Capitol Hill hears case for behavioral health prevention

How will the US realize the goal of the Affordable Care Act to shift the balance of medical expenditures from today’s imbalance of 97% treatment/3% prevention, to a 70%/30% balance by the end of this decade?  And, where might such a major effort begin?

These questions—and their answers—were at the core of a December 5 public policy forum, “Harnessing Community Support for Health and Well-being,” hosted by ACMHA—The College of Behavioral Health Leadership.  The forum was unusual because, after decades of functioning as a kind of industry think tank, ACMHA members took their discussion straight to a Senate briefing room on Capitol Hill. The goals of their three-hour briefing, whose audience included many Congresional staff, were  1) demonstrating that the research base for a sustained prevention effort is in place; 2) highlighting of the enormous role of family and community factors in long-term individual and population health; 3) arguing for active engagement of families and children in community educational and prevention programs, and 4) calling on Congress for greater latitude in using available resources for disease prevention work.

Tom Bornemann, PhD, the director of mental health programs at the Carter Center (Atlanta, Ga.) launched the briefing by suggesting that “health is about more than health care,” and that in order to understand public health challenges, it is vital to recognize that “people don’t live in a bubble,” and that basic behavioral, environmental, and social determinants play an enormous and unappreciated role in long-term health.  

Thanks to advances in knowledge, Bornemann asserted that it is now essential—for the US to “get past the point of playing catch-up” with public health problems. “We need to work upstream,” he said, suggesting that Congress help lead a new conversation about prevention that recognized the value of delivering research-based knowledge and prevention practices through innovative, engaging, and sustained community-based programs.

Public health problems rooted in childhood trauma

Vincent Felitti, MD, a clinical professor of Medicine at the University of California, continued the briefing by outlining the implications of the Adverse Childhood Experiences (ACE) study, which he co-authored. He began by juxtaposing a series of images. “What is it,” he asked, “that in a space of just 20 years, can transform the remarkable potential of a newborn like this into the reality of a homeless man lying in the street, like this?” Then, with images showing an obese woman at 408 lbs and the same woman, a year later, at 132 pounds following a medically-supervised fast, he asked what problem would cause this woman, after successfully losing more than 270 lbs, to regain 37 pounds in just three weeks, then go on to regain more than 400 pounds and disappear for 12 years before returning?”

The answer to both questions, he learned, was found in the detailed life histories of the individuals, specifically in After her sudden weight gain, the woman revealed a history of incest as a child. Subsequent detailed histories from 300 other individuals undergoing obesity treatment revealed a high prevalence of childhood abuse, neglect, or major family dysfunction. After sharing the findings with CDC researchers at an obesity treatment conference, Felitti joined with pediatrician Robert Anda, MD, to pursue a large-scale epidemiologic study to determine the prevalence of abusive or “adverse” experiences in childhood and their long-term impacts on life and health.  The study would come to include over 17,000 mostly white, middle and upper-middle class, college educated people in enrolled in a Kaiser-Permanente Health plan.

In 1995, the release of the ACE study results—which focused on 10 ACEs that were prevalent among the original group of obese patients (figure 1)—demonstrated a “startling” prevalence of ACEs among the general population (Figure 2). Felitti added that subsequent analysis showed that two of three individuals report at least one ACE and that when one is reported, there is an 87% likelihood that one more is present and a 50% likelihood that two more are present but unreported. Felitti noted that, regardless of category, the ACEs were found to be “essentially co-equal” in terms of their long-term health implications. 

Overall, he said that ACEs drive health risks to individuals in two ways:

·         by increasing individual’s likelihood of engaging in risky health behaviors (overeating, smoking, drinking, drug use, risky sex) and

·         by contributing to chronic stress that affects neurological and physical development by causing dysregulation of the body’s stress response and, over time, disruption of the molecular controls that modulate the expression of an individual’s genes.

Felitti explained that ACEs are readily detectable using simple ACE questionnaires and, once acknowledged, can contribute powerfully to the bond of understanding and trust between provider and patient and to the success of mental health and addiction treatment. But, history shows that ACEs usually go undetected because practitioners often fail to inquire about them. “These are difficult and uncomfortable issues to discuss with a patient,” said Felitti.  

More ACEs can make treatment less effective

Felitti went on to demonstrate the powerful correlation between high ACE scores and significant increases in health risk behaviors and health problems . As ACE scores increase (Figure 3), individuals are:

·         More likely to engage in negative or high-risk health behaviors

·         More likely to experience significant mental health or substance use disorders

·         More likely to experience physical health problems and chronic diseases

·         More likely to engage in domestic violence

·         More likely to die prematurely from suicide or chronic physical health problems

Based on the prevalence of ACEs in the general population, Felitti projected that “Every doctor in the US sees about two patients per day with ACE Scores of five or higher. These patients,” he asserted, “will be unrecognizable other than by the fact that they will likely be the most difficult and intractable cases of the day.”

These patients tend to be difficult to treat because their histories of trauma affect the way that they see health problems and solutions. Often, Felitti suggested, what appears to a provider to be the patient’s problem (e.g., smoking, obesity, teenage sex) is really the patient’s solution—the patient’s way of coping with the lingering impact of their adverse experiences (Figure 4).  He argued that without a thorough understanding of each patient’s ACE history conventional treatment of common public health problems is bound to fail. To make progress in care, he said that the provider must appreciate the patient’s trauma history and incorporate it into any effective treatment approach.

Linkage to to adult poverty

Felitti asserted that the damaging reach of childhood trauma extends into the workplace as well, noting that individuals with high ACE scores are less likely to succeed there as well. Pointing to measures of worker absenteeism and serious performance problems, which increased in line with ACE scores among those in the study (Figure 5), he stated that “toxic environments are real enough at some worksites, but are not nearly as prevalent as toxic childhoods among the workers.”  

Then, he pointed to a measure of serious financial problems, which also increased in line with ACE scores among study participants. Based on that chart, Felitti suggested that “the social and public-health problem of poverty can be reconsidered, less as a problem in itself than as an outcome of deeper causes.”  

Felitti concluded that “the ACE Study indicates that adverse childhood experiences are the most basic and long-lasting cause of health-risk behaviors, mental illness, social malfunction, disability, biomedical disease, and death.” He then called for wider collection of ACE histories from patients as a means of “finding a simple way to identify early mental health concerns before they progress into addictions, chronic diseases, and early deaths.”

Even as professionals seek out means of preventing or mitigating the disease-causing impacts of adverse childhood experiences, Felitti suggested a very simple intervention, available to any provider.  “Simply asking [about ACE history], listening, and accepting the patient’s reality is critical.”  A study found that when providers used this intervention, doctor office visits were reduced 35%. “The patients weren’t medically changed or healed, but they were less stressed, less worried about their problems,” he said.

After presentations about the key elements of highly effective community-based mental health and diabetes prevention programs in Philadelphia and in South Carolina, the audience shifted its focus to possible next steps for a longer-term, national prevention effort. 

Behavioral Healthcare will continue to follow the evolution of behavioral health prevention programs in future stories.