Disability Awareness	29 April 2002

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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

For consumers of all ages, early detection, assessment, and linkage with treatment and supports can prevent mental health problems from compounding and poor life outcomes from accumulating. Early intervention can have a significant impact on the lives of children and adults who experience mental health problems.

Emerging research indicates that intervening early can interrupt the negative course of some mental illnesses and may, in some cases, lessen long-term disability. New understanding of the brain indicates that early identification and intervention can sharply improve outcomes and that longer periods of abnormal thoughts and behavior have cumulative effects and can limit capacity for recovery.¹¹⁵

If Untreated, Childhood Disorders Can Lead to a Downward Spiral

Early childhood is a critical period for the onset of emotional and behavioral impairments.¹¹⁵ In 1997, the latest data available, nearly 120,000 preschoolers under the age of six - or 1 out of 200 - received mental health services.¹¹⁶ Each year, young children are expelled from preschools and childcare facilities for severely disruptive behaviors and emotional disorders.

Since children develop rapidly, delivering mental health services and supports early and swiftly is necessary to avoid permanent consequences and to ensure that children are ready for school. Emerging neuroscience highlights the ability of environmental factors to shape brain development and related behavior. Consequently, early detection, assessment, and links with treatment and supports can prevent mental health problems from worsening.

Without intervention, child and adolescent disorders frequently continue into adulthood. For example, research shows that when children with co-existing depression and conduct disorders become adults, they tend to use more health care services and have higher health care costs than other adults.¹¹⁷ If the system does not appropriately screen and treat them early, these childhood disorders may persist and lead to a downward spiral of school failure, poor employment opportunities, and poverty in adulthood. No other illnesses damage so many children so seriously.¹¹⁸

One of the many factors that can affect the emotional health of young children is the mental health status of their parents. For example, depression among young mothers has been shown to influence the mental health of their young children.^{119; 120} These findings are significant because mental disorders that occur before the age of six can interfere with critical emotional, cognitive, and physical development, and can predict a lifetime of problems in school, at home, and in the community.¹²¹

Early detection, assessment, and links with treatment and supports can prevent mental health problems from worsening.

Schools Can Help Address Mental Health Problems

Currently, no agency or system is clearly responsible or accountable for young people with serious emotional disturbances. They are invariably involved with more than one specialized service system, including mental health, special education, child welfare, juvenile justice, substance abuse, and health.

The mission of public schools is to educate all students. However, children with serious emotional disturbances have the highest rates of school failure. Fifty percent of these students drop out of high school, compared to 30% of all students with disabilities.⁸¹ Schools are where children spend most of each day. While schools are primarily concerned with education, mental health is essential to learning as well as to social and emotional development. Because of this important interplay between emotional health and school success, schools must be partners in the mental health care of our children.

Schools are in a key position to identify mental health problems early and to provide a link to appropriate services. Every day more than 52 million students attend over 114,000 schools in the U.S. When combined with the six million adults working at those schools, almost one-fifth of the population passes through the Nation's schools on any given weekday.¹²² Clearly, strong school mental health programs can attend to the health and behavioral concerns of students, reduce unnecessary pain and suffering, and help ensure academic achievement.

People with Co-occurring Disorders Are Inadequately Served

Early intervention and appropriate treatment can also reduce pain and suffering for children and adults who have or who are at risk for co-occurring mental and addictive disorders.^{115; 123} Seven to ten million people in the United States have at least one mental disorder in addition to an alcohol or drug abuse disorder.^{124; 125} Too often, these individuals are treated for only one of the two disorders - if they are treated at all.

In his speech announcing the Commission, the President used an example that affirms this point. The President spoke of:

"... a 14-year-old boy who started experimenting with drugs to ease his severe depression. This former honor student became a drug addict. He dropped out of school, was incarcerated six times in 16 years. Only two years ago, when he was 30 years old, did the doctors finally diagnose his condition as bipolar disorder, and he began a successful program ..."

Co-occurring substance use and mental disorders can occur at any age. Research suggests that as many as half of the adults who have a diagnosable mental disorder will also have a substance use disorder at some point during their lifetime.^{106; 126}

A substantial number of children and adolescents also have co-occurring mental illnesses and substance use disorders.¹²⁴ If one co-occurring disorder remains untreated, both usually get worse. Additional complications often arise, including the risk for other medical problems, unemployment, homelessness, incarceration, suicide, and separation from families and friends.¹²⁴

Older adults are at risk of developing both depression and alcohol dependence for perhaps the first time in their lives. This phase of the life cycle has new risk factors for both of these disorders. The number of older adults with mental illnesses is expected to double to 15 million in the next 30 years.¹²⁷ Mental illnesses have a significant impact on the health and functioning of older people and are associated with increased health care use and higher costs.^128-130 The current mental health service system is inadequate and unprepared to address the needs associated with the anticipated growth in the number of older people requiring treatment for late-life mental disorders.¹²⁷

Individuals with co-occurring disorders challenge both clinicians and the treatment delivery system. They most frequently use the costliest services (emergency rooms, inpatient facilities, and outreach intensive services), and often have poor clinical outcomes.¹²⁴ The combination of problems increases the severity of their psychiatric symptoms and the likelihood for suicide attempts, violent behaviors, legal problems, medical problems, and periods of homelessness.¹²⁴

Studies show that few providers or systems that treat mental illnesses or substance use disorders adequately address the problem of co-occurring disorders. Only 19% of people who have co-occurring serious mental illnesses and substance dependence disorders are treated for both disorders; 29% are not treated for either problem. For people with less serious mental illnesses and substance dependence problems, the pattern of under-treatment is even worse. Most (71%) receive no treatment; only 4% receive treatment for both disorders.¹²⁴ The same pattern of under-treatment holds for youth with co-occurring disorders.¹³¹

Widespread barriers impede effective treatment for people with co-occurring disorders at all levels, including Federal, State, and local governments, and individual treatment agencies.

Mental Health Problems Are Not Adequately Addressed in Primary Care Settings

People with mental health disorders are routinely seen in primary care settings. The Epidemiologic Catchment Area Study, conducted in the early 1980s, found that while people with common mental illnesses had some contact with primary care services, few received specialty mental health care. About half of the care for common mental disorders is delivered in general medical settings.^{7; 132; 133} Primary care providers actually prescribe the majority of psychotropic drugs for both children and adults. While primary care providers appear positioned to play a fundamental role in addressing mental illnesses, there are persistent problems in the areas of identification, treatment, and referral.

Despite their prevalence, mental disorders often go undiagnosed, untreated, or under-treated in primary care. Primary care providers' rates of recognition of mental health problems are still low, although the number identified is increasing. When mental illnesses are identified, they are not always adequately treated in the primary care setting, and referrals from primary care to specialty mental health treatment are often never completed.

Despite their prevalence, mental disorders often go undiagnosed, untreated, or under-treated in primary care.

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}

Of individuals who die by suicide, approximately 90% had a mental disorder,²¹ and 40% of these individuals had visited their primary care doctor within the month before their suicide.^{135; 136} During visits in the primary care setting, the question of suicide was seldom raised.

A significant percentage of patients in primary care shows signs of depression,¹³⁷ yet up to half go undetected and untreated.¹³⁸ This is especially problematic for women,¹³⁹ people with a family history of depression,¹⁴⁰ the unemployed,¹⁴¹ and those with chronic disease,¹⁴¹ all of whom are at increased risk for depression.

A significant percentage of patients in primary care shows signs of depression, yet up to half go undetected and untreated.

Of all the children they see, primary care physicians identify about 19%with behavioral and emotional problems.¹⁴² While these providers frequently refer children for mental health treatment, significant barriers exist to referral, including lack of available specialists, insurance restrictions, appointment delays, and stigma. In one study, 59% of youth who were referred to specialty mental health care never made it to the specialist.¹⁴²

Finally, it is noteworthy that there is a parallel problem in specialty mental health care. Specialty mental health providers often have difficulty providing adequate medical care to consumers with co-existing mental and physical illnesses.¹²⁴ Given that individuals with serious mental illnesses, such as schizophrenia, have high levels of non-psychiatric medical illnesses and excess medical mortality, this is also a troubling situation.¹⁴³

Achieving the Goal

Recommendation

4.1 Promote the mental health of young children.

Early Detection Can Reduce Mental Health Problems

Early detection and treatment of mental disorders can result in a substantially shorter and less disabling course of illness.^{144; 145} As the mental health field becomes increasingly able to identify the early antecedents of mental illnesses at any age, interventions must be implemented, provided in multiple settings, and connected to treatment and supports.


Early interventions, such as the Nurse-Family Partnership (See Figure 4.1.), and educational efforts can help a greater number of parents, the public, and providers learn about the importance of the first years of a child's life and how to establish a foundation for healthy social and emotional development.

Quality screening and early intervention should occur in readily accessible, low-stigma settings, such as primary health care facilities and schools, and in settings where a high level of risk for mental health problems exists, such as juvenile justice and child welfare.

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:

• Build on coordination mechanisms already in place, such as Part C of the Individuals with Disabilities Education Act (IDEA); and

• Expand the coordination of services for children ages 3 through 21 for those who qualify for services under Part B of IDEA, thus building capacity for improved and increased services in communities.

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:

• Training a workforce skilled in treating young children and their families;

• Training primary health providers to screen for and recognize early signs of emotional and behavioral problems and to offer connections to appropriate interventions;

• Eliminating barriers to coverage, such as a required psychiatric diagnosis when an alternative diagnosis that minimizes labeling and stigma is more appropriate; and

• Including "social and emotional check-ups" in primary health care.

The IDEA specifically provides for a statewide, comprehensive, interagency system for early prevention services for children with disabilities from birth to 3 years old who have a developmental delay and physical, cognitive, communication, social or emotional, or adaptive development problem, or have a diagnosed physical or mental condition that has a high probability of resulting in a developmental delay.

More effort is needed to heighten public awareness of the developmental requirements for children's social and emotional well-being - just as public awareness of the early developmental and educational needs for reading skills has been increased through public and private initiatives.

When children with disabilities reach age 3, they may be eligible for services under Part B of IDEA if they have one of the specified impairments and if, because of the impairment, they need special education and related services. However, services and other resources for children who have emotional and mental health issues are sometimes less readily available with respect to workforce, interventions, and financing, than other services, such as speech and language therapy or physical therapy.

Addressing the mental health of young children may also involve providing information, supports, and treatment for parents. For the young child, treating the parents' mental health problems also benefits the child.¹⁵⁰

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

Growing evidence shows that school mental health programs improve educational outcomes by decreasing absences, decreasing discipline referrals, and improving test scores.¹¹⁴ The key to improving academic achievement is to identify mental health problems early and, when needed, provide appropriate services or links to services. The extent, severity, and far-reaching consequences make it imperative that our Nation adopt a comprehensive, systematic approach to improving the mental health status of children.

Clearly, school mental health programs must provide any screening or treatment services with full attention to the confidentiality and privacy of children and families. The Columbia University TeenScreen® program provides a model for early intervention. (See Figure 4.2.)

The Commission recommends that Federal, State, and local child-serving agencies fully recognize and address the mental health needs of youth in the education system. They can work collaboratively with families to develop, evaluate, and disseminate effective approaches for providing mental health services and supports to youth in schools along a critical continuum of care. This continuum includes education and training, prevention, early identification, early intervention, and treatment.

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:

• Working with parents, local providers, and local agencies to support screening, assessment, and early intervention;

• Ensuring that mental health services are part of school health centers;

• Ensuring that these services are Federally funded as health, mental health, and education programs;

• Building on a recommendation from the President's Commission on Excellence in Special Education¹⁵⁵ to implement empirically supported prevention and early intervention approaches at the school district, local school, classroom, and individual student levels; and

• Creating a State-level structure for school-based mental health services to provide consistent State-level leadership and collaboration between education, general health, and mental health systems.

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 is a means of coordinating both substance abuse and mental health interventions to treat the whole person more effectively. From studies and first-hand experiences, many researchers and clinicians in these fields believe that both disorders must be addressed as primary illnesses and treated as such. Integrated treatment can improve client engagement, reduce substance abuse, improve mental health status, and reduce relapses for all age groups.¹²⁴

Integrated services should appear seamless to the individual who seeks and receives care. Mental health and substance abuse treatment can be integrated by one clinician, two or more clinicians working together, one program, or a network of services.

A key challenge to developing integrated treatment programs is overcoming the traditional separation between mental health and substance abuse treatment.

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

A key challenge to developing integrated treatment programs is overcoming the traditional separation between mental health and substance abuse treatment. At least 36 States are attempting some change to their systems by addressing this problem through creative leadership with a sustained vision and by engaging strong local stakeholder support - including consumers and families - in program design and advocacy.¹²⁴ However, much remains to be accomplished.

Studies of these efforts have shown that State and local regulatory issues and impediments to multiple State and local funding streams continue as major barriers to changing the systems. The Commission commends the Substance Abuse and Mental Health Services Administration (SAMHSA) for its Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Disorders and supports the five-year blueprint for action contained in the report.¹²⁴

The Commission supports implementing systematic screening procedures to identify mental health and substance use problems and treatment needs in all settings in which children, youth, adults, or older adults are at high risk for mental illnesses or in settings in which a high occurrence of co-occurring mental and substance use disorders exists. In addition to specialty mental health and substance abuse treatment settings, screening for co-occurring disorders should be implemented when an individual enters the juvenile or criminal justice systems, child welfare system, homeless shelters, hospitals, senior housing, long-term care facilities, nursing homes, and other settings where populations are at high risk. Screening should also occur periodically after an individual enters any of these facilities.

When mental health problems are identified, children, youth, adults, and older adults should be linked with appropriate services, supports, or diversion programs. Additionally, given the high incidence of substance use disorders among parents of children in the child welfare system, where indicated, these parents should be screened for co-occurring disorders and linked with appropriate treatment and supports.

The Commission supports coordinated and, where appropriate, integrated mental health and substance abuse screening, assessment, early intervention, and treatment for co-occurring disorders in all Federally funded adult and child health and human services, criminal and juvenile justice programs, and veteran's services. Health and mental health training programs that receive HHS funding should include co-occurring disorders in curriculum design and training experiences.

The Center for Medicare and Medicaid Services (CMS) should be encouraged to develop and implement policy guidance to promote access and use of covered services by Medicaid and Medicare beneficiaries with co-occurring mental and substance use disorders.

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

The Commission suggests that collaborative care models should be widely implemented in primary health care settings and reimbursed by public and private insurers. Numerous studies have documented the effectiveness of collaborative care models.^160-162 Expanded screening and collaborative care models, such as the Collaborative Care Model for treating late-life depression in primary care settings (See Figure 4.3.), could save lives.

The Commission notes that the Federal government could better coordinate the funding and the clinical care provided by publicly funded community health clinics to consumers with multiple conditions, including physical, mental, and co-occurring substance use disorders. This effort would include improved coordination of care between Health Resources and Services Administration-funded community health clinics and SAMHSA- or State-supported community mental health centers.

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

Expanded screening and collaborative care models could save lives.

The Commission recommends that Medicare, Medicaid, the Department of Veterans Affairs, and other Federal and State-sponsored health insurance programs and private insurers identify and consider payment for core components of evidence-based collaborative care, including:

• Case management,

• Disease management,

• Supervision of case managers, and

• Consultations to primary care providers by qualified mental health specialists that do not involve face-to-face contact with clients.