Risk is further splintering of the field and concerns that all patients would be perceived as needing COD treatment
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Program Accreditation and Licensure• Accreditation is a voluntary performance-based process used to assess an organization or institution based on established quality and safety standards. Surveyors are carefully trained to conduct the evaluation; funders and third party payors usually require accreditation of institutions and agencies
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Program Accreditation and Licensure• Licensure is a right or permission granted by the state to engage in a business, perform an act or engage in a transaction that would be unlawful with such a right or permission (Merriam-Webster 1996) • States regulate the licensing of programs & hospitals; regulations may include policies, procedures, types of staff, facility safety standards and types of care specific programs can offer
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Core Capabilities for Programs Serving COD Clients• Following services are needed:– Integrated screening and assessment– Staged interventions– Assertive Outreach– Motivational interventions– Simultaneous Interventions– Risk Reduction– Tailored mental health and substance abuse treatment– Counseling– Social Support Interventions– Longitudinal view of remission and recovery– Cultural sensitivity and competence (CSAT 2005)
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Current Issues Regarding State Licensure of Programs• COD programs need to have appropriately trained & certified/licensed staff; comprehensive services including a full array of mental health and substance abuse treatment; supportive services; and implementation of evidence-based practices• Most programs are licensed by State mental health and substance abuse agencies respectively: funding streams are separate; different data collection systems; different staffing patterns; distinct service requirements
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Models of Licensure Standards for COD Programs • Comprehensive Continuous Integrated System of Care (CCISC) model is being implemented in several states (CSAT 2005)• CCISC integrates mental health and substance abuse systems to provide a comprehensive system of care including policies, financing, programs, clinical practices and basic clinician competencies (Minkoff 2003; CSAT 2005)
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Benefits of Licensure and Accreditation for COD Programs• Elimination of many obstacles that currently exist• Programs would be able to screen and assess for COD and some could be designated as programs to provide enhanced services• Programs that wish to specialize in COD treatment could be recognized• National accreditation would create consistent standards for programs including administrative, staffing and programmatic
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Issues and Future Direction• Little research exists on whether licensed/certified clinicians have better outcomes than those not certified• Though competencies in substance abuse are being added to practice standards few curricula provide adequate education or training• Evidence-based practices for COD treatment need to be incorporated into education and training standards• State program licensure practices still make programs providing COD treatment jump through a maze of regulations• JCAHO has not yet established national standards for dual diagnosis programs
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References• American Association for Marriage and Family Therapy Core Competency Taskforce. (2004) The MFT Core Competencies, Alexandria, VA: AAMFT• Association of Social Work Boards. Model social work practice act. www.aswb.org/Model_law.pdf• Association of State and Provincial Psychology Boards. The practice of psychology. www.asppb.org/exam/practice.asp• Center for Substance Abuse Treatment. 2005. Substance Abuse Treatment for Persons with Co- occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No (SMA) 05-3992. Rockville, MD: SAMHSA
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References• Center for Substance Abuse Treatment (1998). Addiction Counseling Competencies: The Knowledge, Skills and Attitudes of Professional Practice. Technical Assistance Publication Series No. 21. DHHS Publication No. (SMA) 98-3171. Rockville, MD: SAMHSA• Harwood, H.J., Kowalski, J., and Ameen, A. (In press). Training on substance abuse of behavioral health professionals. Falls Church, VA: The Lewin Group• Illinois Alcohol and Other Drug Abuse Professional Certification Association. (2002). Mental Illness/Substance Abuse Professional Role Delineation Study. www.iaodapca.org.• Merriwam-Webster. (1996) Merriam-Webster’s Dictionary of Law. Springfield MA: Merriam-Webster.
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References• Minkoff, K. (2003). Comprehensive, continuous, integrated system of care model description. http://www.zialogic.org/CCISC.htm.• Schoon, C.G. & Smith, I.L. (2000). The licensure and certification mission. In C.G. Schoon and I.L. Smith (Eds.) The licensure and certification mission: Legal, social and political foundations (pp1-3). New York: Professional Examination Services.• Shimberg, B. & Roederer, (1994). Questions a legislator should ask. Lexington, KY: The Council on Licensure, Enforcement and Regulation.• Substance Abuse and Mental Health Services Administration (2003).Strategies for developing treatment programs for people with co- occurring substance abuse and mental disorders.DHHS Publication No. (SMA) 03-3782. Rockville, MD: SAMHSA• Substance Abuse and Mental Health Services Administration. (2002) Report to Congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. http://als.samshsa.gov/reports/congress2002/CoOccurringRPT.pdf.SAMHSA’S Co-Occurring Center for Excellence (COCE)
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Overview• Purpose of licensure and certification for professionals is to protect the public and ensure that practitioners have meet standards for practice.• Purpose of licensure and accreditation of programs is to ensure that they meet state regulations and/or national operating standards and also protect the public.
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Licensure and Certification of Professionals – Key Definitions• Licensure: A license is a property right of an individual and as a property right a license is backed by the laws of the State in which it is granted. (Shimberg &Roederer, 1994) “…it is illegal for a person to practice a profession without meeting standards imposed by the State.” (Schoon & Smith, 2000)
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Licensure and Certification of Professionals - Key Definitions• Certification: A process established by a private sector body that defines standards for professional practice. It may prohibit the use of a title or designation but often does not restrict someone from practicing a profession. (Schoon & Smith 2000)
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Licensure and Certification of Professionals – Key Definitions• Difference between licensure and certification is that certification is voluntary, not overseen by a governmental body and usually does not prohibit someone from practicing• Some states use the term “certified to indicate a license-e.g. “certified independent social worker” instead of “licensed independent social worker
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Purpose of Licensure and Certification• Provides assurance that practitioners– have met standards of practice – Can perform scope of practice established for the profession– Have demonstrated knowledge and skill to practice• Provides protection from incompetent and unscrupulous professionals
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Current Scopes of Practice and Core Competencies• Scopes of Practice for social workers, psychologists and psychiatrists include assessment, diagnosis, treatment of mental, emotional and behavioral disorders • The scopes of practice for psychiatrists, psychologists, social workers, mental health counselors, and marriage and family therapists also include addiction treatment • However, pre-service education for these disciplines contains little content on addictions
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Specialty Credentials• Specialty credentials in addictions exist for psychiatrists, psychologists, social workers and licensed professional counselors• Fewer than 7 percent of practitioners hold these national credentials (Harwood, et al, in press)• Some States (e.g.CT, IL, PA) have developed or are in the process of developing specialty credentials in COD but they are generally for addiction counselors
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Specialty Credentials Requirements• Mental Health Practitioners need to know the Transdisciplinary Foundations as described in the Addiction Counseling Competencies (CSAT 1998)– Understanding Addictions (models & theories; behavioral, psychological, physical health and social effects of psychoactive substances)– Treatment knowledge (continuum of care; importance of social, family and other support systems; understanding and application of research; interdisciplinary approach to treatment– Application to Practice (Understanding of diagnostic and placement criteria; understanding of variety of helping strategies– Professional Readiness (Understanding of diverse cultures; disabilities
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Specialty Credentials• For addiction counselors providing COD treatment the domains that have been identified include:– Assessment/evaluation/diagnosis– Clinical Competence– Case Management– Pharmacology and medical issues– Systems Integration– Professional Responsibility (IAODAPCA 2002)
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Benefits and Risks Related to Specialty Credentials• Enhance competencies of practitioners in providing services to clients with COD • Integrates COD services into practice• Specialty credentials are voluntary and not required for those providing COD services• Lack of pre-service education in COD may preclude effective screening, assessment, intervention and referrals for COD clients
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Elements of a COD Certification• Need comprehensive understanding of substance abuse & mental disorders– Remission– Recovery– Resilience• Competencies should include integrated assessment, engagement, integrated treatment planning and treatment, and long term integrated treatment methods (CSAT 2005)
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Benefits and Risks of a COD Credential• Currently a specialty credential for COD practice exists mainly for substance abuse professionals in several states• Other disciplines have an addiction certification• Advantage of developing a national COD credential is the creation of a scope of practice and competencies specifically designed for working with COD clients• Risk is further splintering of the field and concerns that all patients would be perceived as needing COD treatment
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Program Accreditation and Licensure• Accreditation is a voluntary performance-based process used to assess an organization or institution based on established quality and safety standards. Surveyors are carefully trained to conduct the evaluation; funders and third party payors usually require accreditation of institutions and agencies
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Program Accreditation and Licensure• Licensure is a right or permission granted by the state to engage in a business, perform an act or engage in a transaction that would be unlawful with such a right or permission (Merriam-Webster 1996) • States regulate the licensing of programs & hospitals; regulations may include policies, procedures, types of staff, facility safety standards and types of care specific programs can offer
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Core Capabilities for Programs Serving COD Clients• Following services are needed:– Integrated screening and assessment– Staged interventions– Assertive Outreach– Motivational interventions– Simultaneous Interventions– Risk Reduction– Tailored mental health and substance abuse treatment– Counseling– Social Support Interventions– Longitudinal view of remission and recovery– Cultural sensitivity and competence (CSAT 2005)
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Current Issues Regarding State Licensure of Programs• COD programs need to have appropriately trained & certified/licensed staff; comprehensive services including a full array of mental health and substance abuse treatment; supportive services; and implementation of evidence-based practices• Most programs are licensed by State mental health and substance abuse agencies respectively: funding streams are separate; different data collection systems; different staffing patterns; distinct service requirements
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Models of Licensure Standards for COD Programs • Comprehensive Continuous Integrated System of Care (CCISC) model is being implemented in several states (CSAT 2005)• CCISC integrates mental health and substance abuse systems to provide a comprehensive system of care including policies, financing, programs, clinical practices and basic clinician competencies (Minkoff 2003; CSAT 2005)
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Benefits of Licensure and Accreditation for COD Programs• Elimination of many obstacles that currently exist• Programs would be able to screen and assess for COD and some could be designated as programs to provide enhanced services• Programs that wish to specialize in COD treatment could be recognized• National accreditation would create consistent standards for programs including administrative, staffing and programmatic
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Issues and Future Direction• Little research exists on whether licensed/certified clinicians have better outcomes than those not certified• Though competencies in substance abuse are being added to practice standards few curricula provide adequate education or training• Evidence-based practices for COD treatment need to be incorporated into education and training standards• State program licensure practices still make programs providing COD treatment jump through a maze of regulations• JCAHO has not yet established national standards for dual diagnosis programs
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References• American Association for Marriage and Family Therapy Core Competency Taskforce. (2004) The MFT Core Competencies, Alexandria, VA: AAMFT• Association of Social Work Boards. Model social work practice act. www.aswb.org/Model_law.pdf• Association of State and Provincial Psychology Boards. The practice of psychology. www.asppb.org/exam/practice.asp• Center for Substance Abuse Treatment. 2005. Substance Abuse Treatment for Persons with Co- occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No (SMA) 05-3992. Rockville, MD: SAMHSA
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References• Center for Substance Abuse Treatment (1998). Addiction Counseling Competencies: The Knowledge, Skills and Attitudes of Professional Practice. Technical Assistance Publication Series No. 21. DHHS Publication No. (SMA) 98-3171. Rockville, MD: SAMHSA• Harwood, H.J., Kowalski, J., and Ameen, A. (In press). Training on substance abuse of behavioral health professionals. Falls Church, VA: The Lewin Group• Illinois Alcohol and Other Drug Abuse Professional Certification Association. (2002). Mental Illness/Substance Abuse Professional Role Delineation Study. www.iaodapca.org.• Merriwam-Webster. (1996) Merriam-Webster’s Dictionary of Law. Springfield MA: Merriam-Webster.
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References• Minkoff, K. (2003). Comprehensive, continuous, integrated system of care model description. http://www.zialogic.org/CCISC.htm.• Schoon, C.G. & Smith, I.L. (2000). The licensure and certification mission. In C.G. Schoon and I.L. Smith (Eds.) The licensure and certification mission: Legal, social and political foundations (pp1-3). New York: Professional Examination Services.• Shimberg, B. & Roederer, (1994). Questions a legislator should ask. Lexington, KY: The Council on Licensure, Enforcement and Regulation.• Substance Abuse and Mental Health Services Administration (2003).Strategies for developing treatment programs for people with co- occurring substance abuse and mental disorders.DHHS Publication No. (SMA) 03-3782. Rockville, MD: SAMHSA• Substance Abuse and Mental Health Services Administration. (2002) Report to Congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. http://als.samshsa.gov/reports/congress2002/CoOccurringRPT.pdf.

Mental Health Screenings and Trauma-Related Counseling in Substance Abuse Treatment Facilities

Mental Health Screenings and Trauma-Related Counseling in Substance Abuse Treatment FacilitiesIn Brief •In 2009, more than half (62 percent) of all substance abuse treatment facilities provided brief mental health screenings that could be used to identify clients in need of trauma services; less than half (42 percent) provided full diagnostic mental health assessments


•Facilities that primarily focused on a mix of mental health and substance abuse treatment services were more likely than facilities with other primary focuses to report using trauma counseling "always or often" (30 vs. 16 to 26 percent)


•Facilities that were operated by tribal governments (55 percent) were more likely than facilities that were operated by the Federal Government (37 percent), private for-profit organizations (36 percent), private non-profit organizations (35 percent), or State or local, county, or community governments (32 percent each) to offer domestic violence services



Research shows that the experience of traumatic events and the possible sequelae of posttraumatic stress disorder (PTSD) often co-occur with a substance abuse disorder1 and are present among many substance abuse treatment clients.2 Common types of trauma include being exposed to a natural disaster or violence in combat or noncombat situations and experiencing physical assault or domestic violence. Because of the relationship between substance use and trauma-related mental health problems, it is recommended that substance abuse treatment facilities offer mental health screenings and assessments to determine whether or not a client is suffering from a trauma-related illness3 and/or has been involved in domestic violence.4

This report explores the extent to which mental health screenings, mental health assessments, trauma-related counseling, and domestic violence services are provided in substance abuse treatment facilities. The provision of these services in treatment facilities is captured by the 2009 National Survey of Substance Abuse Treatment Services (N-SSATS).

Mental Health Screenings and Assessments


Mental health screenings and assessments can be used in treatment facilities to identify clients who have been exposed to one or more traumatic events and who have problematic symptoms associated with such exposure. The Center for Substance Abuse Treatment (CSAT) guidelines for best practice with substance abuse treatment clients differentiate between mental health screenings and mental health assessments. Screenings assist in identifying substance abuse clients that show signs of mental health problems by asking questions that elicit a yes or no response; assessments define the nature of the mental health problem and gather more detailed information that may be used to develop treatment plans for clients with co-occurring mental health and substance abuse problems.5

More than half (62 percent) of the 13,513 treatment facilities that responded to N-SSATS provided brief mental health screenings for clients, but less than half (42 percent) provided full diagnostic mental health assessments. Facilities with a primary focus on mental health services, a mix of mental health and substance abuse treatment services, or general health care were more likely than facilities that primarily focused only on substance abuse treatment services to provide mental health screenings or mental health assessments (Figure 1).

Figure 1. Facilities Providing Mental Health Screenings or Assessments, by Primary Focus of Treatment Facility: 2009

Source: 2009 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS).

Figure 1 Table. Facilities Providing Mental Health Screenings or Assessments, by Primary Focus of Treatment Facility: 2009 Primary Focus Mental Health Screenings Mental Health Assessments
Substance Abuse Treatment Services 45% 20%
Mental Health Services 94% 89%
Mix of Mental Health and Substance Abuse Treatment Services 90% 76%
General Health Care 85% 75%
Other/Unknown 53% 21%
Source: 2009 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS).

Treatment facilities that were operated by the Federal Government (68 percent) were more likely than facilities operated by State governments (52 percent); local, county, or community governments (50 percent); private non-profit organizations (43 percent); tribal governments (40 percent); or private for-profit organizations (36 percent) to provide mental health assessments (Figure 2). Additionally, facilities that were operated by the Federal Government (79 percent) were more likely than those operated by other types of governments or organizations to provide mental health screenings.

It is recommended that substance abuse treatment providers screen all clients in substance abuse treatment for exposure to domestic violence in order to identify batterers and survivors. After substance abuse treatment providers identify those clients who have been involved in domestic violence, the provider may then determine what services the clients may need.4 Domestic violence services may include, for example, specialized counseling, medical services, or legal services.

N-SSATS provides information regarding whether or not treatment facilities offer domestic violence services. In 2009, less than half (35 percent) of treatment facilities offered domestic violence services. Facilities that primarily focused on a mix of mental health and substance abuse treatment services (46 percent) or general health care (44 percent) were more likely than those that focused on mental health services (37 percent) or substance abuse treatment services (30 percent) to offer domestic violence services.

Discussion

Mental health problems, specifically those related to trauma and/or domestic violence, often co-occur with substance abuse. Mental health screenings Mental health problems, specifically those related to trauma and/or domestic violence, often co-occur with substance abuse. Mental health screenings and assessments may be used by substance abuse treatment facilities to identify clients who are suffering from mental health problems related to trauma. By first identifying these clients, treatment providers may then develop a comprehensive treatment plan and assist clients with gaining access to trauma-related services. Treatment plans for clients with these co-occurring problems should address their substance abuse and incorporate evidenced-based interventions that aim to reduce the biological, psychological, and behavioral symptoms associated with trauma.6

The data in this report provide a snapshot of the extent to which the treatment system is identifying and providing certain services to clients suffering from co-occurring substance abuse and trauma-related mental health problems. This information may be used to increase public health awareness about substance abuse and trauma-related mental health problems, and inform behavioral health care reform initiatives that increase the treatment system’s capacity to provide needed trauma-related services to substance abuse clients.

End Notes

1 Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060.
2 Nanjavits, L. M. (2002). Clinicians’ views on treating posttraumatic stress disorder and substance use disorder. Journal of Substance Abuse Treatment, 22, 79-85.
3 Center for Substance Abuse Treatment. (1995). Anxiety disorders. In Assessment and treatment of patients with coexisting mental illness and alcohol and other drug abuse (Treatment Improvement Protocol [TIP] Series 9, DHHS Publication No. SMA 95-3061). Rockville, MD: Substance Abuse and Mental Health Services. (Original work published 1994) Retrieved from http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A30236
4 Fazzone, P. A., Holton, J. K., & Reed, B. G. (Consensus Panel Co-Chairs); Center for Substance Abuse Treatment. (1997). Substance abuse treatment and domestic violence (Treatment Improvement Protocol [TIP] Series 25, DHHS Publication No. SMA 97-3163). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A46712
5Sacks, S., & Ries, R. K. (Consensus Panel Co-Chairs); Center for Substance Abuse Treatment. (2005). Substance abuse treatment for persons with co-occurring disorders (Treatment Improvement Protocol [TIP] Series 42, DHHS Publication No. SMA 05-3922). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A74073
6 Shalev, A., Bonne, O., & Eth, S. (1996). Treatment of post traumatic stress disorder: A review. Psychosomatic Medicine, 58, 165-182.

Care of Adults With Mental Health and Substance Abuse Disorders in U.S. Community Hospitals

Care of Adults With Mental Health and Substance Abuse Disorders in U.S. Community Hospitals, 2004
Executive Summary
Mental health and substance abuse (MHSA) disorders place a substantial burden on individuals, families, the health care system, and the economy. Beyond the personal costs of these conditions, mental illness and substance abuse result in lost productivity, increased medical expenditures, and other costs including those resulting from law enforcement activities.

Community hospitals play an important role in the treatment of individuals with MHSA disorders. For some of these patients, the MHSA disorder is the principal diagnosis, or the main reason for the hospital stay. For others, the MHSA disorder complicates a principal non-MHSA diagnosis and is listed on the hospital record as a secondary diagnosis. In 2004, 24 percent of stays in community hospitals were for patients with principal and/or secondary MHSA diagnoses.

In 2004, adults with a mental health and/or substance abuse diagnosis accounted for 1 out of 4 stays at U.S. community hospitals—7.6 million hospital stays.

This Fact Book examines community hospital care for adults 18 years of age and older with MHSA diagnoses. Community hospitals are non-Federal, short-term (or acute care) general and specialty hospitals. They include any type of hospital that is open to the public, such as academic medical centers, medical specialty hospitals, and public hospitals, but they do not include specialty psychiatric or substance abuse treatment facilities.

This Fact Book provides an overview of hospital stays involving MHSA disorders and addresses these key questions:

■What are the common reasons for hospitalization, by type and diagnosis?
■How do stays vary by gender and age?
■How are patients admitted to the hospital?
■What is the mean length of stay?
■How much do hospital stays cost?
■What percentage of hospital resource use is attributable to MHSA disorders?
■Who is billed for hospital stays?
■Where do patients go after they are discharged?
In addition, this Fact Book presents detailed statistics on three special topics related to MHSA hospitalizations:

■Dual diagnosis stays (i.e., the patient has both a substance-related and a mental health disorder).
■Stays related to suicide or attempted suicide.
■Maternal stays complicated by a mental health or substance abuse disorder.
Eleven mutually exclusive categories of MHSA disorders are examined in this Fact Book:

•Mood disorders.
•Substance-related disorders.
•Delirium, dementia, and amnestic and cognitive disorders.
•Anxiety disorders.
•Schizophrenia and other psychotic disorders.
•Personality disorders.
•Adjustment disorders.
•Disruptive behavior disorders.
•Impulse control disorders.
•Disorders usually diagnosed in infancy, childhood, and adolescence.
•Miscellaneous mental disorders.
What Are the Common Reasons for Hospitalization, by Type and Diagnosis?
In 2004, nearly 1 out of 4 hospital stays for adults in U.S. community hospitals involved MHSA disordersi—about 7.6 million hospitalizations. Of these, 1.9 million hospitalizations (6 percent of adult hospital stays) had a principal MHSA diagnosis and 5.7 million (18 percent) were primarily for non-MHSA diagnoses but had a secondary mental health or substance abuse diagnosis.

The top 5 MHSA diagnosesii seen in the hospital were mood disorders, substance-related disorders, delirium/dementia, anxiety disorders, and schizophrenia. One out of every 10 hospital stays included a diagnosis of mood disorders (over 3.3 million stays). One out of every 14 hospital stays included substance-related disorders (2.3 million stays). One out of every 20 stays was related to delirium/dementia (1.7 million stays).


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iBased on all-listed diagnoses.
iiBased on all-listed MHSA diagnoses.


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How Do Stays Vary by Gender and Age?
Gender
There were more MHSA-related hospital stays for women than for men. Although women comprised 51 percent of the U.S. adult population, they accounted for 58 percent of MHSA-related stays and 62 percent of non-MHSA stays. The most frequent MHSA diagnosis among hospitalized women was mood disorders. Substance abuse was the most frequent MHSA diagnosis in the hospital for men. Substance-related disorders were 3 times more common among hospitalized men than women.

Age
Older age groups accounted for a disproportionate share of hospital stays for MHSA disorders in 2004. For example, adults 80 and older comprised 5 percent of the U.S. adult population, yet they accounted for nearly 21 percent of MHSA hospital stays. In contrast, adults ages 18 to 44 comprised over half the total U.S. population, but accounted for 30 percent of MHSA hospital stays.

Among adults younger than 80, the most common MHSA diagnosis was mood disorders. Overall, 11 percent of stays for people 18-44 years of age, 13 percent of those 45-64 years of age, and 8 percent of those 65-79 years of age included a diagnosis of mood disorders. For adults 80 and older, delirium/dementia was the most common MHSA diagnosis; this disorder was noted in 21 percent of hospital stays for this age group, but mood disorders ranked second for this age group (8 percent of stays).

The second most common MHSA diagnosis for adults ages 18-64 was substance-related disorders, which was noted in about 10 percent of all hospital stays for this age group.

The distribution of age varied by the top 5 most common MHSA diagnoses. Almost half of all substance-related stays were for adults ages 18-44 while nearly all (93 percent) of the stays related to dementia/delirium were for adults age 65 and older.

One out of every 10 hospital stays included a diagnosis of mood disorders.

One out of every 14 hospital stays involved substance-related disorders.

The most frequent MHSA diagnosis among hospitalized women was mood disorders.

The most frequent MHSA diagnosis for men was substance-related disorders. Substance-related disorders were 3 times more common among hospitalized men than women.

Adults 80 and older comprised 5 percent of the U.S. adult population, yet they accounted for 21 percent of MHSA hospital stays.


How Are Patients Admitted to the Hospital?
Nearly 61 percent of MHSA-related admissions occur through the emergency department (ED) compared to only 45 percent of admissions with no MHSA diagnosis.

Adults with only secondary MHSA diagnoses were the most likely to be admitted through the ED—64 percent—compared with 51 percent for admissions with principal MHSA diagnoses only.

What Is the Mean Length of Stay?
Adults with any MHSA diagnosis (principal or secondary) stayed in the hospital longer than adults with non-MHSA diagnoses (5.8 versus 4.5 days). The difference was even more pronounced for adults with only a principal MHSA diagnosis—they stayed in the hospital an average of 8 days compared with 5 days for patients with non-MHSA diagnoses.

How Much Do Hospital Stays Cost?
Cost, by Type
The mean total cost for a hospital stay with any MHSA diagnosis ($7,800) was $1,100 lower than for stays with no MHSA diagnosis ($8,900). The mean cost per day for MHSA hospitalizations also was lower than for non-MHSA hospital stays—$1,600 per day compared with $2,300 per day—indicating that MHSA stays were less resource intensive.

The difference in cost was even more pronounced for adults with only a principal MHSA diagnosis. The mean total cost for a hospital stay with only a principal MHSA diagnosis was 39 percent lower than non-MHSA stays ($6,400 versus $8,900), and costs per day were 171 percent lower ($900 versus $2,300).

Cost, by Principal Diagnosis
Hospitalizations for the 5 most common principal MHSA diagnoses—mood disorder, schizophrenia, substance-related disorders, dementia/delirium, and anxiety disorders—cost $9.9 billion nationally.

The most common principal MHSA diagnosis—mood disorders—had the highest aggregate inpatient hospital costs of all MHSA diagnoses at $3.4 billion nationally in 2004. On a per stay basis, schizophrenia was the most expensive of the common principal MHSA diagnoses to treat at $8,000 per stay.

Hospitalizations for the 5 most common principal MHSA diagnoses cost $9.9 billion nationally.
About 33 percent of all uninsured stays, 29 percent of Medicaid stays, and 26 percent of Medicare stays were related to MHSA disorders, compared with only 16 percent of privately insured stays.

Over 66 percent of adult hospital stays with MHSA diagnoses were billed to the government in 2004.

Who Is Billed for Hospital Stays?
A large proportion of stays for the uninsured and for patients covered by Medicaid and Medicare were related to MHSA disorders. About 33 percent of all uninsured stays, 29 percent of Medicaid stays, and 26 percent of Medicare stays were related to MHSA disorders. On the other hand, only 16 percent of privately insured stays were related to MHSA disorders.

Expected Primary Payer, by Type
Over 66 percent of adult hospital stays with MHSA diagnoses were billed to the government in 2004. Medicaid was billed for 18 percent of all MHSA-related stays and Medicare was billed for 49 percent of all MHSA stays. In comparison, 57 percent of hospital stays with non-MHSA diagnoses were billed to the government.

Stays for patients with MHSA diagnoses were 36 percent more likely to be billed as uninsured than stays unrelated to MHSA diagnoses. Nearly 8 percent of MHSA stays were uninsured compared with about 5 percent of stays with non-MHSA diagnoses. Patients with both principal and secondary MHSA diagnoses were the most likely to be uninsured—nearly 13 percent compared with 5 percent for patients with non-MHSA diagnoses.

Only about 23 percent of stays with MHSA diagnoses were billed to private health insurance compared with about 37 percent of stays with non-MHSA diagnoses.

Expected Primary Payer, by Principal Diagnosis
Hospital stays related to schizophrenia and those associated with delirium/dementia were the most likely to be billed to the government. Over 78 percent of hospital stays for schizophrenia were billed to the government (35 percent to Medicaid and 44 percent to Medicare). Similarly, 90 percent of hospital stays for delirium/dementia were billed to the government (4 percent to Medicaid and 86 percent to Medicare). Schizophrenia is a qualifying disorder for Medicaid, and delirium/dementia is more frequent among the elderly who are covered by Medicare. In contrast, 53 percent of hospital stays for mood disorders and 52 percent of stays for substance-related disorders were billed to government payers.

Where Do Patients Go After They Are Discharged?
Adults with MHSA disorders were more likely to be transferred to non-acute health care facilities (which include psychiatric facilities, nursing homes, and rehabilitation centers) compared to those with non-MHSA diagnoses. Although only 11 percent of non-MHSA stays ended in transfers to non-acute facilities, 16 percent of stays for a principal MHSA diagnosis ended with such a transfer in 2004. Because of the large proportion of elderly patients with dementia as a secondary diagnosis, 27 percent of hospital stays with only secondary MHSA diagnoses ended with transfer to non-acute health care facilities.

Hospital stays that were principally for MHSA disorders were the least likely to be discharged to home health care. Only 2 percent of hospital stays for principal MHSA diagnoses ended in discharge to home health care, compared with 11 percent of stays with only secondary MHSA diagnoses and 10 percent of non-MHSA stays.

Over 78 percent of hospital stays for schizophrenia and 90 percent of hospital stays for delirium/dementia were billed to the government.
Hospital stays related to MHSA disorders accounted for roughly one-fourth of total resource use: 24 percent of all adult stays, 29 percent of days in the hospital, and 22 percent of total hospital costs.

About 3 percent of all hospital stays (nearly 1 million hospitalizations) involved dual diagnosis—both substance-related and mental health disorder.

Men and adults 18-44 are most likely to have a dual diagnosis—55 percent and 60 percent, respectively.



What Percentage of Hospital Resource Use Is Attributable to MHSA Disorders?
MHSA disorders accounted for roughly one-fourth of total resource use in 2004. MHSA disorders were involved in about 24 percent of all adult hospital stays, 29 percent of days in the hospital, and 22 percent of total hospital costs.

Dual Diagnosis Stays
A person with both a substance-related problem and a mental health disorder is considered to have a dual diagnosis. In 2004, nearly 1 million adult hospital stays involved a dual diagnosis—3 percent of all hospital stays. About 13 percent of all MHSA-related hospital stays involved a dual diagnosis.

Among dual diagnosis stays, 34 percent of patients had alcohol-related problems, 45 percent had drug-related problems, and 22 percent had both alcohol- and drug-related problems. The most frequent mental health disorder associated with substance-related problems was mood disorders (68 percent). All other mental health disorders were much less frequent. Anxiety disorders were seen in about 19 percent of hospital stays with a dual diagnosis and schizophrenia was seen in about 18 percent of these stays.

Most dually diagnosed inpatients were men and were younger. Fifty-five percent of stays with a dual diagnosis were for men, even though 41 percent of other MHSA stays and 38 percent of non-MHSA stays were for men. Similarly, nearly 60 percent of all dually diagnosed inpatients were ages 18-44, even though this age group comprised only 26 percent of other MHSA stays and 33 percent of adult non-MHSA hospital stays.

Hospital stays for dual diagnosis were more likely to be billed as uninsured or billed to Medicaid than to any other payer.

Suicide-Related Stays
In 2004, nearly 179,000 adult hospital stays were related to suicide or suicide attempts. By far, the most frequent mechanism of injury for suicide-related hospitalizations was poisoning. Nearly two-thirds of hospital stays for suicide attempts were a result of poisoning, while 1 in 10 hospital stays for suicide attempts was a result of cutting/piercing. Firearms were implicated in only 1 percent of suicide-related hospital stays.

Nearly all suicide-related hospital stays involved MHSA disorders (93 percent). The single most common MHSA diagnosis related to attempted suicide was mood disorders, which accounted for nearly 70 percent of all suicide-related stays.

Adults hospitalized for suicide attempt were younger than other patients. Most suicide-related hospital stays occurred among adults ages 18-44 (72 percent), followed by adults ages 45-64 (24 percent). Patients ages 65 and older made up less than 4 percent of all suicide-related stays. Uninsured stays and stays billed to Medicaid made up nearly half of all suicide-related hospitalizations. Even though only 5 percent of non-MHSA hospital stays were uninsured, 22 percent of suicide-related stays were uninsured. Nearly 13 percent of non-MHSA hospital stays were billed to Medicaid compared with 23 percent of suicide-related stays.

There were nearly 179,000 adult hospital stays related to suicide or suicide attempts.

Poisoning accounted for 2 out of 3 suicide-related stays—the most frequent mechanism of injury.

Most suicide-related stays (72 percent) were among adults 18-44.

Although only 5 percent of non-MHSA hospital stays were uninsured, 22 percent of suicide-related stays were uninsured.

Five percent of maternal hospital stays involved at least one MHSA disorder.

Medicaid was billed for 38 percent of non-MHSA-related maternal stays but almost 57 percent of MHSA-related maternal stays.



Maternal Stays
In 2004, nearly 4.6 million hospital stays were for women with maternal conditions and of these, 240,000 (5 percent) were complicated by at least one MHSA disorder. Women with MHSA disorders complicating a maternal stay were disproportionately younger, ages 18-24. Even though this group accounted for only 32 percent of non-MHSA-related maternal stays, they were responsible for 40 percent of all MHSA-related maternal stays.

Medicaid was much more likely to be billed for maternal stays complicated by MHSA disorders compared with all other payers. Medicaid was billed for 38 percent of non-MHSA-related maternal stays but almost 57 percent of maternal stays with MHSA disorders.

Return to Contents

Foreword
The mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. To help fulfill this mission, AHRQ develops a number of powerful databases, including those created by the Healthcare Cost and Utilization Project (HCUP). HCUP is a Federal-State-Industry partnership designed to build a standardized, multi-State health data system; HCUP features databases, software tools, and statistical reports to inform policymakers, health system leaders, and researchers.

For data to be useful, they must be disseminated in a timely, accessible way. To meet this objective, AHRQ launched HCUPnet, an interactive, Internet-based tool for identifying, tracking, analyzing, and comparing statistics on hospital utilization, outcomes, and charges (http://www.hcupnet.ahrq.gov/). Menu-driven HCUPnet guides users in tailoring specific queries about hospital care online; with a click of a button, users receive answers within seconds.

To make HCUP data even more accessible, AHRQ disseminates HCUP Statistical Briefs, an online publication series that presents simple, descriptive statistics on a variety of specific, focused topics (http://www.hcup-us.ahrq.gov/reports/statbriefs.jsp). Statistical Briefs are made available regularly throughout the year and have covered topics such as hospitalizations among the uninsured, the national bill for hospital care by payer, and hospitalizations related to childbirth.

In addition, AHRQ produces the HCUP Fact Books to highlight statistics about hospital care in the United States in an easy-to-use, readily accessible format. Each Fact Book provides information about specific aspects of hospital care—the single largest component of our health care dollar. These national estimates are benchmarks against which States and others can compare their own data.

This Fact Book examines inpatient care of mental health and substance abuse (MHSA) disorders. Because HCUP nationwide databases do not include data from long-term care facilities, specialty psychiatric hospitals, or substance-abuse treatment facilities, this report provides a detailed analysis of the treatment of these disorders in short-term, non-Federal, community hospitals. This Fact Book considers MHSA disorders among adults ages 18 and older and offers comprehensive statistics on special topics related to MHSA hospitalizations.

We invite you to tell us how you are using this Fact Book and other HCUP data and tools and to share suggestions on how HCUP products might be enhanced to further meet your needs. Please e-mail us at hcup@ahrq.gov or send a letter to the address below.

Irene Fraser, Ph.D.
Director
Center for Delivery, Organization, and Markets
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850

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Contributors
HCUP is based on data collected by individual State Partner organizations (including State departments of health, hospital associations, and private agencies). These organizations provide the data to AHRQ where the data are converted to uniform data products. Without the participation of the following Partner organizations, HCUP and the 2004 Nationwide Inpatient Sample (NIS) would not be possible:

•Arkansas Department of Health & Human Services
•Arizona Department of Health Services
•California Office of Statewide Health Planning & Development
•Colorado Health and Hospital Association
•Connecticut Integrated Health Information (Chime, Inc.)
•Florida Agency for Health Care Administration
•Georgia Hospital Association (GHA)
•Hawaii Health Information Corporation
•Illinois Department of Public Health
•Indiana Hospital & Health Association
•Iowa Hospital Association
•Kansas Hospital Association
•Kentucky Cabinet for Health and Family Services
•Maryland Health Services Cost Review Commission
•Massachusetts Division of Health Care Finance and Policy
•Michigan Health & Hospital Association
•Minnesota Hospital Association
•Missouri Hospital Industry Data Institute
•Nebraska Hospital Association
•Nevada Department of Human Resources
•New Hampshire Department of Health and Human Services
•New Jersey Department of Health & Senior Services
•New York State Department of Health
•North Carolina Department of Health and Human Services
•Ohio Hospital Association
•Oregon Association of Hospitals and Health Systems
•Rhode Island Department of Health
•South Carolina State Budget & Control Board
•South Dakota Association of Healthcare Organizations
•Tennessee Hospital Association
•Texas Department of State Health Services
•Utah Department of Health
•Vermont Association of Hospitals and Health Systems
•Virginia Health Information
•Washington State Department of Health
•West Virginia Health Care Authority
•Wisconsin Department of Health & Family Services
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Introduction
For those diagnosed with mental health and/or substance abuse (MHSA) disorders, social relationships are strained, and the ability to perform at school and work is impaired. Many are too debilitated to work. The loss of wages is a burden on families and the loss of labor negatively impacts the economy. Moreover, the financial burden of treatment for these chronic conditions is substantial.1-2

Although an untold number of individuals who suffer from MHSA disorders will go untreated, for those who do receive care, treatment settings are varied. Some will seek care in outpatient or ambulatory settings, where the majority of specialty MHSA care takes place. Others will need more intense treatment in an inpatient setting—community hospitals or long-term, residential facilities. With the continued drop in psychiatric beds in specialty facilities, community hospitals have become the primary source of short-term inpatient care.1, 3

This Fact Book examines community hospital stays for adults with MHSA disorders in 2004. MHSA disorders examined in this Fact Book include:

•Mood disorders.
•Substance-related disorders.
•Delirium, dementia, and amnestic and cognitive disorders.
•Anxiety disorders.
•Schizophrenia and other psychotic disorders.
•Personality disorders.
•Adjustment disorders.
•Disruptive behavior disorders.
•Impulse control disorders.
•Disorders usually diagnosed in infancy, childhood or adolescence.
•Miscellaneous mental disorders.
In addition, several special topics are addressed, such as dual diagnosis, hospitalizations for suicide attempt, and maternal stays complicated by MHSA disorders.

Information on data sources and methods are available at the end of the Fact Book. A glossary contains MHSA terms used in this Fact Book. Appendix A provides information on the mapping of diagnostic codes to MHSA disorders. Appendix B provides more detailed information on hospital stays for specific principal MHSA disorders. Appendix C highlights common principal and secondary diagnoses by gender and age.

Treatment in Community Versus Specialty Hospitals
This Fact Book presents information on MHSA stays in U.S. community hospitals, which are defined by the American Hospital Association as “all non-Federal, short-term (or acute care) general and specialty hospitals.”4 Although community hospitals include any type of hospital that is open to the public, such as academic medical centers, medical specialty hospitals, and public hospitals, they do not include specialty psychiatric or substance abuse treatment facilities.

■In 2004, nearly all community hospitals in the United States (98.0 percent) provided care to patients with MHSA disorders.
■Almost one-fourth of adult stays in community hospitals (23.8 percent) involved a MHSA disorder.
■Almost 10 times as many patients with MHSA disorders—7.6 million—were seen in community hospitals as in psychiatric facilities.
■Although specialty psychiatric facilities provided nearly 27 million days of care annually, community hospitals provided over 44 million days of care to patients with MHSA disorders.
■Stays in community hospitals were considerably shorter than stays in specialty facilities. The mean length of stay for MHSA disorders was 5.8 days in community hospitals compared to 33.0 days in specialty psychiatric facilities.

Eating Disorders

EATING DISORDERS
What are eating disorders?

Who has eating disorders?

What are the symptoms of eating disorders?

What medical problems can arise as a result of eating disorders?

What is required for a formal diagnosis of an eating disorder?

How are eating disorders treated?

For a referral to the nearest therapist specializing in eating disorders

What are eating disorders?

Eating disorders often are long-term illnesses that may require long-term treatment. In addition, eating disorders frequently occur with other mental disorders such as depression, substance abuse, and anxiety disorders (NIMH, 2002). The earlier these disorders are diagnosed and treated, the better the chances are for full recovery. This fact sheet identifies the common signs, symptoms, and treatment for three of the most common eating disorders: anorexia nervosa, bulimia nervosa, and binge-eating disorder (NIMH, 2002).
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Who has eating disorders?

Research shows that more than 90 percent of those who have eating disorders are women between the ages of 12 and 25 (National Alliance for the Mentally Ill, 2003). However, increasing numbers of older women and men have these disorders. In addition, hundreds of thousands of boys are affected by these disorders (U.S. DHHS Office on Women's Health, 2000).
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What are the symptoms of eating disorders?

Anorexia nervosa - People who have anorexia develop unusual eating habits such as avoiding food and meals, picking out a few foods and eating them in small amounts, weighing their food, and counting the calories of everything they eat. Also, they may exercise excessively.

Bulimia nervosa - People who have bulimia eat an excessive amount of food in a single episode and almost immediately make themselves vomit or use laxatives or diuretics (water pills) to get rid of the food in their bodies. This behavior often is referred to as the "binge/purge" cycle. Like people with anorexia, people with bulimia have an intense fear of gaining weight.

Binge-eating disorder - People with this recently recognized disorder have frequent episodes of compulsive overeating, but unlike those with bulimia, they do not purge their bodies of food (NIMH, 2002). During these food binges, they often eat alone and very quickly, regardless of whether they feel hungry or full. They often feel shame or guilt over their actions. Unlike anorexia and bulimia, binge-eating disorder occurs almost as often in men as in women (National Eating Disorders Association, 2002).
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What medical problems can arise as a result of eating disorders?

Anorexia nervosa - Anorexia can slow the heart rate and lower blood pressure, increasing the chance of heart failure. Those who use drugs to stimulate vomiting, bowel movements, or urination are also at high risk for heart failure. Starvation can also lead to heart failure, as well as damage the brain. Anorexia may also cause hair and nails to grow brittle. Skin may dry out, become yellow, and develop a covering of soft hair called lanugo. Mild anemia, swollen joints, reduced muscle mass, and light-headedness also commonly occur as a consequence of this eating disorder. Severe cases of anorexia can lead to brittle bones that break easily as a result of calcium loss.

Bulimia nervosa - The acid in vomit can wear down the outer layer of the teeth, inflame and damage the esophagus (a tube in the throat through which food passes to the stomach), and enlarge the glands near the cheeks (giving the appearance of swollen cheeks). Damage to the stomach can also occur from frequent vomiting. Irregular heartbeats, heart failure, and death can occur from chemical imbalances and the loss of important minerals such as potassium. Peptic ulcers, pancreatitis (inflammation of the pancreas, which is a large gland that aids digestion), and long-term constipation are also consequences of bulimia.

Binge-eating disorder - Binge-eating disorder can cause high blood pressure and high cholesterol levels. Other effects of binge-eating disorder include fatigue, joint pain, Type II diabetes, gallbladder disease, and heart disease.
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What is required for a formal diagnosis of an eating disorder?

Anorexia nervosa - Weighs at least 15 percent below what is considered normal for others of the same height and age; misses at least three consecutive menstrual cycles (if a female of childbearing age); has an intense fear of gaining weight; refuses to maintain the minimal normal body weight; and believes he or she is overweight though in reality is dangerously thin (American Psychiatric Association [APA], 1994; NIMH, 2002).

Bulimia nervosa - At least two binge/purge cycles a week, on average, for at least 3 months; lacks control over his or her eating behavior; and seems obsessed with his or her body shape and weight (APA, 1994; NIMH, 2002).

Binge-eating disorder - At least two binge-eating episodes a week, on average, for 6 months; and lacks control over his or her eating behavior (NIMH, 2002).
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How are eating disorders treated?

Anorexia nervosa - The first goal for the treatment of anorexia is to ensure the person's physical health, which involves restoring a healthy weight (NIMH, 2002). Reaching this goal may require hospitalization. Once a person's physical condition is stable, treatment usually involves individual psychotherapy and family therapy during which parents help their child learn to eat again and maintain healthy eating habits on his or her own. Behavioral therapy also has been effective for helping a person return to healthy eating habits. Supportive group therapy may follow, and self-help groups within communities may provide ongoing support.

Bulimia nervosa - Unless malnutrition is severe, any substance abuse problems that may be present at the time the eating disorder is diagnosed are usually treated first. The next goal of treatment is to reduce or eliminate the person's binge eating and purging behavior (NIMH, 2002). Behavioral therapy has proven effective in achieving this goal. Psychotherapy has proven effective in helping to prevent the eating disorder from recurring and in addressing issues that led to the disorder. Studies have also found that Prozac, an antidepressant, may help people who do not respond to psychotherapy (APA, 2002). As with anorexia, family therapy is also recommended.

Binge-eating disorder - The goals and strategies for treating binge-eating disorder are similar to those for bulimia. Binge-eating disorder was recognized only recently as an eating disorder, and research is under way to study the effectiveness of different interventions (NIMH, 2002).
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For a referral to the nearest therapist specializing in eating disorders, contact:

National Association of Anorexia Nervosa and Associated Disorders
P.O. Box 7
Highland Park, IL 60035
Hotline: 1-847-831-3438
http://www.anad.org/

National Eating Disorders Association
Informational and Referral Program
603 Stewart Street, Suite 803
Seattle, WA 98101
1-800-931-2237
http://www.nationaleatingdisorders.org

Note: The above is a suggested resource. It is not meant to be a complete list.