Caribbean Exploratory Research Center

3rd Annual Health Disparities InstituteMarriott Frenchman’s Reef

St. Thomas, USVIOctober 21-22, 2010

October 21, 2010

JM Valmond, MS, MPH, University of Texas School of Public Health, Houston, Texas

G Callwood, PhD, RN, Caribbean Exploratory Research Center,

University of the Virgin Islands (UVI), St. Thomas, USVI

ObjectivesAt the end of this presentation participants will be

able to:1.  Describe the mental health and substance abuse

system of care in the United States Virgin Islands (USVI)

2.  Discuss issues and challenges impacting the mental health and substance abuse system of care in the USVI population

3. Explore strategies and opportunities to strengthen the mental health and substance abuse system of care for all segments of the USVI population

Background• The U.S. Virgin Islands are an unincorporated

territory of the United States • Residents are U.S. citizens, but do not vote in

U.S. presidential elections.• Population 111, 470 (2005 estimates, 2005 VI

Household Income & Expenditure Survey) residing on the four main islands of St. Croix, St. Thomas, St. John and Water Island.

• 76.2% Black, 13.1% White, 1.1% Asian American and 6.1% Other (2000 U.S. Census).

• 47.6% Male, 52.4% female (2000 US Census)

Background (cont’d)33.2% report they are foreign born, of which the

majority (92.2%) are from the Caribbean21.2% report race as Hispanic/Latino for St. Croix,

7.3% for St. ThomasOf population 5 and older, 25.3% speak language other

than English at home; for St. Croix and St. Thomas, the language most spoken is Spanish

Families living below the poverty level in 1999 was 28.7%, with St. Croix at 34.8%, St. Thomas at 23% and St. John at 14.8%

2000 US Census

USVI Public Health System Context/frameworkUS Department of Health and Human Services

“Achieving the Promise: Transforming Mental Health Care in America”-Commission on Mental Health (2003)

Healthy People 2010/2020Substance Abuse and Mental Health Services

Administration (SAMHSA)USVI Department of Health (DOH)

USVI Healthy People 2010/2020Division of Mental Health, Alcoholism and Drug

Dependency Services

VI Healthy People 2010Focus Area

Goals Objectives Issues and Challenges

18. Mental Health & Mental Disorders

Improve mental health and ensure access to appropriate, quality mental health services

•Increase the proportion of children with mental health problems who receive treatment.•Increase the proportion of adults with mental health disorders who receive treatment for both disorder•Increase the proportion of persons with co-occurring substance abuse and mental disorders who receive treatment for both disorders

•No reliable data on the incidence of mental illness in the community;•Major problems in delivery, coordination and integration of services;•Lack of services for children with mental disorders; •Increase in demand for counseling and case management services, especially among women and children

VI Healthy People 2010Focus Area

Goals Objectives Issues and Challenges

26. Substance Abuse

Reduce substance abuse to protect health, safety, and quality of life for all, especially children

Reduce the treatment gap for illicit drugs in the general population

Reduce the Treatment Gap for Alcohol Problems

•Alcohol most commonly used substance; •Increase in alcohol use among early teenage adolescents;•Alcoholism accounts for most co-occurring disorders;•Marijuana second to alcohol, especially in teen males;•Crack-cocaine preferred by adult Black and cocaine by adult White;•Heroin drug of choice for both Hispanic and White adults

Mental Health and Substance Abuse System of Care in the

USVIVirgin Islands Mental Health Planning & Advisory Council

Professional Boards

USVI Department of Health (DOH)• Legal authority set forth in Virgin Islands Code,

Titles 3 and 19; • Functions as both the state regulatory agency and

the territorial public health agency for the U.S. Virgin Islands.

• Responsible for regulation of health care providers and facilities, policy development and planning, as well as vital statistics for the population.

• Direct responsibility for conducting programs of health promotion, protection and preventive medicine

USVI DOH (cont’d)• Organized into two major divisions – Public Health

Services and Health Promotion & Statistics. • Unlike state health departments on the U.S.

mainland the DOH provides health services in its community health centers territory wide.

• Boards license and regulate health care professionals.

• Employs over 600 • Budget of $ 73,931,617 million includes

$36,187,883 in Federal Funds (Governor’s Budget, FY 2011)

Division of Mental Health, Alcoholism and Drug Dependency Services

(DMHADDS)• Division within Public Health Services charged with

establishing and administering programs designed to offer prevention and treatment intervention in the areas of substance abuse prevention, substance abuse treatment, mental health and residential services.

• Goals: – To provide comprehensive prevention and

treatment intervention services to clients, including children, who have mental challenges and who abuse substances ;

– To foster self-management and wellness behavior that would promote and sustain recovery

Source: DMHADDS

Division of Mental Health, Alcoholism and Drug Dependency Services (DMHADDS)Service sites:

– St. ThomasSt. Thomas Mental Health Clinic, Charlotte

Amalie– St. Croix

Christiansted Community Mental Health Clinic

Frederiksted Mental Health Clinic– St. John

Morris F. DeCastro Clinic, Cruz bay, St. John

Division of Mental Health, Alcoholism and Drug Dependency Services (DMHADDS)Clients served (FY 2009)Served 667 clients in 4 clinics; 21 in methadone program

(available on St. Croix only)264 seen in St. Thomas-St. john; 403 in St. Croix district51% female; 49% male71 % report non-Hispanic, and 17% Hispanic, 12% otherApproximately 16% under the age of 18Prevention services on St. Croix reached in excess of 800

youth with evidenced-based outreach programsSchizophrenia, bi-polar disorder most frequent diagnoses

seen in mental health clinics

DMHADDS Reports

Division of Mental Health, Alcoholism and Drug Dependency ServicesPrevention/primary care services

(Community Health Clinics):• Case management (1 case manager on St.

Thomas, 4 on St. Croix to serve its two clinics, and none on St. John)

• Crisis intervention• Individual, family, child, and group counseling• Medication management• Psychological testing and evaluation

Division of Mental Health, Alcoholism and Drug Dependency ServicesPrevention/primary care services

(Community Health Clinics) (cont’d)• consultation • court reports • referrals (e.g.. HIV/STD/TB clinic, MH clinic,

GYN, AA, NA) • evaluations for emergency commitments; • Opiate Treatment Program ( aka the

Methadone Treatment Program)-screening, daily medication and group counseling

Division of Mental Health, Alcoholism and Drug Dependency Services• Long-term Residential Services

Eldra Schulterbrandt Residential Long-term Care Facility, St. Thomas-29 beds

New residential facility due to open (32-bed), St. Thomas, adjacent to Eldra Schulterbrandt Facility

Off-island placements Outreach Programs School-based prevention programs Presentations to work sites/other organizations

by request Community outreach services

Acute Care

Two public hospitals provide acute inpatient mental health services

• Juan F Luis Hospital-Psychiatric Unit, St. Croix– 8-bed unit, with average census of 1-3– Top 5 conditions: chronic schizophrenia, bipolar

disorder(manic phase), drug-abusers, suicides and situational depressed (possible bipolar)

– Staffing of 2 Psychiatrists, 1 Psychologist, 6 RN (1 Certified Psych), 2 LPN, 4 CNA

• Roy Lester Schneider Hospital and Medical Center-Neurological-Behavioral Unit, St. Thomas– 21-bed unit, with average census of 8-10– Top 3 conditions: schizophrenia, bipolar, suicide

Other government agencies: Department of Human Services (DHS)-Virgin

Islands Behavioral Service/Youth Rehabilitation Center-residential treatment/programs for troubled youth

Department of Education (VIDOE)-referral of students by school counselors

Department of Justice (DOJ)-Residential Substance Abuse Treatment Program (RSAT) for inmates/referrals and court-orders

VI Department of Public Safety (VIDPS)-forensic psychology/data on substance related vehicular accidents/first responders/intervention with mentally ill and homeless

Private sector providers/servicesPsychiatristsPsychologistsCounselors/Counseling servicesPsychotherapyResidential services for adolescents-

Seaview, St. Thomas

Community Based/non-profit organizations

Programs/services:• St. Croix Unity Coalition- community substance abuse prevention• Council On Alcoholism and Drug Dependence (COAST)- community

substance abuse prevention, St. Thomas• St. Croix Mission Outreach-residential and outpatient treatment,

continuing care support groups, rental/utility/food assistance, care management for homeless and addicted

• Ten Thousand Helpers of St. Croix-homeless center, biennial mental health conference, youth programs, hope and recovery for mentally ill

• The Village Virgin Islands Partners in Recovery-halfway house, women’s after care, outpatient, EAP, Solutions Improvisation, Partners in Parenting for both mentally ill and substance abuse clients

• Clear Blue Sky-clubhouse for mentally ill rejoining the community • Karen’s House-assisted living facility• Kidscope/Family Resource Center• Al-anon• Alcoholics Anonymous (AA)• Narcotics Anonymous (NA)• A.R.C.H-Better Choices for a Better Future (youth prevention

programs)

Community Based/non-profit organizations

Advocacy • Disability Rights Center of the USVI (legal

rights/advocates for persons with disabilities, including mentally ill)

• The Virgin Islands Alliance for Mental Health Consumers/Survivors, Inc.

• The Virgin Islands Alliance for the Mentally Ill, Inc.

• Ten Thousand Helpers of St. Croix, Inc.• Clear Blue Sky

DOH Public Health System Strengths

Service Delivery/access:• Services provided in community health clinics allow for

better access and care coordination• System of care involves the consumer or family in

developing and implementing treatment plans• Services provided regardless of ability to pay• Committed staff, some trained in the recovery model of

care (best practice model)• St. Croix prevention staff utilize CSAP six strategies for

effective prevention and outreach

Site visit Report

Issues and Challenges Impacting the Mental Health and Substance Abuse System of Care in the USVIAlcohol remains the most commonly used substance among

high school youth and adultsOn average, 35% (compared to 48% for mainland US)

reported use in the past 30 days (YRBS), with Hispanic males in grades 11 and 12 being most at risk (VIP SIG Needs Assessment Report, 2006)

Adult rates are similar to US mainland rates, around 46% compared to just over 50% for US

Schizophrenia seems to be the most commonly seen mental illness at USVI (RLS/JFL staff interviews) inpatient facilities

Suicide seems to be on the riseMentally ill homeless VIP-SIG Grant: Prevention Needs Assessment (2006)

Issues and Challenges Impacting the Mental Health and Substance Abuse System of Care in the USVIPublic health sector:• Limited to no reliable data • Only basic services provided on a regular basis

for adults with Severe Mental Illness (SMI)• Limited community-based, supportive services for

children with Severe Emotional Disorder (SED). • Insufficient case management and outreach

services• No recovery elements due largely to lack of

resources needed to implement• • 2009 Site Visit Report, Community Mental Health Block Grant Monitoring

Issues and Challenges Impacting the Mental Health and Substance Abuse System of Care in the USVIPublic health sector (cont’d):• Difficult access to certain services due to cost

and time constraints for inter-island travel • Levels of service different by island • Waiting lists for basic services• Staff shortages-psychiatrists, mental health

staff at all levels, social workers• No cultural competency training program for

service providers or mandated services for diverse sub-populations

Issues and Challenges Impacting the Mental Health and Substance Abuse System of Care in the USVIPublic Health Sector Funding

Total funding declined from 2007($8,568,163) to 2009 ($6,270,767)

Local funding increased ($4,822,166-$5,365,722) slightly;

Federal funds of $1,690,472 (FY 2011 Budget projections)

Medicaid not significant source of revenue due to Federal cap on Medicaid Title XIX programs

Issues and Challenges Impacting the Mental Health and Substance Abuse System of Care in the USVIIssues related to overall system of care:• Limited meaningful data for system oversight, planning

and evaluation• Fragmented system of care• Lack of transitional programs from acute care to

outpatient services and related support services • Serious gaps in services/continuum of services, to

include suicide prevention and services for homeless mentally ill

• Staffing (shortages, non-competitive salaries, professional development)

• Dwindling funding for mental health and substance abuse

2009 Site visit report

Issues and Challenges Impacting the Mental Health and Substance Abuse System of Care in the USVIChallengesTransforming mental health care in the US Virgin Islands• Building capacity in the health care system, to include

surveillance and dissemination of meaningful data for program planning and resource allocation

• Building capacity in the community, to include trained staff and providers at all levels in the continuum of care

• Making the service delivery system recovery oriented• Increased advocacy

Strategies and opportunities to strengthen the system of care for all segments of the population

• Infrastructure for ongoing data collection, analysis and dissemination

• A strategic plan focused on recovery and resilience throughout the life stages

• Improved service delivery for children and adolescents

• Stronger advocacy

Strategies and opportunities to strengthen the system of care for all segments of the population

Data InfrastructureRequired to enhance capacity for data

collection and managementWork with DOE and CDC to resume Youth

Risk Behavior Surveillance (YRBS) in middle school and high schools

Increase utilization of Behavior Risk Factor Surveillance System (BRFSS) data

2007 Virgin Islands Epidemiological Profile

Strategies and opportunities to strengthen the system of care for all segments of the population

Data Infrastructure (continued)Develop and implement comprehensive

surveillance system, to include data from the private sector, hospitals and related agencies provided services to the population

Conduct regular consumer surveys

2007 Virgin Islands Epidemiological Profile

Strategies and opportunities to strengthen the system of care for all segments of the populationStrategic Plan:

• Needs assessment to determine services for mental health and substance abuse prevention and treatment, to include the mentally ill homeless and dual-diagnoses (2000/2006)

• Comprehensive evaluation to identify gaps in service delivery, such as coordination of discharge planning with the hospitals and transitional services to ensure continuity of care to reduce recidivism and promote recovery

Strategies and opportunities to strengthen the system of care for all segments of the populationStrategic Plan (continued):

• Increased outreach activities to promote services in the least restrictive setting and to provide support clients in their own environment

• Include recovery and support services, such as housing, vocational rehabilitation, employment, and peer support for clients, to foster self-management and wellness

Strategies and opportunities to strengthen the system of care for all segments of the populationImproved service for children and adolescentsComprehensive, reliable needs assessment for

children and adolescent mental health and substance abuse services

Strategic plan for children and adolescent services, to include suicide prevention and care, as well services across the continuum of care and use of technology to increase access

Trained staff at all levelsIncreased screening for mental illness and substance

abuseImproved coordination with school counselors for

prevention, early identification and treatment

Strategies and opportunities to strengthen the system of care for all segments of the populationAdvocacy:• Consent decree requires development of a 5-year plan• The plan should include Evidence-Based Practices

(EBPs) (such as Assertive Community Treatment, Supported Employment, Supportive Housing, Cognitive Behavioral Therapy, Multisystemic Therapy, and Functional Family Therapy)

• Promote consumer-and family-run organizations, peer assistance, recovery support, and self-directed care

• Six goals set forth in “Achieving the Promise: Transforming Mental Health Care in America” can guide development of local goals

Strategies and opportunities to strengthen the system of care for all segments of the populationDepartment of Human Services (DHS):Initiative to develop a strategic plan for

intergovernmental youth services systems• Comprehensive strategic plan to engage key

stakeholders in the mental health, juvenile justice, and educational systems in implementing a coordinated and seamless network of services for children, adolescents and their families

2009 Site Visit Report

References Arria, AM and Anthony, JC (2000) Final Report: Alcohol and Other Drug-Related Health Needs of Adults Living in the USVI. USVI DOH Division of Mental Health, Alcoholism and Drug Dependency Services; 57pp Disability Rights Center of the Virgin Islands (2008) Working Toward An Effective Mental Health Care System In The United States Virgin Islands; 26pp http://www.governordejongh.com/budget/fy2010/FY2010-Executive-Budget.pdf. FY 2011 Executive Budget.Government of the USVI, Department of Health: Office of Minority Health (2003) Healthy Virgin Islands 2010: Improving Health for All; 124pp.Government of the USVI, Department Of Health: Division Of Mental Health, Alcoholism And Drug Dependency Services (2009) Community Mental Health Services Block Grant Monitoring Report September 22–25; Government of the USVI, Department of Health (2007) Virgin Islands Epidemiological Profile. 67 ppPacific Institute For Research and Evaluation (2008) Summary of findings from the 2007 Virgin Islands Youth Risk Behavior Survey. USVI DOH Division of Mental Health, Alcoholism and Drug Dependency Services ; 62ppPresident’s Commission on Mental Health (2003) Final Report: Achieving the Promise: Transforming Mental Health Care in America. http://www.census.gov/census2000/pdf/usvifullprofile.pdf. US Census

www.cia.gov/library/publications/the-worldfactbook. Virgin IslandsUniversity of the Virgin Islands. 2005 Household, Income and Expenditure SurveyPacific Institute For Research and Evaluation/Virgin Islands Prevention-State Incentive Grant (2006) Prevention Needs Assessment; A summary of social and health indicators related to adolescent substance abuse use in the Virgin Islands

Acknowledgements• Gloria Callwood, PhD, RN, Director-Caribbean Exploratory

Research Center (CERC)• Doris Hepburn, MA, Director, Mental Health, Alcoholism and

Substance Abuse and her staff• Najib Malik, RNC, Head Nurse, Psychiatric Ward, Juan F Luis

Hospital, St. Croix, USVI• Desiree Bertrand, MSN, RN, Research Coordinator,

CERC/Faculty (part-time), UVI, St. Croix, USVI• Jaslene Williams, MSW, Consultant/ARCH Institute• Noreen Michael, PhD, former Director-Health Statistics/Chief of

Staff-UVI President• Theresa Byrd, DrPH, RN, Associate Professor for Health

Promotion and Behavioral Sciences, UT School of Public Health, Houston, TX

Mental Health and Substance Abuse in the United States Virgin

Islands

Thank you!