Presented at the California Mental Health System Summit Sacramento, CA

1

Institute of Medicine Prevention Report
Recommended Prevention and Early Intervention
Measures

• Presented at the California Mental Health
  System Summit Sacramento, CA
• May 22, 2009
• By Ricardo F. Muñoz, Ph.D. University of
  California, SF
• San Francisco General Hospital

2

Report of the Committee on the Prevention of
Mental Disorders and Substance Abuse

• Slides 2-33 are from
• IOM Public Briefing
• March 25, 2009
• Washington DC

3
Committee Members

• KENNETH WARNER (Chair), School of Public Health,
  University of Michigan
• THOMAS BOAT (Vice Chair), Cincinnati Childrens
  Hospital Medical Center
• WILLIAM R. BEARDSLEE, Department of Psychiatry,
  Childrens Hospital Boston
• CARL C. BELL, University of Illinois at Chicago,
  Community Mental Health Council
• ANTHONY BIGLAN, Center on Early Adolescence,
  Oregon Research Institute
• C. HENDRICKS BROWN, College of Public Health,
  University of South Florida
• E. JANE COSTELLO, Department of Psychiatry and
  Behavioral Sciences, Duke University Medical
  Center
• TERESA D. LaFROMBOISE, School of Education,
  Stanford University
• RICARDO F. MUÑOZ, Department of Psychiatry,
  University of California, San Francisco
• PETER J. PECORA, Casey Family Programs and School
  of Social Work, University of Washington
• BRADLEY S. PETERSON, Pediatric Neuropsychiatry,
  Columbia University
• LINDA A. RANDOLPH, Developing Families Center,
  Washington, DC
• IRWIN SANDLER, Prevention Research Center,
  Arizona State University
• MARY ELLEN OCONNELL, Study Director

4
Committee Charge

• Review promising areas of research
• Highlight areas of key advances and persistent
  challenges
• Examine the research base within a developmental
  framework
• Review the current scope of federal efforts
• Recommend areas of emphasis for future federal
  policies and programs of research

5
Prevention AND Promotion
6
Defining Prevention and Promotion

• Prevention of relapse, co-morbidity are
  considered treatment, not prevention
• Endorsed classification of prevention as
  universal, selective or indicated
• Added promotion as a complementary intervention
  approach

7
Mental Health Promotion Aims to

• Enhance individuals
• ability to achieve developmentally appropriate
  tasks (developmental competence)
• positive sense of self-esteem, mastery,
  well-being, and social inclusion
• Strengthen their ability to cope with adversity

8
Disorders Are Common and Costly

• Around 1 in 5 young people (14-20) have a
  current disorder
• Estimated 247 billion in annual costs
• Costs to multiple sectors education, justice,
  health care, social welfare
• Costs to the individual and family

9
Preventive Opportunities Early in Life

• Early onset (¾ of adult disorders had onset by
  age 24 ½ by age 14)
• First symptoms occur 2-4 years prior to onset of
  a diagnosable disorder
• Common risk factors for multiple problems and
  disorders

10
Prevention Window
11
Core Concepts of Prevention

• Prevention requires a paradigm shift
• Mental health and physical health are inseparable
• Successful prevention is inherently
  interdisciplinary
• Mental, emotional, and behavioral (MEB) disorders
  are developmental
• Coordinated community level systems are needed to
  support young people
• Developmental perspective is key

12
Preventive Intervention Opportunities
13
Two Approaches to Targeting Interventions

• Target specific disorders -- depression,
  substance abuse, schizophrenia
• Target risk and protective factors for multiple
  disorders -- poverty, maltreatment, family
  disruption, community and school risk factors

14
Impressive Evidence of Efficacy

• Interventions show effects on wide range of
  serious problems such as substance abuse,
  depression, antisocial behavior, child abuse
• Interventions improve positive outcomes such as
  school success, self-esteem
• Multi-year effects of some interventions

15
Evidence from Studies that Target Specific
Disorders

• Indications that incidence of adolescent
  depression can be reduced
• Emerging evidence to prevent onset of full-blown
  schizophrenic episodes

16
Family-Based Programs Prevent Multiple Problems
and Disorders

• Parenting Programs (Incredible Years, Triple P,
  Strengthening Families 10-14)
• Home Visiting (Nurse Family Partnership)
• Family Disruption Interventions (e.g., Divorce,
  Maternal Depression)

17
School-Based Programs Prevent Multiple Problems
Build Strengths

• Comprehensive Early Childhood Education
• Good Behavior Game
• PATHS
• Life Skills Training
• Linking Interest of Families and Teachers
• Fast Track
• Adolescent Transitions Program

18
Implementation

• Need effectiveness and implementation trials
• Need community-researcher partnerships
• Implementation research has highlighted
• complexity
• important role of community

19
Screening

• Screening should meet modified WHO criteria
• Validated tool
• Responsive to community priorities
• Intervention available
• Parent endorsement

20
Recommendation Themes

• Putting Knowledge into Practice
• Continuing Course of Rigorous Research

21
Putting Knowledge Into Practice Overarching
Recommendations

• The federal government should make the healthy
  mental, emotional, and behavioral development of
  young people a national priority,
• Establish public goals for the prevention of
  specific MEB disorders and the promotion of
  healthy development among young people, and
• provide needed research and service resources to
  achieve these aims.

22
Putting Knowledge Into Practice Overarching
Recommendations

• The White House should create an ongoing
  mechanism involving federal agencies,
  stakeholders (including professional
  associations), and key researchers to develop and
  implement a strategic approach to the promotion
  of mental, emotional, and behavioral health and
  the prevention of MEB disorders and related
  problem behaviors in young people.
• The Departments of Health and Human Services,
  Education, and Justice should be accountable for
  coordinating and aligning their resources,
  programs, and initiatives with this strategic
  approach and for encouraging their state and
  local counterparts to do the same.

23
Putting Knowledge Into Practice Overarching
Recommendations

• States and communities should develop networked
  systems to apply resources to the promotion of
  mental health and prevention of MEB disorders
  among their young people.
• These systems should involve individuals,
  families, schools, justice systems, healthcare
  systems and relevant community-based systems.
  Such approaches should build on available
  evidence-based programs and involve local
  evaluations to assess the implementation process
  of individual programs or policies and to measure
  community-wide outcomes.

24
Putting Knowledge Into Practice Data Collection
and Monitoring

• HHS should provide annual prevalence data and
  data on key risk factors
• SAMHSA should expand service use data collection

25
Putting Knowledge Into Practice Funding

• Prevention set-aside in mental health block grant
  
• Braided funding
• Fund state, county, and local prevention and
  promotion networks

26
Putting Knowledge Into Practice Funding (Contd)

• Target resources to communities with elevated
  risk factors (e.g., poverty)
• Facilitate researcher-community partnerships
• Prioritize use of evidence-based programs and
  promote rigorous evaluation across range of
  settings

27
Putting Knowledge Into Practice Workforce
Development

• HHS, ED, and Justice should develop training
  guidelines
• Set aside funds for competitive prevention
  training grants
• Professional training programs should include
  prevention
• Certification and accrediting bodies should set
  relevant standards

28
Continuing a Course of Rigorous
ResearchOverarching Recommendations

• The National Institutes of Health, with input
  from other funders of prevention research, should
  develop a comprehensive 10-year research plan
  targeting the promotion of mental health and
  prevention of both single and comorbid MEB
  disorders. This plan should consider current
  needs, opportunities for cross-disciplinary and
  multi-institute research, support for the
  necessary research infrastructure, and
  establishment of a mechanism for assessing and
  reporting progress against 10-year goals.

29
Continuing a Course of Rigorous
ResearchOverarching Recommendations

• Research funders should establish parity between
  research on preventive interventions and
  treatment interventions

30
Envisioning the Future

• Factors shown to improve the physical and mental
  health of children are addressed and enhanced by
  the systems that provide services to them.
• Families and children have ready access to the
  best available evidence-based preventive
  interventions delivered in their own communities
  in a culturally competent and respectful
  (nonstigmatizing) way.
• Preventive interventions are provided as a
  routine component of school, health, and
  community service systems.

31
Envisioning the Future

• 4. A well organized public health monitoring
  system is in play to track the incidence and
  prevalence of MEB disorders and used to
  appropriately direct resources.
• 5. Services are coordinated and integrated with
  multiple points of entry for children and their
  families (e.g., schools, health care settings,
  and youth centers).

32
Envisioning the Future (continued)

• As new preventive interventions are developed,
  they are rapidly deployed in multiple systems.
• Families are informed that they have access to
  resources when they need them without barriers of
  culture, cost, or type of service.
• Families and communities are partners in the
  development and implementation of preventive
  interventions.

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Envisioning the Future (continued)

• 9. The development and application of preventive
  intervention strategies contribute to narrowing
  rather than widening health disparities.
• 10. Teachers, child care workers, health care
  providers, and others are routinely trained on
  approaches to support the behavioral and
  emotional health of young people and the
  prevention of MEB disorders.

34

Ideas for California inspired by the Institute
of Medicine Prevention Report

• Slides 34 - end
• were prepared by
• Ricardo F. Muñoz, Ph.D. to illustrate
  how some ideas from the prevention report might
  apply to California

35
Identifying Populations at Risk

• Using data from California

36
Prevalence of Mental Disorders in California
Mexican-Americans (Fresno County)(Vega, Kolody,
Aguilar-Gaxiola, et al., Arch Gen Psych, 1998)
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Prevalence of Mental Disorders in California
Mexican-Americans (Fresno County)(Vega, Kolody,
Aguilar-Gaxiola, et al., Arch Gen Psych, 1998)
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Ways to reduce prevalence (total cases)

• Prevalence Total number of cases in a
  population during a certain time period.
• Incidence Total number of NEW cases in
  population during a specified period.
• To reduce prevalence, you can
• Identify and successfully treat all known cases
• Identify populations at risk, and prevent new
  cases
• Preventing new cases reducing incidence
• Reducing incidence reduces prevalence

39
Developing culturally and linguistically
appropriate intervention manuals

• At San Francisco General Hospital, we have been
  developing and testing depression prevention and
  treatment manuals for English and Spanish
  speakers.
• We have some manuals in Chinese and Japanese.
• Some have been adapted for African-American
  women.
• The manuals can be downloaded for free at
  http//www.medschool.ucsf.edu/latino/manuals.aspx

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Limitations of traditional interventions

• A major limitation of our manuals is that they
  require mental health staff to administer them.
  If a location does not have a Spanish-speaking or
  Chinese-speaking provider, (or English-speaking
  provider, for that matter), the manual cannot be
  used.

45
Transcending space and time

• Telemedicine applications can transcend space
  Providers can provide consultation or prevention
  services at a distance.
• However, the time they are spending with a person
  away from their location is time they are not
  spending with people locally, who also need their
  assistance.
• How could we transcend time, as well?

46
The IOM report suggests innovative uses of
technology(Recommendation 7-3)

• Technology
• Research funders should support research on the
  effectiveness of mass media and Internet
  interventions, including approaches to reduce
  stigma.
• Transcending time
• Can we develop interventions that can be used
  simultaneously, anywhere, at any time?

47
Limitations of traditional service provision

• We will never train enough health care providers
  The World Health Organization reports that there
  are
• 1.1 billion smokers
• 121 million people with clinical depression
• 76 million with alcohol use disorders
• We clearly need to increase our efforts to train
  more health care providers, but we also need to
  try something new.

48
Medications and face-to-face interventions are
consumable

• Medications can only be used once
• Face-to-face health care can only be used once
• Once a clinical session ends, its therapeutic
  value cannot be shared with other patients
• Once a prevention session ends, those who did not
  attend the session cannot benefit from the amount
  of time given by the provider

49
We must go beyond traditional health care

• We need re-usable interventions that can be used
  again and again, without losing their therapeutic
  power
• To reduce health disparities, we need to develop
  methods to reach people even if the local health
  care system cannot provide them with the health
  care interventions they need
• We also need interventions that can be shared
  widely without taking anything away from local
  populations

50
Evidence-based Internet Interventions

• Empirically tested online methods
  to change individual behavior
  to prevent or ameliorate
  health problems.

51
An AnalogyMedications vs. Web Interventions
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Evidence-based Internet interventions transcend
space and time

• Once developed and tested, these interventions
  can be used by people locally and shared with
  people who speak the same language at a time and
  place of their choosing.
• They can be used privately, reducing stigma.
• They reduce the need to travel to health care
  settings.
• They are administered exactly as tested, avoiding
  the problem of drift from the way the
  intervention was tested.

53
Think globally,Act locally,Share globally.

• California could be a source of evidence-based
• Internet interventions
• for the world.

54
Proof of concept studies Can Internet stop
smoking interventions match the patch?

• What would constitute success?
• A benchmark Nicotine Patch studies yield the
  following six-month quit rates
• Placebo patch 5 - 8
• Nicotine patch 14-22
• So, if we yielded around 20 quit rates, the
  Internet Stop Smoking Project would have
  reasonable efficacy.

55
Smoking by Latinos is a Major Health Problem in
California (2002 figures) (Presented by W. Max,
H-Y Sung, L-Y Tucker, 2008)

• Although only 13.1 of California Latinos smoke,
  they represented nearly 1 million of all adult
  smokers in CA (25)
• CA Latinos spent 666 million on health care for
  smoking-attributable diseases
• Total smoking-attributable costs for CA Latinos
  were nearly 1.4 billion

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Our published Internet smoking cessation studies
have yielded up to 26 quit rates at six months
(Muñoz, Lenert, Delucchi, Stoddard, Pérez,
Penilla, Pérez-Stable, NTR, 2006)
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Participants entering data on our Website
(2000-2008)
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We find disparities in access to smoking
cessation aids by language
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and by country
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However, Web quit rates () are similar across
languages(Missing Smoking)
66
and across countries (Missing Smoking)
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Internet interventions can reduce health
disparities

• In smokers seeking to quit via the Web, we found
• Similar smoking patterns across languages and
  countries.
• Disparities in access to smoking cessation aids
  across languages and countries
• Yet, similar smoking cessation outcomes by
  evidence-based Web interventions
• Could the same strategy be applied to other
  health problems and languages?

68
The UCSF/SFGHInternet World Health Research
CenterSystematic Development of Evidence-based
Web Interventions Health Problems x Languages
69
Preventing Depression Promising findings in
published trials
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Preventing postpartum depression

• Where to start? As early as possible.
• Can we prevent postpartum depression?
• Will doing so help prevent depression in the
  babies?
• The Mothers and Babies Course.
• Over half of CA births have been to Latino
  parents since July 2001, so interventions must be
  in Spanish and English.

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TV mood management segments reduce symptoms of
depression
Muñoz, Glish, Soo-Hoo, Robertson, 1982 (AJCP)
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Resources

• Depression prevention and treatment manuals in
  Spanish and English (some in Chinese, Japanese)
• http//www.medschool.ucsf.edu/latino/manuals.aspx
  
• Internet Stop Smoking site
• English www.stopsmoking.ucsf.edu
• Spanish www.dejardefumar.ucsf.edu
• Internet Mothers and Babies Course
• English www.healthypregnancy.ucsf.edu
• Spanish www.embarazosaludable.ucsf.edu

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References

• National Research Council and Institute of
  Medicine. Preventing Mental, Emotional, and
  Behavioral Disorders Among Young People Progress
  and Possibilities. Committee on Prevention of
  Mental Disorders and Substance Abuse Among
  Children, Youth, and Young Adults Research
  Advances and Promising Interventions. Mary Ellen
  OConnell, Thomas Boat, and Kenneth E. Warner,
  Editors. Board on Children, Youth, and Families,
  Division of Behavioral and Social Sciences and
  Education. Washington, DC The National Academies
  Press. 2009.
• The 45-page Executive Summary can be downloaded
  for free from http//www.nap.edu/catalog.php?recor
  d_id12480
• The full report can also be ordered online there.