Magazine article Behavioral Healthcare Executive

Capitol Hill Hears Case for Behavioral Health Prevention

Magazine article Behavioral Healthcare Executive

Capitol Hill Hears Case for Behavioral Health Prevention

Article excerpt

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 Dec. 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 goal of the three-hour briefing, whose audience included many Congressional staffers, was to demonstrate that the research base for a sustained, nationwide disease-prevention effort is available, that family and community factors play an enormous role in long-term health, and that engaging communitybased education and prevention programs are essential.

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 any individual's 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 recognizes 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 coauthored.

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 another question: "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 their exposure to traumatic events during childhood. When asked about the circumstances of her sudden weight gain, for example, the woman revealed a history of incest as a child. This experience led her to gain weight as a defense mechanism, a means to make her less attractive to her would-be abuser.

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 enrolled in a Kaiser-Permanente Health plan in California.

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 what Felitti called a "startling" prevalence of ACEs among the general population (Figure 2). …

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