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President's New Freedom
Commission on Mental Health

Achieving the Promise: Transforming Mental Health Care in America

Goal 4: Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice

Recommendations

    4.1 Promote the mental health of young children.

    4.2 Improve and expand school mental health programs.


    4.3 Screen for co-occurring mental and substance use disorders and link with integrated treatment strategies.


    4.4 Screen for mental disorders in primary health care, across the life span, and connect to treatment and supports.

Understanding the Goal

Early Assessment and Treatment Are Critical Across the Life Span

If Untreated, Childhood Disorders Can Lead to a Downward Spiral

Schools Can Help Address Mental Health Problems

People with Co-occurring Disorders Are Inadequately Served

Mental Health Problems Are Not Adequately Addressed in Primary Care Settings

While effective treatments exist for most common mental disorders, studies have shown that many consumers seen in primary care settings do not receive them.7; 134 Even in the 1990s, most adults with depression, anxiety, and other common mental disorders did not receive appropriate care in primary care settings.7; 134 Older adults, children and adolescents, individuals from ethnic minority groups, and uninsured or low-income patients seen in the public sector are particularly unlikely to receive care for mental disorders.5; 16

Achieving the Goal

Recommendation

    4.1 Promote the mental health of young children.

Early Detection Can Reduce Mental Health Problems

Figure 4.1. Model Program: Intervening Early to Prevent Mental Health Problems

Program

Nurse-Family Partnership

Goal

To improve pregnancy outcomes by helping mothers adopt healthy behavior, improve child health and development, reduce child abuse and neglect, and improve families' economic self-sufficiency.

Features

A nurse visits the homes of high-risk women when pregnancy begins and continues for the first year of the child's life. The nurse adheres to visit-by-visit protocols to help women adopt healthy behaviors and to responsibly care for their children. In many states, Nurse-Family Partnership programs are funded as special projects or through State appropriations.

Outcomes

For mothers: 80% reduction in abuse of their children, 25% reduction in maternal substance abuse, and 83% increase in employment. For children (15 years later): 54% to 69% reduction in arrests and convictions, less risky behavior, and fewer school suspensions and destructive behaviors. This is the only prevention trial in the field with a randomized, controlled design and 15 years of follow-up. The program began in rural New York 20 years ago and its benefits have been replicated in Denver and in minority populations in Memphis.146-148

Biggest challenge

To preserve the program's core features as it grows nationwide. The key feature is a trained nurse, rather than a paraprofessional, who visits homes. A randomized, controlled trial found paraprofessionals to be ineffective.149

How other organizations can adopt

Modify requirements of Federal programs, where indicated, to facilitate adopting this successful, cost-effective model.

Sites

270 communities in 23 states.

For additional information

http://www.nccfc.org/nurseFamilyPartnership.cfm

The Commission suggests a national focus on the mental health needs of young children and their families that includes screening, assessment, early intervention, treatment, training, and financing services. The national focus will:

A coordinated, national approach to these issues will help eliminate social and emotional barriers to learning and will promote success in school and in other community settings for young children. This effort may involve collaborations among parents, mental health providers, and early childhood and child care programs. Other important dimensions of the approach will include:

Recommendation

    4.2 Improve and expand school mental health programs.

Schools Should Have the Ability to Play a Larger Role in Mental Health Care for Children

Figure 4.2. Model Program: Screening Program for Youth

Program

Columbia University TeenScreen® Program

Goal

To ensure that all youth are offered a mental health check-up before graduating from high school. TeenScreen® identifies and refers for treatment those who are at risk for suicide or suffer from an untreated mental illness.

Features

All youngsters in a school, with parental consent, are given a computer-based questionnaire that screens them for mental illnesses and suicide risk. At no charge, the Columbia University TeenScreen® Program provides consultation, screening materials, software, training, and technical assistance to qualifying schools and communities. In return, TeenScreen® partners are expected to screen at least 200 youth per year and ensure that a licensed mental health professional is on-site to give immediate counseling and referral services for youth at greatest risk. The Columbia TeenScreen® Program is a not-for-profit organization funded solely by foundations. When the program identifies youth needing treatment, their care is paid for depending on the family's health coverage.

Outcomes

The computer-based questionnaire used by TeenScreen® is a valid and reliable screening instrument.151 The vast majority of youth identified through the program as having already made a suicide attempt, or at risk for depression or suicidal thinking, are not in treatment.152 A follow-up study found that screening in high school identified more than 60% of students who, four to six years later, continued to have long-term, recurrent problems with depression and suicidal attempts.153

Biggest challenge

To bridge the gap between schools and local providers of mental health services. Another challenge is to ensure, in times of fiscal austerity, that schools devote a health professional to screening and referral.

How other organizations can adopt

The Columbia University TeenScreen® Program is pilot-testing a shorter questionnaire, which will be less costly and time-consuming for the school to administer. It is also trying to adapt the program to primary care settings.

Website

www.teenscreen.org

Sites where implemented

69 sites (mostly middle schools and high schools) in 27 States

The No Child Left Behind Act of 2001154 is designed to help all children, including those with serious emotional disturbances reach their optimal potential and achievement. To fulfill the promise of this Act, schools must work to remove the emotional, behavioral, and academic barriers that interfere with student success in school. Consequently, it is critical to strengthen mental health programs in schools. This effort may involve:

Since the IDEA requires that a variety of professionals collaborate in the school and in the community, the Commission urges that coordinating services be regarded as a "related service" in the child's Individual Education Plan (IEP). In developing the IEP, there should be a stronger family focus and youth involvement and support. The training and research funds designated in this Act should be considered for use to train teachers, related services professionals, and parents to recognize signs of emotional and behavioral problems in children, make appropriate referrals for assessment and services and classroom accommodations, and implement and evaluate evidence-based school mental health interventions.

On a related topic, the Commission recognizes the particular challenges for youth in transition from adolescence to adulthood. IDEA has transition requirements beginning at age 14, but to date, these requirements have not resulted in acceptable post-school outcomes.

Studies show that approximately 42% of students with serious emotional disturbances graduate from high school as opposed to 57% of students with other disabilities.81 Schools and local mental health agencies could improve their collaboration and use of evidence-based practices to develop transition-to-work services so that children with serious emotional disorders can move successfully from school to employment or to post-secondary education.

Recommendation

    4.3 Screen for co-occurring mental and substance use disorders and link with integrated treatment strategies.

Treatment for Co-occurring Disorders Must Be Integrated

Integrated treatment often involves other systems as well, because individuals with co-occurring disorders typically have a wide range of health and social service needs. For example, children in the juvenile justice system are at high risk for co-occurring mental and substance abuse disorders.156 Similarly, in the child welfare system, research strongly demonstrates that children in foster care at a high-risk for maladaptive outcomes, including socio-emotional, behavioral, and psychiatric problems warranting mental health treatment and supports.157-159

Recommendation

    4.4 Screen for mental disorders in primary health care, across the life span, and connect to treatment and supports.

Expand Screening and Collaborative Care in Primary Care Settings

Figure 4-3. Model Program: Collaborative Care for Treating Late-Life Depression in Primary Care Settings

Program

IMPACT-Improving Mood: Providing Access to Collaborative Treatment for Late Life Depression

Goal

To recognize, treat, and prevent future relapses in older patients with major depression in primary care. About 5% -10% of older patients have major depression, yet most are not properly recognized and treated. Untreated depression causes distress, disability, and, most tragically, suicide.

Features

Uses a team approach to deliver depression care to elderly adults in primary care setting. Older adults are given a choice of medication from a primary care physician or psychotherapy with a mental health provider. If they do not improve, their level of care is increased by adding supervision by a mental health specialist.

Outcomes

The intervention, compared to usual care, leads to higher satisfaction with depression treatment, reduced prevalence and severity of symptoms, or complete remission.163

Biggest challenge

To ensure that the intervention is readily adapted from the research setting into the practice setting.

How other organizations can adopt

Be receptive to organizational changes in primary care and devise new methods of reimbursement.

Sites

Study sites in California, Texas, Washington, North Carolina, Indiana

 

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