Considering a public health approach: the public health framework might work well in addressing mental health and substance use problems.

The term "public health" is mentioned infrequently in mental health and substance use service circles. Hence, I took special notice when Terry Cline, PhD, administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), used this term in his remarks at the American College of Mental Health Administration's annual Santa Fe Summit. Dr. Cline said that public health may be a useful framework for addressing the problems our fields are confronting.

Public health is a population-based approach to tackling important healthcare issues, with emphasis on prevention efforts. Public health has had a long and successful history in the United States. The U.S. Public Health Service was created in 1798. PHS provided health checks to millions of immigrants who arrived at Ellis Island, and the PHS led the national response to the 1918 flu pandemic. Virtually every state and county has a public health department. Several of the federal agencies in the Department of Health and Human Services (the Health Resources and Services Administration, Indian Health Service, SAMHSA, and CDC) deliver public health services. The American Public Health Association advocates for better public health infrastructure. In a terrorist attack, avian flu pandemic, or natural disaster, state and local public health agencies would be among the first responders.

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Although some overlaps exist, mental health and substance use care differ from the public health model in several important ways. First, the mental health and substance use care fields principally are concerned with interventions that focus on the person rather than those that focus on an entire population. In effect, we work from the inside outward; public health works from the outside inward.

Second, with the notable exceptions of advances being made in substance abuse prevention and suicide prevention, the mental health and substance use care systems have little focus on prevention activities, either at a person or population level. By contrast, public health practice seeks to identify the causes of problems in populations and to eradicate them before they occur.

Third, public health looks at all of the health problems confronting a population, not just one or two of them. As a result of these differences, policy work in the mental health and substance use care fields tends to have an individual or subgroup focus that does not encompass an entire community or the full range of problems that a community is confronting.

What is it about public health infrastructure and practice that may make them particularly useful to the mental health and substance use care fields? Below I describe several attributes of public health worthy of emulation by the mental health and substance use care fields. Specifically:

* Most people understand public health. For example, they understand the role vaccination of an entire population plays in community disease prevention.

* Public health works with entire populations and communities. As a result of this broad focus, public health is able to identify the full range of health problems confronting communities and to create community collaboratives to address them.

* Public health recognizes that different communities have different problems. Importantly, as a result, solutions are adapted to these differences. A tradition of local "public health advocates" exists. These advocates work with local politicians, consumers, health professionals, family members, and community groups to arrive at consensus-based solutions to community problems.

* Public health identifies the source of a problem and seeks to eradicate it, preferably through prevention activities. Hence, the best care for an avian flu pandemic would be to prevent it in the first place through vaccinations of an entire population and a program of risk-reduction activities, such as hand washing and social distancing.

* Public health transcends particular disciplines and is comfortable with multidisciplinary approaches. Physicians, epidemiologists, public health officers, and information technology specialists can work together effectively on a common problem.

* Public health recognizes that the person holds the key to health. Hence, training is employed to improve knowledge so that one can better manage one's own health and disease.

* Public health measures outcomes. This strong measurement tradition promotes accountability and allows early modification of approaches when desired results are not achieved.

Public health gives our fields a prevention-oriented framework for linking community dynamics, disease, service response, and outcomes. This framework encourages us to intervene and change community dynamics that lead to health problems. It also can promote better understanding by members of the community about mental illness and substance use disorders.

Clearly, the public health model alerts us to identify the actual health problems of entire communities and to craft specific solutions that focus on the problems' causes. This can be done best by creating a broad-based community collaborative that spans the consumer, family, provider, social, and political groups in the community and that works with them to identify the sources of problems and practical solutions.

By focusing on causes, our fields will be designing systematic prevention and early intervention responses to community health problems. To do so effectively, we need to bring mental healthcare, substance use treatment, primary care, and social services expertise together with system design, information technology, and evaluation experts.

Consumer and family empowerment, including the development of skills to move out of poverty and into mainstream society, needs to be considered part of "our" work. Unlike today, a clear goal should be to help consumers and family members become more independent and self-sufficient so they no longer need ongoing service support. Finally, we must measure both problems and solutions. After all, if you do not measure it, you cannot address it.

I hope I have enticed you to take a look at the public health framework. It is community and prevention oriented, adaptable and collaborative, and consumer and family empowering. Our core concepts--wellness, recovery, and resiliency--are quite compatible with the public health model. Mental health and substance use issues are public health problems. The tools of public health will be useful in addressing them.

To contact Dr. Manderscheid, e-mail rmanderscheid@constellagroup.com.

BY RONALD W. WANDERSCHEID, PHD

ABOUT THE AUTHOR

Ronald W. Manderscheid, PhD, currently Director of Mental Health and Substance Use Programs at the consulting firm Constella Group, LLC, worked for more than 30 years in the federal government on behavioral health research and policy. He is a member of Behavioral Healthcare's Editorial Board.

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