Mood Disorders
How much of the population is affected by mood disorders?
What causes mood disorders / mental illness?
Are mood disorders treatable?
What are some common mood disorders?
More information about bipolar disorder: description; symptoms; formal diagnosis;
treatment
More information about depression: description; symptoms; formal diagnosis;
treatment
For more information and referrals
How much of the population is affected by mood disorders?
Each year, almost 44 million Americans experience a mental disorder. In fact, mental illnesses are among the most common conditions affecting health today.
What causes mood disorders / mental illness?
Researchers believe most serious mental illnesses are caused by complex imbalances in the brain's chemical activity. They also believe environmental factors can play a part in triggering, or cushioning against, the onset of mental illness.
Are mood disorders treatable?
Like other diseases, mental illnesses can be treated. The good news is that most people who have mental illnesses, even serious ones, can lead productive lives with proper treatment. Mood disorders are one form of serious mental illness.
What are some common mood disorders?
Two of the most common mood disorders are depression and bipolar disorder, also known as manic-depressive illness.
Bipolar Disorder
Description:
Extreme mood swings punctuated by periods of generally even-keeled behavior characterize this disorder. Bipolar disorder tends to run in families. This disorder typically begins in the mid-twenties and continues throughout life. Without treatment, people who have bipolar disorder often go through devastating life events such as marital breakups, job loss, substance abuse, and suicide.
Symptoms:
Mania-expansive or irritable mood, inflated self-esteem, decreased need for sleep; increased energy; racing thoughts; feelings of invulnerability; poor judgment; heightened sex drive; and denial that anything is wrong. Depression-feelings of hopelessness, guilt, worthlessness, or melancholy; fatigue; loss of appetite for food or sex; sleep disturbances, thoughts of death or suicide; and suicide attempts. Mania and depression may vary in both duration and degree of intensity.
Formal Diagnosis:
Although scientific evidence indicates bipolar disorder is caused by chemical imbalances in the brain, no lab test exists to diagnose the disorder. In fact, this mental illness often goes unrecognized by the person who has it, relatives, friends, or even physicians. The first step of diagnosis is to receive a complete medical evaluation to rule out any other mental or physical disorders. Anyone who has this mental illness should be under the care of a psychiatrist skilled in the diagnosis and treatment of bipolar disorder.
Treatment:
Eighty to ninety percent of people who have bipolar disorder can be treated effectively with medication and psychotherapy. Self-help groups can offer emotional support and assistance in recognizing signs of relapse to avert a full-blown episode of bipolar disorder. The most commonly prescribed medications to treat bipolar disorder are three mood stabilizers: lithium carbonate, carbamazepine, and valproate.
Depression
Description:
When a person's feelings of sadness persist beyond a few weeks, he or she may have depression. According to the National Institute for Mental Health, three to four million men are affected by depression; it affects twice as many women. Researchers do not know the exact mechanisms that trigger depression. Two neurotransmitters-natural substances that allow brain cells to communicate with one another-are implicated in depression: serotonin and norepinephrine.
Symptoms:
Changes in appetite and sleeping patterns; feelings of worthlessness, hopelessness, and inappropriate guilt; loss of interest or pleasure in formerly important activities; fatigue; inability to concentrate; overwhelming sadness; disturbed thinking; physical symptoms such as headaches or stomachaches; and suicidal thoughts or behaviors.
Formal Diagnosis:
Four or more of the previous symptoms have been present continually, or most of the time, for more than 2 weeks. The term clinical depression merely means the episode of depression is serious enough to require treatment. Major depression is marked by far more severe symptoms, such as literally being unable to drag oneself out of bed. Another form of depression, known as seasonal affective disorder, is associated with seasonal changes in the amount of available daylight.
Treatment:
Some types of cognitive/behavioral therapy and interpersonal therapy may be as effective as medications for some people who have depression. Special bright light helps many people who have seasonal affective disorder.
Three major types of medication are used to treat depression: tricyclics; the newer selective serotonin re-uptake inhibitors (SSRIs), and monoamine oxidase inhibitors (MAO inhibitors). Electroconvulsive therapy uses small amounts of electricity applied to the scalp to affect neurotransmitters in the brain. Usually referred to as ECT, this highly controversial and potentially life-saving technique is considered only when other therapies have failed, when a person is seriously medically ill and/or unable to take medication, or when a person is very likely to commit suicide. Substantial improvements in the equipment, dosing guidelines and anesthesia have significantly reduced the possibility of side effects.
For more information and referrals to specialists and self-help groups in your State, contact:
Depression and Bipolar Support Alliance (DBSA)
(formerly the National Depressive and Manic-Depressive Association)
730 N. Franklin Street, Suite 501
Chicago, IL 60601-3526
Telephone: 800-826-3632
Fax: 312-642-7243
www.dbsalliance.org
Note: These are suggested resources. It is not meant to be a complete list.
Showing posts with label BBS Accredited Ceus. Show all posts
Showing posts with label BBS Accredited Ceus. Show all posts
May 19, 2010
March 28, 2010
A guide to mental health concerns for victims of violent crime
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.
Where can I go for help?
The healing process takes time, and many questions, hurdles and frustrations may surface along the way.
Contact Information
SAMHSA’s Mental Health Services Locator
www.mentalhealth.samhsa.gov/databases
SAMHSA’s National Mental Health
Information Center
1-800-789-2647
1-866-889-2647 (tdd)
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.
Where can I go for help?
The healing process takes time, and many questions, hurdles and frustrations may surface along the way.
Contact Information
SAMHSA’s Mental Health Services Locator
www.mentalhealth.samhsa.gov/databases
SAMHSA’s National Mental Health
Information Center
1-800-789-2647
1-866-889-2647 (tdd)
March 18, 2010
GIRL POWER! Is Good Mental Health
GIRL POWER!
Is Good Mental Health
GIRL POWER! is paving the way for girls to build confidence, competence, and pride in themselves, in other words, enhancing girls' mental wellness. Girl Power! is also providing messages and materials to girls about the risks and consequences associated with substance abuse and with potential mental health concerns. For instance, did you know:
Girls are seven times more likely than boys to be depressed and twice as likely to attempt suicide.*
Girls are three times more likely than boys to have a negative body image (often reflected in eating disorders such as anorexia and bulimia).*
One in five girls in the U.S. between the ages of 12 and 17 drink alcohol and smoke cigarettes.*
Girls who develop positive interpersonal and social skills decrease their risk of substance abuse.*
Girls who have an interest and ability in areas such as academics, the arts, sports, and community activities are more likely to develop confidence and may be less likely to use drugs.*
On the other hand, this also is a time when girls may make decisions to try risky behaviors, including drinking, smoking, and using drugs.*
The Girl Power! Campaign, under the leadership of the Center for Substance Abuse Prevention (CSAP), Substance Abuse and Mental Health Services Administration (SAMHSA) is collaborating with the Center for Mental Health Services (CMHS) to provide this valuable mental health information.
* Girl Power! Hometown Media Kit, Center for Substance Abuse Prevention, 1997.
Substance Abuse and Mental Health
Results from a study of nearly 6,000 people aged 15 to 24 show that among young people with a history of both a mental disorder and an addictive disorder, the mental disorder is usually reported to have occurred first. The onset of mental health problems may occur about 5 to 10 years before the substance abuse disorders.**
This provides a "window of opportunity" for targeted substance abuse prevention interventions and needed mental health services.
** "National Comorbidity Survey," Ronald C. Kessler, Ph.D., et al., American Journal of Orthopsychiatry, June 1996.
What Is Mental Health?
Mental health is how we think, feel, and act in order to face life's situations. It is how we look at ourselves, our lives, and the people we know and care about. It also helps determine how we handle stress, relate to others, evaluate our options, and make choices. Everyone has mental health.
A young girl's mental health affects her daily life and future. Schoolwork, relationships, and physical health can be affected by mental health. Like physical health, mental health is important at every stage of life. Caring for and protecting a child's mental health is a major part of helping that child grow to become the best she can be.
Girls' independence is usually encouraged in childhood, and their strengths nurtured. Most girls become emotionally, mentally, and physically healthy young adults. But sometimes, during the transition from childhood to adolescence, extra care is necessary, so that a girl's self-esteem and coping skills are not diminished. For more information on teen mental health, call 1-800-789-2647 and ask for the brochure: "You and Mental Health: What's the Deal?" (Order # CA-0002)
Nurturing Your Child's Mental Health
Parents and other caregivers are responsible for children’s physical safety and emotional well-being. Parenting styles vary; there is no one right way to raise a child. Clear and consistent expectations for each child, by all caregivers, are important. Many good books are available in libraries or at bookstores on child development, constructive problem-solving, discipline styles, and other parenting skills. The following suggestions are not meant to be complete.
Do your best to provide a safe home and community for your child, as well as nutritious meals, regular health check-ups, immunizations, and exercise.
Be aware of stages in child development so you don’t expect too much or too little from your child.
Encourage your child to express her feelings; respect those feelings. Let your child know that everyone experiences pain, fear, anger, and anxiety.
Try to learn the source of these feelings. Help your child express anger positively, without resorting to violence.
Promote mutual respect and trust. Keep your voice level down—even when you don’t agree. Keep communication channels open.
Listen to your child. Use words and examples your child can understand. Encourage questions.
Provide comfort and assurance. Be honest. Focus on the positives. Express your willingness to talk about any subject.
Look at your own problem-solving and coping skills. Do you turn to alcohol or drugs? Are you setting a good example? Seek help if you are overwhelmed by your child’s feelings or behaviors or if you are unable to control your own frustration or anger.
Encourage your child’s talents and accept limitations.
Set goals based on the child’s abilities and interests—not someone else’s expectations. Celebrate accomplishments. Don’t compare your child’s abilities to those of other children; appreciate the uniqueness of your child. Spend time regularly with your child.
Foster your child’s independence and self-worth.
Help your child deal with life’s ups and downs. Show confidence in your child’s ability to handle problems and tackle new experiences.
Discipline constructively, fairly, and consistently. (Discipline is a form of teaching, not physical punishment.) All children and families are different; learn what is effective for your child. Show approval for positive behaviors. Help your child learn from her mistakes.
Love unconditionally. Teach the value of apologies, cooperation, patience, forgiveness, and consideration for others. Do not expect to be perfect; parenting is a difficult job. Many good books are available in libraries or at bookstores on child development, constructive problem-solving, discipline styles, and other parenting skills.
Mental Health Problems
Many children experience mental health problems that are real and painful and can be severe.
Mental health problems affect at least one in every five young people, at any given time. At least 1 in 10 children may have a serious emotional disturbance that severely disrupts his or her ability to function.
Tragically an estimated two-thirds of all young people with mental health problems are not getting the help they need. Mental health problems can lead to school failure, alcohol or other drug abuse, family discord, violence, or even suicide.
Is Good Mental Health
GIRL POWER! is paving the way for girls to build confidence, competence, and pride in themselves, in other words, enhancing girls' mental wellness. Girl Power! is also providing messages and materials to girls about the risks and consequences associated with substance abuse and with potential mental health concerns. For instance, did you know:
Girls are seven times more likely than boys to be depressed and twice as likely to attempt suicide.*
Girls are three times more likely than boys to have a negative body image (often reflected in eating disorders such as anorexia and bulimia).*
One in five girls in the U.S. between the ages of 12 and 17 drink alcohol and smoke cigarettes.*
Girls who develop positive interpersonal and social skills decrease their risk of substance abuse.*
Girls who have an interest and ability in areas such as academics, the arts, sports, and community activities are more likely to develop confidence and may be less likely to use drugs.*
On the other hand, this also is a time when girls may make decisions to try risky behaviors, including drinking, smoking, and using drugs.*
The Girl Power! Campaign, under the leadership of the Center for Substance Abuse Prevention (CSAP), Substance Abuse and Mental Health Services Administration (SAMHSA) is collaborating with the Center for Mental Health Services (CMHS) to provide this valuable mental health information.
* Girl Power! Hometown Media Kit, Center for Substance Abuse Prevention, 1997.
Substance Abuse and Mental Health
Results from a study of nearly 6,000 people aged 15 to 24 show that among young people with a history of both a mental disorder and an addictive disorder, the mental disorder is usually reported to have occurred first. The onset of mental health problems may occur about 5 to 10 years before the substance abuse disorders.**
This provides a "window of opportunity" for targeted substance abuse prevention interventions and needed mental health services.
** "National Comorbidity Survey," Ronald C. Kessler, Ph.D., et al., American Journal of Orthopsychiatry, June 1996.
What Is Mental Health?
Mental health is how we think, feel, and act in order to face life's situations. It is how we look at ourselves, our lives, and the people we know and care about. It also helps determine how we handle stress, relate to others, evaluate our options, and make choices. Everyone has mental health.
A young girl's mental health affects her daily life and future. Schoolwork, relationships, and physical health can be affected by mental health. Like physical health, mental health is important at every stage of life. Caring for and protecting a child's mental health is a major part of helping that child grow to become the best she can be.
Girls' independence is usually encouraged in childhood, and their strengths nurtured. Most girls become emotionally, mentally, and physically healthy young adults. But sometimes, during the transition from childhood to adolescence, extra care is necessary, so that a girl's self-esteem and coping skills are not diminished. For more information on teen mental health, call 1-800-789-2647 and ask for the brochure: "You and Mental Health: What's the Deal?" (Order # CA-0002)
Nurturing Your Child's Mental Health
Parents and other caregivers are responsible for children’s physical safety and emotional well-being. Parenting styles vary; there is no one right way to raise a child. Clear and consistent expectations for each child, by all caregivers, are important. Many good books are available in libraries or at bookstores on child development, constructive problem-solving, discipline styles, and other parenting skills. The following suggestions are not meant to be complete.
Do your best to provide a safe home and community for your child, as well as nutritious meals, regular health check-ups, immunizations, and exercise.
Be aware of stages in child development so you don’t expect too much or too little from your child.
Encourage your child to express her feelings; respect those feelings. Let your child know that everyone experiences pain, fear, anger, and anxiety.
Try to learn the source of these feelings. Help your child express anger positively, without resorting to violence.
Promote mutual respect and trust. Keep your voice level down—even when you don’t agree. Keep communication channels open.
Listen to your child. Use words and examples your child can understand. Encourage questions.
Provide comfort and assurance. Be honest. Focus on the positives. Express your willingness to talk about any subject.
Look at your own problem-solving and coping skills. Do you turn to alcohol or drugs? Are you setting a good example? Seek help if you are overwhelmed by your child’s feelings or behaviors or if you are unable to control your own frustration or anger.
Encourage your child’s talents and accept limitations.
Set goals based on the child’s abilities and interests—not someone else’s expectations. Celebrate accomplishments. Don’t compare your child’s abilities to those of other children; appreciate the uniqueness of your child. Spend time regularly with your child.
Foster your child’s independence and self-worth.
Help your child deal with life’s ups and downs. Show confidence in your child’s ability to handle problems and tackle new experiences.
Discipline constructively, fairly, and consistently. (Discipline is a form of teaching, not physical punishment.) All children and families are different; learn what is effective for your child. Show approval for positive behaviors. Help your child learn from her mistakes.
Love unconditionally. Teach the value of apologies, cooperation, patience, forgiveness, and consideration for others. Do not expect to be perfect; parenting is a difficult job. Many good books are available in libraries or at bookstores on child development, constructive problem-solving, discipline styles, and other parenting skills.
Mental Health Problems
Many children experience mental health problems that are real and painful and can be severe.
Mental health problems affect at least one in every five young people, at any given time. At least 1 in 10 children may have a serious emotional disturbance that severely disrupts his or her ability to function.
Tragically an estimated two-thirds of all young people with mental health problems are not getting the help they need. Mental health problems can lead to school failure, alcohol or other drug abuse, family discord, violence, or even suicide.
March 15, 2010
Screening Children and Adolescents (5–18 Years)
Screening Children and Adolescents (5–18 Years)
Screening for child and adolescent behavioral disorders using the Pediatric Symptom Checklist (PSC) is widely used in many medical practices and Medicaid programs. The current literature documents the ability of this brief, one-page instrument to identify children in need of further behavioral evaluation. Unfortunately, there are no randomized, controlled studies that document outcomes on screened individuals or groups, compared with populations not screened. PSC screening is classified “targeted” rather than “general” because the studies needed to provide a firmer evidence base have not been done.
A. Screening for Evidence of Behavioral Disorder
The PSC is a brief, one-page, 35-question instrument designed for use by parents in the doctor’s waiting room. The questionnaire is designed to detect behavioral and psychosocial problems in children from 2 to 16 years of age, and it has been used effectively in persons up to 18 years of age (Bernal et al., 2000). Each of the questions can be answered with a “never,” sometimes,” or “often,” with scores of 0, 1, or 2, respectively, attributed to each answer. Scores of 24, 28, or higher, depending on the age of the child, are considered indicative of a possible behavioral or psychosocial problem and will warrant further exploration by the clinician (Jellinek & Murphy, 1999).
The PSC has been suggested as a tool for universal use with children 2 to 16 years of age to screen for behavioral and psychosocial problems (Jellinek & Murphy, 1988; Walker, LaGrone, & Atkinson, 1989; Murphy, Arnett, Bishop, Jellinek, & Reede, 1992; Jellinek & Murphy, 1999, Gardner, 2002; Jellinek et al., 1999). In use since the 1970s, the PSC has been tested and used in tens of thousands of children; scored well in a test of its usefulness to the Medicaidsponsored Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program (Murphy et al., 1996); and is used in several States in the context of their EPSDT programming (Jellinek & Murphy, 1999; Bernal et al., 2000; Gardner, Kelleher, & Pajer, 2002).
The PSC has been found to be acceptable to parents, regardless of socioeconomic status or ethnicity, and to clinicians and clinic office staff (Murphy et al., 1992; Murphy, Reede, Jellinek, & Bishop 1992; Jellinek et al., 1999; Navon, Nelson, Pagano, & Murphy, 2001). It has been validated against more elaborate classification instruments—the Child Behavior Checklist (CBCL) and the Clinician’s Global Assessment Scale (CGAS (Walker et al., 1989; Jellinek & Murphy, 1999). It also routinely generates prevalence rates for pediatric psychosocial and behavioral disorders of approximately 12 percent, which is consistent with other estimates of pediatric behavioral and psychosocial disorders (Jellinek & Murphy, 1999; Jellinek, 1999). The expected increase in psychosocial dysfunction with lower socioeconomic class (Jellinek, Little, Murphy, & Pagano, 1995) and the expected correlation with maternal psychological distress and marital adjustment (Sanger, MacLean, & Van Slyke, 1992) have been clearly documented.
The primary outcome measure noted in the PSC literature has been the percentage of children referred for behavioral or psychosocial evaluation and treatment. This rate of referral has dramatically increased with the introduction of the PSC in every study where this measure has been reported (Navon et al., 2001). In one study, the referral rate increased from 1.5 percent before implementation of the PSC to 12 percent, then dropped back to 2 percent after the PSC screening was discontinued (Murphy et al., 1992). This review found no studies that address the behavioral and psychosocial benefits to the children screened or costs associated with referral of false-positive cases.
One study published in 2000 (Bernal et al., 2000) reported average log costs for health and psychiatric care for all children studied at $393 per year, and costs of those with anxious, depressed symptoms at $805 per year. Chronically ill children showed the highest health care costs, with average log costs of $1,138 per year. Psychosocial dysfunction was associated with higher costs. Unfortunately, this study did not explore whether detection and treatment of the psychosocial dysfunction could lower these costs. With a documented minimum sensitivity (accurately detecting true “positives” or those with the illness) of 80 percent, and a specificity (detecting those without disease) of 68 percent or better (Jellinek et al., 1988; Jellinek & Murphy, 1999), this screening instrument may miss up to 20 percent of children who have serious problems, and refer up to 32 percent of well children to diagnostic interviews that prove negative for any treatable behavioral or psychosocial behavior. Although these efficacy statistics are within acceptable ranges for screening instruments, they do speak to costs of program implementation that need to be considered. Like virtually all other screening programs, little or no benefit will accrue without follow-up treatment for those found to be in need of such treatment. Owing to the research findings, the PSC may be considered a “targeted” service for use in health care delivery settings with providers and health care systems wishing to use it.
The available literature leaves unanswered the possible use of the PSC when the primary care practitioner suspects a significant behavioral problem but does not have enough information to confirm or deny this impression. For such cases, health care systems may wish to make this instrument available to providers for selective use, at their discretion.
The PSC, along with articles describing its proper use on the Pediatric Development and Behavior Web site, is available at www.dbpeds.org/handouts/ (Jellinek & Murphy, 1999) under “screening.” It should be used without modification, other than for translation when working with non- English-speaking families.
The PSC consists of 35 very brief statements to which the parent responds “never,” “sometimes,” or “often.” Presented on a single page with check-off boxes, sample statements include: “Complains of aches/pains; tires easily, little energy; has trouble with a teacher; acts as if driven by a motor … .” The responses are graded on a zero-to-two scale. Depending on age, a score of 24, 28, or greater is considered indicative of significant psychosocial impairment (Jellinek & Murphy, 1999).
Summary: Children and Adolescents 5–18 Years
Screening for potential child and adolescent behavioral disorders using the PSC is widely used in medical practices and Medicaid programs. Because of its low burden (brief), ease of use, wide applicability, and validity, the literature supports its use by health plans with all children in a health care system. In this report, such screening is classified as a “targeted” service rather than “general” because no randomized controlled trials that could document outcomes have been attempted.
Screening for child and adolescent behavioral disorders using the Pediatric Symptom Checklist (PSC) is widely used in many medical practices and Medicaid programs. The current literature documents the ability of this brief, one-page instrument to identify children in need of further behavioral evaluation. Unfortunately, there are no randomized, controlled studies that document outcomes on screened individuals or groups, compared with populations not screened. PSC screening is classified “targeted” rather than “general” because the studies needed to provide a firmer evidence base have not been done.
A. Screening for Evidence of Behavioral Disorder
The PSC is a brief, one-page, 35-question instrument designed for use by parents in the doctor’s waiting room. The questionnaire is designed to detect behavioral and psychosocial problems in children from 2 to 16 years of age, and it has been used effectively in persons up to 18 years of age (Bernal et al., 2000). Each of the questions can be answered with a “never,” sometimes,” or “often,” with scores of 0, 1, or 2, respectively, attributed to each answer. Scores of 24, 28, or higher, depending on the age of the child, are considered indicative of a possible behavioral or psychosocial problem and will warrant further exploration by the clinician (Jellinek & Murphy, 1999).
The PSC has been suggested as a tool for universal use with children 2 to 16 years of age to screen for behavioral and psychosocial problems (Jellinek & Murphy, 1988; Walker, LaGrone, & Atkinson, 1989; Murphy, Arnett, Bishop, Jellinek, & Reede, 1992; Jellinek & Murphy, 1999, Gardner, 2002; Jellinek et al., 1999). In use since the 1970s, the PSC has been tested and used in tens of thousands of children; scored well in a test of its usefulness to the Medicaidsponsored Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program (Murphy et al., 1996); and is used in several States in the context of their EPSDT programming (Jellinek & Murphy, 1999; Bernal et al., 2000; Gardner, Kelleher, & Pajer, 2002).
The PSC has been found to be acceptable to parents, regardless of socioeconomic status or ethnicity, and to clinicians and clinic office staff (Murphy et al., 1992; Murphy, Reede, Jellinek, & Bishop 1992; Jellinek et al., 1999; Navon, Nelson, Pagano, & Murphy, 2001). It has been validated against more elaborate classification instruments—the Child Behavior Checklist (CBCL) and the Clinician’s Global Assessment Scale (CGAS (Walker et al., 1989; Jellinek & Murphy, 1999). It also routinely generates prevalence rates for pediatric psychosocial and behavioral disorders of approximately 12 percent, which is consistent with other estimates of pediatric behavioral and psychosocial disorders (Jellinek & Murphy, 1999; Jellinek, 1999). The expected increase in psychosocial dysfunction with lower socioeconomic class (Jellinek, Little, Murphy, & Pagano, 1995) and the expected correlation with maternal psychological distress and marital adjustment (Sanger, MacLean, & Van Slyke, 1992) have been clearly documented.
The primary outcome measure noted in the PSC literature has been the percentage of children referred for behavioral or psychosocial evaluation and treatment. This rate of referral has dramatically increased with the introduction of the PSC in every study where this measure has been reported (Navon et al., 2001). In one study, the referral rate increased from 1.5 percent before implementation of the PSC to 12 percent, then dropped back to 2 percent after the PSC screening was discontinued (Murphy et al., 1992). This review found no studies that address the behavioral and psychosocial benefits to the children screened or costs associated with referral of false-positive cases.
One study published in 2000 (Bernal et al., 2000) reported average log costs for health and psychiatric care for all children studied at $393 per year, and costs of those with anxious, depressed symptoms at $805 per year. Chronically ill children showed the highest health care costs, with average log costs of $1,138 per year. Psychosocial dysfunction was associated with higher costs. Unfortunately, this study did not explore whether detection and treatment of the psychosocial dysfunction could lower these costs. With a documented minimum sensitivity (accurately detecting true “positives” or those with the illness) of 80 percent, and a specificity (detecting those without disease) of 68 percent or better (Jellinek et al., 1988; Jellinek & Murphy, 1999), this screening instrument may miss up to 20 percent of children who have serious problems, and refer up to 32 percent of well children to diagnostic interviews that prove negative for any treatable behavioral or psychosocial behavior. Although these efficacy statistics are within acceptable ranges for screening instruments, they do speak to costs of program implementation that need to be considered. Like virtually all other screening programs, little or no benefit will accrue without follow-up treatment for those found to be in need of such treatment. Owing to the research findings, the PSC may be considered a “targeted” service for use in health care delivery settings with providers and health care systems wishing to use it.
The available literature leaves unanswered the possible use of the PSC when the primary care practitioner suspects a significant behavioral problem but does not have enough information to confirm or deny this impression. For such cases, health care systems may wish to make this instrument available to providers for selective use, at their discretion.
The PSC, along with articles describing its proper use on the Pediatric Development and Behavior Web site, is available at www.dbpeds.org/handouts/ (Jellinek & Murphy, 1999) under “screening.” It should be used without modification, other than for translation when working with non- English-speaking families.
The PSC consists of 35 very brief statements to which the parent responds “never,” “sometimes,” or “often.” Presented on a single page with check-off boxes, sample statements include: “Complains of aches/pains; tires easily, little energy; has trouble with a teacher; acts as if driven by a motor … .” The responses are graded on a zero-to-two scale. Depending on age, a score of 24, 28, or greater is considered indicative of significant psychosocial impairment (Jellinek & Murphy, 1999).
Summary: Children and Adolescents 5–18 Years
Screening for potential child and adolescent behavioral disorders using the PSC is widely used in medical practices and Medicaid programs. Because of its low burden (brief), ease of use, wide applicability, and validity, the literature supports its use by health plans with all children in a health care system. In this report, such screening is classified as a “targeted” service rather than “general” because no randomized controlled trials that could document outcomes have been attempted.
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.
February 27, 2010
Questions to Help Children Talk About a Disaster
Emergency Mental Health and Traumatic Stress
Tips for Teachers
Questions to Help Children Talk About a Disaster
Disasters hit children hard. It is difficult for them to understand and accept that there are events in their lives that cannot be predicted or controlled. Perhaps worst of all, we as adults cannot "fix" a disaster, solve it, or keep it from happening again.
As a classroom teacher, you can play an important role in the healing process of children who are affected by a disaster. One technique you can use to help children cope and heal is to assist them in expressing their experiences and feelings by talking. This technique works best when you use "open-ended" questions that require more than a "yes" or "no" answer. There are many leading questions you can use to encourage children to talk, such as:
Where were you and what were you doing when the disaster happened?
What was your first thought when it happened?
What did other people around you do during/after the disaster?
Was anyone you know hurt or killed?
Did/do you dream about the disaster?
What reminds you of the disaster?
What do you do differently since the disaster?
How do you feel now?
How have you gotten through rough times before?
What, if anything, would you do differently if this happened again?
As the children begin to open up, encourage various views. Acknowledge their experiences and reassure them that what they are feeling is "normal." Play a guiding role, rather than trying to control the discussions.
Allow children with low language skills, shyness, or discomfort to be silent. It might be helpful to encourage peer support for these children. If a child has limited English-language skills, consider asking for a translator to help the child express him/herself. Create an atmosphere in which a child can feel comfortable sharing experiences and feelings in any language. The goal of the process is to help children feel better. If any of your students show serious signs of distress, consult a school counselor or mental health professional.
Tips for Teachers
Questions to Help Children Talk About a Disaster
Disasters hit children hard. It is difficult for them to understand and accept that there are events in their lives that cannot be predicted or controlled. Perhaps worst of all, we as adults cannot "fix" a disaster, solve it, or keep it from happening again.
As a classroom teacher, you can play an important role in the healing process of children who are affected by a disaster. One technique you can use to help children cope and heal is to assist them in expressing their experiences and feelings by talking. This technique works best when you use "open-ended" questions that require more than a "yes" or "no" answer. There are many leading questions you can use to encourage children to talk, such as:
Where were you and what were you doing when the disaster happened?
What was your first thought when it happened?
What did other people around you do during/after the disaster?
Was anyone you know hurt or killed?
Did/do you dream about the disaster?
What reminds you of the disaster?
What do you do differently since the disaster?
How do you feel now?
How have you gotten through rough times before?
What, if anything, would you do differently if this happened again?
As the children begin to open up, encourage various views. Acknowledge their experiences and reassure them that what they are feeling is "normal." Play a guiding role, rather than trying to control the discussions.
Allow children with low language skills, shyness, or discomfort to be silent. It might be helpful to encourage peer support for these children. If a child has limited English-language skills, consider asking for a translator to help the child express him/herself. Create an atmosphere in which a child can feel comfortable sharing experiences and feelings in any language. The goal of the process is to help children feel better. If any of your students show serious signs of distress, consult a school counselor or mental health professional.
Disaster counseling
DISASTER COUNSELING SKILLS
Disaster counseling involves both listening and guiding. Survivors typically benefit from both talking about their disaster experiences and being assisted with problem-solving and referral to resources. The following section provides "nuts-and-bolts" suggestions for workers.
ESTABLISHING RAPPORT
Survivors respond when workers offer caring eye contact, a calm presence, and are able to listen with their hearts. Rapport refers to the feelings of interest and understanding that develop when genuine concern is shown. Conveying respect and being nonjudgmental are necessary ingredients for building rapport.
ACTIVE LISTENING
Workers listen most effectively when they take in information through their ears, eyes, and "extrasensory radar" to better understand the survivor's situation and needs. Some tips for listening are:
Allow silence - Silence gives the survivor time to reflect and become aware of feelings. Silence can prompt the survivor to elaborate. Simply "being with" the survivor and their experience is supportive.
Attend nonverbally - Eye contact, head nodding, caring facial expressions, and occasional "uh-huhs" let the survivor know that the worker is in tune with them.
Paraphrase - When the worker repeats portions of what the survivor has said, understanding, interest, and empathy are conveyed. Paraphrasing also checks for accuracy, clarifies misunderstandings, and lets the survivor know that he or she is being heard. Good lead-ins are: "So you are saying that . . . " or "I have heard you say that . . . "
Reflect feelings - The worker may notice that the survivor's tone of voice or nonverbal gestures suggests anger, sadness, or fear. Possible responses are, "You sound angry, scared etc., does that fit for you?" This helps the survivor identify and articulate his or her emotions.
Allow expression of emotions - Expressing intense emotions through tears or angry venting is an important part of healing; it often helps the survivor work through feelings so that he or she can better engage in constructive problem-solving. Workers should stay relaxed, breathe, and let the survivor know that it is OK to feel.
SOME DO'S AND DON'T'S
Do say:
These are normal reactions to a disaster.
It is understandable that you feel this way.
You are not going crazy.
It wasn't your fault, you did the best you could.
Things may never be the same, but they will get better, and you will feel better.
Don't say:
It could have been worse.
You can always get another pet/car/house.
It's best if you just stay busy.
I know just how you feel.
You need to get on with your life.
The human desire to try to fix the survivor's painful situation or make the survivor feel better often underlies the preceding "Don't say" list. However, as a result of receiving comments such as these, the survivor may feel discounted, not understood, or more alone. It is best when workers allow survivors their own experiences, feelings, and perspectives.
Disaster counseling involves both listening and guiding. Survivors typically benefit from both talking about their disaster experiences and being assisted with problem-solving and referral to resources. The following section provides "nuts-and-bolts" suggestions for workers.
ESTABLISHING RAPPORT
Survivors respond when workers offer caring eye contact, a calm presence, and are able to listen with their hearts. Rapport refers to the feelings of interest and understanding that develop when genuine concern is shown. Conveying respect and being nonjudgmental are necessary ingredients for building rapport.
ACTIVE LISTENING
Workers listen most effectively when they take in information through their ears, eyes, and "extrasensory radar" to better understand the survivor's situation and needs. Some tips for listening are:
Allow silence - Silence gives the survivor time to reflect and become aware of feelings. Silence can prompt the survivor to elaborate. Simply "being with" the survivor and their experience is supportive.
Attend nonverbally - Eye contact, head nodding, caring facial expressions, and occasional "uh-huhs" let the survivor know that the worker is in tune with them.
Paraphrase - When the worker repeats portions of what the survivor has said, understanding, interest, and empathy are conveyed. Paraphrasing also checks for accuracy, clarifies misunderstandings, and lets the survivor know that he or she is being heard. Good lead-ins are: "So you are saying that . . . " or "I have heard you say that . . . "
Reflect feelings - The worker may notice that the survivor's tone of voice or nonverbal gestures suggests anger, sadness, or fear. Possible responses are, "You sound angry, scared etc., does that fit for you?" This helps the survivor identify and articulate his or her emotions.
Allow expression of emotions - Expressing intense emotions through tears or angry venting is an important part of healing; it often helps the survivor work through feelings so that he or she can better engage in constructive problem-solving. Workers should stay relaxed, breathe, and let the survivor know that it is OK to feel.
SOME DO'S AND DON'T'S
Do say:
These are normal reactions to a disaster.
It is understandable that you feel this way.
You are not going crazy.
It wasn't your fault, you did the best you could.
Things may never be the same, but they will get better, and you will feel better.
Don't say:
It could have been worse.
You can always get another pet/car/house.
It's best if you just stay busy.
I know just how you feel.
You need to get on with your life.
The human desire to try to fix the survivor's painful situation or make the survivor feel better often underlies the preceding "Don't say" list. However, as a result of receiving comments such as these, the survivor may feel discounted, not understood, or more alone. It is best when workers allow survivors their own experiences, feelings, and perspectives.
February 23, 2010
Substance Abuse and Chemical Dependency Continuing Education CEU
B. 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.
for more information on this topic click link below
substance abuse ceus continuing education
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.
for more information on this topic click link below
substance abuse ceus continuing education
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.
February 21, 2010
What is the difference between an Online Interactive CE Course and a Homestudy Course?
What is the difference between an Online Interactive CE Course and a Homestudy Course?
If you submit a completed course/exam to the CE provider via regular mail, then you have taken a homestudy course. If the course/exam is completed and submitted online, then the hours are approved as regular continuing education. Many state boards, such as the California Board of Behavioral Services, allow all required continuing education to be earned from online interactive continuing education courses. Check with your respective board to determine the amount of hours/units are permitted online.
If you submit a completed course/exam to the CE provider via regular mail, then you have taken a homestudy course. If the course/exam is completed and submitted online, then the hours are approved as regular continuing education. Many state boards, such as the California Board of Behavioral Services, allow all required continuing education to be earned from online interactive continuing education courses. Check with your respective board to determine the amount of hours/units are permitted online.
February 20, 2010
BUSINESS AND PROFESSIONS CODE OF CALIFORNIA
BUSINESS AND PROFESSIONS CODE OF CALIFORNIA
CHAPTER 13. MARRIAGE AND FAMILY THERAPISTS
ARTICLE 1. REGULATION
§4980. NECESSITY OF LICENSE
(a) Many California families and many individual Californians are experiencing difficulty and distress, and are in need of wise, competent, caring, compassionate, and effective counseling in order to enable them to improve and maintain healthy family relationships. Healthy individuals and healthy families and healthy relationships are inherently beneficial and crucial to a healthy society, and are our most precious and valuable natural resource. Marriage and family therapists provide a crucial support for the well-being of the people and the State of California. (b) No person may engage in the practice of marriage and family therapy as defined by Section 4980.02, unless he or she holds a valid license as a marriage and family therapist, or unless he or she is specifically exempted from that requirement, nor may any person advertise himself or herself as performing the services of a marriage, family, child, domestic, or marital consultant, or in any way use these or any similar titles, including the letters “M.F.T.” or “M.F.C.C.,” or other name, word initial, or symbol in connection with or following his or her name to imply that he or she performs these services without a license as provided by this chapter. Persons licensed under Article 4 (commencing with Section 4996) of Chapter 14 of Division 2, or under Chapter 6.6 (commencing with Section 2900) may engage in such practice or advertise that they practice marriage and family therapy but may not advertise that they hold the marriage and family therapist’s license.
§4980.01. CONSTRUCTION WITH OTHER LAWS; NONAPPLICATION TO CERTAIN PROFESSIONALS AND EMPLOYEES
(a) Nothing in this chapter shall be construed to constrict, limit, or withdraw the Medical Practice Act, the Social Work Licensing Law, the Nursing Practice Act, or the Psychology Licensing Act. (b) This chapter shall not apply to any priest, rabbi, or minister of the gospel of any religious denomination when performing counseling services as part of his or her pastoral or professional duties, or to any person who is admitted to practice law in the state, or who is licensed to practice medicine, when providing counseling services as part of his or her professional practice. (c) (1) This chapter shall not apply to an employee working in any of the following settings if his or her work is performed solely under the supervision of the employer: (A) A governmental entity. (B) A school, college, or university. (C) An institution that is both nonprofit and charitable. (2) This chapter shall not apply to a volunteer working in any of the settings described in paragraph (1) if his or her work is performed solely under the supervision of the entity, school, or institution.
10
(d) A marriage and family therapist licensed under this chapter is a licentiate for purposes of paragraph (2) of subdivision (a) of Section 805, and thus is a health care practitioner subject to the provisions of Section 2290.5 pursuant to subdivision (b) of that section. (e) Notwithstanding subdivisions (b) and (c), all persons registered as interns or licensed under this chapter shall not be exempt from this chapter or the jurisdiction of the board
§4980.02. PRACTICE OF MARRIAGE, FAMILY AND CHILD COUNSELING; APPLICATION OF PRINCIPLES AND METHODS
For the purposes of this chapter, the practice of marriage and family therapy shall mean that service performed with individuals, couples, or groups wherein interpersonal relationships are examined for the purpose of achieving more adequate, satisfying, and productive marriage and family adjustments. This practice includes relationship and pre-marriage counseling. The application of marriage and family therapy principles and methods includes, but is not limited to, the use of applied psychotherapeutic techniques, to enable individuals to mature and grow within marriage and the family, the provision of explanations and interpretations of the psychosexual and psychosocial aspects of relationships, and the use, application, and integration of the coursework and training required by Sections 4980.36, 4980.37, and 4980.41.
§4980.03. DEFINITIONS
(a) "Board," as used in this chapter, means the Board of Behavioral Sciences. (b) "Intern," as used in this chapter, means an unlicensed person who has earned his or her master's or doctor's degree qualifying him or her for licensure and is registered with the board. (c) "Trainee," as used in this chapter, means an unlicensed person who is currently enrolled in a master's or doctor's degree program, as specified in Section 4980.36 and 4980.37, that is designed to qualify him or her for licensure under this chapter, and who has completed no less than 12 semester units or 18 quarter units of coursework in any qualifying degree program. (d) "Applicant," as used in this chapter, means an unlicensed person who has completed a master's or doctoral degree program, as specified in Section 4980.36 and 4980.37, and whose application for registration as an intern is pending, or an unlicensed person who has completed the requirements for licensure as specified in this chapter, is no longer registered with the board as an intern, and is currently in the examination process. (e) "Advertise," as used in this chapter, includes, but is not limited to, any public communication, as define din subdivision (a) of Section 651, the issuance of any card, sign, or device to any person, or the causing, permitting, or allowing of any sign or marking on, or in, any building or structure, or in any newspaper or magazine or in any directory, or any printed matter whatsoever, with or without any limiting qualification. Signs within church buildings or notices in church bulletins mailed to a congregation shall not be construed as advertising within the meaning of this chapter. (f) "Experience," as used in this chapter, means experience in interpersonal relationships, psychotherapy, marriage and family therapy, and professional enrichment activities that satisfies the requirement for licensure as a marriage and family therapist pursuant to Section 4980.40. (g) "Supervisor," as used in this chapter, means an individual who meets all of the following requirements:
(1) Has been licensed by a state regulatory agency for at least two years as a marriage and family therapist,
11
licensed clinical social worker, licensed psychologist, or licensed physician certified in psychiatry by the American Board of Psychiatry and Neurology. (2) Has not provided therapeutic services to the trainee or intern. (3) Has a current and valid license that is not under suspension or probation. (4) Complies with supervision requirements established by this chapter and by board regulations. (h) "Client centered advocacy," as used in this chapter, includes, but is not limited to, researching, identifying, and accessing resources, or other activities, related to obtaining or providing services and supports for clients or groups of clients receiving psychotherapy or counseling services.
§4980.04. MARRIAGE AND FAMILY THERAPIST ACT
This chapter shall be known and may be cited as the Marriage and Family Therapist Act.
§4980.07. ADMINISTRATION OF CHAPTER
The board shall administer the provisions of this chapter.
§4980.08. LICENSE TITLE NAME CHANGE
(a) The title “licensed marriage, family and child counselor” or “marriage, family and child counselor” is hereby renamed “licensed marriage and family therapist” or “marriage and family therapist,” respectively. Any reference in any statute or regulation to a “licensed marriage, family and child counselor” or “marriage, family and child counselor” shall be deemed a reference to a “licensed marriage and family therapist” or “marriage and family therapist”. (b) Nothing in this section shall be construed to expand or constrict the scope of practice of a person licensed pursuant to this chapter. (c) This section shall become operative July 1, 1999.
§4980.10. ENGAGING IN PRACTICE
A person engages in the practice of marriage and family therapy who performs or offers to perform or holds himself or herself out as able to perform this service for remuneration in any form, including donations.
§4980.30. APPLICATION FOR LICENSE; PAYMENT OF FEE
Except as otherwise provided herein, a person desiring to practice and to advertise the performance of marriage and family therapy services shall apply to the board for a license, pay the license fee required by this chapter, and obtain a license from the board.
§4980.31. DISPLAY OF LICENSE
A licensee shall display his or her license in a conspicuous place in the licensee’s primary place of practice.
CHAPTER 13. MARRIAGE AND FAMILY THERAPISTS
ARTICLE 1. REGULATION
§4980. NECESSITY OF LICENSE
(a) Many California families and many individual Californians are experiencing difficulty and distress, and are in need of wise, competent, caring, compassionate, and effective counseling in order to enable them to improve and maintain healthy family relationships. Healthy individuals and healthy families and healthy relationships are inherently beneficial and crucial to a healthy society, and are our most precious and valuable natural resource. Marriage and family therapists provide a crucial support for the well-being of the people and the State of California. (b) No person may engage in the practice of marriage and family therapy as defined by Section 4980.02, unless he or she holds a valid license as a marriage and family therapist, or unless he or she is specifically exempted from that requirement, nor may any person advertise himself or herself as performing the services of a marriage, family, child, domestic, or marital consultant, or in any way use these or any similar titles, including the letters “M.F.T.” or “M.F.C.C.,” or other name, word initial, or symbol in connection with or following his or her name to imply that he or she performs these services without a license as provided by this chapter. Persons licensed under Article 4 (commencing with Section 4996) of Chapter 14 of Division 2, or under Chapter 6.6 (commencing with Section 2900) may engage in such practice or advertise that they practice marriage and family therapy but may not advertise that they hold the marriage and family therapist’s license.
§4980.01. CONSTRUCTION WITH OTHER LAWS; NONAPPLICATION TO CERTAIN PROFESSIONALS AND EMPLOYEES
(a) Nothing in this chapter shall be construed to constrict, limit, or withdraw the Medical Practice Act, the Social Work Licensing Law, the Nursing Practice Act, or the Psychology Licensing Act. (b) This chapter shall not apply to any priest, rabbi, or minister of the gospel of any religious denomination when performing counseling services as part of his or her pastoral or professional duties, or to any person who is admitted to practice law in the state, or who is licensed to practice medicine, when providing counseling services as part of his or her professional practice. (c) (1) This chapter shall not apply to an employee working in any of the following settings if his or her work is performed solely under the supervision of the employer: (A) A governmental entity. (B) A school, college, or university. (C) An institution that is both nonprofit and charitable. (2) This chapter shall not apply to a volunteer working in any of the settings described in paragraph (1) if his or her work is performed solely under the supervision of the entity, school, or institution.
10
(d) A marriage and family therapist licensed under this chapter is a licentiate for purposes of paragraph (2) of subdivision (a) of Section 805, and thus is a health care practitioner subject to the provisions of Section 2290.5 pursuant to subdivision (b) of that section. (e) Notwithstanding subdivisions (b) and (c), all persons registered as interns or licensed under this chapter shall not be exempt from this chapter or the jurisdiction of the board
§4980.02. PRACTICE OF MARRIAGE, FAMILY AND CHILD COUNSELING; APPLICATION OF PRINCIPLES AND METHODS
For the purposes of this chapter, the practice of marriage and family therapy shall mean that service performed with individuals, couples, or groups wherein interpersonal relationships are examined for the purpose of achieving more adequate, satisfying, and productive marriage and family adjustments. This practice includes relationship and pre-marriage counseling. The application of marriage and family therapy principles and methods includes, but is not limited to, the use of applied psychotherapeutic techniques, to enable individuals to mature and grow within marriage and the family, the provision of explanations and interpretations of the psychosexual and psychosocial aspects of relationships, and the use, application, and integration of the coursework and training required by Sections 4980.36, 4980.37, and 4980.41.
§4980.03. DEFINITIONS
(a) "Board," as used in this chapter, means the Board of Behavioral Sciences. (b) "Intern," as used in this chapter, means an unlicensed person who has earned his or her master's or doctor's degree qualifying him or her for licensure and is registered with the board. (c) "Trainee," as used in this chapter, means an unlicensed person who is currently enrolled in a master's or doctor's degree program, as specified in Section 4980.36 and 4980.37, that is designed to qualify him or her for licensure under this chapter, and who has completed no less than 12 semester units or 18 quarter units of coursework in any qualifying degree program. (d) "Applicant," as used in this chapter, means an unlicensed person who has completed a master's or doctoral degree program, as specified in Section 4980.36 and 4980.37, and whose application for registration as an intern is pending, or an unlicensed person who has completed the requirements for licensure as specified in this chapter, is no longer registered with the board as an intern, and is currently in the examination process. (e) "Advertise," as used in this chapter, includes, but is not limited to, any public communication, as define din subdivision (a) of Section 651, the issuance of any card, sign, or device to any person, or the causing, permitting, or allowing of any sign or marking on, or in, any building or structure, or in any newspaper or magazine or in any directory, or any printed matter whatsoever, with or without any limiting qualification. Signs within church buildings or notices in church bulletins mailed to a congregation shall not be construed as advertising within the meaning of this chapter. (f) "Experience," as used in this chapter, means experience in interpersonal relationships, psychotherapy, marriage and family therapy, and professional enrichment activities that satisfies the requirement for licensure as a marriage and family therapist pursuant to Section 4980.40. (g) "Supervisor," as used in this chapter, means an individual who meets all of the following requirements:
(1) Has been licensed by a state regulatory agency for at least two years as a marriage and family therapist,
11
licensed clinical social worker, licensed psychologist, or licensed physician certified in psychiatry by the American Board of Psychiatry and Neurology. (2) Has not provided therapeutic services to the trainee or intern. (3) Has a current and valid license that is not under suspension or probation. (4) Complies with supervision requirements established by this chapter and by board regulations. (h) "Client centered advocacy," as used in this chapter, includes, but is not limited to, researching, identifying, and accessing resources, or other activities, related to obtaining or providing services and supports for clients or groups of clients receiving psychotherapy or counseling services.
§4980.04. MARRIAGE AND FAMILY THERAPIST ACT
This chapter shall be known and may be cited as the Marriage and Family Therapist Act.
§4980.07. ADMINISTRATION OF CHAPTER
The board shall administer the provisions of this chapter.
§4980.08. LICENSE TITLE NAME CHANGE
(a) The title “licensed marriage, family and child counselor” or “marriage, family and child counselor” is hereby renamed “licensed marriage and family therapist” or “marriage and family therapist,” respectively. Any reference in any statute or regulation to a “licensed marriage, family and child counselor” or “marriage, family and child counselor” shall be deemed a reference to a “licensed marriage and family therapist” or “marriage and family therapist”. (b) Nothing in this section shall be construed to expand or constrict the scope of practice of a person licensed pursuant to this chapter. (c) This section shall become operative July 1, 1999.
§4980.10. ENGAGING IN PRACTICE
A person engages in the practice of marriage and family therapy who performs or offers to perform or holds himself or herself out as able to perform this service for remuneration in any form, including donations.
§4980.30. APPLICATION FOR LICENSE; PAYMENT OF FEE
Except as otherwise provided herein, a person desiring to practice and to advertise the performance of marriage and family therapy services shall apply to the board for a license, pay the license fee required by this chapter, and obtain a license from the board.
§4980.31. DISPLAY OF LICENSE
A licensee shall display his or her license in a conspicuous place in the licensee’s primary place of practice.
February 16, 2010
Depression and Mood Disorders
Depression and Mood Disorders
The Prevalence of Major Depression and Mood Disorders in Suicide
for more information on this topic and ceus, visit link below
Depression and Mood Disorders CEUs for MFTs, LCSWs, LPCs, and Social Workers
Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.
Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.
Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.
The Prevalence of Major Depression and Mood Disorders in Suicide
for more information on this topic and ceus, visit link below
Depression and Mood Disorders CEUs for MFTs, LCSWs, LPCs, and Social Workers
Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.
Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.
Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.
January 26, 2010
continuing education mft
continuing education mft
For mental health professionals
BBS Accredited Ceus
Courses are focused strictly on mental health CEU requirements. Our founders and course writers include practicing clinical mental health professionals, making our courses relevant to today’s continuing education requirements. Our courses satisfy CEU requirements for the following professions in the following states:
Marriage and Family Therapists (MFT/LMFT/MFTI)
California, Colorado, Florida, Kentucky, Louisiana, Massachusetts, Nevada, Ohio, Oregon, Texas
Clinical Social Worker (CSW/LCSW/ASW)
Arkansas, California, Colorado, Florida, Hawaii, Michigan, Missouri, New York, Oregon
Alcohol and Drug Counselors (CADC I/CADC II)
California
Prevention Specialists (CPS)
California
Clinical Supervisors (CCS)
California
Professional Counselors (LPC/CPC)
Colorado, Hawaii, Kentucky, Louisiana, Missouri, Oregon, Texas
Mental Health Counselor (MHC)
Florida
Continuing education (CEU) courses offered
Aspira Continuing Education’s courses encompass all areas of mental health practice. Whether you are completing CEUs for your certification or maintain your license, our online continuing education courses provide the fastest, lowest cost, most convenient way to fulfill your CEU requirements.
We offer courses in the following subjects:
Aging and Long Term Care CEUs
Alcoholism and Substance Abuse Dependency CEUs
Anger Management CEUs
Anxiety Disorders CEUs
Assessment and Diagnosis CEUs
Bipolar Disorder CEUs
Boundaries CEUs
Boundaries in Marriage CEUs
Child Abuse Assessment and Reporting CEUs
Cognitive Behavioral Therapy CEUs
Conflict Resolution CEUs
Crisis Counseling CEUs
Depressive Disorders CEUs
Family Therapy CEUs
From Panic to Power CEUs
Group Therapy CEUs
HIV and AIDS CEUs
How To Build a Thriving Fee-for-Service Practice CEUs
Human Sexuality CEUs
Law and Ethics CEUs
Managed Care CEUs
Mom's House, Dad's House CEUs
Panic Disorder CEUs
Post Traumatic Stress Disorder CEUs
Psychopharmacology CEUs
Spousal and Partner Abuse CEUs
Step-Wives CEUs
For mental health professionals
BBS Accredited Ceus
Courses are focused strictly on mental health CEU requirements. Our founders and course writers include practicing clinical mental health professionals, making our courses relevant to today’s continuing education requirements. Our courses satisfy CEU requirements for the following professions in the following states:
Marriage and Family Therapists (MFT/LMFT/MFTI)
California, Colorado, Florida, Kentucky, Louisiana, Massachusetts, Nevada, Ohio, Oregon, Texas
Clinical Social Worker (CSW/LCSW/ASW)
Arkansas, California, Colorado, Florida, Hawaii, Michigan, Missouri, New York, Oregon
Alcohol and Drug Counselors (CADC I/CADC II)
California
Prevention Specialists (CPS)
California
Clinical Supervisors (CCS)
California
Professional Counselors (LPC/CPC)
Colorado, Hawaii, Kentucky, Louisiana, Missouri, Oregon, Texas
Mental Health Counselor (MHC)
Florida
Continuing education (CEU) courses offered
Aspira Continuing Education’s courses encompass all areas of mental health practice. Whether you are completing CEUs for your certification or maintain your license, our online continuing education courses provide the fastest, lowest cost, most convenient way to fulfill your CEU requirements.
We offer courses in the following subjects:
Aging and Long Term Care CEUs
Alcoholism and Substance Abuse Dependency CEUs
Anger Management CEUs
Anxiety Disorders CEUs
Assessment and Diagnosis CEUs
Bipolar Disorder CEUs
Boundaries CEUs
Boundaries in Marriage CEUs
Child Abuse Assessment and Reporting CEUs
Cognitive Behavioral Therapy CEUs
Conflict Resolution CEUs
Crisis Counseling CEUs
Depressive Disorders CEUs
Family Therapy CEUs
From Panic to Power CEUs
Group Therapy CEUs
HIV and AIDS CEUs
How To Build a Thriving Fee-for-Service Practice CEUs
Human Sexuality CEUs
Law and Ethics CEUs
Managed Care CEUs
Mom's House, Dad's House CEUs
Panic Disorder CEUs
Post Traumatic Stress Disorder CEUs
Psychopharmacology CEUs
Spousal and Partner Abuse CEUs
Step-Wives CEUs
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