Letter about Healthy People 2010 Objectives

December 15, 1998

Office of Disease Prevention and Health Promotion
Hubert H. Humphrey Building, Room 738G
200 Independence Avenue S.W.
Washington, D.C. 20201
ATTN: Healthy People 2010 Objectives

Dear Sir or Madam:

On behalf of the American Psychological Association (APA), I am pleased to submit comments on the Healthy People 2010 Objectives. APA is the largest association of psychologists in the world, with 155,000 members and affiliates. Its goals are to advance psychology as a science, as a practice, and as a means of promoting human welfare.

The two main goals of Healthy People 2010 -- to increase quality and years of healthy life, and to eliminate health disparities -- are well chosen. You are to be congratulated on seeking to assess progress toward the first goal by a variety of different measures, including the use of Health Related Quality of Life (QOL) measures. The best of these scales integrate self-perceptions about physical and mental health, providing a great deal of information policymakers can use beyond the standard death and disease indices. QOL measures are now routinely a part of research grants in many parts of the National Institutes of Health, including the National Heart, Lung and Blood Institute, as well as in several health surveys sponsored by the U.S. Department of Health and Human Services (DHHS).

APA concurs wholeheartedly with the goal to eliminate health disparities. In this regard, our association has worked to increase the amount of NIH-sponsored research into the links between socioeconomic status and health, as well as racial and ethnic disparities in initiation of tobacco use and treatment of tobacco addiction. While it appears to be an ambitious target, it is achievable given sufficient resources toward basic and applied research; training, particularly of health providers in underrepresented groups; increased intergovernmental efforts (e.g., joint projects on violence prevention sponsored by DHHS and the Department of Justice); and sustained efforts of the Healthy People 2010 consortium.

The outline of the goals and objectives of Healthy People 2010 displayed in the figure on p.23 is clear and easily understood. It is especially gratifying for the APA that the objective, "Promote Healthy Behaviors" is displayed so prominently. As was mentioned in APA's comments last year, this association is spearheading an initiative for the President to designate the Years 2000 to 2010, "The Decade of Behavior." This initiative seeks to bring forward the contributions of behavioral and social science to address some of our nation's most pressing problems in health, safety and education. In each of those areas, HP 2010 is proposing to help change behavior on an individual or community-wide basis in order to improve the nation's health. Thus we see a fortuitous overlap in the objectives of the two initiatives, and hope to work closely with the Administration and the consortium to promote our sciences in the national interest.

Below APA provides more specific comments to many of the objectives included in the draft for public comment of the Healthy People 2010 Objectives.

4. Educational and Community-Based Programs

References to mental health and physical health should be intertwined throughout this chapter and throughout the report in general. Although there is a separate section on mental health, it is in the disease and disorder section. Mental health is a critical focus in overall health and is essential to quality of life as addressed in this chapter. More specifically, in the second paragraph of the Overview and in the Summary, mental health should be designated as a sector of the community. Mental and physical health should also be included under the Draft 2010 Objectives - Goal 2: Mental health education.

7. Injury/Violence Prevention

An additional goal should be added to address the availability of mental health resources for both victims and perpetrators of violence. Services should be available to aid in the resolution of any past occurrences, as well as to prevent future acts of violence. The attainment of this goal could be assessed in part through the collection of emergency services/health care provided to victims, as well as in prisons for perpetrators. It should also be noted that females are portrayed almost exclusively as victims in this report. This does not reflect the growing rate of violence among young women.

Media literacy should also be addressed in the context of risk factors for violence and more generally in the report regarding the influence of the media on health.

10. Access to Quality Health Services

The first objective under this section to "Reduce to 0 percent the proportion of children and adults under 65 without health care coverage" is a highly laudable goal, the achievement of which would greatly improve the lives of millions of Americans. Recent enactment of the State Children's Health Insurance Program (CHIP) will help to extend coverage to children whose parents are working but uninsured. In order to be effective, efforts to increase access to health services must address financial, cultural, language, and geographic barriers.

21. HIV

Condom use (p. 21-12). It is essential to develop and implement data collection methods for unmarried, sexually active women---particularly young women and women of color. Condom use requires the consent and cooperation of the male partner, and women---particularly young women--- cannot always successfully negotiate its use. Nonconsensual sex is a reality for too many women, therefore abstinence is not always an option. Research, development, and dissemination of female-controlled prevention methods (e.g., topical microbicides) are critically needed. In addition, behavioral research and effective education strategies that are culturally competent are urgently needed to address effective negotiation skills for women, particularly young women.

23. Mental Health and Mental Disorders

Throughout this section, it would be beneficial to shift the focus from the reduction of mental disorders to the promotion of mental health. The approach taken to address an issue in large measure frames the response. Approaching the issues from a health-based perspective might encourage the adoption of more creative and strength-building responses. It would also direct attention to individuals with less severe difficulties who are still in need of services. In so doing, attention would be directed to the full continuum of needs, from preventive intervention to treating individuals with severe mental illness who may be homeless or at risk of suicide.

Overview

Racial/Ethnic Differences (p. 23-4). More research is clearly needed to examine the epidemiology of mental disorders among racial/ethnic groups. Particularly given the growing diversity of our nation's population, it is essential to understand the prevalence and risk factors associated with various mental disorders. In this regard, ethnic and racial status has an impact on when and how individuals are identified for treatment, the manifestations of symptoms, patterns of help-seeking behaviors, and use of treatment (Kazdin, 1993). For instance, it is well documented that Latino families are less likely than white, non-Latinos to seek help from agencies and professionals (e.g., McMiller & Weisz, 1996). This relationship persists even when controlling for SES and insurance coverage, pointing to the likely role played by cultural and attitudinal factors (e.g., mistrust of health professionals) and service system barriers (Freiman & Cunningham, 1995). Thus, it is imperative to understand cultural values and meanings associated with mental health problems and their treatment to ensure that appropriate services are provided, accessed, and utilized.

Accordingly, APA suggests that item 9 on p. 12 be changed to read: "Require all States to have a plan to develop cultural competence within their mental health delivery system."

Gender Differences (p. 23-5, lines 3-16). While it is important to note that women outnumber men in many adult disorders, no mention is made that the reverse is true in childhood. The following sentences might be added: "During the early years, boys are at far greater risk than girls for many disorders, including learning disabilities, behavioral disorders, and ADHD. In fact, boys outnumber girls four to one in diagnoses of ADHD in childhood."

Children and Adolescents (p. 23-5, lines 18-39). It would be helpful to include care access and utilization objectives for children and adolescents. In this regard, it would also be useful for research purposes to increase the number of age categories for which data is aggregated to include the following: 10-14, 15-19, and 20-24 years. Furthermore, indices of resiliency and positive developmental outcomes for monitoring child and youth health objectives should be incorporated as well.

Comorbidity (23-6, lines 24-45). The following statement might be included in this section regarding comorbidity among children: (insert after line 39) "About 40-70% of depressed children develop an additional disorder, with 20-50% developing two or more comorbid diagnoses (Cicchetti & Toth, 1998)."

Draft 2010 Objectives

1. Suicide (p. 23-9). This goal is particularly salient for American Indian/Native Alaskan populations. For the past 15 years, suicide has been the second leading cause of death for 15- to 24-year-old American Indians and Alaska Natives. The suicide rate for this age group is 31.7 per 100,000, as compared to a rate of 13.0 per 100,000 for persons in this age group for all races in the U.S. population.

4. Developmental/Former 6.3 (p. 23-10, lines 31-48). Estimates are that 2.5% of children and 8% of teens experience clinical depression at any given time, with 15-20% of all children experiencing clinical depression before age 18 (Cicchetti & Toth, 1998). A desirable goal would be to reduce this rate by 50%.

        a. Eating Disorders (p.23-10). The specific objectives for eating disorders should include the following (references are provided below):

1. Decrease to at least 1% the proportion of girls and women in the nation who suffer from bulimia nervosa.

2. Decrease to at least .25% the proportion of girls and women in the nation who suffer from anorexia nervosa.

3. Decrease to at least 3% the proportion of girls and women in the nation who have atypical eating disorders.

Eating disorders are a growing public health problem. Although estimates of the prevalence of eating disorders exist, these numbers should not be considered definitive due to research limitations, such as differences between studies or problems with sampling, methods of assessment, and definitions of key concepts such as "binge eating." Additionally, many researchers conclude that eating disorders are most likely underreported, due to their connection with secretiveness and shame. The figures presented below are "point prevalences," i.e., they refer to the percent frequency for a given point or period in time.

Bulimia Nervosa (defined strictly in terms of frequent binge-eating and purging via use of self-induced vomiting and/or laxatives)
        among middle and high school girls -- 1-3%
        among college women -- 1-4%
        among community samples -- 1-2%

Anorexia Nervosa 
        among middle and high school girls -- .25 - 1%

Atypical Eating Disorders (defined as sets of signs and symptoms that are not extensive or severe enough to meet all the criteria for the "full syndromes" of Anorexia Nervosa or Bulimia Nervosa)
        among postpubertal females in the community -- 3-6%
        among middle and high school girls -- 2-13%

By combining these figures and keeping in mind the limits imposed by methodology, a conservative estimate of the percentage of postpubertal females affected by eating disorders (which cause significant misery and disruption in their lives) is .5 - 10% (e.g., .5% anorexia nervosa + 2% bulimia nervosa + 4% atypical eating disorder).

10. Developmental (training) (p. 23-13, lines 11-13). Mental health screening needs to include detection of child abuse. Reference could be made to the association between child abuse and later disorders, as follows: "Given the known connection between child abuse and later problems, such as depression, antisocial behavior, substance abuse, and social isolation, mental health screening should include basic questions designed to assist in the detection and treatment of child maltreatment."

We further suggest that the objective be changed to read as follows: "Require all primary care providers to be trained to screen and, when appropriate, make referrals to mental health providers for mental health problems of infants, toddlers, preschool children, school-aged children, and adolescents."

Additionally, the following statement should be added: "Require all primary care providers to be trained to offer information and make referrals for parent training that focuses on the mental health needs of infants, toddlers, and preschoolers."

12. (Former 6.13) (p. 23-14). This item should be changed to read: "Increase to 60 percent the proportion of primary care providers who routinely review with patients their cognitive, emotional, and behavioral functioning and make referrals to mental health providers to deal with any problems identified."

16. Developmental (p. 23-15, lines 1-17). It is not clear why this section on child mental health care focuses exclusively on ADHD or the basis for the prognosis figures. The section should also refer to the outcomes for anxious or depressed children who do not receive services, for example. Specific suggested wording changes are as follows: Beginning in the middle of line 12, replace "one third" with "some." In line 16, replace the sentence beginning "Effective treatment . . . " with "Empirically validated treatments exist for treatment of ADHD and for management of the symptoms associated with the disorder. These treatments are available for individuals of all ages. In addition to the successful programs for treatment of ADHD, there are many scientifically validated programs for the treatment of such critical problems as adolescent depression, conduct disorder, and enuresis. Effective treatment of these problems in childhood reduces the risk of later problems."

22. Developmental (23-17, line 1). This item should be changed to read: "Require all states to address services for individuals with co-occurring mental health and substance abuse disorders." There is a developing consensus that co-occurring disorders must be treated simultaneously. Within the Public Health Service, SAMHSA has been a leader in convening groups to address this issue.

26. Substance Abuse

The draft well describes the problem of substance abuse and its implications for American society. The objectives listed below could be stronger in relation to the importance of comprehensive and available treatment.

Means to Achieving Goals (26-8 to 26-21). Very ambitious goals to reduce substance abuse determinants or reduce substance abuse consequences are stated on these pages. Unfortunately, the prevention/treatment/rehabilitation modalities to achieve these goals receive little attention, beyond that included on p. 26-6 (lines 15-21). It is suggested that government agencies and provider organizations review these goals with an eye to developing specific prevention, treatment, and rehabilitation goals that can be implemented by federal, state, and private systems (that include health, justice, and the employment sector). Specific comments follow, but these need to be augmented as suggested above.

Substance Abuse and Workplace (26-24, l. 21). Substance abuse in, and affecting, the workplace is another important topic that needs more explication. Objectives for specific prevention/screening/treatment strategies need to be developed with close collaboration between employers and providers.

Substance Abuse and Criminal Justice (26-22 - 26-26). The repository of many substance abuse problems is the criminal justice system. This fact raises a number of issues that Chapter 26 might examine in more detail. The use of drug courts, the provision of substance abuse treatment, and follow-up in the form of treatment/rehabilitation after prison are topics that could benefit from a public health focus.

Community Partnerships (26-24, l. 41). DHHS should be commended for recognizing the importance of community partnerships and coalitions to conduct comprehensive substance abuse prevention efforts. It is suggested that the goal be broadened to include treatment as well. This would be particularly helpful in the areas addressed above (the criminal justice system and the workplace).

We appreciate the opportunity to respond to the Draft Goals for Healthy People 2010. I and my staff are available for any additional clarification on these comments. We look forward to working with you to help achieve these goals.

Sincerely,

Michael Honaker, Ph.D.
Deputy Chief Executive Officer

References

Cicchetti, D., & Toth, S.L. (1998). The development of depression in children and adolescents. American Psychologist, 53(2), 221-241.

Crowther, J. H., Wolf, E. M., & Sherwood, N. (1992). Epidemiology of bulimia nervosa. In J. M. Crowther, D. L. Tennenbaum, S. F. Hobfoll, & M. A. P. Stephens (Eds.). The etiology of bulimia nervosa: The individual and familial context (pp. 1-26). Washington, D.C.: Taylor & Francis.

Fairburn, C.G., Hay, P. J., & Welch, S. L. (1993). Binge eating and bulimia nervosa: Distribution and determinants. In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature, assessment, and treatment (pp. 123-143). New York: Guilford.

Freiman, M.P., & Cunningham, P.J. (1997). Use of health care for the treatment of mental problems among racial/ethnic subpopulations. Medical Care Research and Review, 54(1), 80-100.

Gordon, R. A. (1990). Anorexia and bulimia: Anatomy of a social epidemic. New York: Blackwell.

Hoek, H. W. (1995). The distribution of eating disorders. In K. D. Brownell & C. G. Fairburn (Eds.) Eating disorders and obesity: A comprehensive handbook (pp. 207-211). New York: Guilford.

Kazdin, A.E. (1993). Research issues in child psychotherapy. In Kratochwill, T.R., Morris, R.J., et al. Handbook of psychotherapy with children and adolescents. Boston: Allyn & Bacon, Inc.

McMiller, W.P., & Weisz, J.R. (1996). Help-seeking preceding mental health clinic intake among African-American, Latino and Caucasian youths. Journal of the American Academy of Child and Adolescent Psychiatry, 35(8), 1086-1094.

Shisslak, C.M., Crago, M., & Estes, L.S. (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18(3), 209-219.