Plenary SessionFriday, 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, MDDepartment 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 unimaginable

nakedness 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

7

Outline of Presentation 1. Institute of Medicine Prevention Report

2. Institute of Medicine Parental Depression Report

3. Preventive interventions focused on parental depression

4. Policy – Expansion of Medicaid and the ACA. An opportunity for treatment for depressed mothers

5. 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

The Committee

33

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

12

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

13

Preventive Intervention Opportunities

14

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

16

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.”

Risks for DepressionSpecific: 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

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 InterventionsPromising 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

1. Family Talk - Beardslee, et al., 20092. Prevention of depression - Garber, et al.,

2009 –moderated by acute parental depression

3. Parent/Child Coping Session - Compas et al., in press.

4. Mothers’ and babies’ program - Munoz

IOM 2009 24

Across both reports and in a variety of different risk situations, very strong

evidence exists for the valueof parenting programs.

25

Special Opportunities and Challenges

1. Developing systems that can give two-generational responses to parental depression

2. Responding to the needs of vulnerable populations, especially low income, culturally and ethnically diverse families

3. Responding to families experiencing depression along with other comorbidities in family adversities

4. 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 modules1. Taking a history2. Psychoeducation and the family’s

story3. Seeing the children4. Planning the family meeting5. Holding the family meeting6. One week follow-up, check-in7. 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

1. Pay attention to the timing of the meeting.

2. Gain commitment to the process from the entire family.

3. Begin by identifying specific major concerns and addressing them.

4. Bring together and reknit the family history.

5. Plan to talk more than once.

6. Draw on all the available resources to get through depression.

Narrative Project for FamiliesWho Sustained Changes – Self-Reflection Over

Time

1. The emergence of the healer within2. 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 Team

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

FAMpod Collaborations

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.

Urban Institute Project

Expanded continuous coverage for low income women

Mandated coverage of preventative services including depression screening

Integrated care initiatives

ACA Opportunities

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

Expanded Treatment under Medicaid Could be Cost-neutral or Cost-saving

Accountable Care Organizations

Patient-Centered Medical Homes

Health Homes

Medicaid Managed Care◦ Carve in◦ Carve out

Emerging Integrated Care Initiatives

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

as parents 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.

Practical Tips III Attention to the family narrative and what

has been disrupted is important in helping the family get back on track in re-establishing rituals and having regular conversations.

A primary care physician is in the best position to provide family-centered preventive care for depression and to facilitate treatment.

Key Ongoing Themesfrom IOM Work

Major depression can be prevented

How to ameliorate the effects of poverty

Encouragement of nurturing environments

How to incorporate family prevention perspectives under the ACA

53

IOM Forum on Promoting Children’s Cognitive, Affective

and Behavioral HealthA focus on implementation and disseminationof health promotion and prevention strategies.

The first forum dealt with effectiveparenting interventions.

Co-chairs:

Dr. C. Hendricks BrownDr. William R. Beardslee

54

http://www.iom.edu/Reports/2014/Strategies-for-Scaling-Effective-Family-Focused-Preventive-Interventions.aspx

Key Research Issues for the Future

Poverty. What degree of interventions in what sectors is necessary to significantly change outcomes?

What are the best policy payment and clinical strategies for family-based mental health prevention in primary care?

How can systems both make enduring improvements and deal with the enormous pace of change and regulation?

Initiative fatigue?

56

Key Research Issues for the Future

(continued) International research - What characterizes

countries that invest heavily in young children and their parents. What can we learn that helps us make the same investments in this country.

How does one address and achieve scientific equity in the study of vulnerable populations?

57

Thank You … For more information, please contact:

william.beardslee@childrens.harvard.edu

Materials for Head Start parents and teachers about resilience and depression available at www.childrenshospital.org/familyconnections

Web-based training in Family Talk and other resources available at www.fampod.org

Perry DF, Miranda J, Ammerman RT, and Beardslee WR. Depression in mothers: More Than the Blues – A Toolkit for Family Service Providers. 2014, Washington, DC. Substance Abuse and Mental Health Services Administration. [On-line] http://store.samhsa.gov/product/SMA14-4878

References 1. Beardslee WR. When a parent is depressed: How to protect

your children from the effects of depression in the family. Originally published in hardcover under the title, Out of the darkened room: When a parent is depressed: Protecting the children and strengthening the family, by Little, Brown and Company, 2002. First paperback edition, 2003.

2. Beardslee WR. Commitment and Endurance: Common themes in the life histories of civil rights workers who stayed. Am J Orthopsychiatry, 1983, 53(1), 34-42.

References (continued)3. Beardslee WR, Ayoub C, Avery MW, Watts CI, and O’Carroll KL.

Family Connections: An approach for strengthening early care systems in facing depression and adversity. Am J Orthopsychiatry. 2010, 80(4), 482-95.

4. Beardslee WR, Brent DA, Weersing VR, Clarke GN, Porta G, Hollon SD, Gladstone TRG, Gallop R, Lynch FL, Iyengar S, DeBar L, and Garber J. Prevention of depression in at-risk adolescents: Longer-term effects. JAMA Psychiatry, 2013, 70(11), 1161-1170. doi: 10.1001/jamapsychiatry.2013.295. Available on-line in PubMed PMCID: PMC 3978119.

References (continued)5. Beardslee WR, Solantaus TS, Morgan BS, Gladstone TR, and

Kowalenko NM. Preventive interventions for children of parents with depression: International perspectives. MJA, 2012, Open 1 Suppl 1, 23-27.

6. Beardslee WR, Gladstone TRG, and O’Connor E. Transmission and prevention of mood disorders among children of affectively ill parents: A review. JAACAP, 2011, 50, 1098-1109. {On-line] www.jaacap.org.

7. Beardslee WR, Lester P, Klosinski L, Saltzman W, Woodward K, Nash W, Mogil C, Koffman R, and Leskin G. Family-centered preventive intervention for military families: Implications for implementation science. Prev Sci, 2011. DOI: 10.1007/s11121-011-0234-S. [On-line] Open source publication: http://www.springerlink.com/content/8265h1k18u4x77nr/fulltext.pdf

References (continued)8. Berwick DM, Nolan TW, and Whittington J. The triple aim:

Care, health, and cost. Health Affairs, 2008, 27(3), 759-769. doi: 10.1377/hlthaff.27.3.759. [on-line] http://content.healthaffairs.org/content/27/3/759.fuull.html.

9. Biglan A, Flay BR, Embry DD, and Sandler IN. The critical role of nurturing environments for promoting human well-being. Am Psychol. 2012. 257-271.

10. Cuijpers P, Beckman ATF and Reynolds III C. Preventing Depression: A Global Priority. JAMA, 2012, 1033-1034.

11. Cuijpers P, von Straten A, Smit F, Miahlopoulos C, and Beckman A. Preventing the onset of depressive disorders: a meta-analytic review of psychological interventions. Am J Psychiatry, 2008, 165(10), 1271-80.

References (continued)12. Garber J, Clarke GN, Weersing VR, Beardslee WR, Brent DA,

Gladstone TRG, DeBar LL, Lynch FL, D’Angelo E, Hollon SD, Shamseddeen W, and Iyengar S. Prevention of depression in at-risk adolescents: A randomized controlled trial. JAMA, 2009, 301(21), 2215-2224. [On-line] http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2737625.

13. Golden O, Hawkins A, and Beardslee WR. Home visiting and maternal depression: Seizing the opportunities to help mothers and young children. Urban Institute. 2011.

References (continued)14. Howell E, Golden O, and Beardslee W. Emerging opportunities for

addressing maternal depression under Medicaid. Urban Institute. 2013 [On-line] http://www.urban.org.

15. Merry SN, Herrick SE, Cox GR, Brudevole-Iversen T, Bir JJ, McDowell H. Psychological and educational interventions for preventing depression in children and adolescents. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD003380. DOI: 10.1002/14651858.CD003380.pub3.

16. Munoz RF, Beardslee WR, and Leykin Y. Major depression can be prevented. Am Psychol. 2012. 67(4). 285-295.

17.

References (continued)17. National Research Council and Institute of Medicine. Preventing

Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Committee on Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults: Research Advances and Promising Interventions. Mary Ellen O’Connell, Thomas Boat, and Kenneth E. Warner, Editors. Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press. 2009. [On line] http://www.nap.edu/catalog.php?record_id=12480.

18. National Research Council and Institute of Medicine. Depression in parents, parenting and children: Opportunities to improve identification, treatment, and prevention efforts. Washington, DC: The National Academies Press. 2009. [On line] http://www.nap.edu/catalog.php?record_id=12565.

References (continued)19. Perrino T, Beardslee W, Bernal G, Brincks A, Cruden G, Howe G,

Murry V, Pantin H, Prado G, Sandler I, and Hendricks Brown C. Towards scientific equity for the prevention of depression and internalizing symptoms in vulnerable youth. Prev Sci. In Press.

20. Perry DF, Miranda J, Ammerman RT, and Beardslee WR. Depression in Mothers: More Than the Blues—A Toolkit for Family Service Providers. 2014, Washington, DC: Substance Abuse and Mental Health Services Administration. [On-line] http://store.samhsa.gov/product/SMA14-4878 .