Plenary Session Friday, October 17, 2014 8:30 to 10:00 AM
“Mental Health Promotion and Prevention in Primary Care: An Idea Whose Time Has Come” Presentation by William R. Beardslee, MD Department of Psychiatry Boston Children’s Hospital and Harvard Medical School
Disclosure William R. Beardslee, MD, has nothing to disclose. Dr. Beardslee receives NIMH funding, foundation funding, and serves as a consultant to other research projects, governmental and nongovernmental agencies.
“The child is the bearer of whatever the futureshall be … At this center … his incomparable tendernessto experience, his malleability, the almost unimaginablenakedness and defenselessness of this wondrousfive-windowed nerve and core.”James Agee, “Let Us Now Praise Famous Men”
“The pediatrician can regard the family as carrying the ‘chromosomes’ that perpetuate the culture and also form the cornerstone of emotional development.”Beardslee & Richmond. Mental Health of the Young: An Overview
“If you always do what you’ve always done, you’ll always get what you’ve always got.” ~ Albert Einstein Health care reform must challenge existing paradigms and develop new paradigms.
Envisioning the Future • What should a heath care system look like that fully meets the needs of families , incorporates prevention and treatment, and reflects cultural competence and cultural humility? IOM 2009
Outline of Presentation • Institute of Medicine Prevention Report • Institute of Medicine Parental Depression Report • Preventive interventions focused on parental depression • Policy – Expansion of Medicaid and the ACA. An opportunity for treatment for depressed mothers • Practical and Policy Implications
Prevention of Mental Illness • Family-centered care • Prevention of mental illness and problem behavior • Population level impact
The Triple Aims of the ACA • Improving the experience of care • Improving the health of populations • Reducing costs
Preventive OpportunitiesEarly 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 diagnosable disorder • Common risk factors for multiple problems and disorders
Mental Health PromotionAims 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
Implementation • Strong across the board evidence for family-based prevention strategies • Need to move from efficacy toward effectiveness trials • Implementation research has highlighted: • complexity • important role of community • Cultural humility and cultural and linguistic competence are essential for implementation
Recommendation Themes • Putting Knowledge into Practice • Continuing Course of Rigorous Research
A Central Theme • “The scientific foundation has been created for the nation to begin to create a society in which young people arrive at adulthood with the skills, interests, assets, and health habits needed to live healthy, happy, and productive lives in caring relationships with others.”
“One factor lurks in the background of every discussion of the risks for mental, emotional, and behavioral disorders and antisocial behavior: poverty ... Although not the focus of this report, there is evidence that changes in social policy that reduce exposure to these risks are at least as important for preventing mental, emotional and behavioral disorders in young people as other preventive interventions. We are persuaded that the future mental health of the nation depends crucially on how, collectively, the costly legacy of poverty is dealt with.”
Specific: Extensive family history of depression, especially parents Prior history of depression Depressogenic cognitive style Bereavement General (Risks for many disorders) Exposure to trauma Poverty Social isolation Job loss Unemployment Family breakup Loss of community Dislocation / immigration Historical trauma Risks for Depression
A series of recent meta-analyses demonstrate that in both adults and children, a significant number of episodes of major depression can be prevented.
Treatment: Current Evidence • A variety of safe and effective strategies exist for treating adults with elevated symptoms or major depression, including: • cognitive behavioral • interpersonal therapy • medication • A variety of strategies to deliver these treatments exist in a wide range of settings • Almost no studies report whether the adults treated are parents or whether treatment affects children
Treatment: Current Evidence, continued. • Individuals should have informed choices in treatment “tools” that are available to them • Treatment tools and strategies to deliver these treatments should be • flexible, • efficient, • inexpensive, and above all • acceptable to the participants in a wide variety of community and clinical settings
Preventive Interventions • Promising preventive intervention strategies exist. They include, for the most part: • Treating the parents • Providing help with parenting • Using a two-generational approach • Some also directly involve children.
Depression Prevention Examples: IOM Report Family Talk - Beardslee, et al., 2009 Prevention of depression - Garber, et al., 2009 –moderated by acute parental depression Parent/Child Coping Session - Compas et al., in press. Mothers’ and babies’ program - Munoz IOM 2009
Across both reports and in a variety of different risk situations, very strong evidence exists for the value of parenting programs.
Special Opportunities and Challenges • Developing systems that can give two-generational responses to parental depression • Responding to the needs of vulnerable populations, especially low income, culturally and ethnically diverse families • Responding to families experiencing depression along with other comorbidities in family adversities • Developing complex interventions that build on collaborative integrative and comprehensive service models
Core Challenges Lack of a home for prevention. It is not owned by any one professional discipline. Lack of a trained workforce Lack of infrastructure to support the introduction of new programs Lack of a payment system Historically, a lack of attention to prevention as opposed to treatment
Family Talk Component Studies 1979 - 1985:Risk Assessment - Children of Parents with Mood Disorders 1983 - 1987: Resiliency Studies and Intervention Development 1989 - 1991: Pilot Comparison of Public Health Interventions 1991 - 2000: Randomized Trial Comparing Psychoeducational Family Interventions for Depression 1997 - 1999: Family CORE in Dorchester 1998: Narrative Reconstruction 2000: Efficacy to Effectiveness – Countrywide programs in Finland and at least five other places; Project FOCUS with the Navy; Family Connections
Characteristics of Resilient Youth • Activities - Intense Involvement in Age Appropriate Developmental Challenges - in School, Work, Community, Religion, and Culture • Relationships - Deep Commitment to Interpersonal Relationships - Family, Peers, and Adults Outside the Family • Self-Understanding - Self-Reflection and Understanding in Action
Resilience in Parents • Commitment to parenting • Openness to self-reflection • Commitment to family connections and growth of shared understanding
Seven modules Taking a history Psychoeducation and the family’s story Seeing the children Planning the family meeting Holding the family meeting One week follow-up, check-in Long-term follow-up
Three Randomized Trials of Family Talk • High rankings - 3.5 out of a possible 4.0 in the National Registry of Evidence-based Programs and Practices for strength of evidence, SAMHSA.
Six Principles for a Successful Family Meeting • Pay attention to the timing of the meeting. • Gain commitment to the process from the entire family. • Begin by identifying specific major concerns and addressing them. • Bring together and reknit the family history. • Plan to talk more than once. • Draw on all the available resources to get through depression.
Narrative Project for FamiliesWho Sustained Changes – Self-Reflection Over Time • The emergence of the healer within • The need to understand depression anew across development • Children’s growth • Vicissitudes of parental illness
Effective Family Programme I – Dr. Tytti Solantaus, Finland • Plan from the beginning to change child mental health system from a diagnosis and treatment system to a health promotive and prevention system. • A ten-year effort to locate services for parents struggling with adversity in all mental health and health clinics.
Effective Family Programme II – Dr. Tytti Solantaus, Finland • A family of interventions • A master trainer strategy • Adaptation of the approach to many different parental adversities
Latino Adaptation • Familismo • Allocentric orientation • Kinds of separation in immigrant families • Differing involvement of parents and children in the mainstream culture • Immigration narrative
What helps parents cope with depression? • Focus on the children • Visualizations. Envisioning a better future • Prayer, songs, religion, church community, spiritual healing • Support groups • Helping others, sharing information • Focusing in the present: “viviendo de dia a dia” (living day to day) • Not giving up: “seguir la lucha” • Alternative medicine • Humor: “al mal tiempo buena cara” “yo no lloro, yo me rio”
Web-based training in Family Talk available at www.fampod.org. The Family Connections program is available at www.childrenshospital.org/familyconnections.
FAMpod Home Page http://fampod.org
Urban Institute Project Olivia Golden, Amelia Hawkins, Tracy Vericker, Jennifer Macomber, Embry Howell, William Beardslee, and others. • three-year project • best ways to help depressed low income women with young children • subsequent two-year project • working with federal policymakers • best possible entry points through which to help young children. The focus on maternal depression was chosen because it is widespread among low income mothers, there is strong clinical evidence about effective treatment, and yet very few low income mothers, even those severely depressed, receive treatment.
ACA Opportunities • Expanded continuous coverage for low income women • Mandated coverage of preventative services including depression screening • Integrated care initiatives
Expanded Treatment under Medicaid Could be Cost-neutral or Cost-saving • Reduced depression can increase employment • Early treatment can avoid more serious depressive episodes • Treating a mother’s depression can reduce child physical and mental health problems
Emerging Integrated Care Initiatives • Accountable Care Organizations • Patient-Centered Medical Homes • Health Homes • Medicaid Managed Care • Carve in • Carve out
Practical Implications Parental depression is prevalent in family practice. Parental depression is treated when recognized and can have a multiplier positive affect on the family when recognized and treated. Available evidence confirms that we should both treat parents and ask them about how their kids are doing and support their parenting.
Practical Tips I Screening and referral are useful when available referral sources have been identified. PHQ-2 is a good initial screener when followed with the PHQ-9. Attention to the system in which primary care occurs and its ability to deal effectively with depressed parents are as important as any particular intervention.
Practical Tips II Working with parents who are depressed asparents first is essential. Elicit the parents’ concerns both about himself/herself and about the children. Brief parenting interventions and referral of children for evaluation are also helpful. Follow-up is essential.