The New York City Department of Health and Mental Hygiene (DOHMH) has a unique mandate in our City to prevent illness and disability. How does this mandate translate to our work in behavioral health? This inaugural publication of Behavioral Health News, with its focus on the interconnectedness between mental health, substance use, and physical health challenges, provides an opportunity to highlight prevention approaches to mental illness and substance use and how we at DOHMH incorporate these approaches into our work.
“Prevention” in behavioral health can be interpreted broadly; many of our services and programs are designed to prevent or reduce disability, and consequently to promote resiliency and recovery. But in this discussion, I will focus on those strategies that aim to avoid the development of behavioral health problems in the first place, or to reduce the progress of early illness or behavior into more serious forms.
Early Intervention for Psychotic Illness: Following a “first-episode” of psychotic illness such as schizophrenia, which often occurs in young adulthood, the course of remission and relapse can be unpredictable. Often, individuals develop significant disability. But evidence has accumulated over the past several decades that intervening early in the course of schizophrenia and related illnesses can change this negative trajectory and produce sustained remission. Specialized treatment, including low-dose medication prescribing, counseling, family therapy, and supported education/employment, are emerging as critical components to achieving the best outcomes. Unfortunately, as with most mental illnesses, years often go by between the time symptoms develop and when individuals begin receiving sustained care. So the challenge is two-part: identify, engage, and support young people experiencing a first episode of psychosis and provide them with specialized, comprehensive care. The New York State Office of Mental Health is supporting the development of new clinics specializing in this area, and we at the NYC DOHMH are developing an initiative to work with hospitals to support individuals who are admitted with first-episode psychosis and link them to care. This is exciting work, especially because it represents a prevention approach to serious mental illness.
Opioid Misuse and Overdose: We are in the midst of a national epidemic of prescription painkiller misuse and its consequences of dependence and overdose. Rates of misuse (using a medication in a way other than prescribed or without a prescription) are rising in parallel with the rate of prescribing of these powerful drugs. Prescription opioid misuse is more common in New York City than use of cocaine or heroin. In essence, this is an epidemic that originates in the medical system: physicians trying to address their patients’ pain have been prescribing these drugs without sufficient regard for the potential for serious adverse consequences. These consequences are the result both of risk to the individual for whom the drugs are prescribed (overdose risk rises sharply with the dose taken) and also, via the potential for unused pills to be obtained by others. In New York City, overdose fatalities associated with prescription opioids increased by 65% between 2005 and 2011; on Staten Island, which is the epicenter of the crisis in the City, rates increased by 260%. DOHMH is working intensively on preventing these tragic outcomes, with a focus on the medical community, where we are encouraging more judicious, safer prescribing of these medications. We have developed prescribing guidelines for office-based and emergency department physicians, are visiting nearly every prescriber’s office on Staten Island to provide education and tools and have supported the State’s initiative to improve its prescription monitoring program. Critically, as these and other initiatives serve to decrease the availability of these drugs in New York City communities, the treatment system must have capacity and be accessible to those who need it, and we are working to make sure that effective modalities of care, especially medications such as buprenorphine, in a variety of settings, are available. In another prevention effort, DOHMH and the State Health Department’s AIDS Institute both administer programs to distribute an antidote to opioid overdose – naloxone (Narcan) – to lay community members who may be in a position to reverse an overdose (the medication is administered as an injection, like an Epi-Pen, or sprayed into the nose). Thousands of people have been trained and given naloxone to carry, and hundreds of overdose reversals have been reported.
Syringe Exchange: Preventing illness among people who are using drugs is a key priority. In collaboration with the AIDS Institute, DOHMH oversees the system of syringe exchange in New York City. In addition to providing clean syringes, these programs assist individuals in gaining access to other important medical, behavioral health, and social services.
Adverse Childhood Experiences: The association between adverse childhood experiences (ACEs) — such as maltreatment, parental loss, or significant family disruption—and subsequent mental illness and substance use, is increasingly recognized, via studies such as the Centers for Disease Control’s ACE study in California, and in survey data from the National Comorbidity Survey Replication (NCS-R). One analysis of NCS-R, by Greene and colleagues, provocatively estimated that over 20% of child and adult mental illness and substance use is associated with ACEs. Other research has shown that serious trauma in childhood is also associated with psychotic illness later in life. These findings suggest that reducing trauma and promoting healthy early child development may be powerful prevention strategies to promote behavioral health. A comprehensive and multicomponent approach is essential, and should include parenting supports, such as the intensive Nurse-Family Partnership; Head Start, Early Head Start and other educational models; routine monitoring of development and screening for problems in primary pediatrics practices, identification and treatment of maternal depression, clinical/educational services such as Early Intervention, and other programs. One DOHMH initiative to integrate many of these components is Project LAUNCH, targeting the East Harlem and Hunts Point neighborhoods, in which we are working with caregivers, pediatricians, daycares, schools, and behavioral health organizations to build a network that comprehensively promotes children’s positive social-emotional development population-wide.
One implication of a prevention-oriented perspective is that it prompts policymakers and planners to think “upstream” – toward strategies that do not rely primarily on individual interactions between, say, clinicians and consumers, but rather on interventions to change the social and physical environments that shape behaviors and affect mental health. Increasing evidence from epidemiologic studies documents the complex influences of, for example, the attributes of the neighborhood in which a person lives on the likelihood of their developing symptoms of depression. Social isolation and social connectedness affect mental health. The social environment affects drinking behaviors. How do we design public health strategies that address these influences? How can we in behavioral health learn from and collaborate with other public health practitioners who are concerned with environmental and social determinants of health? Care and treatment providers should be important contributors to this thinking and add their perspectives and experience to the development of creative approaches.
Adding a prevention focus amplifies the impact of our ongoing work to improve the system of care and treatment for individuals living with mental illnesses and substance use disorders. It also reminds us that the rate of these conditions in our communities is not fixed and unchangeable. The prevention perspective also challenges us to consider how connected many of the issues we face are and how upstream solutions potentially can have broad impact across a variety of outcomes.