Integrate Substance Use Prevention & Mental Health Services

Introductory Paragraph

A national study shows that one in five Americans has a mental health issue. In this study, young adults between the ages of 18 and 24, indicated that more than 61 percent of respondents who had used opioids not prescribed to them had done so primarily to relieve anxiety and stress. Early identification, screening, accurate diagnosis, and effective treatment of mental health and substance use conditions can alleviate suffering for individuals and their families dealing with behavioral health challenges. Early access and detection of mental health conditions can expedite recovery, enhance educational and employment opportunities, positively impact relationships, and ultimately improve quality of life.

Mandated screenings for physical health concerns are in place for issues such as vision and hearing. Similarly, early detection of mental health and substance use should occur for young people who may be vulnerable to these issues. These screenings should occur as they do for early detection of physical conditions in venues such as schools, primary health care providers, and other community areas. Communities should be given the tools and support necessary to identify signs of mental health or substance use issues at the earliest possible time. This position is endorsed by the United States Preventive Services Task Force and the American Academy of Pediatrics, specifically for depression in youth over age 12. Early detection and screening will reduce the likelihood and consequences of delaying care.

Resources such as access to comprehensive mental health and substance use evaluations should be available to parents and guardians whenever warning signs are observed. Access to adequate care can reduce barriers to learning and improve educational, behavioral, and health outcomes for our youth. The most effective services promote collaboration among all of the people available to help. Pertinent individuals include families, educators, child welfare caseworkers, health insurers, community mental health providers, and substance use treatment providers. Reducing barriers and creating incentives can improve collaboration across systems and funding sources.

In order to improve mental health detection and treatment outcomes, some barriers need to be addressed. Health disparities such as lack of health insurance, cultural factors that discourage mental health treatment, and socioeconomic status need to be addressed to ensure adequate care to all individuals. Disparities in communities may be a factor in the early diagnosis and treatment of mental health conditions and can increase mental illness challenges in already vulnerable and underserved individuals, families, and communities.

Key Information

Mental Health and Drug Addiction

Mental health and drug addiction are undeniably linked. According to the National Institute on Drug Abuse “Many individuals who develop substance use disorders (SUD) are also diagnosed with mental disorders, and vice versa. Multiple national population surveys have found that about half of those who experience a mental illness during their lives will also experience a substance use disorder and vice versa.” Studies have shown that around 1 in 4 individuals that have a serious mental illness also have an SUD. Many people attempt to use drugs to self-medicate their mental illness or escape their situation, so understanding mental health is essential to any prevention or recovery effort. The National Alliance of Mental Illness (NAMI) has distilled the following statistics from SAMHSA and CDC:

• 1 out of 5 U.S. adults experience mental illness each year
• 1 out of 20 U.S. adults experience serious mental illness each year
• 1 out of 6 U.S. youth, aged 6-17, experience a mental health disorder each year
• 50% of all lifetime mental illness begins by age 14, and 75% by age 24
• Suicide is the 2nd leading cause of death among people aged 10-14

Youth Are Struggling with Mental Health Issues

A nationwide U.S. survey of over 1,300 youth conducted in 2018 shows evidence of a growing mental health crisis affecting 14 to 22-year-olds. The survey, sponsored by Hopelab and Well Being Trust (WBT), found that many teens and young adults who were experiencing moderate to severe symptoms of depression utilized online resources for help. Common uses of the Internet included researching mental health issues online (90 percent), accessing other people’s health stories through blogs, podcasts, and videos (75 percent), using mobile apps related to well-being (38 percent), and connecting with health providers through digital tools such as texting and video chat (32 percent).

Co-Occurring Disorders

Co-occurring disorders, or dual diagnosis, refers to simultaneous having a mental health disorder and an SUD. It is common for people with addictions to also suffer from depression, anxiety, or more severe mental illnesses such as schizophrenia or bipolar disorder. Research shows that people who use alcohol or other drugs early in life are more likely to have mental or emotional problems. It’s also true that many people with mental illnesses “self-medicate” with alcohol or other drugs to numb emotional pain, relieve anxiety, or quiet their thoughts. In the past, the medical profession treated one disorder first, typically the substance use disorder, before addressing the other. It is now understood that treating both simultaneously leads to better outcomes. Any successful addiction treatment program will include a mental health assessment and treat co-occurring disorders at the same time.

Depression

Stigmatization of depression can reduce the likelihood of people reaching out to get the mental care they need. Instead, depressed people may ask for prescriptions to treat physical ailments, and use these prescription drugs to treat their emotional pain. Other factors to consider are listed below:

• Because depression is under-diagnosed and under-treated, depression and opioid abuse are strongly concurrent.
• People with depression show abnormalities in the body’s release of its own opioid. chemicals
• Depression tends to exacerbate pain—it makes chronic pain last longer and impacts the recovery process after surgery.
• Depression nearly doubles the risk that someone already using opioids will continue to use them long-term.
• Depressed people are about twice as likely to misuse their painkillers for non-pain symptoms.
• Depressed individuals are between two and three times more likely to ramp up their own doses of painkillers.
• Adolescents with depression are also more likely to use prescription painkillers for non-medical reasons and to become addicted.
• Depressed people are likely to keep using opioids, even when their pain has subsided.

Rural Areas

Shortages of mental-health providers are prominent in rural areas where the opioid epidemic hit the hardest. Some have suggested that providing mental health care to those suffering from chronic pain may help detangle the relationship between pain and depression. Overall, improving detection and treatment of mental health conditions includes improved early screening, assessment, and access to treatment as well as outreach and education in communities.

Homelessness

The unhoused population poses a unique opportunity to address the challenges of integrating substance use and mental health services, as well as in advancing work on health disparities and social determinants of health. Efforts made in harm reduction have highlighted the need for increasing awareness of the intersection of three primary issues facing unhoused people within their social contexts -- economic hardship, mental illness, and/or substance use disorder. The complex intersection of these three distinct but related issues amplify the stigma associated with each issue by itself. While awareness of co-occurring disorders has increased, public perceptions of safety versus the delivery of essential social and behavioral health services has generated confusion on effective solutions to a rapidly growing problem. This often polarizes support for increased law enforcement and support for increased social services. Medication-Assisted Treatment (MAT) is one domain with the substance use field which is successfully navigating this apparent conflict. Various policy recommendations to control the prescription of opiates and the treatment of opioid addiction have been made by the National Healthcare For Homeless Council and are detailed in the SAFE Solutions article titled "Expand Access to Medicated Assisted Treatment/Recovery (MAT/MAR) Two of these policy recommendations are listed below:

• Reduce stigma and treat addiction as a disease. The main barrier to any type of treatment for persons experiencing homelessness is a lack of stable housing. In addition, drug screens are often required when accessing housing, and employers often require drug screens for employment. Landlords and employers need to accept Buprenorphine prescribed as part of a MAT plan as a medical treatment process, and not have it count negatively against a person by including it as a prohibited substance. Addiction needs to be seen as a disease and not a moral failing, and engagement in MATs as a health care intervention should not be a liability to accessing housing or employment.
• Train all health care disciplines on addiction. Expanding awareness of addiction and providing substance abuse education for medical students, residents, practicing physicians, and all other health care providers is essential. Curricula which treat substance use conditions similarly to other chronic disorders and provide more adequate basic preparation need to be implemented. In addition, continuing education opportunities to learn about evidence-based practices for the treatment of SUDs need to be provided, and programs to support the adoption of MAT, screening, brief intervention, and referral to treatment need to be identified and implemented.

Recovery-Oriented Systems of Care (ROSC)

ROSC reflects a systems approach which has been successful in improving the quality of SUD service provision. It is an approach which requires collaboration between agencies -- with a person-centric posture. ROSC has utility for adoption within the prevention community, perhaps as PROSC (Prevention AND Recovery-Oriented Systems of Care). ROSC is described in the SAFE Solutions article titled, "Create Recovery-Ready Communities."

Relevant Research

Prevention and Early Intervention in Youth Mental Health. This research article addresses the need to move the provision of mental health services from a secondary prevention approach (early intervention) to a series of primary prevention strategies -- reducing the onset of mental illness by promoting mental health for all youth. "Evidence suggests that it would be unrealistic to consider promotion and prevention in mental health responsibility of mental health professionals alone. Integrated and multidisciplinary services are needed." This calls for broader community engagement that is guided by mental health professionals.

Findings of the Early Detection and Intervention Center Dresden. This article summarizes research on adolescents and young adults who sought help for bipolar disorders. The intervention and treatment recommendations provide insight into the complexity of prevention and intervention in one specific mental illness context, thus, facilitating an understanding of the challenges associated with prevention of co-occurring disorders.

Impactful Federal, State, and Local Policies

SAMSHA Infant & Early Childhood Mental Health Grants are authorized under the 21st Century Cures Act. The purpose of this program is to improve outcomes for children, from birth up to 12 years of age, by developing, maintaining, or enhancing infant and early childhood mental health promotion, intervention, and treatment services.

Project AWARE (Advancing Wellness and Resiliency in Education). SAMHSA also provides State Education Agency grants to develop sustainable infrastructure for school-based mental health programs and services and to ensure that school-aged youth have access to and are connected with appropriate and effective behavioral health services. With Project AWARE, SAMHSA aims to promote the healthy social and emotional development of school-aged youth and prevent youth violence in school settings. Through this program, schools are implementing evidence-based, culturally appropriate prevention programs that support youth at the universal, selective, and indicated levels.

Medicaid -- Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is designed to ensure that Medicaid benefits meet the needs of youth with SUD. States must comply with their obligations under Medicaid’s EPSDT requirements which enable youth to address their substance use disorders, to receive treatment and continuing care, and to participate in recovery services and supports. NAMI provides guidance on advocacy for mental health screening associated with the EPSDT program.

HRSA Pediatric Mental Health Access The purpose of this program is to promote behavioral health integration into pediatric primary care by supporting pediatric mental health care tele-health access programs.

Available Tools and Resources

SAMHSA:

• SAMHSA 988 website. An easier-to-use 988 Partner Toolkit is now searchable and designed to help you better navigate the bank of the materials available for promoting 988 in your community. The toolkit has all the same video PSAs, social media promotions, print materials, logo and branding, radio, FAQs, messaging, and other 988 marketing materials. You can now easily search and filter all 988 materials by target audience, population, language, and resource type, allowing you to find the right materials that resonate with your audiences.
• Resources for Suicide and Substance Use Prevention in Youth. This webinar includes best practices for suicide prevention and intervention.
• Comprehensive Case Management for Substance Abuse Treatment. This publication is in the SAMHSA Treatment Improvement Protocol Series.

SAFE Project:

• Bridging Prevention and Recovery (BPR): A Community Approach to Systems Change. This SAFE Project program, offered in-person and virtually, guides community leaders through an action-oriented model to systemically integrate prevention and recovery systems to strengthen programs and improve outcomes. BPR is a 3.5 day training program that culminates with 6 technical assistance sessions tailored to each community’s unique set of needs to support implementation and sustainability of joint prevention and recovery community projects.
• See the wiki titled "Become a Trauma-Informed Community" for more detailed information on the relationship between SUD and trauma-related mental health concerns.

The National Institute of Mental Health provides resources on how to find immediate help, health care providers, how to decide if a provider is right for you, how to join a study, and resources to learn more about mental disorders.

The American Academy of Child and Adolescent Psychiatry provides a service that helps find child and adolescent psychiatrists throughout America.

Mental Health America. MHA's work is driven by its commitment to promote mental health as a critical part of overall wellness, including prevention services for all; early identification and intervention for those at risk; integrated care, services, and supports for those who need them; with recovery as the goal.

National Alliance on Mental Illness (NAMI) provides advocacy and education to support all individuals and families affected by mental illness build better lives. NAMI provides a website, "Mental Health by the Numbers" which provides statistics that can be used to promote mental health awareness.

Communities that Care promotes a range of youth mental and behavioral health outcomes, including survey tools, a parenting program, and a variety of prevention education programs.

Early Mental Health Screening and Intervention. This clinical practice brief by the American Mental Health Counselors Association (AMHCA) provides information on intervention and screening across the lifespan.

Identifying Mental Health and Substance Use Problems of Children and Adolescents: A Guide for Child-Serving Organizations. This manual offers guidance and tools for identifying mental illness or substance use issues early in children and adolescents in various setting, such as in schools, the juvenile justice and child welfare systems, and when receiving primary care.

Mental Health During Global Conflict. People across the world may find they struggle with their mental health during times of global conflict. This does not affect only those in active combat. These are humanitarian crises, impacting an entire community or region and beyond. This page addresses how mental health might be affected by major conflict events like war, terrorism, geopolitical tension, territorial disputes, and political instability.

Promising Practices

Virtual Reality Medical Center (VRMC) has been working since the 1990s to use virtual reality to treat mental illness. An early clinical trial of their software found that after an average of seven sessions, 45 percent of those treated no longer screened positive for PTSD and 62 percent had reliably improved. VRMC uses simulation technologies for:

• Treating patients with anxiety disorders
• Training for both military and civilian populations
• Enhancing various educational programs
• Desensitization
• Sessions at home
• Reduction of the number of sessions people need

M3 Information provides a mental health screening tool that measures outcomes based on a 27-question diagnostic checklist targeted for adults aged 18 and older. The M3 Checklist accurately measures outcomes based on question responses for major depression, bipolar disorder, anxiety disorder and post-traumatic stress disorder (PTSD).

MyStrength is a digital platform that integrates state-of-the-art technologies to support people in addressing mental and behavioral health issues. It can be integrated with a professional practice to allow them to see more patients more efficiently and better meet the needs of their patients between in-person visits.