Mental and behavioral health ELIZABETH C. KATz, EUGENE M. DUNNE, SAMANTHA LOOKATCH AND JOSHUA S CAMINS CHAPTER OUTLINE work, school, home). Within the broader category of mental MENTAL HEALTH/BEHAVIORAL DISORDERS AND SUICIDE 252 A. Definitions 252 gnostic categories. The most prevalent of the emotional disorders, and therefore the most costly to individua B. Epidemiology 253 C. Costs 254 and society, are depression and anxiety. Table 21-1 outlines mood(depressive), anxiety, and trauma disorders, the mental IL. RISK AND PROTECTIVE FACTORS 255 health disorders that are the focus of this chapter. A, Biologic Risk Factors 255 B. Psychological Risk Factors 256 C. Social risk factors 256 BEHAVIORAL DISORDERS D. Environmental Risk Factors 256 Behavioral disorders involve substance use or participation E. Culture/Diversity 257 n non-drug-related risky behaviors (e.g, gambling, overeat Protective Factors 257 ng), also known as behavioral addictions, to such an extent III PREVENTION AND HEALTH PROMOTION that they appear compulsive ("out of control" of the indi- STRATEGIES 257 vidual) and pose serious threats to the participant's health A. Theoretical Framework 257 and well-being. Behavioral disorders represent extreme cases B. Public Policy 258 of typical behaviors(e.g, alcohol dependence; overeat C. Media Campaign point of obesity) D. Screening 258 Substance use, both licit(e.g, alcohol, tobacco)and illicit E. Psychosocial Interventions 259 (e, g,, cocaine, heroin), varies along a continuum(Fig. 21-1 ef Interventions 259 Misuse of a substance is often indicative of a risk for more 2. Longer-Term pathological use. Pathological use may be characterized by macologic Interventions 260 IV. SUMMARY 261 HIV infection, incarceration ), tolerance(need to take n 8. continued substance use despite serious consequences of REVIEW QUESTIONS, ANSWERS, AND EXPLANATION experience It withdrawal whether other beh ors, such as overeating, excessive video game or Internet use, and sexual behavior, may be considered behavioral addic- Depression, anxiety, schizophrenia, and substance abuse tions. The following arguments favor the behavioral addic- prominent among the mental health and behavioral disor- tion concept ders. Affecting more than 450 million people worldwide and associated with substantial morbidity and mortality, these Such behaviors often appear compulsive (outside the individual's control). disorders are critical targets for prevention efforts because of Participation is continued despite experiencer their toll on individuals and socie egative consequences. y resp addiction is also involved in excessive pursuit of these MENTAL HEALTH/BEHAVIORAL DISORDERS AND SUICIDE Research also suggests that substance and behavioral orbid. Although strong evidenc A. Definitions upports the inclusion of pathological gambling and exces MENTAL HEALTH DISORDER sive Internet use within the broader of addictive disorders, evidence supporting other behavioral addictions Mental health disorder is a broad term that refers to a set of (e.g,, kleptomania, sexual addiction)is less compelling emotions, cognitions, and behaviors that cause distress to However, others consider the evidence in support of the food individuals or others are abnormal from the bective of addiction concept, specifically as it relates to compulsive the society or culture, and result in harm to self or others overeating and bulimia, to be compelling. Obesity is dis- in functional impairment in one or more domains (i.e, cussed in Chapter 19
CHAPTER 2 Mental and Behavioral Health Table 21- Mood, Anxiety, and Trauma Disorders: Key Conditions and Descriptic Category Defning Conditions Category Description Mood( depressive Major depressive disorder Pervasive and persistent feelings of sadness or loss of Dysthymic disorder Weight loss/gain; decreased energy or agitation; poor Anxiety disorders sorder with or without agoraphobia anxiety impulsive disorder Trauma disorders Anxiety disorder resulting from exposure to traumatic event Acute stress disorder rape, war/combat, natural disaster,terrorism Individual perceives self or other person to be at risk of Individual reexperience event through vivid dreams or memories, with dissociation an Modified from American Psychiatric Association: Diagnostic and statistical manual of mental disorders, ed 4 n), Washington, DC 2000, APA. set of shared and unique criteria, The mood disorders category also cludes bipolar disorder, which is not addressed in this chapter. The trauma disorders are included in the anxiety disorders category in DSM-IV-TR; however, because their prevention and treatment are often different from other anxiety disorders, they are treated as a separate category in this chapter. Experimentation Trying a substance one or more times MisuseHconsesiuen! use that has not resulted in serious Abuse Continued use in spite of problems or use in dangerous situations Dependence eristic withdrawal ymptoms, and functional Figure 21-l Continuum of substance use SUICIDE (age 18 or older)met criteria for a mental health disorder in he past year. Table 21-2 outlines prevalence estimates for Suicide is a purposeful act directed toward ending one's mood(depressive), anxiety, and trauma disorders. Whereas suicide is intended to refer to successful completion of the act, the term suicide attempt is intended to refer to any ct of self-harm, including parasuicidal behavior such BEHAVIORAL DISORDER cutting, regardless of the intent of the behavior or the Figure 21-2 presents rates of licit and illicit substance use. utcome Suicidal ideation refers to thoughts about killing Among licit substances, alcohol is most often used, with 52% or harm of individuals age 12 or older reporting tobacco use in the ast year, followed closely by tobacco products, used by 28% of individuals age 12 years and older. While not as pre revalent as alcohol and tobacco, illicit substances are used at alarming MENTAL HEALTH DISORDERS rates and include marija juana, cocaine, heroin, and amphet amines. Evidence indicates abuse of prescription medica Mental health disorders affect a large segment of the U.S. tions (i.e,, use for nonprescribed purposes such as " getting population. Research suggests that about one in five adults high"or to help study) has been increasing in recent years
SECTION 3 Preventive medicine and public health Table 21-2 Prevalence Estimates for Depressive, Anxiety, and Trauma Disorders 口 Adults(aged26to49) Disorders Prevalence 口 Older adults(age50+) Mood 11% for any mood dis all ages sorder, all ages 6%6-8% for any mood As many as 30%0 experience subclinical depressed mood lasting 2 or more weeks Suicidal thoughts ade a plan Made an attempt Anxiety Figure 2-3 Past-yea lence estimates for suicidal ideation eria for disorder 3.6%o for posttraumatic stress disorder(PTSD), attempts in young adults age 18-24, adults age 26-49, and older adults 50 and older.( From Substance Abuse and Mental Health Services 5%6-51% meet criteria for PtSD (lifetime) after Administration: Suicidal thoughts and behaviors among adults: the NSDUH report,rockville,Md,2009,OffceofAppliedStudieshttp:// depend on severity of trauma and www.samhsa.gov/data/2k9/165/suicide.htm) methodologic issues* the U.S. population. Eating or food addictions are believed to affect 3%, with women affected more often than mel CONCURRENT MENTAL HEALTH AND BEHAVIORAL DISORDERS There is a high degree of comorbidity among mental health 100.0 disorders and between mental health and behavioral disor- 口 Youth(1 ders. Specifically, anxiety and depression are present concur- 80.0% a Young adults(18 to 25 years) rentlyinabout 50%of patients. Amongsubstance-dependent individuals, 60%to 80%of adults and 60% of youth have a comorbid mental health disorder. Moreover, approximately 25% to 30% of depressed and anxious adults meet criteria 40.0% for a substance use disorder. Behavioral addictions (e. g gambling, overeating, Internet overuse)are often associated 20.0% with other behavioral and drug addictions, as well as psychi atric disorders Suicide accounted for more than 32 000 adult deaths in serious thoughts about killing themselves than make a ide. Research also suggests Note: NR= Not reported; Binge drinking is defined as consuming 5 more alcoholic beverages in a sitting for males and 4 or more that for every one successful suicide, there are as many as drinks for females 20 attempts. Among youth, estimates suggest that between 9.4%(ages 12 to 13)and 12.7%(ages 14 to 17)were at erious risk for suicide by virtue of having had serious sui Figure 21-2 Past-month prevalence estimates for substance use, cidal ideation or having made a previous attempt. Among 2009. Binge drinking, cigarette smoking, illicit substances, and prescription those at high risk, 37% made a suicide attempt in the past rug use in persons age 12 and older, adolescents age 12-17, and youn adults age 18-25.(Modified from Substance Abuse and Mental Health year(Fig. 21-3) Services Administration: Results from the 2009 National Survey on Drug use and Health, Rockville, Md, 2010, Offce of Applied Studies; and National Institute of Alcohol Abuse and Alcoholism: NIAAA council C. Costs approves definition of binge drinking.) Mental health and behavioral disorders are stly Among behavioral addictions, pathological gambling is costs primar result from mental health care utilization estimated to affect 1% to 2% of the U.S. population, Sexual the costs associated with substance use disorders include behavior considered pathological is estimated to affect 50 both health care utilization (outpatient treatment; In regard to problematic Internet use, whereas 6% of users pitalization) as well as incarceration and interdiction can be considered addicted, this represents less than 1% of effor
CHAPTER 2 Mental and Behavioral Health through injection/intravenous drug use(IDU) or risky sexual practices with infected partners. Drug use during 5193181051810 pregnancy is associated with withdrawal symptoms among infants after birth and an increased risk of offspring develop 150 88100 SUICIDE Following a successful suicide, bereavement of family and friends can be lengthy and complicated. In addition to grief, surviving family members and friends feel guilty, con fused, depressed, and anxious and may even experience su cidal thoughts or make suicide attempts themselves. 8 I. RISK AND PROTECTIVE FACTORS Figure 21-4 Overall economic impact of mental health and ehavioral disorders. Annual estimate: year of estimate: 1998(alcohol). Factors that affect the development of mental and behavioral 2007(tobacco), 2002(illicit drugs ); year of estimate: 2002. (a from Dozois health disorders fall within several broad categories: biologic, DIA,Westra HA: In Dozois DIA, Dobson KS, editors: The prevention of anxiety 1 Whereas some may be directly modifiable through educa- hological, social, environmental, and cultural American Psychological Association; b from Substance Abuse and Mental Health Services Administration: State estimates of substance use and mental health tion or treatment(e. g, negative thinking), other risk fac disorders from the 2008-2009 National Surveys on Drug use and Health (e.g., temperament)may not. However, some suggest that a NSDUH Series H-40, HHS Pub No SMA ll-4641, Rockville, Md, 20ll, Office diathesis-stress model may serve as the most useful frame work for understanding the development of mental health disorders and behavioral problems. This model suggests MENTAL HEALTH DISORDERS that preexisting biologic and psychological vulnerabilit predispose a vulnerable individual to problematic emotions In addition to economic impacts, mental health disorders are and behaviors when facing stress that exceeds one's ability to associated with the following.: cope. Thus, it is important to be able to recognize these a Educational and occupational impairment nonmodifiable factors because they may help identify those Difficult social relationship most in need of prevention and intervention efforts Stress and mental health problems in family members caring for an affected person A. Biologic Risk Factors ■ Poor quality of life a Development of, and impaired recovery fre Genetics have been found to account for 30% to 40% of an individual's risk for anxiety and depression2,2 and 50%to Substance abuse/dependence 60%of risk for substance dependence(although heritability Death by suicide or other causes estimates for drug dependence are more variable than for alcohol dependence). Research on addictio gests that although environmental e prom BEHAVIORAL DISORDERS inent role in the early stages of us genetics is more influential in the to pathologi Substance use disorders cause significant morbidity and cal use. 2 mortality both in the United States and worldwide. Alcohol Endophenotypes represent inherited traits that are risk tobacco, illicit substances, and prescription medications are factors for disorder and are both present and detectable before all responsible for a substantial number of avoidable deaths the disorder is expressed. Table 21-3 lists traits that represent because of their deleterious health effects. Specifically, exces ossible endophenotypes for mental health and behavioral sive use of both licit and illicit substances is associated with disorders. Other biologic factors associated with dysphoric ardiovascular disease and many different types of cancer. mood(either anxiety or depression) include the following By impairing attention, concentration, and judgment, alcohol consumption is believed to be a causal factor in risky Hormonal changes(e. g, mood disorder with postpartum sexual practices,incre onset the risk of unwanted pregnan- Pediatric autoimmune neuropsychiatric disorders associ- cies and sexually transmitted infections(STIs), aggressiv behavior, and fatal motor vehicle crashes. Smoking during ted with streptococcal infections(PANDAS), associated pregnancy is associated with premature birth as well as low with a rapid onset of tics, Tourette s syndrome, and birth weight, which increase the risk for attention-deficit obsessive-compulsive disorder in children yperactivity disorder (ADHD), conduct problems, and Amount of daylight(e.g, mood disorder with seasonal poor school achievement. pattern) Nonprescription use of medications accounts for a sub- Disturbances of the circadian rhythm" stantial number of emergency department admissions and The pharmacologic properties of drugs explain why the tly increases the are used. In particular, users often report that they use sub isk of contracting infectious diseases(e. g, HIV, hepatitis B) stances" to feel good, to feel better, to alter consciousness
256 SECTION 3 Preventive medicine and public Health Table 21-3 Inherited Temperaments or Traits Indicative of Risk for Anxiety, Mood( Depressive), and Substance use Disorders Disorder Traits Anxiety and dency toward introversion, shyness, and caution in Increase risk ( tendency to be fussy, agitated, and irritable) Negative affect(tendency toward negative, depressed, irritable, or angry mood) Increase ris Alcohol dependence Facial flushing Decrease risk Decreased sensitivity to effects of alcohol Increase risk Alcchol nd drug avioral disinhibition, sensation seeking, impulsivity, impaired ex Psychiatric disorders Increase risk Increase risk modified from Dozois DJA, Dobson KS, editors: The prevention of anxiety and depression: theory, research, and practice, Washington, DC, 2004, American Psychological +Modified from Miller WR, Carroll KM, editors: Rethinking substance abuse: what the science show, and what we should do about it, New York, 2006, Guilford. tModified from Giegling L, Olgiati P, Hartmann AM, et al: Personality and attempted suicide. Analysis of anger, aggression and impulsivity, J Psychiatr Res 43: 1262-1271, 2009 d to do better (e. g, steroids to enhance physical perfor- such drugs are safer than illicit substances and pose no mance, prescription lulants to enhance academic serious health risks, o performance) The extent to which an individual believes that others The presence of one disorder may be a risk factor for would benefit from the persons death(" perceived burden another. Specifically, anxiety often precedes, and thus may be sameness")and that the individuals basic needs for affilia a causal factor in, the development of depression. Exter- tion are not being met(thwarted belongingness")are risk nalizing disorders during childhood(e. g, conduct disorder, factors for suicidal ideation. Suicide risk increases when ADHD) are associated with an increased risk of substance suicidal thoughts are combined with an increased acceptance se problems that persist into adulthood. Other potential of suicide as a viable option and feelings of hopelessness associations between psychiatric and substance use disorders One of the best predictors of future suicide attempts is past include the following suicidal behavior. Pathological substance use causes anxiety, depression and other mental health disorders by increasing stress or C. Social Risk Factors impacting sensitive neural systems. Anxiety, depression, and other mental health disorders Among vulnerable individuals, exposure to anxious parents o cause pathological substance use because substances help or to substance-using peers"increases the risk of develop to regulate negative moods ing an anxiety or substance use disorder, respectively. Psychiatric and substance use disorders share genetic risk Parental depression significantly increases the risk of de factors(e.g, difficult temperament, negative affectivity) Press wy of emotional availability and bonding, or family and other risks(e. g, maladaptive responses to stress, lack disruption D irect exposure to a threatening stimulus a Psychiatric and substance use disorders reciprocally infl (e.g, trauma, social evaluation) will also lead to the devel ence one anothe opment of specific phobias and traumatic stress disorders Direct-to-consumer advertising of psychotherapeutics may play a role in perceptions of these drugs and nonmedical B. Psychological Risk Factors use. Excessive attention and glorification of suicides in the media are believed to increase the risk for copycat Individuals' thoughts, beliefs, expectancies, and self- behavior naped through an interaction of emperaments, sensitive neural systems, hormones, and early D. Environmental Risk Factors learning experiences and thereby influence of mental health and behavioral disorders. Thus, both Stress and adverse early environments, such as those charac- depression and anxiety are associated with maladaptive terized by child abuse and neglect, domestic violence, dis- thought patterns, although the content of the maladap, 6 factors for anxiety and depression, behavioral problems, e crimination, and poverty, are among the most significant risk thoughts associated with anxiety and depression differs. Similarly, beliefs about the effects of a substance, known as and suicide. Beyond stress, other environmental risk factors outcome expectancies, influence the age of onset and level of for mental and behavioral health disorders are as follows substance use. Positive expectancies(beliefs that drinking will produce positive outcomes)are associated with increased Social isolation use, but negative expectancies do not appear to deter use. Inadequate transportation, housing, education, employ- Moreover, one explanation for the increase in nonmedical use of prescribed medications includes the perception that Poor parenting practices
CHAPTER 2 Mental and Behavioral Health 257 a Easy access to drugs and alcohol and exposure to drug- that risk. Achieving developmental milestones at appropriate usIng peers times, being physically healthy, and being physically active Increases in the number of prescriptions written for are associated with good mental health. Possessing at leas opioid and stimulant medications, as well as availability average cognitive ability is also associated with lower rates of for purchase online anxiety and depression. 22 ■ Poverty Cognitive, social, environmental, and cultural factors that contribute to good mental and behavioral health outcome The following environmental risk factors are specific to Secure attachment during infancy, which contributes to a Inaccessibility of mental health services n Serious physical illness Strong attachments to family, school, and community a Communities where highly lethal means for committing suicide are readily available a Social support and positive parenting practices"27 a Adequate coping skills for managing stress ■ High self-esteem E. Culture/Diversi a Strong religious beliefs and religious affiliation, is a critical factor in determining both 1. PREVENTION AND HEALTH risk and resilience for mental health and behavioral disorders For example, research suggests that anxiety and mood disor- PROMOTION STRATEGIES ders are more prevalent among women, wher reas subsea use"and suicideare more frequent among men. However, The Institute of Medicine(IOM)proposed a typology for lthough men have an earlier onset of substance use and use prevention of mental health and behavioral problems based more heavily than women, research suggests that rates of ciga- on that used for physical health problems. This typology rette smoking are gender comparable. Moreover, women who comprises three categories: universal, selective, and indi do use substances may progress to pathological use more cated. Similar to primary prevention, universal prevention rapidly and have greater difficulty in quitting than men efforts are targeted toward an entire population, regardless Social injustice and discrimination are significant risk of risk level. The other two IOM categories involve second factors for mental health and behavioral disorders. Stigma ary prevention, because they are directed toward those at and discrimination may explain why mental and behavioral greater risk for mental health and behavioral disorders disorders are more prevalent among sexual minorities These individuals possess risk factors such as anxious tem (lesbian, gay, transgendered). Age is also a risk factor for the parament or early childhood adversity(. e, selective preven development of these disorders. Some argue that individuals tion), or they are experiencing subclinical symptoms that do rer age 50 are at higher risk than their younger counter not meet the criteria for disorder, such as anxious mood parts, but others find that young adults are at greater risk without functional impairment (i. e, indicated prevention or suicidal ideation and attempts. Selective prevention and indicated prevention are collec- minority status has also been implicated as a risk factor tively referred to as targeted prevention for experiencing traumatic events as well as for developing Because the ioM classification does not address preven all mental health and behavioral disorders. Onset of sub- tion of relapse or reduction of harm among individuals who ance use is later among African Americans and Hispanics are experiencing or have experienced a first episode of dis experience different levels of substance use disorders, pos- tertiary prevention, is also needed s hich is most similar to than among Caucasians. Moreover, racial and ethnic groups order, a fourth category, treatment, sibly because of genetic and social factors. For example, the increased risk of alcoholism among Native Americans may A. Theoretical Framework be caused by an inherited low-level response to alcohol whereas the relatively low rates of alcoholism among Asians The health belief model provides a framework for under may result from an inherited flushing response. Jewish standing how people perceive themselves to be at risk for people may experience lower rates of alcoholism because developing problems and factors associated with decisions drinking occurs in the context of family and religious to enact disorder prevention and health-promotion behav rituals. Ethnic minorities are also at higher risk for com- iors(see Chapter 15). The health belief model was created mitting suicide. However, the relationship between ethnic/ in the late 1950s in response to the lack of utilization of racial minority status and mental health/behavioral prob public health efforts to vaccinate people for tuberculosis. The lems may largely be caused by the effects of poverty and lack model includes the following four cognitive dimensions that f access to adequate mental health care and behavioral impact an individuals willingness to modify risky health health care behaviors F. Protective Factors 1. Perceived susceptibility is the extent to which individual ze that they are at risk for developing an undesir Even among individuals predisposed to develop a mental able health outcome health or behavioral disorder by virtue of one or more risk 2. Perceived severity involves the extent to which associated factors, the availability of protective factors can help mitigate consequences are perceived to be grave
SECTION 3 Preventive medicine and public health 3. Perceived benefir 4. Perceived barriers to change D. Screening Screening programs may be used as universal prevention of its importance in predicting the likelihood of behavior in a variety of settings(e. g, primary care physician offices, change. Self-efficacy refers to confidence or a belief in one's schools, emergency rooms) to determine level of risk and competence to do what is needed to enact health-enhancing type of intervention required. For example he psed qu assessment tool (PAT)is a 20-item self-administer ionnaire for families of chronically ill children that assesses B. Public Policy 10 domains of risk factors. The pat was found to be a valid tool, with most families requiring universal prevention(con- Universal prevention efforts include policy changes fewer geted toward an entire population and serve to reduce the selective prevention(services targeted toward specific risk Cidence of mental health or behavioral disorders, Strate actor identified), and the fewest requiring indicated preven- ies shown to improve mental health outcomes include the tion(involving referral to behavioral health specialist A list of measures is useful for identifying risk of develop oving nutrition and housing ng oving access to education and health care sitivity), diagnosing or mood disorders, and assessing n Improving access to work and reducing poverty general mental health, functional impairment, and quality of life he most widely used risk factors measure Although legal approaches to substance use(e. g, incar- the 21-item Beck depression and Beck anxiety invento ceration of drug users; interdiction efforts) may prevent which provide criteria for determining the severity of symp experimentation or initial use of substances, these efforts toms (i. e, mild to profound ); individuals scoring in the mild ave been largely ineffective for stopping established use to moderate range could be candidates for selective or indi The following policies have led to decreases in rates of sub- cated prevention efforts whereas those scoring higher would stance use and related problems likely need treatment. The brief psychiatric rating scale (BPRS)is a validated 24-item diagnostic screening tool a"Sin taxes"(increasing the cost of alcohol and assessing five domains of mental health problems: thought cigarettes) disorder, withdrawal, anxiety-depression, hostility-suspicion a Reducing the availability of alcohol by regulating number and activity. Although its psychometric properties are and open hours of plac good, diagnoses must be confirmed with a more thorough a Advertising bans assessment A number of brief screening tools have also been devel In oped for assessing the presence and extent of substance use In addition to the efforts noted thus far, which would problems as well as motivation to quit. The four-item CAGE reduce suicide rates by reducing anxiet (cut down, ant er) and 24-item Mich and substance use, other suicide prevention tht gan Alcoholism Screening Test(MAST) are effective identifying problematic levels of alcohol use. t>,t The Rutgers a Reducing the toxicity of gasoline and car exhausts Alcohol Problem Index(RAPI)* is an 18-item measure that Minimizing access to high places such as rooftops and assesses dI rinking-related consequences. A revision of the MAST, the drug abuse screening test (DAST), is a 20-item a Enforcing gun control policies measure that can be used to identify individuals who are a Controlling the availability of pesticides and prescription using or at risk for using illicit substances medications.32 Also, the addiction severity index(ASI, 5th edition)is a structured interview widely used in both substance abi Selective or indicated prevention efforts might include treatment clinics and treatment research. The ASI assesses improving accessibility, affordability, and perceived helpful- severity of problems in seven domains related to drug and ness of mental health or substance abuse treatment, esp use: me ledical, employment, alcohol, drug, legal, cially for groups with limited access family/social, and psychiatric. Advantages include good psy chometric properties and guiding treatment planning. Dis C. Media Campaigns advantages of the asi are that it takes 45 minutes to Universal prevention efforts may include media campaigns administered properf e wers must be trained to ensure it i administer and inter that highlight the consequences of substance use. The Legacy A comprehensive assessment of smoking should include Foundations"Truth"campaign links smoking with serious measures of motivation, nicotine dependence, past quit healthconsequencesanddeath(http://www.thetruth.com/).attemptssmokinghistoryothersubstanceusepresenceof elevision advertisements are effective for reducing drun psychiatric conditions, and treatment preferences. All these driving crashes and related trauma. Similarly, counterman factors will affect whether a quit attempt is made and whether keting, or antitobacco advertisements, have been found to that attempt is successful. Nicotine dependence can be increase knowledge and negative beliefs about the use of assessed with the six-item Fagerstrom Test of Nicotine tobacco. Media campaigns can be similarly effective for Dependence and two-item heaviness of smoking index. Both reducing illicit substance use. measures include a question regarding the amount of time
CHAPTER 2 Mental and Behavioral Health elapse Returning to baseline levels of use No recognition of a problem No intention to quit Maintenance Sustaining abstinence Recognition of a problem No immediate plans to qui Action Making plans to quit in the near future Figure 21-5 Stages of change modeL. Modifed from Prochaska IO, DiClemente CC: Psychotherapy 19: 276-288, 1982.) between waking and smoking the first cigarette, which is universal school-based drug prevention programs delivered strongly associated with level of dependence. Motivation can by police officers is Project daRE( Drug Abuse Resistance be assessed using the contemplation ladder, which has Education). Despite its popularity, meta-analyses show tha smokers indicate their readiness to stop smoking on a scale dare produces either no effect or possibly harmful effects of 0 to 10 he contemplation ladder has its theoretical in terms of youth drug use. Conversely, school-based inter foundation in the stages of change model, which is com- ventions that teach drug refusal skills and address outcome prised of five stages and is reinitiated by a relapse(Fig. expectancies for drugs, delivered as either universal or 21-5). The contemplation ladder may also be useful for selected prevention programs, can be effective for decreasing ssessing motivation to quit among users of alcohol and substance use. other drugs. These measures could be used in combination Universal efforts to prevent suicide involve psychoeduca with a brief physician intervention (e. g, five "A"model tional programs targeted to asing awareness of the described later)to enhance motivation to quit as well as symptoms of mental health disorders, their role in suicide, guide decisions about the most appropriate approach and available resources. In gatekeeper training, for example, encourage cessation selected individuals are trained to recognize warning si While simply asking about thoughts of suicide and the of depression and suicide and to intervene with distressed presence of a plan is considered a reasonable strategy for persons. A systematic review found that gatekeeper training identifying individuals at risk of killing themselves, using the improved trainee's knowledge, skills, and attitudes toward depressive symptom index(DSI)suicidality subscale is rec- intervening and, in specific populations, produced reduc mmended. This four-item measure, with scores from 0 to tions in suicidal ideation and attempts. Research on the 12(higher scores indicate greater risk), assesses presence and efficacy of crisis centers and hotlines, both targeted preven frequency of suicidal ideation, presence of a plan, and per on programs, is inconclusive. vasiveness of the desire to kill oneself. a cutoff score of 3 is Targeted brief interventions and brief treatments for sub- ecommended to ensure that all high-risk persons are iden stance use and mental health disorders include motivational fied while minimizing false positives interviewing(MI), a brief intervention(1-4 sessions)devel oped to encourage internal motivation for change. MI has E. Psychosocial Interventions been effective for enhancing treatment retention and reduc- ing substance use and related negative consequences Brief Intervention Recently, MI has been effectively applied to the treatment of mental health disorders, either to increase motivation to ew prevention programs ally target anxiety. How ven the significant numb shared risk factors betvyser, engage in treatment or to encourage patients in treatment to ake the steps necessary to achieve therapeutic change(e. g anxiety and other mental and behavioral problems, exposure exercises)"(see Chapter 15) prevention programs aimed at other disorders will likely In addition to MI, research suggests that advice by a phy. have a broad beneficial impact for preventing anxiety. sician may be sufficient to enhance motivation to change School-based programs are effective for improving coping behavior and to enter treatment. The U.S. Public Health and social skills and thereby reducing the risk of depression Service and National Cancer Institute developed the five "A and anxiety. One of the most well-known and widely used program, a brief intervention designed to assist physicians
SECTION 3 Preventive medicine and public health in assessing patient smoking status and encouraging them to the risk of traumatic stress disorder symptoms). Conversely, quit. The five"Amodel, based on research on persuasion cognitive restructuring and exposure therapies effectively and the health belief model, involves these five steps reduce symptoms of PTSD and prevent relapse. l. Ask all patients about their current smoking status. he same 2. Advise smoking patients to quit. Provide feedbac principles as CISD and involve providing survivors with the role of smoking in causing or exacerbatir m information about resources and with opportunities to share current health concerns, as well as personalized tion about the benefits of however, such approaches either have no beneficial effects or 3. Assess their smoking and related health status may be harmful because the suicidal act is glorified, inspiring 4. Assist patients in their quit attempts. Refer them for psy- suicidal thoughts in participants and copycat behavior. 4 hosocial treatment, or discuss pharmacologic treatment Effective treatments for substance dependence include contingency management and social network and family 5. Arrange a follow-up appointment in the next 3 months models. Contingency management( CM)models operate on the premise that drug use is highly reinforcing and that moti The five A"program has been shown to be effective for vation for abstinence can be increased when abstinence and motivating patients to quit smoking"(see Box 15-2 articipation in non-drug-related activities are reinforced CM interventions use a variety of reinforcements, including vouchers with monetary value that can be exchanged for 2. Longer-Term Interventions goods and services, retail items/gift certificates, and for heroin users,take-home methadone doses. Although CM is most Consistent with the finding that insecure attachment is asso- effective for promoting drug abstinence when reinforcement ed is present(with high rates of relapse once the reinforcement interventions that help to facilitate maternal responsiveness is removed), it does seem to be an effective approach for and expression of positive affect, as well as teach effective improving compliance(counseling session attendance; taking renting skills to reduce child abuse and neglect, are likel medication as prescribed) during treatment, which may o enhance resilience of at-risk children(e. g, impoverished translate into longer-term posttreatment benefits parents, teenage mother). School-based and community Social network and family models are rooted in research based programs that encourage prosocial behavior, foster showing that social support is critical for increasing the like expression of positive affect, and teach empathy and cogni lihood of treatment entry and engagement, abstinence, and tive skills for effectively regulating negative emotions as well sustained recovery. In addition to interventions that focus or as problem-solving skills have been useful for improving involving drug-free family members and significant others eneral mental health and substance use. Programs that in treatment, self-help groups(e.g, Alcoholics Anonymous, address substance use and other risky behaviors teach skills Narcotics Anony mous, Rational Recovery) are also effective that are also effective for increasing resilience and preventing for improving substance use outcomes mental health disorders. 2 F. Medical/Pharmacologic Interventions disorders. CBT focuses on restructuring maladaptive cogni tion and teaching effective strategies for coping with stress. Pharmacotherapies, particularly selective serotonin reuptake In addition, it also identifies thoughts, feelings, and behav- inhibitors(SSRIs)and serotonin-norepinephrine reuptake iors(triggers) that maintain substance use and teaches strate- inhibitors (SNRIs), are often used for the treatment of gies for coping with triggers(people, places, things, thoughts, anxiety and depression with the goal of reducing symptoms feelings). Exposure may be used as part of CBr to foster and improving overall quality of life. However, research sug- extinction of the learned association between environmental gests that the effectiveness of SSRis and benzodiazepines for ues and fear as well as between triggers and drug craving. treating anxiety are limited to the period of medication are effec: suggests that cognitive and behavioral approaches administration, with patients experiencing a relapse of e for preventing a first depressive episode, for symptoms on cessation. Similarly, pharmacotherapy is less ncouraging drug abstinence during treatment, and for pro- effective than cognitive therapy for preventing relapse after moting sustained abstinence. Also, patients show continued medication discontinuation, although relapse appears to be reductions in substance use for as long as I year after CBt reduced if(1)the patient experiences full remission of symp ends. For anxiety, CBT is more effective than pharmaco- toms(partial remission of symptoms increases the risk of therapy for producing symptom reduction and preventing relapse after discontinuing medication) and(2)medication relapse. Research on the relative effectiveness of psychos- is continued for at least 4 to 6 months after remission of for ubstance use shows that both are equally effective when However, research does suggest that the increased risk of Ised as monotherapy and that their combination offers no suicide associated with pharmacologic treatment can be advantage mitigated by the addition of CBT After exposure to trauma, intervening with individuals Pharmacologic interventions for substance use(Table exhibiting symptoms of acute stress disorder(ASD)might 21-4)either encourage abstinence initiation or prevent help to forestall the development of posttraumatic stress relapse through the following: disorder (PTSD). However, research on critical incidents stress debriefing( CISD), a popular brief intervention for Blocking the effects of drugs and thereby reducing their individuals exposed to trauma, has been mixed; some studies euphoric effects; such drugs will also instigate the onset find it helpful, and others find it is iatrogenic (i.e, increasing of withdrawal symptoms (i.e, antagonists
CHAPTER 2 Mental and Behavioral Health Table 21-4 Pharmacotherapies for Substance use Disorders Medication Mechanism of Action GABA agonist dent patients nhibits breakdown of acetylaldehyde: produces g:only effective if administration headache, facial flushing, and nausea/vomit pervised, otherwise patients are noncomplia distress associated with tor activity; reduces Promotes maintenance of abstinence: more effective than placebo Ondansetron Reduces serotonin receptor activity Discourages drinking; particularly effective for alcoholism with onset before age 25 Nicotine es nicotine obtained through smoking: ng recommended for short-term use only B Uncertain; presumably blocks the reinforcing Effective for promoting smoking abstinence initiation effects of nicotine Nicotine vaccine Blocks nicotine from entering brain, reducing its Currently under investigation euphoric effects Opioids Methadone all opioid agonist Effective as a maintenance medicatio Buprenorphine rtial opioid agonist Naltrexone Effective for reversing overdose Patient must be fully detoxified to begin medication; poor Under investigation for use in rapid opioid detoxification Modified from Miller WR, Carroll KM, editors: Rethinking substance abuse: what the science shows, and what we should do about it, New York, 2006, Guilford Y-Aminobutyric acid. Mimicking the effects of drugs and therefore preventing society. Research has begun to identify the shared and unique withdrawal as well as blocking their euphoric effects risk factors as well as protective factors associated with these disorders. Shared risk factors include poor parent-child a Preventing drugs from entering the brain and thereby bonding and inadequate parenting skills, parental mental Ing health problems, poverty, and stress. Unique risk factors behavioral inhibition for anxiety and depression versus dis- Although considerable research has been done to identify inhibition for behavioral disorders; anxious role models for effective pharmacotherapies for stimulants, such as cocaine, anxiety disorders; and substance-using role models for sub none has received U.S. Food and Drug Administration stance use disorders. Shared protective factors include social FDA) approval at present. However, ongoing research is support and social and emotional competence. Despite testing the efficacy of a cocaine vaccine. Moreover, there advances in the development of effective prevention and are no FDA-approved pharmacotherapies for marijuan intervention approaches, further research is needed to ens which is itself now a legal medical therapy in many states that prevention policies and interventions are grounded o In addition to interventions that increase abstin theory, are culturally-informed and relevant, and reflect and prevent relapse, other medical interventions are designed state-of-the-art (evidence-based)knowledge, to reduce the to reduce harm and prevent overdose or death. For example, burden of these disorders while improving quality of life programs in which opioid-addicted individuals are pre scribed and trained to use naloxone(opioid antagonist)are effective for reversing the effects of opiate overdose in as References many as 96% of cases. Needle exchange programs, in which I. Hosman C, Jane-Llopis E, Saxena S: Prevention of mental dis- injection drug users can safely exchange used for unused orders: effective interventions and policy options-summary hypodermic needles, are designed to prevent transmission of report, Oxford, 2005, Oxford University Press infectious diseases as well as facilitate entry into treatment. 2. American Psychiatric Association: Diagnostic and statistical revention education and HIV testing, providing condoms, manual of mental disorders, ed 4, text revision, Washington, DC, and drug substitution therapy may help reduce the spread 2000,AP of Hiv and other transmissible infections 3. Miller WR, Carroll KM, editors: Rethinking substance abuse: should do about it New York, 2006. Guilford I. SUMMARY 4. Holden C: Behavioral" addictions: do they exist? Science 294:980-982,2001 5. Grant JE, Potenza MN, Weinstein A, et al: Introduction lental health/behavioral disorders and suicide are prevalent to behavioral addictions, Am) Drug Alcohol Abuse 36: 233-241 and exact significant tolls on individuals, families, and
