mental health center case study

162 Case Studies: Real Stories Of People Overcoming Struggles of Mental Health

At Tracking Happiness, we’re dedicated to helping others around the world overcome struggles of mental health.

In 2022, we published a survey of 5,521 respondents and found:

• 88% of our respondents experienced mental health issues in the past year.
• 25% of people don’t feel comfortable sharing their struggles with anyone, not even their closest friends.

In order to break the stigma that surrounds mental health struggles, we’re looking to share your stories.

Overcoming struggles

They say that everyone you meet is engaged in a great struggle. No matter how well someone manages to hide it, there’s always something to overcome, a struggle to deal with, an obstacle to climb.

And when someone is engaged in a struggle, that person is looking for others to join him. Because we, as human beings, don’t thrive when we feel alone in facing a struggle.

Let’s throw rocks together

Overcoming your struggles is like defeating an angry giant. You try to throw rocks at it, but how much damage is one little rock gonna do?

Tracking Happiness can become your partner in facing this giant. We are on a mission to share all your stories of overcoming mental health struggles. By doing so, we want to help inspire you to overcome the things that you’re struggling with, while also breaking the stigma of mental health.

Which explains the phrase: “Let’s throw rocks together”.

Let’s throw rocks together, and become better at overcoming our struggles collectively. If you’re interested in becoming a part of this and sharing your story, click this link!

Case studies

July 30, 2024

Overcoming a Rare Autoimmune Disease With a Careful Diet and Self-Improvement

“There were weeks when I wouldn’t leave my house, feeling too overwhelmed and exhausted to face the world. I tend to isolate myself rather than reaching out to others, which only compounded my feelings of loneliness and despair. I had to repattern my behavior and learn to ask for help or talk about my feelings, but it wasn’t easy. I internalized a lot of my pain and frustration, which made me feel even more isolated.”

Struggled with: Anxiety Autoimmune disease

Helped by: Self-improvement

July 23, 2024

Surviving The Boston Marathon Bombings While Facing TBI and Medical Gaslighting

“As I literally lived on his couch, with my port-a-potty in his living room, my partner eventually applied for permanent disability status for me. But, even the doctor gaslighted me, told me I was physically able to work, and reported the same to the government. In reality, I was so dizzy with vertigo, this same doctor refused to let me walk to and from our car, by myself, fearing I’d fall and sue!”

Struggled with: CPTSD Traumatic Brain Injury

Helped by: Treatment

July 16, 2024

Somatic Therapy Helped Me Heal From CPTSD After Years of Childhood Abuse

“At 22 years old, I knew that I was dying of alcoholism. I accepted that. The trauma symptoms I experienced were too overwhelming to stop drinking. When I was sober, I would sometimes experience 30 to 40 body memories of being sexually assaulted–again and again in succession. I drank to feel numb.”

Struggled with: Abuse Addiction CPTSD Suicidal

Helped by: Social support Therapy

July 9, 2024

Learning To Live With Irritable Bowel Syndrome With Therapy And A Positive Mindset

“Raising four young children and battling a chronic illness with no cure was challenging for me. On the outside, I looked OK. But I wasn’t and in some ways today still have flare-ups and struggles, the difference is, I now know how to maintain it, especially knowing this will be the rest of my life regardless!”

Struggled with: Irritable Bowel Syndrome

Helped by: Therapy Treatment

July 4, 2024

How A Rescue Dog Helped Me Overcome TBI, Depression and Suicidal Ideation

“I sat on the summer-hot pavement, and no one stopped or asked me if I was okay. No one called the police. People walked around me as quickly as possible. When I was all cried out, I walked home to my empty house. I bought a set of knives, ostensibly for cooking, but that was not the reason. I had thought about pills, and every day I researched how many of each prescription drug I was on would I need to take to die. Using a sharp knife seemed so much easier.”

Struggled with: Depression Suicidal Traumatic Brain Injury

Helped by: Medication Pets Volunteering

July 2, 2024

Walking El Camino de Santiago Helped Me Reconnect With My Authentic Self

“Beneath the outward bravado, I battled with self-doubt and kept wondering why genuine connections seemed beyond my ability. Even though I put out valiant efforts to conceal it, my inner turmoil seeped out, leaving me feeling exposed and vulnerable. And, I knew they could tell.”

Struggled with: Feeling lost People-pleasing Self-doubt

Helped by: Self-acceptance Self-awareness

June 27, 2024

My Journey of Overcoming Heartbreak Thanks to Self-Care and The Support Of Friends

“I’ve learned that finding the right people to confide in, those who offer genuine support and empathy, can make a significant difference in navigating these challenges. It takes time and trust to build those connections, but they are invaluable.”

Struggled with: Breakup

Helped by: Self-Care Social support

June 19, 2024

How Therapy, Self-Help and Medication Help Me Live With Depression and Anxiety

“When the next depressive episode hit in 2018, I was devastated. How could this happen again when I thought I had it all figured out? I experienced some of the darkest moments of my life and a nearly complete loss of hope.”

Struggled with: Anxiety Bipolar Disorder Depression Suicidal

Helped by: Medication Therapy

June 11, 2024

Sharing My Journey From Alcohol and Substance Abuse to Sobriety and Happiness

“I felt prettier, smarter, funnier when alcohol entered my body so I simply continued numbing through the years. The progression of this disease of alcoholism turned into a nasty drug habit and those feelings of insecurity turned into deep darkness when I was “off my meds”. Or in other words, without alcohol or drugs.”

Struggled with: Addiction Depression Suicidal

Helped by: Rehab Therapy

June 4, 2024

Finding Happiness and Self-Love After Escaping Death From Burning 90% Of My Body

“It was like starting life over again, except you know how to do things you physically can’t do, which emotionally drains you. There was definitely a sense of resentment and feeling sorry for myself, I think that is natural. You wonder what you did to deserve that, you wonder if things are ever going to get better, you wonder how people will treat you. When you are confined to a bed for weeks on end, really all you can do is wonder.”

Struggled with: Physical trauma

Helped by: Self-improvement Social support

Mental Health Case Study: Understanding Depression through a Real-life Example

Through the lens of a gripping real-life case study, we delve into the depths of depression, unraveling its complexities and shedding light on the power of understanding mental health through individual experiences. Mental health case studies serve as invaluable tools in our quest to comprehend the intricate workings of the human mind and the various conditions that can affect it. By examining real-life examples, we gain profound insights into the lived experiences of individuals grappling with mental health challenges, allowing us to develop more effective strategies for diagnosis, treatment, and support.

The Importance of Case Studies in Understanding Mental Health

Case studies play a crucial role in the field of mental health research and practice. They provide a unique window into the personal narratives of individuals facing mental health challenges, offering a level of detail and context that is often missing from broader statistical analyses. By focusing on specific cases, researchers and clinicians can gain a deeper understanding of the complex interplay between biological, psychological, and social factors that contribute to mental health conditions.

One of the primary benefits of using real-life examples in mental health case studies is the ability to humanize the experience of mental illness. These narratives help to break down stigma and misconceptions surrounding mental health conditions, fostering empathy and understanding among both professionals and the general public. By sharing the stories of individuals who have faced and overcome mental health challenges, case studies can also provide hope and inspiration to those currently struggling with similar issues.

Depression, in particular, is a common mental health condition that affects millions of people worldwide. Disability Function Report Example Answers for Depression and Bipolar: A Comprehensive Guide offers valuable insights into how depression can impact daily functioning and the importance of accurate reporting in disability assessments. By examining depression through the lens of a case study, we can gain a more nuanced understanding of its manifestations, challenges, and potential treatment approaches.

Understanding Depression

Before delving into our case study, it’s essential to establish a clear understanding of depression and its impact on individuals and society. Depression is a complex mental health disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities. It can affect a person’s thoughts, emotions, behaviors, and overall well-being.

Some common symptoms of depression include:

– Persistent sad, anxious, or “empty” mood – Feelings of hopelessness or pessimism – Irritability – Loss of interest or pleasure in hobbies and activities – Decreased energy or fatigue – Difficulty concentrating, remembering, or making decisions – Sleep disturbances (insomnia or oversleeping) – Appetite and weight changes – Physical aches or pains without clear physical causes – Thoughts of death or suicide

The prevalence of depression worldwide is staggering. According to the World Health Organization, more than 264 million people of all ages suffer from depression globally. It is a leading cause of disability and contributes significantly to the overall global burden of disease. The impact of depression extends far beyond the individual, affecting families, communities, and economies.

Depression can have profound consequences on an individual’s quality of life, relationships, and ability to function in daily activities. It can lead to decreased productivity at work or school, strained personal relationships, and increased risk of other health problems. The economic burden of depression is also substantial, with costs associated with healthcare, lost productivity, and disability.

The Significance of Case Studies in Mental Health Research

Case studies serve as powerful tools in mental health research, offering unique insights that complement broader statistical analyses and controlled experiments. They allow researchers and clinicians to explore the nuances of individual experiences, providing a rich tapestry of information that can inform our understanding of mental health conditions and guide the development of more effective treatment strategies.

One of the key advantages of case studies is their ability to capture the complexity of mental health conditions. Unlike standardized questionnaires or diagnostic criteria, case studies can reveal the intricate interplay between biological, psychological, and social factors that contribute to an individual’s mental health. This holistic approach is particularly valuable in understanding conditions like depression, which often have multifaceted causes and manifestations.

Case studies also play a crucial role in the development of treatment strategies. By examining the detailed accounts of individuals who have undergone various interventions, researchers and clinicians can identify patterns of effectiveness and potential barriers to treatment. This information can then be used to refine existing approaches or develop new, more targeted interventions.

Moreover, case studies contribute to the advancement of mental health research by generating hypotheses and identifying areas for further investigation. They can highlight unique aspects of a condition or treatment that may not be apparent in larger-scale studies, prompting researchers to explore new avenues of inquiry.

Examining a Real-life Case Study of Depression

To illustrate the power of case studies in understanding depression, let’s examine the story of Sarah, a 32-year-old marketing executive who sought help for persistent feelings of sadness and loss of interest in her once-beloved activities. Sarah’s case provides a compelling example of how depression can manifest in high-functioning individuals and the challenges they face in seeking and receiving appropriate treatment.

Background: Sarah had always been an ambitious and driven individual, excelling in her career and maintaining an active social life. However, over the past year, she began to experience a gradual decline in her mood and energy levels. Initially, she attributed these changes to work stress and the demands of her busy lifestyle. As time went on, Sarah found herself increasingly isolated, withdrawing from friends and family, and struggling to find joy in activities she once loved.

Presentation of Symptoms: When Sarah finally sought help from a mental health professional, she presented with the following symptoms:

– Persistent feelings of sadness and emptiness – Loss of interest in hobbies and social activities – Difficulty concentrating at work – Insomnia and daytime fatigue – Unexplained physical aches and pains – Feelings of worthlessness and guilt – Occasional thoughts of death, though no active suicidal ideation

Initial Diagnosis: Based on Sarah’s symptoms and their duration, her therapist diagnosed her with Major Depressive Disorder (MDD). This diagnosis was supported by the presence of multiple core symptoms of depression that had persisted for more than two weeks and significantly impacted her daily functioning.

The Treatment Journey

Sarah’s case study provides an opportunity to explore the various treatment options available for depression and examine their effectiveness in a real-world context. Supporting a Caseworker’s Client Who Struggles with Depression offers valuable insights into the role of support systems in managing depression, which can complement professional treatment approaches.

Overview of Treatment Options: There are several evidence-based treatments available for depression, including:

1. Psychotherapy: Various forms of talk therapy, such as Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT), can help individuals identify and change negative thought patterns and behaviors associated with depression.

2. Medication: Antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs), can help regulate brain chemistry and alleviate symptoms of depression.

3. Combination Therapy: Many individuals benefit from a combination of psychotherapy and medication.

4. Lifestyle Changes: Exercise, improved sleep habits, and stress reduction techniques can complement other treatments.

5. Alternative Therapies: Some individuals find relief through approaches like mindfulness meditation, acupuncture, or light therapy.

Treatment Plan for Sarah: After careful consideration of Sarah’s symptoms, preferences, and lifestyle, her treatment team developed a comprehensive plan that included:

1. Weekly Cognitive Behavioral Therapy sessions to address negative thought patterns and develop coping strategies.

2. Prescription of an SSRI antidepressant to help alleviate her symptoms.

3. Recommendations for lifestyle changes, including regular exercise and improved sleep hygiene.

4. Gradual reintroduction of social activities and hobbies to combat isolation.

Effectiveness of the Treatment Approach: Sarah’s response to treatment was monitored closely over the following months. Initially, she experienced some side effects from the medication, including mild nausea and headaches, which subsided after a few weeks. As she continued with therapy and medication, Sarah began to notice gradual improvements in her mood and energy levels.

The CBT sessions proved particularly helpful in challenging Sarah’s negative self-perceptions and developing more balanced thinking patterns. She learned to recognize and reframe her automatic negative thoughts, which had been contributing to her feelings of worthlessness and guilt.

The combination of medication and therapy allowed Sarah to regain the motivation to engage in physical exercise and social activities. As she reintegrated these positive habits into her life, she experienced further improvements in her mood and overall well-being.

The Outcome and Lessons Learned

Sarah’s journey through depression and treatment offers valuable insights into the complexities of mental health and the effectiveness of various interventions. Understanding the Link Between Sapolsky and Depression provides additional context on the biological underpinnings of depression, which can complement the insights gained from individual case studies.

Progress and Challenges: Over the course of six months, Sarah made significant progress in managing her depression. Her mood stabilized, and she regained interest in her work and social life. She reported feeling more energetic and optimistic about the future. However, her journey was not without challenges. Sarah experienced setbacks during particularly stressful periods at work and struggled with the stigma associated with taking medication for mental health.

One of the most significant challenges Sarah faced was learning to prioritize her mental health in a high-pressure work environment. She had to develop new boundaries and communication strategies to manage her workload effectively without compromising her well-being.

Key Lessons Learned: Sarah’s case study highlights several important lessons about depression and its treatment:

1. Early intervention is crucial: Sarah’s initial reluctance to seek help led to a prolongation of her symptoms. Recognizing and addressing mental health concerns early can prevent the condition from worsening.

2. Treatment is often multifaceted: The combination of medication, therapy, and lifestyle changes proved most effective for Sarah, underscoring the importance of a comprehensive treatment approach.

3. Recovery is a process: Sarah’s improvement was gradual and non-linear, with setbacks along the way. This emphasizes the need for patience and persistence in mental health treatment.

4. Social support is vital: Reintegrating social activities and maintaining connections with friends and family played a crucial role in Sarah’s recovery.

5. Workplace mental health awareness is essential: Sarah’s experience highlights the need for greater understanding and support for mental health issues in professional settings.

6. Stigma remains a significant barrier: Despite her progress, Sarah struggled with feelings of shame and fear of judgment related to her depression diagnosis and treatment.

Sarah’s case study provides a vivid illustration of the complexities of depression and the power of comprehensive, individualized treatment approaches. By examining her journey, we gain valuable insights into the lived experience of depression, the challenges of seeking and maintaining treatment, and the potential for recovery.

The significance of case studies in understanding and treating mental health conditions cannot be overstated. They offer a level of detail and nuance that complements broader research methodologies, providing clinicians and researchers with invaluable insights into the diverse manifestations of mental health disorders and the effectiveness of various interventions.

As we continue to explore mental health through case studies, it’s important to recognize the diversity of experiences within conditions like depression. Personal Bipolar Psychosis Stories: Understanding Bipolar Disorder Through Real Experiences offers insights into another complex mental health condition, illustrating the range of experiences individuals may face.

Furthermore, it’s crucial to consider how mental health issues are portrayed in popular culture, as these representations can shape public perceptions. Understanding Mental Disorders in Winnie the Pooh: Exploring the Depiction of Depression provides an interesting perspective on how mental health themes can be embedded in seemingly lighthearted stories.

The field of mental health research and treatment continues to evolve, driven by the insights gained from individual experiences and comprehensive studies. By combining the rich, detailed narratives provided by case studies with broader research methodologies, we can develop more effective, personalized approaches to mental health care. As we move forward, it is essential to continue exploring and sharing these stories, fostering greater understanding, empathy, and support for those facing mental health challenges.

References:

1. World Health Organization. (2021). Depression. Retrieved from https://www.who.int/news-room/fact-sheets/detail/depression

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

3. Beck, A. T., & Alford, B. A. (2009). Depression: Causes and treatment. University of Pennsylvania Press.

4. Cuijpers, P., Quero, S., Dowrick, C., & Arroll, B. (2019). Psychological treatment of depression in primary care: Recent developments. Current Psychiatry Reports, 21(12), 129.

5. Malhi, G. S., & Mann, J. J. (2018). Depression. The Lancet, 392(10161), 2299-2312.

6. Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., … & Schatzberg, A. F. (2016). Major depressive disorder. Nature Reviews Disease Primers, 2(1), 1-20.

7. Sapolsky, R. M. (2004). Why zebras don’t get ulcers: The acclaimed guide to stress, stress-related diseases, and coping. Holt paperbacks.

8. Yin, R. K. (2017). Case study research and applications: Design and methods. Sage publications.

• Research article
• Open access
• Published: 01 April 2021

Three case studies of community behavioral health support from the US Department of Veterans Affairs after disasters

• Tamar Wyte-Lake   ORCID: orcid.org/0000-0001-8449-7701 1 , 2 ,
• Susan Schmitz 1 ,
• Reginald J. Kornegay 3 ,
• Felix Acevedo 4 &
• Aram Dobalian 1 , 5  

BMC Public Health volume  21 , Article number:  639 ( 2021 ) Cite this article

2471 Accesses

2 Citations

Metrics details

Community disaster resilience is comprised of a multitude of factors, including the capacity of citizens to psychologically recover. There is growing recognition of the need for public health departments to prioritize a communitywide mental health response strategy to facilitate access to behavioral health services and reduce potential psychological impacts. Due to the US Department of Veterans Affairs’ (VA) extensive experience providing trauma-informed behavioral healthcare to its Veterans, and the fact that VA Medical Centers (VAMCs) are located throughout the United States, the VA is well situated to be a key partner in local communities’ response plans. In this study we examined the role the VA can play in a community’s behavioral health response using case studies from three disasters.

This study investigated experiences of VA employees in critical emergency response positions ( N  = 17) in communities where disasters occurred between 2017 and 2019. All respondents were interviewed March–July 2019. Data were collected via semi-structured interviews exploring participants’ experiences and knowledge about VA activities provided to communities following the regional disasters. Data were analyzed using thematic and grounded theory coding methods.

Respondents underscored VA’s primary mission after a disaster was to maintain continuity of care to Veterans. The majority also described the VA supporting community recovery. Specifically, three recent events provided key examples of VA’s involvement in disaster behavioral health response. Each event showed VA’s integration into local response structures was facilitated by pre-existing emergency management and clinical relationships as well as prioritization from VA leadership to engage in humanitarian missions. The behavioral health interventions were provided by behavioral health teams integrated into disaster assistance centers and non-VA hospitals, VA mobile units deployed into the community, and VA telehealth services.

Conclusions

Recent disasters have revealed that coordinated efforts between multidisciplinary agencies can strengthen communities’ capacity to respond to mental health needs, thereby fostering resilience. Building relationships with local VAMCs can help expedite how VA can be incorporated into emergency management strategies. In considering the strengths community partners can bring to bear, a coordinated disaster mental health response would benefit from involving VA as a partner during planning.

Peer Review reports

Disaster behavioral health

The current COVID-19 pandemic, while still underway, has already demonstrated the need for psychological interventions to manage the isolation, stress, and trauma stemming from the ongoing disaster [ 1 , 2 , 3 , 4 , 5 ]. While the scale of the event is unprecedented, interest in understanding the psychological consequences of disasters is not unique to the pandemic [ 6 , 7 , 8 , 9 , 10 ]. Generally, studies exploring the impacts of disasters on behavioral health have found increases in psychological distress in the short term, with the potential for some individuals to experience long-term psychiatric disorders such as posttraumatic stress disorder, depression, and anxiety [ 6 , 7 , 8 , 9 , 10 ].

To ameliorate the potential negative health effects to impacted populations, numerous early interventions have been explored [ 7 , 11 , 12 , 13 , 14 ]. Some countries such as the Netherlands and Iceland use federally structured plans to implement disaster behavioral health interventions [ 12 , 15 ]. And countries like New Zealand have invested heavily in developing extensive mental health programs in response to large scale disaster events [ 16 , 17 ]. In the United States, federal entities strive to create resources and guidance on implementing behavioral health services after disaster, however, interventions are generally managed and delivered by state, territory, and local agencies [ 14 , 18 , 19 ]. Often, after federally declared disasters, the US Federal Government additionally provides funding through the Crisis Counseling Assistance and Training Program (CCP) to community behavioral health programs [ 8 , 13 , 20 ]. Yet the structure and content of interventions are left to the discretion of the implementing agency.

Regardless of the services provided, having a plan in place prior to a disaster can facilitate implementation [ 8 , 11 , 12 , 13 , 19 , 21 , 22 ]. Few publications detail the creation of a local disaster behavioral health response plans [ 15 , 18 , 20 ] or describe the process in which interventions were deployed following an incident [ 7 , 10 , 15 , 20 , 23 , 24 ]. Common themes arising in studies exploring disaster behavioral health plans or interventions are the need for interdisciplinary teams and interagency collaboration [ 8 , 12 , 18 , 19 , 20 ] and strong community response [ 16 ].

The United States Department of Veterans Affairs

One interagency partner often overlooked in the United States is the U.S. Department of Veterans Affairs (VA) Veterans Health Administration (VHA). Previous publications on VHA’s participation in collaborative disaster planning and preparedness efforts with local communities identified barriers to its involvement [ 25 , 26 ]. One such barrier is that the community, and sometime even VHA employees, are unaware that VHA is tasked with planning for and acting to support “national, state, and local emergency management, public health, safety and homeland security efforts” [ 9 , 27 ]. This responsibility to contribute to community efforts is called the VA’s Fourth Mission and is in addition to VHA’s duty to ensure continuity of services to veterans after a disaster.

The expertise of VHA’s 322,030 healthcare professionals and support staff who provide a range of services at its 1255 healthcare facilities spread throughout the U.S. and its territories makes VHA a valuable potential partner in disaster response [ 28 ]. In addition to inpatient and ambulatory medical care, VHA provides a variety of reintegration programs including trauma recovery and behavioral health services for Veterans and their families at its facilities and through community-based care at Vet Centers, Mobile Vet Centers, and college and university campuses [ 29 ]. How these services are applied in community response efforts has been detailed in the grey literature [ 28 , 30 , 31 , 32 ].

This study highlights the potential role of local VA facilities in supporting local behavioral health activities after a disaster, and specifically, presents three exemplars of VHA integrating into communities’ disaster behavioral health response and providing behavioral health support to non-Veterans. The three VA facilities and the events they responded to are: (1) VA Pacific Island Healthcare System (VAPIHC), which is based in Honolulu, Hawaii but provides care to Veterans throughout numerous Pacific Islands. On October 24th, 2018, Super Typhoon Yutu made direct landfall on the Mariana Islands, a US Commonwealth with a nascent established VA tele-mental health clinic on the island of Tinian. This was the strongest typhoon ever recorded to strike the area, severely damaging or destroying many buildings and much of the critical infrastructure of Tinian [ 33 ]; (2) Orlando VA Healthcare System, which serves east central Florida, and encompasses 7 counties. On June 12, 2016, a domestic terrorist attack [ 34 ], targeted hate crime, and one of the deadliest mass shootings in the U.S. occurred at a local establishment, Pulse Nightclub. In a matter of hours, 49 people were killed and 53 were wounded before law enforcement breached the building and ended the violence [ 35 ]; and (3) VA Southern Nevada HCS (VASNHCS), located in and providing care throughout Las Vegas, Nevada. On October 1, 2017, the worst mass shooting in modern history took place at the Route 91 Harvest Music Festival on the downtown Las Vegas Strip. A gunman opened fire on a crowd of more than 22,000, killing 58 people and wounding 413 [ 36 ]. These cases provide examples of interagency partnerships and the implementation of collaborative responses for communities developing their own plans to address the behavioral health needs of their citizens during disasters, including the ongoing COVID-19 pandemic.

Study design

The results presented in this paper stem from a larger study broadly examining the role of local VA facilities in responding to regional large-scale disasters. This study used qualitative interview methods to elicit study participants’ experiences during disasters impacting the U.S. between 2016 and 2018 (see Table  1 for the full list of the disasters covered in the study, the impacted US states and territories, and VA entities affiliated with the impacted areas). Findings on disaster behavioral health functions were pulled as a subset of data and analyzed. The VA Greater Los Angeles Healthcare System Institutional Review Board (Los Angeles, California USA) approved this study.

Setting and sample

The full study sample was purposively chosen to represent individuals with emergency response roles critical to coordinating VA’s local response to disasters. Emergency management personnel at various levels of the VA were the first point of contact and, when applicable, identified additional individuals with critical response roles to interview. Additional respondents were recruited independently by the project team These facilities made up the broad recruitment sample. Due to some respondents covering multiple disasters or being deployed to disasters outside their normal service region, not all entities were included in the final sample.

Data collection methods

Data were collected through semi-structured, 60-min telephone interviews between March–August 2019, using an interview guide developed for this study (see Additional file  1 ). Interviews were conducted individually with each respondent and led jointly by at least two of the authors. Interviews explored participants’ experiences and knowledge about VA activities in the community, specifically focusing on how VA networked and coordinated with non-VA community agencies. Interviews were audio-recorded, although one respondent declined to be recorded.

Analysis plan

A total of 17 individuals were interviewed. However, five interviews did not indicate collaborating with non-VA entities and were therefore not included in the analysis. Due to their involvement in multiple disasters, two respondents were interviewed twice. At completion of the interviews, this resulted in 13 interview recordings being transcribed, and one set of interview notes (due to interviewee declining to be recorded), resulting in a total of 14 interviews that were analyzed with Atlas.ti (v.7) using a grounded theory approach. In phase one of analysis, one author reviewed all 14 interviews, using inductive coding to identify emergent themes in the data, and informed by extensive conversations about project findings held by the project team at the conclusion of each interview [ 37 ]. As a product of this process, a significant emergent theme [ 37 ] was the presence of interagency partnerships implementing collaborative responses to address the behavioral health needs of local citizens during disasters. A decision was made by the project team to narrow the focused coding analyses [ 37 ] to the way local VA facilities engaged in a behavioral response within their local community, in response to their respective large-scale disaster events.

In phase two of the analysis, the initial codes identified by SS were reviewed by TWL for consistency and agreement. Codes not deemed consistent to the focus topic were dropped. Additional grounded themes were confirmed by the team and applied to the data set [ 37 ]. Consensus on final codes was achieved, and one code list was finalized. In phase three of the analysis, the final code list was applied across all relevant interviews. The final code list had a focus on behavioral health response, including behavioral health activities, method of delivery, reactions of staff, and types of impacted community populations, but also included an identification of high level themes across all disasters, including VA expertise, integrating into local, established response activities, identification of local needs, and logistical challenges. Authors TWL and SS then independently coded each interview and resolved discrepancies by consensus.

All respondents played a substantial role in VA’s activities following the respective disasters. However, only 12 participants indicated the VAMC they supported collaborated with non-VA partners during the event in question. Included disasters ranged from widespread to geographically contained; weather-related to acts of violence; and direct impact on VA facilities ranged from none to significant. Though not all respondents described intensive engagement with the community following the event, all respondents described the importance of integrating into local, established response activities. This translated into involvement in community-wide drills and planning committees and following the lead of local incident command. Respondents indicated one of the areas where the VA could provide support to the community was in disaster behavioral health relief operations.

Activities described by respondents were often centered around tasks where the VA could reduce the caseload of other community agencies by identifying Veterans obtaining services in the community and meeting their needs regardless if they were previously enrolled in VA benefits. One key activity described by several respondents included outreach into local shelters. As one respondent explained, VA staff at shelters “[distribute] fliers [that] outline that our counselors are experts in trauma, loss, and in readjustment. They also provide referrals to Veterans for a variety of services, including housing and employment. We also offered free counseling for all community members impacted .”

Identifying where shelters were established and receiving authorization to deploy VA assets to those locations required coordination with local authorities. Multiple respondents mentioned connecting with emergency management running relief efforts to describe available VA resources and detail the services available to both Veterans and the community at large. In some of the events explored in this study, the non-VA authorities were unaware of what the VA could offer while others had pre-existing relationships that allowed for more transparent understanding of how the VA could support response efforts. One respondent went on to describe how the disaster that impacted their VAMC led to additional outreach to local jurisdictions and shelter coordinating agencies (e.g., the American Red Cross) to build relationships and understanding specifically of the behavioral health services the VA could deploy, if needed and approved.

Respondents noted there were specific benefits to conducting outreach in locations where other agencies provided services to the people impacted such as shelters and Local Assistance Centers. They noted that VA staff could more easily reach Veterans to enroll them, if eligible, into VA services and offer care to those who usually used non-VA health and mental health facilities, thereby supporting local agencies by reducing potential patient loads elsewhere. Additionally, by positioning resources at a central location, VA could more readily offer community members services as an extension of their work with Veterans. One specific resource identified as useful for Veteran and community support was Mobile Vet Centers, which have the primary goal of providing social work and mental health services to Veterans. In cases where respondents mentioned this resource, they underscored that non-Veteran community members who requested services in the first days after the disaster were never turned away.

Three community profiles

Three disaster events described by respondents distinctly highlighted cases where the VA was deeply involved in the local community’s disaster behavioral health response. Each event showed VA’s integration into local response structures was facilitated by pre-existing emergency management and clinical relationships, as well as prioritization from VA leadership to engage in humanitarian missions to support the community.

Telehealth in Tinian, Mariana Islands

Prior to Super Typhoon Yutu impacting the Mariana Islands, the VA Pacific Island Healthcare System (VAPIHC) established tele-mental health services on the island of Tinian. These services were located at a non-VA owned healthcare clinic using pre-positioned VA telemedicine equipment and coordinated with the clinic director and staff. Typhoon Yutu devastated the island and led to many Tinian healthcare clinic employees losing their homes. The clinic with VA tele-mental health equipment became a temporary housing site for staff as it was undamaged by the storm. The clinic director realized that in addition to sheltering needs, employees also experienced significant trauma. However, there were limited mental health resources on the island. Once VA became aware of the need, it worked with other federal agencies to manage the logistics of implementing services that took advantage of pre-positioned VA resources.

“… it was a relationship that we had with [the US Department of Health and Human Services] (HHS) and a relationship that we had with the folks on Guam and Saipan … we have a lot of relationships going on. So, we knew that we had that telehealth equipment. We also knew that Tinian was … hit pretty hard. And that there was a lot of grief. And so I can’t say how it totally emerged, but there’s so many relationships and there’s so much communication during an emergency.”

Respondents reported it was initially challenging to identify whether VA could provide mental health services in the community and how the services would be funded. Staff at all levels of the VA worked with the Federal Emergency Management Agency (FEMA) and HHS to get official authorization as well as receive federal funding for VAPIHC to provide time limited tele-mental health interventions to clinic staff on Tinian. VAPIHC Tele-mental Health Hub coordinated with the local clinic director to inform employees about available services and utilized technology onsite to provide weekly support groups for 13 health center employees.

Director’s 50 in Orlando, Florida and the pulse nightclub shooting

The Orlando VA Healthcare System (OVAHCS) houses a unique emergency response team “The Director’s 50.” Made up of multi-disciplinary VA healthcare workers, including mental health professionals (i.e. psychologists, psychiatrists, mental health nurses), the Director’s 50 can deploy a team of up to 50 volunteers within 2 hours to areas throughout the region when authorized by the Orlando VAMC Director. As described by one respondent, the mission of the team is,

“to provide an immediate gap fill to an emergency before VA can get its assets organized and into a formal support and response role. So the team is multi-disciplinary and multi-functional with its capabilities, so that it can immediately address the needs of the emergency response until VA can formalize how it’s going to provide their support to the community.”

The Director’s 50 includes interdisciplinary clinical and service support training for all members such as triage and treatment services, mental health intervention, peer counseling, and psychological support to trauma. Through participation in community-wide exercises and drills, the Director’s 50 has built versatile capabilities and strong relationships with local emergency management agencies and area hospitals.

In response to the Pulse Nightclub Shooting, VA Central Office requested OVAHCS to deploy the Director’s 50 to provide VA resources and support the community’s response. The team activated their mass notification system to alert their nearly 100 volunteer members and quickly assembled an initial response team of about 15 clinical, mental health, and support professionals within 1 hour. Respondents noted having internal approval can speed up the process of deploying teams. In general, to distribute VA resources into the community, a federal disaster declaration is required to initiate the Robert T. Stafford Disaster Relief and Emergency Assistance Act or where the HHS Secretary has activated the National Disaster Medical System, both of which grant VA the ability to provide assistance. Therefore, respondents noted a need to balance expectations of leadership to help quickly, while also ensuring VA resources were legally allowed to be used in the response.

One thing that facilitated OVAHCS’s integration into the local response system was a pre-existing relationship with the City of Orlando’s Office of Emergency Management and the Central Florida Medical Disaster Coalition, which facilitated the Director’s 50 integration into the city’s response and allowed them to report to the victim reunification center. The team was tasked.

“to be the initial communication to the family members for those victims that actually passed away. So, 49 victims, our team was assigned to go ahead and be the initial contact to let them know that their loved ones had passed, and to begin the coordination for services, grief counseling and victim advocacy, you know, to help them prepare the initial points of piecing together their lives after being notified of such tragic events.”

Accordingly, the initial multi-disciplinary team narrowed its focus to mainly members with mental health expertise. Over the next 2 weeks, the team worked with the community, helping to manage vigils and gatherings for the public, and continuing grief counseling and mental health support for the whole community, including providing peer behavioral health support to municipal first responders. Since this act of violence targeted people who were Lesbian Gay Bisexual Transgender Queer (LGBTQ) frequenting Pulse Nightclub, not only were relatives of victims or survivors from inside the building affected, but the entire LGBTQ community felt the traumatic impact of the shooting. One respondent described the importance of providing mental health support from multiple community agencies when a disaster of this magnitude occurs,

“And they [the people who were at the shooting] truly needed a place, and this is why we were there for greater than just the 24-48 hours of initially identifying the people who was killed during the shooting, you had everyone that was inside of the club who were seeking a place where they could go and receive the care and support that they needed as well. And obviously, you know, this is something that is an endemic issue with healthcare as a whole, is the access to mental health counseling and services. So VA, as well as some other partnering mental health organizations were able to supply that need right there at the site where they were doing victim notification or victim reunification and family support. We were able to do that.”

One respondent noted a key point to remember about the Director’s 50, “they are all volunteers...And these people will go—you know, 24 hours a day, day in and day out, to execute that mission. And we have to think about team resiliency.” This included caring for team member’s well-being by rotating staff and providing and attending to the mental heath of one another. As described by one respondent,

“Because when it was all said and done, the team was very affected by what they had to do. You know, just imagine hearing—you know, overwhelming grief for every one of the 49 victims’ families that would show up. And the team took that burden on … and I will tell you, to this day, it still affects the people who went and supported that mission. And they really—those who supported that mission have a greater reverence for what we do now, as a team. So you’d never have to ask them to—whether they are going to support anything related to the Director’s 50. That comradery that’s there, they won’t let their own kind of—go into the bowels of despair like that, alone.”

Integrating into community response in Las Vegas, Nevada after the route 91 harvest festival shooting

As a large city with many national and international visitors, respondents described Las Vegas as having a very centralized emergency response structure. Relationships between VA Southern Nevada HCS (VASNHCS) and local response agencies and area hospitals were described as “tightknit” with great working relationships where organizations plan and prepare for disasters together. As one respondent put it,

“what I do know is my community. I know my community partners. I know what they have, what they don’t have, they know what I have, what I don’t have. And that’s what makes us so resilient. That’s community.”

Although located too far away from the Las Vegas Strip to actively receive injured victims when the shooting occurred at the Route 91 Harvest Music Festival, VASNHCS activated its Hospital Incident Command System so it could actively participate in the community’s response and organize efforts. A Multi-Agency Coordination Center (MACC) organized the response activities, and respondents underscored the value of both pre-existing relationships and an understanding of the county’s emergency response structure. As explained by a respondent,

“You can’t wait for your community to ask you. You have to be on the forefront and know what they need. And you only do that by knowing your community. You know, I spent probably as much time in my community as I do in my medical center. A lot of the time, it’s my own time, but again, it builds that relationship that when they’re updating their mass casualty plan, one of the people they’re calling is [me].”

This previous collaboration, as well as being present at the MACC, allowed VASNHCS to identify community needs that it could address.

As news of the shooting spread, VA leadership tasked VASNHCS with deploying staff into the community. However, it was challenging to balance the push from VA to deploy with continuing to respect established local coordination structures. VASNHCS maintained a presence within the Medical Area Surge Command of the MACC to offer resources and expertise, waiting for requests, instead of directly deploying assets outside of the established system.

In the immediate response, VASNHCS assisted with managing fatalities. It offered morgue space to the county and initiated the mass fatality plan to increase morgue capacity. This provided the county and partner hospitals space for victims until they could be processed, and families could claim them. Additionally, VASNHC offered a Psychological First Aid (PFA) team.

Initially, VASNHCS deployed their PFA team to the community’s family reunification center. The team was composed of social workers, psychologists, psychiatrists, administrators (as support staff), canteen services (for water and snacks to sustain clients and staff), and the medical center’s Chief of Staff. As the situation evolved, the MACC received requests from local agencies for psychological assistance and VASNHCS transitioned to directly integrating into area hospitals.

Three Las Vegas hospitals received the bulk of the injured or dead and recognized the need for psychological interventions with their staff. Due to their close relationships with other hospitals, one respondent explained that they were familiar with the Employee Assistance Program (EAP) at these hospitals. The respondent knew it would take time for the EAP to arrive onsite and they would most likely focus on clinical staff involved in directly treating the injured. Therefore, VASNHCS developed a three-pronged approach to complement EAP services at the receiving hospitals. Firstly, the PFA team provided what one respondent called “ trauma therapy ” to hospital staff, regardless whether they worked the night of the shooting. The assistance extended beyond clinical staff to non-clinical departments, such as environmental services/housekeeping, whose staff were also impacted through their response roles.

Respondents reported one of the reasons their response in the hospitals was so successful was that the team was multidisciplinary, allowing staff from different departments to talk to people in similar positions, which was valued by the recipients.

“So for example, we have a nurse that’s trained in trauma, psychological first aid. So they want the nurses at [the hospital with a patient surge], they want to talk to our team. They were still processing. But when we brought our nurse into the ward, they were more than willing to open up to her, because she was one of them. She was part of their tribe. So we try to match our tribe to their tribe, and that’s why we were successful.”

Secondly, the VASNHCS team worked with victims of the shooting, providing PFA and social work services. Thirdly, they integrated with family members of patients at the hospitals and provided them items that they did not otherwise have because they were visitors to Las Vegas. Examples included coordinating free transportation to and from hospitals and hotels, connecting them to local mortuary services, and providing information about how to access services when they returned home.

The PFA team ran for 24 h a day, for 7 days in those three impacted hospitals. To balance VA patient care with the community response mission, VASNHCS staff volunteered shifts outside of their normal work hours. One respondent described the overwhelming desire of VA staff to help their community.

“And while it didn’t impact our staff or our clinics, or our patients, it impacted our community. I think another thing that still amazes me to this day, was the outpour of our staff and what I mean by that is they were coming out of the woodwork to support. We had more volunteers working an eight-hour shift and then coming in [to volunteer] at five o’clock or four o’clock and working to midnight to two in the morning and not go home until four or five in the morning, and then go to work the next day, because we didn’t want to impact our patient care. And they were doing this out of their—you know, because they care. They care about the community, they care about the event, they care about the people. And then at the end of the day, you know, we had more volunteers than we had placements, because we did not want to overwhelm the health systems with all of these VA personnel.”

However, with new volunteers each shift, a key lesson learned was to have a daily team debrief. As people changed daily, a debrief provided key information and a running tally of support being provided to save time and avoid reinventing the wheel identifying contacts or systems already developed.

Another lesson was that preparedness requires ongoing maintenance. The importance of ongoing preparedness was underscored when VASNHCS realized that leading up to the shooting, they had reduced their focus on PFA training. As described by one respondent, “ We noticed that we need that continuous [psychological first aid] training, that we need continuous exercising, and it’s not an easy fit, to send a bunch of people to someone else’s hospital or an area to do that kind of service .” They also realized the first wave of personnel went into community hospitals without basic supplies they needed to provide services, including basic items such as pens, PFA guides, and informational brochures.

Three months following the shooting, the VASNHCS Emergency Manager, working with the Chief of Social Work hosted a lunch for staff who volunteered to thank them for their involvement. During that event, they realized volunteers were not only impacted by the event itself, but also by their time providing support in the community. They therefore created a forum to again gather staff who had deployed at the 6 month and 9 month marks to eat and talk about the impact of the event on the healthcare system and themselves. On the 1 year anniversary, management had a special event for the volunteers,

“we actually had people from the community that we supported coming in and they broke bread with our team and what they did was, they talked about what the impact of the VA Southern Nevada Healthcare System was going into that event, and how we helped them bridge the gap [of mental health support] that was crucial at that time, and how appreciative they were to our cause and our Clark County Office of Emergency Management gave all our staff that responded T-shirts that said Vegas Strong, because they wanted them to know that we—they appreciated the work that we did for them to support our community.”

The need for attention to the psychological well-being of individuals during and after a disaster has been well proven as disasters have been found to be associated with both short and long-term symptoms and disorders [ 6 , 7 , 8 , 9 , 10 , 38 ]. Although in some parts of the world there are federally structured plans to implement disaster behavioral health interventions, in the United States there is a patchwork system that often relies on support and resource allocation from a multitude of agencies [ 8 , 13 , 14 , 18 , 19 , 20 ]. In this study we examined the role the VA can play in a community’s disaster relief effort and highlighted the opportunity for VA to support behavioral health response focusing specifically on case studies from three disasters.

Essential to effective emergency management is an understanding of, and engagement with, available resources in a local community. This is of particular importance when considering complex individual and group needs such as behavioral health support. VA Medical Centers can be seen as challenging partners to work with because they are both a federal entity and a local healthcare facility [ 26 ]. However, in the case of Super Typhoon Yutu, the federal positioning of the VA and its connection with HHS and FEMA facilitated the deployment of VAPIHC virtual resources. The regional respondents who supported the VA disaster mission in Tinian described how preexisting relationships with federal partners facilitated authorization and funding.

Another potential challenge to incorporating the VA into response efforts is that prior to offering services, VA leadership must balance the mission of the agency with community needs, without contradicting the restrictions of the Stafford Act. In all three presented cases, VA’s behavioral health support was not formally included in a city or county response plan, and yet pre-existing relationships between key stakeholders facilitated the provision of VA behavioral health services to support identified community needs. Respondents also described participating in interagency coordinating groups, response trainings, and exercises before the disaster. These activities aided in a deeper understanding of the response structures each partner operated under and encouraged strong rapport between agencies.

Relationships between VA emergency management and local emergency management proved invaluable as VA staff understood that services should not be provided without first engaging local response coordinators. All VA facility leadership and emergency managers are required to be trained in the Incident Command System (ICS) and National Incident Management System (NIMS), which are the coordinating structures all U.S. response agencies work within [ 39 ]. As a health care provider at a national level, VHA falls within the operations section Essential Support Function (ESF) 8: Public Health and Medical Services to support the Department of Health and Human Services [ 40 ]. Local jurisdictions may also connect with VAMCs through ESF 8 representation. For example, the VA has provided significant support to communities impacted by COVID-19. As of July 8, 2020, VA provided more than 330,000 pieces of Personal Protective Equipment (PPE) in support of the Fourth Mission, as well as hand sanitizer, laundry support, test kits and testing support, and webcams for use with existing equipment to state and local facilities. In addition, VA has admitted 279 non-Veterans to VA Medical Centers because of the pandemic [ 27 ]. Much of this coordination was done through ESF 8 coordination at a local or national level.

While respondents did not go into detail about their participation in the emergency management structure, some participants described their VA’s roles within emergency operations as liaisons. Groups such as this could report to either the planning, operations, or command sections within the ICS. Group supervisors would most commonly report to the operations section chief, likely through branch directors, given that the focus of the work would be more on specialized functions as needed for tactical operations. Regardless of where they fit, their presence at emergency operations centers and command posts facilitated communication to allow for VA’s integration into incident action plans. Particularly during the response to mass casualty events in Orlando and Las Vegas, understanding the local response network and then proffering available services was essential to avoid confusion or duplication of activities. By working within the established coordination centers, VA’s efforts were effectively integrated into the greater community behavioral health response and were deployed to points of greatest need. Although a detailed understanding of the integration of VA activities into ICS structures fell outside of the scope of this work, future assessment of the integration of VA representatives into local, state, and/or regional ICS structures could help clarify roles and identify which section liaisons best support (e.g., operations, planning, logistics) [ 40 ].

VA is increasingly strengthening partnerships with agencies that provide behavioral health services to Veterans and their families who use non-VA community-based care [ 41 ]. In each case example, the primary support provided by VA to the community was the provision of behavioral health services in response to an identified need. Respondents described this as being due, in large part, to the recognition of VA’s expertise in trauma and post-trauma treatment, thereby allowing these resources to come to the forefront. While not mentioned by the respondents, an additional value that VA providers add to disaster behavioral health responses is their exposure to and understanding of the unique needs of various populations throughout their communities. In addition to ensuring care is culturally competent to the unique identity of being a Veteran, VA staff must respect the diversity of Veterans themselves. Just like the U.S. population at large, Veterans represent a range of ages, races, genders, sexual orientations, socioeconomic statuses, etc. and mental health services must be considerate of this diversity. The VA recognizes this and offers training to providers to understand and respect their patients’ unique needs [ 42 ]. Working with a variety of populations preposition VA staff to have a deeper understanding of the post-disaster needs of the wider community.

Two of the case examples described in this study especially bring to the forefront the importance of disaster behavioral health response planning and implementation teams understanding unique experiences of community members. Super Typhoon Yutu directly impacted an archipelago housing a majority Asian and/or Pacific Island population. The Pulse Nightclub shooting, while a terrorist event, was a targeted hate crime intended to inflict violence on the LGBTQ community. Disaster behavioral health interventions for these affected groups not only need to take into consideration the importance of cultural competency but also the potential of re-traumatization and distinct population mental health needs.

In the Northern Mariana Islands, while there is a mix of ethnic groups (Filipino, Chamorro, Chinese, Carolinian, Korean, Palauan, etc.), many either identify as or are categorized more broadly as Asian and/or Pacific Islanders. Although there are more than 1.4 million people who are considered Pacific Islanders living the in the U.S., there is a dearth of information on the mental health of this population [ 43 ]. Similarly, the prevalence and incidence rates of mental illness in the Mariana Islands is not well studied [ 44 ]. Some sources attribute this lack of understanding to a disproportionate underuse of mental health services [ 43 ]. However, Asian and Pacific Islanders within the U.S. and those territories affiliated with it often experience transgenerational trauma, discrimination, continued loss from colonization, historical trauma, and mental health stigma which can impact psychological wellbeing and help seeking behavior. Additionally, cultural elements (collectivism, reverence for the past, hierarchical social order, etc.) of this population are important to understand when providing behavioral health services [ 43 , 45 ]. One of the reasons respondents indicated that the VA was asked to provide assistance following Typhoon Yutu was the lack of availability of mental health services in Tinian. The established VA telehealth technology increased accessibility to behavioral practitioners from VAPIHC who most likely were experienced working with Asian and Pacific Island populations since more than 55,000 Veterans who identify as this ethnicity live in Island Areas or Hawaii [ 46 , 47 ].

The Pulse Nightclub Shooting was a terrorist driven hate crime targeting individuals who identified as LGBTQ. Members of this group often experience discrimination, stigma, and trauma throughout their lives. Discrimination and heterocentric health and mental health practices can marginalize this population and impact help seeking behavior [ 48 , 49 ]. This is of particular concern as individuals who are LGBTQ face numerous mental health disparities with a higher likelihood of experiencing depression, anxiety, substance misuse, and suicide attempts. The shooting not only targeted LGBTQ people but it also took place during Latin Pride Night meaning many of the victims and casualties were LGBTQ Latinx. The resulting psychological impacts of the Pulse Nightclub shooting on those directly impacted, people who are LGBTQ Latinx, and individuals in the wider LGBTQ community have been investigated and show experiences of trauma and impacts on perceived safety [ 50 ]. At the time of the shooting, the Orlando VAMC had established relationships with LGBTQ local mental health services and had staff knowledgeable in the needs of this community [ 51 ]. In fact, in the recent past, the VA has increased its efforts to ensure Veterans who are LGBTQ receive the highest quality patient-centered care possible [ 52 ]. Mental health services in particular have bolstered recognition of the complex needs of these Veterans [ 52 ].

All three cases demonstrate innovative ways VA can provide behavioral health support outside of their facilities, i.e., via telehealth capabilities across an ocean and into a healthcare clinic, teams of mobile units reaching directly into the community to support victims, victims’ families, and the community at large, and finally by incorporating PFA teams directly into hospitals to support staff, patients, and patients’ families. This flexibility across sites to address different needs and populations while using varying available infrastructure support, is paramount to any local jurisdiction’s ability to meet on the ground needs following a disaster. It demonstrates the variability between VAMCs and the importance of local disaster behavioral health planning teams to pre-identify resources to assess local capacity. Plans can then be developed that access and deploy the tools/skills of interdisciplinary and interagency teams. Building processes to deploy local health and mental health practitioners can lead to more rapid implementation of interventions and help ensure the diversity of the impacted community is recognized and respected. Additional studies focused on how communities develop disaster behavioral health plans could provide insight into which agencies are involved and how they collaborate. It may also be useful to assess whether and how these plans are implemented to identify best practices.

In addition to the people directly impacted by disasters, respondents underscored the importance of offering support to responders as well. There is growing recognition that health care workers are themselves front-line response workers who may be psychologically impacted when caring for others, leading to a growing emphasis on the importance of selfcare and employee wellbeing [ 39 , 40 , 41 , 42 ]. In all three case studies, behavioral health support was, at least in part, directed toward healthcare workers. In the case of Las Vegas, a respondent highlighted the advantage of having behavioral health support come from individuals who understood the culture of the population they were helping, e.g., nurses supporting nurses. Further, respondents in Las Vegas and Orlando highlighted the importance of supporting deployed behavioral health team members. They detailed actions to maintain staff well-being by having rotating shifts, encouraging peer support, and facilitating gatherings for staff to publicly thank them for their efforts and allow them to address their experiences together as a group. Understanding the needs of healthcare and behavioral health personnel and building support networks into response frameworks can help better sustain and strengthen the overall response process.

A primary limitation of this study is that interviews were conducted up to one and a half years after the disasters described, potentially impacting recall. However, multiple interviewees corroborated the information presented for each of the case studies. Another limitation is that this study focused exclusively on the experiences of VA employees fulfilling mission requirements and their description of instances where VA acted in support of the Fourth Mission. Very few of the respondents directly provided the behavioral health interventions. These perspectives could provide deeper understanding of the interventions themselves as well as the impacts they may have on practitioners. Neither community members nor coalition partners were interviewed in this study. Future research would benefit from both interviewing non-VA participants to explore additional perspectives and gain greater insight on how local jurisdictions experienced collaborating with VA representatives and exploring alternative approaches to mental health units within and outside VA to examine whether and when different approaches may be preferable.

As the largest integrated healthcare system in the United States, VA can play an important role in disaster response across the country. As recognition of VA’s expertise in behavioral health grows, particularly around trauma and post-trauma treatment, VA should be considered a strong potential partner in behavioral health responses. Local VAMC staff are part of the community in which they live and the Veterans they serve are a microcosm of the larger population of the U.S. As the respondents in this study showed, there is a deep desire by VA staff to provide support following a disaster if they are able. Anticipating potential behavioral health concerns, and having a plan to address them, can foster community disaster resilience. While these plans may be different for each jurisdiction, they can be strengthened by identifying and incorporating a range of partners. Having preexisting relationships where VA’s capabilities are known before a disaster occurs can facilitate the rapid deployment of VA resources into identified areas of community need. The case studies presented demonstrate the flexible nature of these resources. By extending knowledge about innovative ways to share behavioral health and other resources in a disaster response, communities and healthcare coalitions can be better prepared to engage collectively and rapidly mobilize essential assets to support the wellbeing of those who need it most.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Crisis Counseling Assistance and Training Program

U.S. Department of Veterans Affairs

Veterans Health Administration

VA Medical Center

VA Pacific Island Healthcare System

VA Southern Nevada HCS

Veterans Health Administration Health Care System

Veterans Integrated Service Network

Office of Emergency Management

US Department of Health and Human Services

Federal Emergency Management Agency

Lesbian Gay Bisexual Transgender Queer

Multi-Agency Coordination Center

Psychological First Aid

Employee Assistance Program

Personal Protective Equipment

Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912–20. https://doi.org/10.1016/S0140-6736(20)30460-8 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Fiorillo A, Gorwood P. The consequences of the COVID-19 pandemic on mental health and implications for clinical practice. Eur Psychiatry. 2020;63(1):e32. https://doi.org/10.1192/j.eurpsy.2020.35 .

Article   CAS   PubMed   Google Scholar  

Pfefferbaum B, North CS. Mental health and the COVID-19 pandemic. N Engl J Med. 2020;383(6):510–2. https://doi.org/10.1056/NEJMp2008017 .

Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatr. 2020;33(2):e100213. https://doi.org/10.1136/gpsych-2020-100213 .

Article   PubMed   PubMed Central   Google Scholar  

Vigo D, Patten S, Pajer K, Krausz M, Taylor S, Rush B, et al. Mental health of communities during the COVID-19 pandemic. Can J Psychiatr. 2020. https://doi.org/10.1177/0706743720926676 .

Beaglehole B, Mulder RT, Frampton CM, Boden JM, Newton-Howes G, Bell CJ. Psychological distress and psychiatric disorder after natural disasters: systematic review and meta-analysis. Br J Psychiatry. 2018;213(6):716–22. https://doi.org/10.1192/bjp.2018.210 .

Article   PubMed   Google Scholar  

Beinecke R, Raymond A, Cisse M, Renna K, Khan S, Fuller A, et al. The mental health response to the Boston bombing: a three-year review. Int J Ment Health. 2017;46(2):89–124. https://doi.org/10.1080/00207411.2017.1294969 .

Article   Google Scholar  

Beinecke RH. Addressing the mental health needs of victims and responders to the Boston Marathon bombings. Int J Ment Health. 2014;43(2):17–34. https://doi.org/10.2753/IMH0020-7411430202 .

Dobalian A, Callis R, Davey VJ. Evolution of the Veterans Health Administration’s role in emergency management since September 11, 2001. Disaster Med Public Health Prep. 2011;5(S2):S182–4. https://doi.org/10.1001/dmp.2011.61 .

Heslin KC, Stein JA, Dobalian A, Simon B, Lanto AB, Yano EM, et al. Alcohol problems as a risk factor for postdisaster depressed mood among U.S. veterans. Psychol Addict Behav. 2013;27(1):207–13. https://doi.org/10.1037/a0030637 .

Hobfoll SE, Watson P, Bell CC, Bryant RA, Brymer MJ, Friedman MJ, et al. Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry. 2007;70(4):283–337. https://doi.org/10.1521/psyc.2007.70.4.283 .

Jacobs J, Oosterbeek M, Tummers LG, Noordegraaf M, Yzermans CJ, Duckers MLA. The organization of post-disaster psychosocial support in the Netherlands: a meta-synthesis. Eur J Psychotraumatol. 2019;10(1):1544024. https://doi.org/10.1080/20008198.2018.1544024 .

North CS, Pfefferbaum B. Mental health response to community disasters: a systematic review. JAMA. 2013;310(5):507–18. https://doi.org/10.1001/jama.2013.107799 .

Watson PJ, Ruzek JI. Academic/state/federal collaborations and the improvement of practices in disaster mental health services and evaluation. Admin Pol Ment Health. 2009;36(3):215–20. https://doi.org/10.1007/s10488-009-0212-4 .

Thordardottir EB, Gudmundsdottir B, Petursdottir G, Valdimarsdottir UA, Hauksdottir A. Psychosocial support after natural disasters in Iceland-implementation and utilization. Int J Disaster Risk Reduction. 2018;27:642–8. https://doi.org/10.1016/j.ijdrr.2017.11.006 .

Fergusson DM, Horwood LJ, Boden JM, Mulder RT. Impact of a major disaster on the mental health of a well-studied cohort. JAMA Psychiatry. 2014;71(9):1025–31. https://doi.org/10.1001/jamapsychiatry.2014.652 .

Gray L, MacDonald C, Mackie B, Paton D, Johnston D, Baker MG. Community responses to communication campaigns for influenza A (H1N1): a focus group study. BMC Public Health. 2012;12(1):1–12.

Compton MT, Cibulas BK, Gard B, Kaslow NJ, Kotwicki RJ, Reissman DB, et al. Incorporating community mental health into local bioterrorism response planning: experiences from the DeKalb County Board of Health. Community Ment Health J. 2005;41(6):647–63. https://doi.org/10.1007/s10597-005-8846-5 .

Pfefferbaum B, Flynn BW, Schonfeld D, Brown LM, Jacobs GA, Dodgen D, et al. The integration of mental and behavioral health into disaster preparedness, response, and recovery. Disaster Med Public Health Prep. 2012;6(1):60–6. https://doi.org/10.1001/dmp.2012.1 .

Elrod CL, Hamblen JL, Norris FH. Challenges in implementing disaster mental health programs: state program directors’ perspectives. Ann Am Acad Pol Soc Sci. 2016;604(1):152–70.

Gil-Rivas V, Kilmer RP. Building community capacity and fostering disaster resilience. J Clin Psychol. 2016;72(12):1318–32. https://doi.org/10.1002/jclp.22281 .

Melmer P, Carlin M, Castater CA, Koganti D, Hurst SD, Tracy BM, et al. Mass casualty shootings and emergency preparedness: a multidisciplinary approach for an unpredictable event. J Multidiscip Healthc. 2019;12:1013–21. https://doi.org/10.2147/JMDH.S219021 .

Naturale A, Lowney LT, Brito CS. Lessons learned from the Boston Marathon bombing victim services program. Clin Soc Work J. 2017;45(2):111–23. https://doi.org/10.1007/s10615-017-0624-7 .

Reifels L, Pietrantoni L, Prati G, Kim Y, Kilpatrick DG, Dyb G, et al. Lessons learned about psychosocial responses to disaster and mass trauma: an international perspective. Eur J Psychotraumatol. 2013;4.

Dobalian A. The US Department of veterans affairs and sustainable health care coalitions. Disaster Med Public Health Prep. 2015;9(6):726–7. https://doi.org/10.1017/dmp.2015.136 .

Schmitz S, Wyte-Lake T, Dobalian A. Facilitators and barriers to preparedness partnerships: a veterans affairs medical center perspective. Disaster Med Public Health Prep. 2018;12(4):431–6. https://doi.org/10.1017/dmp.2017.92 .

VA Fourth Mission Summary [ https://www.va.gov/health/coronavirus/statesupport.asp ].

Office of Public and Intergovernmental Affairs [ https://www.va.gov/opa/pressrel/searchResults.cfm ].

Affairs USDoV: VA Office of mental health and suicide prevention guidebook. 2018.

Google Scholar  

Lawrence Q. VA secretary Wilkie: ‘We are the surge force’. In: The coronavirus crisis: NPR. NPR.org ; 2020.

Services UDoHH. HHS, FEMA, DOD and VA continue to provide sustained and critical medical care support for Puerto Rico as part of Trump Administration response to Hurricane Maria. In . HHS.gov News: US Department of Health & Human Services; 2017.

Steinhauer J. The V.A. Prepares to back up a health care system threatened by coronavirus: The New York Times; 2020.

Agency FEM. Super typhoon Yutu: one year later: FEMA; 2019.

Foundation NP: After-action review of the orlando fire department response to the attack at pulse nightclub. 2018.

Investigation FBo: Active shooter incidents in the United States in 2016 an 2017. 2018.

Department LVMP: 1 October after action review. 2018.

Charmaz K, Belgrave LL. Grounded theory: The Blackwell Encyclopedia of Sociology; 2007. https://doi.org/10.1002/9781405165518.wbeosg070 .

Lowe SR, Galea S. The mental health consequences of mass shootings. Trauma Violence Abuse. 2017;18(1):62–82. https://doi.org/10.1177/1524838015591572 .

Department of Veterans Affairs. National incident management system compliance: VHA Directive 0320.12(1): Administration VH. Washington, DC; 2021.

Veterans Health Administration. COVID-19 response plan: Management OoE; 2020.

US Department of Defense DoVA, Department of Health & Human Services. Interagency task force on military and veterans mental health; 2017. p. 1–31.

National Academies of Sciences E, and Medicine, Health and Medicine Division, Board on Health Care Services, Committee to Evaluate the Department of Veterans Affairs Mental Health Services. Evaluation of the Department of Veterans Affairs Mental Health Services: National Academies Press (US); 2018.

Subica AM, Aitaoto N, Link BG, Yamada AM, Henwood BF, Sullivan G. Mental health status, need, and unmet need for mental health services among U.S. Pacific islanders. Psychiatr Serv. 2019;70(7):578–85. https://doi.org/10.1176/appi.ps.201800455 .

Buettner K, Sablan J, Funk M, Arriola, J, Price, S, Sugiura, K, Diminic S, Drew N. WHO profile on mental health in development (WHO proMIND): Commonwealth of the Northern Mariana Islands. Geneva, World Health Organization; 2013. https://apps.who.int/iris/bitstream/handle/10665/85304/9789241505741_eng.pdf;jsessionid=A222F532F705877A650948706A437484 . Accessed 26 Mar 2021.

Mental health in the Asian Americans/Pacific Islander Community [ https://www.amsa.org/2020/09/04/mental-health-in-the-asian-americans-pacific-islander-community/#:~:text=Mental%20Health%20of%20Pacific%20Islanders&text=According%20to%20a%202019%20study%20for%20the%20general%20US%20population ].

Alessi EJ. Acknowledging the impact of social forces on sexual minority clients: introduction to the special issue on clinical practice with LGBTQ populations: Springer; 2013.

Veteran Population [ https://www.va.gov/vetdata/veteran_population.asp ].

Ussher JM. Heterocentric practices in health research and health care: implications for mental health and subjectivity of LGBTQ individuals. Fem Psychol. 2009;19(4):561–7. https://doi.org/10.1177/0959353509342933 .

LGBTQI [ https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/LGBTQI ].

Stults CB, Kupprat SA, Krause KD, Kapadia F, Halkitis PN. Perceptions of safety among LGBTQ people following the 2016 pulse nightclub shooting. Psychol Sex Orientat Gend Divers. 2017;4(3):251–6. https://doi.org/10.1037/sgd0000240 .

Lesbian, Gay, Bisexual and Transgender Veteran Care [ https://www.orlando.va.gov/services/lgbt/index.asp ].

National Academies of Sciences E, and Medicine. Evaluation of the Department of Veterans Affairs Mental Health Services: National Academies of Sciences E, and Medicine; 2018.

Download references

Acknowledgements

Not applicable.

This work was supported by the US Department of Veterans Affairs, Veterans Health Administration, Office of Emergency Management and the Office of Population Health. The views expressed in this presentation are those of the author and do not necessarily reflect the position or policy of the VA or the US government.

Author information

Authors and affiliations.

Department of Veterans Affairs, Veterans Emergency Management Evaluation Center (VEMEC), 16111 Plummer St. MS-152, North Hills, CA, 91343, USA

Tamar Wyte-Lake, Susan Schmitz & Aram Dobalian

Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA

Tamar Wyte-Lake

Orlando VA Medical Center, 13800 Veterans Way, Orlando, FL, 32728, USA

Reginald J. Kornegay

VA Southern Nevada Healthcare System, 6900 N. Pecos Road, North Las Vegas, NV, 89086, USA

Felix Acevedo

Division of Health Systems Management and Policy, University of Memphis School of Public Health, Memphis, TN, USA

Aram Dobalian

You can also search for this author in PubMed   Google Scholar

Contributions

TWL and SS planned the study, including instrumentation, conducted the data analysis, and wrote the paper. RJK and FA supported the qualitative analysis and contributed to revising the paper. AD helped to plan the study and contributed to revising the manuscript. All authors have read and approved the manuscript.

Corresponding author

Correspondence to Tamar Wyte-Lake .

Ethics declarations

Ethics approval and consent to participate.

The Greater Los Angeles VA Healthcare System Institutional Review Board (Los Angeles, CA USA) approved this study. As the research presented no more than minimal risk of harm to subjects and involved no procedures for which written consent would be normally required outside of the research context, the study received a waiver for documentation of consent from the Institutional Review Board, and verbal, recorded audio consent was approved.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1..

2017 Disaster Qualitative Study: Collaboration Project Interview Guide. Interview guide utilized during project’s semi-structured interviews.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Wyte-Lake, T., Schmitz, S., Kornegay, R.J. et al. Three case studies of community behavioral health support from the US Department of Veterans Affairs after disasters. BMC Public Health 21 , 639 (2021). https://doi.org/10.1186/s12889-021-10650-x

Download citation

Received : 05 August 2020

Accepted : 18 March 2021

Published : 01 April 2021

DOI : https://doi.org/10.1186/s12889-021-10650-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Emergency preparedness
• Behavioral health; disaster response
• US Department of Veterans Affairs

BMC Public Health

ISSN: 1471-2458

• General enquiries: [email protected]

Providing Sustainable Mental and Neurological Health Care in Ghana and Kenya: Workshop Summary (2016)

Chapter: 4 case studies, 4 case studies.

Throughout the workshop, case studies were presented of some of the successful mental health projects in Ghana, Kenya, and around the world. Although each case study was multifaceted and addressed many challenges, the workshop participants focused on distilling lessons learned from each project that could be applied to potential mental health demonstration projects.

AFRICA MENTAL HEALTH FOUNDATION 1 : COMMUNITY PARTNERSHIPS

Founded in 2004, AMHF has stated the vision of being “the center of excellence in Africa for research, training, knowledge translation, and advocacy in mental health.” 1 AMHF uses a multidisciplinary, multisectoral approach to improve mental health through programs at all levels, from physician specialist training to community-based stigma reduction, including school-based programs. According to David Ndetei, AMHF’s greatest successes have been in creating community partnerships and joint ownership of programs. One partnership in particular that has been successful is the relationship AMHF has built with traditional and faith healers. AMHF works with them to build awareness of mental health disorders, to develop skills to screen for and refer cases of mental illness, and to deliver evidence-based, mhGAP-adapted psychosocial interventions. Other partnerships critical to the success of their programs, noted

_______________________

1 See http://www.africamentalhealthfoundation.org (accessed July 14, 2015).

Ndetei, include those with county government where health services have been devolved and with the government of Kenya.

BASICNEEDS 2

BasicNeeds was founded in 2000 with the goal of improving the lives of people around the world diagnosed with a mental illness or epilepsy, by ensuring that their basic needs are met and their rights are recognized and respected.

Ghana 3 : Building Capacity of NGOs

BasicNeeds’ Mid-Ghana Project is focused on the Ashanti and Brong Ahafo regions. It is a community-based model that seeks to ensure that people with mental illness or epilepsy can access their human rights. Specifically, BasicNeeds’ activities can be categorized into four main areas: identifying and supporting people who have treatment needs; training community health workers; creating awareness; and supporting service delivery through psychiatric outreach to communities. Since 2000, BasicNeeds Ghana has provided 7,800 women, men, and children with mental illness or epilepsy and caregivers access to mental health and development services through community-based mental health, and it has developed 130 self-help user groups as a mechanism for patients and caregivers to express their needs and claim their rights to inclusion and development. Peter Yaro, executive director of BasicNeeds Ghana, said that a key component of their work is training local partners such as NGOs. BasicNeeds trains and supports key local partners on their Mental Health and Development model to enable the organizations to gain accreditation as a BasicNeeds franchise partner. The components of the model include capacity building, community mental health, sustainable livelihoods (e.g., promoting social reintegration), research, advocacy, policy, and collaboration. The NGOs they work with are not necessarily mental health organizations: for the Mid-Ghana project, for instance, the organizations were focused on child labor, reproductive health care, education, and women’s issues. Yaro said that this type of collaboration among NGOs is a great way to align mental health activities with what

2 See http://www.basicneeds.org (accessed July 14, 2015).

3 See http://www.basicneeds.org/where-we-work/ghana (accessed July 14, 2015).

the NGOs are already doing. He cautioned, however, that even though many NGOs are interested in working in mental health, they “sometimes do not know how.” He said that if given the proper support and training, these NGOs can be valuable partners in improving community mental health. As a result, BasicNeeds Ghana established two regional mental health alliances that bring together more than 45 community-based organizations/NGOs and decentralized government ministries, departments, and agencies to foster these collaborations and implement work in mental health.

Kenya 4 : Patients as Ambassadors

BasicNeeds works at the community level to build the capacity of people with MNS disorders to participate in their own treatment and recovery, as well as to reduce stigma and prepare the rest of the community to help people with MNS disorders. Joyce Kingori reported that the critical partners of BasicNeeds are the adults and children with MNS disorders “who have taken the courage to come and get treatment, to share their stories, to provide their insights.” BasicNeeds uses mental health “ambassadors”: young people who have been treated and now work to create awareness among their peers, and to reach out to provide support to those in need. Kingori noted that in addition to the critical partnership with patients, BasicNeeds also has important partnerships with organizations such as KAWE and AMHF, as well as the MoH and local government and health officials.

DIRECT RELIEF 5 AND BREAST CARE INTERNATIONAL 6 : COLLABORATION

Founded in 1948, Direct Relief provides medical resources to areas affected by poverty or emergency situations. It focuses primarily on maternal and child health, disease prevention and treatment, emergency preparedness and response, and strengthening health systems. 5 In partnership with Breast Care International (BCI), a Ghanaian-based organization dedicated to breast cancer awareness, the two organizations conducted a mental

4 See http://www.basicneeds.org/where-we-work/kenya (accessed July 14, 2015).

5 See http://www.directrelief.org/about (accessed July 14, 2015).

6 See http://www.breastcareghana.com/about (accessed July 14, 2015).

health research project in the Ashanti region of Ghana. They are currently collecting data on the burden of mental health and examining what types of mental health services are available, with the purpose of using the data to recommend measures to address the challenges in the region. Andrew Schroeder, director of research and analytics for Direct Relief, and Samuel Kwasi Agyei, of BCI, stressed the importance of collaboration in their work. Schroeder noted that the collaboration with BCI was critical to the success of the project because they are a community-based organization that is trusted in the area in which they work. In addition, because of BCI’s interest in broad-based health care, the project is working to embed mental health care services in the general health care system, rather than operating as a stand-alone mental health program, thus making improvements that are systematic and sustainable.

EMERGING MENTAL HEALTH SYSTEMS IN LOW- AND MIDDLE-INCOME COUNTRIES (EMERALD) 7 : STRENGTHENING HEALTH SYSTEMS

EMERALD, or Emerging Mental Health Systems in Low- and Middle-Income Countries, is a 5-year program (2012–2017) that works in six countries (Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda) to improve mental health outcomes by improving health system performance, said Jibril Abdulmalik, Co-Investigator of EMERALD at the University of Ibadan in Nigeria. The program consists of six work packages: (1) project management and coordination; (2) capacity building in mental health systems research; (3) adequate, fair, and sustainable resourcing for mental health (health systems inputs); (4) integrated provision of mental health services (mental health system processes); (5) improved coverage and goal attainment in mental health (health system outputs); and (6) dissemination. EMERALD seeks to strengthen the system itself through activities such as holding trainings for policy makers, researchers, and service users; providing scholarships for students seeking advanced degrees in mental health; developing curricula for master’s training in public mental health; helping countries with cost projections; facilitating the integration of mental health into primary care; and improving health information systems. Abdulmalik added that having cultivated

7 See http://www.emerald-project.eu (accessed July 14, 2015).

relationships with policy makers and key stakeholders was useful to understanding health care systems hierarchy, as well as leveraging existing platforms. He acknowledged that some of these individual efforts are “droplets” in a bucket, but he hoped that the EMERALD project, as a whole, would result in a comprehensive template for strengthening mental health systems in low- and middle-income countries.

FIGHT AGAINST EPILEPSY 8 : STAKEHOLDER ENGAGEMENT

WHO and the Ghana MoH, with support from Sanofi Espoir Foundation, have teamed up for a 4-year project (2012–2015) to reduce the epilepsy treatment gap, using a variety of strategies: promoting training of all health care providers, improving community awareness to reduce stigma and increase demand for care, and integrating epilepsy care within the primary health care system. Since the initiation of the project:

• A national/district coordinating committee was established;
• A situation analysis report was developed at the national, regional, and district levels;
• 330 volunteers and 404 primary health care providers were trained in epilepsy management;
• Gradual scale up occurred, with coverage now in 10 districts in 5 regions;
• A monitoring and evaluation strategy was developed; and
• A draft model of epilepsy care was developed.

Cynthia Sottie, national coordinator of the Fight Against Epilepsy project at the Ghana Health Service, said that engaging with stakeholders at all levels, at all stages of the project, has been critical to the project’s success. She noted that they have involved the Minister of Health, representatives from the teaching hospitals, national and international NGOs, the Mental Health Society of Ghana, regional health directors, faith healers, and community members. By involving so many stakeholders from the beginning of the project, “everybody was involved [and] everybody knows what is going on at each time.” Sottie said that everyone’s in-

8 See http://fondation-sanofi-espoir.com/download/2012-10-22_CP_Ghana_EN.pdf (accessed July 14, 2015).

volvement was vital to getting the support and participation necessary to carry out the project.

KENYA ASSOCIATION FOR THE WELFARE OF PEOPLE WITH EPILEPSY 9 : PUBLIC EDUCATION

KAWE was founded in 1982 and seeks to improve the lives of those with epilepsy through a variety of efforts, including the training of primary health workers, awareness creation and stigma reduction through community projects, medical provision and support (e.g., epilepsy clinics, patient groups), and policy advocacy at the MoH in Kenya. Between 2000 and 2014, KAWE trained 1,814 clinical officers and nurses and 3,095 CHWs, and the organization’s awareness programs reached an estimated 254,000 people directly and more than 3 million through mass media, said Osman Miyanji. In addition, more than 25,000 patients have been registered throughout clinics in Nairobi, Kenya, as a result of KAWE’s community programs, and from a training perspective, the organization helped launch national epilepsy guidelines and developed a more comprehensive curriculum for medical training institutions. Miyanji reported that KAWE has demonstrated that they can close the treatment gap, and he noted that in 30 years of experience, public education to address social stigma and reduce ignorance has been a key element of their success.

THE KINTAMPO PROJECT 10 : FOCUS ON COMMUNITY- BASED CARE

The Kintampo Project, a collaboration between Ghana and the United Kingdom, is “training a new generation of mental health workers,” said Joseph B. Asare. The project trains clinical psychiatry officers (CPOs) and community mental health officers (CMHOs). CPOs can diagnose mental illness and prescribe medication, while CMHOs focus on detection of mental illness in the community, education of local people, and reducing stigma and discrimination. CMHOs work in part by developing relationships with local families, schools, prayer camps, and tradi-

9 See http://www.kawe-kenya.org (accessed July 14, 2015).

10 See http://www.thekintampoproject.org (accessed July 14, 2015).

tional healers. The organization’s objective is to have one CPO and two to three CMHOs in each of Ghana’s 216 districts by 2017. Through the Kintampo Project, workers have been trained and deployed all over Ghana, helping thousands of the most needy people. The project is on track to boost the mental health workforce by 60 percent and the number of patients treated per year by 500 percent. By focusing on community-based care, Kintampo is shifting the focus of mental health care away from large hospitals and into the community where it is most needed, Asare said.

PROGRAM FOR IMPROVING MENTAL HEALTH CARE (PRIME) 11 : BUY-IN, BUY-IN, BUY-IN

Tedla Wolde-Giorgis provided an overview of PRIME’s efforts to integrate mental health into the existing health delivery system in five countries (Ethiopia, India, Nepal, South Africa, and Uganda). The purpose of the 6-year study, launched in 2011, is to research the magnitude, impact, and tractability of mental disorders in low- and middle-income countries. Using Ethiopia as an example, Wolde-Giorgis reported that integration was an incredibly complex process (beyond the instructions in the mhGAP intervention guide [IG]) that required buy-in from decision makers at all levels—national, regional, and community—as well as support from health care facilities and NGOs. Wolde-Giorgis said that, regardless of the level of support at the top, a top-down approach will not work; ultimately, the day-to-day work is done in the community and facilities, so it must be led at this level. He also noted that stigma reduction is a critical part of getting buy-in at the community level. For an effort to be sustainable, the buy-in must be continuous—it is not a one-time effort. Leadership must be continuously reminded of the importance of mental health and how it aligns with national priorities because there are so many other competing health concerns and health initiatives (e.g., MDGs).

11 See http://www.prime.uct.ac.za (accessed July 14, 2015).

PROJECT FIVES ALIVE! 12 : SCALING UP

The goal of Project Fives Alive! is to reduce mortality rates among children below age 5. Sodzi Sodzi-Tettey said the project uses a quality improvement approach, which requires forming quality improvement teams, having the teams develop initiatives on how to change mortality rates, implementing these initiatives, and then using data to assess if there was a positive effect. The project started in 9 hospitals but has since been scaled up to 200 hospitals. Sodzi-Tettey said that the initial 9 hospitals were chosen because they were high-burden hospitals with high rates of mortality for children below age 5. By the end of the first 18 months of operation, 6 of the 9 hospitals showed significant improvement in mortality reduction. By learning what worked in these high-burden hospitals, the project created a “change package,” which consisted of data-driven initiatives that had led to improvement related to improving delay in seeking and providing care and to reliable use of protocols. Sodzi-Tettey said that of the 134 hospitals in which the project currently operates, nearly 70 percent have adopted ideas from the change package, while also developing their own initiatives (e.g., targeted health education on early care-seeking using interactive platforms, triage systems for screening and emergency treatment of critically ill children, and training staff on protocols, followed by regular coaching and mentoring) ( Twum-Danso et al., 2012 ). In these 134 hospitals, there has been a 31 percent reduction in facility-based mortality in children younger than age 5. Sodzi-Tettey reported on three lessons learned from the project. First, initiatives should be tested promptly and on a small scale; this creates data that management can use to decide whether or not to implement a change. Second, teams should be empowered to know and use their own data. Sodzi-Tettey said that many workers were used to reporting data to the top but had not been aware of their own performance. Once they had the ability to track their own progress, they became even more invested in improvement. Finally, Sodzi-Tettey said that sustainability is only possible if a project understands and works within the existing health system, rather than with its own schedule and priorities.

12 See http://www.ihi.org/engage/initiatives/ghana/pages/default.aspx (accessed July 14, 2015).

PARTNERS IN HEALTH IN RWANDA 13 : INTEGRATION OF MENTAL HEALTH INTO THE GENERAL CARE SYSTEM THROUGH PUBLIC-SECTOR COLLABORATION AND LEVERAGE OF EXISTING HEALTH PLATFORMS

Partners In Health strives “to bring the benefits of modern medical science to those most in need of them and to serve as an antidote to despair.” 13 The Partners In Health program in Rwanda focused on close collaboration within the public sector to integrate mental health care into the general community-based care system within the district. At each level (hospital, health centers, and community), health workers were trained in mental health care. Partners In Health’s primary mental health endeavor in Rwanda was the integration of mental health care into health centers using existing structure of intensive supported supervision and quality improvement following training. One challenge that the program faced was resistance from the staff to admitting and treating psychiatric patients in the general ward. Smith offered several reasons for the resistance, including stigma and discrimination. She said the most successful strategy for reducing stigma among the health care workers was effective treatment of patients. When staff saw people come in with very acute psychiatric conditions, receive treatment, and get better, the workers’ perspective on mental health was significantly changed. Smith recalled the story of a district hospital manager who unknowingly hired a former patient to work on the grounds of the hospital. When he learned that she had been admitted to his hospital as a psychiatric patient only 2 months earlier, and was now capable of holding a job, he “became a big advocate for the work.” Smith said, “It was the witnessing of people getting better that was the most destigmatizing.” In addition to reducing stigma, Smith said that another key element of successful integration was leveraging the existing system structures and human resources. Rather than restructuring or bringing in new people, they worked within the existing system by mapping skill sets and matching them to the skills needed for mental health care. Smith said that by using what was already available, a much more rapid and efficient integration into primary care was possible.

13 See http://www.pih.org (accessed July 14, 2015).

MENTAL HEALTH CARE IN TURKEY: POLICY DEVELOPMENT

Oğuz Karamustafalioğlu, professor of psychiatry at Üsküdar University, provided an overview of mental health care in Turkey. He noted the high treatment gap for schizophrenia, depression, and substance use problems, and the lack of human and material (i.e., psychiatric beds) resources needed to adequately meet the demands of patients. In 2006, the MoH in Turkey released a National Mental Health Policy (NMHP) 14 aimed at mobilizing resources to ensure that mental health care services are accessible and balanced. Karamustafalioğlu stated that the NMHP encouraged preventative methods to decrease the burden of mental disorders, to increase attainable mental health care and services at both primary and secondary care levels, to encourage the respect of human rights for those with a mental illness, and to support the necessary legislation to protect their rights. Although there have been some successes since the NMHP was released—including an increase in the outpatient mental health care units at the general hospitals, the number of adult and child psychiatrists, and public education and awareness programs about mental health to reduce stigma—he emphasized that there is still more to be done to provide care and treatment to all patients.

WORLD ASSOCIATION FOR SOCIAL PSYCHIATRY AND SANOFI: COUNTRY-SPECIFIC APPROACHES

Sanofi’s Access to Medicines department works in some of the world’s poorest countries, disseminating information about MNS disorders, improving diagnosis, and making treatment affordable and accessible to patients, said Francois Bompart. Programs are specifically tailored to each country in which they work, an approach that is critical to success. For example, Sanofi works in Comoros, a small group of islands off the coast of Mozambique. Bompart said that several issues complicate mental health care in Comoros: transportation is difficult and expensive, and there is only one psychiatrist in the country. In order to work within these confines, Sanofi is working to train primary health care providers to use telemedicine to connect to the one psychiatrist—a tailored ap-

14 See https://www.mindbank.info/item/69 (accessed August 13, 2015).

proach that works for the specific context of Comoros but might be wholly inappropriate elsewhere. Similarly, in Guatemala, Sanofi tailored its approach by choosing to partner with a local NGO instead of the MoH because of instability in the government. With regards to cultural and societal sensitivities, Bompart noted that in some areas in countries such as Morocco, traditional and faith healers were not involved in the awareness programs given the local contexts.

686 PROJECT IN CHINA: FOCUS ON GENERAL PRACTITIONERS

The 686 project was a 2004 initiative that launched mental health reform in China after the severe acute respiratory syndrome (SARS) epidemic. Prior to the reform, mental health institutions (565 hospitals) were worn and outdated, there were no community-based mental health care services, and medical insurance was provided only to employed people. Ma Hong, deputy director of mental health programs at the China MoH, stated that initially, the government granted 6.86 million Yuan (860,000 USD) to train providers in mental health, and as the program continued, it covered free hospital treatment for patients and out-of-pocket medical costs for impoverished patients. Hong noted that it was critical to learn how to express the need for funding and the overall burden of mental health in the language of the government. The project consisted of 60 demonstration projects reaching a population of 42.9 million people, in which providers were trained; hospital services were expanded to communities; and, when universal medical insurance was implemented in China, the project covered out-of-pocket costs for impoverished patients. One significant challenge was that while there was adequate funding for services, the human resources necessary to actually provide care lagged behind. Hong said, “Money does not equal service—human resources development is much slower than simply building a new hospital.” She proposed that too much reliance on specialists in rural areas is misguided, and that when building a mental health program, the focus should be on expanding general practitioners’ knowledge of mental health and building their capacity to diagnose and treat MNS disorders. Hong noted that a hospital–community continuous care system has since been established and 4.29 million patients have been registered in the health information system, including 3.41 million patients who have received community health care, 61.7 percent of whom are farmers.

This page intentionally left blank.

Mental, neurological, and substance use (MNS) disorders have a substantial impact on global health and well-being. Disorders such as depression, alcohol abuse, and schizophrenia constitute about 13 percent of the total burden of disease. Worldwide, MNS disorders are the leading cause of disability, and the 10th leading cause of death. Despite this high burden, there is a significant shortage of resources available to prevent, diagnose, and treat MNS disorders. Approximately four out of five people with serious MNS disorders living in low- and middle-income countries do not receive needed health services.

This treatment gap is particularly high in Sub-Saharan Africa (SSA). Challenges to MNS care in SSA countries include a lack of trained mental health professionals, few mental health facilities, and low prioritization for MNS disorders in budget allocations. African countries, on average, have one psychiatrist for every 2 million people, whereas European countries have one psychiatrist per 12,000 people.

Expanding on previous efforts to address the development and improvement of sustainable mental health systems in SSA, the Institute of Medicine convened this 2015 workshop series, bringing together key stakeholders to examine country-specific opportunities to improve the health care infrastructure in order to better prevent, diagnose, and treat MNS disorders. Providing Sustainable Mental and Neurological Health Care in Ghana and Kenya summarizes the presentations and discussions from these workshops.

READ FREE ONLINE

Welcome to OpenBook!

You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

Do you want to take a quick tour of the OpenBook's features?

Show this book's table of contents , where you can jump to any chapter by name.

...or use these buttons to go back to the previous chapter or skip to the next one.

Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

Switch between the Original Pages , where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

To search the entire text of this book, type in your search term here and press Enter .

Share a link to this book page on your preferred social network or via email.

View our suggested citation for this chapter.

Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

Get Email Updates

Do you enjoy reading reports from the Academies online for free ? Sign up for email notifications and we'll let you know about new publications in your areas of interest when they're released.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

A community mental health center case study: innovations and issues

• PMID: 5173037

PubMed Disclaimer

Similar articles

• The West Philadelphia Community Mental Health Consortium in retrospect: supraprocess and infraprocess. Loepold RL. Loepold RL. Semin Psychiatry. 1971 Feb;3(1):245-63. Semin Psychiatry. 1971. PMID: 4372718 No abstract available.
• Hanging fire on a big need to know. London P. London P. MH. 1975 Winter;59(1):32-5. MH. 1975. PMID: 1113686 No abstract available.
• The effect of a community mental health center upon state hospital utilization. Dyck G. Dyck G. Am J Psychiatry. 1974 Apr;131(4):453-6. Am J Psychiatry. 1974. PMID: 4856040 No abstract available.
• Social and community interventions. Kelly JG, Snowden LR, Muñoz RF. Kelly JG, et al. Annu Rev Psychol. 1977;28:323-61. doi: 10.1146/annurev.ps.28.020177.001543. Annu Rev Psychol. 1977. PMID: 324380 Review. No abstract available.
• A review of the recent literature: paraprofessionals and community mental health. Nash KB, Lifton N, Smith SE. Nash KB, et al. Community Ment Health Rev. 1978 Mar-Apr;3(2):1, 3-8. doi: 10.1300/J257v03n02_01. Community Ment Health Rev. 1978. PMID: 10297427 Review. No abstract available.
• Streamlined selection of cancer antigens for vaccine development through integrative multi-omics and high-content cell imaging. Han KC, Park D, Ju S, Lee YE, Heo SH, Kim YA, Lee JE, Lee Y, Park KH, Park SH, Lee HJ, Lee C, Jang M. Han KC, et al. Sci Rep. 2020 Apr 3;10(1):5885. doi: 10.1038/s41598-020-62244-z. Sci Rep. 2020. PMID: 32245999 Free PMC article.
• Search in MeSH
• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

Part 2 Lucy’s Story

2.4 Lucy case study 3: Mental illness diagnosis

Nicole Graham

Introduction to case study

Lucy has experienced the symptoms of mental illness during her lifespan; however, it was not until her early twenties that she was formally diagnosed with bipolar affective disorder. In the case study below, we explore the symptomology that Lucy experienced in the lead up to and post diagnosis. Lucy needs to consider her mental illness in relation to her work as a Registered Nurse and as she continues to move through the various stages of adulthood.

Learning Objectives

By the end of this case study, you should be able to:

• Identify and consider the symptoms of mental illness.
• Develop an understanding of contributing biopsychosocial stressors that may exacerbate the symptoms of mental illness as experienced by Lucy.
• Critically analyse the professional, ethical, and legal requirements and considerations for a registered health professional living with chronic illness.

Lucy’s small group of friends describe her as energetic and ‘a party person’. Although she sometimes disappears from her social group for periods of time, her friends are not aware that Lucy experiences periods of intense depression. At times Lucy cannot find the energy to get out of bed or even get dressed, sometimes for extended periods. As she gets older, these feelings and moods, as she describes them, get more intense. She loves feeling high on life. This is when she has an abundance of energy, is not worried about what people think of her and often does not need to sleep. These are the times when she feels she can achieve her goals. One of these times is when she decides to become a nurse. She excels at university, loves the intensity of study, practice and the party lifestyle. Emergency Nursing is her calling. The fast pace, the quick turnaround matches her endless energy. The fact that she struggles to stay focused for extended periods of time is something she needs to consider in her nursing career, to ensure it does not impact negatively on her care.

Unfortunately, Lucy has experienced challenges in her career. For example, her manager often comments on her mental illness after she had openly disclosed her diagnosis. It is challenging for her to hear her colleagues speak badly about a person who presents with mental illness. The stigma she hears directed at others challenges her. She is also very aware that it could be her presenting to the Emergency Department when she is unwell and in need of further support. Lucy is constantly worried that her colleagues will read her medical chart and think she is unsafe to practice.

While the symptoms that cause significant distress and disruption to her life began in her late teens, they intensified after she commenced antidepressant medication after the loss of her child. She subsequently ceased taking them due to side effects. These medications particularly impact on her ability to be creative and reduce her libido and energy. By the time she turns 18, she notices more frequent, intense mood swings, often accompanied by intense feelings of anxiety. During her high periods, Lucy enjoys the energy, the feeling of euphoria, the increased desire to exercise, her engagement with people, and being impulsive and creative. Lucas appreciates her increased libido. However, during these periods of high mood, Lucy also has impaired boundaries and is often flirtatious in her behaviour towards both friends and people she doesn’t know. She also increases her spending and has limited sleep. Lucas is often frustrated by this behaviour, leading to fights. On occasion Lucas slaps her and gets into fights with the people she is flirting with. These periods can last days and sometimes weeks, always followed by depressive episodes.

When she is in the low phases of her mood, Lucy experiences an overwhelming sense of hopelessness and emptiness. She is unable to find the energy to get out of bed, shower or take interest in simple daily activities. Lucas gets frustrated and dismisses Lucy’s statements of wanting to end her life as ‘attention seeking’. Lucy often expresses the desire to leave this world when she feels this way. When Lucas seeks support from the local general practitioner, nothing really gets resolved. The GP prescribes the medication; Lucy regains her desire to participate in life; then stops the medication due to side effects which extend to gastrointestinal upsets, on top of the decrease in libido and not feeling like herself. When Lucy is referred to a psychologist, she does not engage for more than one session, saying that she doesn’t like the person and feels they judge her lifestyle. When the psychologist attempts to explore a family history of mental illness, Lucy says no- one in her family has it and dismisses the concept.

The intense ups and downs are briefly interrupted with periods of lower intensity. During these times, Lucy feels worried about various aspects of her life and finds it challenging to let go of her anxious thoughts. There are times when Lucy has symptoms like racing heart, gastrointestinal update and shortness of breath. She spends a great deal of time wanting her life to be better. Her desire to move on from Lucas and to start a new life becomes more intense. Lucy is confident this is not a symptom of depression; it is just that she is unhappy in her relationship. Lucy starts to consider career options, feeling that not working affects her lifestyle, freedom and health. As she explores different options on the internet, Lucy comes across a chat room. Using the chat name ‘Foxy Lady 20’, she develops new friendships. She finds herself talking a lot with a man named Lincoln who lives on the Gold Coast.

After a brief but intense period talking with Lincoln online, Lucy abruptly decides to leave Lucas and her life in Bundaberg to move in with Lincoln. Lincoln, aged 26, 5 years older than Lucy, owns a modest home on the Gold Coast and has stable employment at the local casino. Their relationship progresses quickly and within a month Lincoln has proposed to Lucy. They plan to marry within 12 months.

Lucy is now happy with her life and feels stable. She decides to pursue a degree in nursing at the local university. Lucy enrols and makes many new friends, enjoying the intensity of study and a new social scene. Her fiancé Lincoln also enjoys the social aspects of their relationship. During university examination periods, Lucy experiences strong emotions. At the suggestion of an academic she respects, she makes an appointment with the university counselling service. After the first 3 appointments, Lucy self-discovers, with the support of her counsellor, that she might benefit from a specialist consultation with a psychiatrist. She comes to recognise that her symptoms are not within the normal range experienced by her peers. Lincoln is incredibly supportive and attends the appointments with Lucy, extending on the information she provides. Lucy reveals information about her grandmother, who was considered eccentric, and known for her periods of elevated mood and manic behaviour. The treating psychiatrist suggests Lucy may be living with bipolar affective disorder and encourages her to trial the medication lithium.

Lucy does not enjoy the side effects of decreased energy, nausea and feeling dazed and ceases taking the lithium during the university break period. This causes Lucy to again experience an intense elevation of her mood, accompanied by risk-taking behaviours. Lucy goes out frequently, nightclubbing and being flirtatious with her friends. She becomes aggressive towards a woman who confronts Lucy about her behaviour with her boyfriend in the nightclub. This is the first time Lucy exhibits this type of response, along with very pressured speech, pacing and an inability to calm herself. The police are called. They recommend Lucy gets assessed at the hospital after hearing from Lincoln that she has ceased her medication. Lucy is admitted for a brief period in the acute mental health ward. After stabilising and recommencing lithium, Lucy returns to the care of her psychiatrist in the community. The discharge notes report that Lucy had been previously diagnosed with bipolar disorder, may also be experiencing anxiety related symptoms, and have personality vulnerabilities.

Lucy is in the final year of her university studies when she has a professional experience placement in the emergency ward. Lucy really enjoys the fast pace, as well as the variety of complex presentations. Lucy feels it matches her energy and her desire for frequent change. After she completes her studies, Lucy applies and is successful in obtaining a position at the local hospital. Throughout her initial graduate year, Lucy balances life with a diagnosis of mental illness as well as a program of her own self-care. She finds the roster patterns in particular incredibly challenging and again becomes unwell. She goes through a period of depression and is unable to work. During this period, Lucy experiences an overwhelming sense of hopelessness and considers ending her life. Again, she requires a higher level of engagement from her treating team. Lucy agrees she is not fit to work during this time and has a period of leave without pay to recover. She has disclosed to her manager that she has been diagnosed with a mental illness and later discusses how shift work impacts her sleep and her overall mental wellbeing.

Over time, Lucy develops strategies to maintain wellness. However, she describes her relationship with the Nursing Unit Manager as strained, due to her inability to work night shift as her medical certificate shows. Lucy says she is often reminded of the impact that her set roster has on her colleagues. Lucy also feels unheard and dismissed when she raises workplace concerns, as her manager attributes her feelings to her mental health deteriorating. Lucy has a further period when her mental health deteriorates. However, this time it is due to a change in her medication.

As Lucy and Lincoln have a desire to have a child, Lucy was advised that she cease lithium in favour of lamotrigine, to reduce the risk of harm to the baby. Lucy ceases work during the period when her mental health deteriorates during the initial phase of changing medication. Lucy recommences lithium after she ceases breastfeeding their son at 4 months, with good effect and returns to work.

Case study questions

• Consider the symptoms that Lucy experiences and indicate whether they align with the suggested diagnosis.
• Identify the biopsychosocial contributing factors that could impact mental health and wellness.
• Review and identify the professional disclosure requirements of a Registered Nurse who lives with mental illness in your local area.
• Identify self-care strategies that Lucy or yourself as a health professional could implement to support mental health and wellbeing.

 Thinking point

Sometimes people do not agree with a diagnosis of mental illness, which can be incorrectly labelled as ‘denial’ by health professionals. It is possible that the person is unable to perceive or be aware of their illness. This inability of insight is termed anosognosia (Amador, 2023). The cause of anosognosia in simple terms can be due to a non-functioning or impaired part of the frontal lobe of the brain, which may be caused by schizophrenia, bipolar disorder or other diseases such as dementia (Kirsch et al., 2021).

As healthcare workers will likely care for someone who is experiencing anosognosia, it is important to reflect on how you may work with someone who does not have the level of insight you would have hoped. Below is a roleplay activity whereby you can experience what it might be like to communicate with someone experiencing anosognosia. Reflect on your communication skills and identify strategies you could use to improve your therapeutic engagement.

Role play activity – Caring for a person who is experiencing anosognosia

Learning objectives.

• Demonstrate therapeutic engagement with someone who is experiencing mental illness
• Identify effective communication skills
• Reflect on challenges and identify professional learning needs

Resources required

• Suitable location to act out scene.
• One additional person to play the role of service user.

Two people assume role of either service user or clinician. If time permits, switch roles and repeat.

• Lucy has been commenced on lithium carbonate ER for treatment of her bipolar disorder.
• Lucy is attending the health care facility every week, as per the treating psychiatrist’s requests.
• The clinician’s role is to monitor whether Lucy is experiencing any side effects.

Role 1 – Clinician

• Clinician assumes role of health care worker in a health care setting of choice.
• Lucy has presented and your role is to ask Lucy whether she is experiencing any side effects and whether she has noticed any improvements in her mental state.

Role 2 – Lucy who lives with bipolar

• Lucy responds that she does not understand the need for the tablets. She also denies having a mental illness. Lucy says she will do what she is told, but does not think there is anything wrong with her. Lucy thinks she is just an energetic person who at times gets sad, which she describes as ‘perfectly normal.’ Lucy is not experiencing any negative side effects, but says she would like clarification about why the doctor has prescribed this medication.

Post role play debrief

Reflect and discuss your experiences, both as Lucy and as the clinician. Identify and discuss what was effective and what were the challenges.

Identify professional development opportunities and develop a learning plan to achieve your goals.

Additional resources that might be helpful

• Australian Prescriber: Lithium therapy and its interactions
• LEAP Institute: The impact of anosognosia and noncompliance (video)

Key information and links to other resources

Fisher (2022) suggests there are large numbers of health professionals who live with mental illness and recognise the practice value that comes with lived experience. However, the author also notes that as stigma is rife within the health care environment, disclosing mental illness can trigger an enhanced surveillance of the health professional’s practice or impede professional relationships (Fisher, 2022).

It is evident that the case studies derived from Lucy’s life story are complex and holistic care is essential. The biopsychosocial model was first conceptualised in 1977 by George Engel, who suggests it is not only a person’s medical condition, but also psychological and social factors that influence health and wellbeing (Engel,2012).

Below are examples of what you as a health professional could consider in each domain.

• Biological: Age, gender, physical health conditions, drug effects, genetic vulnerabilities
• Psychological:  Emotions, thoughts, behaviours, coping skills, values
• Social:  Living situation, social environment, work, relationships, finances, education

Developing skills through engaging in reflective practice and professional development is essential. Each person is unique, which requires you as the professional to adapt to their particular circumstances. The resources below can help you develop understanding of both regulatory requirements and the diagnosis Lucy is living with.

Organisations providing information relevant to this case study

• Rethink Mental Illness: Bipolar disorder
• Australian Health Practitioner Regulation Agency (AHPRA): Resources – helping you understand mandatory notifications
• Australian Health Practitioner Regulation Agency (AHPRA): Podcast – Mental health of nurses, midwives and the people they care for
• Black Dog Institute: TEN – The essential network for health professionals
• Borderline Personality Disorder Community
• National Institute of Mental Health (NIMH): Anxiety disorders

 Case study 3 summary

In this case study, Lucy’s symptoms of mental illness emerge in her teenage years. Lucy describes periods of intense mood, both elevated and depressed, as well as potential anxiety-related responses. It is not until she develops a therapeutic relationship with a university school-based counsellor that she realises it might be beneficial to engage the services of a psychiatrist. After she is diagnosed with bipolar affective disorder she engages in treatment. Lucy shares her experience of both inpatient and community treatment as well as her professional practice requirements in the context of her mental illness.

Amador, X. (2023). Denial of anosognosia in schizophrenia. Schizophrenia Research , 252 , 242–243. https://doi.org/10.1016/j.schres.2023.01.009

Engel, G. (2012). The need for a new medical model: A challenge for biomedicine. Psychodynamic Psychiatry, 40 (3), 377–396. https://doi.org/10.1521/pdps.2012.40.3.377

Fisher, J. (2023). Who am I? The identity crisis of mental health professionals living with mental illness. Journal of Psychiatric and Mental Health Nursing . Advance online publication. https://doi.org/10.1111/jpm.12930

Kirsch, L. P., Mathys, C., Papadaki, C., Talelli, P., Friston, K., Moro, V., & Fotopoulou, A. (2021). Updating beliefs beyond the here-and-now: The counter-factual self in anosognosia for hemiplegia. Brain Communications , 3 (2), Article fcab098. https://doi.org/10.1093/braincomms/fcab098

Case Studies for Health, Research and Practice in Australia and New Zealand Copyright © 2023 by Nicole Graham is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

Share This Book

Student mental health is in crisis. Campuses are rethinking their approach

Amid massive increases in demand for care, psychologists are helping colleges and universities embrace a broader culture of well-being and better equipping faculty to support students in need

Vol. 53 No. 7 Print version: page 60

• Mental Health

By nearly every metric, student mental health is worsening. During the 2020–2021 school year, more than 60% of college students met the criteria for at least one mental health problem, according to the Healthy Minds Study, which collects data from 373 campuses nationwide ( Lipson, S. K., et al., Journal of Affective Disorders , Vol. 306, 2022 ). In another national survey, almost three quarters of students reported moderate or severe psychological distress ( National College Health Assessment , American College Health Association, 2021).

Even before the pandemic, schools were facing a surge in demand for care that far outpaced capacity, and it has become increasingly clear that the traditional counseling center model is ill-equipped to solve the problem.

“Counseling centers have seen extraordinary increases in demand over the past decade,” said Michael Gerard Mason, PhD, associate dean of African American Affairs at the University of Virginia (UVA) and a longtime college counselor. “[At UVA], our counseling staff has almost tripled in size, but even if we continue hiring, I don’t think we could ever staff our way out of this challenge.”

Some of the reasons for that increase are positive. Compared with past generations, more students on campus today have accessed mental health treatment before college, suggesting that higher education is now an option for a larger segment of society, said Micky Sharma, PsyD, who directs student life’s counseling and consultation service at The Ohio State University (OSU). Stigma around mental health issues also continues to drop, leading more people to seek help instead of suffering in silence.

But college students today are also juggling a dizzying array of challenges, from coursework, relationships, and adjustment to campus life to economic strain, social injustice, mass violence, and various forms of loss related to Covid -19.

As a result, school leaders are starting to think outside the box about how to help. Institutions across the country are embracing approaches such as group therapy, peer counseling, and telehealth. They’re also better equipping faculty and staff to spot—and support—students in distress, and rethinking how to respond when a crisis occurs. And many schools are finding ways to incorporate a broader culture of wellness into their policies, systems, and day-to-day campus life.

“This increase in demand has challenged institutions to think holistically and take a multifaceted approach to supporting students,” said Kevin Shollenberger, the vice provost for student health and well-being at Johns Hopkins University. “It really has to be everyone’s responsibility at the university to create a culture of well-being.”

Higher caseloads, creative solutions

The number of students seeking help at campus counseling centers increased almost 40% between 2009 and 2015 and continued to rise until the pandemic began, according to data from Penn State University’s Center for Collegiate Mental Health (CCMH), a research-practice network of more than 700 college and university counseling centers ( CCMH Annual Report , 2015 ).

That rising demand hasn’t been matched by a corresponding rise in funding, which has led to higher caseloads. Nationwide, the average annual caseload for a typical full-time college counselor is about 120 students, with some centers averaging more than 300 students per counselor ( CCMH Annual Report , 2021 ).

“We find that high-caseload centers tend to provide less care to students experiencing a wide range of problems, including those with safety concerns and critical issues—such as suicidality and trauma—that are often prioritized by institutions,” said psychologist Brett Scofield, PhD, executive director of CCMH.

To minimize students slipping through the cracks, schools are dedicating more resources to rapid access and assessment, where students can walk in for a same-day intake or single counseling session, rather than languishing on a waitlist for weeks or months. Following an evaluation, many schools employ a stepped-care model, where the students who are most in need receive the most intensive care.

Given the wide range of concerns students are facing, experts say this approach makes more sense than offering traditional therapy to everyone.

“Early on, it was just about more, more, more clinicians,” said counseling psychologist Carla McCowan, PhD, director of the counseling center at the University of Illinois at Urbana-Champaign. “In the past few years, more centers are thinking creatively about how to meet the demand. Not every student needs individual therapy, but many need opportunities to increase their resilience, build new skills, and connect with one another.”

Students who are struggling with academic demands, for instance, may benefit from workshops on stress, sleep, time management, and goal-setting. Those who are mourning the loss of a typical college experience because of the pandemic—or facing adjustment issues such as loneliness, low self-esteem, or interpersonal conflict—are good candidates for peer counseling. Meanwhile, students with more acute concerns, including disordered eating, trauma following a sexual assault, or depression, can still access one-on-one sessions with professional counselors.

As they move away from a sole reliance on individual therapy, schools are also working to shift the narrative about what mental health care on campus looks like. Scofield said it’s crucial to manage expectations among students and their families, ideally shortly after (or even before) enrollment. For example, most counseling centers won’t be able to offer unlimited weekly sessions throughout a student’s college career—and those who require that level of support will likely be better served with a referral to a community provider.

“We really want to encourage institutions to be transparent about the services they can realistically provide based on the current staffing levels at a counseling center,” Scofield said.

The first line of defense

Faculty may be hired to teach, but schools are also starting to rely on them as “first responders” who can help identify students in distress, said psychologist Hideko Sera, PsyD, director of the Office of Equity, Inclusion, and Belonging at Morehouse College, a historically Black men’s college in Atlanta. During the pandemic, that trend accelerated.

“Throughout the remote learning phase of the pandemic, faculty really became students’ main points of contact with the university,” said Bridgette Hard, PhD, an associate professor and director of undergraduate studies in psychology and neuroscience at Duke University. “It became more important than ever for faculty to be able to detect when a student might be struggling.”

Many felt ill-equipped to do so, though, with some wondering if it was even in their scope of practice to approach students about their mental health without specialized training, Mason said.

Schools are using several approaches to clarify expectations of faculty and give them tools to help. About 900 faculty and staff at the University of North Carolina have received training in Mental Health First Aid , which provides basic skills for supporting people with mental health and substance use issues. Other institutions are offering workshops and materials that teach faculty to “recognize, respond, and refer,” including Penn State’s Red Folder campaign .

Faculty are taught that a sudden change in behavior—including a drop in attendance, failure to submit assignments, or a disheveled appearance—may indicate that a student is struggling. Staff across campus, including athletic coaches and academic advisers, can also monitor students for signs of distress. (At Penn State, eating disorder referrals can even come from staff working in food service, said counseling psychologist Natalie Hernandez DePalma, PhD, senior director of the school’s counseling and psychological services.) Responding can be as simple as reaching out and asking if everything is going OK.

Referral options vary but may include directing a student to a wellness seminar or calling the counseling center to make an appointment, which can help students access services that they may be less likely to seek on their own, Hernandez DePalma said. Many schools also offer reporting systems, such as DukeReach at Duke University , that allow anyone on campus to express concern about a student if they are unsure how to respond. Trained care providers can then follow up with a welfare check or offer other forms of support.

“Faculty aren’t expected to be counselors, just to show a sense of care that they notice something might be going on, and to know where to refer students,” Shollenberger said.

At Johns Hopkins, he and his team have also worked with faculty on ways to discuss difficult world events during class after hearing from students that it felt jarring when major incidents such as George Floyd’s murder or the war in Ukraine went unacknowledged during class.

Many schools also support faculty by embedding counselors within academic units, where they are more visible to students and can develop cultural expertise (the needs of students studying engineering may differ somewhat from those in fine arts, for instance).

When it comes to course policy, even small changes can make a big difference for students, said Diana Brecher, PhD, a clinical psychologist and scholar-in-residence for positive psychology at Toronto Metropolitan University (TMU), formerly Ryerson University. For example, instructors might allow students a 7-day window to submit assignments, giving them agency to coordinate with other coursework and obligations. Setting deadlines in the late afternoon or early evening, as opposed to at midnight, can also help promote student wellness.

At Moraine Valley Community College (MVCC) near Chicago, Shelita Shaw, an assistant professor of communications, devised new class policies and assignments when she noticed students struggling with mental health and motivation. Those included mental health days, mindful journaling, and a trip with family and friends to a Chicago landmark, such as Millennium Park or Navy Pier—where many MVCC students had never been.

Faculty in the psychology department may have a unique opportunity to leverage insights from their own discipline to improve student well-being. Hard, who teaches introductory psychology at Duke, weaves in messages about how students can apply research insights on emotion regulation, learning and memory, and a positive “stress mindset” to their lives ( Crum, A. J., et al., Anxiety, Stress, & Coping , Vol. 30, No. 4, 2017 ).

Along with her colleague Deena Kara Shaffer, PhD, Brecher cocreated TMU’s Thriving in Action curriculum, which is delivered through a 10-week in-person workshop series and via a for-credit elective course. The material is also freely available for students to explore online . The for-credit course includes lectures on gratitude, attention, healthy habits, and other topics informed by psychological research that are intended to set students up for success in studying, relationships, and campus life.

“We try to embed a healthy approach to studying in the way we teach the class,” Brecher said. “For example, we shift activities every 20 minutes or so to help students sustain attention and stamina throughout the lesson.”

Creative approaches to support

Given the crucial role of social connection in maintaining and restoring mental health, many schools have invested in group therapy. Groups can help students work through challenges such as social anxiety, eating disorders, sexual assault, racial trauma, grief and loss, chronic illness, and more—with the support of professional counselors and peers. Some cater to specific populations, including those who tend to engage less with traditional counseling services. At Florida Gulf Coast University (FGCU), for example, the “Bold Eagles” support group welcomes men who are exploring their emotions and gender roles.

The widespread popularity of group therapy highlights the decrease in stigma around mental health services on college campuses, said Jon Brunner, PhD, the senior director of counseling and wellness services at FGCU. At smaller schools, creating peer support groups that feel anonymous may be more challenging, but providing clear guidelines about group participation, including confidentiality, can help put students at ease, Brunner said.

Less formal groups, sometimes called “counselor chats,” meet in public spaces around campus and can be especially helpful for reaching underserved groups—such as international students, first-generation college students, and students of color—who may be less likely to seek services at a counseling center. At Johns Hopkins, a thriving international student support group holds weekly meetings in a café next to the library. Counselors typically facilitate such meetings, often through partnerships with campus centers or groups that support specific populations, such as LGBTQ students or student athletes.

“It’s important for students to see counselors out and about, engaging with the campus community,” McCowan said. “Otherwise, you’re only seeing the students who are comfortable coming in the door.”

Peer counseling is another means of leveraging social connectedness to help students stay well. At UVA, Mason and his colleagues found that about 75% of students reached out to a peer first when they were in distress, while only about 11% contacted faculty, staff, or administrators.

“What we started to understand was that in many ways, the people who had the least capacity to provide a professional level of help were the ones most likely to provide it,” he said.

Project Rise , a peer counseling service created by and for Black students at UVA, was one antidote to this. Mason also helped launch a two-part course, “Hoos Helping Hoos,” (a nod to UVA’s unofficial nickname, the Wahoos) to train students across the university on empathy, mentoring, and active listening skills.

At Washington University in St. Louis, Uncle Joe’s Peer Counseling and Resource Center offers confidential one-on-one sessions, in person and over the phone, to help fellow students manage anxiety, depression, academic stress, and other campus-life issues. Their peer counselors each receive more than 100 hours of training, including everything from basic counseling skills to handling suicidality.

Uncle Joe’s codirectors, Colleen Avila and Ruchika Kamojjala, say the service is popular because it’s run by students and doesn’t require a long-term investment the way traditional psychotherapy does.

“We can form a connection, but it doesn’t have to feel like a commitment,” said Avila, a senior studying studio art and philosophy-neuroscience-psychology. “It’s completely anonymous, one time per issue, and it’s there whenever you feel like you need it.”

As part of the shift toward rapid access, many schools also offer “Let’s Talk” programs , which allow students to drop in for an informal one-on-one session with a counselor. Some also contract with telehealth platforms, such as WellTrack and SilverCloud, to ensure that services are available whenever students need them. A range of additional resources—including sleep seminars, stress management workshops, wellness coaching, and free subscriptions to Calm, Headspace, and other apps—are also becoming increasingly available to students.

Those approaches can address many student concerns, but institutions also need to be prepared to aid students during a mental health crisis, and some are rethinking how best to do so. Penn State offers a crisis line, available anytime, staffed with counselors ready to talk or deploy on an active rescue. Johns Hopkins is piloting a behavioral health crisis support program, similar to one used by the New York City Police Department, that dispatches trained crisis clinicians alongside public safety officers to conduct wellness checks.

A culture of wellness

With mental health resources no longer confined to the counseling center, schools need a way to connect students to a range of available services. At OSU, Sharma was part of a group of students, staff, and administrators who visited Apple Park in Cupertino, California, to develop the Ohio State: Wellness App .

Students can use the app to create their own “wellness plan” and access timely content, such as advice for managing stress during final exams. They can also connect with friends to share articles and set goals—for instance, challenging a friend to attend two yoga classes every week for a month. OSU’s apps had more than 240,000 users last year.

At Johns Hopkins, administrators are exploring how to adapt school policies and procedures to better support student wellness, Shollenberger said. For example, they adapted their leave policy—including how refunds, grades, and health insurance are handled—so that students can take time off with fewer barriers. The university also launched an educational campaign this fall to help international students navigate student health insurance plans after noticing below average use by that group.

Students are a key part of the effort to improve mental health care, including at the systemic level. At Morehouse College, Sera serves as the adviser for Chill , a student-led advocacy and allyship organization that includes members from Spelman College and Clark Atlanta University, two other HBCUs in the area. The group, which received training on federal advocacy from APA’s Advocacy Office earlier this year, aims to lobby public officials—including U.S. Senator Raphael Warnock, a Morehouse College alumnus—to increase mental health resources for students of color.

“This work is very aligned with the spirit of HBCUs, which are often the ones raising voices at the national level to advocate for the betterment of Black and Brown communities,” Sera said.

Despite the creative approaches that students, faculty, staff, and administrators are employing, students continue to struggle, and most of those doing this work agree that more support is still urgently needed.

“The work we do is important, but it can also be exhausting,” said Kamojjala, of Uncle Joe’s peer counseling, which operates on a volunteer basis. “Students just need more support, and this work won’t be sustainable in the long run if that doesn’t arrive.”

Further reading

Overwhelmed: The real campus mental-health crisis and new models for well-being The Chronicle of Higher Education, 2022

Mental health in college populations: A multidisciplinary review of what works, evidence gaps, and paths forward Abelson, S., et al., Higher Education: Handbook of Theory and Research, 2022

Student mental health status report: Struggles, stressors, supports Ezarik, M., Inside Higher Ed, 2022

Before heading to college, make a mental health checklist Caron, C., The New York Times, 2022

Related topics

• Mental health
• Stress effects on the body

Contact APA

You may also like.

• Health topics
• Data and statistics
• Media centre
• Information resources

Section menu

You are here.

• Mental health in emergencies
• WHO strategies and interventions
• Read our publications
• Training resources
• Watch our videos
• What you can do
• Mental health action plan 2013–2030
• Mental health gap action programme (mhGAP)
• Get connected
• MHPSS dashboard

Mental health and substance use

Case studies.

Upgrading the care environment and safeguarding human rights through enhancing the efficiency of the National Center for Mental Health in Jordan

This case study highlights the technical and financial support provide by WHO Jordan to the National Center for Mental Health (NCMH) in Jordan from September 2021 to January 2022 to upgrade its facilities, reorganize the service delivery model and enhance staff capacities from to create a more therapeutic environment for patients while upholding human rights. These activities were carried out in line with the National Mental Health and Substance Use Action Plan 2022–2026, which WHO Jordan helped to update in 2022. The Action Plan advocates for community-based mental health services, delivered in an integrated way across the health system, to both improve quality of care¬ and protect human rights.

Reducing the stigma of mental health disorders in Tunisia with a focus on future doctors

This case study highlights stigma related to mental health disorders which exists in the health care system and among health care providers in Tunisia. For people living with mental health disorders, it is a major barrier to seeking help, accessing quality care and treatment, and recovery. It focuses on implementing innovative solutions for health care providers like the Responding to Experienced and Anticipated Discrimination (READ) anti-stigma training for medical students, to improve the ability of future doctors, specifically fifth-year medical students at Tunis Medical School to overcome the stigma of mental health disorders and improve quality of care and life for people living with mental health disorders.

President’s initiative to promote and improve mental health in schools in Pakistan

This country case study highlights the President’s initiative, launched by the Government of Pakistan, to promote and improve mental health in schools, with an emphasis on technology to improve access to mental health. This 5-year initiative focuses on training teachers in skills and strategies to promote mental health in their schools and recognize and manage mental health problems early on.

Providing mental health support in humanitarian emergencies: an opportunity to integrate care in a sustainable way

This country case study highlights the approach taken in Sudan, in collaboration with WHO and UNHCR, to strengthen national mental health systems through responses provided in humanitarian settings. The approach – which has led to increased capacity for mental health services within the broader health system – includes three core elements: the engagement of community leaders; the integration of support within the broader health system; and ensuring the quality of services provided through supportive supervision.

The National Integrated Parenting Skills Training Program

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This featured program from Iran is for parents. It is based on the Parent Management Training (PMT) principles, and aims to improve child-parent interaction as a prevention strategy for child abuse, maltreatment and neglect, through equipping parents with the skills and confidence they need to be self-sufficient and manage family issues independently.

School Health Implementation Network in the Eastern Mediterranean Region (SHINE)

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This project in Pakistan aims to evaluate the enhanced WHO’s School Mental Health Program aiming to reduce socio-emotional difficulties within school-going children through an online training platform and chat-bot for school teachers in rural Rawalpindi.

First 24/7 mental health helpline in Pakistan

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This project aims to address the gap in access to mental health care through providing 24/7 accessible mental health helpline, that operates free of cost for people with mental health conditions who wish to anonymously (or otherwise) seek help from qualified psychiatrists and psychologists.

Mental health system reform in Afghanistan

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This project aims to rebuild the Afghan healthcare system through integrating mental health into basic health services. It focuses on provision of non-pharmacological psychosocial interventions linked to community programs supported by secondary level psychiatric care.

Family Well-being Centers: Delivering Community-based Mental Health Support in Syria

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This featured program from Syria aims to integrate Mental Health and Psychosocial Support (MHPSS) services at the community level in order to enhance service access for populations at risk of severe mental distress and to reduce the linked dual-stigma of mental health conditions and gender-based violence.

Iran National Suicide Prevention Program

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This featured holistic and integrated program from Iran aims to reduce the rates of suicide attempts and suicide mortality within the general population through including evidence-based suicide prevention approaches within policy and practice.

Towards an Effective Integration of Mental Health in Primary Care in Kuwait

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This featured program from Kuwait aims to create a best practice model for integrating mental health services into primary care through an integration approach that ensures comprehensive, specialized and high-quality mental health care.

WHO mhGAP Implementation in Saudi Arabia: Integrating Mental Health in Primary Health Care

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This featured program from Saudi Arabia aims to provide effective primary mental health care services and training for primary health care workers to diagnose and deal with common mental health conditions.

Suicide Prevention in Tunisia

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This featured program from Tunisia aims to reduce the incidence of suicide and suicidal through the formulating a better understanding of the causality of suicidal behavior within Tunisia and defining a prevention strategy to integrate within the national strategy as a priority action.

Our Step Association

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This featured program from Jordan aims to increase the participation of service users and their families as key stakeholders in the mental health field, and to advocate for their rights and increase awareness of mental health.

Integrating MHPSS into Primary Health Care Centers in Lebanon

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This featured program from Lebanon aims to provide Mental Health and Psychosocial Support (MHPSS) services for Palestinian refugees in Lebanon by delivering collaborative stepped-care mental health services through a supportive network of specialists at 27 primary healthcare centers across Lebanon.

Mental Health System Reform in Jordan

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This featured program in Jordan aims to provide community-based mental health care to displaced Iraqis and Jordanians through mental health reform that is focusing on shifting attention from a humanitarian agenda to a development agenda.

Humanitarian Crisis and Mental Health Reform in Lebanon

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This featured program in Lebanon aims to reform the mental health system and scale up evidence-based services through the establishment of a National Mental Health Programme that merges both humanitarian and development agendas.

Step-by-step: e-mental health in Lebanon

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This project in Lebanon aims to reduce the burden of depression among people who are faced with adversity, through developing and testing a WHO brief and scalable psychological intervention delivered through the internet.

Mental Health and Psychosocial Support (Phase II) in Palestine

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This project in Palestine aims to improve access to mental health services through implementing a five-year plan including deinstitutionalization, decentralization of care, redistribution of resources and integration of mental health into general health care services.

WHO-QualityRights Initiative in Lebanon within the national mental health reform

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This project aims to improve the quality and human rights aspects of mental health services in Lebanon, through conducting a pilot that assessed the quality and human rights aspects in two private facilities providing inpatient mental health services using WHO QualityRights Tool Kit.

Developing Qatar’s First Mental Health Attitudes and Awareness Measure

This country case study is part of a series developed in collaboration with the Mental Health Innovation Network with the aim of highlighting mental health innovations within the Eastern Mediterranean Region. This project aims to develop indicators to measure improvements in attitudes and awareness of mental health within the population The Attitudes and Awareness Survey will allow the Ministry of Public Health (MOPH) to measure change over time, as activities are undertaken to increase awareness and reduce stigma about mental health

Thinking healthy programme in Pakistan

This country case study highlights the Thinking Healthy Programme in Pakistan. This initiative aims to reduce perinatal depression and its negative impact on child development in resource-poor settings through task shifting. In summary, this is an evidence-based intervention for perinatal depression incorporating cognitive and behavioral techniques into community health workers’ routine work.

Pakistan marks World Mental Health Day with Presidential initiative

This country case study highlights the Presidential initiative launched by the Government of Pakistan to improve mental health at national level. The initiative aimed at improving the mental health of mothers and young people. Efforts to improve the mental health of mothers was guided by WHO’s Thinking Healthy Programme, which aims to reduce perinatal depression in low socioeconomic settings and to improve health outcomes in their children through the adaptation and integration of Cognitive Behavior Therapy into the routine work of community health workers. Efforts to improve the mental health of young people was guided by the School Mental Health Package, which was developed by the WHO Regional Office for the Eastern Mediterranean. The package aims to develop and enhance the skills of those involved in the educational process, to recognize the signs and symptoms, provide better support for young people, become stronger advocates for mental health, and effect legislation that protects the rights of people living with mental health disorders. 

Related links

Global Mental Health Perspectives from the Eastern Mediterranean Region

Help and services

• Cyber security

WHO Offices

• WHO headquarters
• WHO African Region
• WHO Region of the Americas
• WHO South-East Asia Region
• WHO European Region
• WHO Western Pacific Region

Connect with us

Study Reveals Lack of Access as Root Cause for Mental Health Crisis in America

Mental health services in the U.S. are insufficient despite more than half of Americans (56%) seeking help. Limited options and long waits are the norm, but there are some bright spots, with 76% of Americans now seeing mental health as important as physical health.

Washington, D.C.

Today, Cohen Veterans Network (CVN), a national not-for-profit philanthropic organization, and National Council for Mental Wellbeing, the unifying voice of America’s health care organizations that delivers mental health and addiction treatment and services, issued the inaugural America’s Mental Health 2018 , a comprehensive study of access to mental health care, at the 2018 Cohen Veterans Care Summit in Washington D.C. The study, which assesses Americans’ current access to and attitudes towards mental health services, revealed American mental health services are insufficient, and despite high demand, the root of the problem is lack of access – or the ability to find care.

The study offers a comprehensive analysis of the state of mental health care in the U.S. It is comprised of a two-pronged research project that includes an online survey of 5,000 American adults, and a robust analysis of third-party data measuring patients’ access to mental health services in terms of four pillars – providers, facilities, funding and perceived satisfaction among patients.

“There is a mental health crisis in America. My experience establishing mental health clinics across the country, coupled with this study, shows that more needs to be done to give Americans much needed access to mental health services,” said Cohen Veterans Network President and Chief Executive Officer Dr. Anthony Hassan. “If we want to save lives, save families and save futures we must reimagine our behavioral health system and take concrete steps to improving consumers’ ability to find the care they need, when they need it, and on their terms.”

Despite Strong Demand for Mental Health Services, Common Barriers Remain

The demand for mental health services is stronger than ever, with nearly six in 10 (56%) Americans seeking or wanting to seek mental health services either for themselves or for a loved one. These individuals are skewing younger and are more likely to be of lower income and have a military background. The large majority of Americans (76%) also believe mental health is just as important as physical health.

“This study confirmed what we hear from our members every day, that individuals and families continue to struggle to find the help they desperately need,” said Linda Rosenberg, President and CEO of National Council for Mental Wellbeing. “Mental health and addiction providers need adequate funding to hire skilled staff, employ evidence-based practices and adopt innovative technologies – all of which will help us meet demand.”

Despite this strong demand and growing societal awareness of the importance of mental health in the U.S., the study revealed that the overwhelming majority of Americans (74%) do not believe such services are accessible for everyone, and about half (47%) believe options are limited.

These beliefs are driven by several perceived barriers in Americans’ ability to seek mental health treatment, including:

• High Cost and Insufficient Insurance Coverage : Forty-two percent of the population saw cost and poor insurance coverage as the top barriers for accessing mental health care. One in four (25%) Americans reported having to choose between getting mental health treatment and paying for daily necessities.

Several individuals blamed the U.S. government and insurers for not providing enough funding and support for access. Nearly one in five of Americans, or 17%, noted they have had to choose between getting treatment for a physical health condition and a mental health condition due to their insurance policy. The majority (64%) of Americans who have sought treatment believe the U.S. government needs to do more to improve mental health services.

• Limited Options and Long Waits : Access to face-to-face services is a higher priority for Americans seeking mental health treatment than access to medication. Ninety-six million Americans, or 38%, have had to wait longer than one week for mental health treatments. And nearly half of Americans, or 46%, have had to or know someone who has had to drive more than an hour roundtrip to seek treatment.

While most Americans have heard of telehealth as an option for treating mental health issues, only 7% have reported using it. When asked if they would be open to using it, almost half, or 45%, of Americans who have not already tried telehealth services said they would be open to the idea of trying a service to address a current or future mental health need.

• Lack of Awareness : While most Americans do try to seek out treatment, there also is a large portion of the population who have wanted to but did not seek treatment for themselves or loved ones (29%)– in part due to not knowing where to go if they needed this service. What’s more, fifty-three million American adults (21%) have wanted to see a professional but were unable to for reasons outside of their control.

Furthermore, younger Americans (i.e., Gen Z and Millennials) are less sure about resources for mental health services, compared to older generations. This younger generation was also more likely to find it too hard to figure out legitimate resources online. Instead, many turned to unreliable resources for information, including Facebook, YouTube and Twitter.

• Social Stigma: Nearly one-third of Americans, or 31%, have worried about others judging them when they told them they have sought mental health services, and over a fifth of the population, or 21%, have even lied to avoid telling people they were seeking mental health services. This stigma is particularly true for younger Americans, who are more likely to have worried about others judging them when they say they have sought mental health services (i.e. 49% Gen Z vs. 40% Millennials vs. 30% Gen X vs. 20% Boomers).

Stark Disparities in Accessibility at State and Income Levels

Based on the analysis of third-party data, states are struggling to keep up with demand due to lack of funding and facilities, and, to a lesser extent, providers. Texas, Wisconsin and Georgia ranked among the lowest in terms of lacking adequate number of providers, facilities and funding to support the states’ populations. Pennsylvania, New York and Minnesota ranked among the top.

There is also a large disparity in access to mental health care based on level of income and location. Individuals located in rural areas and of lower-income are less likely to say that mental health services are extremely accessible to them.

Compared to middle- and high-income households, low-income Americans are less likely to know where to go for treatment and more likely to use a community center verses a qualified mental health center. Of the Americans that have not sought mental health treatment, more than half, or 53%, were in low-income households.

In addition, compared to Americans living in urban and suburban areas, individuals living in rural areas are less likely to proactively seek mental health specialists they need, and instead go to their primary care doctor or community center for treatment. Rural Americans are also less accepting of mental health services and care.

The Path Forward

The Cohen Veterans Network and National Council for Mental Wellbeing believe that more must be done to improve access to care for everyday Americans. Specifically, younger Americans need more information on how and where to access care. There must also be a better understanding of the real cost of delivering mental health care and related reimbursement rates, which typically cover only a small portion of care. This is critical to help attract new providers into the field and more must be done to train and retain providers to help ensure people can get help when they need it. Finally, we must ensure standards of care are consistent through continued adoption of evidence-based practices.

For more information on the comprehensive study results and how CVN and National Council are working to address mental wellness and accessibly across the country, please visit www.cohenveteransnetwork.org/AmericasMentalHealth or www.TheNationalCouncil.org .

About America’s Mental Health 2018

Cohen Veterans Network and National Council for Mental Wellbeing partnered with Ketchum Analytics who conducted an online survey among 5,000 Americans, representative of the U.S. population based on age, gender, region, household income and race/ethnicity. The survey was conducted between July 31 – August 12, 2018, with a margin of error of +/- 1.38 at the 95% confidence level. Through the survey, the following groups were identified: veterans, active duty military and those with a secondary relationship with a veteran as well as those who have sought mental health treatment (Mental Health Treatment Seekers). A custom index was developed, ranking each state according to its mental health service access. Third-party data was gathered to determine access based on four pillars: providers, facilities, funding and satisfaction. Data was aggregated and averaged to each state, resulting in a score between 0 and 100, where 100 indicates the greatest access.

About Cohen Veterans Network

The Cohen Veterans Network (CVN) is a 501(c)(3) national not-for-profit philanthropic organization for post-9/11 veterans and their families. CVN focuses on improving mental health outcomes, with a goal to build a network of outpatient mental health clinics for veterans and their families in high-need communities, in which trained clinicians deliver holistic evidence-based care to treat mental health conditions. There are currently 10 Steven A. Cohen Military Family Clinics nationwide.

About The National Council

Founded in 1969, the National Council for Mental Wellbeing is a membership organization that drives policy and social change on behalf of over 3,400 mental health and substance use treatment organizations and the more than 10 million children, adults and families they serve. We advocate for policies to ensure equitable access to high-quality services. We build the capacity of mental health and substance use treatment organizations. And we promote greater understanding of mental wellbeing as a core component of comprehensive health and health care. Through our Mental Health First Aid (MHFA) program, we have trained more than 3 million people in the U.S. to identify, understand and respond to signs and symptoms of mental health and substance use challenges.

Media Contact

Sophia Majlessi [email protected] 202-621-1631

Recent News

May 3, 2024

Apr 23, 2024

Mar 18, 2024

As described in the Privacy Policy of the American Psychiatric Association (APA), this website utilizes cookies for multiple purposes including to provide you with personalized content, evaluate and analyze the use of our site, and to identify which advertisements bring users to APA’s websites. By closing this message, continuing the navigation, or otherwise continuing to view the APA’s websites & applications, you confirm that you understand and accept the terms of the APA’s Privacy Policy, including the use of cookies. Read our full Privacy Policy here .

Mobile search

Lakeside industries.

Headquarters

Issaquah, WA

Number of Employees

Construction

Tackling Stigma and Making it Safe to Talk about Mental Health

Safety has been ingrained in the family-caring culture of Lakeside Industries. And part of addressing safety includes also focusing on employee mental health and well-being. Lakeside's leadership sees this as a valued aspect of the company’s operation.

Established in 1954, Lakeside Industries is a third-generation family-owned construction business. With 650 employees, Lakeside operates 11 divisions and one affiliated company with 20 production facilities in Washington and Oregon. The company is a union contractor with signed agreements with three labor unions that provide skilled labor, including unions representing: 1) operating engineers 2) laborers and 3) teamsters.

The company is active in the local communities and operates with an ethos of "giving back to those we serve." Each division of the company finds creative ways to impact their local community. For example, food drives and adopting families in need during the holidays or return to school season. This promotes employees feeling connected to the community and making a difference in community activities and philanthropy, which reinforces unity, togetherness and teamwork.

The Organization's Workplace Mental Health and Wellness Initiative

Getting started.

While incidents of suicide impact every industry, Cal Beyer, director of Risk Management at Lakeside understood the higher risk among men in the construction industry. The construction industry has the highest suicide rate of any occupational group. Men out-pace women nearly four to one in suicide deaths.

Cal explains the tough guy and gal mentality of construction as "suck it up and get through whatever is thrown at you." The idea of being open to personal issues at work, is difficult for most in this industry. Many perceive that sharing mental health struggles would be met with indifference. So for Cal, the question became "how do we reduce stigma and make it okay to talk about mental health concerns in a tough-guy and gal environment"?

In 2014, Cal and his team began integrating mental health and suicide awareness into the safety health and wellness program and practices. In integrating and launching this initiative, Lakeside:

• incorporated a safety orientation video that included information on how the company addresses mental health and suicide prevention at work,
• used free, downloadable posters available from the Construction Industry Alliance for Suicide Prevention, and
• gave all new hires three wallet cards in the orientation process that had information on these resources: Crisis Text Line, National Suicide Prevention Lifeline, and Lakeside's Employee Assistance Program.

Leadership Support

Cal emphasizes the importance of leadership buy-in. When he presented the business case, the company president and CFO were on board. Lakeside's leadership embraced the concept of weaving mental health and suicide prevention into their safety, health and wellness program.

Once they learned that there was a need to offer expanded behavioral health services, leadership went a step further by supporting a custom Employee Assistance Program that would expand coverage. Ordinarily, EAPs cover the employees in a health plan. A union employer provides health benefits for the union member and the employer provides health benefits for the administrative salaried employees. Lakeside’s leadership was generous to expand the EAP to cover hourly union member employees in addition to the administrative salaried employees.

Other key personnel involved in the Workplace Mental Health and Wellness Initiative included Risk Management & Safety, responsible for the development and ongoing promotion of the initiative; Human Resources, responsible for administering the EAP and providing confidential follow-up with employees and families seeking integrated benefits; and Divisional Management, responsible for incorporating mental health discussions into the new hire orientation and supporting the program.

Communicating the Initiative Internally and Externally.

Since Lakeside began addressing mental health, they've successfully communicated this work through multiple channels, including the following:

• Company newsletter. Including important telephone numbers for Crisis Text Line, National Suicide Prevention Lifeline and the company's Employee Assistance Program, along with articles and resources on mental health.
• Supervisory and managerial training. Including guest speaker Dr. Jenn Stuber from the University of Washington's Forefront Suicide Prevention nonprofit, who presented to 175 supervisors at Lakeside's Annual Leadership Conference.
• Peer-to-peer communication. Using a "How to Have the Conversation" resource during interactive divisional safety meetings addressing behavioral health and safety scenarios. Lakeside foremen and safety team members give Safety Toolbox Talks addressing why mental health and suicide prevention are workplace safety topics.
• "Pocket Packets". Three wallet cards and two hard hat stickers in a small coin envelope to make the topics of mental health and suicide prevention "portable" and accessible.
• External communication. Contributing numerous articles for construction industry publications. Lakeside personnel presented at numerous suicide prevention summits, association meetings and conferences. They also created a Mental Health and Suicide Prevention Resource Directory for companies to use and shared resources with construction associations.
• Industry advocacy. Taught 18 safety, human resources, operations and union professionals how to conduct toolbox talks on mental health and suicide prevention by leading toolbox talks for 1,150 employees on job sites in Seattle. Taught union and non-union apprenticeship coordinators how to incorporate mental health and suicide prevention into orientation and training curricula. Helped organize two construction industry stakeholder groups in Washington and Oregon to collaborate on suicide prevention.
• Internal acknowledgement. Humanitarian Awards presented to two employees for their work on mental health and suicide prevention.
• Other marketing materials. An affiliated company (Bayview Asphalt in Seaside, OR) provided special sweatshirts with mental health and suicide prevention messages to reinforce the importance to community members. The sweatshirts and t-shirts were designed by employees of the company. All employees were given shirts to wear in the community. The shirts and sweatshirts have the suicide prevention ribbon on the front, one of 4 different messages, and the phone numbers and logo for the National Suicide Prevention Lifeline.

Measuring Impact

The initial goal of the Workplace Mental Health and Wellness Initiative was to reduce stigma related to mental health and suicide and to see if it was possible to combine psychological safety with a caring safety culture. The second goal was to see if employees would engage when given the opportunity to talk about mental health in the workplace. The third goal was to make the initiative self-sustaining by getting everyone comfortable sharing resources and talking about mental health.

As a result of Lakeside's efforts, they have seen greater acceptance of mental health and suicide prevention and employees are more willing to share their experiences.

By ensuring employees know how and where to get help when needed, Lakeside has consistently seen an increase in:

• EAP utilization.
• Employees volunteering in community mental health events.
• Employees volunteering by sharing their lived experience and serving as peer-to-peer resources.
• Employees testifying or sending letters of support for suicide prevention legislation.
• Leaders participating in joint labor-management training sessions with unions on mental health, suicide prevention and addiction recovery.

Lessons Learned

Like many organizations, the Lakeside team faced some challenges in addressing mental health. One of the biggest was overcoming the stigma, especially because it can be a taboo topic in the construction industry. Lakeside found that by "baking" the mental health topic into a safety, health and wellness culture and programs, employees began to be more accepting.

While Cal and his team have learned many lessons along the way, here is his advice for other employers starting up or revamping a workplace mental health initiative:

• Get leadership support right away.
• Acknowledge the "awkward" and "uncomfortable" feelings people may experience but teach employees how to overcome that awkwardness and how to engage in conversations about mental health and well-being.
• Partner with labor unions to help make mental health and suicide prevention a safety topic and priority.
• Share resources and communicate often.
• Don't give up, recognize this is a worthy fight.

The plan is to continue allowing the initiative to evolve and grow by sharing resources.

The Center appreciates the contributions of Cal Beyer, Director of Risk Management for Lakeside to this case study.

• Peterson C, Stone DM, Marsh SM, et al. Suicide Rates by Major Occupational Group — 17 States, 2012 and 2015. MMWR Morb Mortal Wkly Rep 2018;67:1253–1260. DOI: http://dx.doi.org/10.15585/mmwr.mm6745a1
• National Vital Statistics Reports. Vol. 68, No. 9. (June 24, 2019) accessed at https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_09-508.pdf .
• Centers for Disease Control and Prevention. Suicide Rates by Major Occupational Groups, 2018. Retrieved from https://www.cdc.gov/mmwr/volumes/67/wr/mm6745a1.htm .
• American Foundation for Suicide Prevention. http://www.afsp.org .
• American Psychiatric Association Foundation. Center for Workplace Mental Health. http://workplacementalhealth.org/
• Associated General Contractors of Washington. https://www.agcwa.com/suicide-prevention-resources/
• Construction Industry Alliance for Suicide Prevention (CIASP). http://www.preventconstructionsuicide.com .
• Crisis Text Line: Text “HELP” to 741-741
• National Suicide Prevention Lifeline: 1-800-273-8255
• Mindwise Screening: http://www.preventconstructionsuicide.com/MindWise_Screening .
• NAMI (the National Alliance on Mental Illness). http://www.NAMI.org .

Across every industry, field, and background, employers have an incredible opportunity

Get Free Tools, Resources & Mental Health News

• The Business Case
• Mental Health Topics
• Case Studies
• Employer Resources
• News & Multimedia
• Take Action
• Corporate Sponsors
• Center Advisory Council
• Depression Calculator
• Access to Care
• AD/HD in Adults
• Alcohol Use Disorders
• Anxiety Disorders
• Autism Spectrum Disorders
• Bipolar Disorder
• Collaborative Care
• Eating Disorders
• Employee Assistance Programs
• Integrated Care
• Knowing the Warning Signs
• Mental Health Parity
• Opioid Disorders
• Physician Burnout
• Postpartum Depression and Anxiety
• Posttraumatic Stress Disorder
• Reasonable Job Accommodations
• Suicide Prevention
• Workplace Stress
• Violence in the Workplace
• Share Your Story
• Guides and Toolkits
• Infographics
• Training and Turnkey Programs
• Multimedia and Webcasts
• Partnerships and Initiatives
• COVID-19: Mental Health and Well-being
• Mental Health Works Issues
• Let's Talk: Mental Health Works
• Mental Health Works Podcast
• Economic Impact of ADHD in the United States
• Quantifying the Cost of Depression
• Survey of U.S. Workers Reveals Impact on Productivity from Depression
• Gender Pay Gap Contributes to Increased Rates of Depression and Anxiety Among Women
• How to Effectively Invest In Suicide Prevention
• Suicide Rates Across Job Categories: CDC Report
• Understanding & Addressing Violence in the Workplace
• Employee Mental Health & Well-being During & Beyond COVID-19
• Literature Review: Young Adult Worker Mental Health
• May Is Mental Health Month Toolkit
• Mental Health and Well-being in the Construction Industry Survey Report
• Mental Health Works Guide
• Recommendations for Improving Access to Mental Health and Substance Use Care
• Returning to the Workplace Guide
• Supporting Caregivers in the Workplace
• The Working Well Toolkit
• War in Ukraine: How Business Leaders Can Support Employees Affected by the Crisis
• Working Remotely During COVID-19
• Infographic: 988 Crisis Hotline
• Infographic: Beating Burnout at Work
• Infographic: Depression
• Infographic: Five Myths and Facts About Depression
• Infographic: Mental Health Parity
• Infographic: Supporting Someone Experiencing Anxiety
• Infographic: The Collaborative Care Model
• Notice.Talk.Act.® at Work
• Right Direction
• Frontline Connect
• The Path Forward Initiative

Study finds large gaps in mental health care for people with chronic pain

Millions of people with chronic pain fall into gaps in the mental health care system when it comes to treating symptoms of anxiety and depression, according to new research from the Comprehensive Center for Pain & Addiction.

A new University of Arizona Health Sciences study found that adults with chronic pain are more likely to experience symptoms of anxiety and depression than people without chronic pain, yet they access mental health care at lower rates and are less likely to have their mental health needs met in treatment. 

In 2021, approximately 51.6 million U.S. adults experienced chronic pain, according to the Centers for Disease Control and Prevention. The study showed that while people living with chronic pain represent 20.4% of the U.S. adult population, they make up an estimated 55.5% of U.S. adults with clinically significant anxiety and depression symptoms. 

“People living with chronic pain may form a distinct population with special mental health care needs,” said lead author Jennifer S. De La Rosa, PhD , strategy director for the U of A Health Sciences Comprehensive Center for Pain & Addiction , which funded the study. “Improving outcomes for people with chronic pain will include connecting more people to mental health care, as well as increasing the availability of mental health care that is responsive to their needs.” 

Jennifer De La Rosa, PhD, is the strategy director for the University of Arizona Health Sciences Comprehensive Center for Pain & Addiction and an assistant research professor at the College of Medicine – Tucson’s Department of Family and Community Medicine.

Photo by Noelle Haro-Gomez, U of A Health Sciences Office of Communications

The paper, “The unmet mental health needs of U.S. adults living with chronic pain,” was recently published in the journal PAIN .

This study builds on previous Comprehensive Center for Pain & Addiction research that found 1 in 20 U.S. adults have a combination of chronic pain and symptoms of anxiety or depression, and adults living with chronic pain are approximately five times more likely to have untreated symptoms of anxiety or depression compared to those not living with chronic pain.

The new study examined the degree to which people with chronic pain and mental health symptoms accessed and benefitted from mental health treatment. The research team analyzed data from 31,997 people who participated in the National Health Interview Survey, which has been identified as the best single source for the surveillance of chronic pain.

Researchers identified chronic pain-associated disparities in three areas: the need for mental health treatment; the use of mental health treatment; and the success of treating anxiety and depression symptoms when mental health treatment was used.

They found that 43.2% of U.S. adults living with chronic pain – approximately 21.5 million people – had a mental health need. By comparison, mental health care needs were identified in only 17.4% of U.S. adults who do not have chronic pain.

Among all U.S. adults with mental health treatment needs, chronic pain was associated with a 40.3% reduction in the odds of using mental health treatment.

“For those with chronic pain, the narrative about what needs to be done to address mental health is qualitatively different than for those who don’t have chronic pain,” said De La Rosa, who is an assistant research professor in the  U of A College of Medicine – Tucson’s Department of Family and Community Medicine . “Improving health care for people with chronic pain includes not only connecting people to care, but also addressing a disproportionate failure to achieve relief, even in the context of caregiving."

Researchers found that when mental health treatment is used, U.S. adults with chronic pain are more than twice as likely as others to experience continuing anxiety or depression symptoms.  

The study team found that only 44.4% of people with chronic pain, an estimated 9.5 million people, used mental health services and had their anxiety and depression symptoms adequately treated compared with 71.5% of those without chronic pain. When mental health treatment was used, U.S. adults with chronic pain are more than twice as likely as others to experience continuing anxiety or depression symptoms. 

People living with chronic pain represent 20.4% of the U.S. adult population, yet they make up an estimated 55.5% of U.S. adults with clinically significant anxiety and depression symptoms.

“There are many possible reasons an individual with chronic pain might have suboptimal mental health experiences, including the accessibility of care and the feasibility of attending appointments,” De La Rosa said. “Additionally, few mental health providers are trained in chronic pain, so only a small percentage of people living with chronic pain are likely receiving mental health treatment that is designed to address their needs. By further examining the role chronic pain plays in our national mental health crisis, we have a potentially transformative scientific and policy opportunity to build the United States health care system’s capacity to address co-occurring chronic pain and mental health challenges.”

“This study identified a significant gap in meeting the mental health needs of people who live with chronic pain,” said senior author  Todd Vanderah, PhD , director of the Comprehensive Center for Pain & Addiction, Regents Professor and head of the  Department of Pharmacology  in the U of A College of Medicine – Tucson and a BIO5 Institute member. “Our goal at the Comprehensive Center for Pain & Addiction is to use this information to reimagine and transform health care for chronic pain. By recognizing and treating the co-occurrence of anxiety and depression symptoms and chronic pain, we can empower millions of people affected by pain to thrive.”

Other co-authors from the Comprehensive Center for Pain & Addiction include Medical Director Mohab Ibrahim, MD, PhD , professor of  anesthesiology  at the College of Medicine – Tucson and director of the  Chronic Pain Management Clinic ; Policy Director Beth E. Meyerson, PhD, MDIV , professor of family and community medicine at the College of Medicine – Tucson; and members Alicia M. Allen, PhD , associate professor of family and community medicine at the College of Medicine – Tucson; Kyle Suhr, PhD , associate professor of psychiatry at the College of Medicine – Tucson; and  Benjamin R. Brady, DrPH . Other co-authors are doctoral student  Katherine E. Herder and  Jessica S. Wallace , a program evaluator in the College of Medicine – Tucson’s Department of Family and Community Medicine.

Jennifer S. De La Rosa, PhD     Assistant Research Professor, Department of Family and Community Medicine, College of Medicine – Tucson Strategy Director, Comprehensive Center for Pain & Addiction

Todd Vanderah, PhD Director, U of A Health Sciences Comprehensive Center for Pain & Addiction Regents Professor and Head, Department of Pharmacology, College of Medicine – Tucson Professor, Department of Anesthesiology, College of Medicine – Tucson Professor, Department of Neurology, College of Medicine – Tucson Member, BIO5 Institute

Related Stories

Study shows millions of people live with co-occuring chronic pain and mental health symptoms

Phil Villarreal Uof A Health Sciences Office of Communications 520-403-1986, [email protected]

Transforming the understanding and treatment of mental illnesses.

Información en español

Celebrating 75 Years! Learn More >>

• Health Topics
• Brochures and Fact Sheets
• Help for Mental Illnesses
• Clinical Trials

COVID-19 and Mental Health

What is covid-19.

COVID-19 is a disease caused by a virus named SARS-CoV-2. COVID-19 most often affects the lungs and respiratory system, but it can also affect other parts of the body. Some people develop post-COVID conditions, also called  Long COVID  . These symptoms can include neurological symptoms such as difficulty thinking or concentrating, sleep problems, and depression or anxiety.

Why is NIMH studying COVID-19 and mental health?

Both SARS-CoV-2 and the COVID-19 pandemic have significantly affected the mental health of adults and children. Many people experienced symptoms of  anxiety ,  depression , and substance use disorder during the pandemic. Data also suggest that people are more likely to develop mental illnesses or disorders in the months following COVID-19 infection. People with Long COVID may experience many symptoms related to brain function and mental health  .

While the COVID-19 pandemic has had widespread mental health impacts, some people are more likely to be affected than others. This includes people from racial and ethnic minority groups, mothers and pregnant people, people with financial and housing insecurity, children, people with disabilities, people with preexisting mental illnesses or substance use problems, and health care workers. 

How is NIMH research addressing this critical topic?

NIMH is supporting research to understand and address the impacts of the pandemic on mental health. This includes research to understand how COVID-19 affects people with existing mental illnesses across their entire lifespan. NIMH also supports research to help meet people’s mental health needs during the pandemic and beyond. This includes research focused on making mental health services more accessible through telehealth, digital tools, and community-based interventions.

NIMH is also working to understand the unique impacts of the pandemic on specific groups of people, including people in underserved communities and children. For example, NIMH supports research investigating how pandemic-related factors, such as school disruptions, may influence children’s brain, cognitive, social, and emotional development.

Where can I learn more about COVID-19 and mental health?

• NIMH video: Mental Illnesses and COVID-19 Risks
• NIMH Director’s Messages about COVID-19
• NIMH events about COVID-19
• NIMH news about COVID-19

Where can I learn more about Long COVID and COVID-19?

• NIH page on Long COVID 
• NIH RECOVER Initiative  
• CDC COVID-19 resources 

How can I find help for mental health concerns?

If you have concerns about your mental health, talk to a primary care provider. They can refer you to a qualified mental health professional, such as a psychologist, psychiatrist, or clinical social worker, who can help you figure out the next steps. Find tips for talking with a health care provider about your mental health.

You can learn more about getting help on the NIMH website. You can also learn about finding support  and locating mental health services  in your area on the Substance Abuse and Mental Health Services Administration (SAMHSA) website.

Last Reviewed:  May 2024

Unless otherwise specified, the information on our website and in our publications is in the public domain and may be reused or copied without permission. However, you may not reuse or copy images. Please cite the National Institute of Mental Health as the source. Read our copyright policy to learn more about our guidelines for reusing NIMH content.

• Things to Do
• Travel & Explore
• Investigations
• Advertise with Us
• Newsletters
• AZ International Auto Show & New Car Buyer's Guide 2020 Model Year
• Connect With Us
• For Subscribers
• Contributor Content
• Home & Garden Ideas

Having trouble finding a therapist? A community health center might be able to help

Arizonans feeling discouraged in a search for mental health care might want to try one of the state's community health centers, which have expanded their services rapidly after a pandemic-fueled spike in demand.

Federally qualified community health centers across Arizona accept most health insurance plans, offer care on a sliding fee scale, and don't turn anyone away for an inability to pay.

The centers, depending on the site, offer mental and behavioral health services, from depression screenings to therapy and psychiatry, including psychiatric medication management and medication-assisted treatment for people with substance-use disorders.

Marana-based MHC Healthcare , which reports that its behavioral health patient numbers have jumped by 67% since 2020, just hired two psychiatrists and is looking to further expand its behavioral health program. Mountain Park Health Center, which has locations across metro Phoenix, is launching a pilot therapy program for adolescents this year, and El Rio Health in Tucson last year created a first-ever adolescent behavioral health program because of needs that emerged during the pandemic.

When the pandemic hit Arizona in 2020, before the availability of the COVID-19 vaccine, communities of color and lower-income people were disproportionately affected by illness and death. People in those communities were often front-line workers and living with multiple family members in one housing unit, which meant they were less able to isolate if exposed to the virus.

Those hit hardest by COVID-19 often were getting their medical care at community health centers, which are located in medically underserved areas across the state. The centers quickly found themselves responding to a higher need for services related to grief and trauma, to behavior problems in kids, and to general anxiety and depression.

"We're going to be seeing the fallout of this (COVID-19) for decades, as far as mental health goes," said Nancy Hagener, director of integrated behavioral health services at Mountain Park Health Center, which operates nine clinics in the Phoenix area. "We are not over the pandemic by any means. That's why I feel it's so important to grow our program here."

Community health centers often refer to their programs as “behavioral health." According to center leaders as well as a federal government definition , that includes mental health care, as well as the promotion of resilience and well being; the treatment of mental and substance use disorders; and the support of those who experience or are in recovery from those conditions, along with their families and communities.

Arizona health centers to start a psychiatric residency program

Mountain Park Health Center has had an integrated behavioral health component of its primary care services since the early 2000s, but has in recent years been expanding its behavioral health workforce. Hagener said she's hopeful that the therapy program for kids ages 12 to 17 at Mountain Park's Baseline Clinic will be the first of more mental health expansion at Mountain Park.

"It's been a long time coming. The pandemic definitely prompted us to say 'OK, it's time,'" Hagener said of the therapy program. "We're starting with adolescents first, because the need is so high with them."

Marana-based MHC Healthcare's active behavioral health patient number increased to more than 9,000 people from 5,400 before the pandemic, leaders said. During the summer of 2025, MHC expects to begin a psychiatric residency program for medical school graduates.

El Rio Health's behavioral health staff of more than 100 is about double the number it had at the beginning of the pandemic, said Vanessa Seaney, who is El Rio's chief of behavioral health and integration. Patient mental health needs began to rise in April 2020, "and it has not stopped," Seaney said.

El Rio's adolescent behavioral health program, which includes a child and adolescent psychiatrist, launched in June 2022, and almost everyone on the provider team from that program speaks Spanish, Seaney said. The program, which has seen about 700 youths since it began, doesn't treat kids under the age of 12, though that's a plan for the future, she said.

El Rio also has a program for adults and adolescents known as MAT, or medication-assisted treatment for treating opioid use disorder, a problem that increased significantly during the pandemic , state and federal data show.

Like MHC Healthcare, El Rio is expecting to start a psychiatric residency program for medical school graduates. El Rio leaders anticipate their residency program beginning in 2024.

Keep reading: Demand for mental health care is up, but many Arizona providers don't take insurance

'We've been successful in recruiting staff, but do we need more? Yes.'

Demand for all kinds of mental health care, including psychiatric services, has risen since COVID-19. But the biggest rise has been in requests for therapy, El Rio's Seaney said.

"The demand for therapy really significantly increased through the pandemic, and there can be a wait for that. We are doing everything we can to bring in more clinicians, offer telehealth services," Seaney said. "We've been successful in recruiting staff, but do we need more? Yes."

At the Chiricahua Community Health Centers Inc. in rural Cochise County, behavioral health director Tamika Sullivan said the growth in mental health needs during COVID-19 was "massive." The need has gone down somewhat, but it's not back to pre-pandemic levels, she said.

"A year or two ago, we had one of the counseling agencies (in Sierra Vista) close down that worked with children, so we had a big scramble to take in new kids from that agency," Sullivan said. "That was a little difficult. ... I wouldn't say we're overwhelmed now, but could I use more staff? Oh, yes."

The Chiricahua Community Health Centers employs three psychiatric nurse practitioners and a fourth, who will work in the border city of Douglas, is scheduled to begin in October. Chiricahua has had a job opening for a psychiatrist for about six to eight months. The lack of a psychiatrist means some patients who need a psychiatric evaluation with in-depth screening will have to go to Tucson or Phoenix, Sullivan said.

"Psychiatry and neuropsychiatrists, there just are not a lot of them in general," she said.

Adelante Healthcare, which has nine locations in Maricopa County, has had a behavioral health component for years, but like many other federally qualified health centers in Arizona, significantly expanded those offerings over the past few years, said Susan Boyles, Adelante's director of behavioral health.

Adelante's behavioral health staff has gone from six employees four years ago to the current 102. It has plans to add more providers and intake specialists in the next few months.

Like some other community health centers across Arizona, Adelante has long used a collaborative model of integrating employees who are called behavioral health consultants into regular medical visits, whether it's primary care, pediatrics or dental.

Adelante's behavioral health program includes telehealth therapists and on-site therapists with dedicated caseloads, which means adults or children who get care there are able to stick with one therapist over time, Boyles said. Adelante also has case managers who work with providers to ensure patients' other needs are being met as well, including physical health and factors such as food security, transportation and housing. Adelante also does psychiatric evaluations.

If mental health care is needed that goes beyond Adelante's capacity, Boyles said the center will refer elsewhere, "but offer assistance to patients for coordination of care."

'We in community health do this as part of our mission'

While most community health centers historically offered physical health care and later added mental and behavioral health services, Phoenix-based Valle del Sol community health center began with a mission of offering mental and behavioral health.

It was founded more than 50 years ago by a group of community members who were concerned about local Latinos struggling with substance use disorders and other health disparities, president and CEO Mike Renaud said.

It's only in the past five years that Valle del Sol has begun offering more primary care services, he said. Valle del Sol has approximately 250 employees, 190 of whom are behavioral health staff, and it is hiring more, Renaud said. The population of people who sought and received behavioral health services at Valle del Sol increased by about 60% between 2020 and the end of 2022, Renaud said.

"We're recruiting for all levels of behavioral health staff. It's a challenge, and it gets particularly acute when you look at specialties. Child psychiatry is a very in-demand field, and those recruits can take many, many months. Addiction specialists are also very in demand," Renaud said.

Valle del Sol offers therapy, and the goal is for patients to remain with the same therapist, just as they would if they were to seek care from a private provider, he said.

"We in community health do this as part of our mission. We are here because we want to make sure people get the help they need to be successful in life," Renaud said. "We provide the same high level of care to anyone who walks through our doors. ... We've got a lot of need to meet, but we are definitely committed to doing it."

Reach health care reporter Stephanie Innes at  [email protected]  or at 602-444-8369. Follow her on X, formerly Twitter:  @stephanieinnes .

40 Facts About Elektrostal

Written by Lanette Mayes

Modified & Updated: 01 Jun 2024

Reviewed by Jessica Corbett

Elektrostal is a vibrant city located in the Moscow Oblast region of Russia. With a rich history, stunning architecture, and a thriving community, Elektrostal is a city that has much to offer. Whether you are a history buff, nature enthusiast, or simply curious about different cultures, Elektrostal is sure to captivate you.

This article will provide you with 40 fascinating facts about Elektrostal, giving you a better understanding of why this city is worth exploring. From its origins as an industrial hub to its modern-day charm, we will delve into the various aspects that make Elektrostal a unique and must-visit destination.

So, join us as we uncover the hidden treasures of Elektrostal and discover what makes this city a true gem in the heart of Russia.

Key Takeaways:

• Elektrostal, known as the “Motor City of Russia,” is a vibrant and growing city with a rich industrial history, offering diverse cultural experiences and a strong commitment to environmental sustainability.
• With its convenient location near Moscow, Elektrostal provides a picturesque landscape, vibrant nightlife, and a range of recreational activities, making it an ideal destination for residents and visitors alike.

Known as the “Motor City of Russia.”

Elektrostal, a city located in the Moscow Oblast region of Russia, earned the nickname “Motor City” due to its significant involvement in the automotive industry.

Home to the Elektrostal Metallurgical Plant.

Elektrostal is renowned for its metallurgical plant, which has been producing high-quality steel and alloys since its establishment in 1916.

Boasts a rich industrial heritage.

Elektrostal has a long history of industrial development, contributing to the growth and progress of the region.

Founded in 1916.

The city of Elektrostal was founded in 1916 as a result of the construction of the Elektrostal Metallurgical Plant.

Located approximately 50 kilometers east of Moscow.

Elektrostal is situated in close proximity to the Russian capital, making it easily accessible for both residents and visitors.

Known for its vibrant cultural scene.

Elektrostal is home to several cultural institutions, including museums, theaters, and art galleries that showcase the city’s rich artistic heritage.

A popular destination for nature lovers.

Surrounded by picturesque landscapes and forests, Elektrostal offers ample opportunities for outdoor activities such as hiking, camping, and birdwatching.

Hosts the annual Elektrostal City Day celebrations.

Every year, Elektrostal organizes festive events and activities to celebrate its founding, bringing together residents and visitors in a spirit of unity and joy.

Has a population of approximately 160,000 people.

Elektrostal is home to a diverse and vibrant community of around 160,000 residents, contributing to its dynamic atmosphere.

Boasts excellent education facilities.

The city is known for its well-established educational institutions, providing quality education to students of all ages.

A center for scientific research and innovation.

Elektrostal serves as an important hub for scientific research, particularly in the fields of metallurgy , materials science, and engineering.

Surrounded by picturesque lakes.

The city is blessed with numerous beautiful lakes , offering scenic views and recreational opportunities for locals and visitors alike.

Well-connected transportation system.

Elektrostal benefits from an efficient transportation network, including highways, railways, and public transportation options, ensuring convenient travel within and beyond the city.

Famous for its traditional Russian cuisine.

Food enthusiasts can indulge in authentic Russian dishes at numerous restaurants and cafes scattered throughout Elektrostal.

Home to notable architectural landmarks.

Elektrostal boasts impressive architecture, including the Church of the Transfiguration of the Lord and the Elektrostal Palace of Culture.

Offers a wide range of recreational facilities.

Residents and visitors can enjoy various recreational activities, such as sports complexes, swimming pools, and fitness centers, enhancing the overall quality of life.

Provides a high standard of healthcare.

Elektrostal is equipped with modern medical facilities, ensuring residents have access to quality healthcare services.

Home to the Elektrostal History Museum.

The Elektrostal History Museum showcases the city’s fascinating past through exhibitions and displays.

A hub for sports enthusiasts.

Elektrostal is passionate about sports, with numerous stadiums, arenas, and sports clubs offering opportunities for athletes and spectators.

Celebrates diverse cultural festivals.

Throughout the year, Elektrostal hosts a variety of cultural festivals, celebrating different ethnicities, traditions, and art forms.

Electric power played a significant role in its early development.

Elektrostal owes its name and initial growth to the establishment of electric power stations and the utilization of electricity in the industrial sector.

Boasts a thriving economy.

The city’s strong industrial base, coupled with its strategic location near Moscow, has contributed to Elektrostal’s prosperous economic status.

Houses the Elektrostal Drama Theater.

The Elektrostal Drama Theater is a cultural centerpiece, attracting theater enthusiasts from far and wide.

Popular destination for winter sports.

Elektrostal’s proximity to ski resorts and winter sport facilities makes it a favorite destination for skiing, snowboarding, and other winter activities.

Promotes environmental sustainability.

Elektrostal prioritizes environmental protection and sustainability, implementing initiatives to reduce pollution and preserve natural resources.

Home to renowned educational institutions.

Elektrostal is known for its prestigious schools and universities, offering a wide range of academic programs to students.

Committed to cultural preservation.

The city values its cultural heritage and takes active steps to preserve and promote traditional customs, crafts, and arts.

Hosts an annual International Film Festival.

The Elektrostal International Film Festival attracts filmmakers and cinema enthusiasts from around the world, showcasing a diverse range of films.

Encourages entrepreneurship and innovation.

Elektrostal supports aspiring entrepreneurs and fosters a culture of innovation, providing opportunities for startups and business development .

Offers a range of housing options.

Elektrostal provides diverse housing options, including apartments, houses, and residential complexes, catering to different lifestyles and budgets.

Home to notable sports teams.

Elektrostal is proud of its sports legacy , with several successful sports teams competing at regional and national levels.

Boasts a vibrant nightlife scene.

Residents and visitors can enjoy a lively nightlife in Elektrostal, with numerous bars, clubs, and entertainment venues.

Promotes cultural exchange and international relations.

Elektrostal actively engages in international partnerships, cultural exchanges, and diplomatic collaborations to foster global connections.

Surrounded by beautiful nature reserves.

Nearby nature reserves, such as the Barybino Forest and Luchinskoye Lake, offer opportunities for nature enthusiasts to explore and appreciate the region’s biodiversity.

Commemorates historical events.

The city pays tribute to significant historical events through memorials, monuments, and exhibitions, ensuring the preservation of collective memory.

Promotes sports and youth development.

Elektrostal invests in sports infrastructure and programs to encourage youth participation, health, and physical fitness.

Hosts annual cultural and artistic festivals.

Throughout the year, Elektrostal celebrates its cultural diversity through festivals dedicated to music, dance, art, and theater.

Provides a picturesque landscape for photography enthusiasts.

The city’s scenic beauty, architectural landmarks, and natural surroundings make it a paradise for photographers.

Connects to Moscow via a direct train line.

The convenient train connection between Elektrostal and Moscow makes commuting between the two cities effortless.

A city with a bright future.

Elektrostal continues to grow and develop, aiming to become a model city in terms of infrastructure, sustainability, and quality of life for its residents.

In conclusion, Elektrostal is a fascinating city with a rich history and a vibrant present. From its origins as a center of steel production to its modern-day status as a hub for education and industry, Elektrostal has plenty to offer both residents and visitors. With its beautiful parks, cultural attractions, and proximity to Moscow, there is no shortage of things to see and do in this dynamic city. Whether you’re interested in exploring its historical landmarks, enjoying outdoor activities, or immersing yourself in the local culture, Elektrostal has something for everyone. So, next time you find yourself in the Moscow region, don’t miss the opportunity to discover the hidden gems of Elektrostal.

Q: What is the population of Elektrostal?

A: As of the latest data, the population of Elektrostal is approximately XXXX.

Q: How far is Elektrostal from Moscow?

A: Elektrostal is located approximately XX kilometers away from Moscow.

Q: Are there any famous landmarks in Elektrostal?

A: Yes, Elektrostal is home to several notable landmarks, including XXXX and XXXX.

Q: What industries are prominent in Elektrostal?

A: Elektrostal is known for its steel production industry and is also a center for engineering and manufacturing.

Q: Are there any universities or educational institutions in Elektrostal?

A: Yes, Elektrostal is home to XXXX University and several other educational institutions.

Q: What are some popular outdoor activities in Elektrostal?

A: Elektrostal offers several outdoor activities, such as hiking, cycling, and picnicking in its beautiful parks.

Q: Is Elektrostal well-connected in terms of transportation?

A: Yes, Elektrostal has good transportation links, including trains and buses, making it easily accessible from nearby cities.

Q: Are there any annual events or festivals in Elektrostal?

A: Yes, Elektrostal hosts various events and festivals throughout the year, including XXXX and XXXX.

Elektrostal's fascinating history, vibrant culture, and promising future make it a city worth exploring. For more captivating facts about cities around the world, discover the unique characteristics that define each city . Uncover the hidden gems of Moscow Oblast through our in-depth look at Kolomna. Lastly, dive into the rich industrial heritage of Teesside, a thriving industrial center with its own story to tell.

Was this page helpful?

Our commitment to delivering trustworthy and engaging content is at the heart of what we do. Each fact on our site is contributed by real users like you, bringing a wealth of diverse insights and information. To ensure the highest standards of accuracy and reliability, our dedicated editors meticulously review each submission. This process guarantees that the facts we share are not only fascinating but also credible. Trust in our commitment to quality and authenticity as you explore and learn with us.

Share this Fact:

Get the Reddit app

A subreddit for those who enjoy learning about flags, their place in society past and present, and their design characteristics

The flag of Elektrostal, Moscow Oblast, Russia which I bought there during my last visit

By continuing, you agree to our User Agreement and acknowledge that you understand the Privacy Policy .

Enter the 6-digit code from your authenticator app

You’ve set up two-factor authentication for this account.

Enter a 6-digit backup code

Create your username and password.

Reddit is anonymous, so your username is what you’ll go by here. Choose wisely—because once you get a name, you can’t change it.

Reset your password

Enter your email address or username and we’ll send you a link to reset your password

Check your inbox

An email with a link to reset your password was sent to the email address associated with your account

Choose a Reddit account to continue

Warning: The NCBI web site requires JavaScript to function. more...

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Forum on Neuroscience and Nervous System Disorders; Board on Health Sciences Policy; Board on Global Health; Institute of Medicine; National Academies of Sciences, Engineering, and Medicine. Providing Sustainable Mental and Neurological Health Care in Ghana and Kenya: Workshop Summary. Washington (DC): National Academies Press (US); 2016 Feb 25.

Providing Sustainable Mental and Neurological Health Care in Ghana and Kenya: Workshop Summary.

• Hardcopy Version at National Academies Press

4 Case Studies

Throughout the workshop, case studies were presented of some of the successful mental health projects in Ghana, Kenya, and around the world. Although each case study was multifaceted and addressed many challenges, the workshop participants focused on distilling lessons learned from each project that could be applied to potential mental health demonstration projects.

AFRICA MENTAL HEALTH FOUNDATION 1 : COMMUNITY PARTNERSHIPS

Founded in 2004, AMHF has stated the vision of being “the center of excellence in Africa for research, training, knowledge translation, and advocacy in mental health.” 1 AMHF uses a multidisciplinary, multisectoral approach to improve mental health through programs at all levels, from physician specialist training to community-based stigma reduction, including school-based programs. According to David Ndetei, AMHF's greatest successes have been in creating community partnerships and joint ownership of programs. One partnership in particular that has been successful is the relationship AMHF has built with traditional and faith healers. AMHF works with them to build awareness of mental health disorders, to develop skills to screen for and refer cases of mental illness, and to deliver evidence-based, mhGAP-adapted psychosocial interventions. Other partnerships critical to the success of their programs, noted Ndetei, include those with county government where health services have been devolved and with the government of Kenya.

BASICNEEDS 2

BasicNeeds was founded in 2000 with the goal of improving the lives of people around the world diagnosed with a mental illness or epilepsy, by ensuring that their basic needs are met and their rights are recognized and respected.

Ghana 3 : Building Capacity of NGOs

BasicNeeds' Mid-Ghana Project is focused on the Ashanti and Brong Ahafo regions. It is a community-based model that seeks to ensure that people with mental illness or epilepsy can access their human rights. Specifically, BasicNeeds' activities can be categorized into four main areas: identifying and supporting people who have treatment needs; training community health workers; creating awareness; and supporting service delivery through psychiatric outreach to communities. Since 2000, BasicNeeds Ghana has provided 7,800 women, men, and children with mental illness or epilepsy and caregivers access to mental health and development services through community-based mental health, and it has developed 130 self-help user groups as a mechanism for patients and caregivers to express their needs and claim their rights to inclusion and development. Peter Yaro, executive director of BasicNeeds Ghana, said that a key component of their work is training local partners such as NGOs. BasicNeeds trains and supports key local partners on their Mental Health and Development model to enable the organizations to gain accreditation as a BasicNeeds franchise partner. The components of the model include capacity building, community mental health, sustainable livelihoods (e.g., promoting social reintegration), research, advocacy, policy, and collaboration. The NGOs they work with are not necessarily mental health organizations: for the Mid-Ghana project, for instance, the organizations were focused on child labor, reproductive health care, education, and women's issues. Yaro said that this type of collaboration among NGOs is a great way to align mental health activities with what the NGOs are already doing. He cautioned, however, that even though many NGOs are interested in working in mental health, they “sometimes do not know how.” He said that if given the proper support and training, these NGOs can be valuable partners in improving community mental health. As a result, BasicNeeds Ghana established two regional mental health alliances that bring together more than 45 community-based organizations/NGOs and decentralized government ministries, departments, and agencies to foster these collaborations and implement work in mental health.

Kenya 4 : Patients as Ambassadors

BasicNeeds works at the community level to build the capacity of people with MNS disorders to participate in their own treatment and recovery, as well as to reduce stigma and prepare the rest of the community to help people with MNS disorders. Joyce Kingori reported that the critical partners of BasicNeeds are the adults and children with MNS disorders “who have taken the courage to come and get treatment, to share their stories, to provide their insights.” BasicNeeds uses mental health “ambassadors”: young people who have been treated and now work to create awareness among their peers, and to reach out to provide support to those in need. Kingori noted that in addition to the critical partnership with patients, BasicNeeds also has important partnerships with organizations such as KAWE and AMHF, as well as the MoH and local government and health officials.

DIRECT RELIEF 5 AND BREAST CARE INTERNATIONAL 6 : COLLABORATION

Founded in 1948, Direct Relief provides medical resources to areas affected by poverty or emergency situations. It focuses primarily on maternal and child health, disease prevention and treatment, emergency preparedness and response, and strengthening health systems. 5 In partnership with Breast Care International (BCI), a Ghanaian-based organization dedicated to breast cancer awareness, the two organizations conducted a mental health research project in the Ashanti region of Ghana. They are currently collecting data on the burden of mental health and examining what types of mental health services are available, with the purpose of using the data to recommend measures to address the challenges in the region. Andrew Schroeder, director of research and analytics for Direct Relief, and Samuel Kwasi Agyei, of BCI, stressed the importance of collaboration in their work. Schroeder noted that the collaboration with BCI was critical to the success of the project because they are a community-based organization that is trusted in the area in which they work. In addition, because of BCI's interest in broad-based health care, the project is working to embed mental health care services in the general health care system, rather than operating as a stand-alone mental health program, thus making improvements that are systematic and sustainable.

EMERGING MENTAL HEALTH SYSTEMS IN LOW- AND MIDDLE-INCOME COUNTRIES (EMERALD) 7 : STRENGTHENING HEALTH SYSTEMS

EMERALD, or Emerging Mental Health Systems in Low- and Middle-Income Countries, is a 5-year program (2012−2017) that works in six countries (Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda) to improve mental health outcomes by improving health system performance, said Jibril Abdulmalik, Co-Investigator of EMERALD at the University of Ibadan in Nigeria. The program consists of six work packages: (1) project management and coordination; (2) capacity building in mental health systems research; (3) adequate, fair, and sustainable resourcing for mental health (health systems inputs); (4) integrated provision of mental health services (mental health system processes); (5) improved coverage and goal attainment in mental health (health system outputs); and (6) dissemination. EMERALD seeks to strengthen the system itself through activities such as holding trainings for policy makers, researchers, and service users; providing scholarships for students seeking advanced degrees in mental health; developing curricula for master's training in public mental health; helping countries with cost projections; facilitating the integration of mental health into primary care; and improving health information systems. Abdulmalik added that having cultivated relationships with policy makers and key stakeholders was useful to understanding health care systems hierarchy, as well as leveraging existing platforms. He acknowledged that some of these individual efforts are “droplets” in a bucket, but he hoped that the EMERALD project, as a whole, would result in a comprehensive template for strengthening mental health systems in low- and middle-income countries.

FIGHT AGAINST EPILEPSY 8 : STAKEHOLDER ENGAGEMENT

WHO and the Ghana MoH, with support from Sanofi Espoir Foundation, have teamed up for a 4-year project (2012−2015) to reduce the epilepsy treatment gap, using a variety of strategies: promoting training of all health care providers, improving community awareness to reduce stigma and increase demand for care, and integrating epilepsy care within the primary health care system. Since the initiation of the project:

• A national/district coordinating committee was established;
• A situation analysis report was developed at the national, regional, and district levels;
• 330 volunteers and 404 primary health care providers were trained in epilepsy management;
• Gradual scale up occurred, with coverage now in 10 districts in 5 regions;
• A monitoring and evaluation strategy was developed; and
• A draft model of epilepsy care was developed.

Cynthia Sottie, national coordinator of the Fight Against Epilepsy project at the Ghana Health Service, said that engaging with stakeholders at all levels, at all stages of the project, has been critical to the project's success. She noted that they have involved the Minister of Health, representatives from the teaching hospitals, national and international NGOs, the Mental Health Society of Ghana, regional health directors, faith healers, and community members. By involving so many stakeholders from the beginning of the project, “everybody was involved [and] everybody knows what is going on at each time.” Sottie said that everyone's involvement was vital to getting the support and participation necessary to carry out the project.

KENYA ASSOCIATION FOR THE WELFARE OF PEOPLE WITH EPILEPSY 9 : PUBLIC EDUCATION

KAWE was founded in 1982 and seeks to improve the lives of those with epilepsy through a variety of efforts, including the training of primary health workers, awareness creation and stigma reduction through community projects, medical provision and support (e.g., epilepsy clinics, patient groups), and policy advocacy at the MoH in Kenya. Between 2000 and 2014, KAWE trained 1,814 clinical officers and nurses and 3,095 CHWs, and the organization's awareness programs reached an estimated 254,000 people directly and more than 3 million through mass media, said Osman Miyanji. In addition, more than 25,000 patients have been registered throughout clinics in Nairobi, Kenya, as a result of KAWE's community programs, and from a training perspective, the organization helped launch national epilepsy guidelines and developed a more comprehensive curriculum for medical training institutions. Miyanji reported that KAWE has demonstrated that they can close the treatment gap, and he noted that in 30 years of experience, public education to address social stigma and reduce ignorance has been a key element of their success.

THE KINTAMPO PROJECT 10 : FOCUS ON COMMUNITY-BASED CARE

The Kintampo Project, a collaboration between Ghana and the United Kingdom, is “training a new generation of mental health workers,” said Joseph B. Asare. The project trains clinical psychiatry officers (CPOs) and community mental health officers (CMHOs). CPOs can diagnose mental illness and prescribe medication, while CMHOs focus on detection of mental illness in the community, education of local people, and reducing stigma and discrimination. CMHOs work in part by developing relationships with local families, schools, prayer camps, and traditional healers. The organization's objective is to have one CPO and two to three CMHOs in each of Ghana's 216 districts by 2017. Through the Kintampo Project, workers have been trained and deployed all over Ghana, helping thousands of the most needy people. The project is on track to boost the mental health workforce by 60 percent and the number of patients treated per year by 500 percent. By focusing on community-based care, Kintampo is shifting the focus of mental health care away from large hospitals and into the community where it is most needed, Asare said.

PROGRAM FOR IMPROVING MENTAL HEALTH CARE (PRIME) 11 : BUY-IN, BUY-IN, BUY-IN

Tedla Wolde-Giorgis provided an overview of PRIME's efforts to integrate mental health into the existing health delivery system in five countries (Ethiopia, India, Nepal, South Africa, and Uganda). The purpose of the 6-year study, launched in 2011, is to research the magnitude, impact, and tractability of mental disorders in low- and middle-income countries. Using Ethiopia as an example, Wolde-Giorgis reported that integration was an incredibly complex process (beyond the instructions in the mhGAP intervention guide [IG]) that required buy-in from decision makers at all levels—national, regional, and community—as well as support from health care facilities and NGOs. Wolde-Giorgis said that, regardless of the level of support at the top, a top-down approach will not work; ultimately, the day-to-day work is done in the community and facilities, so it must be led at this level. He also noted that stigma reduction is a critical part of getting buy-in at the community level. For an effort to be sustainable, the buy-in must be continuous—it is not a one-time effort. Leadership must be continuously reminded of the importance of mental health and how it aligns with national priorities because there are so many other competing health concerns and health initiatives (e.g., MDGs).

PROJECT FIVES ALIVE! 12 : SCALING UP

The goal of Project Fives Alive! is to reduce mortality rates among children below age 5. Sodzi Sodzi-Tettey said the project uses a quality improvement approach, which requires forming quality improvement teams, having the teams develop initiatives on how to change mortality rates, implementing these initiatives, and then using data to assess if there was a positive effect. The project started in 9 hospitals but has since been scaled up to 200 hospitals. Sodzi-Tettey said that the initial 9 hospitals were chosen because they were high-burden hospitals with high rates of mortality for children below age 5. By the end of the first 18 months of operation, 6 of the 9 hospitals showed significant improvement in mortality reduction. By learning what worked in these high-burden hospitals, the project created a “change package,” which consisted of data-driven initiatives that had led to improvement related to improving delay in seeking and providing care and to reliable use of protocols. Sodzi-Tettey said that of the 134 hospitals in which the project currently operates, nearly 70 percent have adopted ideas from the change package, while also developing their own initiatives (e.g., targeted health education on early care-seeking using interactive platforms, triage systems for screening and emergency treatment of critically ill children, and training staff on protocols, followed by regular coaching and mentoring) ( Twum-Danso et al., 2012 ). In these 134 hospitals, there has been a 31 percent reduction in facility-based mortality in children younger than age 5. Sodzi-Tettey reported on three lessons learned from the project. First, initiatives should be tested promptly and on a small scale; this creates data that management can use to decide whether or not to implement a change. Second, teams should be empowered to know and use their own data. Sodzi-Tettey said that many workers were used to reporting data to the top but had not been aware of their own performance. Once they had the ability to track their own progress, they became even more invested in improvement. Finally, Sodzi-Tettey said that sustainability is only possible if a project understands and works within the existing health system, rather than with its own schedule and priorities.

PARTNERS IN HEALTH IN RWANDA 13 : INTEGRATION OF MENTAL HEALTH INTO THE GENERAL CARE SYSTEM THROUGH PUBLIC-SECTOR COLLABORATION AND LEVERAGE OF EXISTING HEALTH PLATFORMS

Partners In Health strives “to bring the benefits of modern medical science to those most in need of them and to serve as an antidote to despair.” 13 The Partners In Health program in Rwanda focused on close collaboration within the public sector to integrate mental health care into the general community-based care system within the district. At each level (hospital, health centers, and community), health workers were trained in mental health care. Partners In Health's primary mental health endeavor in Rwanda was the integration of mental health care into health centers using existing structure of intensive supported supervision and quality improvement following training. One challenge that the program faced was resistance from the staff to admitting and treating psychiatric patients in the general ward. Smith offered several reasons for the resistance, including stigma and discrimination. She said the most successful strategy for reducing stigma among the health care workers was effective treatment of patients. When staff saw people come in with very acute psychiatric conditions, receive treatment, and get better, the workers' perspective on mental health was significantly changed. Smith recalled the story of a district hospital manager who unknowingly hired a former patient to work on the grounds of the hospital. When he learned that she had been admitted to his hospital as a psychiatric patient only 2 months earlier, and was now capable of holding a job, he “became a big advocate for the work.” Smith said, “It was the witnessing of people getting better that was the most destigmatizing.” In addition to reducing stigma, Smith said that another key element of successful integration was leveraging the existing system structures and human resources. Rather than restructuring or bringing in new people, they worked within the existing system by mapping skill sets and matching them to the skills needed for mental health care. Smith said that by using what was already available, a much more rapid and efficient integration into primary care was possible.

• MENTAL HEALTH CARE IN TURKEY: POLICY DEVELOPMENT

Oğuz Karamustafalioğlu, professor of psychiatry at Üsküdar University, provided an overview of mental health care in Turkey. He noted the high treatment gap for schizophrenia, depression, and substance use problems, and the lack of human and material (i.e., psychiatric beds) resources needed to adequately meet the demands of patients. In 2006, the MoH in Turkey released a National Mental Health Policy (NMHP) 14 aimed at mobilizing resources to ensure that mental health care services are accessible and balanced. Karamustafalioğlu stated that the NMHP encouraged preventative methods to decrease the burden of mental disorders, to increase attainable mental health care and services at both primary and secondary care levels, to encourage the respect of human rights for those with a mental illness, and to support the necessary legislation to protect their rights. Although there have been some successes since the NMHP was released—including an increase in the outpatient mental health care units at the general hospitals, the number of adult and child psychiatrists, and public education and awareness programs about mental health to reduce stigma—he emphasized that there is still more to be done to provide care and treatment to all patients.

• WORLD ASSOCIATION FOR SOCIAL PSYCHIATRY AND SANOFI: COUNTRY-SPECIFIC APPROACHES

Sanofi's Access to Medicines department works in some of the world's poorest countries, disseminating information about MNS disorders, improving diagnosis, and making treatment affordable and accessible to patients, said Francois Bompart. Programs are specifically tailored to each country in which they work, an approach that is critical to success. For example, Sanofi works in Comoros, a small group of islands off the coast of Mozambique. Bompart said that several issues complicate mental health care in Comoros: transportation is difficult and expensive, and there is only one psychiatrist in the country. In order to work within these confines, Sanofi is working to train primary health care providers to use telemedicine to connect to the one psychiatrist—a tailored approach that works for the specific context of Comoros but might be wholly inappropriate elsewhere. Similarly, in Guatemala, Sanofi tailored its approach by choosing to partner with a local NGO instead of the MoH because of instability in the government. With regards to cultural and societal sensitivities, Bompart noted that in some areas in countries such as Morocco, traditional and faith healers were not involved in the awareness programs given the local contexts.

• 686 PROJECT IN CHINA: FOCUS ON GENERAL PRACTITIONERS

The 686 project was a 2004 initiative that launched mental health reform in China after the severe acute respiratory syndrome (SARS) epidemic. Prior to the reform, mental health institutions (565 hospitals) were worn and outdated, there were no community-based mental health care services, and medical insurance was provided only to employed people. Ma Hong, deputy director of mental health programs at the China MoH, stated that initially, the government granted 6.86 million Yuan (860,000 USD) to train providers in mental health, and as the program continued, it covered free hospital treatment for patients and out-of-pocket medical costs for impoverished patients. Hong noted that it was critical to learn how to express the need for funding and the overall burden of mental health in the language of the government. The project consisted of 60 demonstration projects reaching a population of 42.9 million people, in which providers were trained; hospital services were expanded to communities; and, when universal medical insurance was implemented in China, the project covered out-of-pocket costs for impoverished patients. One significant challenge was that while there was adequate funding for services, the human resources necessary to actually provide care lagged behind. Hong said, “Money does not equal service—human resources development is much slower than simply building a new hospital.” She proposed that too much reliance on specialists in rural areas is misguided, and that when building a mental health program, the focus should be on expanding general practitioners' knowledge of mental health and building their capacity to diagnose and treat MNS disorders. Hong noted that a hospital–community continuous care system has since been established and 4.29 million patients have been registered in the health information system, including 3.41 million patients who have received community health care, 61.7 percent of whom are farmers.

See http://www ​.africamentalhealthfoundation ​.org (accessed July 14, 2015).

See http://www ​.basicneeds.org (accessed July 14, 2015).

See http://www ​.basicneeds ​.org/where-we-work/ghana (accessed July 14, 2015).

See http://www ​.basicneeds ​.org/where-we-work/kenya (accessed July 14, 2015).

See http://www ​.directrelief.org/about (accessed July 14, 2015).

See http://www ​.breastcareghana.com/about (accessed July 14, 2015).

See http://www ​.emerald-project.eu (accessed July 14, 2015).

See http: ​//fondation-sanofi-espoir ​.com/download ​/2012-10-22_CP_Ghana_EN.pdf (accessed July 14, 2015).

See http://www ​.kawe-kenya.org (accessed July 14, 2015).

See http://www ​.thekintampoproject.org (accessed July 14, 2015).

See http://www ​.prime.uct.ac.za (accessed July 14, 2015).

See http://www ​.ihi.org/engage ​/initiatives/ghana/pages/default ​.aspx (accessed July 14, 2015).

See http://www ​.pih.org (accessed July 14, 2015).

See https://www ​.mindbank.info/item/69 (accessed August 13, 2015).

• Cite this Page Forum on Neuroscience and Nervous System Disorders; Board on Health Sciences Policy; Board on Global Health; Institute of Medicine; National Academies of Sciences, Engineering, and Medicine. Providing Sustainable Mental and Neurological Health Care in Ghana and Kenya: Workshop Summary. Washington (DC): National Academies Press (US); 2016 Feb 25. 4, Case Studies.
• PDF version of this title (3.7M)

In this Page

• AFRICA MENTAL HEALTH FOUNDATION: COMMUNITY PARTNERSHIPS
• DIRECT RELIEF AND BREAST CARE INTERNATIONAL: COLLABORATION
• EMERGING MENTAL HEALTH SYSTEMS IN LOW- AND MIDDLE-INCOME COUNTRIES (EMERALD): STRENGTHENING HEALTH SYSTEMS
• FIGHT AGAINST EPILEPSY: STAKEHOLDER ENGAGEMENT
• KENYA ASSOCIATION FOR THE WELFARE OF PEOPLE WITH EPILEPSY: PUBLIC EDUCATION
• THE KINTAMPO PROJECT: FOCUS ON COMMUNITY-BASED CARE
• PROGRAM FOR IMPROVING MENTAL HEALTH CARE (PRIME): BUY-IN, BUY-IN, BUY-IN
• PROJECT FIVES ALIVE!: SCALING UP
• PARTNERS IN HEALTH IN RWANDA: INTEGRATION OF MENTAL HEALTH INTO THE GENERAL CARE SYSTEM THROUGH PUBLIC-SECTOR COLLABORATION AND LEVERAGE OF EXISTING HEALTH PLATFORMS

Other titles in this collection

• The National Academies Collection: Reports funded by National Institutes of Health

Recent Activity

• Case Studies - Providing Sustainable Mental and Neurological Health Care in Ghan... Case Studies - Providing Sustainable Mental and Neurological Health Care in Ghana and Kenya

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

Current time by city

For example, New York

Current time by country

For example, Japan

Time difference

For example, London

For example, Dubai

Coordinates

For example, Hong Kong

For example, Delhi

For example, Sydney

Geographic coordinates of Elektrostal, Moscow Oblast, Russia

Coordinates of elektrostal in decimal degrees, coordinates of elektrostal in degrees and decimal minutes, utm coordinates of elektrostal, geographic coordinate systems.

WGS 84 coordinate reference system is the latest revision of the World Geodetic System, which is used in mapping and navigation, including GPS satellite navigation system (the Global Positioning System).

Geographic coordinates (latitude and longitude) define a position on the Earth’s surface. Coordinates are angular units. The canonical form of latitude and longitude representation uses degrees (°), minutes (′), and seconds (″). GPS systems widely use coordinates in degrees and decimal minutes, or in decimal degrees.

Latitude varies from −90° to 90°. The latitude of the Equator is 0°; the latitude of the South Pole is −90°; the latitude of the North Pole is 90°. Positive latitude values correspond to the geographic locations north of the Equator (abbrev. N). Negative latitude values correspond to the geographic locations south of the Equator (abbrev. S).

Longitude is counted from the prime meridian ( IERS Reference Meridian for WGS 84) and varies from −180° to 180°. Positive longitude values correspond to the geographic locations east of the prime meridian (abbrev. E). Negative longitude values correspond to the geographic locations west of the prime meridian (abbrev. W).

UTM or Universal Transverse Mercator coordinate system divides the Earth’s surface into 60 longitudinal zones. The coordinates of a location within each zone are defined as a planar coordinate pair related to the intersection of the equator and the zone’s central meridian, and measured in meters.

Elevation above sea level is a measure of a geographic location’s height. We are using the global digital elevation model GTOPO30 .

Elektrostal , Moscow Oblast, Russia