| Terrorist Attacks Seen Generating ‘Unique Mental Health Needs’
The U.S. Senate Subcommittee on Public Health in a hearing called two weeks after the September 11 terrorist attacks, said the nation should mount "a comprehensive strategy to determine whether these assaults and others possible in the future generate unique public health needs." The Department of Health and Human Services has recognized the need to add mental and behavioral health services to our response to the traumatic occurrence, said subcommittee member Senator Bill Frist (R-TN). He cited $28 million made available by HHS for mental health services and assessment of the long-term needs of the affected states, plus another $21.2 million to further supplement the existing mental health systems in the affected areas. But the unprecedented media coverage of the events of September 11 and the ongoing nature of terrorist threat set this apart from any previous incident in gauging reliably the extent of mental health needs that might result, not only in the immediate areas but in communities across the country, Michael Faenza, president of the National Mental Health Association, told the subcommittee. "We are particularly concerned that those most affected may be the nation’s children—not only those who were affected directly but also those living throughout the country who experienced the tragedy through television and the worried expressions of their parents and other adults in their lives. Unlike adults, children have little experience to help them place the disaster into perspective." Studies conducted following the Oklahoma City bombing showed that sixth graders who lived 100 miles from Oklahoma City, knew no one involved, and only witnessed the event on television experienced post-traumatic stress disorder symptoms and functional impairment, Faenza pointed out. "It is likely that the prevalence of mental health disorders among children and adults throughout the nation will increase markedly" in the wake of the current attacks, and the country does not have the mental health structure in place to cope with that increase, he cautioned. Faenza proposed that Congress immediately provide funds, in the 2002 appropriation for the Department of Health and Human Services, for grants to help communities develop coordinated efforts across systems, including public health and education, to enable early identification and treatment of mental health problems. But those funds shouldn’t come from existing programs that serve children and adolescents with chronic mental health needs, he emphasized, since children with pre-existing mental health problems can be particularly vulnerable to the effects of traumatic stress. Senator Frist, a physician, noted that he is cosponsoring legislation
in this session of Congress to asure equitable treatment for mental
health in insurance and services. "Going forward, our private mental
and behavioral health system must also be strengthened," he said.
"We must work together to develop a comprehensive strategy to address
the ramifications of this tragedy as well as to prevent and prepare
for any future terrorist attacks. As part of this effort, let us commit
ourselves to strengthening our ability to respond to mental and behavioral
challenges arising out of future crises." Cost-Effectiveness of a School-Based Smoking Prevention Program In life years saved and medical costs saved, a school-based tobacco use prevention program was highly cost-effective compared to other widely accepted prevention interventions, according to researchers who reported their findings in the September issue of Archives of Pediatrics and Adolescent Medicine. "School-based prevention programs of this type (a curriculum to counteract social influences and misconceptions that lead to tobacco use) warrant careful consideration by policymakers and program planners," said researchers from the Centers for Disease Control and Prevention and the University of Southern California at Los Angeles. The 10-lesson intervention curriculum—the program used was Project Toward No Tobacco Use (TNT)—was delivered by trained health educators to a cohort of 1,234 seventh-grade students in eight junior high schools. A two-lesson booster session was delivered to eighth-graders in the second year. The efficacy evaluation was based on 770 ninth-grade students who participated in the seventh and eighth grades and in both the baseline and a two-year follow-up survey. The direct costs of the combined intervention included 120 hours of training for nine health educators at an hourly rate of $10, plus $500 per day for the master trainer who conducted the training. The health educators then worked eight weeks each at an hourly rate of $10 for eight hours (5-6 for teaching, 2-3 for preparation). Each health educator received a copy of the teacher manual, which cost $45, and each student received a student guide that cost $3.69. Total intervention cost was $16,403 ($13.29 per student). . Hw much the intervention may have saved in dollars was calculated by applying "smoking progression" models to assess the likelihood that "experimenters" (had ever smoked a cigarette), current smokers, or current nonsmokers would become "established" smokers by age 26. Using conservative parameters, the researchers decided that 34.9 of the 770 students were prevented by the intervention from becoming established smokers. Based on studies that show the average cost of medical care for a smoker over a lifetime is $9,379 more than for a nonsmoker, the researchers pointed out that preventing 34.9 students from becoming smokers saved tens of thousands of dollars in medical expenditures alone. There were also savings to society from preventing premature deaths and increasing the quality of life—avoiding hospitalizations and disability, for example—with those benefits estimated at $2,770 per life year saved. The study is believed by its authors to be the first ever to examine the cost-benefit of school-based smoking prevention programs. But as more school-based programs demonstrate effectiveness in preventing smoking, it will be increasingly important to study their cost-effectiveness, they point out. The study, "Cost-effectiveness of a School-Based Tobacco-Use
Prevention Program," was published in the September 2001 issue
of Archives of Pediatrics and Adolescent Medicine. Reprints are available
from Li Yan Wang, lgw@cdc.gov. Concerned that current efforts to expand the State Children’s Health Insurance Program (SCHIP) to include parents might reduce the funds available to insure children, Senator Chris Bond (R-MO) asked the General Accounting Office to investigate SCHIP enrollment and funding through fiscal year 2000. The GAO reported that:
Expanding the SCHIP program beyond children is an issue of ongoing interest, the GAO noted, partly because some analysts believe that providing health insurance to parents may lead to increased coverage for children. The SCHIP statute allows a state to enroll parents of eligible children if the state can show that it’s cost-effective to do so, but the cost-effectiveness test (proving that the cost of insuring both adults and children in a family does not exceed the cost of insuring only the children) is hard to pass. Congress enacted SCHIP in 1997 to reduce the number of low-income uninsured children in families with incomes that are too high for Medicaid. The appropriation for 10 years (1998 through 2007) is $40 billion, with the federal funding distributed to states on a formula based on the number of low-income children in a state. SCHIP generally targets children in families with incomes up to 200 percent of the poverty level (that would be $35,000 for a family of four in 2001), but 13 state programs cover children in families above that income level. The GAO report, "Children’s Health Insurance: SCHIP Enrollment
and Expenditure Information," which includes state-by-state expenditures,
can be read online at the GAO website, www.gao.gov.
Click on "GAO Reports" and scroll to September 7, 2001. How the suicides of terrorists who died in attacks on the World Trade Center and the Pentagon will affect young people in the United States is as yet unknown, but in a congressional hearing held ironically just four days before the attacks, psychologists, bereaved parents, and the U.S. Surgeon General confirmed the grim statistics about youths who take their own lives in this country and suggested some ways to identify those children and prevent their self-destruction. First of all, said psychology professor David Jones of Catholic University in Washington, D.C., it’s important to realize that many young people who commit suicide do not really want to be dead. "There are many motivations and goals inherent in youthful suicidal behaviors, such as attention-seeking or trying to change a seemingly intractable situation. We know that 90 percent of youths who kill themselves have identifiable psychological, social, and familial problems that can be helped with appropriate identification, referral, and treatment." We also know, Jones pointed out, that more than 80 percent of youths who die by suicide tell other people of their intentions, and that those people do not take the communication seriously and fail to intervene. And though we do not know nearly enough about what prevents youth suicide, he said, "At this point I am pleased to report that there are some encouraging preliminary data about the suicide prevention role that thoughtfully developed school-based prevention programs can have in their emphasis on skill-building, problem solving, and coping with strong emotions." From a clinician’s viewpoint, Jones said, "Let me tell you what it is like to look into the eyes of a 14-year-old boy who has suicide on his mind. First, it is hard to make eye contact—most young people I see do not trust adults, especially a clinical psychologist. So, it takes a great deal of skill and dogged determination to make a connection with a suicidal young person. If I am lucky, I start to find a link—it may be music, sports, or a vague discussion about school or parents. In my experience, in that first glimmer of a relational link with a teenager there is almost always hope because these kids are almost always seeking something we all seek. They are seeking a relationship—not a pill, not a boot-strapping lecture from yet another adult, and certainly not pity; they simply want a real and genuine friendship with someone who might just actually care about them for who they really are." A high school student who lost friends to suicide told the hearing that students in his school developed a "Yellow Ribbon Suicide Prevention Program" with a simple message "It is okay to ask for help." The biggest problem the program runs into is adults, Stan Collins said—"they still don’t like to say the ‘s’ word, and they believe all the myths about suicide, number one being ‘talk about suicide and you’ll cause one.’" Instead, the student-run program encourages young people to talk to one another about suicidal thoughts, on the premise that "talking about suicide is the first step to breaking down the terrible isolation that a person considering it feels." Surgeon General David Satcher testified that suicide remains the third leading cause of death in the United States for young people between the ages of 10 and 24, the second-highest rate of firearm-related suicide and the 12th highest rate overall among the wealthiest nations. A study by federal agencies found that 15 percent of school-related deaths are suicides. Few studies have examined protective factors for suicidal behavior in young people, though both family- and school-connectedness are believed to be protective. Biophysical risk factors, Satcher said, include mental disorders, especially mood disorders such as schizophrenia and anxiety; alcohol and other substance abuse disorders; hopelessness; impulsive and/or aggressive tendencies; history of trauma or abuse; some major physical illness; and a family history of suicide. Sociocultural risk factors may include lack of social support and a feeling of isolation; stigma associated with help-seeking behavior; barriers to accessing health care, especially mental health and substance abuse; and exposure, including through the media, to others who have died by suicide.
A new publication from the attorney general, A National Strategy for
Suicide Prevention: Goals and Objectives for Action, suggests formation
of a public/private group in a community to explore ways to provide effective
mental health support to schools and urges increasing the number of school
districts in which school-based clinics incorporate mental health and
substance abuse assessment and management into their scope of activities.
The 200-page report is available online at www.mentalhealth.org/suicideprevention
or www.surgeongeneral.gov/library
or may be requested by telephone at 1-800-789-2647, reference document
number SMA 3517. WORTH NOTING Schools Report Little ADHD Drugs Diversion, Abuse An investigation by the U.S. General Accounting Office that questioned only principals in junior and senior high schools concluded that there is little diversion or abuse of Ritalin or other drugs that are dispensed to students at school to control attention deficit disorder. The GAO didn’t extend its inquiry to elementary schools because it was assumed that elementary-age children are less likely than older students to sell or trade ADHD drugs or to abuse them. In the middle and high schools surveyed, the GAO found 8 percent of principals knew of ADHD drug diversions in their schools during the first nine months of school year 2000-2001, most reporting only one incident. Medications are kept locked in 96 percent of the schools, according to principals, and students are observed while taking their medication. The GAO report, "Attention Disorder Drugs: Few Incidents of Diversion of Abuse Identified by Schools," can be read online at www.gao.gov. Click on "GAO Reports" and scroll to September 17. FDA Sites Update Drugs Information
The federal Food and Drug Administration has added two new Internet sites of interest to health care professionals. A "Drug Shortages" site lists drugs that are in limited supply, gives the reasons for the shortage, and advises practitioners how to obtain such scarce products. The "Human Drug Advisory Committees" site contains transcripts of FDA advisory committees’ discussions of new drugs submitted for the agency’s approval, with briefing documents and the addresses of committee members. The site also lists upcoming advisory committee meetings. Both sites can be accessed at www.fda/gov/cder. Information on drug withdrawals can also be found there. Prescribing Oral Contraceptives When asked what oral contraception they would prescribe for younger patients, 37 percent of doctors polled in a 2001 survey by Contraceptive Technology said their first choice of nonformulary oral contraceptives for the younger age group would be Ortho-Tri-Cyclen. Thirteen percent name Alesse as their first choice, 11.7 percent said Ortho-Cyclen, and 14 percent said "other." The providers said that more than half their patients of all ages use oral contraception. AAP Cites Inadequate Funding of Child Drug Abuse Services
In a policy statement released October 1, the American Academy of Pediatrics charged that inadequate private and public funding prevents many drug-abusing children and adolescents from receiving appropriate treatment. The statement cites restrictive benefits under private insurance plans and failure of states to provide adequate reimbursement for drug abuse prevention, assessment, and treatment under Medicaid . The AAP urges expanding drug abuse treatment to alternative sites, including schools, and expanding the Early and Periodic Screening, Diagnosis, and Treatment program to include drug abuse detection and referral for treatment. The AAP statement appeared in the October issue of the journal Pediatrics. Resources The following information was referenced in the News Alerts section of this website during the month of September: The National Center for Health Statistics September 10 released its 25th annual statistical report on the nation’s health. Highlights of the report are available via Acrobat Reader at http://www.cdc.gov/nchs/products/pubs/pubd/hus/highlits.htm.The full text of the report, "Health, United States, 2001, with Urban and Rural Health Chartbook," is available online at www.cdc.gov/nchs. The Centers for Disease Control and Prevention September 19 released the findings of the School Health Policies and Programs Study (SHPPS) 2000, a comprehensive assessment of school health programs at state, district, school, and classroom levels nationwide. The report is published in the Journal of School Health and can also be read on the CDC web site at www.cdc.gov/shpps. Tables include data on schools with security policies, the percentage of schools with mental health or social services staff development, districts that require screening with follow-up, information kept in student records, and states or districts offering staff development for school nurses. |