That statement has guided a pioneering integration of mental health and
public health in New York City and a remarkable exercise in population-based
strategic planning targeting mental health and substance abuse problems.
Lloyd Sederer, M.D., executive deputy commissioner of mental hygiene
services in the New York City Department of Health and Mental Hygiene,
described the city's endeavors at last month's Institute on Psychiatric
Services in New York.FIG1
Lloyd Sederer, M.D., executive deputy commissioner of mental hygiene
services in New York City, describes innovative strategies to integrate mental
health and public health. Sederer spoke last month at APA's Institute on
Psychiatric Services. See page 11.
Sederer detailed a range of population-based strategies targeting four
broad public health areas—depression screening and treatment, screening
and intervention for substance abuse, expansion of supportive housing, and
focus on quality improvement on the part of community-based agencies funded by
The strategies are part of an effort to integrate mental health and public
health that began with the merger of the public health and mental hygiene
departments in 2002. That merger has allowed the same kind of population-based
approaches to be applied to mental health and substance abuse that are
typically applied to health problems such as SARS, avian flu, or contaminated
food, he said.
"The same understanding that there are diseases inherent to a
population and preventive-intervention strategies that can make a difference
to a population hasn't been well developed and hasn't been part of the
identity of a [mental health] agency," he said. "But we decided
that we should be doing that."
Under Sederer's leadership, the department is responsible for planning,
purchasing, and monitoring quality control of public mental health services,
oversight of population-based mental health interventions, and advocacy. The
department funds 1,500 programs and 365 agencies serving 500,000 people, with
an annual budget of $825 million.
Before taking on the position in New York, Sederer was director of APA's
Division of Clinical Services from 2001 to 2003.
A signature aspect of the initiative described by Sederer is the use of
instruments to screen for depression in primary care settings and for
substance abuse in Emergency Departments (EDs). This is part of an
encompassing health policy in the city known as Take Care New York (TCNY).
"This is a health policy that addresses preventable causes of illness
and death and focuses on underserved communities with a disproportionately
high disease burden," he said.
TCNY's 10 target intervention goals include the following:
According to the New York City Health and Nutrition Examination Survey,
only 37 percent of New Yorkers with depression report receiving mental health
treatment, and only 26 percent of African Americans and 27 percent of
Hispanics with depression are in treatment. These figures compare with nearly
half (49 percent) of white people who receive needed treatment for
"If you want to do something [in public health], you have to go where
the people are," Sederer said. "So we decided that we needed to go
to primary care. Depression is more common than every other condition seen in
primary care. And what we see are two principal patterns—either people
don't go to get treatment or they go for one visit. So we know we have this
dataset that makes for a chilling picture of a public mental health crisis. We
have a highly prevalent yet treatable disease, but about 4 in 10 of those with
depression don't get treatment, and 1 in 8 is getting minimally adequate
treatment. This situation would never be allowed if we were talking about
tuberculosis, HIV/AIDS, or diabetes. Why should it be allowed for
What was missing, Sederer said, was an easy-to-use instrument for
ascertaining depression severity in the primary care setting. The instrument
that was chosen to fill the gap was the nine-item Patient Health Questionnaire
One PHQ-9 question, for example, asks the respondent how often he or she
has experienced nine symptoms of depression in the prior two weeks, including
having little interest in activities; feeling down, depressed, or hopeless; or
having trouble sleeping. Respondents choose one of four choices: not at all,
several days, more than half the days, or nearly every day.
A second question asks respondents to rate how difficult these problems
have made it to do work, take care of things at home, or get along with other
people. Response choices are not at all difficult, somewhat difficult, or
The instrument also includes a treatment algorithm that outlines treatment
options ranging from self-management techniques taught by the primary care
physician to specialty referral for more severe or refractory cases
(Psychiatric News, May 20, 2005).
"We have worked to make this screening a required field in the
electronic medical record throughout all the primary care practices in the
Health and Hospitals Corporation," he said. "That rollout will be
complete by the end of this year, and that will get us screening 16 percent of
all New Yorkers. We are going to keep this march going until at a certain
point we are going to hit the tipping point."
At that point, Sederer believes, the popularity of the
screening—supplemented by the fear of liability for practices that don't
screen—will quickly cause the PHQ-9 to become a standard of
Similarly, the city has sought to address substance abuse and alcoholism
through widespread population-based screening at the point in the health care
system at which much substance abuse makes itself felt—in the city's
To do this, Sederer said the agency has implemented Screening, Brief
Intervention, Referral, and Treatment (SBIRT), an evidence-based program that
emergency department and other medical staff can use to detect problem
drinking or drug use and then provide a brief intervention. SBIRT is designed
to reach people at a "teachable moment," immediately following
some traumatic consequence of their substance abuse, when they are most likely
to be receptive.
"If you reach people after a bad consequence of their
disease—in the ER or the trauma center or in a primary care setting,
their defensive state is reduced," Sederer said. "This
intervention borrows on all the authority of the doctor or nurse to engage
people in terms of recognizing the consequences of their substance abuse and
taking responsibility at a point where they are much more apt to do
Through collaboration with the New York City Health and Hospitals
Corporation, Sederer's department has given funds to five hospitals to
implement SBIRT in their EDs, has trained more than 300 ED clinicians, and is
linking with hospital chemical-dependency programs and training primary care
physicians to use the intervention.
A third strategy the department is pursuing is to expand supportive housing
for the city's mentally ill population. "We took the position that
nobody stands a chance of recovering from these conditions unless they are
safely and reliably housed," Sederer said.
He said the agency managed to "pull off an incredible deal" to
build 9,000 additional units of supportive housing, almost doubling the
existing supply of housing for people with severe and persistent mental
illness in New York City.
The success of the effort was driven not only by the all-too-obvious excess
of people living on the streets, he said, but also by the proven
cost-effectiveness of supportive housing (see chart).
"This is a compelling part of effective advocacy," Sederer
said. "You have to make three arguments—a moral argument, a
clinical argument, and the economic argument. If you've got all three, you
stand a chance."
Finally, Sederer said the department has sought to introduce evidence of a
process of quality improvement as a contractual requirement for all funded
agencies in a program. Four key areas were identified as part of the Quality
Impact program: consumer perceptions of care, screening for and treatment of
co-occurring mental disabilities and disorders, cultural competence, and
becoming a "welcoming clinic."
Sederer said the goal was to make quality improvement a standard of doing
business with the agency in the same way that the Joint Commission on
Accreditation of Healthcare Organizations has made quality improvement a
standard for hospitals.
"But when we looked at 100 of our community-based agencies, virtually
none of them did this. This was an opportunity to introduce a method for
training people to think about problems in a systematic way across the mental
health system in the city."
Despite some initial resistance, Sederer said, "most of the really
good agencies found it was a way to improve their staff's professionalism, to
improve their performance, and to illustrate what they are doing to their
boards. They found that there were a lot of positive benefits."▪