Remarks by
A. Kathryn Power, M.Ed.
Director
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
A Public Health Approach to Suicide Prevention is Transformation in Action!
January 8, 2008
Kansas City, MO
Thank you Richard (Dr. Richard McKeon, coordinator of the SAMHSA/CMHS Suicide Prevention Initiative) for your kind introduction and for inviting me to join you this morning.
It’s a New Year and I believe it’s a new day for mental health in America. No longer are we content simply to treat an individual with a mental disorder after he or she becomes sick. At our Nation’s colleges and universities, no longer is it enough to have programs in place that respond after a student takes his or her own life. Science, experience, and public policy are all pointing us in a new direction, one in which promoting health and preventing disease are the cornerstones of a transformed system of care. You are the vanguard of a cultural shift that says, in effect, none of us is healthy unless all of us are healthy.
What I’ve just described to you—a focus on health promotion and disease prevention as it affects the community at large—is one of the basic tenets of a public health approach to mental health care.
We must examine and embrace a public health approach to mental health care because, unfortunately, it’s not a new day for Marc Strizzi, a kind, thoughtful, 17-year old high school senior who excelled at pole vaulting and was being recruited by a number of colleges. Marc jumped to his death from a highway overpass in Albany, New York, 2 weeks before Christmas. One of his friends told the local paper, “I can honestly say he’s the last person in the world I thought this would happen to.” But another student said that Strizzi—by all accounts not only a star athlete but a cherished friend—was also troubled. Young men like Marc Strizzi—full of promise and pain—are the reason we’re here today.
In the time I have with you this morning, I’ll address three questions that are critical to the work you do.
- The first question has two parts: what is public health and why do you need to care about it?
- The second question is what are some successful public health strategies for preventing suicide among college students? I’m pleased to be able to share some of the innovative work you are doing on campuses around the country.
- And the final question is perhaps the most important—what can you do to advance the understanding of mental health as a critical public health issue?
What Is Public Health?
Public health is at once a simple and profound concept. In a seminal 1988 report, the Institute of Medicine defined public health as “what society does collectively to assure the conditions for people to be healthy.” Public health engages both private and public organizations and individuals in accomplishing this mission.
Work by a group of U.S. Public Health Service agencies and major public health organizations in the mid-1990s defined three core functions of public health as:
- The assessment and monitoring of the health of communities and populations at risk to identify health problems and priorities;
- The formulation of public policies designed to solve identified local and national health problems and priorities; and
- The assurance that all populations have access to appropriate and cost-effective care and evaluation of the effectiveness of that care.
Perhaps one of the best ways to understand public health is to compare it to clinical care, which focuses on the treatment of individuals as opposed to whole communities. Doctors usually treat individual patients one-on-one for a specific injury or illness. Public health professionals monitor and diagnose the health concerns of entire communities and promote healthy practices and behaviors to ensure that our populations stay healthy. Indeed, the underlying premise of the public health model is simply this: it is inherently better to promote health and to prevent illness before an illness begins.
This is not only humane; it may be cost-effective, as well. In a 2002 update on the public health of our Nation, the Institute of Medicine notes, “the vast majority of health care spending, as much as 95 percent by some estimates, is directed toward medical care and biomedical research. However, there is strong evidence that behavior and environment are responsible for over 70 percent of avoidable mortality, and health care is just one of several determinants of health.” As my boss, SAMHSA Administrator Terry Cline, likes to say, we need to focus our money and our efforts upstream rather than waiting for folks to fall in the river.
But why should any of this matter to us as mental health professionals? Certainly, we’re all familiar with some of the major public health achievements of the last century. Vaccines and antibiotics have made once-life threatening diseases preventable or less serious. Our homes, workplaces, and automobiles have become safer. Tobacco is now recognized as a serious health hazard, and since 1972, death rates for coronary heart disease have decreased by 51 percent.
These changes came about because scientists, policymakers, and citizens recognized that health is multifaceted and is impacted by broader social, economic, and environmental factors. In short, as I noted earlier, we are all healthy when each of us is healthy. We know the risks of second-hand smoke. We understand it is not safe to drink and drive. We get our flu shot each year.
Indeed, as former Surgeon General C. Everett Koop pointed out, “Health care is vital to all of us some of the time, but public health is vital to all of us all of the time.”
The emphasis on a public health approach to mental health, rather than on the treatment of individuals with serious mental illnesses, has increased as more Americans have come to understand that mental health is essential to overall health. Within the more inclusive public health context, all individuals within a community—whether that community is a college or university, a neighborhood, or a Nation—are affected by the health of its individual members. We simply cannot afford to ignore the mental health and substance abuse needs of any of our citizens—including and most especially our young people—if we want to have healthy campuses, healthy neighborhoods, and a healthy Nation.
We know that when measured across all age groups, mental illnesses are the leading causes of disability worldwide. Five of the top 10 diseases associated with significant disability and disease burden are mental illnesses. We also know that half of all diagnosable lifetime cases of mental illness begin by age 14, and three-fourths of all lifetime cases start by age 24.
We recognize that our Nation’s most dramatic and measurable consequence of undiagnosed, untreated, or inadequately treated mental health problems is suicide. Suicide claims the lives of more than 31,000 American adults and children each year and is the third leading cause of death for youth ages 15 to 24.
Our college students may be particularly vulnerable. In the 2006 National College Health Assessment, 44 percent of the students surveyed reported that they “felt so depressed it was difficult to function” during the past year, and 9 percent said that they had “seriously considered suicide” during the year.
Depression or other mental health conditions may manifest for the first time during college, when students are dealing with academic pressures, living away from home, and handling new financial responsibilities and relationships. Some students may arrive on campus with pre-existing mental health needs that often are undiagnosed. Still others students with mental health problems—who in the not so distant past might have been unlikely to attend college—may be struggling with their recovery.
Clearly, if we felt we couldn’t make a difference in these students’ lives, we wouldn’t be here today. In fact, science has triggered dramatic changes in the way we think about behavioral health. Once believed to be debilitating, lifelong conditions, mental disorders are now understood to be as treatable as most physical illnesses. Today—given the right combination of treatment and support and a voice in decisions concerning their care—individuals with mental and substance use disorders can and do recover.
But why wait until problems arise before we offer help? Suicide is a preventable tragedy.
The public health model is well suited to help promote an individual’s recovery and prevent negative consequences. It recognizes that mental health does not reside solely in the individual but also within the web of interactions among the individual, the family, the school, the neighborhood, and the community in which he or she lives. In particular:
- Recognizing that mental health and substance use problems can lead to other health and social problems, a public health approach is holistic, taking into consideration all aspects of the individual’s wellbeing.
- Public health seeks long-term solutions that are best achieved by high-quality care before symptoms and co-occurring conditions become severe. Accordingly, prevention is as important as treatment.
- Public health employs evidence-based practices and always measures outcomes.
- Finally, a public health model focuses treatment and care on the needs of the individual, but also develops interventions for the entire population.
In essence, public health is mental health transformation in action!
What Are Some Successful Public Health Strategies?
Once we understand and accept the fact that mental health is essential to overall health, and that a systemic rather than individual approach can be highly effective, we can adopt or adapt some successful public health strategies to promote health and prevent suicides among our college students. I’d like to highlight three such strategies today, under the general themes of prevention, communication, and collaboration.
Prevention
In the second century B.C., the Chinese philosopher Liu An wrote, “A skillful doctor cures illness when there is no sign of disease, and thus the disease never comes.” In the process of transforming our mental health system to be client-driven, recovery-focused, and evidence-based, we must come to see that prevention is a cornerstone for our new system—not an afterthought. This is one of the reasons SAMHSA is fully committed to full implementation of the National Strategy for Suicide Prevention, which is a dynamic public-private partnership that makes suicide prevention the public health priority it deserves to be.
At SAMHSA, we take a broad view of prevention. We believe, as does the Institute of Medicine, that it is important to prevent the onset of a disorder. However, we also understand, as the National Institute of Mental Health has noted, that prevention can also apply to interventions that prevent comorbidity, relapse, disability, and the consequences of serious mental illnesses for individuals and families. In fact, I like to think of treatment that reduces the likelihood and severity of future mental health problems as prevention-minded treatment. If we can identify and address the symptoms of a mental health problem when a student presents to the health center with unexplained symptoms, we’re practicing prevention-minded treatment.
The corollary to prevention-minded treatment is treatment-minded prevention. It is essential that those who are implementing prevention programs at our colleges and universities have good relationships with mental health clinicians on campus or in the community so they can help students who are exhibiting symptoms of a mental illness get whatever treatment services they need.
This is exactly what occurred when a resident advisor (RA) at the South Dakota School of Mines and Technology in Rapid City found a freshman crying uncontrollably in her dorm. The RA, who was trained as a gatekeeper, took time to visit with the student and found out that she feeling very depressed, homesick, and suicidal. The RA took her to the residence hall director and together they walked her to the counseling office where she received in-house counseling for several sessions.
I know this scene has played out on every campus represented here today. Not only is this treatment-minded prevention, this is transformation in action!
Another important concept related to promotion and prevention is “resilience.” The term “resilience” has its origins in physics and architecture. To be “resilient” means that a building material, such as tempered steel, has the ability to withstand stress.
This same term has been adapted to describe a person’s ability to face the challenges of life. Resilience often is defined as “the ability of a person to spring back from and successfully adapt to adversity.” It means that an individual can withstand stress, adapt, adjust and continue to function well.
Resilience is not a static trait. Rather, resilience in a person is dynamic and varies across time and life domains, including relationships, academic and professional life, and health. Individuals do not develop resilience by “pulling themselves up by their bootstraps” when faced with life’s challenges.
Instead, resilient adaptation to adversity comes about as a result of characteristics of an individual interacting with resources in the environment. Students who are educated and empowered to make healthy choices, and who know where and how to find help when they need it, can be as strong as tempered steel.
Howard University in Washington, DC, is helping its students develop healthy coping skills by requiring those who attend the annual springtime “Notorious Before Break Party” to show proof they have visited at least five tables with health-related information before they are allowed to eat! The tables feature such topics as responsible dating, sexually transmitted diseases, domestic violence, depression screening, recognizing signs of a suicidal crisis, knowing when and how to refer someone for help, and responsible drinking and staying sober. Students who know that there are healthy options and that their choices will be supported will have an easier time withstanding the inevitable stresses of college life.
Communication
Educating students about healthy choices is also a key component of the next strategy I want to highlight, which is the importance of communication.
I know you’ll be getting an update on Thursday about lessons learned from the tragic shootings at Virginia Tech. Directly following the incident, the President asked the Secretaries of Health and Human Services and Education and the U.S. Attorney General to meet with educators, mental health experts, law enforcement, and State and local officials across the country to discuss the broader issues raised by this tragedy. Among their findings, which they presented in a special Report to the President, was the fact that improved awareness and communication are key to prevention.
The group that advised the Secretaries and the Attorney General noted that parents, teachers, and students need to understand the warning signs of mental health problems and encourage individuals who need help to seek it. To do so, participants in the community meetings stressed the need to promote cultures of trust, respect, and open communication; to reduce student isolation; to normalize the act of seeking help; and to promote sound mental health by destroying stereotypes and myths regarding these illnesses.
We can’t underestimate how powerful discrimination and isolation are in keeping our students from seeking treatment for mental health problems. Results of SAMHSA’s annual National Survey on Drug Use and Health reveal that the prevalence of serious psychological distress is high among young adults ages 18 to 25, yet this age group shows the lowest rate of help-seeking behaviors.
To help send the important messages that mental health problems are nothing to be ashamed of and treatment is effective, SAMHSA has launched the Campaign for Mental Health Recovery. Aimed at young people ages 18 to 25, the campaign theme is “What a Difference a Friend Makes.” Our goal is to encourage young people to support their friends who are experiencing mental health problems.
The Campaign includes public service TV and radio ads and print materials. I know many of you saw the PSAs at last year’s conference, and we’re delighted to know that some grantees are using them.
If you haven’t seen them, I would encourage you to visit the Campaign’s Web site at www.whatadifference.samhsa.gov, where you can view the television spots and hear the radio ads.
As part of a targeted college outreach effort this fall, which was one of the recommendations in the Report to the President on Virginia Tech, we distributed 500,000 informational materials to incoming college freshman around the Nation. We are also distributing a community outreach toolkit about the campaign to 1,100 campuses. The toolkit includes all of the TV and radio spots in English and Spanish, as well as print ads, fact sheets, and information for working with the local media. We have arranged to have these kits sent to each of you, as well.
We don’t have to look any further than the group in this room to know how successful a communications strategy can be. At the University of California at Irvine, the social marketing campaign “Don’t Erase Your Future” uses quotes from prominent individuals—such as Albert Einstein, William Shakespeare, Rosa Parks, and Marie Curie—and asks the unsettling question, “What if they had committed suicide?” The campaign also includes information about the personal and not-widely-known struggles these individuals overcame, such as the fact that Albert Einstein failed his college entrance exam and William Shakespeare had relationship difficulties.
The campaign, which you can view online at www.donteraseyourfuture.org, was launched with a chalk art demonstration where UCI students drew portraits of the historical icons featured in the campaign. Student artists worked most of the day, and project staff distributed informational items during the demonstration. A few days later, staff received an e-mail from a counselor who saw a suicidal client that day. The client commented that she “had felt less suicidal after she ran into the drawings of Martin Luther King and Marie Curie. She said that it gave her some hope when she read the quotes about what would have happened if they were not alive.”
This truly is transformation in action!
Collaboration
Finally, I want to touch on the importance of collaboration. No one individual or agency, public or private, can do this hard work alone. Public health is, first and foremost, community health, and the community must be engaged and educated about its importance.
One area of collaboration that’s vitally important is the link between behavioral and primary health care. I’m reminded that no less an authority than Hippocrates, widely credited as the father of medicine, believed that the mind and the body are one.
A wealth of research supports the concept that behavioral health is inextricably linked to overall physical health. Sadly, we know that the life expectancy for individuals with serious mental illnesses is about 25 years less than that of the general population. The increased morbidity and mortality are largely due to treatable medical conditions that are caused by modifiable risk factors, including smoking, obesity, substance abuse, and inadequate access to medical care.
Higher rates of acuity of health conditions result in personal suffering and loss and greater health costs to the Nation. Clearly, we must attend to both mental and physical health as good stewards of public health on our campuses and in our communities.
Participants in the community meetings that framed the Report to the President on Virginia Tech stressed the importance of integrating primary care and mental health services. Unfortunately, on many college campuses, even when the student health service is in the same building as the counseling center, the two aren’t integrated and don’t share responsibility for patients or patient records.
In the broader community, we know that many individuals are more likely to visit their primary care physician than to see a specialty mental health provider. In fact, data suggest that primary care physicians are responsible for about 50 percent of all office visits during which antidepressants are prescribed. This is one of the reasons SAMHSA is involved in a number of activities that aim to strengthen the capacity of primary care providers to identify, refer, or provide treatment for mental disorders and that support the concept and practice of wellness for consumers of mental health services.
At Arizona State University, the Counseling and Consultation Office and the Wellness and Health Promotion Office, together with the Campus Health Service and Campus Recreation, are part of the Live Well Network, which provides integrated medical, psychological, physical fitness, and wellness programs and services. On the Tempe campus, the Counseling and Consultation Office provides oversight for the campus suicide prevention grant, and the Wellness and Health Promotion Office coordinates day-to-day implementation.
Wellness and Health Promotion staff have expertise in using the public health approach to prevention and the infrastructure to produce educational materials and posters; plan, implement and evaluate awareness activities; provide training sessions; and implement peer education programs. The Counseling and Consultation Office has expertise in responding to depression and suicide. By working together, these two campus offices that impact students’ lives are able to blend their professional training and expertise to yield stronger outcomes. This is transformation in action!
What Can You Do to Promote a Public Health Response?
When I began my remarks, I said the most important question I would try to address is “what can you do to advance the understanding of mental health as a critical public health issue?” First and foremost, I think each and every one of us, and I count myself among you, has to be willing to embrace a new way of thinking about mental illness, about mental health transformation, and about the roles we’ve been taught to play.
The movement toward a public health perspective on mental health requires both the belief that mental health is essential to overall health and that society as a whole must take part in transforming an individual disease-based model into a systems approach to ensuring health. But more than that, it requires a new way of thinking that challenges us to move beyond our clinical education to examine the broader implications of what we were trained to do.
If you’re like me, you got into this line of work to help individuals. And we must hold onto the best of our clinical training because it helps us understand why people think and feel and behave as they do. Moreover, there will always be individuals in need of clinical services.
However, we have to expand our horizons to embrace the truth in John Donne’s classic observation, “no man is an island.” We must be willing and able to consider the mental, emotional, behavioral, spiritual, and physical health of an individual as the cornerstone of good public policy. I know this likely runs counter not only to your own professional background but also to what others on your campuses expect from you. You were hired to treat students not change systems. Yet a college or university is a wonderful environment in which to advocate, collaborate, and yes perhaps agitate. Change is not always easy, but when students’ lives are at risk, adhering to the status quo is not an option.
In short, what I’m asking you to do is to lead the charge for systemic change that sees transformation of the mental health system as a public health imperative that literally saves lives.
Kerry Knox, a University of Rochester researcher who worked with David Litts of the Suicide Prevention Resource Center and others to design an effective suicide prevention program for the Air Force, believes that a key factor in the program’s success is its history of being championed by three-star and four-star generals. Knox is now working with MIT and five other universities to evaluate how parts of the Air Force program can be implemented on a university campus. I know that some of you are using the Air Force model on your campuses and are looking forward to Knox’s findings.
We need you to be the three-star and four-star generals on your campuses and in your communities.
We need you, as Terry Cline has said, to be “messengers of hope, teachers of prevention, builders of resilience, and architects of improved service systems that push onward toward a whole health approach.”
Finally, we need you to never lose sight of your goals and dreams, so that our students will never let go of theirs. It was Robert F. Kennedy who said:
Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope…and crossing each other from a million different centers of energy and daring those ripples build a current that can sweep down the mightiest walls of oppression and resistance.
Thank you for sending forth tiny ripples of hope as you strive to ensure that no student ever feels so alone that he or she considers suicide a viable option. We have much to gain, and everything to lose, if we don’t persevere in this important work.
But with your energy and leadership we will persevere.
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