SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

Silver Hill Hospital FEBRUARY 2014 Community Health Needs Assessment

An in-depth assessment of the mental health and substance abuse needs of the Fairfield County community. SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

TABLE OF CONTENTS

Executive Summary ...... 2

Introduction ...... 4

Silver Hill Hospital...... 4

Definition of Community Served ...... 5

Process and Methods ...... 7

Community Interviews ...... 8

Community Health Needs Assessment: Data and Research...... 10

Substance Abuse ...... 10

Alcohol ...... 10

Illicit Drugs ...... 14

Tobacco ...... 18

Mental Health ...... 20

General...... 20

Mood & Anxiety Disorders ...... 23

Psychotic & Personality Disorders ...... 24

Eating Disorders ...... 25

Suicide ...... 26

Dual Diagnoses ...... 28

Community Input and Existing Resources ...... 30

Themes from Community Input ...... 30

Existing Resources in the Community ...... 38

Prioritized Health Needs of Our Community ...... 47

Endnotes ...... 50

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

EXECUTIVE SUMMARY

Silver Hill Hospital (SHH) is a not-for-profit specialty hospital for mental health and substance abuse needs for adolescents (ages 13-17) and adults (ages 18+). Silver Hill Hospital’s primary community comprises Fairfield County, Connecticut, a county of an estimated 933,835 residents according to the 2012 U.S. Census. We determined our community by looking at historical volume experience for inpatient, outpatient and residential admissions.

Between May and November 2013, we conducted primary and secondary data research and interviewed over 20 community stakeholders to develop the Community Health Needs Assessment and the accompanying 2014-2017 Implementation Plan. We assessed the following issues in our community: 1) Substance Abuse (alcohol, drugs and tobacco); 2) Mental Health Issues (mood and anxiety disorders, psychotic and personality disorders, eating disorders and suicide); and 3) Dual Disorders (co-occurring mental health and substance abuse issues). When possible, we examined Fairfield County or the Southwest Region as opposed to the state of Connecticut or the U.S. overall. We also paid particular attention to potentially underserved populations in our community including adolescents and young adults, women, minorities and seniors.

FINDINGS IN BRIEF

Fragmentation of Services. Somewhat counter-intuitively, people on public assistance often have more and better services than those available to people with insurance, who make up the bulk of Fairfield County. The state system offers wrap-around services focused on the full continuum of care, housing and supported employment, education and peer services. There are no corollaries in the private sector. As a result, the mental health system for youth and adults alike is fragmented and less holistic than it should be. In addition, there is a gap in services for young adults (ages 18-25). Despite the negative view many hold of the public sector’s mental health and substance abuse programs, there is something we, as a private-sector provider to a mostly well-off patient population, can learn from public assistance programs.

Alcohol Abuse Among Adults, Adolescents and Seniors. Fairfield County has a particular problem with alcohol abuse. The rate for binge alcohol use and alcohol dependence here is higher than in Connecticut and the U.S. as a whole. The problem is not limited to adults. Connecticut adolescents aged 12-17 are second only to Montana in binge alcohol use. The growing community of seniors, whose bodies no longer metabolize alcohol in the same way, are also in danger of abusing alcohol. There is also a treatment gap, with 7.8% of adults aged 12 and over needing treatment for alcohol use compared to 6.9% nationwide.

Marijuana and Prescription Drug Abuse Among Adults and Adolescents. There is an increasing need for treatment of illicit drug use in the Southwest Region. Over the last several years, the incidence of prescription drug abuse has climbed, mirroring national trends. Unfortunately, there is a gap in knowledge in the provider community regarding treatment for opioid addiction. Marijuana is also a serious issue for adolescents in the region. Despite its perception as less dangerous than alcohol or other drugs, marijuana is an addictive drug with long-term side-effects for adolescents. Parents’ understanding the facts and legal implications is critical to changing use patterns among adolescents in Fairfield County.

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

Mental Illness Among Young Adults, Women and Hispanics. Adults in Connecticut do not differ significantly from the U.S. as a whole in major depressive episodes, serious mental illness or suicidal ideation. Young adults (ages 18- 25), however, have a slightly higher rate of serious mental illness than the U.S. population as a whole. Women nationwide are more likely than men to report poor mental health; Connecticut is no exception. Girls are also much more likely to be depressed than boys, and at younger ages. Likewise, Hispanic youth in Connecticut are more likely to be depressed than others. Stigma associated with seeking medical treatment for mental illness in the Hispanic community, however, acts as a barrier to care. In general, the high-pressure environment of our mostly affluent community contributes to pathological behavior, and the community could benefit from education around coping skills and mindfulness, particularly for the “sandwich generation,” who must care for both aging parents and school-aged adolescents.

A Dearth of Resources for Eating Disorders. Over 4% of women in Connecticut have an eating disorder, twice the rate for men. Sadly, the rates in Connecticut are driven by younger teens. According to community stakeholders, there is a real lack of resources – both inpatient and outpatient – for those suffering from eating disorders. There is also a lack of understanding by providers, parents and school administrators regarding how to handle an emerging or suspected eating disorder, particularly for adolescents.

Suicide Among Adolescents and Young Adults. Both adolescents and young adults are disproportionately affected by suicide in this community as evidenced by the three high school suicides that have taken place this school year. In the state of Connecticut between 2005 and 2010, suicide was the third leading cause of death among adolescents aged 10-14, the second leading cause of death among adolescents aged 15-19 and the third leading cause of death among 20-24 year-olds. The Southwest Region also has a higher rate of alcohol-related suicides than the rest of the state.

Community Outreach Needed, Particularly to Adolescents, Seniors and Minorities. Silver Hill Hospital has not fully exhausted its community reach. There are several opportunities to raise visibility of our services, offer information referrals and provide education -- both for individuals/families and practitioners. We already provide Grand Rounds programs for practicing clinicians, but there are also school psychologists, guidance counselors, seniors counselors and other community members who could benefit from professional development. We also noted a gap in services for some underserved communities including youth, seniors and minorities and learned of stigma associated with attending a program on the Hospital’s grounds.

PRIORITIES

Based on our research and conversations, we determined the following priorities in meeting community needs using three criteria: 1) Urgency: How critical is the need?; 2) Size: How big is the need?; and 3) Capacity: How able are we, as a behavioral health institution, to address the need? Will we make an impact?

We elaborate on the following four priorities in the Implementation Plan: 1) Substance Abuse Programs for Adults (including Outpatient Detox and Chronic Pain and Recovery); 2) Enhanced Adolescent Programming (including an enhanced Transitional Living Program and an Intensive Outpatient Program); 3) Enhanced Eating Disorder Program; and 4) A Community Liaison Position (for outreach to underserved populations including youth and families, senior citizens and minorities as well as partnering with existing community programs).

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

INTRODUCTION

Health care costs in the U.S. continue to rise despite efforts to contain them. In fact, the share of GDP devoted to health care spending grew from 9% of GDP in 1980 to 16% of GDP in 2008, one of the largest increases in the developed world.1

At the same time, resources available for health care are limited. In order to most effectively and efficiently care for the health of our population within these restricted means, providers must conduct systematic assessments of the most pressing needs of their communities. This realization, of course, is nothing new. The importance of population health assessments was explained nicely 15 years ago in this 1998 article from BMJ:

Distinguishing between individual needs and the wider needs of the community is important in the planning and provision of local health services. If these needs are ignored then there is a danger of a top-down approach to providing health services, which relies too heavily on what a few people perceive to be the needs of the population rather than what they actually are.2

In this report, we discuss the needs of our community with regard to mental health and substance abuse, and set forth priorities for addressing those needs.

SILVER HILL HOSPITAL

Silver Hill Hospital (SHH) is a not-for-profit Institution for Mental Diseases as defined under The Social Security Act 1905(i) and Title 42 Paragraph 435.1009 of the Code of Federal Regulations. As a specialty hospital, we have assessed the mental health and substance abuse needs of our community for those we treat, i.e., adolescents (ages 13-17) and adults (ages 18+).

SHH’s mission is to provide our patients with the best available treatment of mental illness and addiction and to offer continuing support, counseling and education to our patients and their families in every phase of illness and recovery. SHH has first-class hospital staff and a wide range of treatment options encompassing both traditional medicine and complementary and alternative therapies, as well as family programs which help both patients and their families cope better. The facility is set within a serene countryside environment that is conducive to healing.

We provide comprehensive treatment for a wide range of disorders -- from schizophrenia to addictions -- and along the care continuum, including acute inpatient care, residential (transitional living) programs, intensive outpatient programs and, in some cases, a 12-month post-discharge follow-up program. Our affiliation with the Yale University School of Medicine Department of Psychiatry helps us stay on the cutting edge of treatment advances.

SHH has an 18-bed traditional psychiatric acute care unit plus a 26-bed locked unit for lower-risk inpatients, including 10 adolescent inpatient beds. SHH also offers six different residential programs -- known as Transitional Living Programs (TLPs) -- treating the illnesses of addiction, co-occurring disorders, personality disorders, psychotic disorders and chronic pain and addiction. We also offer four Intensive Outpatient Programs in dual diagnoses and dialectical behavioral therapy (DBT) as well as a women-only trauma and addiction program.

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

For the fiscal year 2013 ending February 28, 2013, SHH had 1,877 inpatient admissions and 726 TLP admissions. About three-quarters of our inpatient admissions came from professional referrals (doctors, hospitals), and the remaining one-quarter were self- or family referrals. About 20% of all inpatients were adolescents aged 13-17; 55% were female.

A quarter of the patients who are treated in our inpatient programs continue their treatment in one of our Transitional Living (residential) programs (TLPs), which provide an intensive behavioral and counseling program in a more open environment. If a patient in a residential program needs to briefly move back to the inpatient program for additional stabilization, that move and the transition back to the residential program is easy and seamless. Silver Hill Hospital's Recovery Support and Follow-up Service (RSFS) is the most comprehensive post- discharge support and follow-up service offered by any psychiatric hospital. Patients discharging from the Addiction or Co-Occurring Disorders TLP are automatically enrolled in the RSFS for 12 months. The goals of RSFS are to facilitate a smooth transition from treatment to recovery and to increase the likelihood of continued recovery during the first critical year.

About two-thirds of inpatients and TLP residents come to SHH with a dual diagnosis: a primary diagnosis of substance abuse and an associated psychiatric disorder or a primary diagnosis of a psychiatric disorder plus a secondary diagnosis of a chemical dependency. Very often, an associated disorder is not recognized by the patient and not identified by the provider. This makes full recovery less likely. At Silver Hill Hospital we put a lot of effort into identifying these co-occurring or dual problems and treating both of them at the same time. We have 13 full- time psychiatrists on our staff and a treatment team with extensive training and experience in dual diagnoses.

At Silver Hill Hospital, we understand the impact of a psychiatric and substance use illness on families, and we help families move beyond the suffering caused by these illnesses. Depending on the program, we offer weekly family forums, DBT family groups and an intensive four-day family program – all to help family members learn how to support the patient’s recovery and preserve the stability and integrity of their own lives.

Learn more about Silver Hill Hospital on our website at www.silverhillhospital.org.

DEFINITION OF COMMUNITY SERVED

Silver Hill Hospital’s primary community comprises Fairfield County, Connecticut, a county of an estimated 933,835 residents according to the 2012 U.S. Census.3 The Bridgeport-Stamford-Norwalk Metropolitan Service Area (MSA) comprises the total of Fairfield County with 23 towns: Bethel, Bridgeport, Brookfield, Danbury, Darien, Easton, Fairfield, Greenwich, Monroe, New Canaan, New Fairfield, Newtown, Norwalk, Redding, Ridgefield, Shelton, Sherman, Stamford, Stratford, Trumbull, Weston, Westport and Wilton.4

We determined our community by looking at historical volume experience. Over the last five years, SHH had 9,485 inpatient admissions, of which 34% lived in Fairfield County and 62% resided in Connecticut. As for residential and outpatient programs, last year 22% of our residential patients came from Fairfield and 34% came from Connecticut. Our Transitional Living Program is internationally regarded and attended. As for outpatient programs, 70% of our patients came from Fairfield County and 80% came from Connecticut.

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

Fairfield County is made up of 24% youth and adolescents, 14% elderly and 51% women. In addition, 17% of the community is Hispanic. The table below also shows that Fairfield County is wealthier (higher median household income) and more educated (higher percentage with at least a Bachelor’s degree) than the state of Connecticut or the nation as a whole.

Select Fairfield County Demographic Statistics Fairfield CT USA Basic Demographics Population, 2012 estimate 933,835 3,590,347 313,914,040 % of total state population 26% Persons under 18 years, percent, 2011 24% 22% 24% Persons 65 years and over, percent, 2011 14% 14% 13% Female persons, percent, 2011 51% 51% 51%

Ethnicity White persons, percent, 2011 (a) 81% 82% 78% Black persons, percent, 2011 (a) 12% 11% 13% Persons of Hispanic or Latino Origin, percent, 2011 (b) 17% 14% 17% White persons not Hispanic, percent, 2011 66% 71% 63%

Education & Economic Indicators Bachelor's degree or higher, percent of persons age 25+, 2007-2011 44% 36% 28% Homeownership rate, 2007-2011 70% 69% 66% Median value of owner-occupied housing units, 2007-2011 $466,700 $293,100 $186,200 Median household income, 2007-2011 $82,558 $69,243 $52,762 Persons below poverty level, percent, 2007-2011 8% 10% 14%

Source: U.S. Census Bureau. http://quickfacts.census.gov/qfd/states/09000.html

The map below, from Community Commons5 shows that Fairfield County has four main areas of density: Stamford, Norwalk, Bridgeport and Danbury.

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

The table below, adapted from CDC data, shows that, in general, residents of Fairfield County are more likely to binge drink than are residents of the state of Connecticut or the nation as a whole. However, Fairfield residents are also less likely to be smokers or limited in activities by disability, and more likely to be in “excellent” or “very good” health and insured than are residents the state of Connecticut or the U.S as a whole.6

Behavioral Risk Factors, 2010 Fairfield CT USA Alcohol Heavy drinkers (adult men having more than two drinks per 5.6% 5.0% 5.0% day and adult women having more than one drink per day) Binge drinkers (males having five or more drinks on one 20.5% 17.4% 15.1% occasion, females having four or more drinks on one occasion)

Tobacco Use Adults who are current smokers 10.0% 13.2% 17.3% Smoke every day 6.1% 9.2% 12.4% Smoke some days 3.9% 4.0% 4.8% Former smoker 29.5% 29.2% 25.1% Never smoked 60.5% 57.6% 56.6%

Disability Adults who are limited in any activities because of physical, 14.3% 16.6% 21.2% mental, or emotional problems

General Health Excellent or Very Good 67.6% 60.4% 54.8% Fair or Poor 9.4% 11.0% 14.9%

Access to Care Any kind of health care coverage 91.4% 90.2% 85.0% Adults 18-64 with health care coverage 89.8% 88.4% 82.2%

Source: CDC, Behavioral Risk Factor Surveillance System (2010 data). USA includes States & DC. http://www.cdc.gov/brfss/index.htm

PROCESS AND METHODS

The core committee for the assessment consisted of Elizabeth Moore, Chief Operating Officer; Heather Porter, Director of Marketing; and Heidi Leatherman, Director of Accounting. We also employed the resources of an independent health care consultant, Debra C. Gaisford.

The committee met on May 28, August 14, October 3 and October 15, 2013. We researched available data online, interviewed community stakeholders and assessed priorities. After we had conducted the assessment, we met again with the Chief Executive Officer, Dr. Sigurd Ackerman, the Medical Director, Dr. Eric Collins, the Chief Financial Officer, Ruurd Leegstra and the Director of Social Work, Janet Isdaner, to determine priorities and address implementation.

On December 5, 2013, we presented our findings and recommendations to the Marketing Committee of the Board of Directors for its members’ review. The full Board of Directors reviewed the assessment on January 23, 2014.

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

COMMUNITY INTERVIEWS

We spoke to the following individuals and groups as part of our Community Health Needs Assessment between May and November 2013.

May 14, 2013 Chronic Pain Recovery Center (CPRC) Open Forum at Silver Hill Hospital. Physicians and outreach staff from the hospital met with 13 community practitioners, practice managers and Connecticut State Drug Control officials (Department of Consumer Protection) to discuss the issue of addiction to opioid-based pain medication as a result of chronic pain.

Jul. 31, 2013 Linda M. Autore, President & CEO of Laurel House, a non-profit organization located in Stamford, Connecticut that provides resources and opportunities for people living with serious psychiatric illnesses such as schizophrenia to lead fulfilling and productive lives in the communities where they live, work and go to school. Ms. Autore is also a member of Silver Hill Hospital’s Board of Directors.

Aug. 13, 2013 Alan M. Barry, Ph.D., Commissioner of Social Services for the town of Greenwich, Connecticut and formerly the administrator for the Department of Psychiatry at Norwalk Hospital.

Sep. 17, 2013 Claudette Kunkes, Ph.D., a psychologist in private practice in Fairfield County. She specializes in providing counseling for adult women. Dr. Kunkes is also a member of Silver Hill Hospital’s Board of Directors.

Sep. 19, 2013 Barbara Greenberg, Ph.D., a clinical psychologist, is an expert on subjects related to parenting, teens, communication, love, family and lifestyle. Dr. Greenberg specializes in the treatment of adolescents. She maintains her full-time private practice in Fairfield County and is the Adolescent Consultant at Silver Hill Hospital. She writes regularly for such publications as Psychology Today and the Huffington Post and is the co-author of the book Teenage as a Second Language – A Parent’s Guide to Becoming Bilingual.

Sep. 19, 2013 Erin Kleifield, Ph.D., a private practitioner specializing in eating disorders and mindfulness.

Sep. 20, 2013 Dan Wartenberg, Chief Executive Officer of the Southwest Connecticut Mental Health System (SWCMHS), the local mental health authority in Region One for Connecticut’s Department of Mental Health & Addiction Services (DMHAS).

Sep. 23, 2013 Kate Mattias, MPH, JD, the Executive Director of the Connecticut chapter of the National Alliance on Mental Illness (NAMI), a nationwide grassroots mental health advocacy organization.

Sep. 26, 2013 Aaron Krasner, MD, a psychiatrist specializing in the treatment of adults, children, adolescents, and families who resides in Fairfield County and practices privately in New York City. Silver Hill Hospital recently hired Dr. Krasner to revamp our adolescent transitional living program.

Oct. 1, 2013 Peter Case, former President (still on the Board), and Lorraine Zegibe, Head of Community Outreach for the Stamford/Greenwich affiliate of NAMI.

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

Oct. 10, 2013 Jacqueline D’Louhy, MSW, Director of Youth and Family Services for the Town of New Canaan; Kate Boyle, a Youth and Family Services Specialist with the Town of New Canaan; and Melba Neville, RN, Senior Services Outreach Worker for the Town of New Canaan.

Oct. 10, 2013 Attended monthly meeting of the Hispanic Advisory Council of Greater Stamford, a network of social services agencies, employers, professionals and healthcare providers that deliver services to the Hispanic community of Greater Stamford.

Oct. 17, 2013 Margaret Watt, MPH, Executive Director of the Southwest Connecticut Regional Mental Health Board, a citizens’ advisory council created by State mandate to assess and promote mental health and addiction services in Southwestern Connecticut.

Oct. 24, 2013 Bill Piper, Chief Executive Officer of the Waveny Care Network, which provides a comprehensive continuum of care to older adults, including skilled nursing, assisted living, independent living, home health care, geriatric care managers and outpatient rehabilitation services in New Canaan and the surrounding communities.

Nov. 11, 2013 Ingrid Gillespie, Director of the Lower Fairfield County Regional Action Council (LFCRAC), a regional resource to support local mental health initiatives.

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

COMMUNITY HEALTH NEEDS ASSESSMENT: DATA AND RESEARCH

We assessed the following issues in our community:

. Substance abuse o Alcohol o Drugs (including marijuana and prescription medication) o Tobacco . Mental health issues o Mood and anxiety disorders (e.g., depression, anxiety, etc.) o Psychotic and personality disorders (e.g., schizophrenia, borderline personality disorder, etc.) o Eating disorders (e.g., anorexia, bulimia, etc.) o Suicide . Dual disorders (co-occurring mental health and substance abuse issues)

When possible, we examined Fairfield County or the Southwest Region as opposed to the population of the state of Connecticut or the U.S. overall. We also paid particular attention to potentially underserved populations in our community including:

. Adolescents . Women . Hispanics . Seniors

SUBSTANCE ABUSE

The National Center for Addiction and Substance Abuse at Columbia University (CASAColumbia) estimates that only one in 10 (10.9%, 2.5 million) of those individuals in need of addiction treatment (excluding nicotine) receive it, leaving a treatment gap of 20.7 million individuals. The proportion of individuals in need of addiction treatment who actually receive it has changed little since 2002, when 9.8 % of those in need received it. Fortunately, the northeast is estimated to have the smallest treatment gap nationwide.7

ALCOHOL

Data indicate that one of Fairfield County’s most pressing Populations

substance abuse issue is alcohol, particularly when compared Issues General Adolescents Women Hispanics Seniors

to the state of Connecticut and the U.S. as a whole. The Substance Abuse statistics below are from the 2008-2010 National Surveys on Alcohol

Drug Use and Health (NSDUH) sub-state data and include Drugs

information for the “Southwest” Region of Connecticut, which Tobacco 8 encompasses most of Fairfield County. Mental Health Mood & Anxiety Disorders Psychotic Disorders Eating Disorders

Suicide 10

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

 The rate for binge alcohol use in the last month for individuals aged 12+ (defined as drinking five or more drinks on the same occasion) was 26.85%, compared to 26.48% in Connecticut and 23.47% in the U.S. as a whole.  The rate for binge alcohol use in the last month for individuals aged 12-20 was 21.42%, compared to 22.43% in Connecticut and 17.47% in the U.S. as a whole.  The rate of alcohol dependence in the last year was 3.37%, compared to 3.30% in Connecticut and 3.47% in the U.S. as a whole; the rate of dependence or abuse was 7.86%, compared to 8.01% in Connecticut and 7.29% in the U.S. as a whole.  The percent of individuals needing but not receiving treatment for alcohol use in the past year was 7.78%, compared to 7.71% in Connecticut and 6.90% in the U.S. as a whole.

The higher rates of alcohol abuse and dependence in Southwest Connecticut are not offset by higher use rates of illegal drugs in other parts of the country. In fact, when taken together, abuse or dependence on alcohol or illicit drugs in Southwest Connecticut was still slightly higher at 9.37% than the U.S. as a whole (8.89%).9

Connecticut Department of Mental Health and Addiction Services (DMHAS) data corroborates national reports. In Connecticut overall, the percent of primary heroin admissions recently dropped after years of steady increases giving rise to alcohol as, once again, the most frequently reported substance at admission.10 (This trend could, however, be driven by the fact that insurance companies are increasingly denying authorization to patients for opioid detoxification. See the section on Illicit Drugs for more information.)

The table below shows binge alcohol use, a leading indicator for alcohol abuse issues, in Connecticut and the Southwest Region. In both the state and sub-state surveys our state and region fared worse than the nation overall. And while the state rate declined on par with the U.S. rate between the 2008-2009 and 2010-2011 surveys, the Southwest Connecticut rate increased 0.2% between the 2006-2008 and 2008-2010 surveys. In fact, in the 2008-2010 survey, Southwest Connecticut was 60th among 407 regions and catchment areas in the U.S. for binge drinking among individuals aged 12 and older, up from 67th place in the prior survey.11

Binge Alcohol Use in the Past Month NSDUH Location 12+ Total U.S. 23.5% 2008-2009 State Data Connecticut 27.0% 2006, 2007, 2008 Southwest CT 26.7% Substate Data

Total U.S. 22.9% 2010-2011 State Data Connecticut 26.3% 2008, 2009, 2010 Southwest CT 26.9% Substate Data

Total U.S. -0.7% Change between Connecticut -0.7% Surveys Southwest CT 0.2%

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

More locally, in 2007, alcohol was the most common primary drug for patients admitted for publicly funded treatment from each of the four towns in Sub-Region 1A of the Southwest Connecticut Region: Darien (53%), Greenwich (52%), New Canaan (53%) and Stamford (35%).12

Sub-Region 1C (Greater Bridgeport) demonstrates similar, pervasive issues. For example, a 2006 random digit dial survey of Bridgeport households found that one third of Bridgeport residents reported having had an alcoholic drink during the past 30 days. Drinking was more prevalent among the unemployed (49%) and Portuguese speakers (62%). Higher rates of drinking were also reported by those who were college educated (42%) and those making more than $50,000 per year (59%).13

The map below from Community Commons14 contains Behavioral Risk Factor Surveillance System (BRFSS) data from the CDC between 2005 and 2011 for Fairfield County. It indicates that Fairfield County is consistently in the highest category (above 18%) in the nation when it comes to adults aged 18 and over who are heavy drinkers.

SPOTLIGHT ON UNDERSERVED POPULATION: ADOLESCENTS

The table below demonstrates Fairfield County’s issue with alcohol. In both surveys, Connecticut adolescents aged 12-17 were second only to Montana in their binge alcohol in the last month at a rate of 13.3% in 2008-2009 and 10.2% in 2010-2011. These rates are well above the national rates. Some progress was made between 2009 and 2011, for the rate decreased 3.1%, faster than the national rate. Note, however that the young adult population aged 18-25 (half of which is still underage) actually increased its rate of binge drinking between the two surveys.15

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

Binge Alcohol Use in the Past Month NSDUH Location 12+ 12-17 18-25 26+ Total U.S. 23.5% 8.9% 41.5% 22.3% 2008-2009 State Data Connecticut 27.0% 13.3% 46.9% 25.6%

Total U.S. 22.9% 7.6% 40.1% 21.8% 2010-2011 State Data Connecticut 26.3% 10.2% 48.0% 24.8%

Change between Total U.S. -0.7% -1.3% -1.4% -0.5% Surveys Connecticut -0.7% -3.1% 1.1% -0.8%

The CDC’s Youth Risk Behavior Survey (YRBS) further emphasizes the region’s issue with alcohol. Across Connecticut, of 9th-12th graders surveyed in 2011:16

 15.6% admitted to trying alcohol before the age of 13, compared to 20.5% in the U.S. as a whole. This figure rose to 20.7% for Hispanic and Latino teens in Connecticut.  41.5% drank alcohol at least one day in the last 30 days, compared to 38.7% in the U.S. as a whole.  22.3% binged on alcohol in the last 30 days, compared to 21.9% in U.S. as a whole.

In Fairfield County, adolescent patterns are no different than those of adults, showing better statistics than the state of Connecticut but worse than the U.S. as a whole:

 In the Southwest Region, 30.62% of individuals aged 12-20 consumed alcohol in the past month compared to 31.35% in Connecticut and 26.54% nationally.17  In the Southwest Region, 21.42% of individuals aged 12-20 engaged in binge drinking compared 26.48% in Connecticut and 17.47% nationally.18 (The high rates of adolescent binge drinking in Connecticut appear to be driven by the Eastern Region, which had a rate of 24.1%.)  In 2005, there were 318 treatment admissions for underage (ages 12-20) drinking (rate of 33.3 adolescents per 10,000).19  In 2008, almost 60% of 9th-12th graders reported alcohol use in the past 30 days and 5% reported having used alcohol 10 or more times in the past month in Sub-Region 1A of Southwest Connecticut (includes Darien, Greenwich, New Canaan and Stamford).20

SPOTLIGHT ON UNDERSERVED POPULATION: SENIORS

According to the NIH, as people age, they may become more sensitive to alcohol's effects. One reason is that older people metabolize alcohol more slowly. Also, the amount of water in the body decreases with age. As a result, older adults have a higher percentage of alcohol in their blood than younger people – or than they used to -- after drinking the same amount. Aging lowers the body's tolerance for alcohol, causing older adults to experience the effects of alcohol, such as slurred speech and lack of coordination, more readily than when they were younger. An older person can develop problems with alcohol even though his or her drinking habits have not changed. Finally, many medicines interact with alcohol and can be harmful to older adults.21

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

A July 2012 report from SAMHSA indicates that, by 2020, the number of adults aged 50 or older needing substance abuse treatment is expected to double from 2.8 million (2002 to 2006 annual average) to 5.7 million. According to the Treatment Episode Data Set (TEDS), substance abuse treatment admissions of individuals aged 50 or older increased by nearly 50% between 2004 and 2009. Unfortunately, data from the National Survey of Substance Abuse Treatment Services (N-SSATS) show that in 2009 fewer facilities offered special programs or groups for seniors or older adults than in 2004.22

ILLICIT DRUGS

Data indicate that while there is a fair amount of illegal drug Populations

use in the Southwest Region, prevalence rates are lower than Issues General Adolescents Women Hispanics Seniors

for the state of Connecticut or the U.S. as a whole. Substance Abuse Alcohol For example, 2.67% of Southwest Region residents aged 12 Drugs and over said they were dependent on or abused illicit drugs Tobacco in the past year, compared to 2.88% in Connecticut and 2.82% Mental Health 23 in the U.S. as a whole. Mood & Anxiety Disorders Psychotic In terms of treatment, 2.23% of Southwest Region residents Disorders needed but didn’t receive treatment for illicit drug use in the Eating Disorders last year, compared to 2.42% in Connecticut and 2.54% in the Suicide U.S.24 Notably, in the prior NSDUH (2006-2008), the Connecticut and U.S. rates were comparable (2.41% and 2.53%, respectively) but the Southwest Region figure was lower at 1.90%,25 indicating that there is an increasing need for treatment of illicit drug use in our Region, even though it is lower than the state or national rates.

Almost a third of all drug- and alcohol-related admissions to substance abuse services in the state of Connecticut come from young adults aged 20-29. Certain drugs are worse than others. This cohort makes up 58% of the admissions for PCP, and 50% each of admissions for hallucinogens and marijuana.26

Cocaine

In the Southwest Region, 1.66% of adults aged 12 and over used cocaine in the past year, according to the 2008- 2010 NSDUH, compared to 1.82% in Connecticut and 1.94% nationally.27 These figures have all decreased nicely from the 2006-2008 study which found use rates of 2.41% in the Southwest Region, 2.35% in Connecticut and 2.33% nationally.28

State data from the 2011 NSDUH, however, shows that young adults aged 18-25 are truly driving the rate across the state, with 5.7% young adults having used cocaine in the past year compared to 4.6% nationally.29 In addition, data from the 2006 Core Survey of Connecticut college students found that the prevalence of current cocaine use increased from 2.7% in 2001 to 3.0% in 2006.30

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

Opioids: Heroin and Pain Relievers

Primary admissions for heroin use decreased 36% in Connecticut between 2000 and 2010, from 601 to 382 admissions per 100,000 individuals aged 12 and over, but the rate is still nearly 300% higher than the 2010 national rate of 97 admissions per 100,000 adults.31

Overdose deaths from controlled prescription drugs have increased significantly over recent years and now surpass the number of overdose deaths caused by illicit drugs. In the U.S. in 2008, 73.8% (14,800) of overdose deaths were attributable to prescription opioids.32

Primary admissions for pain medication use increased 265% in Connecticut between 2000 and 2010, from 23 to 84 admissions per 100,000 individuals aged 12 and over, compared to an even greater increase (but still lower absolute figure) of 400% nationwide to 60 admissions per 100,000 adults.33

Compared to the U.S. rate of 4.57%, Connecticut’s rate of non-medical use of pain relievers is estimated to be slightly lower, at 4.38% of the adult population (aged 12+) according to the most recent 2011 NSDUH,34 which is higher than the 3.88% rate found in prior survey (2008-2010). The rate in the Southwest Region was estimated at 3.52% in the 2008-2010 survey.35 For young adults (aged 18-25) in Connecticut, the rate of non-medical use of pain relievers was about two and a half times the general adult population at 10.7% (similar to the national ratio).36 The concern is that evidence shows that many people who become addicted to prescription pain relievers move to heroin as a cheaper and more readily available alternative.37

Interpreting the decline in opioid-based primary admissions, however, is complicated by the fact that increasingly, insurance companies view opioid detoxifications as non-life-threatening and therefore not in need of an inpatient stay. In fact, according to our Admissions department, one of the most common reasons individuals who call are not admitted is for seeking inpatient detoxification services their insurance companies will not authorize.

Unfortunately, there is a significant gap in knowledge in the provider community regarding treatment for opioid addiction. Although buprenorphine (Suboxone), is a clinically effective and cost-effective pharmaceutical treatment for opioid addiction, it is under-utilized by physicians and addiction counselors. Researchers at CASAColumbia found that the majority (86%) of addiction counselors reported not being aware of the effectiveness of buprenorphine. And a random sample of internal medicine, family medicine, psychiatry and pain management physicians in Maryland found that only 36% of respondents were willing to prescribe buprenorphine to an established patient and only 28% were willing to prescribe the medication to a new patient.38 In addition, a report from DMHAS in 2012 found that a third of surveyed agencies in Region 1 (which encompasses most of Fairfield County) were unsure of where to refer a client for a buprenorphine maintenance program.39

Marijuana

Marijuana access and use is increasingly becoming a problem in our community and nationwide. Primary admissions for marijuana use doubled in Connecticut between 2000 and 2010, from 137 to 273 admissions per 100,000 individuals aged 12 and over, compared to only a 20% increase nationwide to 127 admissions per 100,000 adults.40 The rate in Connecticut is now more than double that of the national rate.

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The table below, based on 2006-2008 and 2008-2010 NSDUH data, illuminates some differences between the U.S., the state of Connecticut and regional rates of drug use over time.41 Although the Southwest Region is better off than Connecticut or the U.S. as a whole, the data show a trend towards increased use and acceptance of marijuana.

U.S. Connecticut SW Connecticut Marijuana Use in Past Month (’06-‘08) 6.01% 6.58% 5.06% Marijuana Use in Past Year (’06-‘08) 10.31% 11.53% 9.67% Perceptions of Great Risk of Smoking Marijuana 38.18% 35.83% 36.10% Once a Month (’06-‘08) Marijuana Use in Past Month (’08-‘10) 6.58% 7.55% 5.89% Marijuana Use in Past Year (’08-‘10) 11.13% 13.01% 9.73% Perceptions of Great Risk of Smoking Marijuana 34.70% 32.51% 31.46% Once a Month (’08-‘10)

SPOTLIGHT ON UNDERSERVED POPULATION: ADOLESCENTS AND HISPANIC YOUTH

Cocaine

Data on 9th-12th graders from the 2011 YRBS show that Connecticut does not have a significantly worse illicit drug problem than the U.S. as a whole, with the exception of cocaine. Yet, the data also indicate that Hispanic youth are particularly vulnerable to substance abuse issues in Connecticut, with nearly double the rate of heroin use and more cocaine/crack use:42

Ever Used/Done: Connecticut - Connecticut - U.S. All Hispanic

Cocaine/Crack 5.0% 7.1% 3.0%

Heroin 2.9% 4.6% 2.9%

Inhalants 9.0% 10.5% 11.4%

Meth 3.2% 3.7% 3.8%

Ecstasy 6.3% 9.2% 8.2%

Opioids: Heroin and Pain Relievers

Of the teens surveyed by CASAColumbia in 2011, 23% indicated that they knew at least one friend or classmate who used prescription drugs without a prescription to get high. This rate shows no change from prior years: 21% in 2007, 24% in 2008, 25% in 2009 and 25% in 2010.43 As we are learning, many adolescents have access to such prescription medication via their parents’ medicine cabinet.

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Marijuana

Marijuana is a serious issue for adolescents in the region. Despite its perception as less dangerous than alcohol or other drugs, marijuana is an addictive drug with long-term side-effects for adolescents. Some important statistics include:44

 Lifetime risk of dependence rises from 9% to nearly 17% if marijuana smoking is initiated in adolescence.  Adolescents who started smoking marijuana between the ages of 14 and 22 but stopped by age 22 still had greater cognitive problems at age 27 than those who started smoking marijuana as adults.  Compared to controls and individuals who started marijuana use after age 17, those who smoked marijuana before age 17 had greater deficits in executive function, memory, verbal fluency and learning.

In a 2011 study by CASAColumbia 22% of teens reported that marijuana is the easiest drug to obtain compared to cigarettes, beer and prescription painkillers. That is nearly a 50% increase from the prior year, when only 15% of teens named marijuana as the easiest to obtain.45

In the most recent NSDUH (2010-2011), 16.25% of Connecticut teens aged 12-17 had used marijuana in the last year, compared to 13.39% of the general adult population (ages 12+) and 14.13% of teens nationwide.46 The 16.25% figure also represents an increase from the prior survey (2008-2009), which found that 15.9% of Connecticut teens had used marijuana in the prior year.47

Data from the CDC’s 2011 Youth Risk Behavior Survey indicates that Hispanic youth in Connecticut are starting marijuana use earlier than their peers in Connecticut and the U.S.: According to the survey of Connecticut 9th-12th graders in 2011, 6.3% tried marijuana before they were 13, compared to 8.1% in the U.S. as a whole and 8.4% for Hispanic teens in Connecticut.48 In Sub-Region 1A (Darien, Greenwich, New Canaan and Stamford), two local drug treatment programs found in the last few years that almost 60% of youth entering substance abuse treatment have smoked marijuana.49

SPOTLIGHT ON UNDERSERVED POPULATION: WOMEN

According to a July 2013 study by the CDC, deaths from prescription painkiller overdoses among women have increased more than 400% since 1999, compared to 265% among men. For every woman who dies of a prescription painkiller overdose, 30 go to the emergency department for painkiller misuse or abuse. What is more, women aged 25-54, of which there are an estimated 198,000 in Fairfield County, are more likely than other age groups to go to the emergency department from prescription painkiller misuse or abuse. Women aged 45-54, of which there are an estimated 75,000 in Fairfield County, have the highest risk of dying from a prescription painkiller overdose.50,51

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TOBACCO

The most recent NSDUH sub-state data (2008-2010) reported Populations

that 19.54% adults aged 12 and over in the Southwest Region Issues General Adolescents Women Hispanics Seniors

smoked in the past month, compared to 21.56% in Substance Abuse 52 Connecticut and 23.46% in the U.S. as a whole. These figures Alcohol

are slightly lower than the 2006-2008 sub-state data of Drugs 53 19.61%, 21.29% and 24.6%, respectively. In fact, data over Tobacco time from the NSDUH shows that cigarette smoking in Mental Health 54 Mood & Anxiety Connecticut has been steadily decreasing since 1999. Disorders Psychotic Disorders Analysis by the Kaiser Family Foundation also found that Eating Disorders adults in Connecticut were less likely to smoke across the Suicide board and more likely to have attempted to quit in the last year. The table below summarizes this data.55

Percent of Adults Who Smoke, 2011

Location All Adults Male Female White Black United States 20.1% 22.6% 17.7% 20.8% 23.1% Connecticut 17.1% 19.0% 15.4% 16.8% 20.8%

Percent of Adults Who Attempted to Quit Smoking, 2011

Location All Adults Male Female United States 59.6% 59.1% 60.1% Connecticut 62.1% 61.8% 62.4%

Likewise, residents of Fairfield County are less likely to smoke than individuals in the U.S. as a whole:

 Current smokers = 10.0%, compared to 13.2% in Connecticut and 17.3% in the U.S. as a whole56  Adult smokers (2005-2011) = 12%, compared to 15% in Connecticut and 13% in the U.S. as a whole57

The map below from Community Commons58 corroborates this data. It contains Behavioral Risk Factor Surveillance System (BRFSS) data from the CDC between 2005 and 2011 indicating that Fairfield County has a low rate of adult smoking.

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

SPOTLIGHT ON UNDERSERVED POPULATION: ADOLESCENTS

A 2011 report from Columbia University found that teens who have used tobacco are 11 times likelier to have used marijuana than teens who have never used tobacco.59 According to the 2011 Youth Behavior Risk Survey, tobacco use among all 9th-12th graders in Connecticut was as follows:60

 15.9% smoked cigarettes one day in the last 30 days, compared with 18.1% in the U.S. overall (both lower than the rate for adults)  5.4% smoked cigarettes 20 of the last 30 days, compared with 5.4% in the U.S. overall

Interestingly, although Hispanic teens were more likely than the overall cohort to have smoked cigarettes once in the last 30 days (16.5%), they were less likely to have smoked 20 of the last 30 days (4.7%),61 i.e., be regular smokers.

Also troubling is a recent report from the CDC, which found, through its 2011-2012 National Youth Tobacco Survey (NYTS) that electronic cigarette (“e-cigarette”) use among middle and high school students doubled to nearly 7%. An estimated 1.78 million teens nationwide had used an e-cigarette in 2012. According to the report, concerns include “the potential negative impact of nicotine on adolescent brain development, as well as the risk for nicotine addiction and initiation of the use of conventional cigarettes or other tobacco products.”62

SPOTLIGHT ON UNDERSERVED POPULATION: WOMEN AND MINORITIES

Although smoking overall in Connecticut is better than the U.S. as a whole, the Kaiser Family Foundation uncovered certain disparities between Whites and minorities for both men and women. In its analysis, a disparity score greater than 1.00 indicates that minorities are faring worse than whites. A disparity score less than 1.00

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

indicates that minorities are doing better than whites. A disparity score equal to 1.00 indicates that minorities and whites are doing the same.

The table below shows that minority men in Connecticut are faring worse in smoking rates than White men in the state (Disparity Score = 1.11). The data indicate that Hispanic men (26.3% smokers versus 23.3% nationally) and Asian/Native Hawaiian/Pacific Islander men (18.3% versus 15.8% nationally) are driving the disparity. It is worth noting, too, that men are more likely to smoke across the board than women.

Minority women in Connecticut are not facing the same absolute challenges versus Whites, but relative to the U.S. as a whole, disparities in Connecticut among these women are more pronounced. Non-Hispanic Black women (20.4% smokers versus 18.6% nationally) and Hispanic women (17.9% smokers versus 10.8% nationally) seem to be driving this trend.63

Men’s Smoking by Race/ Ethnicity, 2006 – 2008 Data are for men ages 18–64.

Non- Non- Disparity Hispanic All Hispanic Asian and Location Score All Men White Minority Black Hispanic NHPI United States 0.95 25.0% 25.2% 23.9% 26.9% 23.3% 15.8% Connecticut 1.11 21.8% 21.3% 23.6% 22.3% 26.3% 18.3%

Women’s Smoking by Race/Ethnicity, 2006-2008 Data are for women ages 18–64.

Non- Non- Disparity All Hispanic All Hispanic Asian and Location Score Women White Minority Black Hispanic NHPI United States 0.61 20.7% 23.1% 14.0% 18.6% 10.8% 7.4% Connecticut 0.92 17.9% 18.2% 16.6% 20.4% 17.9% 2.4%

MENTAL HEALTH

Scientists estimate that one in four people is affected by mental illness, either directly or indirectly through their families.64

GENERAL

According to the 2011 NSDUH, 19.6% of adults (ages 18+) in the U.S. have a mental illness, of which 10.7% is “mild,” 3.9% is “moderate” and 5.0% is “serious.” The gender break-down is 15.9% of males and 23.0% of females. In the Northeast, 18.4% of adults have a mental illness, of which 4.1% is “serious.” And foreshadowing the rest of this section, young adults aged 18-25 have a much higher rate of mental illness than the population overall, at 29.8%.65

In Connecticut, according to SAMHSA data from the combined 2010 and 2011 NSDUHs, adults do not differ significantly from the U.S. as a whole in major depressive episodes (6.42% of adults 18+ as compared to 6.70% in the U.S.), serious mental illness (4.75% compared to 4.99% in the U.S.) or suicidal ideation (3.62% compared to

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

3.75% in the U.S.). They do, however, seem to have a lower rate of “any mental illness” (18.61% of adults 18+ as compared to 19.83% in the U.S. and 16.85% of adults 26+ as compared to 18.08% in the U.S.).66

According to SAMHSA data from the combined 2010 and 2011 NSDUHs, young adults in Connecticut have a slightly higher rate of “serious mental illness” (7.89% of those aged 18-25) than the U.S. population as a whole (7.69%).67 Indeed, for young adults aged 18-25 reporting “serious psychological distress” on the 2005 and 2006 NSDUHs, Connecticut is in the second highest category nationwide with 19.19-19.88% of individuals.68

According to state-level analyses by the Kaiser Family Foundation, Connecticut fares slightly worse than the U.S. as a whole when it comes to self-reported mental health over the last 30 days, with 36.2% of adults aged 18 and over reporting poor mental health compared to 35.8% in the U.S.69

The gender breakdown of the Kaiser analysis shows that, as expected, women are more likely than men to report poor mental health; Connecticut is no exception. However, men in Connecticut seem to be faring slightly worse (33.5%) than the U.S. overall (31.1%), whereas Connecticut women (38.8%) are faring slightly better than women in the U.S. overall (40.3%).70

The breakdown by race and ethnicity indicates that, while in the U.S. as a whole Blacks and Hispanics report poor mental health, in Connecticut, Blacks were least likely to report poor mental health in the past 30 days of the three race/ethnicity categories. Both Whites and Hispanics were more likely to report poor mental health in Connecticut than in the U.S. as a whole. (Note: for other races/ethnicities, there was insufficient data to compare Connecticut to the U.S.).71

Percentage of Adults Reporting Poor Mental Health, 2011 Location All Adults United States 35.8% Connecticut 36.2%

Location Male Female United States 31.1% 40.3% Connecticut 33.5% 38.8%

Location White Black Hispanic United States 35.2% 37.2% 37.6% Connecticut 36.3% 31.5% 39.7%

Kaiser also provides disparity scores for its indicators. A disparity score greater than 1.00 indicates that minorities are doing worse than whites. A disparity score less than 1.00 indicates that minorities are faring better than whites. A disparity score equal to 1.00 indicates that minorities and whites are doing the same.

The table below shows that minority men in Connecticut are doing better than minority men in the U.S. as a whole. Minority women, however, seem to be doing worse than minority women in the U.S. as a whole. For poor physical or mental health in the last 30 days in particular, minority women fare worse in Connecticut than white women (disparity score > 1.00).72

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

Disparity Score U.S. CT Men’s Serious Psychological Distress in Past Year, 2004 – 2007 0.97 0.88 Days Men’s Physical or Mental Health was Not Good in Past 30 Days, 2006 – 2008 1.06 0.98 Women’s Serious Psychological Distress in Past Year, 2004-2007 0.83 0.85 Days Women’s Physical or Mental Health was Not Good in Past 30 Days, 2006 – 2008 0.99 1.01

Using combined data from 2005-2011, Fairfield County demonstrated an average number of “poor mental health days” of 2.8 in the last 30 days as compared to 3.1 in Connecticut and 2.3 in the U.S. as a whole.73

SPOTLIGHT ON UNDERSERVED POPULATION: ADOLESCENTS AND CHILDREN

In a 2012 study conducted by the Hartford-based Center for Children’s Advocacy, researchers found that almost 20% of “children with co-morbid mental and behavioral risk factors were not identified until 6-9th grades… and one out of four students did not receive special education services despite documentation of emotional and behavioral problems and poor academic progress.”74

However, according to the Kaiser Family Foundation, 65% of children (ages 2-17) with emotional, developmental or behavioral problems received mental healthcare in 2011, as compared with only 61% in the U.S. as a whole.75

SPOTLIGHT ON UNDERSERVED POPULATION: HISPANICS

According to epidemiological research, “Latino adults in need of mental health care are less likely than non-Latino Whites to access mental health services, and when they do receive care, it is more likely to be poor in quality,” although women were more likely to access services than men. The studies also found that, “[l]ow acculturation level was also found to be negatively related to mental health service use,” indicating that cultural factors play a big role in accessing specialty mental health services.76

According to the American Psychiatric Association (APA), Hispanics suffer from mental health issues at the same rate as other populations (or even more, in recent years), but “fewer than 1 in 11 contact a mental health specialist, while fewer than 1 in 5 contact general health care providers. Even fewer Hispanic immigrants seek these mental health services.” Instead, Hispanics tend to “rely on their extended family, community, traditional healers, and/ or churches for help during a mental health crisis.” Key barriers to accessing mental health treatment include economic barriers (cost, lack of insurance), lack of awareness about mental health issues and services and stigma associated with mental illness. 77 Says Henry Acosta, Director of the National Resource Center for Hispanic Mental Health, “Latinos always hear how they have to be self-reliant when they have problems or even turn to prayer.”78 Also important are issues such as language barriers and a lack of culturally appropriate services.

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MOOD & ANXIETY DISORDERS

According to the National Institutes on Mental Health (NIMH), Populations

each year about 6.7% of U.S adults experience major Issues General Adolescents Women Hispanics Seniors

depressive disorder, and anxiety disorders affect about 18% Substance Abuse 79 of adults. Assuming these statistics hold true in Fairfield Alcohol

county, about 47,000 adults (ages 18+) suffer from depression Drugs

and 127,000 adults suffer from anxiety, based on 2012 Census Tobacco data. Mental Health Mood & Anxiety Disorders In 2005-2008, 11% of Americans aged 12 and over took Psychotic Disorders antidepressant medication nationwide.80 Applied to Fairfield Eating Disorders County, this figure would imply that between 80,000 and Suicide 90,000 people take antidepressant medication.

SPOTLIGHT ON UNDERSERVED POPULATION: WOMEN AND GIRLS

According to NIMH, women are 70% more likely than men to experience depression during their lifetime. The average age of onset is 32 years old.81 The 2011 NSDUH survey corroborated this evidence. In 2011, while 6.6% of all adults aged 18 and over had a major depressive episode (MDE) in the past year, the gender breakdown was 4.7% of men and 8.3% of women. When zeroing in on the young adult population aged 18-25, the gender disparity was even more stark: 5.7% of men versus 11.0% of women in that age group had an MDE in the past year.82

Before adolescence, girls and boys experience depression at about the same frequency. By adolescence, however, girls become more likely to experience depression than boys.83 In fact, nationwide among adolescents aged 12-17, 12.1% of girls had a major depressive episode (MDE) in the last year versus 4.5% of boys.84

In Connecticut, according to the 2011 YRBS, there was also a big discrepancy between the sexes, with 31.0% of all girls overall feeling depressed versus 18.0% of boys, but each figure was still less than the U.S. as a whole: 35.9% of girls and 21.5% of boys.85

Nationwide, 8.2% of adolescents aged 12-17 had a major depressive episode (MDE) in the last year according to the 2011 NSDUH. Girls were much worse off in this category, with 12.1% an MDE in the last year, compared to boys, 4.5% of whom experienced an MDE.86

Women are 60% more likely than men to experience an anxiety disorder over their lifetime.87 Women are also more prone than men to having a coexisting anxiety disorder. Women suffering from PTSD, which can result after a person endures a terrifying ordeal or event, are especially prone to having depression.88

SPOTLIGHT ON UNDERSERVED POPULATION: ADOLESCENTS

Not only are girls worse off than boys when it comes to depression, but it is occurring at younger ages. The 2011 NSDUH found that in the past year, 4.1% of 12-13 year-olds, 8.6% of 14-15 year-olds and 11.7% of 16-17 year-olds had a MDE. In the Northeast, the overall adolescent rate is slightly lower, at 7.4%.89

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

A large, national survey of adolescent mental health conducted by NIMH reported that about 8% of teens aged 13- 18 have an anxiety disorder, with symptoms commonly emerging around age six. However, of these teens, only 18% received mental health care.90 Additionally, 3.3% of 13 to 18 year-olds have experienced a seriously debilitating depressive disorder.91 Indeed, these statistics have led the federal government to assign Leading Health Indicator status to its Healthy People 2020 objective to “reduce the proportion of adolescents aged 12 to 17 years who experience major depressive episodes” (MHMD-4.1).92

In Connecticut, according to the 2011 YRBS, 24.4% of high school students “felt so sad or hopeless almost every day for two weeks or more in a row that they stopped doing some usual activities during the past 12 months,” although this was less than the 28.5% rate in the U.S. overall.93

Hispanic youth in Connecticut were much more likely to be depressed than the overall cohort, with 33.5% of Hispanic youth overall, 41.1% of Hispanic girls and 27.0% of Hispanic boys. As compared to the U.S. overall, the Hispanic girls’ rate in Connecticut was almost identical to that of girls in the U.S. overall (41.4%), but Hispanic boys in Connecticut were more likely to answer yes to the question than boys in the U.S. as a whole (24.4%).94 One explanation behind this discrepancy is that Hispanic youth suffer from many of the same emotional problems created by marginalization and discrimination in our society, but without the secure identity and traditional values held by their parents.95

SPOTLIGHT ON UNDERSERVED POPULATION: SENIORS

According to a 2012 report by the Institute of Medicine, nearly 20% of older adults have one or more mental health or substance abuse conditions. Depression and dementia are the most prevalent, but substance use and abuse is a significant problem as well. (See the section on Alcohol above.) Losses that occur frequently in old age, such as the death of a spouse, may trigger or worsen depression and anxiety. It can be difficult to distinguish between clinical depression and grief. Plus, cognitive and sensory impairments can complicate detection and diagnosis.96

Based on Fairfield County’s 2012 Census, 13.7% of the population is aged 65 and older.97 That means more than 125,000 seniors in the community are likely suffering from depression, substance abuse or both.

PSYCHOTIC & PERSONALITY DISORDERS

According to NIMH, about 1.6% of adults in the U.S. have Populations

Borderline Personality Disorder (BPD) in a given year. BPD Issues General Adolescents Women Hispanics Seniors 98 usually begins during adolescence or early adulthood. In Substance Abuse 99 addition, 75-90% of those diagnosed with BPD are women. Alcohol

Drugs About 1% of adults has Schizophrenia, which affects men and Tobacco women equally. It occurs at similar rates in all ethnic groups Mental Health around the world. Symptoms such as hallucinations and Mood & Anxiety 100 Disorders delusions usually start between ages 16 and 30. About Psychotic Disorders Eating Disorders

Suicide

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

300,000 new cases of schizophrenia are diagnosed each year.101

Based on Connecticut Census data for 2012, Fairfield County has about 7,000 adults with Schizophrenia and 11,000 adults with BPD.

In 2010, there were nearly 20,000 inpatient hospital discharges for psychotic conditions among Connecticut residents, with an average length of stay of seven days.102

EATING DISORDERS

Nationwide, eating disorders affect women and adolescents Populations

disproportionately, and our community is no different. In fact, Issues General Adolescents Women Hispanics Seniors

over 4% of women in Connecticut have an eating disorder, Substance Abuse 103 twice the rate for men. Alcohol

Drugs National prevalence rates from the National Eating Disorder Tobacco Association (NEDA) and NIMH are shown in the table Mental Health 104 below. Mood & Anxiety Disorders Psychotic Disorders Eating Disorders

Suicide

Prevalence Data NEDA (2011)(1) NIMH (2007)(2) Overall Female Male Adolescent Prevalence (Lifetime) Anorexia Nervosa (AN) 0.3% Bulimia Nervosa (BN) 0.9% Binge Eating Disorder (BED) 1.6% General 2.8% 2.7%

Adult Prevalence (Lifetime) Anorexia Nervosa (AN) 0.6% 0.9% 0.3% Bulimia Nervosa (BN) 0.6% 0.5% 0.1% Binge Eating Disorder (BED) 2.8% 3.5% 2.0%

Using census demographic data,105 we determined that there are approximately 1,740 adolescents (ages 15-19) with an eating disorder, of which 43% have Anorexia Nervosa (AN) or Bulimia Nervosa (BN). Likewise, there are approximately 4,900 adult females and 1,270 adult males with AN or BN, for a total of over 6,900 individuals suffering from AN or BN in Fairfield County.

With regard to Binge Eating Disorder, prevalence rates indicate there are nearly 1,000 adolescents and over 18,600 adults suffering in the community.

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

SPOTLIGHT ON UNDERSERVED POPULATION: ADOLESCENTS

The CDC’s YRBS 2011 survey offers some interesting facts about Connecticut teens. Although the rate of food restriction was lower in Connecticut than in the U.S. as a whole, it is clear from these numbers that women are disproportionately affected by disordered eating. Among the Hispanic community, however, rates for this type of restriction were higher across the board, and, in an inversion of the usual statistics, males were more likely to restrict food than were females. (See table below.)

A second somewhat surprising finding was that the numbers in Connecticut were driven by younger teens (9th graders). In fact, nearly 18% of the 9th grade girls surveyed indicated that they had not eaten for 24 or more hours during the 30 days before the survey due to weight considerations.106

Did not eat for 24 or more hours to lose weight or to keep from gaining weight (during the 30 days before the survey): Overall Female Male US, All Races, All Grades 12.2% 17.4% 7.2% CT, All Races, All Grades 8.9% 11.6% 6.2% CT, Hispanic, All Grades 11.9% 10.1% 13.3% CT, White, All Grades 8.0% 12.0% 4.2% CT, All, 9th Grade 12.8% 17.8% 7.9% CT, All, 10th Grade 7.2% 9.1% 5.4% CT, All, 11th Grade 8.6% 10.1% 7.0% CT, All, 12th Grade 6.7% 9.1% 4.4%

It is no wonder, then, that the federal government has set as a major goal of its Healthy People 2020 initiative to reduce the proportion of adolescents who engage in “disordered eating” from 14.3% in 2009 to 12.9% in 2020 (MHMD-3).107

SUICIDE

One of the two Mental Health Leading Health Indicators from Populations

the U.S. Department of Health and Human Services’ “Healthy Issues General Adolescents Women Hispanics Seniors

People 2020” initiative is reducing the suicide rate (MHMD-1). Substance Abuse In 2007, the national rate for suicide was 11.3 suicides per Alcohol

100,000 people. The goal for 2020 is a 10% reduction in the Drugs 108 rate to 10.2 suicides per 100,000. Tobacco Mental Health According to a recent CDC analysis of National Vital Statistics Mood & Anxiety Disorders System (NVSS) mortality data, suicide rates among middle- Psychotic Disorders aged adults in the U.S. have increased over the last decade. Eating Disorders From 1999 to 2010, the age-adjusted suicide rate for adults Suicide aged 35–64 years in the U.S. increased by 28.4%, from 13.7 per 100,000 population to 17.6. In Connecticut, the age-adjusted rate grew 30.5%, faster than that of the U.S. as a whole, to 14.5 per 100,000 population.109

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

In the state of Connecticut between 2005 and 2010, suicide was third leading cause of death among 20-24 year- olds, the second leading cause of death among 25-34 year-olds and the fourth leading cause of death among 35-44 and 45-54 year-olds.110 In 2002, Fairfield County saw 42 suicides, a rate of 6.35 per 10,000 residents.111 Over a fifth (167) of the 812 suicides in Connecticut between 2002 and 2004 came from Fairfield County. Only New Haven (200, 25%) and Hartford (208, 26%) Counties had more suicides.112 The Southwest Region shows a significantly higher rate of alcohol-related suicides of 6.4 compared to the State rate of 1.50 based on a per 10,000 population.113

People with certain psychiatric illnesses are more likely to commit suicide than others. For example, 10% of those with Borderline Personality Disorder (BPD) commit suicide and 33% of youth who commit suicide have features, or traits, of BPD. This figure is 400 times higher than the general population, and young women with BPD have a suicide rate of 800 times higher than the general population.114

It is worth noting that although suicide in the elderly is an issue nationwide, residents of Connecticut seem to be less affected by this trend.

SPOTLIGHT ON UNDERSERVED POPULATION: ADOLESCENTS AND HISPANIC YOUTH

Although not a Leading Health Indicator, one of the government’s mental health goals for 2020 is to reduce suicide attempts by adolescents (MHMD-2) from 1.9 per 100 in 2009 to 1.7 per 100 people.115

In the state of Connecticut between 2005 and 2010, suicide was the third leading cause of death among adolescents aged 10-14 and the second leading cause of death among adolescents aged 15-19.116

According to the YRBS 2011 data on suicidal behavior:

 14.6% of 9th-12th graders in Connecticut seriously considered attempting suicide in the 12 months before the survey, compared to 15.6% in the U.S. as a whole.  6.7% made at least one actual attempt, compared with 7.8% in the U.S. as a whole.

The Connecticut rates were higher for girls (17.3% considered and 8.2% attempted) as well as for all Hispanic youth (17.1% considered and 11.0% attempted). This pattern is similar to the U.S. rates overall, where 19.3% of girls considered and 9.8% attempted, while among Hispanics, 16.7% considered and 13.5% attempted.117 According to the Latin Policy Institute, twice as many Latina teenagers in Connecticut (21%) attempt suicide as African American (11%) or non-Latino white (10%) teenage girls.118

Self-injury is also a concern among the adolescent population. The 2011 Connecticut School Health Survey (Youth Behavior Component Report) found that “in Connecticut, 16.1% of high school students purposely hurt themselves without wanting to die (i.e., self-injury) one or more times during the 12 months before the survey. The prevalence of self-injury is significantly higher among female (21.6%) than among male (10.7%) students; and significantly higher among white (16.3%) and Hispanic (20.5%) than among black (9.6%) students.”119

Fairfield County has seen its fair share of adolescent suicides. In fact, there were three teen suicides in the first month of the 2013 school year in Stamford, Stratford and Greenwich, where, a 15-year-old boy killed himself on the first day of school, allegedly after pressure from “bullying.”120 Several students in Ridgefield have also taken

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their own lives in recent years,121 which spurred the creation of the organization Project Resilience, which seeks to encourage the development of programs that address growth and resilience in children and adolescents.122

DUAL DIAGNOSES

Dual diagnoses are far from uncommon. CASAColumbia found Populations

in 2012 that 39.4% of non-institutionalized individuals aged Issues General Adolescents Women Hispanics Seniors

18 and older with addiction met clinical criteria for a mental Substance Abuse health disorder. Conversely, among those aged 18 and older Alcohol

who have a mental health disorder, 30.6% are risky substance Drugs 123 users and 31.4% have addiction. Tobacco Mental Health “Attention deficit/hyperactivity disorder and conduct disorder Mood & Anxiety Disorders are the most common co-occurring mental health disorders in Psychotic Disorders young patients being treated for addiction,” the report noted, Eating Disorders “and anxiety and depression are the most common co- Suicide occurring mental health disorders in older patients; trauma- related disorders are common across age groups.”124

In the course of conversations with experts across the field, we spoke with David Ockert, Ph.D., the Executive Director of New York’s Parallax Center, a highly successful provider of outpatient detoxification services for opioid, alcohol and benzodiazepine addictions. Dr. Ockert says that he has never seen a substance abuser walk through his door without having some kind of co-occurring psychiatric condition, whether it be depression, anxiety or something potentially more serious like bipolar disorder.

About two thirds of people who enter a psychiatric hospital or drug rehab have a co-occurring or dual disorder, either a substance abuse problem with an associated psychiatric disorder or the other way around. Very often, the associated disorder is not recognized by the patient and not identified by the facility. This makes full recovery less likely. At Silver Hill Hospital we put a lot of effort into identifying these co-occurring or dual problems and treating them concurrently.

The availability of centers such as Silver Hill Hospital that can handle multiple, co-occurring mental health and substance abuse issues is critical. The National Alliance for Mental Illness (NAMI) says it best:

Despite much research that supports its success, integrated treatment is still not made widely available to consumers. Those who struggle both with serious mental illness and substance abuse face problems of enormous proportions. Mental health services tend not to be well prepared to deal with patients having both afflictions…. Fragmented and uncoordinated services create a service gap for persons with co- occurring disorders…. Effective integrated treatment consists of the same health professionals, working in one setting, providing appropriate treatment for both mental health and substance abuse in a coordinated fashion.125

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In FY 2013, over two-thirds of inpatients came to Silver Hill Hospital with a dual diagnosis: a primary diagnosis of substance abuse with an associated psychiatric or eating disorder or a primary diagnosis of a psychiatric disorder plus a secondary diagnosis of a chemical dependency. This figure is representative of what we see on the transitional living program (residential) side, as well.

According to the 2011 NSDUH, 3.4% of the U.S. adult (ages 18+) population has a co-occurring disorder. For young adults aged 18-25, that figure increases to 8.9%. In the Northeast, the figure is slightly higher than that of the U.S. at 3.6%.126 Of adults who are dependent or abuse alcohol or illicit drugs, the study found 42.3% have a co- occurring mental illness. Conversely, of adults with any mental illness, 17.5% are dependent on or abuse alcohol or illicit drugs versus 5.8% for the non-mentally ill population.127 The 2011 survey also found that for adults (aged 18+) with a major depressive episode (MDE) in the last year, 20.0% were dependent on or abused drugs or alcohol compared to 7.3% of the population without an MDE in the last year.128 Among those with Borderline Personality Disorder (BPD), about 35% have substance abuse issues and 25% have one or more eating disorders.129

Many people associate co-occurring substance abuse and mental disorders with urban life. But a study conducted in London demonstrated that “the prevalence of substance misuse in patients with severe mental disorders in a suburban area is about as high as that for similar patients in inner-city London.”130 This finding certainly resonates in suburban and small urban Fairfield County.

SPOTLIGHT ON UNDERSERVED POPULATION: YOUNG ADULTS AND WOMEN

With dual disorders, young adults and women again take center stage. Of young adults aged 18-25 with a mental illness -- be it mild, moderate or severe – a full 30% are dependent on or abuse alcohol or illicit drugs compared to 13.7% for the non-mentally ill population. For mentally ill women in that age group, the rate is 37.0% (compared to 17.8% in the non-mentally ill population) versus 25.1% of mentally ill young men (compared to 8.9% of the non- mentally ill population).131

SPOTLIGHT ON UNDERSERVED POPULATION: ADOLESCENTS

Adolescents also suffer from dual disorders. Of the 12-17 year-olds with a major depressive episode (MDE) in the last year, 18.2% were dependent on or abused alcohol or illicit drugs, compared to 5.8% of the same cohort without an MDE. Those figures are only slightly lower than the 20.0% and 7.3%, respectively, for adults aged 18 and over.132

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COMMUNITY INPUT AND EXISTING RESOURCES

We interviewed several community experts and stakeholders (see section above in the introduction for the names and bios of the people with whom we spoke). Several themes emerged from our conversations.

THEMES FROM COMMUNITY INPUT

FRAGMENTED, INSUFFICIENT PRIVATE SECTOR MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES

Several people we spoke to, including Dan Wartenberg, CEO of the Southwest Connecticut Mental Health System (SWCMHS), the local mental health authority for DMHAS; Kate Mattias, Executive Director for the Connecticut NAMI organization; Linda Autore, CEO of Laurel House; and Margaret Watt, Executive Director of the Southwest Regional Mental Health Board (SWRMHB), offer counter-intuitive feedback. People on public assistance, they say, often have more and better services than those available to people with insurance. The state system offers wrap- around services focused on the full continuum of care, housing, supported employment services and supported education services as well as peer services, which provide credible mentors to those suffering from mental illness. There are no corollaries in the private sector. Despite the negative view many hold of the public sector’s programs to address mental health needs, there is something we, as a private-sector provider to a mostly well-off patient population, can learn from public assistance programs.

Ms. Mattias says that the mental health system for youth is “extremely fragmented.” Children with mental illness receive support and services through the Connecticut Department of Children and Families (DCF). When they turn 18, however, they are no longer eligible for these services and must turn instead to the Department of Mental Health and Addiction Services (DMHAS). Ms. Watt also acknowledges that the transition from DCF to DMHAS can be arbitrary and unhelpful at times.

For adults, the system is less fragmented, Ms. Mattias says, but the approach to mental health is not as long-term or holistic as it should be. The mental health system is “founded on episodic care,” she says, while what is needed is a philosophy of “recovery” along a care continuum, much like the Medical Home and Accountable Care Organization models are providing for general healthcare.

Peter Case, former President of the NAMI affiliate in Stamford/Greenwich echoes the need for a continuum care in the mental health community. “Half of psychiatric inpatients discharged from hospitals in Connecticut” he says, “never make it to outpatient care.” Complicating that situation is the fact that there are not enough affordable case management services in the community. Places like the Dubois Center in Stamford (and others in the region) do not accept patients who have insurance, even Medicaid, adds Lorraine Zegibe, head of Community Outreach for Stamford/Greenwich NAMI. Ms. Watt agrees that the lack of case management services compounds users’ inability to navigate the system effectively.

Also contributing to the ineffectiveness and fragmentation of the system is the lack of housing options (e.g., group homes, supervised apartments, sober housing), which inhibits a successful transition into community-based recovery services.

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GAP IN SERVICES FOR YOUNG ADULTS

The data we reviewed suggest a gap in age-appropriate services (both mental health and substance abuse) for young adults (ages 18-25), and the community stakeholders we interviewed agree.

Ms. Autore notes an increasing number of young adults with serious psychiatric illnesses who have, up until now, been living in their parents’ houses without work or support services. Because Fairfield County is an affluent community, many parents have the means to support their adult children, who at one point might have been heading to Harvard or Cornell before their first psychotic break. Such individuals are not eligible for existing public support services. So while personal funds are available, there simply aren’t enough programs geared toward helping such individuals with psychiatric illnesses become productive members of society, resulting in what Ms. Autore characterizes as “an enormous pent-up demand.”

Dr. Alan Barry, Commissioner of Social Services for Greenwich, corroborates Ms. Autore’s experience. Young adults living with a psychiatric illness in their affluent parents’ homes, is a “really difficult population.” There is a lot of denial, Dr. Barry says. Some small support programs exist, but they are not well attended. It is necessary to find problem cases by going to other referral sources like NAMI or hospitals in the region, and then having social workers contact the families. The families, unfortunately, are reluctant to participate due to the stigma associated with schizophrenia and other psychiatric illnesses. Stigma is the biggest barrier to reeducating and reengaging that population.

Ms. Mattias explains that this generation of young adults does not identify with the adults they see in the public mental health system. Instead, they see themselves as having a chronic condition that is manageable, much like any other chronic condition. As a result, young adults drop out of the system but cannot find equivalent services in the private sector. Under the Affordable Care Act, young adults may still be covered for certain mental health services, but not everyone is aware of the new law’s rules.

Mr. Case notes that “despite a recent good start by the Greenwich Department of Social Services and efforts by Laurel House, we still lack enough young adult psychosocial programs” in the lower part of Fairfield County. Some programs do exist in Bridgeport, however.

Ms. Watt also noted the unofficial young adult drop-in program being started by the Department of Social Services and the YMCA in Greenwich as well as the more official Young Adult Services program being held at the Dubois Center in Stamford. But she highlights the “huge issue” of the gap in such services. She suggests one area where Silver Hill can get involved is in setting up or co-sponsoring a drop-in program for young adults in the New Canaan/Darien/Wilton area.

DMHAS and the Southwest Regional Mental Health Board are also collaborating on a new Young Adult technology initiative that will offer an online users’ guide to services such as self-screening, provider resources, understanding insurance and so on. They are hoping to partner with colleges and private providers in the area starting summer 2014.

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PRIMACY OF ADULT SUBSTANCE ABUSE IN THE COMMUNITY

The secondary data we reviewed in previous sections show that substance abuse is a big issue in Fairfield County, particularly alcohol, with opioid-based pain medications a close second.

Ingrid Gillespie, Director of the Lower Fairfield County Regional Action Committee, notes that the region has mimicked national trends when it comes to the increasing use of marijuana and prescription drugs, while alcohol continues to be a huge issue, particularly for the affluent white male population. But, she says, there has been a notable increase in the use of heroin in lower Fairfield County (Stamford, Greenwich), at increasingly younger ages. Whereas heroin addiction was once seen more often among people in their 20s and 30s, agencies and clinicians are now seeing addicts as young as 18. The availability of prescription opioids has led to this increase in heroin use, which is cheaper for addicts.

Barbara Greenberg, Ph.D., a clinical psychologist who lives in Weston, sees a lot of middle-aged women dealing with substance abuse and depression as a result of what she calls “transitions of life”: divorce, empty nest syndrome, menopause and so on. She sees “disconnection” in these women: husbands who work late, older children who have their own lives or who no longer live at home, subtle competition with other women in the community. As a result, they turn to alcohol, marijuana and off-label pain killers to deal with their reality.

Jacqueline D’Louhy and Kate Boyle for the Town of New Canaan Department of Youth and Family Services agree. They see mothers who are binge-drinking (which they call having “mommy juice”), inadvertently modeling dysfunctional drinking behavior for their children and adolescents.

At our Chronic Pain Recovery Center (CPRC) Open Forum in May 2013, 13 community providers, practice managers and Connecticut State Drug Control officers came together to discuss the issue of addiction to pain medication as a result of chronic pain. Many internists in the area do not feel comfortable or qualified to deal with these issues since they have no real training in chronic pain. (This corroborates the aforementioned CASAColumbia study.) There is also a need for patient and family education. Dr. Maria Di Giovanni, a pain specialist in Stamford, suggests that Silver Hill Hospital host an open forum for patients and families to attend anonymously for information, with no additional commitment required. Again, stigma plays a large role in access to services.

The State Drug Control staff discussed its Connecticut Prescription Monitoring and Reporting System (CPMRS) website133 that is available for clinicians to review patient drug history and report issues. The prescription monitoring program collects prescription data for Schedule II through Schedule V drugs into a central database, which can then be used by providers and pharmacists in the active treatment of their patients. The purpose of the CPMRS is to present a complete picture of a patient’s controlled substance use, including prescriptions by other providers, so that the provider can properly manage the patient’s treatment, which may be the referral of a patient to services offering treatment for drug abuse or addiction when appropriate.

As an institution, we believe a tri-state registry would be even more effective in assisting providers and preventing “doctor shopping,” or obtaining prescriptions from multiple providers. Because our community is bordered by New York State and is a one-hour car drive from Massachusetts and New Jersey, individuals currently have multiple opportunities to circumvent the CPMRS.

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COMPLEX SUBSTANCE ABUSE AND MENTAL HEALTH ISSUES FOR ADOLESCENTS

The adolescent population was mentioned independently by almost everyone with whom we spoke. The high- pressure, high-stakes environment of our mostly affluent community contributes to pathological behavior by adolescents because, as Mr. Wartenberg notes, “stress has a kindling effect.” Indeed, there were three teen suicides in Fairfield County during the first month of the 2013-2014 school year alone.

We know from our own admissions department that requests for adolescent outpatient programming is one of the biggest reasons we are forced to refer callers elsewhere. Dr. Aaron Krasner, a psychiatrist specializing in children, adolescents and families, whom we hired recently to help revamp our Adolescent Transitional Living Program, also says that there are very few providers who are comfortable with and capable of treating adolescents. There is often nowhere for these patients to turn.

Dr. Barry maintains “we’re not getting to [adolescents] early enough.” He recommends prevention and early intervention, i.e., approaching children in elementary and middle school, because high school is most likely too late. Direct education on the ills of drug and alcohol abuse is important, but just as critical is indirect education, “helping [kids] with judgment and decision-making.”

Ms. D’Louhy and Ms. Burke stress that integrating with already-existing community programs would be key to reaching adolescents. The stigma associated with ‘going to the hospital,’ even for an outpatient program, is often a deterrent to adolescents and their parents.

Substance Abuse

“We need to have far, outreaching educational arms to parents on the facts…and the risks” of substance abuse, says Ms. Gillespie. Parents, she says, do not know about or understand the new research about the deleterious effects of substance use on developing brains. Parents’ understanding the facts and legal implications is critical to changing use patterns among adolescents in Fairfield County. Marijuana, prescription opioids and other drugs such as PCP and “Molly,” a pure form of MDMA (ecstasy), have joined alcohol in the hands of increasingly younger adolescents.

Dr. Greenberg says adolescent boys in our community tend to use marijuana starting at the end of middle school as a way to cope with the anxiety prevalent in their high-pressure worlds. Dr. Greenberg sees boys who use marijuana every day of the week, or only smoke it alone to relax. What is worse, they seem to believe that they are better drivers when under the influence of marijuana, even though studies have shown that marijuana reduces physical reaction times. She confirms that marijuana has lost the stigma it had as recently as ten years ago, which is contributing to the increase in use, although she maintains that the root cause of the drug use for these teen boys is anxiety disorders.

Awareness is important. Dr. Greenberg currently makes many presentations in the community. But even more critical is creating a forum where community members can discuss these issues that often get swept under the proverbial carpet. We live in a time of more digital communication than ever, but that hasn’t, she says, translated into more actual communication about feelings and hardships. If anything, she says, it has decreased the amount of true social connection we have with one another.

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Unfortunately, parents in the community are also enabling -- even doing drugs with -- their children, including marijuana and cocaine, which some women and their daughters use to lose weight or maintain weight loss. Some parents are also turning a blind eye to drinking when children are out of their “dry season,” or the time they are playing their most competitive sports. There is a lot of pressure on children to be perfect, and parents see drinking during the off season as a way to let their children blow off steam.

While drugs remain taboo, marijuana has gained acceptance among both teens and adults, particularly since its legalization. There is “definitely a misperception among youth and parents,” says Ms. Boyle with regard to the ways in which medically prescribed marijuana is different than buying a few ounces from a local dealer. Marijuana today is much stronger than that smoked by adults when they were in their youth, and there have been instances of marijuana being laced with heroin or PCP. There is a great need for education on the dangers of marijuana, especially for adolescents.

Claudette Kunkes, Ph.D., a psychologist in private practice in Fairfield County, confirms that the rising use of e- cigarettes among adolescents is a concern being raised by her clients, who are mostly adult women in the area. Dr. Greenberg agrees she has seen a rise in the use of e-cigarettes, although she is not convinced it will become a trend for this community.

Mental Health

Adolescents suffering from depression or anxiety often turn to cutting themselves or eating disorders for girls, or “things get swept under the rug” by boys, says Dr. Barry, who then may turn violent against themselves or their classmates. The local Kids in Crisis Program has been embedding full-time counselors in schools in Stamford and Greenwich to try to catch some of these children before they do harm to themselves or others.134 Ms. Gillespie agrees that embedding counselors in the schools goes a long way towards facilitating a “warm hand-off” to youth in crisis.

Dr. Greenberg agrees that girls are more likely to suffer from depression, eating disorders and self-mutilation – which has seen a huge increase over the last ten years – and boys are more likely to act on their anxiety by using drugs or turning violent. Children in the upper class world of Fairfield County, she says, are under enormous pressure over schools and athletic achievement. The competition in the community is fueled by social media, which studies have begun to show affect users’ self-esteem.

Complicating matters is the fact that parents, Ms. Mattias says, are lost when it comes to their post-diagnosis children. Consequently, there is a need for support groups that would empower parents to be better able to help their children.

Dr. Greenberg attributes the recent spate of suicides (in Greenwich, Stamford, Ridgefield and elsewhere) not to an increase in bullying per se, but to an increase in its pervasiveness. With the advent of social media, bullying “follows you to your home,” she says. Adolescents can’t get a break from the feeling of being persecuted, which can be overwhelming. Ms. D’Louhy and Ms. Burke mentioned the same issue. Ingrid Pasten of the Center for Sexual Assault Crisis Counseling and Education (which serves Darien, Greenwich, New Canaan, Norwalk, Stamford, Westport, Weston and Wilton) says that ‘sexting’ is becoming a big issue and a trigger for teens who are

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considering suicide. Although the laws concern sexting are becoming harsher, she expects the issue to continue. Mr. Wartenberg agrees the community could use more suicide prevention in the schools.

The level of stress and perfectionism is high in Fairfield’s affluent communities. Several individuals suggested both facilitated meetings and presentations for parents and adolescents as well as professional development and training for guidance counselors and school psychologists in both the public and private schools.

A “DEARTH” OF RESOURCES FOR EATING DISORDERS

Erin Kleifield, Ph.D. is a clinical psychologist in private practice in New York who lives, however, in Fairfield County. She is working closely with Silver Hill Hospital on revamping its existing eating disorder services. She notes that there is a “dearth” of existing services in the community. In particular, the “school systems are sorely lacking.” The first step in remedying the absence of services is to promote awareness for families, providers and school administrators on what to look for with regard to eating disorders, how to assess the situation and where to refer individuals who need help. Mr. Wartenberg agrees that eating disorders are a “real issue,” and that there is a “lack of expertise” in the region for dealing with these illnesses, both in the inpatient and outpatient settings.

Insight, Dr. Kleifield says, is not sufficient to help those who suffer from eating disorders. Practicing the skills of healthy living is just as important, which is why it is critical that we develop more resources in the community for addressing these disorders.

Dr. Greenberg also works with a lot of women and adolescents in the community. The rate of eating disorders she sees in young girls has been stable over time. However, she has seen a recent increase over the past decade of eating disorders in young men as well as post-menopausal women. Although it would be too speculative to come up with a reason for such increases, Dr. Greenberg cites sports (like wrestling) and body image messages for boys and the social isolation and sense of disconnection women in the community feel during this time of “transition” (kids off to college, menopause, possible divorces). Dr. Kleifield notes that, increasingly, eating disorders are not limited to girls; body image issues are cropping up for boys, too, evidenced by their “sending around pictures of their six packs.”

There is a lot of pressure in Fairfield County’s upper class milieu to be perfect: raise the perfect children, look perfect, have the perfect home. This pressure translates into substance abuse, anxiety and depression, as we have discussed, but also into eating disorders. Both Ms. Watt and Ms. Gillespie agree eating disorders are a “big issue” for both teens and mothers.

POCKETS OF UNDERSERVED COMMUNITIES EXIST

Senior Citizens

The Senior (ages 65+) community makes up 13.7% of Fairfield County’s population, slightly lower than Connecticut as a whole (14.4%) and slightly higher than the U.S. as a whole (13.3%).135 According to the University of Connecticut, however, the percentage of seniors in Fairfield County is expected to increase to 19% by 2030.136

Mr. Wartenberg says there are “many isolated or homebound seniors with real mental health needs.” Many times serious depression is confused with “senility” in senior citizens. People need to recognize that the elderly suffer

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from depression and anxiety, too. He recommends screening days to help raise awareness. Ms. Zegibe agrees that seniors, especially those with mental illness, tend to “isolate,” which can exacerbate symptoms and land them in the hospital. Transportation is one of the biggest issues with this population, who are in dire need of case management outreach services.

Ms. Watt agrees says the seniors who do not attend senior centers are often those most in need of help. The issue is identifying and reaching them. The newly created State Department on Aging’s Older Adult Behavioral Health Workgroup has a couple of outreach programs in the works, one for mental health and one for substance abuse.

Melba Neville, RN, the Seniors Outreach Coordinator for the Town of New Canaan, maintains that substance abuse issues among seniors are swept “under the carpet.” In addition, there is an “assumption that older people don’t get depressed,” which is clearly erroneous. Because their lifestyles change sometimes abruptly when they retire, they can easily become isolated, and some then resort to drinking. Mixing alcohol with the multiple medications seniors are often on and the decreased ability to process alcohol as one ages combine to create a true issue.

Bill Piper, Chief Executive Officer of the Waveny Care Network, which provides a continuum of care to older adults, agrees that substance abuse – particularly of alcohol – in the senior population is a “huge” issue. He also believes seniors might benefit from a senior-specific intensive outpatient program at SHH. Partnering on educational programs with Waveny, the Lapham Center, Staying Put in New Canaan and the local YMCAs would be a great way to reach senior citizens and their families.

Many interviewees agree that programs for seniors would do much better out in the community than on Silver Hill Hospital’s grounds, since the stigma associated with going to a program ‘at the hospital’ might prevent people from attending. Ms. Watt suggests holding programs in the community and targeting adults who are part of the “sandwich generation,” taking care of both their aging parents and growing children.

Children

There are very few psychiatric services for children under the age of 13. The only inpatient program in the community is St. Vincent’s in Westport. Mr. Case notes that there are no intensive outpatient programs for young children in the lower part of Fairfield County, either. (There is a program at Danbury Hospital.) Dr. Krasner also confirms that there are very few child psychiatrists in the community because it is such a tough patient population with which to deal.

Minorities

“The Latino community [in Fairfield] continues to grow,” says Ms. Gillespie. In fact, the Hispanic community makes up 17.4% of Fairfield County’s population, much higher than Connecticut as a whole (13.8%) and slightly higher than the U.S. as a whole (16.7%). Even more telling is the fact that 20% of the county is foreign-born (compared to 13% in Connecticut and the U.S. as a whole) and 28% speaks a language other than English at home (compared to 20% in Connecticut and the U.S. as a whole).137 According to the University of Connecticut, by 2030, the household population of Fairfield County is expected to be 20% Hispanic. The African American population is expected to hold steady at 12%.138

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Mr. Case and Ms. Zegibe have been frustrated at how difficult it can be to get African American, Hispanic and Haitian American individuals to seek out services. Although the need is great, there is a tremendous amount of stigma in these communities about accepting help for mental health and substance abuse issues. NAMI has had most of its success working through local community churches. The Lower Fairfield County Regional Action Committee has also had some success working through churches and local bodegas. Their experience corroborates the American Psychiatric Association report on barriers to access for Hispanics detailed earlier in the assessment.

Ms. Gillespie emphasizes the importance of providers and agencies meeting the population where they physically are, as opposed to having them rely on transportation, to which many Latinos do not have access.

Ms. Watt expresses frustration at the lack of Spanish-speaking and Creole-speaking providers for the Hispanic and Haitian American communities, respectively. Ms. Gillespie also notes the need for bilingual clinicians who can do outreach to the community. Oddly, though, in SWRMHB’s August 2012 needs assessment, language was very low on the list of barriers for both mental health and substance abuse services.139

PREVALENCE OF DUAL DIAGNOSES

According to Dr. Barry, co-occurring substance abuse and mental illness is one of the biggest problems facing our community. There are a lot of people with depression and anxiety, he says, who are “undiagnosed or untreated” and who are “masking it with alcohol.” And, as Ms. Gillespie points out, mental health and substance abuse issues are risk factors for each other.

Mr. Wartenberg agrees there is a “significant gap with co-occurring issues,” particularly for adults, whom his organization treats. The Southwest Connecticut Mental Health System (SWCMHS) sees many people with a primary diagnosis of substance abuse and a secondary diagnosis of depression. “Substance abuse providers are short on psychiatry time,” he says, because there is a real shortage of psychiatrists who want to work with the dually diagnosed population.

The issue of dual diagnoses, however, does not pertain only to depression and anxiety. Ms. Autore stresses that substance abuse – from tobacco to illicit drugs – is a “major, major problem” for the schizophrenic population. Indeed, marijuana use is associated with the onset of psychotic disorders such as schizophrenia, particularly in individuals with an underlying vulnerability to the illness.140 Dr. Kleifield also notes the issue of eating disorders as secondary diagnoses which sometimes rise to the surface during treatment for substance abuse.

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EXISTING RESOURCES IN THE COMMUNITY

Fairfield County is fortunate to have a variety of existing resources available to residents of the community. Below we have outlined the major categories.

PUBLIC HEALTH DEPARTMENTS

The Connecticut Department of Mental Health and Addiction Services (DMHAS) is our dedicated public health department. The state is divided into five regions. Region 1 encompasses Southwest Connecticut, most of which is Fairfield County.

The Connecticut Department of Children and Families (DCF) also runs a program called Care Coordination in Norwalk, Stamford, Bridgeport and Danbury. Care Coordination works with children who have complex behavioral health needs and who are at risk to be, or have already been, separated from their family and/or community for the primary purpose of receiving behavioral health or related services.

The Connecticut Department of Public Health (DPH) is more focused on physical health issues.

Local Mental Health Authorities in Region 1

 Southwest CT Mental Health System (Bridgeport): DMHAS administrative office for Region 1.  F.S. Dubois Center (Stamford): The Community Services Division (CSD) in Stamford is located at the Franklin S. Dubois Center (FSDC) and serves the greater Stamford/Norwalk area. FSDC is responsible for providing ongoing, individualized treatment to persons living in the community with severe behavioral health disorders who are publicly insured, uninsured and in some cases underinsured.  Greater Bridgeport Community Mental Health Center (Bridgeport)

HOSPITALS

Adult Psychiatric Inpatient Departments

In addition to Silver Hill Hospital, there are six private hospitals with inpatient and/or emergency psychiatric services as well as the public health system in Bridgeport.

 Bridgeport Hospital (Bridgeport): Offers inpatient treatment and care for adults in need of hospitalization because of an acute psychiatric illness. Geriatric Psychiatric Inpatient Program provides individualized care and therapeutic groups and family assessments and family support services.  Danbury Hospital (Danbury): Inpatient psychiatric unit for adults.  Norwalk Hospital (Norwalk): Inpatient psychiatric unit for adults.  Saint Vincent’s Behavioral Health (Westport): Acute inpatient treatment for adults with mental health needs. Adults with a dual diagnosis of mental illness and substance abuse are also treated.  Saint Vincent’s Medical Center (Bridgeport): Short-term inpatient care for adults in mental health crisis.  Silver Hill Hospital (New Canaan): Acute inpatient treatment for adults with mental health, substance abuse and co-occurring disorders.

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 Southwest Connecticut Mental Health System (Bridgeport): Inpatient psychiatric care for adults with co- occurring illnesses who have no insurance or who are unable to receive treatment at local hospitals. People with insurance must present at other local hospitals first. Program incorporates both psychiatric and substance abuse disorders into treatment. PICU 1 and 2 are locked psychiatric units providing treatment for acutely ill psychiatric clients who require a safe, supportive and structured hospital level of care. Program will assist with re-entry once the individual is ready to return to community-based living.  Stamford Hospital (Stamford): Offers hospital-based inpatient psychiatric care and consultation/liaison services, behavioral disorder evaluation and treatment for addiction, anxiety and panic disorders, bipolar disorder, dementia, depression, eating disorders, OCD, psychosis, and schizophrenia.

Adolescent Psychiatric Inpatient Departments

 Saint Vincent’s Behavioral Health (Westport): Inpatient treatment for children and adolescents ages 7-17 with acute psychiatric conditions, as well as a specialized program for patients with co-existing psychiatric and substance abuse disorders.  Silver Hill Hospital (New Canaan): Acute inpatient treatment for adolescents ages 13-17.

Psychiatric Emergency Departments

 Bridgeport Hospital (Bridgeport)  Danbury Hospital (Danbury)  Greenwich Hospital (Greenwich)  Norwalk Hospital (Norwalk)  Saint Vincent’s Medical Center (Bridgeport)  Stamford Hospital (Stamford)

Hospital-Based Outpatient Mental Health and Substance Abuse Programs

 Bridgeport Hospital (Bridgeport): Resource For Adult And Child Mental Health (REACH) (Stratford): Intensive Outpatient Program and Partial Hospital Program for adults ages 18+. Programs accept people who have a dual diagnosis of substance abuse and mental illness. Older adults are placed in an Older Adult Track designed specifically for those who are facing mental health issues due to aging.  Danbury Hospital (Danbury): Center For Child And Adolescent Treatment Services (Danbury): Offers psychiatric and substance abuse assessments and intensive outpatient program for children ages 7-12 diagnosed with a psychiatric disorder. Dual Diagnosis Program for youth ages 13-18 with a psychiatric and substance abuse diagnosis.  Greenwich Hospital (Greenwich): Addiction Recovery Center (Greenwich): Diagnostic assessment for adults and substance abuse education/prevention. Recovery Program offers day and evening intensive outpatient programs for those seeking treatment for alcohol and drug dependency.  Norwalk Hospital (Norwalk): Behavioral Health and Addiction Services | Assessment For Substance Abuse/Mental Health Evaluation (Norwalk): Provides mental health evaluation and/or substance abuse assessment for adults, individual and group counseling for patients abusing alcohol and drugs. Also provides IOP, outpatient counseling, DBT therapy, etc.

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 Saint Vincent's Behavioral Health Services (Bridgeport): The Center At Bridgeport Partial Hospital/Intensive Outpatient Program Latino Program & Psychiatric Day Treatment Latino Program (Bridgeport): Partial Hospital is designed to treat patients with acute psychiatric symptoms and diagnosed substance abuse disorders. Program includes group therapy, individual and family therapy and medication management. Intensive Outpatient Program is designed to treat patients with severe psychiatric symptoms.

PRIVATE PHYSICIANS

Silver Hill Hospital maintains a database of nearly 1,600 providers in private or group practices that specialize in mental health and/or substance abuse issues in Fairfield County and neighboring Litchfield County alone. The list includes psychiatrists, psychologists, nurses, social workers, counselors, dietitians and non-psychiatrist physicians, some of whom specialize in adolescent medicine.

COMMUNITY MENTAL HEALTH CENTERS

Fairfield County is fortunate to have in place several residential and community mental health centers. Below is a sampling.

24-Hour Crisis Intervention Services

 Adults: F.S. Dubois Center (Stamford) and Greater Bridgeport Community Mental Health Center (Bridgeport)  Children: Child Guidance of Southern CT (Stamford) and Child Guidance Center (Bridgeport)

Southwest Regional Mental Health Board

The Southwest Regional Mental Health Board is located in Norwalk. A citizens’ advisory council, created by State mandate to assess and promote mental health and addiction services in Southwestern Connecticut. The Regional Mental Health Board has four Catchment Area Councils (CACs) corresponding to different areas of the region. CAC 1 Serves the towns of Darien, Greenwich, New Canaan and Stamford; CAC 2 Serves the towns of Norwalk, Weston, Westport and Wilton; CAC 3 Serves the towns of Bridgeport (western portion), Easton and Fairfield; CAC 4 Serves the towns of Bridgeport (eastern portion), Monroe, Stratford and Trumbull.

DMHAS-Funded Mental Health Programs in Region 1

 Ability Beyond Disability (Bethel)  Applied Behavioral Rehabilitation Research Institute (Bridgeport)  Bridge House, Inc. (Bridgeport)  Catholic Charities of Fairfield County (Bridgeport)  Central Connecticut Coast YMCA (Bridgeport)  Chemical Abuse Service Agency, Inc. (Bridgeport)  Family & Children's Agency, Inc. (Norwalk)  Family Centers, Inc. (Stamford, Darien)  Family Services - Woodfield, Inc. (Bridgeport)

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 Goodwill Industries of Western CT, Inc. (Bridgeport)  Hall Brooke Behavioral Health Services, Inc. (Westport)  Homes With Hope (Interfaith Housing Association) (Westport)  Inspirica Inc. (formerly St Luke's Community Services) (Stamford)  Kennedy Center, Inc. (Trumbull)  Keystone, Inc. (Norwalk)  Laurel House, Inc. (Stamford)  Marrakech Day Services, Inc. (Woodbridge)  Mental Health Association of CT, Inc. (Bridgeport/Stamford)  Micah Housing, Inc. (Fairfield)  The Open Door Shelter (Norwalk)  Operation Hope of Fairfield, Inc. (Fairfield)  Optimus Health Care, Inc. (Bridgeport)  Pathways, Inc. (Greenwich)  Recovery Network of Programs, Inc. (Shelton)  Shelter for the Homeless, Inc. (Stamford)  Southwestern Connecticut Agency on Aging, Inc. (Bridgeport)

Faith-Based Community Mental Health Programs

 Ark Community Residence And Counseling Center (Bridgeport): Spiritually based general counseling provided to individuals and groups of women in Fairfield County, struggling with substance abuse and/or mental health issues.  Catholic Charities (Norwalk, Stamford, Bridgeport): Variety of mental health evaluation and services.  Jewish Family Services (Bridgeport, Stamford, Westport): Counseling services.  Salvation Army (Norwalk): Christian-based pastoral counseling offered on a short term basis.

Other Community Mental Health Programs in Fairfield County

 Amedisys Home Health (Stamford, Stratford, Danbury): Provides in-home mental health nursing.  Child Guidance Center (Norwalk, Darien, Stamford, Greenwich, Fairfield, Bridgeport): Child abuse treatment team provides interdisciplinary evaluation and treatment of physically and emotionally abused children, siblings, and significant non-offending adults in the family. Offers 24-hour crisis intervention and immediate mental health assessment for children under age 19. Bilingual program. The clinic is designated by the Connecticut Department of Children and Families  Connecticut Counseling Centers (Norwalk, Danbury): Substance abuse assessments and mental health evaluations for adults. Mental health and substance abuse outpatient services include individual, couples, family, and group counseling; psychiatric services; dual diagnosis program; and drug and alcohol urine testing. All programs offer bilingual services. Accepts people with co-occurring mental and substance abuse disorders.  Connecticut Renaissance (Norwalk, Stamford, Bridgeport): Adolescent and Family Behavioral Health Program provides treatment for adolescent boys and girls ages 11-16 with mental health, behavioral and substance abuse problems.

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 Constellation Home Care (Norwalk): Offers home-based behavioral health nursing.  Depression and Bipolar Support Alliance (Greenwich, Westport): Support groups for people with depression/bipolar disorder and their family members.  Emotions Anonymous International (Georgetown, Bethel, Bridgeport): Support group for those experiencing emotional difficulties.  Fairfield Counseling Services (Fairfield): Evaluation, psychopharmacology and treatment of anxiety disorders, mood/depressive disorders, personality disorders, adjustment disorders, eating disorders, and post-traumatic stress disorder.  Family and Children's Aid (FCA) Outpatient Psychiatric Enhanced Care Clinic For Children (Danbury): Child guidance clinic for children, adolescents and their families provides a range of outpatient mental health services including assessments and evaluations, counseling, psychiatric treatment, psychopharmacology, and family counseling. Outpatient intervention for children ages 4-18 who have significant behavioral and emotional problems that are related to traumatic life events, even if they do not meet full diagnostic criteria for post-traumatic stress disorder (PTSD).  FSW Walk-In Mental Health Clinic (Bridgeport): Offers individual, couples, and family counseling for children, youth, and adults on a walk-in basis.  Laurel House (Stamford): Provides resources and opportunities for people living with serious psychiatric illnesses such as schizophrenia to lead fulfilling and productive lives in the communities where they live, work and go to school.  Jewish Family Service (Stamford, Westport, Bridgeport): Mental health counseling for children ages 8+.  New England Home Care (Shelton): Offers home-based behavioral health services.  Project Resilience (Ridgefield): Seeks to encourage the development of programs that promote the social and emotional growth and resilience of children and adolescents to seek to prevent suicides and other tragedies.  Project Return (Westport): Residential, after-care and transitional living programs for adolescent girls.  Southwest Community Health Center (Bridgeport): Individual and family counseling for youth ages 10-18 with mental health needs. Individual, child, family, and group mental health counseling for anxiety, depression, marital difficulties, family issues, and domestic violence.  The Center For Women and Families of Eastern Fairfield County (Fairfield, Bridgeport, Monroe): Crisis counseling for victims of sexual assault.  Visiting Nurse Services Of Connecticut (Bridgeport, Trumbull): In-home psychiatric nursing care for people with mental illness.

SUBSTANCE ABUSE TREATMENT AND RECOVERY PROVIDERS

Fairfield County is fortunate to have in place several substance abuse treatment and recovery providers. Below is a sampling.

Region 1 Substance Abuse Action Councils

 Lower Fairfield County Regional Action Council (Stamford): Towns Served: Darien, Greenwich, New Canaan, Stamford  Mid Fairfield Substance Abuse Coalition (Norwalk): Towns Served: Norwalk, Weston, Westport, Wilton

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 Regional Youth/Adult Social Action Project (Bridgeport): Towns Served: Bridgeport, Easton, Fairfield, Monroe, Stratford, Trumbull

DMHAS-Funded Substance Abuse Programs in Region 1

 Chemical Abuse Services Agency, Inc. (Bridgeport)  Connecticut Counseling Centers Inc. (Norwalk)  Connecticut Renaissance, Inc. (Bridgeport)  Council of Churches of Greater Bridgeport, Inc., Co-Op Center (Bridgeport)  Fairfield Counseling Services, Inc. (Fairfield)  Fairfield University Fairfield Corps Advisory (Fairfield)  Family & Children's Agency, Inc. (Norwalk)  Human Services Council of Mid-Fairfield (Norwalk)  Inspirica Inc. (formerly St Luke's Community Services) (Stamford)  Liberation Programs, Inc. (Norwalk, Bridgeport, Stamford)  Norwalk Economic Opportunity Now (NEON) (formerly CTE, Inc.) (Norwalk, Stamford)  Optimus Health Care, Inc. (Bridgeport)  Positive Directions The Center for Prevention and Recovery (Westport)  Recovery Network of Programs, Inc. (RNP) (Shelton)  RCS Annex/Regional Youth Adolescent Program Regional Youth/Adult Substance Abuse Project (Bridgeport)  Stratford Partnerships For Success (PFS) (Stratford)  Trumbull Partnership Against Underage Drinking (TPAUD) (Trumbull)

Faith-Based Substance Abuse Programs

 ARK Community Residence And Counseling Center (Bridgeport): Spiritually based general counseling provided to individuals and groups of women in Fairfield County, struggling with substance abuse and/or mental health issues.  Ashe' Faith Project (Bridgeport): Provides substance abuse education and prevention to anyone in need. Referrals to mental health and substance abuse providers are offered.  Basic House Outreach Ministries Christian Based Supportive Recovery Program (Norwalk): Christian- based sober homes and supportive living center for persons in crisis.  Bethel Recovery Center Christian Based Supportive Recovery Home (Bridgeport): Christian based substance abuse supportive recovery home for women who are addicted to alcohol or other drugs. Services include referral to social services, counseling, and life skills training. Length of stay is 6-24 months. The Center will accept women who are dually diagnosed.  Casa Recovery House (Bridgeport): Offers a three phase (up to 90 days) faith based residential program for adult males recovering from substance abuse. Services include individual, group and family counseling, educational classes, recreational therapy, case management, health services, and pastoral services.  Catholic Charities - Diocese Of Bridgeport (Danbury): Support group for people with a dual diagnosis of substance abuse and mental health disorder.

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 Christian Community Outreach Ministries Discipleship House/New Covenant House (Danbury): Christian based supportive recovery home for men and women ages 18+ who are recovering from substance abuse. Includes 12 step model support groups and pastoral counseling to help residents stay in recovery.  Pivot Ministries Christian Based Residential Substance Abuse Treatment (Bridgeport, Norwalk): Pivot Ministries is a 16 month, Christian based, residential rehabilitation program for men with a history of substance abuse.

Other Substance Abuse Programs in Fairfield County

 APT Foundation Residential Substance Abuse Treatment for Adults (Bridgeport): Residential substance abuse disorder treatment facility provides group therapy, psycho-educational groups, therapeutic leisure activity groups, and NA/AA recovery meetings.  Barnum / Waltersville Family Resource Center (Bridgeport): Positive youth development activities and after school programming include peer mentoring, conflict resolution, substance abuse prevention programs, homework assistance and links to the City's Lighthouse Program.  Boys And Girls Club (Ridgefield, Bridgeport): Youth enrichment programs. Personal development activities include counseling, tutoring, recreational, health, fitness, substance abuse programs, vocational counseling and educational field trips. Smart Moves Program is a prevention program that helps young people resist alcohol, tobacco and other drug use, as well as premature sexual activity.  Casa Hostos Program (Bridgeport): Offers an intensive (28 days) and intermediate (up to 6 months) residential treatment program for Latino adults with alcohol, cocaine, crack, hallucinogen, heroin, inhalant, and prescription medicine addictions. Intensive outpatient substance abuse treatment program provides individual, group and family therapy.  Child and Family Guidance Center (Bridgeport, Fairfield, Stratford): Provides care for families who are experiencing substance abuse and/or parent attachment issues with children. Program services includes home-based, individual and group therapy. Outpatient adolescent substance abuse treatment provides substance abuse treatment and evaluation services for adolescents who are at risk for substance abuse or who are currently abusing.  Connecticut Community For Addiction Recovery (Bridgeport): CCAR holds monthly meetings at regional locations around Connecticut to provide advocacy, organization and support for educating legislators, policy makers, service providers and the general public about the addiction recovery process. Drop-in recovery center offers a place to meet with others in recovery, computers for use in job searches, and support groups for people in recovery and their families, including separate meetings for men and for women.  Courage To Speak Foundation (Norwalk): Drug prevention education curriculum is provided to fourth, fifth and sixth graders.  Danbury Youth Services (Danbury): Psychiatric clinic offers short- and long-term counseling for young people and their families following individualized treatment plans. Counselors offer crisis intervention support, extensive assessment services, substance abuse counseling, parenting skills assistance.  Double Trouble In Recovery (Bridgeport): Self-help organization follows the 12 step model in support groups for people dually diagnosed with a substance abuse problem as well as a psychiatric disorder.

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 Family and Children's Aid Extended Day Treatment For Youth (Danbury): Extended day treatment program for high-risk youth ages 4-17. Offers group, individual and family counseling; alcohol and substance abuse evaluation and treatment; health education.  Housatonic Valley Coalition Against Substance Abuse (HVCASA) (Bethel): Offers program development for substance abuse prevention and treatment programs.  MCCA (Ridgefield, Bridgeport, Danbury): Individual, family and group substance abuse counseling.  New Canaan Cares (New Canaan): Offers presentations on health and wellness to community groups and schools. Offers educational programs for students and parents addressing problems of substance abuse.  New Era Rehabilitation Center (Bridgeport): Provides a substance abuse assessment for adults. Outpatient methadone maintenance treatment program provides detoxification services to adults ages 18+. Outpatient treatment for chemically dependent, substance abusing adults. Additional services include individual and group counseling, drug screenings and medical monitoring. Pregnant/postpartum women ages 18+ are also treated.  Newtown Parent Connection (Newtown): Grassroots organization promotes substance abuse prevention and awareness among parents of children of all ages through public forums, workshops and support groups.  Newtown Youth and Family Services (Sandy Hook): NYFS provides substance abuse counseling for the Newtown School system. Counseling is provided in the schools.  Norwalk Youth Services Bureau Peer Outreach Program (Norwalk): Interactive prevention program open and free to 7th and 8th grade students in the City of Norwalk. Group discussions on topics of interest to teens include: Life Skills, Self-Awareness, Peer Relationships, Substance Abuse, Motivational Exercises and Team Building Activities, etc.  Re-Al Club Substance Abuse Drop In Services (Stamford): Drop-in center for recovering alcoholics who are members of the club. Membership is contingent on a 30-day probationary period.  Ridgefield Community Coalition Against Substance Abuse (RCCASA) (Ridgefield): Community resource for Ridgefield residents facing drug and alcohol abuse issues. Offers educational programs for parents.  Roscco Family Resource Center (Stamford): Offers positive youth development services at a middle school targeted at preventing teen pregnancies and substance abuse.  Southwest Community Health Center (Bridgeport): Chemical dependency evaluations for individuals who have been referred from a variety of sources in the community. Intensive Outpatient Program (IOP) and substance abuse day treatment and counseling offers substance abuse counseling services and a comprehensive outpatient treatment program.  Stamford Counseling Center (Stamford): Relapse prevention counseling is offered for alcohol and drug abuse recovery.  Stratford Community Services Stopping Underage Drinking In Stratford (SUDS) Coalition (Stratford): Works to reduce underage drinking by raising community awareness of the problems associated with underage drinking and limiting youth access to alcohol.  The Connection, Women's Recovery Support Program (Bridgeport): Substance abuse recovery and supportive housing program for non-parenting women ages 18-30, with an emphasis on promoting self- esteem and personal development.  Wellmore Behavioral Health (Danbury): Provides care coordination for children ages 0-18 (or 21 if still receiving services from a local educational authority) who have complex behavioral health needs.

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 Wilton Youth Services Parent Connection (Wilton): Substance abuse education and prevention program.

EATING DISORDER RESOURCES

There are a very limited number of comprehensive programs in Fairfield County.

 The Renfrew Center (Old Greenwich): Offers day treatment, intensive outpatient program and other outpatient services. Also offers a group therapy program for emotional eaters. Residential programs are available at other locations.  Center for Discovery (Southport): Specializes in eating disorder residential treatment for male and female adolescents, aged 11-17.  Wilkins Center (Greenwich): Outpatient center offering complete medical, nutritional and psychiatric services for patients affected by eating disorders and their families.

There are also some eating disorder programs just beyond Fairfield County, including the Institute for Living at Hartford Hospital and Walden Behavioral Care, both in Hartford County, and Wellspring in Bethlehem, Litchfield County.

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

PRIORITIZED HEALTH NEEDS OF OUR COMMUNITY

Based on the research and conversations in the preceding sections, we have determined the following priorities in meeting community needs. We used three criteria for determining priorities:

1. Urgency: How critical is the need? Is it a life and death situation, as issues of mental health and substance abuse sometimes are? 2. Size: How big is the need? Does it affect a large swath of our community? 3. Capacity: How able are we, as a behavioral health institution, to address the need? Will we make an impact?

In our research and conversations, we have found that community-based help is better than technical support. Improving care for depression in low-income communities — places where such help is frequently unavailable or hard to find — provides greater benefits to those in need when community groups such as churches and even barber shops help lead the planning process, according to a brand new study from the RAND Corporation.141

Dr. Alan Barry, Commissioner of Social Services in Greenwich, said it well when he told us, “the best thing Silver Hill Hospital can do [is provide] a comprehensive continuum” of care as individuals step down the slope of acuity. Our inpatient and transitional living programs are well entrenched in the community; we are now turning towards enhancing our residential services and making our outpatient programming just as robust.

We elaborate on the following four priorities, including specific plans and timelines, in the Implementation Plan.

 Priority One: Substance Abuse Programs for Adults o Chronic Pain and Recovery Program o Comprehensive Outpatient Substance Abuse Program, including outpatient detoxification  Priority Two: Enhanced Adolescent Programming o Enhanced Adolescent Transitional Living Program o Intensive Outpatient Program  Priority Three: Enhanced Eating Disorder Program  Priority Four: Community Liaison Position o Outreach to underserved populations including youth and families, senior citizens and minorities o Partnering with existing community programs

There are also some needs identified in this assessment that Silver Hill Hospital will not be addressing at this time. These include:

Smoking Cessation. Although there is some concern for rates of tobacco use among minority populations, the overall rate of smoking in Fairfield County is lower than the national average. The most recent sub-state data from NSDUH (2008-2010) reported that 19.54% adults aged 12 and over in the Southwest Region smoked in the past month, compared to 21.56% in Connecticut and 23.46% in the U.S. as a whole.142 None of our interviewees mentioned cigarettes – even e-cigarettes – unless prompted, and even then, there was not a lot of concern.

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In addition, according to the Tobacco Use Prevention & Control Program in the Connecticut Department of Public Health, there are already eight smoking cessation programs in Fairfield County: three in Bridgeport, one in Danbury, one in Fairfield (town), one in Greenwich, one in Norwalk and one in Stamford.143

Due to the relatively non-urgent and low need as well as the availability of services in the community, Silver Hill Hospital does not feel its resources are best used developing smoking cessation programs.

Long-term Residential Care for Individuals with Serious Psychiatric Conditions. There is a great need for long- term residential programs for individuals with serious psychiatric conditions such as schizophrenia and schizoaffective disorder. For some patients, Michael’s House – Silver Hill Hospital’s short-to-intermediate-term residential program – is just what they need to transition from inpatient care to community living. Programs such as Laurel House in Stamford and others are paving the way to help such individuals develop job and life skills that will enable them to function in society.

Others will never be able to live in the community on their own. Places like Gould Farm in Monterey, Massachusetts offer long-term residential therapeutic communities for individuals living with mental illness.144 At this time, Silver Hill Hospital does not have the physical space or the staff to provide such a service.

Long-term Residential Care for Addicts. Another need in the community is for sober houses as identified by DMHAS in its August 2012 report.145 Again, at this time, Silver Hill Hospital does not have the physical space or staff to provide such a service.

Non-Emergent Evaluation Service for Adolescents. There are 75 school-based health centers (SBHCs) in Connecticut. Four communities in Fairfield County, corresponding to the urban and low-income centers, have SBHCs in their elementary, middle and high schools: Bridgeport (ten sites, sponsored by Optimus Health Care), Norwalk (four sites, sponsored by the Human Services Council), Stamford (five sites serving seven schools, sponsored by Family Centers, Inc.) and Stratford (one site, sponsored by the Stratford Health Department). These clinics offer on-site medical and behavioral health services, health education and in some cases, dental services to children and teens.146

Other local agencies have added to this type of support. For example, the Kids in Crisis program in several communities has begun placing full-time counselors in area high schools as part of its “TeenTalk” effort to help adolescents with personal and family pressures.

We currently provide educational services to adolescents admitted as inpatients or residents in a Transitional Living Program (TLP). In particular, we work with schools to conduct an in-depth educational assessment for all adolescent TLP patients. The first step is to review the existing school assessments up until the point of admission. Next, we offer a battery of screening and psychological testing to understand the patient’s needs. Finally, we develop a detailed “educational roadmap” for the patient to complete appropriate schooling. We also include the patient’s parent(s) in the roadmap. If needed, we refer patients to outside institutions for complete neuropsychological testing, as appropriate.

There is a gap, however, between the counseling services schools can offer and the possible need for a greater level of care (e.g., hospitalization, residential programs, etc.). Because schools do not have enough expertise at

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evaluating such a need, they often send potentially at-risk adolescents to general hospital emergency departments, which do not have the bandwidth to deal with such patients.

In the future, Silver Hill Hospital may consider developing a non-emergent evaluation service for adolescents to fill the gap between school-based programs and hospital admissions. At this time, however, we do not have the staffing necessary to develop such a program. In the meantime, we plan to address the gap in community services for adolescents (and others) through our new Community Liaison position, elaborated upon more fully in the Implementation Plan.

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ENDNOTES

1 Kaiser Family Foundation, “Snapshots: Health Care Spending in the United States & Selected OECD Countries,” April 12, 2011. http://kff.org/health-costs/issue-brief/snapshots-health-care-spending-in-the-united-states- selected-oecd-countries/

2 John Wright, et al, “Development and importance of health needs assessment,” BMJ, 1998 April 25; 316(7140): 1310-1313. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1113037/

3 2012 U.S. Census. http://quickfacts.census.gov/qfd/states/09000.html

4 U.S. Census, Bureau of Labor Statistics

5 http://assessment.communitycommons.org/CHNA/MapGallery.aspx

6 CDC, Behavioral Risk Factor Surveillance System, 2010 (1999-2006 data). USA includes States & DC. http://www.cdc.gov/brfss/index.htm

7 The National Center on Addiction and Substance Abuse at Columbia University, “Addiction Medicine: Closing the Gap Between Science and Practice,” June 2012, 133, 137. http://www.casacolumbia.org/templates/publications_reports.aspx

8 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2010 and 2011 (2010 Data - Revised March 2012). Tables 10, 17, 18 and 23. http://www.samhsa.gov/data/NSDUH/2k11State/NSDUHsae2011/NSDUHsaeStateTabsTOC2011.htm#TopOfPage

9 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2010 and 2011 (2010 Data - Revised March 2012). Table 21. http://www.samhsa.gov/data/NSDUH/2k11State/NSDUHsae2011/NSDUHsaeStateTabsTOC2011.htm#TopOfPage

10 DMHAS Biennial Report, COLLECTION AND EVALUATION OF DATA RELATED TO SUBSTANCE USE, ABUSE, AND ADDICTION PROGRAMS,” 2010 http://www.ct.gov/dmhas/lib/dmhas/opas/biennial2010.pdf

11 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health. Table 10 in the following surveys: 1) 2008 and 2009 (state); 2)2006, 2007 and 2008 (sub-state); 3) 2010 and 2011 (2010 Data - Revised March 2012) (state); 4) 2008, 2009, and 2010 (Revised March 2012) (sub-state) http://www.samhsa.gov/data/

12 Connecticut Department of Mental Health and Addiction Services (DMHAS) Sub-Region 1A Substance Abuse Profile, 2008.

13 Connecticut Department of Mental Health and Addiction Services (DMHAS) Sub-Region 1C Substance Abuse Profile, 2008.

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14 http://assessment.communitycommons.org/CHNA/MapGallery.aspx

15 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health. Table 10 in the following surveys: 2008 and 2009 & 2010 and 2011 (2010 Data - Revised March 2012) http://www.samhsa.gov/data/

16 CDC, Connecticut Youth Risk Behavior Survey 2011 http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?LID=Connecticut

17 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008, 2009, and 2010 (Revised March 2012).Table 12. http://www.samhsa.gov/data/NSDUH/substate2k10/ExcelTables/NSDUHsubstateExcelTabsTOC2010.htm

18 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008, 2009, and 2010 (Revised March 2012). Table 10. http://www.samhsa.gov/data/NSDUH/substate2k10/ExcelTables/NSDUHsubstateExcelTabsTOC2010.htm

19 Connecticut SPF-SIG State Epidemiological Workgroup (SEW) http://commed.uchc.edu/healthservices/sew/default.htm, SPF-SIG Community Level Data Excel Spreadsheet

20 Connecticut Department of Mental Health and Addiction Services (DMHAS) Sub-Region 1A Substance Abuse Profile, 2008.

21 NIH Senior Health http://nihseniorhealth.gov/alcoholuse/alcoholandaging/01.html

22 SAMHSA Data Spotlight, “Older Adult Substance Abuse Treatment Admissions Have Increased; Number of Special Treatment Programs for This Population Has Decreased,” July 12, 2012 http://www.samhsa.gov/data/spotlight/WEB_SPOT_043/WEB_SPOT_043.pdf

23 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008, 2009, and 2010 (Revised March 2012).Table 19. http://www.samhsa.gov/data/NSDUH/substate2k10/ExcelTables/NSDUHsubstateExcelTabsTOC2010.htm

24 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008, 2009, and 2010 (Revised March 2012).Table 22. http://www.samhsa.gov/data/NSDUH/substate2k10/ExcelTables/NSDUHsubstateExcelTabsTOC2010.htm

25 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2006, 2007, and 2008 (Revised March 2012). Table 22. http://www.samhsa.gov/data/NSDUH/substate2k08/Excel/NSDUHsubstateExcelTabsTOC2008.htm

26 SAMHSA Treatment Episode Data Set (TEDS) 2000 – 2010 State Admissions to Substance Abuse Treatment Services, Table 3.7. http://www.samhsa.gov/data/2k13/TEDS2010/TEDS2010StTOC.htm

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27 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008, 2009, and 2010 (Revised March 2012).Table 7. http://www.samhsa.gov/data/NSDUH/substate2k10/ExcelTables/NSDUHsubstateExcelTabsTOC2010.htm

28 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2006, 2007, and 2008 (Revised March 2012). Table 7. http://www.samhsa.gov/data/NSDUH/substate2k08/Excel/NSDUHsubstateExcelTabsTOC2008.htm

29 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2010 and 2011 (2010 Data - Revised March 2012). Table 7. http://www.samhsa.gov/data/NSDUH/2k11State/NSDUHsaeTOC2011.htm

30 SAMHSA Treatment Episode Data Set (TEDS) 2000 – 2010 State Admissions to Substance Abuse Treatment Services, Table 1.6b. http://www.samhsa.gov/data/2k13/TEDS2010/TEDS2010StTOC.htm

31 SAMHSA Treatment Episode Data Set (TEDS) 2000 – 2010 State Admissions to Substance Abuse Treatment Services, Table 1.6b. http://www.samhsa.gov/data/2k13/TEDS2010/TEDS2010StTOC.htm

32 The National Center on Addiction and Substance Abuse at Columbia University, “Addiction Medicine: Closing the Gap Between Science and Practice,” June 2012, 61. http://www.casacolumbia.org/templates/publications_reports.aspx

33 SAMHSA Treatment Episode Data Set (TEDS) 2000 – 2010 State Admissions to Substance Abuse Treatment Services, Table 1.9b. http://www.samhsa.gov/data/2k13/TEDS2010/TEDS2010StTOC.htm

34 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2010 and 2011 (2010 Data - Revised March 2012). Table 8. http://www.samhsa.gov/data/NSDUH/2k11State/NSDUHsaeTOC2011.htm

35 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008, 2009, and 2010 (Revised March 2012).Table 8. http://www.samhsa.gov/data/NSDUH/substate2k10/ExcelTables/NSDUHsubstateExcelTabsTOC2010.htm

36 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2010 and 2011 (2010 Data - Revised March 2012). Table 8. http://www.samhsa.gov/data/NSDUH/2k11State/NSDUHsaeTOC2011.htm

37 DMHAS Biennial Report, Collection and Evaluation of Data Related to Substance Use, Abuse, and Addiction Programs,” 2010 http://www.ct.gov/dmhas/lib/dmhas/opas/biennial2010.pdf

38 The National Center on Addiction and Substance Abuse at Columbia University, “Addiction Medicine: Closing the Gap Between Science and Practice,” June 2012, 207. http://www.casacolumbia.org/templates/publications_reports.aspx

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

39 DMHAS Region 1 Regional Priority Services Report, August 2012.

40 SAMHSA Treatment Episode Data Set (TEDS) 2000 – 2010 State Admissions to Substance Abuse Treatment Services, Table 1.5b. http://www.samhsa.gov/data/2k13/TEDS2010/TEDS2010StTOC.htm

41 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008, 2009, and 2010 (Revised March 2012).Tables 2, 3, 4, 7 and 8. http://www.samhsa.gov/data/NSDUH/substate2k10/ExcelTables/NSDUHsubstateExcelTabsTOC2010.htm

42 CDC, Connecticut Youth Risk Behavior Survey 2011 http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?LID=Connecticut

43 The National Center on Addiction and Substance Abuse at Columbia University, “National Survey of American Attitudes on Substance Abuse XVI: Teens and Parents,” August 2011, 17. http://www.casacolumbia.org/upload/2011/20110824teensurveyreport.pdf

44 Crean et al., “An Evidence-Based Review of Acute and Long-Term Effects of Cannabis Use on Executive Cognitive Functions,” Journal of Addiction Medicine: March 2011 - Volume 5 - Issue 1 - pp 1-8

45 The National Center on Addiction and Substance Abuse at Columbia University, “National Survey of American Attitudes on Substance Abuse XVI: Teens and Parents,” August 2011, 16. http://www.casacolumbia.org/upload/2011/20110824teensurveyreport.pdf

46 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2010 and 2011 (2010 Data - Revised March 2012). Table 2. http://www.samhsa.gov/data/NSDUH/2k11State/NSDUHsaeTOC2011.htm

47 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008 and 2009 (Revised March 2012). Table 2. http://www.samhsa.gov/data/NSDUH/2k09State/NSDUHsae2009/NSDUHsaeExcelTabsTOC-2009.htm

48 CDC, Connecticut Youth Risk Behavior Survey 2011 http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?LID=Connecticut

49 Connecticut Department of Mental Health and Addiction Services (DMHAS) Sub-Region 1A Substance Abuse Profile, 2008.

50 CDC Vital Signs, “Prescription Painkiller Overdoses,” July 2013 http://www.cdc.gov/vitalsigns/PrescriptionPainkillerOverdoses/index.html

51 Population estimates from 2007-2011 American Community Survey 5-Year Estimate of the U.S. Census Bureau http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

52 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008, 2009, and 2010 (Revised March 2012). Table 15. http://www.samhsa.gov/data/NSDUH/substate2k10/ExcelTables/NSDUHsubstateExcelTabsTOC2010.htm

53 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2006, 2007, and 2008 (Revised March 2012). Table 15. http://www.samhsa.gov/data/NSDUH/substate2k08/Excel/NSDUHsubstateExcelTabsTOC2008.htm

54 http://www.ct.gov/dmhas/lib/dmhas/prevention/ctspf/SEWprofiles09.pdf

55 Kaiser Family Foundation State Health Facts http://kff.org/statedata/

56 CDC, Behavioral Risk Factor Surveillance System, 2010 (1999-2006 data). USA includes States & DC. http://www.cdc.gov/brfss/index.htm

57 County Health Ratings and Roadmaps, 2005-2011 data http://www.countyhealthrankings.org/app/connecticut/2013/fairfield/county/outcomes/overall/snapshot/by- rank

58 http://assessment.communitycommons.org/CHNA/MapGallery.aspx

59 The National Center on Addiction and Substance Abuse at Columbia University, “National Survey of American Attitudes on Substance Abuse XVI: Teens and Parents,” August 2011, 25. http://www.casacolumbia.org/upload/2011/20110824teensurveyreport.pdf

60 CDC, Connecticut Youth Behavior Risk Survey 2011 http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?LID=Connecticut

61 CDC, Connecticut Youth Behavior Risk Survey 2011 http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?LID=Connecticut

62 CDC Morbidity and Mortality Weekly Report, “Notes from the Field: Electronic Cigarette Use Among Middle and High School Students — United States, 2011–2012,” September 6, 2013, 62(35); 729-30. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6235a6.htm

63 Kaiser Family Foundation State Health Facts http://kff.org/statedata/

64 NIH, The Science of Mental Illness http://science.education.nih.gov/supplements/nih5/mental/guide/info- mental-a.htm

65 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2011. Tables 1.1B, 1.1B, 1.3B, 1.6B and 1.8B. http://www.samhsa.gov/data/NSDUH/2k11MH_FindingsandDetTables/2K11MHDetTabs/NSDUH- MHDetTabsLOTSect1pe2011.htm#TopOfPage

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

66 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2010 and 2011 (2010 Data – Revised March 2012), Tables 1 and 24 http://www.samhsa.gov/data/NSDUH/2k11State/NSDUHsae2011/NSDUHsaeStateTabsTOC2011.htm#TopOfPage

67 NAMI State Statistics: Connecticut. http://www.nami.org/ContentManagement/ContentDisplay.cfm?ContentFileID=93484

68 Figure 6.2 http://www.oas.samhsa.gov/2k6State/ConnecticutMH.htm

69 Kaiser Family Foundation State Health Facts. http://kff.org/statedata/

70 Kaiser Family Foundation State Health Facts. http://kff.org/statedata/

71 Kaiser Family Foundation State Health Facts. http://kff.org/statedata/

72 Kaiser Family Foundation State Health Facts. http://kff.org/statedata/

73 County Health Ratings and Roadmaps, 2005-2011 data http://www.countyhealthrankings.org/app/connecticut/2013/fairfield/county/outcomes/overall/snapshot/by- rank

74 Spencer, Andrea M., Ph.D, “Blind Spot: Unidentified Risks to Children’s Mental Health,” Center for Children’s Advocacy, Hartford, 2012. http://www.cthealth.org/wp-content/uploads/2011/04/2BlindSpot2012.pdf

75 Kaiser Family Foundation State Health Facts http://kff.org/statedata/

76 Cabasso, Leopoldo et al., “Latino Adults’ Access to Mental Health Care. A Review of Epidemiological Studies,” Administration and Policy in Mental Health and Mental Health Services Research, May 2006, Volume 33, Issue 3, 316-330 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2551758/

77 American Psychiatric Association Office of Minority and National Affairs Fact Sheet, “Mental Health Disparities: Hispanics/Latinos,” 2010 http://www.psychiatry.org/practice/professional-interests/diversityomna/diversity- resources

78 Rodriguez, Cindy Y., “Latinos struggle to find help for mental issues,” CNN.com, October 9, 2013 http://www.cnn.com/2013/10/09/health/latino-mental-health-disparities/

79 NIMH http://www.nimh.nih.gov/health/topics/depression/index.shtml http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

80 Pratt, Laura A. et al, “Antidepressant Use in Persons Aged 12 and Over: United States, 2005–2008,” CDC NCHS Data Brief, No. 76, October 2011. http://www.cdc.gov/nchs/data/databriefs/db76.pdf

81 NIMH http://www.nimh.nih.gov/health/topics/depression/index.shtml

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

82 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2011, Tables 1.53B and 1.54B http://www.samhsa.gov/data/NSDUH/2k11MH_FindingsandDetTables/2K11MHDetTabs/NSDUH- MHDetTabsLOTSect1pe2011.htm#TopOfPage

83 NIMH, “Women and Depression: Discovering Hope” http://www.nimh.nih.gov/health/publications/women-and- depression-discovering-hope/index.shtml

84 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2010 and 2011. Youth Table 2.6B. http://www.samhsa.gov/data/NSDUH/2k11MH_FindingsandDetTables/2K11MHDetTabs/NSDUH- MHDetTabsLOTSect2pe2011.htm#TopOfPage

85 CDC, Connecticut Youth Behavior Risk Survey 2011 http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?LID=Connecticut

86 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2010 and 2011. Youth Tables 2.6B, 2.8B and 2.13B. http://www.samhsa.gov/data/NSDUH/2k11MH_FindingsandDetTables/2K11MHDetTabs/NSDUH- MHDetTabsLOTSect2pe2011.htm#TopOfPage

87 NIMH http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

88 NIMH, “Women and Depression: Discovering Hope” http://www.nimh.nih.gov/health/publications/women-and- depression-discovering-hope/index.shtml

89 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2010 and 2011. Youth Tables 2.6B, 2.8B and 2.13B. http://www.samhsa.gov/data/NSDUH/2k11MH_FindingsandDetTables/2K11MHDetTabs/NSDUH- MHDetTabsLOTSect2pe2011.htm#TopOfPage

90 NIMH http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

91 NIMH http://www.nimh.nih.gov/health/topics/depression/index.shtml

92 HealthyPeople.Gov., Mental Health and Mental Disorders http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=28

93 CDC, Connecticut Youth Behavior Risk Survey 2011 http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?LID=Connecticut

94 CDC, Connecticut Youth Behavior Risk Survey 2011 http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?LID=Connecticut

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

95 Rodriguez, Cindy Y., “Latinos struggle to find help for mental issues,” CNN.com, October 9, 2013 http://www.cnn.com/2013/10/09/health/latino-mental-health-disparities/

96 Institute of Medicine, “The Mental Health and Substance Abuse Workforce for Older Adults,” 2012 http://www.iom.edu/Reports/2012/The-Mental-Health-and-Substance-Use-Workforce-for-Older-Adults/Report- Brief.aspx

97 2012 U.S. Census. http://quickfacts.census.gov/qfd/states/09000.html

98 NIMH http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml

99 Borderline Personality Disorder Resource Center of NewYork-Presbyterian Hospital http://bpdresourcecenter.org/factsStatistics.html

100 http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml

101 NIH, The Science of Mental Illness http://science.education.nih.gov/supplements/nih5/mental/guide/info- mental-a.htm

102 Includes ICD-9-CM codes 290 and 293-299. Connecticut Department of Health Hospitalization Statistics, 2010, Table H-1 http://www.ct.gov/dph/cwp/view.asp?a=3132&q=397512

103 ANAD, Eating Disorder Population by Gender in Each State http://www.anad.org/news/eating-disorder- population-by-gender-in-each-state/

104 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2010 and 2011 (2010 Data - Revised March 2012). http://www.samhsa.gov/data/NSDUH/2k11State/NSDUHsae2011/Index.aspx

105 U.S. Census Bureau 2010 Data http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=DEC_10_DP_DPDP1

106 CDC, Connecticut Youth Risk Behavior Survey 2011 http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?LID=Connecticut

107 HealthyPeople.Gov – Mental Health and Mental Disorders. http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=28#127

108 HealthyPeople.Gov – Mental Health and Mental Disorders. http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=28#124

109 CDC, “Morbidity and Mortality Weekly Report,” May 3, 2013 / 62(17); 321-325 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6217a1.htm?s_cid=mm6217a1_w

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

110 CDC WISQARS (Web-based Injury Statistics Query and Reporting System) Fatal Injury Data http://www.cdc.gov/injury/wisqars/index.html

111 Connecticut SPF-SIG State Epidemiological Workgroup (SEW), SPF-SIG Community Level Data Excel Spreadsheet http://commed.uchc.edu/healthservices/sew/default.htm

112 Connecticut SPF-SIG State Epidemiological Workgroup (SEW), Suicide Rates by Town 2002-2004 http://commed.uchc.edu/healthservices/sew/default.htm

113 Connecticut Department of Mental Health and Addiction Services (DMHAS) Sub-Region 1B Substance Abuse Profile, 2008.

114 Borderline Personality Disorder Resource Center of NewYork-Presbyterian Hospital http://bpdresourcecenter.org/factsStatistics.html

115 HealthyPeople.Gov – Mental Health and Mental Disorders. http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=28#124

116 CDC WISQARS (Web-based Injury Statistics Query and Reporting System) Fatal Injury Data http://www.cdc.gov/injury/wisqars/index.html

117 CDC, Connecticut Youth Risk Behavior Survey 2011 http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?LID=Connecticut

118 “A Profile of Latino Health in Connecticut,” Latino Policy Institute (Hartford: Hispanic Health Council, 2006), 9. http://www.hartfordinfo.org/issues/wsd/health/Profile_Latino_Health.pdf

119 CT Department of Health, “2011 Connecticut School Health Survey Youth Behavior Component Report,” 6. http://www.ct.gov/dph/lib/dph/hisr/pdf/YBC_2011_Report_ForWeb.pdf

120 Yablonski, Steven and Matt Campbell, WFSB, “Greenwich HS Student commits suicide on first day of school,” Aug. 28, 2013. http://www.wfsb.com/story/23278527/greenwich-hs-student-commits-suicide-on-first-day-of- school

121 The Ridgefield Press, “Teen suicide: Watching for signs,” November 27, 2012. http://www.theridgefieldpress.com/11829/teen-suicide-watching-for-signs/

122 Project Resilience Facebook Page. https://www.facebook.com/ProjectResilience

123 The National Center on Addiction and Substance Abuse at Columbia University, “Addiction Medicine: Closing the Gap Between Science and Practice,” June 2012, 52. http://www.casacolumbia.org/templates/publications_reports.aspx

SILVER HILL HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT February 2014

124 The National Center on Addiction and Substance Abuse at Columbia University, “Addiction Medicine: Closing the Gap Between Science and Practice,” June 2012, 53. http://www.casacolumbia.org/templates/publications_reports.aspx

125 NAMI, “Dual Diagnosis and Integrated Treatment of Mental Illness and Substance Abuse Disorder,” September 2003 http://www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID= 54&ContentID=23049

126 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2011, Tables 1.4B and 1.5B http://www.samhsa.gov/data/NSDUH/2k11MH_FindingsandDetTables/2K11MHDetTabs/NSDUH- MHDetTabsLOTSect1pe2011.htm#TopOfPage

127 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2011, Tables 1.15B and 1.16B http://www.samhsa.gov/data/NSDUH/2k11MH_FindingsandDetTables/2K11MHDetTabs/NSDUH- MHDetTabsLOTSect1pe2011.htm#TopOfPage

128 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2011, Table 1.58B http://www.samhsa.gov/data/NSDUH/2k11MH_FindingsandDetTables/2K11MHDetTabs/NSDUH- MHDetTabsLOTSect1pe2011.htm#TopOfPage

129 Borderline Personality Disorder Resource Center of NewYork-Presbyterian Hospital http://bpdresourcecenter.org/co-occuringDisorders.html

130 Wright S. et al, “Dual diagnosis in the suburbs: prevalence, need, and in-patient service use,” Journal of Social Psychiatry and Psychiatric Epidemiology, 2000 Jul; 35(7):297-304. http://www.ncbi.nlm.nih.gov/pubmed/11016524

131 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2011, Table 1.19B http://www.samhsa.gov/data/NSDUH/2k11MH_FindingsandDetTables/2K11MHDetTabs/NSDUH- MHDetTabsLOTSect1pe2011.htm#TopOfPage

132 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2010 and 2011. Youth Table 2.10B. http://www.samhsa.gov/data/NSDUH/2k11MH_FindingsandDetTables/2K11MHDetTabs/NSDUH- MHDetTabsLOTSect2pe2011.htm#TopOfPage

133 See the Connecticut Department of Consumer Protection’s website: http://www.ct.gov/dcp/cwp/view.asp?a=3501&q=411378

134 Kids in Crisis Program http://www.kidsincrisis.org/

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135 U.S. Census, 2011 http://quickfacts.census.gov/qfd/states/09000.html

136 UCONN Connecticut State Data Center, Connecticut County Projections. http://ctsdc.uconn.edu/projections/ct_counties.html

137 U.S. Census, 2011 http://quickfacts.census.gov/qfd/states/09000.html

138 UCONN Connecticut State Data Center, Connecticut County Projections. http://ctsdc.uconn.edu/projections/ct_counties.html

139 DMHAS Region 1 Regional Priority Services Report, August 2012.

140 The National Center on Addiction and Substance Abuse at Columbia University, “Addiction Medicine: Closing the Gap Between Science and Practice,” June 2012, 60. http://www.casacolumbia.org/templates/publications_reports.aspx

141 RAND Corporation, “Incorporating Community Groups Into Depression Care Can Improve Coping Among Low- Income Patients,” June 25, 2013 http://www.rand.org/news/press/2013/06/25.html

142 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008, 2009, and 2010 (Revised March 2012). Table 15. http://www.samhsa.gov/data/NSDUH/substate2k10/ExcelTables/NSDUHsubstateExcelTabsTOC2010.htm

143 For more information, go to http://www.ct.gov/dph/tobacco

144 For more information on Gould Farm, visit http://www.gouldfarm.org

145 DMHAS Region 1 Regional Priority Services Report, August 2012.

146 Connecticut Association of School Based Health Centers website: http://www.ctschoolhealth.org/index.asp