Translating the Surgeon General's Report on Mental Health on Policy and Practice for Children
Anne Riley, Ph.D.
Johns Hopkins School of Hygiene and Public Health
Organized, but did not attend.
Howard Goldman, M.D., Ph.D.
Professor of Psychiatry, University of Maryland
Peter Jensen, M.D.
Director, Institute for the Advancement of Child Mental Health, NYSPI Columbia University
Joan Asarnow, Ph.D.
University of California, Los Angeles
Findings of the Surgeon General's Report on Mental Health
From Ivory Tower to Earthen Trenches: Applying Research to Real
Implementing the Mental Health Report Recommendations in the
Treatment of Adolescent Depression
The recent Surgeon's General report on mental health has brought national attention to mental health concerns throughout the life span. The report's chapter on Child and Adolescent Mental Health has provided a new opportunity to contemplate this aspect of child health. The goal of this session was to provide an opportunity for researchers to discuss the implications of this report for children's healthcare and health services research. The session began with an overview of the Child Mental Health Services Chapter by moderator Howard Goldman, M.D., Ph.D., an editor for the report, and was followed by a discussion of the barriers to dissemination of results-based research by Peter Jensen, M.D. Finally, Joan Asarnow, Ph.D. presented an example of how we can move the child health agenda forward through research.
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Findings of the Surgeon General's Report on Mental Health
There is a great need for a conceptual framework to develop more effective treatments and take advantage of the current public interest in child health. The Mental Health Report recently released by the Surgeon General is over 500 pages in length and a significant portion (one quarter of the report) is related to children and adolescents. The mission behind the report was to raise awareness about mental health and provide an impetus to improve services and treatment.
The idea for a mental health report sprang out of the success of the Surgeon General's report on physical activity. When the report on physical activity was released in 1996, that issue became one of national importance. The report reviewed scientific evidence on the impact of physical activity and lack of physical activity, and made sound recommendations based on that evidence. Because the information was presented as a neutral scientific document from a non-advocate source, professional organizations and others readily promoted the recommendations and looked for ways to operationalize them. It was hoped that a Surgeon General's report on mental health would have a similar effect.
Child health constituents were heavily involved in the development of the report on mental health, which reflects a developmental perspective that was not present in past discussions of mental health. The document provides developmental expectations, psychopathology and disorders that are unique in each life stage, and discusses the potential for recovery. The report does not contain policy recommendations, but it does identify courses of action that expand opportunities to increase mental health services and challenges associated with the identified actions.
The report is intended to provide a tool for advocacy of evidence-based mental health intervention, information about the variety of treatments available and what treatment to expect in response to specific disorders. The broad range of research included in the report is not new. Some of the studies cited, in fact, are over a decade old. The research is used to demonstrate how specific findings have been replicated over time and are now generally accepted as true. For example, in the area of integrated neurotherapy, a variety of research is cited to show how and why some disorders, such as mild depression, are treatable by psychosocial interventions just as well as by pharmacological interventions.
The over-arching goals of the report are to reinforce that:
- Mental health is fundamental to overall health and well-being.
- Mental disorders are real disorders.
- There are many treatments available for mental disorders, and their efficacy is well documented.
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From Ivory Tower to Earthen Trenches: Applying Research to Real World Settings
Dr. Jensen discussed challenges involved in determining whether treatments used successfully in university and research settings are effective in real world settings, and also discussed the challenges of identifying barriers to efficacy. As an example, Dr. Jensen discussed the outcomes and applicability of a 1999 study of attention deficit disorder (ADD). The study, which was the largest clinical study of children ever conducted, compared four groups of children randomly assigned to different treatment modalities:
- Behavioral therapy.
- Medicine and behavioral therapy combination
- A community-based treatment comparison group.
Each group was treated for 14 months and assessed at three, nine and 14 months after the start of the study. The outcomes of the study indicated improvement across all four groups over time. The medical management and behavioral-medical combination yielded comparable outcomes based on teacher-rated attention measures. The combination approach offered no significant advantage over the medicine alone and both outperformed the intensive behavioral treatment and control group.
Perceptions about treatment can impact research results. It was interesting to note that although the study participants were originally divided equally among the groups, 14 percent of the families assigned to the medical management group did not accept the assignment (they wanted some behavioral therapy included) and 25 percent of those assigned to behavioral therapy crossed over to the combination group (to include some medications), whereas only 3 of the 144 families in the medical management group felt that their child needed additional treatment modalities. At the conclusion of the study, 79 percent of the participant families strongly recommended the combination approach and 67 percent strongly recommended the behavioral approach, while a much smaller proportion recommended medical management.
The implications of this data are that parent preferences, as well as efficacy, impact study findings.
Although medical management was just as effective as the behavioral-medicine combination in the research setting, the medical management provided in the community control group was not as effective.
Differences in efficacy were attributed to differences in:
- The frequency of follow-up visits.
- Medicine dosage.
- Daily distribution and feedback obtained regarding the child's behavior.
Barriers to achieving the research-setting level of efficacy in real life include:
- Family factors (e.g., compliance, involvement).
- Provider and organizational factors (skills, modality use).
- System/societal factors (funding, policies).
Dr. Jensen then discussed a second study aimed at increasing mental health services use and the engagement of families in a clinical setting. The study looked at the impact of conducting an introductory call prior to initial clinic visits to get clients to come in for the first visit. The introductory call focused in identifying barriers to coming in for the appointment and problem-solving to address those barriers.
There was a significantly smaller proportion of no-shows among the group that received an introductory call than there were among the "no pre-call" group. Part two of the study assessed the impact of providers inquiring about barriers to keeping return appointments during the patients' first appointment.
Findings showed that a larger percentage of patients who engaged in the "intentions interview" returned for 2nd and 3rd appointments than patients who did not have the interview. The implications of these findings are that involving participants in discussions about their intentions to use mental health services and examining the barriers to their doing so can effectively address some participant-level barriers that impact use of care and can increase participation rates.
Use of mental health services is impeded by provider and organizational-level barriers as well as participant-level barriers. Several studies have shown discrepancies in parent-reports versus physician-reports when asked if the provider asked about the child's mental health. Seventy-seven percent of physicians indicated that they asked about mental health, whereas only 33 percent of parents indicated that the provider asked. On questions regarding how easy it is to talk about mental health issues, 57 percent of physicians indicated that they thought it was difficult, while 76 percent of parents indicated that it is not difficult.
Researchers must consider all three levels of barriers/enhancers to the delivery of mental health services:
- Child/family factors.
- Provider/organizational factors.
- Systematic/societal factors.
Methods that appear to help mitigate the child/family barriers include:
- Educational outreach visits.
- Reminders (mailed or calls).
- Multifaceted interventions (combinations).
- Interactive educational meetings.
Methods that appear to help mitigate the systematic/societal barriers include:
- Offering a grant program or other incentive program to encourage an organization to adopt the report's recommendations as best practices.
- Making advocates and parents knowledgeable about mental health services requests and recommended processes.
- Utilizing a providers' log to testify to legislature and other policymakers to advocate for change.
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Implementing the Mental Health Report Recommendations in the Treatment of Adolescent Depression
Current data, summarized Joan R. Asarnow, indicate that roughly 75 percent of youth with serious mental health needs do not get specialty services. Barriers to treatment for adolescents include the following:
- The problem is not recognized/diagnosed by providers.
- Youth or parent does not see the need for treatment.
- There is stigma associated with mental health issues and treatment.
- Treatment is not perceived as acceptable (e.g., reluctant to consider medication).
- There exist many practical issues such as transportation, time, cost, etc.
Depression is the most prevalent mental health problem among adolescents; it affects 20 percent of the population by the age of 18 years. Efficacious treatments for adolescent depression, such as Selective Serotonin Reuptake Inhibitors (SSRIs) and cognitive-behavioral therapy (CBT), have been identified and tested, but are often unavailable to primary care patients. Recent evidence suggests that these interventions are significantly more effective than placebos, wait list controls, and alternative psychosocial interventions.
Dr. Asarnow discussed her research conducted under the AHRQ grant Youth Partners in Care. This project is examining the impact of a program designed to improve care for depression among adolescents and young adults in primary care. Major goals of the study are:
- To test an innovative model of care for depression among youth in primary care settings.
- To evaluate the effects of the intervention as compared to "usual care."
- To improve quality of care, as indexed by rates of starting and completing known effective treatment regimens.
- To evaluate the impact of treatment on clinical and social outcomes, and on social costs from a family perspective.
The study aims to improve outcomes by increasing initiation and adherence to known effective treatment regimens. The components of the intervention model include:
- Provider education.
- Trained youth care managers for patient/family education.
- Emphasis on patient and provider choice.
- Psychotherapists trained in CBT.
- Local expert teams that tailor the disease management models to the practitioner's existing system of care.
Adolescent patients are screened in primary care providers' waiting rooms using a depression screening tool for children. Entry into the study is based on a positive depression screening. Results based on a preliminary sample reveal that of those adolescents who had a positive depression screen, 78 percent were female, 87 percent had major depressive symptoms, and only 45 percent indicated that they were in excellent health.
The quality improvement intervention includes the following steps:
- Depressed adolescents are referred to a care manager who supports the primary care provider with evaluation.
- Developing a treatment plan.
The final treatment plan is decided upon by the primary care provider, in collaboration with the patient, parent(s), and care manager. A treatment plan might include medication, cognitive-behavior therapy (CBT), or a combination of CBT and referral to specialty care, or the "watch and wait" approach (no immediate therapy recommended). Adaptations were made in the treatment protocols to include a family component and to attend to development processes and tasks specific to adolescence (e.g., issues related to school and transitions to work. Of the initial clients in the quality improvement intervention, 92 percent received some form of treatment.
Early findings indicate that:
- Many youth suffering from depression are children not identified in primary care, perhaps because symptoms are believed to be a result of physical health issues and/or stigma related to depression and mental health treatment.
- There is a need for effective strategies to assist primary care providers in identifying and managing adolescents with depression.
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Current as of June 2000
Translating the Surgeon General's Report on Mental Health on Policy and Practice for Children. The Role of Partnerships: Second Annual Meeting of Child Health Services Researchers. June 27, 2000. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/chsr2rmh.htm
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