Mental Illnesses are Real, Disabling Conditions Affecting All Populations, Regardless of Race or Ethnicity
Major mental disorders like schizophrenia, bipolar disorder, depression, and panic disorder are found world-wide, across all racial and ethnic groups. They have been found across the globe, wherever researchers have surveyed. In the United States, the overall annual prevalence of mental disorders is about 21 percent of adults and children (DHHS, 1999). This Supplement finds that, based on the available evidence, the prevalence of mental disorders for racial and ethnic minorities in the United States is similar to that for whites.
This general finding about similarities in overall prevalence applies to minorities living in the community.2 It does not apply to those individuals in vulnerable, high-need subgroups such as persons who are homeless, incarcerated, or institutionalized. People in these groups have higher rates of mental disorders (Koegel et al., 1988; Vernez et al., 1988; Breakey et al., 1989; Teplin, 1990). Further, the rates of mental disorders are not sufficiently studied in many smaller racial and ethnic groups — most notably American Indians, Alaska Natives, Asian Americans, and Pacific Islander groups
— to permit firm conclusions about overall prevalence within those populations.
This Supplement pays special attention to vulnerable, high-need populations in which minorities are over-represented. Although individuals in these groups are known to have a high-need for mental health care, they often do not receive adequate services. This represents a critical public health concern, and this Supplement identifies as a course of action the need for earlier identification and care for these individuals within a coordinated and comprehensive service delivery system.
Striking Disparities in Mental Health Care Are Found for Racial and Ethnic Minorities
This Supplement documents the existence of several disparities affecting mental health care of racial and ethnic minorities compared with whites:
Minorities have less access to, and availability of, mental health services.
Minorities are less likely to receive needed mental health services.
Minorities in treatment often receive a poorer quality of mental health care.
Minorities are underrepresented in mental health research.
The recognition of these disparities brings hope that they can be seriously addressed and remedied. This Supplement offers guidance on future courses of action to eliminate these disparities and to ensure equality in access, utilization, and outcomes of mental health care.
More is known about the disparities than the reasons behind them. A constellation of barriers deters minorities from reaching treatment. Many of these barriers operate for all Americans: cost, fragmentation of services, lack of availability of services, and societal stigma toward mental illness (DHHS, 1999). But additional barriers deter racial and ethnic minorities; mistrust and fear of treatment, racism and discrimination, and differences in language and communication. The ability for consumers3 and providers to communicate with one another is essential for all aspects of health care, yet it carries special significance in the area of mental health because mental disorders affect thoughts, moods, and the highest integrative aspects of behavior. The diagnosis and treatment of mental disorders greatly depend on verbal communication and trust between patient and clinician. More broadly, mental health care disparities may also stem from minorities’ historical and present day struggles with racism and discrimination, which affect their mental health and contribute to their lower economic, social, and political status. The cumulative weight and interplay of all barriers to care, not any single one alone, is likely responsible for mental health disparities.
Disparities Impose a Greater Disability Burden on Minorities
This Supplement finds that racial and ethnic minorities collectively experience a greater disability burden from mental illness than do whites. This higher level of burden stems from minorities receiving less care and poorer quality of care, rather than from their illnesses being inherently more severe or prevalent in the community.
This finding draws on several lines of evidence. First, mental disorders are highly disabling for all the world's populations (Murray & Lopez, 1996; Druss et al., 2000). Second, minorities are less likely than whites to receive needed services and more likely to receive poor quality of care. By not receiving effective treatment, they have greater levels of disability in terms of lost workdays and limitations in daily activities. Further, minorities are overrepresented among the Nation’s most vulnerable populations, which have higher rates of mental disorders and more barriers to care. Taken together, these disparate lines of evidence support the finding that minorities suffer a disproportionately high disability burden from unmet mental health needs.
The greater disability burden is of grave concern to public health, and it has very real consequences. Ethnic and racial minorities do not yet completely share in the hope afforded by remarkable scientific advances in understanding and treating mental disorders. Because of disparities in mental health services, a disproportionate number of minorities with mental illnesses do not fully benefit from, or contribute to, the opportunities and prosperity of our society. This preventable disability from mental illness exacts a high societal toll and affects all Americans. Most troubling of all, the burden for minorities is growing. They are becoming more populous, all the while experiencing continuing inequality of income and economic opportunity. Racial and ethnic minorities in the United States face a social and economic environment of inequality that includes greater exposure to racism and discrimination, violence, and poverty, all of which take a toll on mental health.
March 13, 2010
March 12, 2010
Mental Health Links - Suicide
Mental Health Links - Suicide
Organizations
Iowa State Prevention Programs
http://www.idph.state.ia.us/bhpl/healthy_iowans_2010.asp
This web site provides an overview of Iowa’s prevention programs for violence and abusive behavior.
Ohio's Suicide Prevention Program
http://www.mh.state.oh.us/kids/suicideprev/suicide.prevention.plan.pdf
Ohio's Suicide Prevention Plan is the next step in saving lives and reducing suicidal behaviors by developing a comprehensive strategy in response to a very complex set of issues.
National Police Suicide Foundation
http://www.psf.org/index.htm
The numbers of deaths due to suicide are 2 to 3 times the number of line of duty deaths among law enforcement agencies and emergency workers. The mission of the National P.O.L.I.C.E. Suicide Foundation is to provide suicide awareness and prevention training programs and support services that will meet the psychological and spiritual needs of emergency workers and their families.
National Resource Center for Suicide Prevention and Aftercare
http://www.thelink.org/html/nrc.htm
The NRC's goal is to provide suicide-related community education in the areas of prevention, intervention, and aftercare, as well as healing support services for families, youth, and those affected by the psychological trauma of suicide.
National Center for Suicide Prevention Training
http://www.ncspt.org/courses/orientation/
The National Center for Suicide Prevention Training (NCSPT) currently has two internet-based workshops. The first one, “Locating, Understanding, and Presenting Youth Suicide Data” and is available on an ongoing basis. The second workshop, "Planning and Evaluation for Youth Suicide Prevention" is being prepared for pilot testing. This web site provides more information on the trainings.
National Strategy for Suicide Prevention Indicators
http://www.nsspi.org/
The goal of the National Strategy for Suicide Prevention Indicators project is to identify and develop indicators for each of the strategy's objectives. Indicators are measured in order to quantify the achievement of an objective.
Klingenstein Third Generation Foundation
http://ktgf.org/index.html
One of the two areas of interest for this foundation are Childhood and Adolescent Depression, including suicide and suicide prevention. Grants have primarily fallen under the categories of Intervention and Referral, Prevention, Public Education/Training, and Infrastructure. The Foundation also sponsors a Fellowship Program for post-doctoral research in depression.
American Association of Poison Control Centers
http://www.aapcc.org
The American Association of Poison Control Centers is a Nationwide organization of poison centers and interested individuals. It provides a forum for poison centers and interested individuals to promote the reduction of morbidity and mortality form poisoning and sets voluntary standards for poison centers. It also produces publications and holds a yearly conference.
American Association of Suicidology
http://www.suicidology.org/index.cfm
The American Association of Suicidology is dedicated to the understanding and prevention of suicide. The organization promotes research, public awareness programs, and education and training for professionals and volunteers.
American College of Emergency Physicians
http://www.acep.org
The American College of Emergency Physicians promotes the highest standards of patient care through its advocacy and leadership. This web site contains information on the organization, fact sheets, information on continuing education, and many other resources.
American Correctional Health Services Association
http://www.corrections.com/achsa/
The ACHSA mission is to be the voice of the correctional healthcare profession, and serve as an effective forum for communication addressing current issues and needs confronting correctional healthcare.
American Foundation for Suicide Prevention
http://www.afsp.org
The American Foundation for Suicide Prevention is the only international non-profit organization dedicated to funding the research and education needed to prevent suicide.
First World Report on Violence and Health (Full Report)
http://www.who.int/violence_injury_prevention/violence/world_report/wrvheng/en/
This report, produced by the World Health Organization, is written mainly for researchers and practitioners. Its goals are to raise global awareness about the problems of violence and to make the case that violence is preventable and that public health systems have a crucial role to play in addressing its causes and consequences.
Befrienders International
http://www.befrienders.org/
Befrienders International is a network of centers run by trained volunteers that offer a free listening service that is non-judgmental and completely confidential. People are befriended by telephone, letter and email, and in face-to-face meetings.
American School Health Association
http://www.ashaweb.org
The American School Health Association unites the many professionals working in schools who are committed to safeguarding the health of school-aged children. The Association, a multidisciplinary organization of administrators, counselors, dentists, health educators, physical educators, school nurses and school physicians, advocates high-quality school health instruction, health services and a healthful school environment.
Association of Maternal and Child Health Programs
http://www.amchp.org
The Association of Maternal and Child Health Programs is an organization representing State public health leaders and other individuals and organizations working to improve the health and well being of all women, children, youth, and families. The group accomplishes its mission through partnerships with government agencies and the participation of its members, families, advocates, health care purchasers, providers, academic and research professionals, and others at the National, State and local levels.
Association of State and Territorial Health Officials
http://www.astho.org
The Association of State and Territorial Health Officials is a National non-profit organization representing the State and territorial public health agencies of the United States, the U.S. Territories, and the District of Columbia. Its members, the chief health officials of these jurisdictions, are dedicated to formulating and influencing sound public health policy, and to assuring excellence in State-based public health practice. This site provides information on events, policy statements, and publications.
Georgia's Suicide Prevention Plan
http://www.georgiasuicidepreventionplan.org
People can stop suicide. This fact is the foundation of the Georgia Suicide Prevention Plan. This web site provides the plan’s text and staff contact information.
Selected Reviews of Suicide Research - 2001
http://www.nimh.nih.gov/suicideresearch/suibib2001.cfm
This list of review articles was compiled by the NIMH Suicide Research Consortium, whose members have found the articles useful when providing technical assistance to grant applicants.
SOS High School Suicide Prevention Program
http://www.mentalhealthscreening.org/sos_highschool
The SOS Suicide Prevention Program provides school health professionals with all the educational materials necessary to replicate this easy-to-use program in a variety of school settings. Schools have the flexibility to make use of the materials in as large or small a program as their needs and resources dictate. The program can also be blended into an existing health curriculum. You can find out more about it at their web site.
Students Against Destructive Decisions
http://www.saddonline.com
Students Against Destructive Decision strive to provide students with the best prevention and intervention tools possible to deal with the issues of underage drinking, other drug use, impaired driving and other destructive decisions. Their site has a number of resources including fact sheets, a resource center, a list of events, and newsletters.
State and Territorial Injury Prevention Directors' Association
http://www.stipda.org
The mission of the State and Territorial Injury Prevention Director’s Association is to promote, sustain, and enhance the ability of State and Territorial public health departments to reduce death and disability associated with injuries. It accomplishes its mission by disseminating information on state-of-the-art injury prevention and control policies and strategies.
Suicide Among the Aged (Canada)
http://www.suicideinfo.ca/csp/go.aspx?tabid=118
This web site illustrates, through statistics, that suicide rates for the elderly exceed suicide rates among adolescents.
Suicide Prevention Action Network of USA (SPAN)
http://www.spanusa.org
The Suicide Prevention Action Network USA is a non-profit national organization that links the energy of those bereaved or touched by suicide with the expertise of leaders in science, health, business, government and public service to achieve the goal of significantly reducing the national rate of suicide by the year 2010.
Suicide Prevention Advocacy Network - California
http://www.span-california.org
Suicide Prevention Advocacy Network-California (SPAN-California) was founded in 1999 as a force for suicide prevention, an arena for collaboration among agencies, and a voice in the California state capital.
The Project Hope Foundation
http://www.project-hope.co.nz
The Project Hope Foundation is dedicated to reducing depression and suicide (especially youth suicide). It has books, videos and instructions on self-education and how to run Life Skills Open Forums.
Training Institute for Suicide Assessment and Clinical Interviewing
http://www.suicideassessment.com/
This group provides mental health professionals with information on the development of suicide prevention skills, crisis intervention skills, and clinical interviewing skills.
University of Washington, MCH Program
http://depts.washington.edu/mchprog/cmh_home.html
On December 8-9, 2002, the Northwest Children's Public Health Network: Building an Action Agenda for Mental Health was held in Seattle, Washington. Representatives from six States met to identify issues specific to the region and their communities and to outline State plans for promoting mental health in children and young people. Four plenary speakers presented information on mental health at various stages of childhood and adolescence and took part in a panel discussion. The details of the meeting are found on this web site.
World Health Organization Fact Sheet on Violence
http://www.who.int/violence_injury_prevention/violence/world_report/wrvh1/en/
This fact sheet, prepared by the World Health Organization, contains worldwide statistics for suicide and self inflicted injuries.
World Health Organization Report on Violence and Health - Summary
http://www.who.int/violence_injury_prevention/violence/world_report/en/Full%20WRVH%20summary.pdf
This document is a comprehensive summary to the World Health Organizations first World Report on Violence and Health.
Online Resources
National Vital Statistics Reports
http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_08.pdf
This report presents the final 1999 data on U.S. deaths and death rates according to demographic and medical characteristics. Trends and patterns in general mortality, life expectancy, and infant mortality are also described.
New Freedom Commission on Mental Health Subcommittee on Suicide Prevention
http://www.mentalhealthcommission.gov/subcommittee/Suicide_Prevention_Outline.doc
Summary Report
Hawaii State Department of Health: Suicide
http://www.state.hi.us/health/shpda/shinjury.pdf
This is a report by the State of Hawaii on injury prevention, both accidental and self-inflicted. IT touches on suicide, domestic violence, and drug and alcohol abuse.
In Harm's Way: Suicide in America
http://www.nimh.nih.gov/publicat/harmaway.cfm
This fact sheet from the National Institute of Mental Health provides statistics about suicide incidents in the United States.
Media Coverage of Suicide
http://www.afsp.org/education/mediacoverage2.8.htm
This site, provided by the American Foundation for Suicide Prevention, illustrates various harmful ways in which the media can depict suicide.
Minnesota Department of Health Report to the Minnesota Legislature: Suicide Prevention Plan
http://www.health.state.mn.us/divs/opa/suicide.pdf
This report to the Minnesota Legislature details the development of the State’s suicide prevention plan.
EL SUICIDIO EN LOS ADOLESCENTES
http://www.aacap.org/publications/apntsfam/suicide.htm
Cada año miles de adolescentes se suicidan en los Estados Unidos. El suicidio es la tercera causa de muerte más frecuente para los jóvenes de entre 15 y 24 años de edad, y la sexta causa de muerte para los de entre 5 y 14 años.
National Organization for People of Color Against Suicide - Statistics
http://www.nopcas.com/stats/
This web site provides statistics on the amount of people who have committed and attempted suicide. It also lists conferences for suicide survivors.
National Registry of Effective Prevention Programs
http://www.modelprograms.samhsa.gov
Information on effective programs that enhance outcomes for substance abuse, violence and high-risk behaviors in community, family, school, clinical, faith-based, and workplace settings.
Depression and Bipolar Support Alliance (DBSA) - Suicide
http://www.dbsalliance.org/info/suicide.html
If you or someone you know suffers from depression or manic depression (also known as bipolar disorder), you understand all too well its symptoms may include feelings of sadness and hopelessness. These feelings can also include thoughts of self-harm or suicide.
Louisiana's Youth Suicide Prevention Program
http://www.dhh.state.la.us/NEWS/YouthSuicide02.htm
The Louisiana Youth Suicide Prevention Task Force is a Statewide response to the U. S. Surgeon General's call to action to prevent suicide. The mission of the Task Force is to develop a Statewide plan on youth suicide prevention in Louisiana. This press release provides more information on the Task Force as well as suicide statistics for Louisiana.
Guidelines for School Based Suicide Prevention Programs
http://www.suicidology.org/associations/1045/files/School%20guidelines.pdf
These guidelines, compiled by the Prevention Division of the American Association of Suicidology, can be used by schools to help prevent suicide. They are in PDF format.
Florida Suicide Prevention Coalition
http://www.floridasuicideprevention.org/
In August, 2002, the Florida Suicide Prevention Task Force announced the Statewide Suicide Prevention Strategy to reduce the incidence of suicide in Florida by one-third by 2005.
Canadian Association for Suicide Prevention
http://www.thesupportnetwork.com/CASP/main.html
This site provides resources and information about suicide prevention. It also contains new bulletins and a list of links to related sites.
A Call to Collaboration: The Federal Commitment to Suicide Prevention
http://www.sprc.org/library/collabcall.pdf
A Call to Collaboration: The Federal Commitment to Suicide Prevention highlights the Department of Health and Human Services' activities and their link to the National Strategy for Suicide Prevention, the plan which will guide the nation's suicide prevention efforts for the next decade.
Air Force Suicide Prevention Program
http://www.osophs.dhhs.gov/ophs/BestPractice/usaf.htm
The Suicide Prevention Program of the Air Force is described and highlighted as one of the nation's most effective health prevention programs.
Children's Safety Network - Injury Data
http://www.injuryprevention.org/info/data.htm
This web page provides charts and tables illustrating children’s injury data for each U.S. State and Territory.
Homicide and Suicide Risks Associated with Firearms in the Home
http://www.annemergmed.com/article/PIIS0196064403002567/fulltext?kwhquery=Homicide+and+Suicide+and+Risks+and+Associated+and+with+and+Firearms+and+Home&search_area=platform%2Bmedline&search_articletype=all&search_cluster=phoenix&search_currenturi=http%3A%2F%2Fjournals.elsevierhealth.com%2Fsearch%2Fquick&search_datecombo=0%3AALL&search_dateradio=combo&search_discipline=all&search_doi=&search_federated=yes&search_issue=&search_keyword=&search_language=all&search_medline=yes&search_mode=platform&search_monthendcombo=jan&search_monthstartcombo=jan&search_operator1=and&search_operator2=and&search_preview=no&search_reqcount=20&search_reqfirst=1&search_resulturi=%2FBRAND%2Fsearch%2Fresults&search_s200=yes&search_searchuri=%2FBRAND%2Fsearch%2Fadvanced&search_sort=relevance&search_startpage=&search_submode=&search_text1=Homicide+and+Suicide+Risks+Associated
This is a document about injury prevention titled, Homicide and Suicide Risks Associated With Firearms in the Home: A national case-control study.
Assisted Suicide and End-of-Life Decisions
http://www.apa.org/pi/aseol/introduction.html
A Report from an American Psychological Association Working Group
Assisted Suicide: A Disability Perspective
http://www.ncd.gov/newsroom/publications/1997/suicide.htm
Written for the National Council on Disability, this paper analyzes the issues related to assisted suicide and discusses current court cases.
At a Glance: Suicide Among the Elderly
http://mentalhealth.samhsa.gov/suicideprevention/elderly.asp
The National Strategy for Suicide Prevention provides this fact sheet on suicide among the elderly.
If You Are Thinking About Suicide...READ THIS FIRST
http://www.metanoia.org/suicide/
The information on this site is intended to help and support persons who may be feeling suicidal.
Legislative Advisories From the American Association on Child and Adolescent Psychiatry
http://www.aacap.org/legislation/Lalerts.htm
These legislative alerts, provided by the American Academy of Child and Adolescent Psychiatry, concern Congressional action on issues related to the health of children and adolescents.
A Public Health Approach to Preventing Suicide
http://www.sprc.org/library/phaprev.pdf
This brochure illustrates how better data collection, including the National Violent Death Reporting System, can inform prevention strategies and make a real difference.
Oklahoma State Youth Suicide Prevention Plan
http://www.health.state.ok.us/program/ahd/spsp.pdf
The Oklahoma Youth Suicide Prevention State Plan works to address the problem of suicide by introducing multi-level strategies that communities can customize based on available resources and experiences.
Preventing Suicide: Individual Acts Create a Public Health Crisis
http://www.cfah.org/factsoflife/vol7no8.cfm
This site provides a resource of background information, interviews, and statistics for health reporters.
Reporting on Suicide: Recommendations for the Media
http://www.afsp.org/education/recommendations/
This is the full report of media recommendations presented on the American Foundation for Suicide Prevention Web site. This resource contains links to the specific media recommendations as well as an introduction to the topic area, a list of danger signs, examples of reporting, and frequently asked questions.
Reporting on Suicide: Recommendations for the Media
http://www.nimh.nih.gov/suicideresearch/mediasurvivors.cfm
This National Institute of Mental Health Web site presents media recommendations that were produced in the spirit of the public-private partnership recommended by the Surgeon General’s National Strategy for Suicide Prevention.
Suicide Prevention
http://mentalhealth.samhsa.gov/suicideprevention
The National Strategy for Suicide Prevention is a collaborative effort between the Substance Abuse and Mental Health Services Administration, the Centers for Disease Control and Prevention, the National Institutes of Health, the Health Resources and Services Administration, and the Indian Health Services. The site has a wealth of resources including a newsroom, links State Suicide Prevention Programs, features publications, and much more.
Suicide Warning Signs
http://mentalhealth.samhsa.gov/publications/allpubs/walletcard/engwalletcard.htm
Tennessee Suicide Prevention Strategies
http://www.state.tn.us/mental/mhs/suicdeprev.pdf
The Tennessee strategy for suicide prevention builds on the fifteen points raised in “The Surgeon General’s Call to Action to Prevent Suicide, 1999.” This publication lists each of the fifteen points and Tennessee’s responses.
The Centre for Suicide Prevention, Manchester, England
http://www.national-confidential-inquiry.ac.uk/
The Centre for Suicide Prevention at the University of Manchester brings together projects on policy and service planning. This United Kingdom research centre in the field of suicidal behaviour carries out studies of suicide and homicide by those in contact with mental health services.
The National Association of Injury Control Research Centers
http://www.naicrc.org
An organization devoted to promoting scholarly activity in injury control, the Association addresses issues relevant to the prevention, acute care and rehabilitation of traumatic injury through multiple activities in research; research dissemination; program development and evaluation; consultation; and education and training.
The Surgeon General's Call To Action To Prevent Suicide, July 1999
http://www.surgeongeneral.gov/library/calltoaction/default.htm
The Surgeon General and the U.S. Department of Health and Human Services outline more than a dozen steps that can be taken by individuals, communities, organizations, and policymakers on this site. Site provides links to other related resources.
Virginia Youth Suicide Prevention Plan
http://www.vahealth.org/civp/preventsuicideva/
The Virginia Youth Suicide Prevention Plan addresses youth suicide in the Commonwealth by focusing on several key areas including: leadership, public awareness, media education, school-based strategies, surveillance, and evaluation. On this site there are statistics, free publications, and the number of a hotline for people contemplating suicide or people who know someone contemplating suicide.
Washington State Youth Suicide Prevention Program
http://www.yspp.org
The mission of the Youth Suicide Prevention Program is to reduce suicide attempts and deaths among Washington State youth. Working toward that goal, the group builds public awareness, offers training, and supports communities taking action.
Wisconsin Suicide Prevention Strategy
http://www.dhfs.state.wi.us/dph_emsip/InjuryPrevention/SuicidePrevention.htm
This report details Wisconsin’s Suicide Prevention Strategy. It provides a framework for getting every interested person in Wisconsin involved in preventing suicide and is designed to guide individuals, agencies, organizations in local communities and at regional and State levels in suicide prevention efforts.
Organizations
Iowa State Prevention Programs
http://www.idph.state.ia.us/bhpl/healthy_iowans_2010.asp
This web site provides an overview of Iowa’s prevention programs for violence and abusive behavior.
Ohio's Suicide Prevention Program
http://www.mh.state.oh.us/kids/suicideprev/suicide.prevention.plan.pdf
Ohio's Suicide Prevention Plan is the next step in saving lives and reducing suicidal behaviors by developing a comprehensive strategy in response to a very complex set of issues.
National Police Suicide Foundation
http://www.psf.org/index.htm
The numbers of deaths due to suicide are 2 to 3 times the number of line of duty deaths among law enforcement agencies and emergency workers. The mission of the National P.O.L.I.C.E. Suicide Foundation is to provide suicide awareness and prevention training programs and support services that will meet the psychological and spiritual needs of emergency workers and their families.
National Resource Center for Suicide Prevention and Aftercare
http://www.thelink.org/html/nrc.htm
The NRC's goal is to provide suicide-related community education in the areas of prevention, intervention, and aftercare, as well as healing support services for families, youth, and those affected by the psychological trauma of suicide.
National Center for Suicide Prevention Training
http://www.ncspt.org/courses/orientation/
The National Center for Suicide Prevention Training (NCSPT) currently has two internet-based workshops. The first one, “Locating, Understanding, and Presenting Youth Suicide Data” and is available on an ongoing basis. The second workshop, "Planning and Evaluation for Youth Suicide Prevention" is being prepared for pilot testing. This web site provides more information on the trainings.
National Strategy for Suicide Prevention Indicators
http://www.nsspi.org/
The goal of the National Strategy for Suicide Prevention Indicators project is to identify and develop indicators for each of the strategy's objectives. Indicators are measured in order to quantify the achievement of an objective.
Klingenstein Third Generation Foundation
http://ktgf.org/index.html
One of the two areas of interest for this foundation are Childhood and Adolescent Depression, including suicide and suicide prevention. Grants have primarily fallen under the categories of Intervention and Referral, Prevention, Public Education/Training, and Infrastructure. The Foundation also sponsors a Fellowship Program for post-doctoral research in depression.
American Association of Poison Control Centers
http://www.aapcc.org
The American Association of Poison Control Centers is a Nationwide organization of poison centers and interested individuals. It provides a forum for poison centers and interested individuals to promote the reduction of morbidity and mortality form poisoning and sets voluntary standards for poison centers. It also produces publications and holds a yearly conference.
American Association of Suicidology
http://www.suicidology.org/index.cfm
The American Association of Suicidology is dedicated to the understanding and prevention of suicide. The organization promotes research, public awareness programs, and education and training for professionals and volunteers.
American College of Emergency Physicians
http://www.acep.org
The American College of Emergency Physicians promotes the highest standards of patient care through its advocacy and leadership. This web site contains information on the organization, fact sheets, information on continuing education, and many other resources.
American Correctional Health Services Association
http://www.corrections.com/achsa/
The ACHSA mission is to be the voice of the correctional healthcare profession, and serve as an effective forum for communication addressing current issues and needs confronting correctional healthcare.
American Foundation for Suicide Prevention
http://www.afsp.org
The American Foundation for Suicide Prevention is the only international non-profit organization dedicated to funding the research and education needed to prevent suicide.
First World Report on Violence and Health (Full Report)
http://www.who.int/violence_injury_prevention/violence/world_report/wrvheng/en/
This report, produced by the World Health Organization, is written mainly for researchers and practitioners. Its goals are to raise global awareness about the problems of violence and to make the case that violence is preventable and that public health systems have a crucial role to play in addressing its causes and consequences.
Befrienders International
http://www.befrienders.org/
Befrienders International is a network of centers run by trained volunteers that offer a free listening service that is non-judgmental and completely confidential. People are befriended by telephone, letter and email, and in face-to-face meetings.
American School Health Association
http://www.ashaweb.org
The American School Health Association unites the many professionals working in schools who are committed to safeguarding the health of school-aged children. The Association, a multidisciplinary organization of administrators, counselors, dentists, health educators, physical educators, school nurses and school physicians, advocates high-quality school health instruction, health services and a healthful school environment.
Association of Maternal and Child Health Programs
http://www.amchp.org
The Association of Maternal and Child Health Programs is an organization representing State public health leaders and other individuals and organizations working to improve the health and well being of all women, children, youth, and families. The group accomplishes its mission through partnerships with government agencies and the participation of its members, families, advocates, health care purchasers, providers, academic and research professionals, and others at the National, State and local levels.
Association of State and Territorial Health Officials
http://www.astho.org
The Association of State and Territorial Health Officials is a National non-profit organization representing the State and territorial public health agencies of the United States, the U.S. Territories, and the District of Columbia. Its members, the chief health officials of these jurisdictions, are dedicated to formulating and influencing sound public health policy, and to assuring excellence in State-based public health practice. This site provides information on events, policy statements, and publications.
Georgia's Suicide Prevention Plan
http://www.georgiasuicidepreventionplan.org
People can stop suicide. This fact is the foundation of the Georgia Suicide Prevention Plan. This web site provides the plan’s text and staff contact information.
Selected Reviews of Suicide Research - 2001
http://www.nimh.nih.gov/suicideresearch/suibib2001.cfm
This list of review articles was compiled by the NIMH Suicide Research Consortium, whose members have found the articles useful when providing technical assistance to grant applicants.
SOS High School Suicide Prevention Program
http://www.mentalhealthscreening.org/sos_highschool
The SOS Suicide Prevention Program provides school health professionals with all the educational materials necessary to replicate this easy-to-use program in a variety of school settings. Schools have the flexibility to make use of the materials in as large or small a program as their needs and resources dictate. The program can also be blended into an existing health curriculum. You can find out more about it at their web site.
Students Against Destructive Decisions
http://www.saddonline.com
Students Against Destructive Decision strive to provide students with the best prevention and intervention tools possible to deal with the issues of underage drinking, other drug use, impaired driving and other destructive decisions. Their site has a number of resources including fact sheets, a resource center, a list of events, and newsletters.
State and Territorial Injury Prevention Directors' Association
http://www.stipda.org
The mission of the State and Territorial Injury Prevention Director’s Association is to promote, sustain, and enhance the ability of State and Territorial public health departments to reduce death and disability associated with injuries. It accomplishes its mission by disseminating information on state-of-the-art injury prevention and control policies and strategies.
Suicide Among the Aged (Canada)
http://www.suicideinfo.ca/csp/go.aspx?tabid=118
This web site illustrates, through statistics, that suicide rates for the elderly exceed suicide rates among adolescents.
Suicide Prevention Action Network of USA (SPAN)
http://www.spanusa.org
The Suicide Prevention Action Network USA is a non-profit national organization that links the energy of those bereaved or touched by suicide with the expertise of leaders in science, health, business, government and public service to achieve the goal of significantly reducing the national rate of suicide by the year 2010.
Suicide Prevention Advocacy Network - California
http://www.span-california.org
Suicide Prevention Advocacy Network-California (SPAN-California) was founded in 1999 as a force for suicide prevention, an arena for collaboration among agencies, and a voice in the California state capital.
The Project Hope Foundation
http://www.project-hope.co.nz
The Project Hope Foundation is dedicated to reducing depression and suicide (especially youth suicide). It has books, videos and instructions on self-education and how to run Life Skills Open Forums.
Training Institute for Suicide Assessment and Clinical Interviewing
http://www.suicideassessment.com/
This group provides mental health professionals with information on the development of suicide prevention skills, crisis intervention skills, and clinical interviewing skills.
University of Washington, MCH Program
http://depts.washington.edu/mchprog/cmh_home.html
On December 8-9, 2002, the Northwest Children's Public Health Network: Building an Action Agenda for Mental Health was held in Seattle, Washington. Representatives from six States met to identify issues specific to the region and their communities and to outline State plans for promoting mental health in children and young people. Four plenary speakers presented information on mental health at various stages of childhood and adolescence and took part in a panel discussion. The details of the meeting are found on this web site.
World Health Organization Fact Sheet on Violence
http://www.who.int/violence_injury_prevention/violence/world_report/wrvh1/en/
This fact sheet, prepared by the World Health Organization, contains worldwide statistics for suicide and self inflicted injuries.
World Health Organization Report on Violence and Health - Summary
http://www.who.int/violence_injury_prevention/violence/world_report/en/Full%20WRVH%20summary.pdf
This document is a comprehensive summary to the World Health Organizations first World Report on Violence and Health.
Online Resources
National Vital Statistics Reports
http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_08.pdf
This report presents the final 1999 data on U.S. deaths and death rates according to demographic and medical characteristics. Trends and patterns in general mortality, life expectancy, and infant mortality are also described.
New Freedom Commission on Mental Health Subcommittee on Suicide Prevention
http://www.mentalhealthcommission.gov/subcommittee/Suicide_Prevention_Outline.doc
Summary Report
Hawaii State Department of Health: Suicide
http://www.state.hi.us/health/shpda/shinjury.pdf
This is a report by the State of Hawaii on injury prevention, both accidental and self-inflicted. IT touches on suicide, domestic violence, and drug and alcohol abuse.
In Harm's Way: Suicide in America
http://www.nimh.nih.gov/publicat/harmaway.cfm
This fact sheet from the National Institute of Mental Health provides statistics about suicide incidents in the United States.
Media Coverage of Suicide
http://www.afsp.org/education/mediacoverage2.8.htm
This site, provided by the American Foundation for Suicide Prevention, illustrates various harmful ways in which the media can depict suicide.
Minnesota Department of Health Report to the Minnesota Legislature: Suicide Prevention Plan
http://www.health.state.mn.us/divs/opa/suicide.pdf
This report to the Minnesota Legislature details the development of the State’s suicide prevention plan.
EL SUICIDIO EN LOS ADOLESCENTES
http://www.aacap.org/publications/apntsfam/suicide.htm
Cada año miles de adolescentes se suicidan en los Estados Unidos. El suicidio es la tercera causa de muerte más frecuente para los jóvenes de entre 15 y 24 años de edad, y la sexta causa de muerte para los de entre 5 y 14 años.
National Organization for People of Color Against Suicide - Statistics
http://www.nopcas.com/stats/
This web site provides statistics on the amount of people who have committed and attempted suicide. It also lists conferences for suicide survivors.
National Registry of Effective Prevention Programs
http://www.modelprograms.samhsa.gov
Information on effective programs that enhance outcomes for substance abuse, violence and high-risk behaviors in community, family, school, clinical, faith-based, and workplace settings.
Depression and Bipolar Support Alliance (DBSA) - Suicide
http://www.dbsalliance.org/info/suicide.html
If you or someone you know suffers from depression or manic depression (also known as bipolar disorder), you understand all too well its symptoms may include feelings of sadness and hopelessness. These feelings can also include thoughts of self-harm or suicide.
Louisiana's Youth Suicide Prevention Program
http://www.dhh.state.la.us/NEWS/YouthSuicide02.htm
The Louisiana Youth Suicide Prevention Task Force is a Statewide response to the U. S. Surgeon General's call to action to prevent suicide. The mission of the Task Force is to develop a Statewide plan on youth suicide prevention in Louisiana. This press release provides more information on the Task Force as well as suicide statistics for Louisiana.
Guidelines for School Based Suicide Prevention Programs
http://www.suicidology.org/associations/1045/files/School%20guidelines.pdf
These guidelines, compiled by the Prevention Division of the American Association of Suicidology, can be used by schools to help prevent suicide. They are in PDF format.
Florida Suicide Prevention Coalition
http://www.floridasuicideprevention.org/
In August, 2002, the Florida Suicide Prevention Task Force announced the Statewide Suicide Prevention Strategy to reduce the incidence of suicide in Florida by one-third by 2005.
Canadian Association for Suicide Prevention
http://www.thesupportnetwork.com/CASP/main.html
This site provides resources and information about suicide prevention. It also contains new bulletins and a list of links to related sites.
A Call to Collaboration: The Federal Commitment to Suicide Prevention
http://www.sprc.org/library/collabcall.pdf
A Call to Collaboration: The Federal Commitment to Suicide Prevention highlights the Department of Health and Human Services' activities and their link to the National Strategy for Suicide Prevention, the plan which will guide the nation's suicide prevention efforts for the next decade.
Air Force Suicide Prevention Program
http://www.osophs.dhhs.gov/ophs/BestPractice/usaf.htm
The Suicide Prevention Program of the Air Force is described and highlighted as one of the nation's most effective health prevention programs.
Children's Safety Network - Injury Data
http://www.injuryprevention.org/info/data.htm
This web page provides charts and tables illustrating children’s injury data for each U.S. State and Territory.
Homicide and Suicide Risks Associated with Firearms in the Home
http://www.annemergmed.com/article/PIIS0196064403002567/fulltext?kwhquery=Homicide+and+Suicide+and+Risks+and+Associated+and+with+and+Firearms+and+Home&search_area=platform%2Bmedline&search_articletype=all&search_cluster=phoenix&search_currenturi=http%3A%2F%2Fjournals.elsevierhealth.com%2Fsearch%2Fquick&search_datecombo=0%3AALL&search_dateradio=combo&search_discipline=all&search_doi=&search_federated=yes&search_issue=&search_keyword=&search_language=all&search_medline=yes&search_mode=platform&search_monthendcombo=jan&search_monthstartcombo=jan&search_operator1=and&search_operator2=and&search_preview=no&search_reqcount=20&search_reqfirst=1&search_resulturi=%2FBRAND%2Fsearch%2Fresults&search_s200=yes&search_searchuri=%2FBRAND%2Fsearch%2Fadvanced&search_sort=relevance&search_startpage=&search_submode=&search_text1=Homicide+and+Suicide+Risks+Associated
This is a document about injury prevention titled, Homicide and Suicide Risks Associated With Firearms in the Home: A national case-control study.
Assisted Suicide and End-of-Life Decisions
http://www.apa.org/pi/aseol/introduction.html
A Report from an American Psychological Association Working Group
Assisted Suicide: A Disability Perspective
http://www.ncd.gov/newsroom/publications/1997/suicide.htm
Written for the National Council on Disability, this paper analyzes the issues related to assisted suicide and discusses current court cases.
At a Glance: Suicide Among the Elderly
http://mentalhealth.samhsa.gov/suicideprevention/elderly.asp
The National Strategy for Suicide Prevention provides this fact sheet on suicide among the elderly.
If You Are Thinking About Suicide...READ THIS FIRST
http://www.metanoia.org/suicide/
The information on this site is intended to help and support persons who may be feeling suicidal.
Legislative Advisories From the American Association on Child and Adolescent Psychiatry
http://www.aacap.org/legislation/Lalerts.htm
These legislative alerts, provided by the American Academy of Child and Adolescent Psychiatry, concern Congressional action on issues related to the health of children and adolescents.
A Public Health Approach to Preventing Suicide
http://www.sprc.org/library/phaprev.pdf
This brochure illustrates how better data collection, including the National Violent Death Reporting System, can inform prevention strategies and make a real difference.
Oklahoma State Youth Suicide Prevention Plan
http://www.health.state.ok.us/program/ahd/spsp.pdf
The Oklahoma Youth Suicide Prevention State Plan works to address the problem of suicide by introducing multi-level strategies that communities can customize based on available resources and experiences.
Preventing Suicide: Individual Acts Create a Public Health Crisis
http://www.cfah.org/factsoflife/vol7no8.cfm
This site provides a resource of background information, interviews, and statistics for health reporters.
Reporting on Suicide: Recommendations for the Media
http://www.afsp.org/education/recommendations/
This is the full report of media recommendations presented on the American Foundation for Suicide Prevention Web site. This resource contains links to the specific media recommendations as well as an introduction to the topic area, a list of danger signs, examples of reporting, and frequently asked questions.
Reporting on Suicide: Recommendations for the Media
http://www.nimh.nih.gov/suicideresearch/mediasurvivors.cfm
This National Institute of Mental Health Web site presents media recommendations that were produced in the spirit of the public-private partnership recommended by the Surgeon General’s National Strategy for Suicide Prevention.
Suicide Prevention
http://mentalhealth.samhsa.gov/suicideprevention
The National Strategy for Suicide Prevention is a collaborative effort between the Substance Abuse and Mental Health Services Administration, the Centers for Disease Control and Prevention, the National Institutes of Health, the Health Resources and Services Administration, and the Indian Health Services. The site has a wealth of resources including a newsroom, links State Suicide Prevention Programs, features publications, and much more.
Suicide Warning Signs
http://mentalhealth.samhsa.gov/publications/allpubs/walletcard/engwalletcard.htm
Tennessee Suicide Prevention Strategies
http://www.state.tn.us/mental/mhs/suicdeprev.pdf
The Tennessee strategy for suicide prevention builds on the fifteen points raised in “The Surgeon General’s Call to Action to Prevent Suicide, 1999.” This publication lists each of the fifteen points and Tennessee’s responses.
The Centre for Suicide Prevention, Manchester, England
http://www.national-confidential-inquiry.ac.uk/
The Centre for Suicide Prevention at the University of Manchester brings together projects on policy and service planning. This United Kingdom research centre in the field of suicidal behaviour carries out studies of suicide and homicide by those in contact with mental health services.
The National Association of Injury Control Research Centers
http://www.naicrc.org
An organization devoted to promoting scholarly activity in injury control, the Association addresses issues relevant to the prevention, acute care and rehabilitation of traumatic injury through multiple activities in research; research dissemination; program development and evaluation; consultation; and education and training.
The Surgeon General's Call To Action To Prevent Suicide, July 1999
http://www.surgeongeneral.gov/library/calltoaction/default.htm
The Surgeon General and the U.S. Department of Health and Human Services outline more than a dozen steps that can be taken by individuals, communities, organizations, and policymakers on this site. Site provides links to other related resources.
Virginia Youth Suicide Prevention Plan
http://www.vahealth.org/civp/preventsuicideva/
The Virginia Youth Suicide Prevention Plan addresses youth suicide in the Commonwealth by focusing on several key areas including: leadership, public awareness, media education, school-based strategies, surveillance, and evaluation. On this site there are statistics, free publications, and the number of a hotline for people contemplating suicide or people who know someone contemplating suicide.
Washington State Youth Suicide Prevention Program
http://www.yspp.org
The mission of the Youth Suicide Prevention Program is to reduce suicide attempts and deaths among Washington State youth. Working toward that goal, the group builds public awareness, offers training, and supports communities taking action.
Wisconsin Suicide Prevention Strategy
http://www.dhfs.state.wi.us/dph_emsip/InjuryPrevention/SuicidePrevention.htm
This report details Wisconsin’s Suicide Prevention Strategy. It provides a framework for getting every interested person in Wisconsin involved in preventing suicide and is designed to guide individuals, agencies, organizations in local communities and at regional and State levels in suicide prevention efforts.
March 11, 2010
Answers in the Aftermath
Answers in the Aftermath
A guide to mental health concerns for victims of violent crime
As a survivor of violent crime, you may face a wide range of emotional and physical struggles, along with some difficult questions that often surface: Why did this happen to me? How will I ever heal from this? Why can’t I connect with others the way I did before? When will I start to feel “normal” again? While the answers may be different for each individual, there are some striking similarities in how trauma affects nearly all victims. Understanding the nature and impact of violent trauma can be essential to the healing process. This brochure is intended as a guide to help you along the path to healing and to avoid some of the common pitfalls along the way.
What is Post Traumatic Stress Disorder (PTSD)?
PTSD is a mental health condition that can be caused by experiencing or observing virtually any kind of deep emotional trauma, especially one that is unexpected. Millions of people in the United States suffer from PTSD, resulting from many different types of trauma—from enduring years of domestic violence to a single violent attack that lasts but a few seconds. PTSD is characterized by both emotional and physical suffering; many afflicted by it find themselves unintentionally revisiting their trauma through flashbacks or nightmares. PTSD can make you feel isolated, disconnected, and “different” from other people—and it can even begin to affect the most routine activities of everyday life. PTSD is a potentially serious condition that should not be taken lightly.
Why is substance abuse common following a traumatic event?
Since violent trauma can bring about so many changes, questions, and uncertainties, many survivors turn to alcohol and illicit drugs in an attempt to get some relief from their almost round-the-clock emotional turmoil and suffering. Substance abuse and mental health problems often accompany violent trauma. All survivors of trauma manage their experiences in different ways. Substance abuse, however, is not only an ineffective tool in healing from trauma, but it also can present a host of additional problems that make the healing process even more difficult.
What can I do if I am experiencing PTSD or if substance abuse becomes a problem for me?
According to a recent study conducted by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the most effective way to combat trauma, substance abuse, and mental health problems is through an integrated, holistic approach, taking into account how each individual problem affects the others. To begin, it can help to share your experiences and concerns with a service provider (e.g. counselor, physician, victim witness coordinator) who can assist in developing a plan to address all of your struggles comprehensively. Psychologists and counselors with experience treating trauma survivors can be very helpful in working through PTSD, and there are prescription drugs available to help ease PTSD symptoms.
PTSD can make you feel isolated, disconnected, and “different” from other people—and it can even begin to affect the most routine activities of everyday life.
What can I do to begin the healing process?
There are some positive steps that you can take right away to begin healing. Here are some suggestions:
Recognize your loss.
Establish safety for yourself.
Respect the way you feel and your right to feel that way.
Talk about your feelings with those you trust.
Connect with other survivors of violence, many of whom experience similar difficulties.
Do not be afraid to seek professional help.
Try to recognize triggers that may take you back to the memory and fear of your trauma.
Try to be patient and avoid making rash decisions—it can take time to figure out where you are, where you want to be, and how to get there.
Take care of yourself—exercise, eat right, and take a deep breath when you feel tense.
Try to turn your negative experience into something positive—volunteer, donate, or do something else to constructively channel your energy and emotions.
Do not abandon hope—believe that healing can and will take place.
A guide to mental health concerns for victims of violent crime
As a survivor of violent crime, you may face a wide range of emotional and physical struggles, along with some difficult questions that often surface: Why did this happen to me? How will I ever heal from this? Why can’t I connect with others the way I did before? When will I start to feel “normal” again? While the answers may be different for each individual, there are some striking similarities in how trauma affects nearly all victims. Understanding the nature and impact of violent trauma can be essential to the healing process. This brochure is intended as a guide to help you along the path to healing and to avoid some of the common pitfalls along the way.
What is Post Traumatic Stress Disorder (PTSD)?
PTSD is a mental health condition that can be caused by experiencing or observing virtually any kind of deep emotional trauma, especially one that is unexpected. Millions of people in the United States suffer from PTSD, resulting from many different types of trauma—from enduring years of domestic violence to a single violent attack that lasts but a few seconds. PTSD is characterized by both emotional and physical suffering; many afflicted by it find themselves unintentionally revisiting their trauma through flashbacks or nightmares. PTSD can make you feel isolated, disconnected, and “different” from other people—and it can even begin to affect the most routine activities of everyday life. PTSD is a potentially serious condition that should not be taken lightly.
Why is substance abuse common following a traumatic event?
Since violent trauma can bring about so many changes, questions, and uncertainties, many survivors turn to alcohol and illicit drugs in an attempt to get some relief from their almost round-the-clock emotional turmoil and suffering. Substance abuse and mental health problems often accompany violent trauma. All survivors of trauma manage their experiences in different ways. Substance abuse, however, is not only an ineffective tool in healing from trauma, but it also can present a host of additional problems that make the healing process even more difficult.
What can I do if I am experiencing PTSD or if substance abuse becomes a problem for me?
According to a recent study conducted by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the most effective way to combat trauma, substance abuse, and mental health problems is through an integrated, holistic approach, taking into account how each individual problem affects the others. To begin, it can help to share your experiences and concerns with a service provider (e.g. counselor, physician, victim witness coordinator) who can assist in developing a plan to address all of your struggles comprehensively. Psychologists and counselors with experience treating trauma survivors can be very helpful in working through PTSD, and there are prescription drugs available to help ease PTSD symptoms.
PTSD can make you feel isolated, disconnected, and “different” from other people—and it can even begin to affect the most routine activities of everyday life.
What can I do to begin the healing process?
There are some positive steps that you can take right away to begin healing. Here are some suggestions:
Recognize your loss.
Establish safety for yourself.
Respect the way you feel and your right to feel that way.
Talk about your feelings with those you trust.
Connect with other survivors of violence, many of whom experience similar difficulties.
Do not be afraid to seek professional help.
Try to recognize triggers that may take you back to the memory and fear of your trauma.
Try to be patient and avoid making rash decisions—it can take time to figure out where you are, where you want to be, and how to get there.
Take care of yourself—exercise, eat right, and take a deep breath when you feel tense.
Try to turn your negative experience into something positive—volunteer, donate, or do something else to constructively channel your energy and emotions.
Do not abandon hope—believe that healing can and will take place.
March 09, 2010
Mental Health Stigma
Anti-Stigma: Do You Know the Facts?
Stigma is not just a matter of using the wrong word or action. Stigma is about disrespect. It is the use of negative labels to identify a person living with mental illness. Stigma is a barrier. Fear of stigma, and the resulting discrimination, discourages individuals and their families from getting the help they need. An estimated 22 to 23 percent of the U.S. population experience a mental disorder in any given year, but almost half of these individuals do not seek treatment (U.S. Department of Health and Human Services, 2002; U.S. Surgeon General, 2001).
The educational information on this web site encourages the use of positive images to refer to people with mental illness and underscores the reality that mental illness can be successfully treated.
Do you know that an estimated 44 million Americans experience a mental disorder in any given year?
Do you know that stigma is not a matter of using the wrong word or action?
Do you know that stigma is about disrespect and using negative labels to identify a person living with mental illness?
Do you know that stigma is a barrier that discourages individuals and their families from seeking help?
Do you know that many people would rather tell employers they committed a petty crime and served time in jail, than admit to being in a psychiatric hospital?
Do you know that stigma can result in inadequate insurance coverage for mental health services?
Do you know that stigma leads to fear, mistrust, and violence against people living with mental illness and their families?
Do you know that stigma can cause families and friends to turn their backs on people with mental illness?
Do you know that stigma can prevent people from getting access to needed mental health services?
DO'S
Do use respectful language
Do emphasize abilities, not limitations.
Do tell someone if they express a stigmatizing attitude.
DONT'S
Don't portray successful persons with disabilities as super human.
Don't use generic labels such as retarded, or the mentally ill.
Don't use terms like crazy, lunatic, manic depressive, or slow functioning.
Stigma is not just a matter of using the wrong word or action. Stigma is about disrespect. It is the use of negative labels to identify a person living with mental illness. Stigma is a barrier. Fear of stigma, and the resulting discrimination, discourages individuals and their families from getting the help they need. An estimated 22 to 23 percent of the U.S. population experience a mental disorder in any given year, but almost half of these individuals do not seek treatment (U.S. Department of Health and Human Services, 2002; U.S. Surgeon General, 2001).
The educational information on this web site encourages the use of positive images to refer to people with mental illness and underscores the reality that mental illness can be successfully treated.
Do you know that an estimated 44 million Americans experience a mental disorder in any given year?
Do you know that stigma is not a matter of using the wrong word or action?
Do you know that stigma is about disrespect and using negative labels to identify a person living with mental illness?
Do you know that stigma is a barrier that discourages individuals and their families from seeking help?
Do you know that many people would rather tell employers they committed a petty crime and served time in jail, than admit to being in a psychiatric hospital?
Do you know that stigma can result in inadequate insurance coverage for mental health services?
Do you know that stigma leads to fear, mistrust, and violence against people living with mental illness and their families?
Do you know that stigma can cause families and friends to turn their backs on people with mental illness?
Do you know that stigma can prevent people from getting access to needed mental health services?
DO'S
Do use respectful language
Do emphasize abilities, not limitations.
Do tell someone if they express a stigmatizing attitude.
DONT'S
Don't portray successful persons with disabilities as super human.
Don't use generic labels such as retarded, or the mentally ill.
Don't use terms like crazy, lunatic, manic depressive, or slow functioning.
March 07, 2010
Models of Preventive Services
Models of Preventive Services
Two well-known models of preventive services are used when referring to behavioral programming for public health or mental health promotion and substance use prevention. They are reviewed briefly here.
The Public Health Model
Public health traditionally defines preventive services as “primary,” “secondary,” or “tertiary.” Primary preventive services, such as immunizations and programs related to tobacco, diet, and exercise, are intended to intervene before the onset of illness to prevent biologic onset of illness. Secondary preventive services include screening to detect disease before it becomes symptomatic, coupled with follow-up to arrest or eliminate the disease. The Pap test and mammography are medical examples of secondary prevention. Tertiary prevention refers to prevention of complications in persons known to be ill. Prevention of stroke through effective treatment of hypertension is an example of tertiary prevention. Much of disease management is tertiary prevention. In the public health model, the three levels of prevention are separate and distinct.
The Continuum of Health Care Model According to the Institute of Medicine (IOM)
When dealing with substance use and other behavioral disorders in clinical settings, the levels of prevention are less distinct than with physical illnesses. The tasks of identifying risk factors and detecting earlystage disease are usually accomplished by patient or family interview. Initial management of both risk and early stage disease is often conducted via patient and family counseling by the primary care provider. Thus, the continuum of the health care model is more practical than the public health model when dealing with preventive behavioral health services.
The continuum of health care model is drawn from a 1994 report of the Institute of Medicine (IOM) (Mrazek & Haggerty, eds., 1994), as originally proposed by Gordon (1983). It differs from the public health model in that it covers the full range of preventive, treatment, and maintenance services. There are three types of preventive services in the IOM model—universal, selective, and indicated. These do not correspond to the primary, secondary, and tertiary services in the public health model. Screening and follow-up preventive behavioral services correspond to secondary prevention within the public health model. Other preventive behavioral services, including most community-based services, correspond to primary or tertiary prevention.
Figure 1. Continuum of Health Care
Source: Reprinted with permission from Reducing Risks for Mental Disorders. Copyright 1994 by the National Academy of Sciences, Courtesy of the National Academy Press, Washington, DC.
In the IOM model, a “universal” preventive measure is an intervention that is applicable to or useful for everyone in the general population, such as all enrollees in a managed care organization. A “selective” preventive measure is desirable only when an individual is a member of a subgroup with above-average risk. An “indicated” preventive measure applies to persons who are found to manifest a risk factor that puts them at high risk (Mrazek & Haggerty, eds., 1994). All these categories describe individuals who have not been diagnosed with a disease.
Universal interventions, on a per-client basis, are relatively inexpensive services offered to the entire population of a lifestage group. They are conducted as a primary prevention or screening to identify sub-populations and individuals who need more intensive screening, preventive, or therapeutic services. A clinical example would be the provision of prenatal care as a universal service for all pregnant women. A behavioral health example would be the use of a simple screening protocol to identify depression in all adult patients at all primary care visits.
Selective interventions are more intensive services offered to subpopulations identified as having more risk factors than the general population, based on their age, gender, genetic history, condition, or situation. For example, more intensive breast cancer screening is provided for women with a family history of breast cancer. A behavioral health example would be offering smoking cessation programming to all smokers.
Indicated interventions are based on higher probability of developing a disease. They provide an intensive level of service to persons at extremely high risk or who already show asymptomatic, clinical, or demonstrable abnormality, but do not meet diagnostic criteria levels yet. Case management and intensive in-home assessment, health education, and counseling are examples of indicated interventions (Mrazek & Haggerty, eds., 1994).
Sometimes a universal service is a screening procedure provided to all, or a primary prevention procedure such as vaccinations for children. The selective service involves diagnostic procedures to confirm or deny a diagnosis, and the indicated service involves much more intensive, individualized services for those at highest risk.
The efficacy and cost-efficiency of preventive services depend on the entire array of universal, selective, and indicated service components. They also depend on the ability of the health care system to target and limit the more costly indicated interventions to those who could most benefit from them.
Appendix C to this report provides a more detailed presentation of the following policy, management, planning, and evaluation issues:
Translation of preventive behavioral research into health care practice
Assessment of the need for preventive services
Assessment of the efficacy of preventive services
Infrastructure and service components for preventive services
“General” vs. “Targeted” Services
Within this monograph, services are also classified into one of two categories, “general” and “targeted,” depending on the evidence base and the nature of the service. Those designated as “general” are supported by the evidence base as being appropriate for universal implementation by all health care systems. Services that are classified here as “targeted” appear to be appropriate for selected populations (e.g., selective or indicated populations if applying the IOM model), or they have a developing research base that is promising. “Targeted” services might also be social or educational interventions that could be provided by nonmedical staff to secure educational and social benefits.
C. Clinical vs. Community Preventive Services
Most preventive behavioral services are delivered in school and community settings, not health care settings (Schinke, Brounstein, & Gardner, 2002; DHHS, 1999). In a 1998 review of indicated preventive behavioral services for children and adolescents, Durlak and Wells (1997) used meta-analysis to review 177 programs—73 percent were in a school setting, compared with 23 percent that were mainly in medical settings. In a similar review published 1 year later by the same authors (Durlak & Wells, 1998), none of the programs was in a medical setting.
This report has been prepared to summarize and analyze the most promising preventive interventions (based on rigorous research studies) for consideration by health care organizations. Only interventions deliverable by health care systems are reviewed in this report. Most community preventive services are oriented toward school-age children, adolescents, and young adults—age groups with relatively low exposure to health care delivery settings. Such services generally are provided by and through schools and community organizations.
Health care settings, however, are effective in reaching pregnant women, infants, adults with major chronic medical illnesses, and those in need of surgical procedures. For example, these settings provide a place to address the behavioral needs of these patients through behavioral screening and preventive services, with follow-up in prescribed regimens of care. In this way, clinical preventive services for depression and substance abuse can reduce emergency room use and hospitalization (Olfson, Sing, & Schlesinger, 1999). Psychoeducational services also can speed recovery of postsurgical patients (Egbert, Battit, Welch, & Bartlett, 1964; Mumford, Schlesinger, & Glass, 1982).
It may not be incumbent upon health care delivery systems to provide highly specialized social and educational support services (Devine, O’Connor, Cook, Wenk, & Curtin, 1988), but health care delivery systems do have a role to play. Through their mental health and social work staff, they maintain working relationships with communitybased, social service, educational, and even correctional agencies to ensure they meet the needs of members of the health care delivery system.
D. Health Care Delivery System Provision of Preventive Behavioral Services
The need for behavioral services is substantial. Many who could benefit from treatment for these disorders do not receive care (Woodward et al., 1997; Harwood, Sullivan, & Malhorta, 2001).
Some of the lack of development of behavioral health services within health care delivery systems may be owing to the perception that mental health and substance use disorder services may be “softer” and therefore less effective than conventional medical therapy. However, the efficacy and cost-efficiency of these services is well established and has been recommended by multiple national organizations since at least the early 1990s (U.S. Preventive Services Task Force [USPSTF], 1996, 2002a, 2003).
The 1994 IOM report was titled Reducing Risks for Mental Disorders—Frontiers for Preventive Intervention Research (Mrazek & Haggerty, eds., 1994). A 1998 follow-up report, Preventing Mental Health and Substance Abuse Problems in Managed Care Settings (Mrazek, 1998), was completed in collaboration with the National Mental Health Association (NMHA). This report recommended widespread implementation of primary preventive programming to address five problem areas within health care systems:
Prevention of initial onset of unipolar major depression across the life span
Prevention of low birthweight and prevention of child maltreatment in children from birth to 2 years of age whose mothers are identified as being at high risk
Prevention of alcohol or drug abuse in children who have an alcohol- or drugabusing parent
Prevention of mental health problems in physically ill patients (comorbidity prevention)
Prevention of conduct disorders in young children
The 1999 Surgeon General Report was titled Mental Health: A Report of the Surgeon General (DHHS, 1999). Although the major focus of this report was care and management of mental disorders, all major preventive services were included.
SAMHSA published two recent prevention-related health care reports. The 2000 literature review titled Preventive Interventions Under Managed Care (Dorfman, 2000) used broader definitions of “prevention” and “mental health services” and recommended six interventions for managed care plans:
Prenatal and infancy home visits
Targeted cessation education and counseling for smokers—especially those who are pregnant
Targeted short-term mental health therapy
Self-care education for adults
Presurgical educational intervention with adults
Brief counseling and advice to reduce alcohol use
This new literature review retains four of the above services and omits numbers three and four on short-term mental health therapy and self-care. The companion document published in 2002 was titled Estimating the Cost of Preventive Services in Mental Health and Substance Abuse Under Managed Care (Broskowski & Smith, 2002). This report provided cost data for each of the services recommended in the 2000 literature review. It also featured, for each set of recommended services, a range of costs and options based on case mix and private versus public insurance coverage. It estimated the cost to managed care organizations (MCOs) to implement recommendations for four possible scenarios ranging from most expensive to least expensive, given drivers such as enrollment mix, staffing, staff salaries, and fixed and variable expenses. This report did not consider savings in other health care expenses. Even with the most expensive of cost profiles, the report did conclude that all six services could be fully implemented at a marginal cost of less than a 1 percent increase in cost, per member per month.
During this period, SAMHSA and the National Committee on Quality Assurance (NCQA)–sponsored Health Employer Data Information Set (HEDIS) program have attempted to bring preventive behavioral services to the attention of the managed care community. In response to market pressures to demonstrate high scores on HEDIS measures, the managed care community has taken giant strides to improve the care of patients with depression and has taken steps to enhance member adherence to prescribed regimens of care for diabetes.
In 1998, SAMHSA’s Center for Substance Abuse Prevention created the National Registry of Effective Programs (NREP) as a resource to help professionals in the field become better consumers of prevention programs (Schinke et al., 2002). NREP reviews and screens evidence-based programs (conceptually sound and/or theoretically driven by risk and protective factors) that, through an expert consensus review of research, demonstrate scientifically defensible evidence. NREP initially focused on substance use prevention but has expanded to include mental health; co-occurring mental health and substance use disorders; adolescent substance use treatment; mental health promotion; and adult mental health treatment. Many programs focus on school and family, but increasingly, programs from community coalitions and environmental programs are being identified as well implemented, well evaluated, and effective.
NREP evaluates programs for substance abuse prevention and treatment, co-occuring disorders, and mental health treatment, promotion, and prevention. After receiving published and unpublished program materials from candidates, NREP reviewers, drawn from 80 experts in relevant fields, rate each program according to 18 criteria for methodological rigor, and they also score programs for adoptability and usefulness to communities (Schinke et al., 2002). Based on the overall scoring, NREP categorizes programs as Model Programs, Effective Programs, Promising Programs, or Programs with Insufficient Current Support. Those wishing to learn more about Model Programs can visit www.modelprograms.samhsa.gov. At this site, there is also a link providing detailed information about NREP and the process for submitting a program for NREP review.
Despite these efforts, behavioral services— both preventive and therapeutic—still are not adequately identified, provided, or arranged by primary care practitioners. They also are not adequately promoted by health care systems. Brief screening instruments for alcohol and drug problems, for example, have been available for a number of years but are not widely used by practicing physicians (Duszynski, Nieto, & Vanente, 1995; National Center on Addiction and Substance Abuse at Columbia University, 2000). In a 2002 review, Garnick et al. (2002) conducted a telephone survey covering 434 MCOs in 60 market areas nationwide and secured useful responses from 92 percent of them. Only 14.9 percent of MCOs required any alcohol, drug, or mental health screening by primary care practitioners. Slightly more than half distributed practice guidelines that addressed mental illness, and approximately one third distributed substance use disorder practice guidelines.
DHHS’s 2003 campaign, Steps to a Healthier U.S., focuses on chronic disease prevention and health promotion with the goals of decreasing both the prevalence of certain chronic diseases and the risk factors that allow conditions to develop. This initiative aims to bring together local coalitions to establish model programs and policies that foster health behavior changes, encourage healthier lifestyle choices, and reduce disparities in health care.
In early 2003, SAMHSA published a review of the delivery of behavioral services by managed care organizations, based on 1999 data. This report, The Provision of Mental Health Services in Managed Care Organizations (Horgan et al., 2003), showed substantial variability from plan to plan, as well as substantial variability among health maintenance organizations (HMOs), pointof- service (POS) plans, and preferred provider organizations (PPOs). All MCOs provided behavioral services, but these services usually had limits and copayments that were more restrictive than for comparable medical services. Fewer than 10 percent required screening for behavioral disorders in primary care settings (Horgan et al., 2003).
Another SAMHSA report, also published early in 2003, offers some insight into discrepancies in coverage, comparing medical to behavioral services and discrepancies in policy and coverage, comparing therapeutic to preventive services. This report, titled Medical Necessity in Private Health Plans: Implications for Behavioral Health Care (Rosenbaum, Kamoie, Mauery, & Walitt, 2003), noted that services are covered by health insurance plans only if they are considered a “medical necessity.” The term medical necessity was defined differently for different services within each health plan, with due consideration given for each of the following five domains:
Contractual scope—whether the contract provides any coverage for certain procedures and treatments, such as preventive and maintenance treatments that are not necessary to restore a patient to “normal functioning.” This dimension preempts any other coverage decision.
Standards of practice—whether the treatment (as judged by the health plan) accords with professional standards of practice.
Patient safety and setting—whether the treatment will be delivered in the safest and least intrusive manner.
Medical service—whether the treatment is considered medical as opposed to social or nonmedical.
Cost—whether the treatment is considered cost-effective by the insurer (Rosenbaum et al., 2003).
The medical necessity report noted that Federal or State regulation is limited in covering how health insurance plans define medical necessity (Rosenbaum et al., 2003). This SAMHSA update is intended to build upon the reports noted above to further enhance implementation of preventive behavioral services in health care settings.
Two well-known models of preventive services are used when referring to behavioral programming for public health or mental health promotion and substance use prevention. They are reviewed briefly here.
The Public Health Model
Public health traditionally defines preventive services as “primary,” “secondary,” or “tertiary.” Primary preventive services, such as immunizations and programs related to tobacco, diet, and exercise, are intended to intervene before the onset of illness to prevent biologic onset of illness. Secondary preventive services include screening to detect disease before it becomes symptomatic, coupled with follow-up to arrest or eliminate the disease. The Pap test and mammography are medical examples of secondary prevention. Tertiary prevention refers to prevention of complications in persons known to be ill. Prevention of stroke through effective treatment of hypertension is an example of tertiary prevention. Much of disease management is tertiary prevention. In the public health model, the three levels of prevention are separate and distinct.
The Continuum of Health Care Model According to the Institute of Medicine (IOM)
When dealing with substance use and other behavioral disorders in clinical settings, the levels of prevention are less distinct than with physical illnesses. The tasks of identifying risk factors and detecting earlystage disease are usually accomplished by patient or family interview. Initial management of both risk and early stage disease is often conducted via patient and family counseling by the primary care provider. Thus, the continuum of the health care model is more practical than the public health model when dealing with preventive behavioral health services.
The continuum of health care model is drawn from a 1994 report of the Institute of Medicine (IOM) (Mrazek & Haggerty, eds., 1994), as originally proposed by Gordon (1983). It differs from the public health model in that it covers the full range of preventive, treatment, and maintenance services. There are three types of preventive services in the IOM model—universal, selective, and indicated. These do not correspond to the primary, secondary, and tertiary services in the public health model. Screening and follow-up preventive behavioral services correspond to secondary prevention within the public health model. Other preventive behavioral services, including most community-based services, correspond to primary or tertiary prevention.
Figure 1. Continuum of Health Care
Source: Reprinted with permission from Reducing Risks for Mental Disorders. Copyright 1994 by the National Academy of Sciences, Courtesy of the National Academy Press, Washington, DC.
In the IOM model, a “universal” preventive measure is an intervention that is applicable to or useful for everyone in the general population, such as all enrollees in a managed care organization. A “selective” preventive measure is desirable only when an individual is a member of a subgroup with above-average risk. An “indicated” preventive measure applies to persons who are found to manifest a risk factor that puts them at high risk (Mrazek & Haggerty, eds., 1994). All these categories describe individuals who have not been diagnosed with a disease.
Universal interventions, on a per-client basis, are relatively inexpensive services offered to the entire population of a lifestage group. They are conducted as a primary prevention or screening to identify sub-populations and individuals who need more intensive screening, preventive, or therapeutic services. A clinical example would be the provision of prenatal care as a universal service for all pregnant women. A behavioral health example would be the use of a simple screening protocol to identify depression in all adult patients at all primary care visits.
Selective interventions are more intensive services offered to subpopulations identified as having more risk factors than the general population, based on their age, gender, genetic history, condition, or situation. For example, more intensive breast cancer screening is provided for women with a family history of breast cancer. A behavioral health example would be offering smoking cessation programming to all smokers.
Indicated interventions are based on higher probability of developing a disease. They provide an intensive level of service to persons at extremely high risk or who already show asymptomatic, clinical, or demonstrable abnormality, but do not meet diagnostic criteria levels yet. Case management and intensive in-home assessment, health education, and counseling are examples of indicated interventions (Mrazek & Haggerty, eds., 1994).
Sometimes a universal service is a screening procedure provided to all, or a primary prevention procedure such as vaccinations for children. The selective service involves diagnostic procedures to confirm or deny a diagnosis, and the indicated service involves much more intensive, individualized services for those at highest risk.
The efficacy and cost-efficiency of preventive services depend on the entire array of universal, selective, and indicated service components. They also depend on the ability of the health care system to target and limit the more costly indicated interventions to those who could most benefit from them.
Appendix C to this report provides a more detailed presentation of the following policy, management, planning, and evaluation issues:
Translation of preventive behavioral research into health care practice
Assessment of the need for preventive services
Assessment of the efficacy of preventive services
Infrastructure and service components for preventive services
“General” vs. “Targeted” Services
Within this monograph, services are also classified into one of two categories, “general” and “targeted,” depending on the evidence base and the nature of the service. Those designated as “general” are supported by the evidence base as being appropriate for universal implementation by all health care systems. Services that are classified here as “targeted” appear to be appropriate for selected populations (e.g., selective or indicated populations if applying the IOM model), or they have a developing research base that is promising. “Targeted” services might also be social or educational interventions that could be provided by nonmedical staff to secure educational and social benefits.
C. Clinical vs. Community Preventive Services
Most preventive behavioral services are delivered in school and community settings, not health care settings (Schinke, Brounstein, & Gardner, 2002; DHHS, 1999). In a 1998 review of indicated preventive behavioral services for children and adolescents, Durlak and Wells (1997) used meta-analysis to review 177 programs—73 percent were in a school setting, compared with 23 percent that were mainly in medical settings. In a similar review published 1 year later by the same authors (Durlak & Wells, 1998), none of the programs was in a medical setting.
This report has been prepared to summarize and analyze the most promising preventive interventions (based on rigorous research studies) for consideration by health care organizations. Only interventions deliverable by health care systems are reviewed in this report. Most community preventive services are oriented toward school-age children, adolescents, and young adults—age groups with relatively low exposure to health care delivery settings. Such services generally are provided by and through schools and community organizations.
Health care settings, however, are effective in reaching pregnant women, infants, adults with major chronic medical illnesses, and those in need of surgical procedures. For example, these settings provide a place to address the behavioral needs of these patients through behavioral screening and preventive services, with follow-up in prescribed regimens of care. In this way, clinical preventive services for depression and substance abuse can reduce emergency room use and hospitalization (Olfson, Sing, & Schlesinger, 1999). Psychoeducational services also can speed recovery of postsurgical patients (Egbert, Battit, Welch, & Bartlett, 1964; Mumford, Schlesinger, & Glass, 1982).
It may not be incumbent upon health care delivery systems to provide highly specialized social and educational support services (Devine, O’Connor, Cook, Wenk, & Curtin, 1988), but health care delivery systems do have a role to play. Through their mental health and social work staff, they maintain working relationships with communitybased, social service, educational, and even correctional agencies to ensure they meet the needs of members of the health care delivery system.
D. Health Care Delivery System Provision of Preventive Behavioral Services
The need for behavioral services is substantial. Many who could benefit from treatment for these disorders do not receive care (Woodward et al., 1997; Harwood, Sullivan, & Malhorta, 2001).
Some of the lack of development of behavioral health services within health care delivery systems may be owing to the perception that mental health and substance use disorder services may be “softer” and therefore less effective than conventional medical therapy. However, the efficacy and cost-efficiency of these services is well established and has been recommended by multiple national organizations since at least the early 1990s (U.S. Preventive Services Task Force [USPSTF], 1996, 2002a, 2003).
The 1994 IOM report was titled Reducing Risks for Mental Disorders—Frontiers for Preventive Intervention Research (Mrazek & Haggerty, eds., 1994). A 1998 follow-up report, Preventing Mental Health and Substance Abuse Problems in Managed Care Settings (Mrazek, 1998), was completed in collaboration with the National Mental Health Association (NMHA). This report recommended widespread implementation of primary preventive programming to address five problem areas within health care systems:
Prevention of initial onset of unipolar major depression across the life span
Prevention of low birthweight and prevention of child maltreatment in children from birth to 2 years of age whose mothers are identified as being at high risk
Prevention of alcohol or drug abuse in children who have an alcohol- or drugabusing parent
Prevention of mental health problems in physically ill patients (comorbidity prevention)
Prevention of conduct disorders in young children
The 1999 Surgeon General Report was titled Mental Health: A Report of the Surgeon General (DHHS, 1999). Although the major focus of this report was care and management of mental disorders, all major preventive services were included.
SAMHSA published two recent prevention-related health care reports. The 2000 literature review titled Preventive Interventions Under Managed Care (Dorfman, 2000) used broader definitions of “prevention” and “mental health services” and recommended six interventions for managed care plans:
Prenatal and infancy home visits
Targeted cessation education and counseling for smokers—especially those who are pregnant
Targeted short-term mental health therapy
Self-care education for adults
Presurgical educational intervention with adults
Brief counseling and advice to reduce alcohol use
This new literature review retains four of the above services and omits numbers three and four on short-term mental health therapy and self-care. The companion document published in 2002 was titled Estimating the Cost of Preventive Services in Mental Health and Substance Abuse Under Managed Care (Broskowski & Smith, 2002). This report provided cost data for each of the services recommended in the 2000 literature review. It also featured, for each set of recommended services, a range of costs and options based on case mix and private versus public insurance coverage. It estimated the cost to managed care organizations (MCOs) to implement recommendations for four possible scenarios ranging from most expensive to least expensive, given drivers such as enrollment mix, staffing, staff salaries, and fixed and variable expenses. This report did not consider savings in other health care expenses. Even with the most expensive of cost profiles, the report did conclude that all six services could be fully implemented at a marginal cost of less than a 1 percent increase in cost, per member per month.
During this period, SAMHSA and the National Committee on Quality Assurance (NCQA)–sponsored Health Employer Data Information Set (HEDIS) program have attempted to bring preventive behavioral services to the attention of the managed care community. In response to market pressures to demonstrate high scores on HEDIS measures, the managed care community has taken giant strides to improve the care of patients with depression and has taken steps to enhance member adherence to prescribed regimens of care for diabetes.
In 1998, SAMHSA’s Center for Substance Abuse Prevention created the National Registry of Effective Programs (NREP) as a resource to help professionals in the field become better consumers of prevention programs (Schinke et al., 2002). NREP reviews and screens evidence-based programs (conceptually sound and/or theoretically driven by risk and protective factors) that, through an expert consensus review of research, demonstrate scientifically defensible evidence. NREP initially focused on substance use prevention but has expanded to include mental health; co-occurring mental health and substance use disorders; adolescent substance use treatment; mental health promotion; and adult mental health treatment. Many programs focus on school and family, but increasingly, programs from community coalitions and environmental programs are being identified as well implemented, well evaluated, and effective.
NREP evaluates programs for substance abuse prevention and treatment, co-occuring disorders, and mental health treatment, promotion, and prevention. After receiving published and unpublished program materials from candidates, NREP reviewers, drawn from 80 experts in relevant fields, rate each program according to 18 criteria for methodological rigor, and they also score programs for adoptability and usefulness to communities (Schinke et al., 2002). Based on the overall scoring, NREP categorizes programs as Model Programs, Effective Programs, Promising Programs, or Programs with Insufficient Current Support. Those wishing to learn more about Model Programs can visit www.modelprograms.samhsa.gov. At this site, there is also a link providing detailed information about NREP and the process for submitting a program for NREP review.
Despite these efforts, behavioral services— both preventive and therapeutic—still are not adequately identified, provided, or arranged by primary care practitioners. They also are not adequately promoted by health care systems. Brief screening instruments for alcohol and drug problems, for example, have been available for a number of years but are not widely used by practicing physicians (Duszynski, Nieto, & Vanente, 1995; National Center on Addiction and Substance Abuse at Columbia University, 2000). In a 2002 review, Garnick et al. (2002) conducted a telephone survey covering 434 MCOs in 60 market areas nationwide and secured useful responses from 92 percent of them. Only 14.9 percent of MCOs required any alcohol, drug, or mental health screening by primary care practitioners. Slightly more than half distributed practice guidelines that addressed mental illness, and approximately one third distributed substance use disorder practice guidelines.
DHHS’s 2003 campaign, Steps to a Healthier U.S., focuses on chronic disease prevention and health promotion with the goals of decreasing both the prevalence of certain chronic diseases and the risk factors that allow conditions to develop. This initiative aims to bring together local coalitions to establish model programs and policies that foster health behavior changes, encourage healthier lifestyle choices, and reduce disparities in health care.
In early 2003, SAMHSA published a review of the delivery of behavioral services by managed care organizations, based on 1999 data. This report, The Provision of Mental Health Services in Managed Care Organizations (Horgan et al., 2003), showed substantial variability from plan to plan, as well as substantial variability among health maintenance organizations (HMOs), pointof- service (POS) plans, and preferred provider organizations (PPOs). All MCOs provided behavioral services, but these services usually had limits and copayments that were more restrictive than for comparable medical services. Fewer than 10 percent required screening for behavioral disorders in primary care settings (Horgan et al., 2003).
Another SAMHSA report, also published early in 2003, offers some insight into discrepancies in coverage, comparing medical to behavioral services and discrepancies in policy and coverage, comparing therapeutic to preventive services. This report, titled Medical Necessity in Private Health Plans: Implications for Behavioral Health Care (Rosenbaum, Kamoie, Mauery, & Walitt, 2003), noted that services are covered by health insurance plans only if they are considered a “medical necessity.” The term medical necessity was defined differently for different services within each health plan, with due consideration given for each of the following five domains:
Contractual scope—whether the contract provides any coverage for certain procedures and treatments, such as preventive and maintenance treatments that are not necessary to restore a patient to “normal functioning.” This dimension preempts any other coverage decision.
Standards of practice—whether the treatment (as judged by the health plan) accords with professional standards of practice.
Patient safety and setting—whether the treatment will be delivered in the safest and least intrusive manner.
Medical service—whether the treatment is considered medical as opposed to social or nonmedical.
Cost—whether the treatment is considered cost-effective by the insurer (Rosenbaum et al., 2003).
The medical necessity report noted that Federal or State regulation is limited in covering how health insurance plans define medical necessity (Rosenbaum et al., 2003). This SAMHSA update is intended to build upon the reports noted above to further enhance implementation of preventive behavioral services in health care settings.
March 02, 2010
Helping Children Cope With Fear & Anxiety
Helping Children Cope With Fear & Anxiety
Whether tragic events touch your family personally or are brought into your home via newspapers and television, you can help children cope with the anxiety that violence, death and disasters can cause.
The Caring for Every Child's Mental Health Campaign offers these pointers for parents and other caregivers:
Encourage children to ask questions. Listen to what they say. Provide comfort and assurance that address their specific fears. It's okay to admit you can't answer all of their questions.
Talk on their level. Communicate with your children in a way they can understand. Don't get too technical or complicated.
Be honest. Tell them exactly what has happened. For example, don't say that someone who has died has "gone to sleep;" children may become afraid of going to bed.
Find out what frightens them. Encourage your children to talk about fears they may have. They may worry that someone will harm them at school or that someone will try to hurt you.
Focus on the positive. Reinforce the fact that most people are kind and caring. Remind your child of the heroic actions taken by ordinary people to help victims of tragedy.
Pay attention. Your children's play and drawings may give you a glimpse into their questions or concerns. Ask them to tell you what is going on in the game or the picture. It's an opportunity to clarify any misconceptions, answer questions and give reassurance.
Develop a plan. Establish a family emergency plan for the future, such as a meeting place where everyone should gather if something unexpected happens in your family or neighborhood. It can help you and your child feel safer.
If you are concerned about your child's reaction to stress or trauma, call your physician or a community mental health center.
To learn more about children's mental health:
Call toll-free: 1.800.789.2647
(TDD): 301.443.9006
Web site: mentalhealth.samhsa.gov/child
Comprehensive Community Mental Health Services
for Children and Their Families Program
Child, Adolescent and Family Branch
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
Whether tragic events touch your family personally or are brought into your home via newspapers and television, you can help children cope with the anxiety that violence, death and disasters can cause.
The Caring for Every Child's Mental Health Campaign offers these pointers for parents and other caregivers:
Encourage children to ask questions. Listen to what they say. Provide comfort and assurance that address their specific fears. It's okay to admit you can't answer all of their questions.
Talk on their level. Communicate with your children in a way they can understand. Don't get too technical or complicated.
Be honest. Tell them exactly what has happened. For example, don't say that someone who has died has "gone to sleep;" children may become afraid of going to bed.
Find out what frightens them. Encourage your children to talk about fears they may have. They may worry that someone will harm them at school or that someone will try to hurt you.
Focus on the positive. Reinforce the fact that most people are kind and caring. Remind your child of the heroic actions taken by ordinary people to help victims of tragedy.
Pay attention. Your children's play and drawings may give you a glimpse into their questions or concerns. Ask them to tell you what is going on in the game or the picture. It's an opportunity to clarify any misconceptions, answer questions and give reassurance.
Develop a plan. Establish a family emergency plan for the future, such as a meeting place where everyone should gather if something unexpected happens in your family or neighborhood. It can help you and your child feel safer.
If you are concerned about your child's reaction to stress or trauma, call your physician or a community mental health center.
To learn more about children's mental health:
Call toll-free: 1.800.789.2647
(TDD): 301.443.9006
Web site: mentalhealth.samhsa.gov/child
Comprehensive Community Mental Health Services
for Children and Their Families Program
Child, Adolescent and Family Branch
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
March 01, 2010
After an Earthquake: Mental Health
After an Earthquake: Mental Health
Following a natural disaster, when many people have suffered great losses, it is normal to feel sad, angry, or nervous.
Some who have experienced a disaster may have bad feelings right away. Others may not notice a change until much later, after the crisis is over. It can take time to feel better and for things to return to normal, especially with so much loss. Many people find support and comfort by talking to surviving family members, close friends, doctors, nurses, and religious leaders. Sometimes, help from mental health professionals may be needed.
Medical follow up will be important for the health and wellbeing of many survivors. Survivors should be encouraged to share questions and concerns about their health with their doctors.
Links to CDC resources and those of other organizations are below. Survivor experiences and needs may differ, so some sites may be more helpful to some than others.
Information available in French, Haitian-Creole, and English:
•Mental Health Information for the Public
•Mental Health Information for Professionals
•Mental Health Advisory for Health Professionals Providing Care for Survivors of the 2010 Haitian Earthquake
•General Mental Health Resources
How to find mental health services in the U.S. by state and information for developing cultural competence in disaster mental health programs.
Care Tips for Survivors of a Traumatic Event: What to Expect in Your Personal, Family, Work, and Financial Life
Things to Remember When Trying to Understand Disaster Events
Signs that Adults Need Stress Management Assistance
Ways to Ease the Stress
Things to Remember When Trying to Understand Disaster Events
No one who sees a disaster is untouched by it.
It is normal to feel anxious about you and your family's safety.
Profound sadness, grief, and anger are normal reactions to an abnormal event.
Acknowledging our feelings helps us recover.
Focusing on our strengths and abilities will help you to heal.
Accepting help from community programs and resources is healthy.
We each have different needs and different ways of coping.
It is common to want to strike back at people who have caused great pain. However, nothing good is accomplished by hateful language or actions.
Signs that Adults Need Stress Management Assistance
Difficulty communicating thoughts
Difficulty sleeping
Difficulty maintaining balance
Easily frustrated
Increased use of drugs/alcohol
Limited attention span
Poor work performance
Headaches/stomach problems
Tunnel vision/muffled hearing
Colds or flu-like symptoms.
Disorientation or confusion
Difficulty concentrating
Reluctance to leave home
Depression, sadness
Feelings of hopelessness
Mood-swings
Crying easily
Overwhelming guilt and self-doubt
Fear of crowds, strangers, or being alone
Ways to Ease the Stress
Talk with someone about your feelings– anger, sorrow, and other emotions-- even though it may be difficult.
Don't hold yourself responsible for the disastrous event or be frustrated because you feel that you cannot help directly in the rescue work.
Take steps to promote your own physical and emotional healing by staying active in your daily life patterns or by adjusting them. This healthy outlook will help yourself and your family. (i.e. healthy eating, rest, exercise, relaxation, meditation.)
Maintain a normal household and daily routine, limiting demanding responsibilities of yourself and your family.
Spend time with family and friends.
Participate in memorials, rituals, and use of symbols as a way to express feelings.
Use existing supports groups of family, friends, and church.
Establish a family emergency plan. Feeling that there is something that you can do can be very comforting.
* When to Seek Help: If self help strategies are not helping or you find that you are using drugs/alcohol in order to cope, you may wish to seek outside or professional assistance with your stress symptoms.
Mental health advisory for health professionals providing care for survivors of the 2010 Haitian earthquake
Updated February 24, 2010
In the aftermath of disasters, many survivors will show acute reactions to stress. Reactions to stress may appear immediately after traumatic events or days and even weeks later. Although many reactions to stress may also be symptoms of psychiatric disorders if they persist, reactions to stress are expected responses to traumatic events in the context of disasters. Reactions to stress may be confusing and frightening, and some may view their reactions as signs of weakness or mental illness. Providing reassurance that it is very natural to have physical and emotional responses after a disaster can help to reduce distress and promote better functioning. Common reactions include:
•Physical Reactions: rapid heart rate, trembling hands, unexplained somatic symptoms (e.g., headaches, backaches, chest or abdominal pain), dizziness, blurry vision, sweating/trembling/shaking for no reason, sleep problems, loss of appetite, feeling choked or smothered
•Cognitive Reactions: problems concentrating or remembering things, confusion, disorientation
•Emotional Reactions: feeling tense and nervous, excessive fatigue, crying often or easily, feeling numb, being angry or irritable, feeling nervous or anxious around reminders of the earthquake, and nightmares/intrusive memories/mental images related to the earthquake
•Interpersonal Reactions: problems in relationships with family or friends, conflict, withdrawal, isolation
In evaluating patients, clinicians should keep in mind that some patients may present with signs and symptoms that appear to be reactions to stress but may also be manifestations of medical illness. Adverse reactions to medications or having recently stopped taking medications are other potential causes of physical or mental status changes that should be considered as part of a clinical evaluation.
Grief – Grief is normal and to be expected given the extensive loss of life that occurred after the earthquake; however sometimes grief can become so severe or persistent as to interfere with daily function to a degree that warrants clinical attention.
Long-Term Psychological Responses: The majority of people who experience reactions to stress after disasters and emergencies show resilience and do not go on to develop long-term psychopathology. However, in some survivors, the symptoms do not resolve. Posttraumatic Stress Disorder (PTSD), anxiety disorders, major depression, or other psychiatric disorders may develop. Such illnesses may be serious, even fatal, and warrant prompt follow up.
Depending on the severity of symptoms, level of function, potential risks, clinical questions, and/or other factors, referral to a mental health professional (and/or another health professional) may be warranted even in the absence of a psychiatric disorder.
Suicidal or homicidal ideation may occur in a variety of psychiatric disorders, and warrant immediate attention.
Alcohol and substance use may also increase suicide risk, as well as the risk of motor vehicle crashes and violence. Alcohol and substance use may increase following natural disasters.
Some examples of symptoms that may be indicative of PTSD include: dissociation (e.g., feeling unreal or outside oneself, having "blank" periods of time that one cannot remember); intrusive re-experiencing (e.g., disturbing memories, nightmares, or flashbacks); avoidance of reminders of the disaster (e.g., avoiding activities that remind one of the earthquake, withdrawing from other people); emotional numbing (e.g., unable to feel emotion, as if empty); hyper-arousal (e.g., startle responses, rage, extreme irritability, intense agitation). Diagnostic criteria for PTSD and other psychiatric disorders are included in the most recent edition of the DSM IV (American Psychiatric Association, 2000).
Risk Factors: People who have experienced any of the following are more likely to experience long-term difficulties and may be at higher risk for developing psychopathology:
•Direct and indirect exposure to the earthquake and its impact, e.g., being injured in the earthquake, seeing injured or dead people, hearing people screaming
•Loss of loved ones or friends
•Exposure to prior traumas (e.g., disasters, sexual abuse, motor vehicle crashes, combat)
•Pre-existing mental health issues such as depression or anxiety disorders
•Social isolation
•Multiple relocations and displacements
•Loss of home, valued possessions, neighborhood, or community
•Recent or subsequent major life stressors or emotional strain (e.g., intense emotional demands, searching for survivors, interacting with bereaved family members)
•Extreme fatigue, weather exposure, hunger, or sleep deprivation
Cross-Cultural Issues: Clinicians should be aware that in Haitian culture, there is stigma associated with experiencing or disclosing behaviors associated with mental illness, and there are different culturally appropriate ways of expressing grief, pain, and loss. Haitian patients may be reluctant to discuss or admit to mental health problems, or may refer to stress and psychiatric symptoms in culturally-specific ways, e.g., referring to saisissement (rapid heartbeat and cool blood, due to trauma), and supernatural causes of symptoms, e.g., voudou and hexes. Any discussions of mental health or reactions to stress should be explained in culturally sensitive, supportive, and non-stigmatizing ways.
Children: Children’s immature abilities to understand and process the immediate and long-term effects of emergencies make them among the most vulnerable members of affected communities. Because of stigma in Haitian culture around mental illness, many children may be reluctant to discuss or admit to mental health problems. Likewise, prior caregivers in Haiti may not have fully explored such issues, even prior to the earthquake. Clinicians should consider potential mental health and developmental issues. Reactions to stress differ depending on developmental level and are generally marked by changes in typical behavior for the specific child or adolescent. Some children will warrant referral to a mental health professional.
Acknowledging Psychological Distress: Clinicians should be aware that many patients may be reluctant to acknowledge psychiatric symptoms or distress. Earthquake survivors may fear being stigmatized within their community or denied entrance to the United States, and aid workers and military personnel may fear being penalized professionally if they have psychiatric diagnoses noted on their medical records. Whenever mental health referrals are warranted, added care should be taken to explain and arrange such referrals to the patient and his/her caregivers in a culturally sensitive, supportive, and non-stigmatizing way.
Potential for Misattribution of Symptoms of Non-Psychiatric Medical Conditions to Psychological Distress – In the aftermath of the earthquake, some patients may experience symptoms of head injury, cardiovascular disease, infection, or other undiagnosed medical conditions which may present themselves through mental status changes. Health care providers examining patients who have survived the earthquake need to be alert to that possibility.
Following a natural disaster, when many people have suffered great losses, it is normal to feel sad, angry, or nervous.
Some who have experienced a disaster may have bad feelings right away. Others may not notice a change until much later, after the crisis is over. It can take time to feel better and for things to return to normal, especially with so much loss. Many people find support and comfort by talking to surviving family members, close friends, doctors, nurses, and religious leaders. Sometimes, help from mental health professionals may be needed.
Medical follow up will be important for the health and wellbeing of many survivors. Survivors should be encouraged to share questions and concerns about their health with their doctors.
Links to CDC resources and those of other organizations are below. Survivor experiences and needs may differ, so some sites may be more helpful to some than others.
Information available in French, Haitian-Creole, and English:
•Mental Health Information for the Public
•Mental Health Information for Professionals
•Mental Health Advisory for Health Professionals Providing Care for Survivors of the 2010 Haitian Earthquake
•General Mental Health Resources
How to find mental health services in the U.S. by state and information for developing cultural competence in disaster mental health programs.
Care Tips for Survivors of a Traumatic Event: What to Expect in Your Personal, Family, Work, and Financial Life
Things to Remember When Trying to Understand Disaster Events
Signs that Adults Need Stress Management Assistance
Ways to Ease the Stress
Things to Remember When Trying to Understand Disaster Events
No one who sees a disaster is untouched by it.
It is normal to feel anxious about you and your family's safety.
Profound sadness, grief, and anger are normal reactions to an abnormal event.
Acknowledging our feelings helps us recover.
Focusing on our strengths and abilities will help you to heal.
Accepting help from community programs and resources is healthy.
We each have different needs and different ways of coping.
It is common to want to strike back at people who have caused great pain. However, nothing good is accomplished by hateful language or actions.
Signs that Adults Need Stress Management Assistance
Difficulty communicating thoughts
Difficulty sleeping
Difficulty maintaining balance
Easily frustrated
Increased use of drugs/alcohol
Limited attention span
Poor work performance
Headaches/stomach problems
Tunnel vision/muffled hearing
Colds or flu-like symptoms.
Disorientation or confusion
Difficulty concentrating
Reluctance to leave home
Depression, sadness
Feelings of hopelessness
Mood-swings
Crying easily
Overwhelming guilt and self-doubt
Fear of crowds, strangers, or being alone
Ways to Ease the Stress
Talk with someone about your feelings– anger, sorrow, and other emotions-- even though it may be difficult.
Don't hold yourself responsible for the disastrous event or be frustrated because you feel that you cannot help directly in the rescue work.
Take steps to promote your own physical and emotional healing by staying active in your daily life patterns or by adjusting them. This healthy outlook will help yourself and your family. (i.e. healthy eating, rest, exercise, relaxation, meditation.)
Maintain a normal household and daily routine, limiting demanding responsibilities of yourself and your family.
Spend time with family and friends.
Participate in memorials, rituals, and use of symbols as a way to express feelings.
Use existing supports groups of family, friends, and church.
Establish a family emergency plan. Feeling that there is something that you can do can be very comforting.
* When to Seek Help: If self help strategies are not helping or you find that you are using drugs/alcohol in order to cope, you may wish to seek outside or professional assistance with your stress symptoms.
Mental health advisory for health professionals providing care for survivors of the 2010 Haitian earthquake
Updated February 24, 2010
In the aftermath of disasters, many survivors will show acute reactions to stress. Reactions to stress may appear immediately after traumatic events or days and even weeks later. Although many reactions to stress may also be symptoms of psychiatric disorders if they persist, reactions to stress are expected responses to traumatic events in the context of disasters. Reactions to stress may be confusing and frightening, and some may view their reactions as signs of weakness or mental illness. Providing reassurance that it is very natural to have physical and emotional responses after a disaster can help to reduce distress and promote better functioning. Common reactions include:
•Physical Reactions: rapid heart rate, trembling hands, unexplained somatic symptoms (e.g., headaches, backaches, chest or abdominal pain), dizziness, blurry vision, sweating/trembling/shaking for no reason, sleep problems, loss of appetite, feeling choked or smothered
•Cognitive Reactions: problems concentrating or remembering things, confusion, disorientation
•Emotional Reactions: feeling tense and nervous, excessive fatigue, crying often or easily, feeling numb, being angry or irritable, feeling nervous or anxious around reminders of the earthquake, and nightmares/intrusive memories/mental images related to the earthquake
•Interpersonal Reactions: problems in relationships with family or friends, conflict, withdrawal, isolation
In evaluating patients, clinicians should keep in mind that some patients may present with signs and symptoms that appear to be reactions to stress but may also be manifestations of medical illness. Adverse reactions to medications or having recently stopped taking medications are other potential causes of physical or mental status changes that should be considered as part of a clinical evaluation.
Grief – Grief is normal and to be expected given the extensive loss of life that occurred after the earthquake; however sometimes grief can become so severe or persistent as to interfere with daily function to a degree that warrants clinical attention.
Long-Term Psychological Responses: The majority of people who experience reactions to stress after disasters and emergencies show resilience and do not go on to develop long-term psychopathology. However, in some survivors, the symptoms do not resolve. Posttraumatic Stress Disorder (PTSD), anxiety disorders, major depression, or other psychiatric disorders may develop. Such illnesses may be serious, even fatal, and warrant prompt follow up.
Depending on the severity of symptoms, level of function, potential risks, clinical questions, and/or other factors, referral to a mental health professional (and/or another health professional) may be warranted even in the absence of a psychiatric disorder.
Suicidal or homicidal ideation may occur in a variety of psychiatric disorders, and warrant immediate attention.
Alcohol and substance use may also increase suicide risk, as well as the risk of motor vehicle crashes and violence. Alcohol and substance use may increase following natural disasters.
Some examples of symptoms that may be indicative of PTSD include: dissociation (e.g., feeling unreal or outside oneself, having "blank" periods of time that one cannot remember); intrusive re-experiencing (e.g., disturbing memories, nightmares, or flashbacks); avoidance of reminders of the disaster (e.g., avoiding activities that remind one of the earthquake, withdrawing from other people); emotional numbing (e.g., unable to feel emotion, as if empty); hyper-arousal (e.g., startle responses, rage, extreme irritability, intense agitation). Diagnostic criteria for PTSD and other psychiatric disorders are included in the most recent edition of the DSM IV (American Psychiatric Association, 2000).
Risk Factors: People who have experienced any of the following are more likely to experience long-term difficulties and may be at higher risk for developing psychopathology:
•Direct and indirect exposure to the earthquake and its impact, e.g., being injured in the earthquake, seeing injured or dead people, hearing people screaming
•Loss of loved ones or friends
•Exposure to prior traumas (e.g., disasters, sexual abuse, motor vehicle crashes, combat)
•Pre-existing mental health issues such as depression or anxiety disorders
•Social isolation
•Multiple relocations and displacements
•Loss of home, valued possessions, neighborhood, or community
•Recent or subsequent major life stressors or emotional strain (e.g., intense emotional demands, searching for survivors, interacting with bereaved family members)
•Extreme fatigue, weather exposure, hunger, or sleep deprivation
Cross-Cultural Issues: Clinicians should be aware that in Haitian culture, there is stigma associated with experiencing or disclosing behaviors associated with mental illness, and there are different culturally appropriate ways of expressing grief, pain, and loss. Haitian patients may be reluctant to discuss or admit to mental health problems, or may refer to stress and psychiatric symptoms in culturally-specific ways, e.g., referring to saisissement (rapid heartbeat and cool blood, due to trauma), and supernatural causes of symptoms, e.g., voudou and hexes. Any discussions of mental health or reactions to stress should be explained in culturally sensitive, supportive, and non-stigmatizing ways.
Children: Children’s immature abilities to understand and process the immediate and long-term effects of emergencies make them among the most vulnerable members of affected communities. Because of stigma in Haitian culture around mental illness, many children may be reluctant to discuss or admit to mental health problems. Likewise, prior caregivers in Haiti may not have fully explored such issues, even prior to the earthquake. Clinicians should consider potential mental health and developmental issues. Reactions to stress differ depending on developmental level and are generally marked by changes in typical behavior for the specific child or adolescent. Some children will warrant referral to a mental health professional.
Acknowledging Psychological Distress: Clinicians should be aware that many patients may be reluctant to acknowledge psychiatric symptoms or distress. Earthquake survivors may fear being stigmatized within their community or denied entrance to the United States, and aid workers and military personnel may fear being penalized professionally if they have psychiatric diagnoses noted on their medical records. Whenever mental health referrals are warranted, added care should be taken to explain and arrange such referrals to the patient and his/her caregivers in a culturally sensitive, supportive, and non-stigmatizing way.
Potential for Misattribution of Symptoms of Non-Psychiatric Medical Conditions to Psychological Distress – In the aftermath of the earthquake, some patients may experience symptoms of head injury, cardiovascular disease, infection, or other undiagnosed medical conditions which may present themselves through mental status changes. Health care providers examining patients who have survived the earthquake need to be alert to that possibility.
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