Resilient health april 2018 by Resilient Health

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A NATIONAL BEHAVIORAL HEALTHCARE SYSTEM PATIENTS TREATED:

TREATMENT SERVICES FOR:

• Adolescents (12-17 years) • Adults

• Primary Mental Health • Substance Use • Dual Diagnosis • Pain • Cognitive Deficits • Trauma and Emotional Dysregulation • Adolescent and Adult Eating Disorders (Females Only) • Adolescent Transgender and Gender Identity

LEVELS OF CARE: • Detox • Residential Treatment • Partial Hospitalization Program • Intensive Outpatient Program • Outpatient Program • Continuing Care

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April 2018

RESILIENT Health

MESSAGE FROM THE EDITOR Welcome to the April Issue.................................................... 4

FEATURE ARTICLES Measurement-Based Care Improves Treatment Outcomes................................................................................ 5

RESILIENT HEALTH is published monthly and copyrighted by Sovereign Health, Inc., all rights reserved. Permission must be granted by the publisher for any use or reproduction of the magazine or any part thereof. Opinions expressed are those of the authors alone and do not necessarily represent the opinions, policies or positions of RESILIENT HEALTH or Sovereign Health, Inc. ©2018, Sovereign Health, Inc. Printed in the U.S.A. Editor-in-Chief TONMOY SHARMA, MBBS, MSc Communications Manager LISE MILLAY STEVENS, M.A. Managing Editor EDWARD ZINTEL e.zintel@sovhealth.com Senior Staff Writer DANA CONNOLLY, Ph.D. Graphic Designer VINOD SHARMA Content Specialist AMIT MALAVIYA

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Treating Depression with Measurement-Based Care.... 9 Depression and Anxiety: Two Conditions That Go Hand in Hand ......................12 Is Collaborative Care the Game Changer on the Opioid Battlefield?..............................................................16 THE QUIZ CORNER: Binge Eating Disorder....................19 The War on Behavioral Health Care: Financial Feuds ...................................................................21 Professional Perspectives: For Better or Worse, Technology Is Changing Behavioral Health Care Delivery.....................................25 Eating Disorders: Be on the Lookout for Eating Disorders in Female Patients...................................................................29 10 Myths About: Eating Disorders........................................................................ 32 At A Glance: Behavioral Health In The News.......................................... 35

RESILIENT HEALTH A Behavioral Health Resource from Sovereign Health Publications, Inc. 1211 Puerta Del Sol, Suite 200 San Clemente, CA 92673 Editorial Tel: (949) 276-5553, ext. 391 Email: editor@reshealth.net Website: www.reshealth.net

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RESILIENT HEALTH | April 2018 3

Message

from the Editor

elcome to the April issue of RESILIENT HEALTH! Alcohol Awareness Month is celebrated all this month; it was founded by the National Council on Alcoholism and Drug Dependence with the goal of reducing the stigma of this very serious disease by encouraging communities to reach out to and educate the public about alcoholism and recovery. Alcoholism is a chronic disease that can, with professional help, be treated; thousands of people recover every day and an estimated 20 million people in this country are currently in recovery. Please join us and NCADD in educating others about alcoholism and removing the stigma of this disorder so that more people feel free to step out of the shadows and find the help they desperately need. This month’s issue is chock-full of information and food for thought. Is collaborative care the silver bullet in combatting the growing U.S. opioid epidemic? Find out how this novel treatment approach uses patient-centered teams to provide a 360° treatment experience based on evidence-based practices and coordination at all levels of care. Our article on depression and anxiety explores the symbiotic and destructive relationship between

4 RESILIENT HEALTH | April 2018

these two disorders, and why screening for them is important. We also dive into measurement-based care by describing the underpinnings of MBC and why it is so important in treating behavioral health issues. Sadly, MBC is grossly under-utilized, but the April piece provides the resources for adding it to your everyday treatment plan (it’s simple!). See the related article on the utility of using MBC in treating depression, which explains how the treatment juggernaut can be applied to a most common mental condition. Our April Fast Facts provides a quick run-down of important mental health stats, many of them surprising, all of them alarming. This month’s focus on eating disorders zooms in on EDs in women and girls, and how these conditions can hide in plain sight. Did you know that one ED in particular is the deadliest mental health condition of all? We’ve paired this piece with 10 eye-opening ED myth busters (hint: EDs are NOT about food) so you can bone up on all things ED.

side look at how financial considerations and access issues conspire in creating huge barriers to care despite extant parity laws meant to ensure adequate mental health treatment. You’ll learn how insurers find ways to circumvent paying for much-needed behavioral health services, leaving patients and providers holding the bag. The Professional Perspectives this time around provides an in-depth discussion on health and artificial intelligence. Is AI a good thing or do the risks of confidential patient information being hacked outweigh the benefits that technology affords? Is the spiritual aspect of recovery in direct conflict with the precision of technology? Read on to find out. Thank you for reading this issue of RESILIENT HEALTH and for all you do, day in and day out, to improve the lives of women, men and children with behavioral health issues. We hope our magazine provides the insight to make that job just a teensy bit easier.

The new installment of the War on Behavioral Health Care takes an inwww.reshealth.net

Measurement-Based Care Improves

Treatment Outcomes By Resilient Health Staff

easurement-based care, the practice of collecting patients’ feedback as clinical data to guide treatment, is the key element in evidence-based and collaborative care. The Substance Abuse and Mental Health Services Administration has acknowledged the utility of measurement-based care in treating mental disorders as www.reshealth.net

an evidence-based practice, and the Joint Commission has made it the standard of care for accreditation. The key element in MBC is the systematic and frequent administration of symptom rating scales to collect feedback from patients that guides current and future treatment. The tools used in MBC for data col-

lection are validated, generally brief, questionnaires and rating scales such as the Generalized Anxiety Disorder-7 (GAD-7) for anxiety, the Patient Health Questionnaire-9 (PHQ-9) for depression, and the Columbia-Suicide Severity Rating Scale (C-SSR), among others, that elicit feedback from patients (for a comprehensive list from SAMSHA-recommended, free screening RESILIENT HEALTH | April 2018 5

tools, visit https://bit.ly/2uANP5x). In the psychotherapeutic setting, the use of MBC has these advantages: Encourages patients to discuss their feeling with counselors Provides patient feedback to inform the care team about what is working and what is not working under the current treatment plan Allows the care team to have a complete picture of how treatment is going (by including patient feedback as well as the team’s notes and observations) Allows for adjusting the treatment plan before discharge and customize care to each patient’s unique needs and preferences, which improves outcomes Allows providers to track symptoms such as withdrawal and anxiety so that worsening symptoms can be addressed Allows practices and networks of treatment centers to assess the effectiveness of programs and approaches, allowing for the discontinuation of ineffective approaches and adoption of ones that work Studies have borne out that eliciting regular feedback from patients significantly improves outcomes, reduces the chances of deterioration in patients’ health (http://bit. ly/2ptkrZ1), and allows individual providers, small practices and large care networks to assess the utility of various programs and therapeutic approaches. Measurement-based care in behavioral health care is an estab6 RESILIENT HEALTH | April 2018

lished, evidence-based model of care that can be integrated with any treatment (http://bit.ly/2ptkrZ1), from diabetes to addiction. The basic principle is to monitor the progress of treatment by administering symptom rating scales, thus combining hard data with clinical evaluation. Unlike other treatment models, consistently using measurement-based care has a positive impact on patients, payers, providers and treatment networks. Medical practitioners and health care providers customize treatment programs based on the real-time data. Furthermore, payers can track patient progress during treatment. Despite the effectiveness of measurement-based care, it has not been widely accepted by clinicians. Unfortunately, only 18 percent of psychiatrists and 11 percent of psychologists in the United States administer symptom rating scales to patients (http://bit.ly/2HQbIrq).

Utility of MeasurementBased Care Across Stakeholders Studies have found that MBC is immensely beneficial to all stakeholders. Through constant monitoring and progressive changes in the treatment, measurement-based care in mental disorders can help patients, clinicians and others. Some of the advantages witnessed by these stakeholders include the following: Patients. Research shows that the addition of MBC to any treatment can result in a significant level of improvement in a patient’s outcomes with respect

to interpersonal problems, psychological disturbance and quality of life. This is particularly true in the case of patients experiencing treatment failure. It also leads to the active engagement of the patient in his or her treatment. Clinicians. MBC provides information and targets that clinicians use to alter the intervention. It also helps them in assessing the treatment process and making differential diagnoses. It assists clinicians in making an objective assessment of the patient’s condition and accurate decisions pertaining to treatment. Mental health organizations. MBC provides data to mental health organizations and acts as an indicator of performance that can be reported to accreditation organizations. This leads to improvements in patient care and the quality of medical services provided.

Challenges in Implementation As mentioned earlier, measurement-based care in behavioral health improves clinical outcomes, increases client engagement and enhances the treatment-related decision-making process. However, resistance to widespread adoption has impeded the growth of MBC nationwide as a viable treatment model. Barriers include: Time restrictions. Despite the many benefits of MBC, clinicians with heavy patient loads feel that too much time will be taken up by changing their approach to an MBC model. However, www.reshealth.net

given that most of the assessment tools are free of charge and are quick and easy to administer, this perceived barrier has little merit.

excellent tool for identifying dual-diagnosis, and research shows that treating all patient disorders concurrently offers the best chance of successful treatment.

Organizational resources. Limited organizational resources, such as access to technology, finances and supervisory support, can impair the implementation of MBC. However, the approach can be integrated into any program and requires minimal resource allocation.

Implementation procedures. Another important challenge is the need to integrate the required logistics and procedures for the administration and review of the validated scales related to MBC. For the effective implementation of MBC, adequate organizational support and training are required, and procedures for guiding treatment and making clinical judgements need to be established. But the fact is, patients who complete symptom rating scales are comparatively more aware of their progress

Patient complexity. Besides depression and anxiety, patients often have complex diagnoses. As a result, therapists who focus mainly on depression or anxiety have expressed that some measures may not be a good fit for their clients. However, MBC is an

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and engaged during the treatment process and have better outcomes. There is no denying that MBC significantly improves outcomes and can be added to virtually any treatment program, for any substance use or mental health condition (or any combo of the two). With addiction spiraling out of control and mental health issues continuing to have a negative impact on millions of lives, there is no excuse for not implementing MBC on a national level. Both providers and patients stand to benefit, and the drawbacks are nil.

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SPECIAL SECTION

Treating Substance Use Disorders:

A Resolution to Embrace Measurement-Based Care Why Measuring Treatment Outcomes is a 21st Century Mandate for Treating Addiction

e are well into the second decade of the 21st century. On almost a weekly basis, new discoveries gleaned from advanced neuroimaging techniques, rigorous clinical trial outcomes data, and the development of novel neuropsychiatric medications are opening new pathways in addiction treatment. Individuals with substance use, and those with the comorbidities of addiction and an underlying psychiatric condition, should be reaping the beneﬁts of evidence-based addiction treatment. But sadly, data show that health care professionals are not implementing evidence-based science (Scott & Lewis, 2015) in treating the 21.5 million Americans who have a substance use disorder (SAMSHA, 2016).

Dr. Tonmoy Sharma, MBBS, MSc CEO, Sovereign Health

of symptoms, and empowers patients to participate in their own care while improving their outcomes (Lambert et al.; 2005).

n 2015, the Kennedy Forum released an Issue Brief titled “Fixing Mental Health Care in America: A National Call for Measurement-Based Care in the Delivery of Behavioral Health Services,” which illustrated the domino eﬀect caused by a

espite the deleterious effects of not implementing an MBC model, clinicians have been slow to change. It is worth noting that, in general, it takes 17 years for 14 percent of research to reach consumers (Balas & Boren; 2000). In addition, clinicians have negative perceptions about MBC, including that the burden of training themselves and their staffs is too onerous, negative feelings about prescribed manuals and protocols, and a belief that specific evidence-based practices may not be appropriate for their clients and their practice settings (Scott & Lewis, 2015).

References

e know that quality health care, including substance use and addiction care, should be ﬁrmly rooted in established biomedical research. Measurement-based care (MBC) — the practice of basing clinical care on client data collected throughout treatment (Scott & Lewis, 2015) — is a core component of evidence-based practices (Klerman, Weissman, Rounsaville & Chevron, 1984; Beck & Beck, 2011). Over the past decade, MBC has emerged as an incontrovertible, evidence-based method that can be used for virtually any health issue (Lambert et al., 2003; Trivedi et al., 2007), and research has shown that applying MBC (such as monitoring symptom change using idiographic assessments) is beneﬁcial for improving client outcomes (Weisz et al., 2011). Overall, MBC elucidates treatment progress, allows for adjusting treatment plans as necessary, reduces exacerbation

services. Providers and, indeed, entire health care systems miss opportunities for ongoing improvement. A lack of symptom rating scales precludes individual practices and health care networks from proving the eﬃcacy of their treatment protocols to third-party payers. This lack of empirical data on treatment success leads to chronic federal and state underfunding of behavioral health treatment, and decisions about reimbursement for services rendered are not aligned with treatments that are proven to be the most beneﬁcial (Kennedy Forum, 2015).

non-MBC approach in behavioral treatment. The conclusions are mind-boggling; per the Brief, a mere 18 percent of psychiatrists and 11 percent of psychologists monitor the eﬃcacy of speciﬁc treatment approaches by routinely administering symptom rating scales and therapist assessments to their patients. This lack of assessment cements clinical inertia, and creates barriers to improving clinical

iven the stakes, we cannot accept that these perceived barriers to MBC are insurmountable, unresolvable or even valid. A lack of evidence-based treatment spells failure for clinicians, institutions, health care networks and, most importantly, our patients. Let us resolve to embrace our brave new world of clinical innovations and scientific advances that enable us to provide the best measurement-based care for substance use and addiction treatment.

Balas, E. A., & Boren, S. A. (2000). Managing clinical knowledge for health care improvement. Yearbook of Medical Informatics, 65–70; Beck J.S., Beck A.T. (2011). Cognitive behavior therapy: Basics and beyond. New York: Guilford Press; Kennedy Forum (2015). Fixing Behavioral Health Care in America: A National Call for Measurement-Based Care in the Delivery of Behavioral Health Services; http:// thekennedyforum-dot-org.s3.amazonaws.com/documents/KennedyForum-MeasurementBasedCare_2.pdf; Klerman G.L., Weissman M.M., Rounsaville B.J., Chevron E.S. (1984). Interpersonal psychotherapy of depression. New York: Basic Books; Lambert, M. J., Whipple, J. L., Hawkins, E. J., Vermeersch, D. A., Nielsen, S. L., & Smart, D. W. (2003). Is It time for clinicians to routinely track patient outcome? A meta-analysis. Clinical Psychology: Science and Practice, 10, 288–301; Lambert, M. J., Harmon, C., Slade, K., Whipple, J. L., & Hawkins, E. J. (2005). Providing feedback to psychotherapists on their patients’ progress: Clinical results and practice suggestions. Journal of Clinical Psychology, 61, 165–174; Scott K., Lewis C.C. (2015). Using Measurement-Based Care to Enhance Any Treatment. Cognitive and Behavioral Practice, 22:49-59; Simons, A. D., Rozek, D. C., & Serrano, J. L. (2013). Wanted: Reliable and valid measures for the science of cognitive behavioral therapy dissemination and implementation. Clinical Psychology: Science and Practice, 20, 181–194; Substance Use and Mental Health Services Administration (2016). Mental and Substance Use Disorders. SAMSHA; Rockville, MD. https://www.samhsa. gov/disorders; Trivedi, M. H., Rush, A. J., Gaynes, B. N., Stewart, J. W., Wisniewski, S. R., Warden, D., … Howland, R. (2007). Maximizing the adequacy of medication treatment in controlled trials and clinical practice: STAR*D measurement-based care. Neuropsychopharmacology, 32, 2479–2489; Weisz, J. R., Chorpita, B. F., Frye, A., Ng, M. Y., Lau, N., Bearman, S. K., … Hoagwood, K. E. (2011). Youth Top Problems: Using idiographic, consumer-guided assessment to identify treatment needs and to track change during psychotherapy. Journal of Consulting and Clinical Psychology, 79, 369.

Treating Depression with Measurement-Based Care By Mridul Gogoi

dvances in health care and recent data from research provide a steady stream of clinically-validated and evidence-based treatment methods for behavioral health professionals that were previously not available. As time progresses, newer treatment procedures and practices keep evolving, yielding www.reshealth.net

scientifically-proven, patient-facing treatments. Measurement-based care (MBC) is one such treatment approach that is gaining ground globally in the health care field. MBC is the practice of implementing clinical care based on patient feedback and data collected throughout the treatment process.

It is already a core component of various earlier evidence-based practices. In fact, MBC could be the missing link in the huge gap between what should be accomplished and what actually has been achieved in clinical practice. The efficacy of MBC has been verified repeatedly in clinical trials as a RESILIENT HEALTH | April 2018 9

often perceive that implementing MBC is time-consuming, expensive, difficult and disruptive, and that training staff is difficult—none of which is true.

Treating Depression: Why Measurement-Based Care Works

practice that improves care and can be used in any medical discipline, including mental health and addiction treatment. Clinical trials have yielded data that support implementing MBC in addressing comorbidities—by weeding out underlying psychiatric conditions that severely impact substance use problems. Research has shown that MBC added to any intervention yields widespread benefits. Using an MBC approach lets providers closely monitor the progress of any treatment, highlights ongoing treatment targets, prevents deterioration of symptoms and improves outcomes for clients. The use of MBC in treating depression (a major cause of disability worldwide) is similarly proven to be extremely effective. Unfortunately, routine implementation of MBC has a long way to go; very few clinicians routinely use it for treating health conditions, be it addiction or mental health issues. In patients with depression, the use of MBC has largely been relegated to only assessing symptoms of disorders such as depression and anxiety,

but it has much broader applications. The use of MBC can help providers to tease out crucial information about a range of factors key in assessing treatment for depression, including symptoms, satisfaction with life and functioning, mechanisms of change, and willingness to change and progress (or lack thereof) over the course of treatment.

Barriers to Treating Depression Although depression is one of the most common mental disorders, the treatment and level of care for it is, overall, inconsistent and inadequate. Although the use of antidepressants has soared in the United States, not many U.S. adults receive the appropriate intervention or any treatment at all, according to a 2016 article in JAMA. The study showed that of patients who screened positive for depression, less than 30 percent received any treatment, and of those who did, only 33 percent of patients with serious psychological distress and 17 percent with less psychological distress received care from a psychiatrist. Providers and treatment networks

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Data show that, when treating depression, the majority of physicians do not routinely use validated treatment guidelines when prescribing antidepressants. The mental health field, unlike other medical specialties, has been slow to embrace newer, evidence-based treatment methods. However, MBC’s ability to observe symptoms over time, assess severity, treatment adherence and medication side-effects offers a simple yet effective way to enhance current and clinically-verified depression treatment methods, and in the process provide optimal, evidence-based and individualized care for patients. However, only 20 percent of mental health professionals routinely use MBC to treat depression. Incorporating MBC into any treatment plan is not complicated; most of the assessment tools are available free of charge online (see the link to the Substance Abuse and Mental Health Services Administration Screening Tools at the end of this article), are easy to use, and take very little time to administer. Using assessment tools to obtain patient feedback during treatment lets the care team identify gaps, assess the provider-patient relationship, track progress, identify potential relapse red flags, and understand if medication (if used) is working. www.reshealth.net

There are other valuable applications of using MBC. The assessments provide valuable data that can be used to evaluate the overall performance of a practice or facility and can be gathered as data that can be supplied for accreditation. Continuous performance assessment can be used for funding decisions, to create new programs and dispose of ones that are ineffective, and to overall improve the quality of care provided and patient outcomes. MBC also encourages clinicians to follow standard treatment practices within an organization, ensuring that every patient seeking depression treatment receives adequate, evidence-based care. MBC streamlines the patient assessment process and facilitates the identification of differential diagnoses and co-occurring conditions, such as substance use. Furthermore, MBC can also aid in enhancing the clinician’s judgement as it offers an objective assessment of the progress made by a patient.

Recent Success of MBC A recent initiative by the U.S. Department of Veteran Affairs has made the use of MBC the standard in treating mental health disorders resulted in positive outcomes for both veterans and providers. The veterans who participate in providing clinically-validated measures at regular intervals better understand the interventions used to treat them. The outcomes are shared promptly with other providers who are part of the care team. The relationship forged between the providers and the veterans improves treatment plans, assessment of progress and adjustwww.reshealth.net

ment of the treatment process over time. The mutual decision-making and regular assessment of treatment plans has led to a higher engagement from the veterans resulting in better treatment outcomes. The success of MBC can be replicated for every patient with mental health conditions, including those with depression, whether moderate or severe. Implement MBC – your facility will thank you for it, your patients will benefit from it.

Sources 1. Beck JS, Beck AT. Cognitive behavior therapy: Basics and beyond. New York: Guilford Press; 2011. 2. Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES. Interpersonal psychotherapy of depression. New York: Basic Books; 1984. 3. Lambert MJ, Whipple JL, Hawkins EJ, Vermeersch DA, Nielsen SL, Smart DW. Is It time for clinicians to routinely track patient outcome? A meta-analysis. Clinical Psychology: Science and Practice. 2003;10(3):288–301. http://dx.doi. org/10.1093/clipsy.bpg025. 4. Trivedi MH, Daly EJ. Measurementbased care for refractory depression: A clinical decision support model for clinical research and practice. Drug and Alcohol Dependence. 2007;88:S61–S71. http://dx.doi.org/10.1016/j. drugalcdep.2007.01.007. 5. Lambert MJ, Harmon C, Slade K, Whipple JL, Hawkins EJ. Providing feedback to psychotherapists on their patients’ progress: Clinical results and practice suggestions. Journal of Clinical Psychology. 2005;61(2):165– 174. http://dx.doi.org/10.1002/ jclp.20113. [PubMed]

6. Treatment of Adult Depression in the United States. JAMA Intern Med. 2016;176:1482-1491. https://www.ncbi.nlm.nih.gov/ pubmed/27571438 7. Morris DW, Trivedi MH. Measurementbased care for unipolar depression. Current Psychiatry Reports. 2011;13(6):446–458. http://dx.doi.org/10.1007/s11920011-0237-8. [PubMed] 8. Bickman L. A measurement feedback system (MFS) is necessary to improve mental health outcomes. Journal of the American Academy of Child and Adolescent Psychiatry. 2008;47(10):1114. 9. Garland AF, Kruse M, Aarons GA. Clinicians and outcome measurement: What’s the use? The Journal of Behavioral Health Services & Research. 2003;30(4):393–405. http://dx.doi.org/10.1007/ BF02287427. [PubMed] 10. Sapyta J, Riemer M, Bickman L. Feedback to clinicians: Theory, research, and practice. Journal of Clinical Psychology. 2005;61(2):145– 153. http://dx.doi.org/10.1002/ jclp.20107. [PubMed]

Resources American Psychiatric Association. Treating Major Depressive Disorder A Quick Reference Guide. https://psychiatryonline. org/pb/assets/raw/sitewide/ practice_guidelines/guidelines/ mdd-guide.pdf Substance Abuse and Mental Health Services Administration. Screening Tools. https://www. integration.samhsa.gov/clinicalpractice/screening-tools)

RESILIENT HEALTH | April 2018 11

Depression and Anxiety:

Two Conditions That Go Hand in Hand By Resilient Health Staff

constant feeling of uneasiness along with intrusive and undesirable thoughts that cause sweaty palms and a hazy sense of an impending catastrophe are some of the ways in which anxiety disorders manifest. Such symptoms are also present in individuals struggling with depressive disorders.

sides of the same coin,” says Geraldine Joaquim, a therapist at Quest Hypnotherapy, a U.K.-based center that prescribes a combination of psychotherapy and hypnosis to help patients cope with their condition. “Effectively we

are all pre-programmed to fall back on these two conditions (as well as anger) from way back to our caveman days. They helped keep our ancestors safe,” she adds.

Both anxiety and depression are often entwined, according to a study by Nicholas Jacobson and Michelle Newman, professors of psychology at Penn State University. Earlier findings suggest that 16 to 50 percent of people with depression also have an anxiety disorder. Both conditions share common symptoms, such as stress, feelings of helplessness and an inability to concentrate. However, anxiety usually manifests in outbursts of energy, whereas depression is characterized by lethargy. “Both anxiety and depression are flip

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Studies show that anxiety and depression tend to assume many forms, making it tough to find a single method to collectively treat these conditions. Many people live with the symptoms of these two correlated, yet distinct, conditions; their complicated natures prevent people from speaking openly about what they are experiencing because of the fear of being stigmatized. Depression and anxiety are characterized by abnormalities in thinking patterns, feelings or behaviors; these persistent symptoms can make a person feel debilitated and stressed. Relentless doubts and never-ending fears can be paralyzing, sapping away a person’s emotional energy. Eventually, the negative effects of these disorders can bring one’s life to a standstill, and in the worst-case scenario, lead to thoughts of suicide to end the suffering. Why are anxiety and worrying such common behaviors? The answers lie in both the positive and negative beliefs that surround anxiety. On the negative side, individuals generally tend to believe that their prolonged anxiety is bound to escalate, take a toll on their health, and unleash a series of misfortunes. On the positive side, many researchers believe that being anxious is a mechanism to prepare emotionally for unpleasant

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outcomes or spur innovative solutions to ease a potential problem. People with anxious thoughts are often viewed as being concerned and conscience-driven individuals. Considering worrying only as a positive action, however, can be emotionally harmful. Anxiety can be reduced by realizing that worrying can protect someone from harm. Persistent anxiety can take a toll on one’s well-being, creating additional stress that can lead to depression. People in the grip of depression lose hope gradually, rendering them incapable of managing their condition and, ultimately, their lives. Both chronic anxiety and fullblown depression feed on each other, escalating symptoms and creating paralysis. Professional treatment is needed to manage both conditions simultaneously and mitigate patients’ symptoms. Anxiety and depression can make patients’ lives miserable by trapping them into a vicious cycle of hopelessness and worry. Psychotherapy sessions with a licensed and trained mental health professional can help patients identify and work through factors that trigger these conditions. Adding medications that improve mood, such as selective serotonin reuptake inhibitors

(SSRIs), and anti-anxiety drugs can help patients navigate their lives while in treatment. Behavioral health professionals can and should screen patients as needed for anxiety and depression; the Substance Abuse and Mental Health Services Administration offers free screening tools for depression and anxiety, available at integration.samhsa.gov/clinicalpractice/screening-tools#anxiety. The site provides screening for suicidal ideation as well, which can help care givers to identify patients at risk. A certain amount of worrying and feeling blue are a normal part of most people’s lives. But for millions, these behaviors wind up dominating their lives and crippling their ability to lead healthy, productive lives. Health care professionals are ideally situated to identify debilitating anxiety and depression and help patients to break the destructive patterns of these common conditions.

RESILIENT HEALTH | April 2018 13

12 FACTS ABOUT

MENTAL HEALTH 1

20 to 25 percent of Americans have a diagnosable mental and/or substance use disorder in any given year.

Only 40 percent of individuals with mental and/or substance use disorders get treatment. Of those who do, less than one-third get minimally adequate care.

Suicide is the 10th leading cause of death in the United States.

Rising rates of suicide and opioid abuse are driving a shocking increase in the death rate of working age Americans.

5 to 6 percent of American adults have a serious mental illness; about 2 percent have disorders that are long-term and disabling, contributing to very high rates of unemployment and poor living conditions.

30 to 40 percent of homeless adults and 15 to 20 percent of people in jails and prisons in the United States have a serious mental illness, often accompanied by a substance abuse problem (in both of these populations).

As many as 10 percent of children have a serious emotional disturbance, contributing to school failure and other serious problems that extend into adulthood.

As the number of older adults doubles over the next two decades, so will the number of elderly people with mental disorders. This includes 5.5 million older adults who currently have Alzhei-

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mer’s disease or another form of dementia. Without advances in preventative medicine, this number will more than double, rising to 11 million with dementia by 2050. 9

Data show that massive growth of minority populations is already happening; the U.S. mental health system already has a tremendous shortage of culturally-competent personnel.

10 Mental and substance use disorders cost hundreds of billions of dollars per year for: (1) treatment of these conditions, (2) treatment of related health conditions, often made more severe, more disabling, and more expensive by behavioral health disorders, (3) government funding of various welfare benefits to support people diagnosed with mental and substance use disorders, (4) criminal justice activities, and (5) lost productivity due to inability to work. 11 Treatment works. There are effective, evidencebased and state-of-the-art interventions that can improve the quality of life for individuals, no matter their diagnosis. 12 Funding mental health services and translating research findings into practice is a worthwhile investment that improves the lives of individuals and their families and significantly reduces overall costs to the healthcare system.

Source: Mental Health Association of New York City

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S E RV I C E S O F S OV E R E I G N H EA LTH

Addiction / Dual Diagnosis Sovereign Health is a leader in the treatment of addiction, mental health disorders and dual diagnosis. Dual diagnosis refers to a mental health condition and substance abuse occurring simultaneously. Sovereign believes that addiction is a chronic brain disease that may include periods of relapse. It is important to note that repeated relapses after periods of sobriety may indicate the presence of an underlying disorder requiring professional treatment.

Treatment Programs Offered:

At Sovereign Health, we specialize in the complex assessment and multidisciplinary care required to successfully treat patients who are struggling with dual diagnosis. Our behavioral health team of masterand doctoral-level therapists are uniquely qualified to treat the mental health conditions that often accompany substance abuse.

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We attribute much of our success to the holistic approach we employ with each individual patient. Multidisciplinary aspects of care are all interrelated and each person has different needs. From arrival to discharge, our treatment team includes each dual diagnosis patient in all decision-making related to his or her own plan of care.

• Telehealth

Patients Served • Adolescents • Adults • Males, Females and Transgender

Levels of Care • Detoxification • Residential Treatment • Partial Hospitalization • Intensive Outpatient • Outpatient • Recovery Management

For more information, please visit

www.sovhealth.com www.reshealth.net

• Primary Mental Health • Substance Use • Dual Diagnosis • Eating Disorders • Pain Recovery • CROSS: Christian Recovery Offering Significant Success • POWER: Primary Opportunities for Women Experiencing Recovery • PRIME: Personal Recovery Integrating Men’s Experiences

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RESILIENT HEALTH | April 2018 15

Is Collaborative Care

the Game Changer on the Opioid Battlefield? By Oscar Lawrence

as she had developed a bump in her stomach. She visited the local health center for a pregnancy test where her fears became a reality; she tested positive.

Engaging in petty thefts to feed her addiction, she dropped out of high school and landed herself in a long-term stay in a correction center. She was eventually released and last autumn, Doris noticed she couldn’t slip into a pair of jeans

Neck deep in addiction, quitting was not an option, as that would mean putting her baby through violent withdrawal symptoms. Left with no options, she increased her daily doses to 40 and even 50 pills. Living in the countryside had its own challenges. The local obstetrician in Otter Lake wasn’t equipped to treat her Percocet addiction and the local buprenorphine provider didn’t treat pregnant patients. As a result, Doris was forced to hide her condition for the fear of losing custody of her baby. Doris is among the estimated 19.3 million people aged 12 years or

hen 21-year-old Doris Baker of Otter Lake, Michigan realized she was pregnant, it wasn’t until four months before the baby was due. Ever since she had her wisdom teeth extracted at age 17, extended use of Percocet (a narcotic consisting of oxycodone and acetaminophen) to cope with the pain left her in shambles. Despite repeated efforts to stay off the drug, she couldn’t help being driven deeper into addiction.

16 RESILIENT HEALTH | April 2018

older classified as needing but not receiving substance use treatment at a specialty facility, according to the 2015 National Survey on Drug Use and Health report.

No Light at the End of the Tunnel In the last two decades, the rampant, nonmedical use of prescription opioids has devastated American society, with no end in sight. Addiction to pharmaceuticals has assumed nightmarish proportions across the United States. The Centers for Disease Control and Prevention reported more than 60,000 overdose deaths involving addictive opioids in 2016 alone; it is estimated that the nation will likely log at least 70,000 deaths due to overdose in 2017. www.reshealth.net

As a nation, we’re losing our children, parents, friends, coworkers and neighbors to “killer pills” even faster than we could imagine. Studies attribute the monumental rates of fatal overdoses, drug dependence and even related criminal activity to the millions of prescriptions written to manage post-surgical pain or other uncomfortable conditions stemming from chronic ailments. Though we’ve fought the good fight, this monster doesn’t seem to retreat. It has grown exponentially larger each year and become more vicious, with terrifying tentacles threatening to take over every inch of the country. It seems that only a true game-changer will save our loved ones and reinvigorate the entire behavioral health care industry. At this juncture, only a breakthrough consisting of evidence-based treatments to bridge the gap between physical and mental health can reverse the life-wrecking effects of lethal opioids and manage other concurrent mental health conditions. Given that patients with opioid use disorder have complex comorbid medical and behavioral needs, the game-changer on the opioid battlefield is a collaborative care model comprised of multidisciplinary care coordination and provider contact between visits, supervised by a care manager with behavioral health training.

approach in treating opioid addiction would mitigate the suffering of individuals in the throes of addiction to deadly opioids.

new ways to provide high-quality services at lower costs with better recovery outcomes. There is ample scientific evidence that a collaborative care approach—treatment that integrates input from primary care providers, care managers, psychiatric consults and other providers—is extremely beneficial for treating patients and monitoring their progress, especially in those recovering from opioid addiction and other substance use issues. The collaborative care approach uses patient-centered care teams

Given that patients with opioid use disorder have

Studies have established that combining medical services results in increased positive outcomes, higher abstinence rates and enhanced patient satisfaction. Research has also shown that collaborative care is more effective for common substance use disorders—such as addiction to opioids—than care provided in traditional settings. A 2017 study, for example, by the National Institute on Drug Abuse demonstrated that collaborative care boosted recovery and lowered relapse rates compared to other treatment methods. The NIDA study also showed that combining evidence-based opioid and alcohol addiction treatment with primary care led to a higher rate of successful recovery, including sustained abstinence after six months, compared to conventional treatment outcomes.

complex comorbid medical and

The Key: Collaborative Care U.S. health care is constantly changing. Providers are challenged to find www.reshealth.net

behavioral needs, the game-changer on the opioid battlefield is a collaborative care model... at one location who collaborate to collect information on patients and formulate a treatment plan. Typical activities include screening for physical and mental illnesses, providing evidenced-based interventions, and tracking outcomes in registries to monitor the quality of care and patients’ progress. The collaborative care model is rooted in measurement-based treatment, population-based care and accountability to patients in a supportive team environment. Wide adoption of this

Given that many Americans with chronic substance use disorders have access to a primary care provider, the study team decided to determine if addiction can be treated successfully in the primary care setting. Of 377 participants with either opioid or alcohol use disorder, researchers assigned 190 to a traditional primary care setting and the remaining 187 to collaborative care. They found that doctors in the collaborative care group were more likely to use medication-assisted treatment (MAT), including RESILIENT HEALTH | April 2018 17

buprenorphine for opioid addiction and naltrexone for alcoholism, and brief sessions of psychotherapy. Within six months, nearly 33 percent of those who received collaborative care remained free of substance use, compared with 22 percent of patients in the regular care group.

Collaborative Care Primary Approaches The primary care setting is ideal for identifying patients who need specialized care. Considering the U.S. opioid crisis, incorporating the collaborative care model into primary care environments for treating opioid use disorder is likely to result in better outcomes, especially when the approach combines psychotherapy with MAT.

The utility of psychotherapy for substance use disorder cannot be overstated. Each rehab center may have its unique approach to psychotherapy, but typically, oneon-one counseling sessions along with group therapy helps patients develop coping mechanisms and alternate thinking patterns to combat drug cravings. And combining psychotherapy with MAT (buprenorphine, naltrexone or methadone) has been shown to facilitate recovery, with minimal withdrawal effects.

tion of physical and mental health care has a significant positive impact on quality of care and health care costs. According to the 2014 Milliman Report, commissioned by the American Psychiatric Association, an estimated $26 billion to $48 billion dollars could be saved annually through effective collaborative care. The information about “Doris Baker” in this article is based on a true story; to protect her privacy, her name and place of residency have been changed.

Integrated interventions aim to treat both extant substance use disorders concurrently with mental or physical health conditions, if present, to prevent relapse and future complications. The integra-

18 RESILIENT HEALTH | April 2018

www.reshealth.net

BINGE Eating Disorder This quiz is designed to help give you some idea about whether a client might suffer from an eating disorder called binge eating disorder (BED). It’s based upon the actual diagnostic criteria used to diagnose this disorder. INSTRUCTIONS: For each item, have your client indicate how much he or she agrees or disagrees with the statement. This takes most people less than two minutes to complete. Have them take their time and answer truthfully for the most accurate results. I am a

year old

Female /

Male /

Other

1. I’ve experienced episodes of binge eating more than once. No Yes 2. My episodes of binge eating are characterized by eating during a specific period (say, within a 2-hour period), an amount of food that is larger than what most people would eat in a similar period, under similar circumstances. No Yes 3. During my binge eating episodes, I’ve experienced a feeling that I lacked control over my eating (e.g., a feeling that I could not stop eating, or control what or how much I was eating during the episode). No Yes 4. The binge eating episodes I’ve experienced have included: Eating much more rapidly than normal E ating large amounts of food when not feeling physically hungry Eating until feeling uncomfortably full F eeling disgusted with myself, depressed, or very guilty afterward E ating alone because of feeling embarrassed by how much I’ve been eating

5. My episodes of binge eating cause me great concern or distress. Not at all Just a little Somewhat Quite a lot All the time 6. My binge eating episodes occur at least once a week for at least 3 months, on average. No, they occur much more rarely than this No, they only occur once or twice a month or so Yes, or even more frequently 7. I’m currently diagnosed with either bulimia or anorexia.

Yes

8. How often do you experience your binge eating episodes? Less than 1 binge eating episode/week 1-3 binge eating episodes/week 4-7 binge eating episodes/week 8-13 episodes/week 14 or more episodes/week

To analyze the results of this quiz, go to psychcentral.com/chi-bin/binge-eating-quiz.cgi. www.reshealth.net

RESILIENT HEALTH | April 2018 19

PRIME Program

P RO G R A MS O F S OV E R E I G N H EA LTH

Sovereign Health

PRIME Program for Men Sovereign Health offers specialized residential addiction treatment for men 40 to 65 years of age through our Personal Recovery Integrating Men’s Experiences (PRIME) Program. PRIME is a 45 - to 60-day program that includes all levels of care, from detoxification to outpatient treatment. This holistic program focuses on the psychosocial, physical and financial health issues facing mature men in the “prime” of their lives. PRIME helps men establish sober and supportive relationships, manage medical conditions and create new employment opportunities. We attribute much of our success to our recognition that developmental issues vary across the life span. Our treatment program is based on an appreciation that men in their 40s and older face unique challenges. Employing research in the areas of neurobiology and developmental psychology, PRIME is designed to facilitate recovery and healing from arrival to discharge. Patients Served • Men in their 40s, 50s and 60s • Men whose careers, families and relationships have been affected by alcohol or drug use • Men requiring maximum anonymity

Levels of Care • Detoxification • Residential Treatment • Partial Hospitalization • Intensive Outpatient • Recovery Management

For more information, please visit

www.sovhealth.com 20 RESILIENT HEALTH | April 2018

Treatment Programs Offered: • Detoxification • Primary Mental Health • Substance Use • Dual Diagnosis • Telehealth

24/7 ADMISSIONS HELPLINE

888.701.7488 www.reshealth.net

The War on Behavioral Health Care:

Financial Feuds By Resilient Health Staff

ay you live in interesting times, is purported to be an ancient Chinese curse. People living in the United States today are certainly living in interesting times. Americans look to the media for truth and understanding, yet the coverage is such that trivial issues are sensationalized, while grave and critical issues sometimes go unnoticed. Apparently, President Trump’s tweet about television news program host Mika Brzezinski’s facelift take precedence over the skyrocketing opioid addiction rates, which increased by nearly 500 percent from 2010 to 2016 (http://bit.ly/2t6diiy). www.reshealth.net

The growing opioid crisis in this country is not new; it’s been going on for decades (http://bit.ly/2j6YEE1). Beginning with aggressive and misleading marketing of painkillers, the crisis has expanded to massive amounts of heroin pouring into the United States from Afghanistan, Mexico and elsewhere. Many people who become addicted to prescription painkillers turn to heroin because it’s cheaper and available without a prescription. Add to this the various synthetic opioids flooding our country, and we’ve got a true national emergency on our hands. The crisis of addiction not only de-

stroys people, it destroys families, communities, nations and cultures. Opioid overdose rates continue to increase exponentially as drug addiction ravages the nation. Just as opium was used to decimate and pillage Imperial China in the 1800s and 1900s, opioids are now destroying America and its children. Hundreds of millions of Chinese people died before a revolution took place to stop opium from entering the country. How many Americans must die until we stop the scourge? The U.S. government seems unable to protect its people from the massive influx of illicit drugs

RESILIENT HEALTH | April 2018 21

into the country. Many parents seem unable to prevent drug use in their own children, let alone organizing community action groups to combat the problem. When addiction does strike a family, parents and loved ones are still unable to get the right kind of help for their loved ones. In fact, only about 1 in 10 who reportedly need addiction treatment ever receive care (http://bit.ly/2tMjmzg). There are many reasons for this shocking discrepancy, many of which are financial in nature. The high costs of staffing and running a facility, little or no reimbursement from insurance companies and state budget cuts all combine to result in a war on mental health and addiction treatment.

Inadequate Reimbursement Treatment providers today are tasked with providing quality care within the current healthcare system, which is built on a for-profit structure. Patients’ insurance reimbursement rates, therefore, must at least be the same as the cost of running a licensed facility. Expenses include overhead, salaries for highly credentialed and experienced professional staff, liability insurance, ancillary costs and much more. In addition, patients often require long-term residential care and treatment for months rather than just days or weeks. And to top it off, treatment is most successful when patients are followed up for months or even years after discharge.

by the time they seek treatment. Patients with addiction and their families have often been financially ravaged because of the addiction. Job loss, legal fees and medical expenses sap savings accounts, leaving nothing to pay off the balance of services not covered by insurance. And that’s assuming they have any coverage at all, which millions of Americans lack.

Stricter medical requirements that limit coverage of certain treatments

Parity laws require mental health services be reimbursed at the same rates as services for other medical and surgical conditions. The Mental Health Parity and Addiction Equality Act of 2008 (MHPAEA) mandates that professional treatment for mental illness and addiction be covered by insurance on par with coverage provided for medical and surgical conditions (http://go.cms. gov/2HjJtlA). Federal statutes were recently added that require the MHPAEA apply to Medicaid managed care, the Children’s Health Insurance Program and essential health benefits (which vary by state). There has been widespread difficulty in the enforcement of parity.

Rather than working toward a solution, many insurance companies find ways to avoid paying for substance use treatment, even as lawmakers move to ensure that third party payers make a profit rather than helping people with mental disorders and addiction get the help they need.

Insurance companies are making mental health and substance use treatment progressively less accessible than treatment for other conditions through stealthy means, including the following:

Typical addiction treatment clientele usually don’t have much money 22 RESILIENT HEALTH | April 2018

Use of requirements that allow insurance companies to decide who gets what level of care, such as residential care only after outpatient care fails Excessively frequent utilization reviews that bog down providers’ resources

Decentralized regulating bodies, which make it harder to hold insurance companies responsible for payments Delays by insurance companies in even beginning to process a claim (the average lag time is 30 days)

Critical Shortage of Psychiatric Beds and Providers When costs outweigh the insurance companies’ reimbursement rates and other subsidies cannot be found, private behavioral health care facilities go broke. Even with the number of new addiction treatment facilities that open every year, there is a shortage of beds to meet the growing need. State psychiatric beds are also in critically short supply despite the current epidemic of mental illness and drug use. According to a June 2016 report from the Treatment Advocacy Center, fewer state psychiatric hospitals are in operation now than at any other time (http://bit.ly/2xyMWrS). At least 40 to 60 beds per 100,000 people are needed, yet budget cuts have reduced that number to fewer than 12, one-fifth of the number www.reshealth.net

needed. This shortage leaves the “sickest of the sick” without treatment, according to John Snook, the center’s executive director. There is a workforce shortage in mental health caregivers, starting with psychiatrists. Of those currently in practice, nearly half accept only cash payment for their services. Doing so helps them to avoid the time-consuming hassle of billing and low or no reimbursement from insurance companies. This workforce shortage also includes mental health nurses, addiction counselors and qualified therapists. Finding care is particularly difficult in rural areas, many of which have been hardest hit by

economic recession and the opioid epidemic, and have a suicide rate twice that of urban areas. The current administration’s Better Health Reconciliation Act will result in billions of dollars being cut from all types of treatment and will further limit access to behavioral health care for all except the few who can afford to pay cash for their treatment.

A Bleak Future for Services As the mental health and addiction crises envelop the nation, behavioral health care treatment centers are facing high costs, low reimbursement rates, state budget cuts, bed shortages and a dearth of

providers. Most people who need psychiatric care don’t receive it. Of note is the fact that 60 percent of people with a substance use problem have a co-occurring mental health issue. The ripple effect of untreated mental illness and addiction is reminiscent of the destruction of China during its opium crisis in the 1800s to 1900s. As fraudulent providers are arrested for billing for therapy their socalled patients never got, leaders in mental health and addiction medicine are striving to establish quality standards in the field.

ALCOHOL AWARENESS MONTH

ounded and sponsored by the National Council on Alcoholism and Drug Dependence (NCADD), Alcohol Awareness Month was established in 1987 to help reduce the stigma often associated with alcoholism by encouraging communities to reach out to the American public each April with information about alcohol, alcoholism and recovery. Alcoholism is a chronic, progressive disease, genetically predisposed and often fatal if untreated. People can and do recover, however. In fact, it’s estimated that as many as 20 million individuals and family members are living lives in recovery. Alcohol Awareness Month provides a focused opportunity across America to increase awareness and understanding of alcoholism, its causes, effective treatment and recovery. It’s an opportunity to decrease stigma and misunderstandings to dismantle the barriers to treatment and recovery, and thus, make seeking help more readily available to those who suffer from this disease. Each April, NCADD’s National Network of Affiliates and other supporting organizations across the country address the nation’s No. 1 public health problem through a broad range of media strategies, awareness campaigns, programs and events in their local communities.

www.reshealth.net

With this year’s theme, “Changing Attitudes: It’s Not a Rite of Passage,” April is filled with local, state and national events aimed at educating people about the treatment and prevention of alcoholism, particularly among youths and the important role that parents can play in giving kids a better understanding of the impact that alcohol can have on their lives. Local NCADD affiliates, as well as schools, colleges, churches and other community organizations sponsor a host of activities that create awareness and encourage individuals and families to get help for alcohol-related problems. For more information, visit ncadd.org/about-ncadd/ events-awards/alcohol-awareness-month.

RESILIENT HEALTH | April 2018 23

FAC I L I T I E S O F S OV E R E I G N H EA LTH

Sovereign Health of Rancho San Diego San Diego, California Sovereign Health of Rancho San Diego is designed specifically to treat adolescent and teen patients struggling with substance use, mental health disorders and behavioral problems. Our residential facility is staffed by a compassionate and multidisciplinary treatment team who are trained to work with adolescents through every step of their treatment. Upon admission, our clinicians diagnose any underlying condition which may be present such as anxiety or depression. After a thorough assessment, patients are given a customized treatment plan to achieve the most successful outcomes. The San Diego facility sits on 25 acres of mountainous landscape with green belts and trees surrounding the property. It is the perfect place for adolescent patients to recover in a safe, tranquil and rural location. Accredited by the Joint Commission, our program utilizes evidence-based treatment modalities combined with a holistic focus for a well-balanced recovery. In addition, the San Diego facility holds a Community Care License from the Department of Social Services. Our licensed clinicians and multi-disciplinary medical professionals use several approaches to combat each presenting condition. Patients Served • Males and Females • 12 – 17 Years Old

Levels of Care • Residential Treatment • Partial Hospitalization • Intensive Outpatient • Recovery Management

For more information, please visit

www.sovteens.com 24 RESILIENT HEALTH | April 2018

Treatment Programs Offered: • Adolescents Only • Primary Mental Health • Substance Use • Dual Diagnosis • Telehealth • Eating Disorders • Gender Diversity & Transgender Identity Service

JOINT COMMISSION ACCREDITED

24/7 ADMISSIONS HELPLINE

888.701.7488 www.reshealth.net

Professional Perspectives: For Better or Worse, Technology Is Changing

Behavioral Health Care Delivery By Dana Connolly, Ph.D.

echnology has transformed health care—surgeons use robotic equipment for surgeries, many patients connect with their primary care doctors via PC for remote diagnoses, cell phone apps remind people to take their medications, pill boxes lock to prevent misuse of prescribed drugs. New electronic diagnostic and therapeutic tools, artificial intelligence (AI), telehealth and electronic medical records are increasingly used in most www.reshealth.net

disciplines. In behavioral health care, certain technological advances have improved addiction and mental health treatment, but there are some lingering pitfalls that must be addressed based on the following assumptions: Mental health is the sum of mental, physical and spiritual health AI lacks the human attributes essential to the healing arts, such as empathy and compassion

Electronic health information will always be at risk for privacy breeches Electronic health information may further marginalize mentally ill individuals

Mental Health Is the Sum of Mental, Physical and Spiritual Health Addiction is widely believed to be both a physical and spiritual malady;

RESILIENT HEALTH | April 2018 25

mental health in general has spiritual aspects as well. That begs the question—how can technology be applied to something as intangible as spirituality? On one hand, if mental health is the sum of mental, physical and spiritual health, then technology has a role in improving overall mental well-being. For example, functional magnetic resonance imaging can aid in the diagnosis of mental disorders by showing brain changes typical of mental disorders. Toxicology screenings motivate patients to remain clean and sober after discharge. Fitness trackers remind recovering patients to exercise regularly and get enough sleep. Telehealth helps connect therapists with patients who have no access to behavioral health care services. These applications show the potential of technology to improve patient care. On the other hand, each person has her or his own unique spiritual journey that cannot be achieved by technology. Once mental and physical health is restored, the spiritual work begins. There is technology that can support the spiritual side of recovery by providing resources such as virtual or drop-in support groups, listings of jobs and volunteer opportunities, and other online resources that connects patients to others. Connecting people to local support group meetings in their communities facilitates spiritual growth, and remote apps such as online reading, journaling and sharing experiences with others nationally and worldwide can do the same.

AI Lacks Human Attributes Essential to Healing, Such as Empathy and Compassion Using technology such as AI in the form of chatbots and virtual therapists can lead to inaccurate diagnoses and assessments, poor decisions and negative patient outcomes. Behavioral health patients should expect the same precision from AI-based treatment that other patients expect from a surgeon who uses AI in surgical procedures. AI proponents argue that AI chatbots and virtual therapists are cheap and effective resources for patients

People with mental illness health issues are already stigmatized by society. and help to solve the problem of provider shortages in behavioral health care. Apps such as Addicaid (addiction recovery) and Woebot (mental health) use AI to provide treatments, such as cognitive behavioral therapy, that would normally be provided by a trained professional. Using a combination of assessment data, clinical research, machine learning and adaptive AI, these apps help keep people on a healthy track throughout the day.

26 RESILIENT HEALTH | April 2018

Other science and technology experts, such as Elon Musk and the late Stephen Hawking, warn that AI technology that uses robots to make decisions for humans could threaten the welfare of humanity. They may have a point— cognitive computers will be able to analyze handwriting and speech for indicators of mental illness in as little as five years, according to IBM. The question is, how will this technology be used to benefit patients? Will it be abused to identify, label and marginalize healthy people for unethical purposes?

Electronic Health Information Is at Risk for Privacy Breeches As our recent national elections have shown, electronic data is vulnerable to hackers and privacy is not guaranteed. Insurance giant Centene/Health Net, for example, suffered massive patient data breaches in 2011 and 2009 that, together, compromised the information of nearly 3.5 million patients. What are the implications for other data breeches in behavioral health care? Electronic health information is protected under the Health Information Privacy Authorization Act (HIPAA) of 1996, which delineates how electronic medical information is to be protected, but breeches occur nonetheless. A recent study by the Brookings Institution ascertains that, “Since 2010, 1,819 data breaches affecting 500 or more patients have occurred in the U.S. originating from both www.reshealth.net

health care providers and their third-party business associates.” That translates to more than 171 million people, more than half the population of the United States. So, what should the penalties be for insurance companies and providers that fail to keep electronic health records secure? In the case of Centene’s 2009 breach, the insurer notoriously lost hard drives containing the personal health information of a million and a half subscribers. After an official search, the company reported that an employee accidently (but securely) had the drives destroyed. As implausible as that may sound, the narrative was accepted and no Centene affiliate was charged with wrongdoing. The company continues to expand and collect new customers, as if nothing had happened. Other insurers have had to pay reparations for HIPAA violations, but this is of no consolation to patients; once the information is out there, it’s out there.

Electronic Health Information May Further Marginalize the Mentally Ill Risk scores are statistical predictions of individual outcomes based on population data and algorithms. “Big data” inevitably leads to risk scoring, as seen in China, Germany and even in the United States. Risk scores can easily lead to unfair consequences when judgements about an individual are based on the average scores of others. Will electronic mental health records be used to calculate such scores that will further marginalize people who are mentally ill?

www.reshealth.net

People with mental illness health issues are already stigmatized by society. The false belief that mental illness is associated with violence is perpetuated in the media and used by governments as an excuse to violate human rights. Recently, president Trump responded to the school shooting in Parkland, Fla., by recommending that guns be taken from mentally ill individuals without due process of law. Such attitudes are not only discriminatory, they are danger-

Nanotechnology involves the ingestion or implantation of tiny electronic devices that can be used to diagnose or treat various illnesses or release medication at time intervals. ous. What if a woman traumatized by domestic violence seeks to arm herself from an estranged husband or boyfriend? Her diagnosis of trauma could deprive her of the very weapon she might need for protection.

Future Directions

health care. Nanotechnology involves the ingestion or implantation of tiny electronic devices that can be used to diagnose or treat various illnesses or release medication at time intervals. For example, new developments in depression treatment include implantable brain stimulation devices and antidepressant medication containing a sensor that communicates with psychiatrists to inform them whether patients are taking their medicine as prescribed. Similar forms of nanotechnology are being studied to treat addiction. But how else might technology inserted in our bodies be used? Will it inform insurers and employers of private health issues? Will it be used to force people to take medication when they are trying a more natural treatment? Certainly, the past few decades have seen incredible advances in innovative technologies that improve health care, with the promise of much more to come. But current addiction, overdose and suicide rates, as well as decreasing life expectancy in countries where health care technology is available, raises doubts about technology’s role in wellness. Some experts argue that a return to more natural approaches to health care would be a wiser direction to take. Technology by itself is neither positive nor negative. It is how technology is used that determines whether it will create a better or worse future.

From potential cures to alienating human-robot hybrids, nanotechnology is quickly emerging as the wave of the future in behavioral

RESILIENT HEALTH | April 2018 27

P RO G R A MS O F S OV E R E I G N H EA LTH

POWER Program for Women Sovereign Health is proud to announce specialized residential treatment services for women 40+ years of age through our POWER Program in Palm Desert, CA. Primary Opportunities for Women Experiencing Recovery (POWER) Program creates hope and recovery for mature women who are struggling with addiction or behavioral health disorders as they recover their physical and mental health. POWER includes all levels of care from detoxification to ongoing care management. The entire program was designed to provide the highest quality care possible to women over 40 and their families, from medical experts to specialized therapeutic modalities. This integrative program utilizes evidenced-based care and medical technology to diagnose and treat all underlying and co-occurring disorders to promote lasting recovery. POWER helps women manage health conditions, repair relationships and establish sober and supportive networks. Many women inadvertently develop unhealthy ways of coping with stress that compound over time until they simply can no longer manage life. In the POWER Program at Sovereign Health, we understand how addiction and mental illness develop and how to treat these inter-related conditions. Our multidisciplinary treatment teams work together to determine each woman’s needs and goals and strive to include her loved ones in the process. From arrival to discharge, patients are the most important members of our treatment teams. Patients Served • Women in their 40’s, 50’s, and 60’s • Women whose health, families, occupation or relationships have been affected by substance use or mental illness • Participants must voluntarily enter the program • Must be medically stable and ambulatory • Not actively suicidal, homicidal or psychotic

Conditions Treated: • Detoxification • Residential treatment • Partial hospitalization • Intensive outpatient • Ongoing care management and telehealth

For more information, please visit

www.sovhealth.com 28 RESILIENT HEALTH | April 2018

Treatment Programs Offered: • Detoxification • Primary Mental Health • Substance Use • Dual Diagnosis • Telehealth

24/7 ADMISSIONS HELPLINE

888.701.7488 www.reshealth.net

Eating Disorders:

be on the lookout for Eating Disorders in Female Patients By Lise Millay Stevens, M.A.

ou might be treating a woman or girl for depression, anxiety or obsessive-compulsive disorder, but another serious mental condition could be lurking in plain sight. This one kills more patients than any other mental condition— eating disorders. It’s estimated that 8-to-10 million people in the United States have an ED, and 30 million will have one at some point during their lives. Only about 1 in 10 receive any treatment at all for their condition. EDs affect people www.reshealth.net

of every age, sex, gender, ethnicity and socioeconomic group, but females are twice as likely to have an ED than males, and these disorders often occur in the setting of another mental health condition. EDs are often fatal, so being on the lookout for these underreported conditions can help save a life. The highest risk age group for EDs is females ages 15 to 24 years, but middle-aged and older women are also vulnerable. The most

common ED is binge-eating disorder (bouts of over-eating followed by feelings of guilt and shame, but absent of purging behaviors—inducing vomiting/taking laxatives), but anorexia nervosa (severe undereating) and bulimia (bouts of overeating followed by guilt, shame and purging) are also prevalent in females. Others include specified feeding and eating disorders (OSFED) and “pica,” or persistent craving and compulsive eating of nonfood substances, common in young children.

RESILIENT HEALTH | April 2018 29

EDs are extremely serious conditions and the most lethal of all mental health conditions; females with anorexia are particularly at high risk for suicide. The serious health effects caused by EDs are well documented. Common side-effects include diabetes, gastrointestinal disorders and severe effects on multiple organ systems, which are all too often fatal. Another ED – diabulimia – causes patients to skip their insulin injections, also risking death. Therefore, screening for and treating EDs is vital to patient safety and well-being.

Complex, Interwoven Causes Research indicates that a range of biological, psychological and sociocultural factors are involved in the development of EDs in females. The primary cause and interaction of these forces varies widely among individual patients. Common triggers include: Biological Causes. EDs run in families, especially those whose members have mental health conditions such as anxiety, depression and ad-

diction. When an ED is suspected, taking a detailed family health history is important to identify highrisk patients. Psychological Causes. Patients who show a tendency to be perfectionists and set unrealistically high goals for themselves (self-oriented perfectionism), are at a higher risk for EDs. This drive to be perfect often extends to having an overly-critical body image and unrealistic goals about obtaining the perfect physique. Unfortunately, the persistent Western norm of “thinner is better” feeds perfectionist tendencies and may even trigger EDs and body dysmorphia—a distorted view of “fatness” and “thinness” common in people with EDs. It’s important to note that, just as people with other mental disorders suffer from food/eating disorders, the reverse is also true. Research has shown that upward of 65 percent of patients with EDs have an accompanying mental health issue that existed before the ED. Twothirds of females with anorexia, for example, have signs of an

30 RESILIENT HEALTH | April 2018

anxiety disorder (including generalized anxiety, social phobia and obsessive-compulsive disorder) before onset of the ED. Another psychological sign to be alert for is behavioral inflexibility—patients who strictly followed rules as children and believed there is only one “right” way of doing things. The isolation, depression and anxiety that frequently accompany both EDs and mental issues cause one to feed the other. Sociocultural Causes. Societal influences, such as “weight stigma,” are also huge influencers on ED development. Many U.S. models, entertainers and athletes—people who are in the public eye—have revealed ongoing struggles with EDs, which might seem to normalize these conditions and even make them chic. Repeated exposure to rail-thin role models in-and-of-itself may spur dissatisfaction with one’s weight and physique. Even the ongoing national conversation about the obesity epidemic, although valid, can inadvertently trigger “weight shaming,” particularly in the context of well-meant but www.reshealth.net

sometimes damaging anti-obesity campaigns. If an ED is suspected, checking patients for a history of being bullied is important; victims of bullying are at higher risk of EDs. Approximately 65 percent of people with an ED subjected to bullying reported that it contributed to developing the problem. Bullying is particularly common in higher weight children, including teasing by friends and family. In addition to therapy for the patient, family members need to be educated about healthy conversations regarding eating. The American Academy of Pediatrics has useful resources on this topic (visit http://bit.ly/2kf8VRA ) as does the Alliance for a Healthier Generation (more at http://bit.ly/1mbaxCv). The role of culture in triggering EDs cannot be understated. Consider screening patients who are recent transplants to the United States if an ED is suspected; pervasive culture of thinness in this country may be taking its toll. (Example: Fiji women who were previously comfortable with their bodies developed eating disorders within three years of being exposed to Western television—74 percent felt “too fat,” 69 percent dieted and 11 percent used self-induced vomiting to control their weight.)

Brittle nails, hair loss A preoccupation with weight, food, fat grams, calories Restrictions/refusal to eat entire categories of food (e.g.; carbohydrates) Frequent comments about “feeling fat” or overweight Constipation, abdominal pain, cold intolerance, lethargy or excess energy A keen interest in “burning” calories and/or excessive exercising Withdrawal from friends and pleasurable activities; isolation A need for control; restrained emotions

Bullying is particularly common in higher weight children, including

Dramatic weight loss and/or dressing in layers to hide it www.reshealth.net

EDs are notoriously difficult to treat, and patients might have several relapses, but recovery is possible. The National Institutes for Mental Health recommends nutrition counseling, reducing exercise and stopping purging as a base, followed by approaches such as individual, group and/or family therapy; medical care and monitoring; psychotherapy such as cognitive behavioral therapy; and medications for depression, anxiety and other mental conditions. For additional resources for you and your patient, visit http://bit.ly/2cSIOb6. Also, read and share the accompanying “10 Myths About Eating Disorders” article on page 32 of RESILIENT HEALTH. Remind your patient that she is not at fault for her ED. Explain that millions of girls and women share their disorder, and that genetics, cultural pressures and if applicable, her co-existing mental health disorder might be to blame. Let her know that the problem is not vanity or a lack of willpower or a moral failing. Assert that recovery from EDs can and does happen every day for thousands of girls and women.

teasing by friends and family. Family members need to be educated about healthy conversations about eating.

What to Look For Female patients with EDs may exhibit signs of their disorder; not all patients will show all these signs, and some may have none. Nevertheless, be alert for:

in people with EDs, a suicide risk screening might be in order (http:// bit.ly/2Dq5Zpv), especially patients who show signs of anorexia.

If an ED is suspected, use a trusted screening tool such as the National Eating Disorders Association questionnaire (see http://bit.ly/2mHVNBz); NEDA also has a hotline (800931-2237) for clinicians as well.. Given the prevalence of suicide RESILIENT HEALTH | April 2018 31

ou b A s h t My

, evens t S y a l e Mil

M.A.

By Lis

1. Eating disorders are primarily about food.

see if a person has an eating disorder, but you can’t tell just by looking at people if they have one.

If someone eats too much, the answer is to just stop eating; if they eat too little, the answer is to just eat.

3. You can never exercise too much.

False! Eating disorders are illnesses, just like pneumonia or diabetes or the flu. They have nothing to do with the willpower to start or stop eating. Instead, eating disorders are complex medical issues caused by many factors such as genetic make-up, societal influences and a history of trauma such as being bullied, physically assaulted or other abuse. All of these factors must be taken into account; eating disorders cannot be willed away. People with these conditions need compassion and treatment.

2. People who are normal or overweight do not have eating disorders. False! People of all sizes, shapes and weights can have an eating disorder. A counselor, therapist, doctor or other health care professional can ask the right questions to 32 RESILIENT HEALTH | April 2018

False! Although getting regular exercise is a good idea, too much can stress the body, especially when a person is not taking in enough calories. Too much exercise can be very unhealthy and cause problems such as dehydration, fatigue and injuries such as shin splints, cartilage damage, stress fractures, osteoporosis, lack of a menstrual cycle, heart problems and arthritis.

4. Only women are affected by eating disorders. False! Women are not the only ones who can suffer from eating disorders; boys and men can have these conditions as well. What is true is that, for a variety of reasons, more girls and women have eating disorders than boys and men do.

www.reshealth.net

5. Eating disorders are a disease of vanity or of choice. False! People do not choose to have eating disorders; they arise from a combination of factors, but vanity and choice have nothing to do with it. Sometimes a person’s genetic makeup or family history are responsible; social factors and environment can play a big role; other mental conditions can be responsible as well.

6. It’s all about the food. False! It isn’t really about the food itself. Sometimes eating disorders are about the pleasure food brings and the need to keep feeling that ‘high’ over and over to block out an unpleasant memory or upsetting feelings. Or it might be the association a person has between a certain food and a pleasant or unpleasant memory. Sometimes, it’s about how a person feels about how their body looks, even when they are mistaken.

balanced meals as they recover from their condition. And the good news is that they can still treat themselves now and then to a high-calorie treat. It’s all about eating differently and getting in three healthy meals plus nutritious snacks.

10. Achieving a normal weight means the eating disorder is cured. False! Treating eating disorders involves treating both psychological and physical conditions as a patient either gains or loses the weight he/she needs to be healthy. Psychological counseling and medications to treat other distressing mental symptoms might be in order, in addition to art therapy, horse therapy, writing a journal or other activities. Regardless, people with eating disorders need compassion and support from family and friends to help them on the road to recovery.

7. Only rich people, gay men, girls and women get eating disorders. False! Eating disorders affect people of all sexes, races, ethnicities, religions, cultures and backgrounds worldwide, on every continent on earth. Although more common in girls and women, anyone can get an eating disorder, and no one should be blamed for having one. About 50 percent of people know someone with an eating disorder or have one themselves. The important thing is to get treated.

8. Only young people get eating disorders. False! Although more common in girls and younger women, eating disorders can happen to anyone at any age. People who are treated for their eating disorder at a young age find it comes back later in life. Other people spend decades with no eating issues but develop one later, in their 50s, 60s or even later.

9. A person has to stop eating, or start eating, or cut out their favorite foods to cure her/his eating disorder. False! One of the first steps in treating an eating disorder is counseling about nutrition – what to eat, when to eat and how much to eat. People can eat normal

www.reshealth.net

RESILIENT HEALTH | April 2018 33

P RO G R A MS O F S OV E R E I G N H EA LTH

Eating Disorders Patients in Sovereign Health’s Eating Disorders Program receive treatment and live in a nurturing, compassionate and non-judgmental environment that helps them recognize their strengths while working to eliminate the shame and guilt associated with eating disorder behaviors. The Eating Disorders Program offers an extensive variety in group therapies, dietary education and outside activities that promote healing. We aim to increase positive behaviors while minimizing the emphasis on negative behaviors. The results we seek for our patients are better self-esteem, more self-confidence, an ability to set and meet goals, and an interest and desire to live a full and meaningful life.

Treatment Provided For:

The Eating Disorders Program at Sovereign Health helps instill hope and belief that there is a better way to deal with the stresses of life. Our priority is to help patients discover a way to live without the focus on food and body image. Eating disorders are life-threatening. Untreated, eating disorders can lead to malnutrition, organ damage and death. The psychiatric effects and impact on relationships are also severe, causing some people with eating disorders to turn to drugs or alcohol to numb their feelings of shame, depression, anxiety and fear.

• Anorexia Nervosa

Patients Served

Levels of Care

• Women • 18 Years and Older

• Partial Hospitalization • Intensive Outpatient

For more information, please visit

www.sovhealth.com 34 RESILIENT HEALTH | April 2018

• Women Only

• Bulimia Nervosa • Binge Eating Disorder

24/7 ADMISSIONS HELPLINE

888.701.7488 www.reshealth.net

At A Glance:

BEHAVIORAL HEALTH IN THE NEWS By Lise Millay Stevens, M.A. CDC: Opioid Overdoses Continue to Increase Nationwide According to the latest data from the Centers for Disease Control and Prevention, emergency department visits for opioid overdoses rose 30 percent nationwide from July 2016 through September 2017. (The CDC defines an opioid as prescription pain medications, heroin and illicitly-manufactured fentanyl.) The Midwest was particularly hard hit—over the 15-month period, ED visits due to opioid overdose rose a stunning 70 percent. However, big www.reshealth.net

city rates also spiked, marking a 54 percent increase in 16 states. The CDC’s data show that the opioid epidemic continues to affect virtually every demographic group: ED overdose rates in men increased 30 percent and in women, 24 percent. Regarding age groups, opioid overdoses increased 31 percent in those 25 to 34 years of age, 36 percent in those 35 to 54 years and 32 percent in people age 55 and older. The CDC report notes that, given the fact that people who have one overdose ED visit are likely

to have another, these visits represent a prime opportunity for health care professionals to intervene. The agency recommends that ED health care professionals provide naloxone and link patients to medication-assisted treatment (MAT) and other professional care to stem the tide of rising overdose ED visits and deaths. “This fast-moving epidemic does not stay within state and county lines,” the report authors comment. “Coordinated action between EDs, health departments, mental health and treatment pro-

RESILIENT HEALTH | April 2018 35

viders, community-based organizations, and law enforcement can prevent opioid overdose and death.” The data are a stark reminder that the opioid epidemic continues to wreak havoc in both rural and urban communities across the entire country. A dramatically stepped-up national effort is needed to ensure that people with substance use disorder, many of whom also suffer from mental health issues, receive coordinated and evidence-based treatment. Otherwise, we can only expect the body count to keep rising.

Critical Shortage of Mental Health Professionals According to a new report, there is a growing U.S. shortage of mental health professionals, particularly in rural areas. Given that these are the very locations most affected by the exploding opioid epidemic, the data do not bode well for the millions of people with untreated substance use and mental health issues, not to mention spiking depression and suicide rates. The National Council Medical Director Institute issued the report. The authors write, “The lack of access has created a crisis throughout the U.S. health care system that is harmful and frustrating for patients, their families and other health care providers, and is becoming increasingly expensive for payers and society at large.” The shortage is spurred by the very factors that improve health care—greater awareness of mental health and substance use issues, and the addition of new patients

under the Affordable Care Act. The authors state that plummeting reimbursement rates for behavioral health care and providers in the field are also to blame. “There is a great irony in the implementation of health care reform,” the authors state. “On one hand, there is increasing recognition of the value of psychiatry and of behavioral health services as key components to the reduction of the total cost of care and improvement of general health outcomes. Yet these developments contrast starkly with the historically low rates of reimbursement for psychiatrists, other providers and their associated outpatient and inpatient services.” The current administration has declared the opioid epidemic a public health emergency but has not provided a plan to increase reimbursement of, and funding for, comprehensive behavioral health services. Until that happens, the drought of qualified professionals is bound to expand.

White House Opioid Summit The Trump administration held its first Opioid Summit on March 1; speakers included the top brass from several U.S. agencies, plus the President and First Lady. According to one news source, the President’s main messages to the audience were that the administration may toughen legal action against opioid manufacturers and may seek the death penalty for drug dealers.

crepancy between Trump’s tough talk and comments by Health and Human Services Secretary Alex Aznar, who advocates medication-assisted therapy and viewing people with addictions as being in need of medical help and as morally corrupt. According to the Post, Dr. Aznar commented, “We need to treat addiction as a medical challenge, not as moral failing.” Summit speakers discussed new rules to allow states to circumvent antiquated legislation that creates barriers to how states use funds for treating mental health and addiction and highlighted the increase funds allocated for fighting the opioid epidemic. However, according to the Post, details were scant on new initiatives and the status of recommendations from the President’s opioid task force, which alarms members of Congress. “While I appreciate that the Trump Administration is continuing to raise awareness about the devastating fentanyl, heroin, and opioid crisis with today’s White House Opioid Summit, what we really need is meaningful action, not just more words,” Sen. Maggie Hassan (D-N.H.) said in a statement, according to the Post article. History shows that cracking down on drug dealers does not curb drug addiction and does nothing to address mental health issues. A year into Trump’s presidency, a clear and detailed plan to mitigate the opioid crisis is still lacking.

The Washington Post’s reporting on the summit highlighted the dis-

36 RESILIENT HEALTH | April 2018

www.reshealth.net

FAC I L I T I E S O F S OV E R E I G N H EA LTH

Sovereign Health of San Clemente San Clemente, California Sovereign Health of San Clemente offers high-quality and comprehensive detox, addiction, dual diagnosis and mental health services in residential, partial hospitalization, intensive outpatient and outpatient settings. We also provide specialized treatment including: a holistic detox recovery program, an eating disorders program and a pain recovery program. All of our programs focus on addressing underlying mental health conditions by utilizing innovative and cutting-edge cognitive testing, rehabilitation techniques, and meaurement-based treatment modalities. In addition to thorough assessments, cognitive behavioral therapy, dialectical behavior therapy and individual and group psychotherapy, we offer alternative therapeutic activities such as yoga, equine therapy, art therapy, mindfulness meditation and breathing techniques to help an individual overcome issues and regain control of his or her life.

Treatment Programs Offered: • Detoxification • Nutritionally Assisted Detox • Primary Mental Health

Our Orange County location acts as the flagship for Sovereign Health services by offering both a treatment center and our main offices. This center sits only a few miles from the Pacific Ocean, providing the ideal setting for anyone seeking behavioral health treatment. We have a caring and understanding staff that helps patients feel comfortable and ultimately focus on healing and rebuilding their lives.

• Substance Use

Patients Served

Levels of Care

• Pain Recovery

• Men and Women • 18 Years and Older

• Detoxification • Residential Treatment • Partial Hospitalization • Intensive Outpatient • Outpatient • Recovery Management

For more information, please visit

www.sovcal.com www.reshealth.net

• Dual Diagnosis • Telehealth • Eating Disorders

24/7 ADMISSIONS HELPLINE

888.701.7488

RESILIENT HEALTH | April 2018 37

1211 Puerta Del Sol, Suite 200 San Clemente, CA 92673 (888) 701-7488 www.sovhealth.com

38 RESILIENT HEALTH | April 2018