The Intersection of Behavioral Health, Mental Health, and Health Literacy Proceedings of a Workshop (2019) / Chapter Skim
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3 Setting the Stage
3 Setting the Stage
Pages 17-36
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From page 17... ...
DEFINING MENTAL HEALTH AND BEHAVIORAL HEALTH: WHAT IS THE DIFFERENCE? 1 After agreeing with the comments of the last session that training in communication issues for health care providers is "woefully inadequate," Wilson Compton said he hoped this workshop would generate some action 1 This section is based on the presentation by Wilson Compton, the deputy director of the National Institute on Drug Abuse, and the statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.
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From page 18... ...
To him, he said, behavioral health includes mental illness as well as substance abuse and addictive disorders. He added that topics such as medication adherence, which is a behavioral issue, are related subjects but are not generally included in the term "behavioral health." Because behavioral health is such an overarching label, it is important to define the term, particularly in publications.
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From page 19... ...
While mental illness may be a more specific term, it, too, includes a broad category of disorders -- autism and autism spectrum disorders, childhood behavioral conditions such as conduct disorder and oppositional d efiant disorder, Alzheimer's disease and other dementias in older adults, and major mental illnesses such as depression, bipolar disorder, or schizophrenia. "Each one of those deserves some separate attention and some nuance," Compton said, "so I remind us that even as we think in these broad categories we need to pay attention as well to the individual needs within each of those diagnostic groups, because while there will be a few similarities, there will be nuances in terms of the specific disorder." The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)
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He did applaud the change in philosophy toward medication that has been adopted by programs such as Betty Ford and Hazelden, stalwarts of 12-step approaches to addiction, when shown the data that their patients were unsuccessful when not offered medication and that they were not continued on medication in the longer term. Concerning approaches to address these issues, Compton said he believes it is possible to change attitudes, reduce stigma, and tailor communication to patients with behavioral health and mental health disorders.
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Steffens said the signs and symptoms of executive dysfunction include trouble grasping the main idea of something, struggling to weigh benefits and risks, general difficulty making decisions, problems holding onto a several-step mental process, trouble initiating lists or making new goals, and a lack of flexibility. Executive function control resides in the brain's frontal lobes, the same brain region involved in a wide variety of mental illnesses and substance use disorders (Arnsten and Rubia, 2012)
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Information processing, the fourth aspect of cognition that comes into play in mental illnesses, refers to the ability to take in environmen
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Some studies of cognitive remediation and cognitive training have shown them to be helpful at improving executive function and memory (Best and Bowie, 2017; Best et al., 2019) , and recent research suggests that neurostimulation may help alleviate some of the underlying cognitive disorders that are part of mental illness (Francis et al., 2018)
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Second, the heath literacy skills needed to successfully manage health are determined by the design and accessibility of a health care system and the demands those place on the individual. Third, reducing cognitive burden entails communicating better, simplifying patient roles by changing workflows and processes, and having a proactive learning health care system that works to understand patients better and uses data to act on that understanding.
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FIGURE 3-1 Conceptual frameworks to link cognition and health literacy. SOURCES: As presented by Michael Wolf at the workshop The Intersection of Behavioral Health, Mental Health, and Health L iteracy on July 11, 2018; Paasche-Orlow and Wolf, 2007; Shippee et al., 2012.
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For example, it is possible to reduce the cognitive load of print health information for individuals with marginal health literacy but not for those with low health literacy. In addition, the evidence supporting the effectiveness of interventions optimizing multimedia and spoken health information is limited.
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"As we get older, we naturally develop multiple morbidities, and we have more and more issues that fall onto our place and create greater self-management demands at the same time that we see a natural age-related decline in cognitive ability." HEALTH LITERACY PRINCIPLES IN MENTAL AND BEHAVIORAL HEALTH4 One of the most important ways to enable shared decision making and patient-centered, integrative, collaborative care and to meet people in their communities, including social online communities, is via a health-literate organization (see Figure 3-2) , Catina O'Leary said.
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Mental illness, O'Leary said, makes it more likely that an individual will experience problems accessing health care because of such system factors as fragmentation and a lack of coordinated care. Another issue is that behavioral health providers, who are "trained communicators," are not versed in the principles of health literacy, she said.
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Four techniques from health literacy -- conducting a health environment assessment, using plain language in written materials and when speaking, developing symptombased communication strategies, and displaying empathy, humanness, and kindness -- are particularly useful with this population. Based on the Integrated Behavioral Health Project's Interagency Toolkit, O'Leary suggested several steps that providers can take to reduce barriers to communicating with their patients with a mental illness and to creating a safe and welcoming environment for them (IBHP, 2013)
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"We had all of these behavioral health providers who did not really have any prior knowledge of verbal communications or written communications and all the sort of standard interventions we do," O'Leary said. She and her team also conducted health environment assessments at 5 of Truman Medical Centers' behavioral health facilities, reviewed and revised 56 pages of existing patient-facing documents, and wrote and designed 96 pages of new client education materials using plain language principles.
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Individuals with low health literacy, she said, tend to have poor health status, use emergency rooms more frequently, and have a higher death rate -- problems that are multiplied for those with mental illness. She also called on the health literacy community to work with mental health systems to integrate health literacy into daily practice by training medical staff on communication strategies to increase patient understanding, educating those who develop health-related documents to use plain language practices, and assessing health systems for their health literacy and helping them apply targeted health literacy best practices to address identified shortcomings.
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He noted that his practice is rolling out a two-step cognitive impairment detection protocol that might serve as a first alert that a person might need more time for an appointment. Steffens said that he hopes such an approach could be expanded to populations of people with chronic and persistent mental illness.
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From page 33... ...
"I would love to know when my patients are drinking, smoking cigarettes, or using other substances," he said. Wolf said that the health literacy field could increase its efforts to make sure that user interfaces are compelling and that they have been developed following health literacy principles.
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For example, he said, those with cognitive impairment and adequate health literacy have outcomes similar to those with normal cognitive capabilities and low health literacy. Jennifer Dillaha from the Arkansas Department of Health recounted the horror she felt one day when she realized that a patient she had seen several times had a cognitive impairment that she had not detected in previous appointments; she said it was similar to the horror she felt when she realized she was seeing patients with low health literacy who were walking out of the appointments and going out into the waiting room and asking their daughter or son to explain what she had just said.
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Davis noted that the Kahn Academy, which offers online videos to help kids master new school subjects, has figured out how to use technology to reduce the cognitive burden for children who have difficulty learning certain subjects, and she asked if researchers are developing similar approaches to help reduce the cognitive burden of patients and families. Wolf said that there are many examples in the health literacy evidence base showing that there are ways of reducing cognitive burden in the health care setting, and that technology plays a role in some of these approaches.
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From page 36... ...
IBHP (Integrated Behavioral Health Project)
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