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PursuingPerfectDepressionCareFromPsychiatricServices,ps.psychiatryonline.org,October2006,Vol.57,No.10.BuildingaSystemofPerfectDepressionCareinBehavioralHealthFromTheJointCommissionJournalonQualityandPatientSafety,April2007,Vol.33,No.4.DepressionCareEffortBringsDramaticDropinLargeHMOPopulation’sSuicideRateFromJournaloftheAmericanMedicalAssociation,May2010,Vol.303,No.19.

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Can suicide be eliminated? Doingso is the goal of the Perfect De-

pression Care program, initiated by theDepartment of Psychiatry at the Hen-ry Ford Health System. Using a frame-work proposed by the Institute ofMedicine to dramatically improvehealth care, the team set out to exam-ine its department’s existing practicesand develop new systems of care. Toencourage high-quality care for chron-ic illnesses, the new system addressesthe community, the health system, pa-tient self-management support, deliv-ery system design, decision support,and clinical information systems. A keyimprovement from this model was anew evidence-based approach to sui-cide prevention, which consists of athree-tiered system of care based on anindividualized and continuous risk as-sessment of each patient.

As a result of these innovations, theHenry Ford Department of Psychiatryhas reduced the suicide rate among itspatients by 75 percent, to 22 per100,000 patients, compared with theexpected rate in the literature of 1,000per 100,000. This success has been sus-tained in each follow-up year since theprogram’s inception in 2001, and theapproach used has become a model fornew programs within the Henry FordHealth System and across the country.

In recognition of its success inreengineering depression care andsignificantly reducing suicide rates,the Perfect Depression Program ofthe Henry Ford Health System wasselected to receive APA’s GoldAchievement Award in the categoryof academic or institutionally basedprograms for 2006. The winningprogram in the category of commu-nity-based programs is described onpage 1521. Each Gold Award winnerwill receive a plaque and a $10,000prize, made possible by a grant fromPfizer, Inc., on October 5 at the In-stitute on Psychiatric Services inNew York City.

The challengeAnnually, depression affects about 10percent of adults in the United States.The leading cause of disability in de-veloped countries, depression resultsin substantial medical care expendi-tures, lost productivity, and absen-teeism. Untreated or poorly treated,depression can be deadly—each yearup to 10 percent of patients with majordepression die from suicide.

In its 2001 report Crossing the Qual-ity Chasm: A New Health System forthe 21st Century, the Institute of Med-icine identified depression as a prioritycondition for immediate national atten-tion. That same year the Robert WoodJohnson Foundation issued a challengeto American health care leaders to“pursue perfect care” by embracing theInstitute of Medicine’s framework as anapproach to program redesign.

The Department of Psychiatry at theHenry Ford Health System acceptedthe foundation’s challenge, choosing asits overall goal the pursuit of a systemof perfect care for persons with de-pression. Through a competitiveprocess the program won funding fromthe foundation, and in 2002 the PerfectDepression Care initiative began itsstart-up phase.

Goal: no suicidesThe overall goal of the initiative was toeliminate suicide. More broadly, theaim of the program was to completelyredesign depression care delivery toachieve breakthrough improvement inquality and safety by using the struc-ture articulated in the Quality Chasmreport. The redesign would focus on sixaims: effectiveness, safety, patient cen-teredness, timeliness, efficiency, andequity among patients. The programdeveloped concrete measures to assessprogress on each of these aims. For ex-ample, effectiveness in eliminating sui-cides would be measured in terms ofthe number per 100,000 networkmembers. Patients’ satisfaction with

remaining aims would be measuredwith a standardized national survey.

The targeted sample was all patientswith depression and other mood disor-ders (about half the clinical volume)being cared for by the Henry Ford De-partment of Psychiatry, a large regionalintegrated delivery system servingsoutheastern Michigan and the entireMidwest. The department owns andoperates a comprehensive behavioralhealth care delivery system that in-cludes ten outpatient centers, a 100-bed psychiatric hospital, a 64-bed resi-dential and outpatient substance abuseprogram, and numerous specialty careand service programs, all staffed by aworkforce of 515 employees. The de-partment receives approximately70,000 outpatient visits and provides46,000 inpatient days of care annually.

Blues Busters teamTo launch the initiative, the depart-ment chair formed and led a 15-mem-ber team to set the vision and strategicgoals for the Perfect Depression Careinitiative. Dubbed the Blues Busters,the team conceptualized, planned, andlaunched the initiative and providedinitial leadership direction and over-sight during implementation. Theteam included the chief operations of-ficer, medical directors of inpatient andoutpatient services, director of qualitymanagement, and other key cliniciansand managers, such as the inpatientnursing leader, several key physicians,therapists, and clinical managers.

Perhaps the largest obstacle to im-plementing the Perfect DepressionCare initiative was the team’s accept-ance of “no suicides” as the goal. SomeBlues Busters eagerly embraced thegoal. Others challenged it, viewing it asunrealistic for a network of 200,000members, most of whom were outpa-tients. The debate was finally resolvedwhen the question was asked, “If zerois not the right number of suicides,then what number is? One? Four?

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Forty?” This debate was a milestone inthe initiative. The team united in itscommitment to pursuing perfection.These critical first steps gave the proj-ect an identity within the departmentand the larger health system.

The department’s board of trusteesprovided leadership and support to theteam by reviewing progress quarterly,encouraging leaders and staff, and rec-ognizing accomplishments in writtencommunications.

Pursuing perfectionStrategyThe approach to achieving perfect de-pression care included six major tac-tics: commit to “perfection” (zero careprocesses defects, or zero suicides) as agoal; map the current care processesand develop a clear vision of how pa-tient care must change; partner withpatients to ensure their voice in careredesign; conceptualize, design, andtest strategies for improvement in fourareas identified in the mapping of cur-rent care—patient partnership, clinicalpractice, access to care, and informa-tion systems; implement relevantmeasures of care quality, continuallyassess progress, and adjust the plan asneeded; and communicate the resultsand celebrate the victories.

Key activitiesMultiple changes were made from 2001to 2005 to redesign depression care.First, the team envisioned how each pa-tient’s care would need to change toachieve optimal care that provided acontinuous healing relationship. Theteam operated on the principle thatperfect depression care must be barrierfree and consistently provide timely andaccurate recognition of suicide risk.

After carefully examining the exist-ing care processes and benchmarkingprocesses in exemplary organizationsacross the country, the team improvedcare in four principal areas.

Partnership with patients. A con-sumer advisory panel was establishedto help redesign the treatment plan-ning process. With the panel’s input,the new plan involves each patient asan active partner in treatment. At eachkey juncture of program development,the team held focus groups with pa-tients and families to solicit feedback.The team also developed a survey to

measure patient satisfaction.Clinical care. A key change was the

development and implementation of asuicide prevention protocol across out-patient and inpatient facilities. Thisprotocol is the core of revised evidence-based depression care guidelines. Theprotocol stratifies patients on the basisof risk—acute, moderate, and low—and requires specific actions withinspecific time frames for each risk level.Such actions include assessing whetherthe patient has access to weapons and,if so, developing a plan for removal;conducting a psychiatric evaluation,providing individual and group psy-chotherapy appropriate to the patient,involving the patient’s family, and pro-viding additional resources to the pa-tient and family. The risk assessmentlooks beyond suicidal ideation for pre-dictors of acute and chronic suicidalrisk. Mood disorders, as well as severeanxiety, severe insomnia, global insom-nia, and severe anhedonia, have beenfound in recent literature to be predic-tors of suicide risk, so all are consideredin the risk assessment.

The depression care guidelines wererevised to ensure a systematic and evi-denced-based approach to coordinat-ing an array of somatic and psychother-apeutic treatments, including psy-chotherapy, psychopharmacology, andbrain stimulation techniques, such aselectroconvulsive therapy. The De-partment of Psychiatry also partneredwith the Beck Institute of Philadelphiato establish and maintain departmen-twide competency in cognitive-behav-ioral therapy and provided training for30 clinicians to achieve certification.Also, the department implemented ev-idence-based clinical protocols to re-duce the risk of falls and medication er-rors in the inpatient facilities.

Access. Three innovations to im-prove access were implemented: drop-in group medication appointments, ad-vanced (same-day) access, and e-mail“visits.” Each outpatient site offers oneor more 90-minute drop-in group ap-pointments weekly, led by a psychia-trist and a social worker. This approachprovides temporary additional accessand group support on short notice. Asecure e-mail system was establishedfor patients who prefer to use it forsome interactions with their behavioralhealth care providers. Also, several

stand-alone behavioral health outpa-tient clinics were physically reintegrat-ed into the medical group’s outpatientclinic buildings to ease access and con-tinuity of care.

Information flow. Several technologi-cal changes improved the flow of infor-mation within the health care systemand to patients. First, electronic medicalrecords were updated to comply withconfidentiality policies and to enablesharing of information between healthcare sites. For example, complete be-havioral health information (includingsuicide risk) is now immediately avail-able to behavioral health clinicians atany site at which the patient is seen.

Second, a comprehensive and secure“Living With Depression” Web sitewas developed for patients and familymembers. In addition to providingtreatment information, the Web sitefeatures video clips of evidence-basedinformation, “ask the expert” forums,and secure chat rooms for informationand support. The secure e-mail com-munication system was establishedwithin this context.

Third, an Intranet was created forthe health system to disseminate thedepression guidelines to all cliniciansand to provide access to a patient reg-istry and other electronic tools to im-prove the quality and efficiency of care.

Funding the initiativeThe Perfect Depression Care initiativewas launched at a time of financial chal-lenge for the Henry Ford Health Sys-tem. One-time financial support wasrequired in three areas: project man-agement support equivalent to one full-time manager for one year, training incognitive-behavioral therapy for 30 cli-nicians, and Web site development andthe other electronic enhancements.Support was provided by the grantfrom the Robert Wood Johnson Foun-dation and by the health system andDepartment of Psychiatry board oftrustees. The trustees raised substantialsums of money to support the develop-ment of critical information technology,including the Web site.

Although improving financial per-formance was not a formal goal of theinitiative, the outcome was essential tothe long-term viability of the programand of the overall health system. From2002 to 2004, the gross contribution

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(total net revenue minus total directexpenses) was improved by nearlyeightfold, mainly by a nearly $3.5 mil-lion reduction in expenses in that peri-od. Expenses were reduced in partthrough improvements in productivitygenerated by the Perfect DepressionCare protocols. Financial success con-tinues for the program. With addition-al grants and support from affiliatedpartners, Perfect Depression Care pro-grams are spreading throughout thestate of Michigan and nationally.

Dramatic reduction in suicideThe goal in the Perfect DepressionCare initiative was to eliminate suicide,which the program has come very closeto achieving. Since implementation ofthe program, the rate of suicide in thepatient population has declined by animpressive 75 percent, from approxi-mately 89 deaths per 100,000 at base-line (2000) to approximately 22 per100,000 for the follow-up interval of2002 to 2005 (p=.007). This improve-ment has been sustained during each ofthe four outcome years. For compari-son, although the expected suicide ratein the general population, per U.S. cen-sus figures, is 11 deaths per 100,000,the suicide rate among patients with anactive mood disorder is estimated at 80to 90 times the rate of the general pop-ulation, and the suicide rate among pa-tients with a history of suicide attemptsis 100 times the rate of the general pop-ulation. This dramatic and sustained re-duction in suicide rate achieved in thePerfect Depression Care program isunprecedented in both the clinical andquality improvement literature. In fact,in two of the four follow-up years, the

suicide rates dropped to levels seen inthe general population.

In addition to the substantially im-proved suicide rate, the level of patientsatisfaction has also greatly improved.The team developed a simple surveyfor patients to assess their care, whichwas piloted with the electroconvulsivetherapy unit. The percentage of pa-tients completely satisfied with all di-mensions of their care increased to over90 percent, from 55 percent on averageduring the baseline period. This level ofsatisfaction has been sustained in theunit for over four years. Although theteam attempted to use the survey in theoutpatient clinics and inpatient servic-es, recording the data is too cumber-some for large, busy services.

Effective modelThe encouraging results of the PerfectDepression Care Initiative are amongthe first to demonstrate that the Quali-ty Chasm report can be a highly effec-tive model for breakthrough quality im-provement in mental health care. Thesuccessful Perfect Depression Care ini-tiative is the prototype for a compre-hensive redesign of behavioral healthcare across the Department of Psychia-try. Work is under way to perfect thecare of persons with anxiety or psychot-ic disorders, and similar care systemsare being developed for violence pre-vention and medication safety.

The program is not only a modeltreatment program but also a model ofhealth systems research. An initiativewas recently launched to spread per-fect depression care to the primary andspecialty medical care settings of thehealth system, in part by reintegrating

behavioral health and medical outpa-tient clinics and redirecting informa-tion flow. The group is also collaborat-ing with the insurance division of thehealth system to develop a depressioncare management product designed toprovide major employers (in particular,the automotive manufacturers in De-troit) with a system of depression carethat will improve employee productivi-ty and lower health care costs. The cre-ative use of information technology hasdrawn attention and support from Mi-crosoft and the Flinn Foundation. Theteam is helping the state of Michigandevelop and implement evidenced-based guidelines for the care of per-sons with mood disorders. Finally, theteam is consulting with numerousmental health care providers, insur-ers, and professional organizationsthroughout the United States to sup-port their efforts to improve their men-tal health care services.

SummaryIn summary, by using the QualityChasm report as a roadmap and byleveraging “pursuing perfection” as astrategic driving force, the Perfect De-pression Care program has achieved un-precedented results in reducing suicideand improving the care of persons withdepression. This approach is economi-cally viable and readily applicable to oth-er mental health care delivery systems.

For more information, contact C. Ed-ward Coffey, M.D., Kathleen and EarlWard Chair, Department of Psychia-try, Henry Ford Health System, 1 FordPlace, Suite 1F, Detroit, MI 48282-3450 (e-mail: [email protected]).

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The American Psychiatric Association’s (APA’s) Psychiatric Services AchievementAwards, funded by Pfizer Inc., recognize programs that have made an outstandingcontribution to the field of mental health, that provide a model for other programs,and that have overcome significant challenges. The winner of the first prize, or GoldAward, in each of two categories—community-based programs and institutionallysponsored programs—receives a $10,000 grant. Programs also may be selected to re-ceive a Silver or Bronze Award.

To obtain an application form for the 2007 competition or for additional information,write to Achievement Awards, APA, 1000 Wilson Boulevard, Suite 1825, Arlington, VA22209-3901; phone: 703-907-8592; or visit www.psych.org/psychpract/awards.cfm.

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193April 2007 Volume 33 Number 4

The Joint Commission Journal on Quality and Patient Safety

Behavioral Health Services, a division of the HenryFord Health System (HFHS; Detroit), provides afull continuum of mental health and substance

abuse services through a large integrated delivery systemof 2 hospitals, 10 clinics, and more than 500 employeesthat serves southeastern Michigan and adjacent states.Through its department of psychiatry, Behavioral HealthServices is also engaged in a large academic enterprise,which includes numerous education, training, andresearch programs.

In 2001, the Institute of Medicine (IOM) report,Crossing the Quality Chasm: A New Health System for the21st Century,1,2 served as a wake-up call to American healthcare. While praising the unparalleled advances in medicalscience in the United States, as well as health care workers’skill, dedication, and self-sacrifice, it indicted the healthcare delivery system for not translating those strengthsinto meaningfully better care for each and every patient.

The Chasm Report spotlighted behavioral health care,identifying depression and anxiety disorders on the shortlist of priority conditions for immediate national attentionand improvement. Annually, depression affects about10% of adults in the United States. The leading cause ofdisability in developed countries, depression results insubstantial medical care expenditures, lost productivity,and absenteeism. Untreated or poorly treated, it can bedeadly; each year as many as 10 percent of patients withmajor depression die from suicide.3

Shortly after publication of the Chasm Report, theRobert Wood Johnson Foundation (RWJF) issued a chal-lenge to American health care leaders to “pursue perfect

Building a System of PerfectDepression Care in Behavioral Health

Codman Awards

C. Edward Coffey, M.D.

For the “Blues Busters” of Behavioral Health Services

Background: Depression, a common, serious disor-der, may result in suicide in up to 10% of afflicted persons.

Methods: In 2001, the Division of Behavioral HealthServices of the Henry Ford Health System (Detroit)launched an initiative to completely redesign depressioncare delivery using the Six Aims and the Ten Rules fromthe Institute of Medicine report Crossing the QualityChasm. This “Perfect Depression Care” initiative, whosekey goal was the elimination of suicide, entailed perform-ance improvement activities in four domains—partner-ship with patients, clinical care (planned care model),access, and information flow.

Results: The rate of suicide in the patient populationdecreased by 75% (p = .007), from ~89 per 100,000 atbaseline (2000) to ~22 per 100,000 for the four-year fol-low-up interval (the average rate for 2002–2005).

Discussion: This sustained reduction in suicide ratesuggests that the process improvements implemented aspart of the Perfect Depression Care initiative substantiallyimproved the care of persons with depression. The initia-tive is the prototype for a comprehensive redesign ofbehavioral health care. Work is under way to “perfect” thecare of persons with anxiety or psychotic disorders, andsimilar care systems are being developed for violence pre-vention and medication safety, with a particular focus onperfecting communication between providers. Pursuingperfection is no longer a project or initiative but a princi-ple driving force embedded in the fabric of our care.

Article-at-a-Glance

Copyright 2007 Joint Commission on Accreditation of Healthcare Organizations

194 April 2007 Volume 33 Number 4


care” by embracing the IOM framework of the Six Aims(Table 1, above) and then Ten Rules for redesign (forexample, care based on continuous healing relationships,customization based on patient needs and values)2 as anapproach to achieve “perfect” care. We accepted the RWJFchallenge, choosing as our overall goal the pursuit of a sys-

tem of perfect care for persons with depression. Througha competitive process, behavioral health services wasselected from among approximately 300 applicants as oneof 12 demonstration projects (“finalists”) for Phase I of“Pursuing Perfection.” Participation in this national col-laborative in 2002 provided our Perfect Depression Careinitiative focus, structure, discipline, and visibility in thestart-up phase.

Today we can report a large and sustained reduction insuicide that is, to our knowledge, unprecedented in theclinical and quality improvement literature.

Methods PLANNING

Our Goal–No Suicides! The overarching goal in thePerfect Depression Care initiative was to eliminate suicide.This audacious goal was a key lever in a broader aim: toachieve breakthrough improvement in quality and safetyby completely redesigning depression care delivery usingthe Six Aims and Ten New Rules articulated in the ChasmReport. To communicate our bold vision, we called theinitiative “Perfect Depression Care.”

OUR STRATEGY

Our approach to achieving Perfect Depression Careconsisted of the following six major tactics:1. Commit to “perfection” (zero defects) as a goal.2. Develop a clear vision of how each patient’s care willchange.3. Partner with patients to ensure their voice in careredesign.4. Conceptualize, design, and test strategies for improve-ment in four high-leverage domains identified when wemapped our current care processes:

■ Patient partnership■ Clinical practice (planned care model)■ Access to care■ Information systems

5. Implement relevant measures of care quality, continual-ly assess progress, and adjust the plan as needed.6. Communicate the results, communicate the results, andcommunicate the results again, and celebrate the victories.

We extensively redesigned depression care, whichincluded the development and implementation of a suicideprevention protocol across both outpatient and inpatient

Henry Ford Health System Behavioral Health

Services Suicide Prevention Guideline

1. What is the Planned Care Model?

■ Background & Definition

■ Planned Care Model for HFBH Perfect Depression

Care

2. Decision Support: Evidence-Based Guidelines

■ HFBH Suicide Prevention Guideline

— Risk Assessment–Key Definitions

— Protocol to Remove Weapons

— Family Interventions

Handout: “Understanding and Helping

Someone Who Is Suicidal”

— Psychotherapy

3. Delivery of Care Design

4. Patient Self-Management

■ Handout: “If you are thinking about suicide…read

this first”

■ HFBH Depression Web site

■ Self-Help Books

5. Community Resources and Support

■ List of Community Support Groups

6. IT Support / Clinical Information Systems

7. Measurement

■ Six Dimensions of Care

■ Risk assessment and outcome measures

■ Patient Satisfaction

■ Ambulatory Chart Audits

8. Guideline Review Schedule

9. Appendix

A. Key Articles

B. APA Practice Guidelines for the Treatment of

Patients with Major Depression

* HFBH, Henry Ford Behavioral Health; IT, information technology;

APA, American Psychiatric Association. A full copy of the guideline is

available on e-mail request from the author

Table 1. Contents Page for the Suicide PreventionGuideline*




facilities. This protocol has become a central component ofour evidence-based depression care guidelines (Table 1).

PERFECT DEPRESSION CARE AS AN ORGANIZING

STRATEGIC PLANNING CONCEPT

We leveraged Perfect Depression Care as a core strategyto drive quality. By using our strategic and operationalplanning process to target and plan for Perfect DepressionCare, we ensured that the initiative was aligned with over-all organization priorities, fully integrated into the work ofleaders and others across the organization, and subject toongoing review of progress and “lessons learned.”

IMPLEMENTING THE PERFECT DEPRESSION

CARE INITIATIVE

In 2001, the vice president of the Division ofBehavioral Health Services [C.E.C.], as leader of thePerfect Depression Care initiative, formed and led a 15-member steering team, which set the initiative’s vision andstrategic goals; conceptualized, planned, and launched theinitiative; and provided initial leadership direction andoversight. The team consisted of key members of the exec-utive team (chief operations officer, medical directors ofinpatient and outpatient services, director of quality man-agement), as well as other key clinicians and managers (forexample, inpatient nursing leader, several key physicians,therapists, and clinical managers). When possible, thechair chose members known to be leaders and change

agents; both leadership and front-line caregiver perspec-tives were represented.

Early on, the team adopted a name and logo (Figure 1,page 196) and after some vigorous discussion, united in acommitment to pursuing perfection. We captured thatcommitment in a promise we make to our patients. Thesecritical first steps helped unite our Blues Busters team andgave our purpose an identity within the department andthe larger health system.

The psychiatry department’s board of trustees, an adviso-ry board composed of 20 volunteer community leaders, alsoplayed a key leadership role in Perfect Depression Care. Theboard and its quality committee reviewed progress quarterly,provided encouragement to leaders and staff, recognizedaccomplishments in written communications, and under-took major philanthropic efforts to support the initiative, inparticular raising substantial sums of money to support thedevelopment of critical information technology, including aDepression Care Web site accessible to registered patients.

All psychotherapists were provided training to developcompetency in Cognitive Behavior Therapy and the sui-cide prevention protocol. Nonclinical staff had importantroles in practice changes such as access improvements andinformation systems innovations.

FISCAL AND STAFF RESOURCES

The Perfect Depression Care initiative required one-time financial support in three key areas:

* The Six IOM (Institute of Medicine) Aims are drawn from Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21stCentury. Washington, D.C.: National Academy Press, 2001.

Table 2. Perfect Depression Care: Key Goals and Indicators*

IOM Aim Goal Measure Data Source

Safety Eliminate inpatient falls

Eliminate inpatient medication errors

Inpatient falls/1,000 days of care

Inpatient medication errors/1,000

days of care

Incident reporting system

Effectiveness Eliminate suicides Number of suicides/100,000 net-

work members

Incident reporting system

Patient-centeredness 100% of patients completely satis-

fied with their care

Overall patient satisfaction PressGaney survey,

Assessment of care survey

Timeliness 100% complete satisfaction Patient satisfaction with timeliness Assessment of care survey

Efficiency 100% complete satisfaction Patient satisfaction with efficiency Assessment of care survey

Equity 100% complete satisfaction Patient satisfaction with equity Assessment of care survey




1. Project management: One full-time equivalent (FTE)of project management support for one year 2. Departmentwide competency in Cognitive BehaviorTherapy, as stated above 3. Information systems development: Depression CareWeb site (substantially funded by the board of trustees),departmental Intranet, electronic medical record (EMR)enhancements

We received considerable guidance and support fromfaculty at the Institute for Healthcare Improvement and theRWJF during our participation in “Pursuing Perfection,” aswell as others (see Acknowledgments).

PERFORMANCE MEASUREMENT

As a participant in Phase I of the Pursuing Perfectioninitiative in 2001, Behavioral Health Services set goals andindicators to drive and monitor improvement during thePerfect Depression Care Initiative in terms of the IOM’sSix Aims (Table 2, page 195) to drive and monitorimprovement. Consistent with the concept of pursuing“perfection,” the Blues Busters team conceptualized goalsin terms of “zero defects”—that is, eliminating suicides,not merely reducing them incrementally—and “completesatisfaction” of every patient every time, not merelyappeasing some of them some of the time.

Defining the goal for effectiveness of care stirred con-troversy in our department. Some members of the BluesBusters team who embraced the “pursuing perfection”concept argued that truly effective care could only meanno suicides. Other team members challenged such a goal,viewing it as unrealistic for a network of approximately200,000 members. The debate was finally resolved whenthe question was asked, “If zero is not the right number ofsuicides, then what number is? 1? 4? 40?” This debate wasa milestone in the Blues Busters’ development—a galva-

nizing issue that helped skeptics see the “logic”of striving for perfection and launched our ini-tiative to transform depression care.

DATA ANALYSIS

We compared the incidence of suicidebetween the baseline period (the year 2000),the start-up period (the year 2001) and thefollow-up interval (the years 2002–2005).Poisson regression was used for testing using

each quarter of data for the three time periods. We displayed the suicide data using a run chart, which

plotted the running 12-month rate of suicide (Figure 2,page 197). The chart also shows the annual rate of suicidein the general population (~11 per 100,000 population,based upon the 2000 U.S. Census), as well as the report-ed rate in patients with a history of a mood disorder whoare currently in remission (~4X–10X the rate in the gener-al population). The rate of suicide in patients with anactive mood disorder is estimated at 80–90X the rate inthe general population, and the suicide rate in patientswith a history of suicide attempts is 100X the rate in thegeneral population.

DATA DISSEMINATION

From the start of the initiative, the Blues Busters teamregularly reviewed results with leaders and managers ofBehavioral Health Services as part of its ongoing strategicand operational performance review. The Blues Bustersalso designed a communication strategy that leveraged thedepartment’s array of established communication meth-ods, ensuring that results, analyses, and lessons learnedwere widely shared with staff and other stakeholders.

Through Web sites and participation in national meet-ings and conferences, department leaders also shared theresults of the Perfect Depression Care initiative with abroader health industry audience, including such groupsas the American Psychiatric Association and the AmericanMedical Group Association.

Performance Improvement ActivitiesOur first step in the Perfect Depression Care initiative wasto use the IOM’s Six Aims and Ten Rules to develop a clearvision of how each patient’s care would be different and todrive bold and innovative thinking about optimal care. If

Figure 1. The logo for the Perfect Depression Care initiative is shown.

Blues Busters Logo




we aimed to eliminate suicide, we asked our-selves, what would it mean to offer a continuoushealing relationship (Rule 1) or to anticipateneeds (Rule 8)? We concluded that perfectdepression care must be barrier free and that wemust consistently provide for timely and accu-rate recognition of suicide risk. We found all tenrules useful as design specifications, and ourcare process changes indeed reflect them all.

We mapped our current care processes andidentified four domains of activity that offeredan opportunity for high-leverage changes toclose the gap between current and perfectcare—partnership with patients, clinical care(planned care model), access, and informationflow. The components of these domains ofactivity are shown in Table 3 (page 198).

Throughout the initiative we maintained afocus on improving the entire system of behav-ioral health care not simply on managing a par-ticular disease such as depression. Some neededimprovements were obvious at once—the sui-cide prevention protocol, for example. Otherimprovements already under way now assumednew priority, such as establishing department-wide competency in Cognitive BehaviorTherapy. Still others emerged over time, as team membersexamined the literature and benchmarked processes inhigh-performing organizations across the United Statesworth emulating—such as advanced access and the drop-ingroup medical appointment, each of which has only rarelybeen implemented in a behavioral health care setting.

In change management, whenever possible, we testchanges on a small scale initially, through a pilot projectinvolving one or a few clinicians. Depending on the pilotresults, we may test the change again or begin implemen-tation and spread. In addition, whenever possible, webuild the internal capacity to make and sustain the change.For example, we equipped a small clinical team with theknowledge and skills to train and certify their colleagues inCognitive Behavior Therapy. Finally, we have implement-ed a measurement system that is integrated into ongoingorganizational performance review and reporting as ameans of assessing the short- and long-term success of ourchanges.

ResultsAs shown in Figure 2, the observed suicide rates rangedfrom 89 per 100,000 for baseline (2000), 77 per 100,000for the start-up (2001), and 22 per 100,000 for the follow-up interval (the average rate for 2002–2005). Theoverall Poisson regression model (2 degrees of freedom,Chi-square test for a period effect) was statistically signif-icant, �2 = 8.0, p = .018. The difference in suicide ratebetween baseline and start-up years was not significant (p = .768), but the suicide rate for the follow-up periodwas significantly lower than that for both the baselineyear (p= .007) and the start-up year (p = .022).

DiscussionDuring the period of 2001–2005 we designed, tested,and implemented multiple practice improvements, so it is difficult to determine which contributed most toour achievement. Yet we are confident that beyond ourpractice improvements, our determination to strive for

Figure 2. This run chart shows the running 12-month rate of suicidefor each year since inception of the Perfect Depression Care Initiative.The annual rates of suicide are also shown for reference populations.

Suicides per 100,000 Health MaintenanceOrganization Patients, 2000–2005




perfection, rather than incremental goals, had a power-ful effect on our results.

Studies such as ours, which rely on a time-series design,are susceptible to potential bias. The main threat to inter-nal validity is “history,” that is, the concern that anobserved change might be due to an event that is not thetreatment of interest. In the context of our study, suiciderates might have reflected major shifts in the communityin factors known to be associated with suicide, such asunemployment and socioeconomic downturn or decliningfamily “connectedness” (for example, declining marriagerates). We are compiling statistics for our primary service

area to formally evaluate such time trends. A preliminaryanalyses revealed relatively stable marriage rates (~44%-59%, depending upon county) but unemployment hasincreased dramatically (from 3.2% in 2000 to 7.3% in2003). Yet the actual suicide rate in our state and tri-coun-ty service area remained relatively stable from 1999 to2003 (~9.8 to 10.0 per 100,000).

A second threat to validity arises due to the potentialfor maturation-selection bias. In the context of this study,suicide rates could have changed if characteristics of ourpatient population (the denominator population), such asage, sex, and race-ethnicity, were changing over time in a

Partnership with Patients

■ Established a consumer advisory panel to ensure the

“voice of the customer” in care redesign

■ Redesigned the treatment planning process, with input

from the consumer advisory panel, to ensure that every

patient has a voice in the design of his or her care work-

ing in an active partnership with clinicians

Clinical Care (Planned Care Model)

■ Developed and implemented an evidence-based suicide

prevention protocol, which has been embedded in the

depression care guidelines.* The suicide prevention pro-

tocol stratified patients into three levels of risk, each of

which required specific interventions. In every case, we

focused heavily on the availability of weapons.

■ Revised the depression care guidelines to ensure a sys-

tematic and evidenced-based approach to coordinating

our array of somatic and psychotherapeutic treatments,

including psychotherapy, psychopharmacology, and

brain stimulation techniques such as electroconvulsive

therapy

■ Partnered with a therapy and research organization to

establish and maintain departmentwide competency in

Cognitive Behavior Therapy.

■ Implemented standardized evidence-based clinical proto-

cols to reduce the risk of falls (modified from the

American Geriatrics Society and the American Medical

Directors Association) and medication errors (modified

from the Institute for Safe Medication Practices) in our

inpatient facilities.

Access

■ Implemented three access innovations: drop-in group

medication appointments, advanced (same-day) access,

and e-mail “visits.” Each outpatient site offers one or

more 90-minute drop-in group appointment(s) weekly,

led by a psychiatrist and a social worker. This approach

provides temporary additional access and group support

on short notice.

■ Physically reintegrated a number of our stand-alone

behavioral health outpatient clinics into the medical

group’s outpatient clinic buildings, to improve access and

continuity of care.

Information Flow

■ Created an electronic medical record for behavioral

healthcare that complies with legal and institutional con-

fidentiality policies, ensures that complete behavioral

health information (including suicide risk) is immediately

available to the behavioral health clinician at any site at

which the patient is seen, and gives our group practice

colleagues access to critical data for safe patient care

through the health system’s electronic medical record

for medical-surgical care

■ Partnered with David Gustafson, Ph.D. and the CHESS

Consortium of the University of Wisconsin to develop

and implement a state-of-the-art depression Web site for

patients and family members that includes evidence-

based information via patient videos and “ask the expert”

forums as well as secure chat rooms for information and

support

■ Established secure e-mail communication for the grow-

ing number of patients who prefer this vehicle for at least

some interactions with their behavioral health care

provider.

■ Partnered with the health system’s information technolo-

gy department to develop an intranet to disseminate

depression guidelines to all clinicians, as well as a

patient registry and other electronic tools to improve the

quality and efficiency of our care.

Table 3. Performance Improvement Activities in Four Domains

* Shown in Figure 2 (page 197).




manner likely to affect suicide rates. For example, suicideis more common among men, the elderly, and whites andNative Americans. We are evaluating the extent to whichsuch characteristics may have changed over time in ourpatients. Preliminary analyses have revealed no clearchanges in age, sex, and race-ethnicity.

The encouraging results of the Perfect Depression CareInitiative suggest that the Chasm Report can be a highlyeffective model for achieving and sustaining breakthroughquality improvement in mental health care.

Energized by this success, we remain focused on driv-ing our suicide rate down to zero, and we are spreadingour success and lessons learned both within and beyondour department. The Perfect Depression Care initiative isthe prototype for a comprehensive redesign of behavioralhealth care across the psychiatry department. Work isunder way to “perfect” the care of persons with anxiety orpsychotic disorders, and similar care systems are beingdeveloped for violence prevention and medication safety,with a particular focus on “perfecting” communicationbetween providers. Essentially, pursuing perfection is nolonger a project or initiative but a principle driving forceembedded in the fabric of our care.

Beyond the psychiatry department, we are also part-nering with our health system and community. We haveimplemented an initiative to spread “perfect depressioncare” to the primary and specialty medical care settingsof our health system. We are also collaborating with theinsurance division of our health system to develop adepression care management product designed to pro-vide major employers (in particular the automotivemanufacturers in Detroit) with a system of depressioncare that will improve their employee productivity andlower health care costs. We have received funding to leverage information technology to help the State of Michigan develop and implement evidence-basedguidelines for the care of persons with mood disordersthroughout the state. Finally, we are consulting with

numerous mental health care providers, insurers, andprofessional organizations throughout the United Statesto support their efforts to improve their behavioralhealth care services.

Summary and ConclusionsStriving for perfect depression care set the Blues Bustersand our entire department on a transformational journey.“Perfect” care required audacious goals—goals that couldonly be accomplished by challenging the most basicassumptions. Usual care and incremental approaches weretaken off the table. Although the business case for pursu-ing perfection is complex, we found it is possible to dra-matically improve care and financial performance at thesame time. This approach is not only economically viablebut is readily applicable to other behavioral health caredelivery systems. The author thanks David Gustafson, Ph.D., who pioneered the CHESS

patient Web site at the University of Wisconsin, for his help in the creation of

the Henry Ford Health System Depression Care Web site, and Judith Beck,

Ph.D., The Beck Institute for Cognitive Therapy and Research, Philadelphia,

for her work in the Cognitive Behavior Therapy project.

J

C. Edward Coffey, M.D., is Vice President, Henry Ford

Health System, Detroit; Chief Executive Officer,

Division of Behavioral Health Services; Kathleen and

Earl Ward Chair of Psychiatry; and Professor of

Psychiatry and Neurology. Please address correspon-

dence to C. Edward Coffey, [email protected].

1. Institute of Medicine: Crossing the Quality Chasm: A New HealthSystem for the 21st Century. Washington, D.C.: National Academy Press,2001.2. Institute of Medicine: Report Brief. Crossing the Quality Chasm: ANew Health System for the 21st Century. http://www.iom.edu/CMS/8089/5432/27184.aspx, pp. 3–4 (last accessed Jan. 24, 2007).3. Institute of Medicine: Reducing Suicide: A National Imperative.Washington, D.C.: National Academy Press, 2002.

References


http://www.iom.edu/CMS/8089/5432/27184.aspx

http://www.iom.edu/CMS/8089/5432/27184.aspx

aged 6 to 17 years who were taking anatypical antipsychotic and 15 000 chil-dren taking albuterol but no antipsy-chotic drugs. Patients with diabetes wereexcluded from both groups. The studyfound that glucose screening was low inboth groups, with 31.6% of the patientstaking antipsychotics receiving suchscreening compared with 12.6% of con-trols. Only 13.4% of the patients treatedwith antipsychotic drugs received lipidtesting compared with 3.1% of con-trols. Further analysis revealed that chil-dren with multiple psychiatric diag-noses and those who used more medicalservices were most likely to be screened.

The results suggest that many physi-cians are falling short of the level of moni-toring recommended in a 2004 consen-sus statement from several professionalgroups, including the American Psychi-atric Association and the American Dia-betes Association. Morrato said that cli-nicians treating pediatric patients, oftenprimary care physicians, may be lessaware of these guidelines, which applyto all age groups, and that there may alsobe systemic barriers to screening.

Correll called for even more aggres-sive monitoring for metabolic changesin pediatric patients taking atypical an-tipsychotics than that recommended in

2004. He said that physicians shouldmonitor these patients’ weight andheight at each visit, and should do a fast-ing glucose test when initiating therapy,3 months later, and every 6 monthsthereafter.

“We are between a rock and a hardplace because these children and ado-lescents are brought to us because theyare severely ill,” he said. “They can’tfunction, so we need to give them ef-fective medications, but we also needto make sure they have the least pos-sible side effects. For that, monitoringand management of these abnormali-ties is crucial.” �

Depression Care Effort Brings Dramatic Dropin Large HMO Population’s Suicide RateTracy Hampton, PhD

WHILE PHYSICIANS AND OTHER

health care workers may notbe able to predict which of

their patients will attempt suicide, theycan implementpreventivestrategies thatmarkedlylowertheriskofsuchtragedies.Now, one pioneering program has dem-onstrated the importance of pursuing 2keyapproachesatonce: carefullyassess-ingpatients for riskof suicideandadopt-ingmeasurestoreducethelikelihoodthata patient will attempt suicide.

The example comes from a quality-improvement initiativethatsucceededinsubstantially bringing down the rate ofsuicide in a population of about 200 000members of a large health maintenanceorganization (HMO). Through the sec-ond quarter of last year, the Perfect De-pressionCareprogramof theBehavioralHealth Services (BHS) division of theHenry Ford Health System resulted in 9consecutivequarterswithoutanysuicides,a dramatic contrast to the annual rate of89 suicides per 100 000 members atbaselineandapproximately230suicidesper 100 000 individuals expected in apatient population. The work has won

severalawards, includingtheJointCom-mission’sEarnestAmoryCodmanAwardand the Gold Achievement Award fromthe American Psychiatric Association.

“I believe we have a model that is ap-plicable to most health care settings andthat could dramatically improve thecare of patients with depression andother major mental disorders that raisethe risk of suicide,” said neuropsychia-trist C. Edward Coffey, MD, Henry Ford

Health System vice president and CEOof BHS, a large integrated mental healthand substance abuse system that in-cludes 2 inpatient hospitals and 10 clin-ics serving southeastern Michigan andadjacent states.

ZERO SUICIDES

The Perfect Depression Care Initiativewas one of 12 national demonstrationprojects (and the only mental health

60

40

80

100

20

0

Sui

cide

s pe

r 10

0 00

0

Baseline Follow-upInitiativeStart-up

Suicide Rates in HAP-HFMG Patients

2000 20092008 2010c2007200620052004200320022001

aHealth Alliance Plan (HAP) health maintenance organization members receiving care from the Henry Ford Medical Group (HFMG). Data source: C. Edward Coffey, MD/Henry Ford Health System.

bData sources: Heron MP et al. Deaths: final data for 2006. Natl Vital Stat Rep. 2009;57(14):30.Xu J et al. Preliminary data for 2007. Natl Vital Stat Rep. 2009;58(1):20.

cIncludes first quarter of 2010.

US general populationb

HAP-HFMG patientsa

A quality-improvementinitiative succeeded incurbing the rate ofsuicide in apopulation of about200 000 members of alarge healthmaintenanceorganization.

MEDICAL NEWS & PERSPECTIVES

©2010 American Medical Association. All rights reserved. (Reprinted) JAMA, May 19, 2010—Vol 303, No. 19 1903

at University of Washington Libraries on November 18, 2011jama.ama-assn.orgDownloaded from

http://jama.ama-assn.org/

proposal) selected in 2001 by the Rob-ert Wood Johnson Foundation to dem-onstrate that a report by the Instituteof Medicine (IOM) could serve as aroadmap for health care redesign. TheIOM report, Crossing the Quality Chasm:A New Health System for the 21st Cen-tury (http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx), praised advances in medical sci-ence in the United States, but it calledfor fundamental change in the US healthcare delivery system and offered astrategy for building a stronger healthsystem.

The IOMreport identifieddepressionand anxiety disorders on a list of prior-ityconditions for immediatenational at-tention and improvement. The goal ofHenryFord’sPerfectDepressionCareini-tiativewastocompletelyredesigndepres-sion care delivery using the 6 aims forhealthcareimprovementfromthereport:safety,effectiveness,patient-centeredness,timeliness, efficiency, and equity. Safetyimprovementsstrivetoavoidinjuriespa-tients receive as a result of their care; ef-fectiveness involves providing servicesbased on scientific knowledge whileavoidingunderuseandoveruse;patient-centeredcareconsidersindividualpatientpreferences,needs,andvaluesandensuresthat patient values guide all clinical de-cisions; timely care reduces delays; effi-cientcareavoidswaste;andequitablecaredoes not vary in quality because of per-sonal characteristics.

As the Perfect Depression Care ini-tiative focused on these aims, it be-came apparent that one goal trumpedall others for driving breakthrough im-provements in care: to reduce the num-ber of suicides to zero in patients seenin both inpatient and outpatient facili-ties. “If we were to provide perfect de-pression care, nobody would kill them-selves,” said Coffey. “Such a ‘perfection’goal was very controversial at the start,but if zero isn’t the right number [of sui-cides], what is?”

The BHS implemented a number oftactics to achieve its audacious goal.“Once we committed to zero suicides,it forced us to commit to things we’d

never think of doing,” said Coffey. Oneexample was to address the availabil-ity of weapons. “We got very seriousabout it and insisted that patients pro-vide us with an inventory of weaponsin their home, and we encouraged themto get rid of them,” he said.

Each patient seen through the BHS isfirst assessed and stratified on the basisof suicide risk: acute, moderate, or low.“Everyone is at risk. It’s just a matter ofwhether it’s acute or whether it re-quires attention but isn’t emergent,” saidCoffey. A patient considered to be at highrisk undergoes a psychiatric evaluationthe same day. A patient at low risk isevaluated within 7 days. Group ses-sions for patients also allow individualsto connect and offer support to one an-other, not unlike the supportive rela-tionships between sponsors and “spon-sees” in 12-step programs.

HOW IT WORKS

For each patient, staff members developa clear vision of how that patient’s carewill change, partnering with patients toensure that the care they receive meetstheir needs. Those involved in a pa-tient’s care also design and test strate-gies for improvements in areas such asthe patient’s access to care, and theyimplement relevant and up-to-date mea-sures of care quality. Finally, they com-municate with each other and con-stantly work to improve patient care bysharing results, analyses, and lessonslearned with staff and other stakehold-ers, such as leaders throughout the healthsystem and members of the initiative’sCommunity Advisory Group (whichincludes patients, their family mem-bers, and other community leaders andadvocates with an interest in mentalhealth).

All patients have access to a depres-sion Web site maintained by the pro-gram and are able to communicate withbehavioral clinicians via e-mail. Eachoutpatient site also offers one or moredrop-in group appointments each weekthat are led by a psychiatrist and a so-cial worker.

All health clinicians within the BHShave access to patients’ electronic medi-

cal records. Each year, all behavioralhealth care staff at the BHS complete acourse on suicide risk and preventionand must score 100% on the follow-uptest or receive additional education. TheBHS also instituted team members calledphysician extenders, who support pa-tients and call them periodically to seehow they are doing. In addition, an In-tranet site gives clinicians access to de-pression guidelines, the patient regis-try, and electronic tools to improve thequality and efficiency of care.

Within the first 4-year follow-up in-terval, the average annual rate of sui-cide in the BHS patient populationdropped 75%, from approximately 89per 100 000 in 2000 to approximately22 per 100 000 (Coffey CE. Jt Comm JQual Patient Saf. 2007;33[4]:193-199).More recently, there has not been a sui-cide in the HMO population in morethan 2 years.

“They’ve really carried this initiativeforward even in the highest-risk pa-tients, who are very vulnerable to sui-cide,” said Donald Berwick, MD, MPP,the president and CEO of the not-for-profit Institute for Healthcare Improve-ment and professor of health policy andmanagement at the Harvard MedicalSchool in Boston. “It’s quite remarkablethat they’ve had no suicides, particu-larly in this group,” added Berwick, whowas nominated in late March by Presi-dent Barack Obama to head the Centersfor Medicare & Medicaid Services.

The success of the initiative demon-strates, said Coffey, “that dramatic—indeed, unimaginable—improvementsin mental health care quality are pos-sible, and that the IOM’s Chasm reportcan indeed serve as a very useful modelfor mental health care redesign.” Headded that because the BHS team (whichcalls itself the “Blues Busters”) de-signed, tested, and implemented mul-tiple practice improvements over sev-eral years, it is difficult to determinewhich strategies contributed most to thegroup’s achievements. However, the de-termination to strive for perfection,rather than incremental goals, had a par-ticularly powerful effect, he said. Prin-ciples behind the Perfect Depres-


1904 JAMA, May 19, 2010—Vol 303, No. 19 (Reprinted) ©2010 American Medical Association. All rights reserved.



sion Care initiative are now being ap-plied to the care of BHS patients withother psychiatric conditions, such asanxiety and psychotic disorders.

Although some patients are reluc-tant to talk about suicide attempts, Cof-fey noted that his team does hear con-sistent themes from patients and theirfamilies. “Patients have come to us andsaid, ‘It’s a good idea that you had metake the gun out of my house; somenights I’d sleep with it on the pillow be-side me.’ ” These sorts of commentsindicate that suicide is often impul-sive and that imposing even a short de-lay can allow the impulse to pass, saidCoffey.

A MODEL PROGRAM

The initiative’s success may spur oth-ers to consider implementing similarmeasures. “People are searching forways to adapt modern improvementmethods to behavioral health, not just

classical medical care,” said Berwick.“Behavioral health is sometimesthought to be more elusive, but DrCoffey and his team successfullyadapted a systematic model, based onthe IOM report, to behavioral health.”

J. John Mann, MD, vice chair for re-search in the department of psychia-try at Columbia University, in NewYork City, noted that the initiative’s re-sults support several previous studiesin Sweden, Hungary, and Germany thatfound that enhanced diagnosis andtreatment of major depression can sub-stantially reduce rates of suicide and sui-cide attempts. “This study now showsa similar strategy can also work in acommunity in the United States andhelps make the case that such ap-proaches should be more widespreadas part of a national suicide preven-tion effort,” he said.

Efforts like the Perfect DepressionCare initiative are important because

depression is the leading mental disor-der associated with suicide risk, saidMorton Silverman, MD, a clinicalassociate professor of psychiatry atthe University of Chicago. He notedthat the initiative’s results are “quiteimpressive.”

Coffey said that a program like thiscan be difficult to emulate because ittakes considerable commitment and aunique culture. Still, despite the chal-lenges in implementing what he callsa “zero defect” program, Coffey be-lieves the BHS approach could be ap-plied to a wide range of medical is-sues, such as medication safety, violenceprevention, and infection control. “Youhave to be able to measure the issue andstrive to pursue perfection,” he said.Berwick agreed, noting that similar suc-cess will require leadership’s commit-ment as well as an atmosphere that en-courages innovation and aggressiveimprovement. �

Integrated Care Key for PatientsWith Both Addiction and Mental IllnessBridget M. Kuehn

DESPITE A GROWING BODY OF EVI-dence that integrated care is im-portant in treating individuals

with addiction and comorbid psychi-atric disorders, such care remains inshort supply. But efforts by scientistsand policy makers aim to improve ac-cess to such treatment.

Substance abuse disorders often oc-cur in patients with other psychiatricillnesses, yet few such individuals re-ceive treatment for their conditionsdespite the serious health and otherconsequences that often result. An es-timated 17.5 million adults had a seri-ous mental illness in 2002 based on theNational Survey on Drug Use andHealth (previously called the NationalHousehold Survey on Drug Abuse), anationally representative survey of more

than 68 000 US individuals. About 4million (23%) were also dependenton or abusing alcohol or illicit drugs(http://www.oas.samhsa.gov/2k4/coOccurring/coOccurring.htm). Butmore than half of these individuals re-ceived no treatment for either condi-tion, about one-third received treat-ment only for their mental illness, 2%received only specialty substance abusetreatment, and just 12% received carefor both conditions.

COMMON VULNERABILITIES

There are a number of potential expla-nations why substance abuse and othertypes of psychiatric illness frequentlyoccur together, explained Nora D.Volkow, MD, director of the NationalInstitute on Drug Abuse (NIDA) in aninterview. She explained that there maybe common genetic or environmental

factors that lead to both conditions. Ad-ditionally, because substance abuse andother mental illnesses affect overlap-ping brain circuits, brain changes re-lated to one disorder may lead to an-other. There may also be complexinteractions between such factors.

One environmental factor that hasbeen strongly associated with the de-velopment of both addiction and othermental illnesses is exposure to stressduring childhood or adolescence. Forexample, a child raised in a householdin which there is parental neglect,physical abuse, or sexual abuse has anelevated risk of developing a sub-stance use disorder, depression, or ananxiety disorder.

“Which of these trajectories you takewhen you get exposed to these envi-ronmental stimuli is a function of ge-netic vulnerability factors and also


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