Top 5 Issues to Consider at the Intersection of Behavioral Health and Public Health

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines behavioral health as including “the promotion of emotional health; the prevention of mental illnesses and substance use disorders; and treatments and services for mental and/or substance use disorders.” Why should public health professionals care about behavioral health?  Two words: disability and premature death.

Recent analysis of Global Burden of Disease data shows mental and substance use disorders were the leading causes worldwide of years lived with disability. Those researchers concluded that until we make prevention and treatment of mental and substance use disorders a public health priority, improvements in population health will face obstacles.  In the United States, the SAMHSA says, “mental illnesses and substance use disorders are common, frequently recurrent, and often serious.”  Comparison across states has shown that those with serious mental illness die earlier than the general population (in one study, from 13 to 30 years earlier, depending on the state).

The National Network of Public Health Institutes (NNPHI) has prioritized behavioral health as a key focus area. NNPHI’s mission is “to support national public health system initiatives and strengthen public health institutes to promote multi-sector activities resulting in measurable improvements of public health structures, systems, and outcomes.” As NNPHI engages with its 40+ member institutes, public health training centers, and national partner organizations in dialogue about the intersection of behavioral health and public health, we see this intersection evolving quickly.

Here is our list of the top five most important issues at the intersection of behavioral health and public health.

5: Population level data

Within the last few years, CDC completed an agency-wide compilation of data from selected CDC surveillance and information systems that measure the prevalence and impact of mental illness in the U.S. adult population. According to a more recent Morbidity and Mortality Weekly Report, public health has seen significant decreases in the number of potentially preventable deaths among several of the five leading causes of death, but the number of potentially preventable deaths from unintentional injuries, including overdose deaths, increased significantly during the same period.

What about population-level data beyond morbidity and mortality? While there is not yet an ongoing population-level stigma surveillance system, a recent literature review of public stigma suggested that stigma is widespread and may even be increasing.

4: Workforce

What do we know about the current and future of the public health workforce and the behavioral health workforce? At just over 800,000 professionals, the behavioral health workforce is substantially larger than a recent high end estimates of the public health workforce (500,000 professionals).

In November 2016, the Health Resources and Services Administration (HRSA) and SAMHSA released an analysis of the nation’s behavioral health workforce. The report, entitled National Projections of Supply and Demand for Selected Behavioral Health Practitioners:  2013—2025, predicts that “under the most conservative projections, by 2025, shortages are projected in a number of key behavioral health professions.”

Public health also projects workforce shortages. As federal, national, state and local organizations develop strategies for collaboration across public health and behavioral health, it is important to understand the challenges and opportunities such projected shortages may bring. Recognizing that epidemiologists are in short supply, NNPHI commends the Council of State and Territorial Epidemiologists for their current and past work enhancing the capacity of the epidemiology workforce in behavioral health, specifically in the SAMHSA Center for Statistics. While small in numbers, these workforce enhancements show great promise in improvements to surveillance and other public health functions.

3: Strategy

Many strategies are addressing intersections of public health and behavioral health. While the recently released Surgeon General’s Report on Alcohol, Drugs, and Health is rightfully receiving wide attention, two other strategies at this intersection of public health and behavioral health deserve an amplifier.

First, the Association of State and Territorial Health Officials’ (ASTHO) 2017  “President’s Challenge, Public Health Approaches to Preventing Substance Misuse and Addictions” describes public health approaches to preventing substance misuse, addictions, and related consequences. This resource is particularly helpful for public health professionals because it is organized by primary, secondary, and tertiary prevention, and users can click through the website for tools, resources and strategies to help their health agency implement each level. Second, the South Carolina Institute of Medicine & Public Health (IMPH) has released its first annual progress report on the implementation of each recommendation from May 2015’s Behavioral Health Taskforce report, “Hope for Tomorrow: The Collective Approach for Transforming South Carolina’s Behavioral Health Systems.” Following the release of the Taskforce report, IMPH formed an Implementation Leadership Council to foster collaboration, create a vision for the implementation of Taskforce recommendations, and catalyze improvements in South Carolina’s behavioral health systems.

2: Major legislation

According to SAMHSA, the Affordable Care Act extended the impact of the Mental Health Parity and Addiction Equity Act (MHPAEA) so that many health plans must offer coverage for mental health or substance use disorders with at least an equal level of benefits as the plans offer for the treatment of physical health problems. As our nation determines the future of the ACA, it will be important to understand the intended and unintended impacts of repeal and replace on mental health parity, especially at the state and local level.

Also worth noting is the Comprehensive Addiction and Recovery Act (CARA) (P.L. 114-198), the first major federal addiction legislation in 40 years. The Community Anti-Drug Coalitions of America has a great summary of CARA’s contents and its implications for public health.  While CARA authorizes many great initiatives and concepts, the key takeaways from the summary come down to…

1: Funding

What is going on with funding for public health and behavioral health? One common risk across public health and behavioral health is reliance on federal discretionary dollars to fund core elements and functions. As a result, professionals working in both public health and behavioral health are on hyper alert regarding potential funding cuts at the federal, state, and local level.

Over time, one can look at the CDC and SAMHSA budget trends as proxies for public health and behavioral health, recognizing that both agencies provide significant extramural funding to the field. The CDC budget trend has been relatively flat the past few years, $6-7 billion, with the agency relying heavily on the Prevention Fund.

The SAMHSA budget trend has also been relatively flat, $3.5-3.7 billion, with a more substantial increased request for fiscal year 2017. The requested increase would support SAMHSA’s role in leading public health efforts to advance the behavioral health of the nation.  Recent headlines at the intersection of behavioral health and public health include the $1 billion of funding for opioid overdose prevention (as part of the 21st Century Cures Act) with noting the funding has come from the Prevention Fund allocations.

This is just a small sampling of what is going on at the intersection of public health and behavioral health. Those looking for more detailed information about the programmatic work occurring across NNPHI and the Public Health Learning Network should: 1) read our current issue of Elevate (especially the interview with APHA Mental Health Section Chair, Margaret Walkover); and 2) consider joining us for the  2017 NNPHI Annual Conference in New Orleans this May. NNPHI’s keynote speaker is Linda Rosenberg, President of the National Council on Behavioral Health.

See the February 2017 edition of Elevate »

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