Flo A. Stein, MPH
NC PIC Project Manager
Chief, Community Policy Management
Division of MH/DD/SAS

EBP Quick Links
MH#1: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
Mental Health Bulletin #1 - Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) was developed to treat post-traumatic stress and related emotional and behavioral problems in children and adolescents.
MH#2: Integrated Dual Disorders Treatment (IDDT)
Mental Health Bulletin #2 - Integrated Dual Disorders Treatment (IDDT) requires that mental health and substance abuse treatment be delivered concurrently by a team of cross-trained clinicians within the same program.
MH#3: Wellness Management and Recovery (WMR)
Mental Health Bulletin #3 - The National Institute of Mental Health estimates that approximately 6% of the U.S. population has severe mental illness (SMI). For North Carolina, that percentage translates to approximately 200,000 people who suffer from severe psychiatric disorders.
MH#4: Family Psychoeducation
Mental Health Bulletin #4 - Persons with severe mental illness (SMI) often rely on family members for the majority of their needed support, and it is estimated that 35-60% of adults with SMI live with family members.
SA#1: Contingency Management (CM)
Substance Abuse Bulletin #1 - Contingency management (CM) is a motivational incentive intervention in which clients with substance use disorders receive small rewards for attending treatment, taking prescribed medication, providing negative urine samples, or complying with other defined treatment-related goals.
SA#2: Strengthening Families Program (SFP)
Substance Abuse Bulletin #2 - The Strengthening Families Program (SFP) is a parenting and family strengthening program for high risk families. It combines science-based (1) parenting-skill training, (2) child life-skill building, and (3) family lifeskill education into a program that improves the child's social/life skills and family functioning and protects the children from the long-term risks of drug abuse.
SA#3: Seeking Safety
Substance Abuse Bulletin #3 - Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder that may result from exposure and sometimes multiple exposures to highly traumatic events such as child abuse, accidents, violent personal assaults, military combat, or natural or human caused disasters.
SA#4: Matrix Intensive Outpatient Treatment
Substance Abuse Bulletin #4 - Matrix was developed in the 1980s by researchers at the University of Southern California and clinicians at the Matrix Institute on Addictions who found that clients addicted to stimulants were challenging the existing treatment system.
SA#5: The Seven Challenges
Substance Abuse Bulletin #5 - The Seven Challenges program was developed in the early 1990s by Dr. Robert Schwebel who recognized the lack of age appropriate substance abuse treatment models for adolescents.
Developing Effective, High-Quality Community Mental Health and Substance Abuse Services: A Guide for Local Management Entities
by Beth Melcher, Ph.D. This manual seeks to clarify and provide guidance to LMEs on how to successfully engage in the service development role. It promotes the implementation of evidence-based and best practice services and supports.
National Registry of Evidence-based Programs and Practices
NREPP is a searchable database of interventions for the prevention and treatment of mental and substance use disorders. SAMHSA has developed this resource to help people, agencies, and organizations implement programs and practices in their communities.

PIC Application

New Online Course on Military Culture for Health Care Professionals

Center for Deployment Psychology (CDP) Releases New Online Course

North Carolina is the home to nearly 800,000 veterans, over 125,000 military members who have served in Iraq and/or Afghanistan, and over 155,000 military children. While veterans are eligible for health and behavioral health services from the US Department of Veterans Affairs (VA), only 51% of Gulf II veterans have enrolled for VA services. The remaining 49% as well as military spouses and children have sought their care from public and private health care facilities. Due to this significant sector of military-connected individuals, it is critical for health and behavioral health care professionals to be competent in military culture.

Last month, the CDP, in collaboration with the US Department of Defense, the US Department of Veteran Affairs, and the Substance Abuse and Mental Health Services Administration, launched the first of four modules in an online course, Military Culture: Core Competencies for Health Care Professionals. The course as a whole will offer a total of eight Continuing Education credits, although each module may also be taken individually. All four modules are anticipated to be available in February 2014.

Module 1: Self-Assessment and Introduction to Military Ethos

Module 2: Military Organization and Roles

Module 3: Stressors and Resources

Module 4: Treatment, Resources, and Tools

Click here to read more about each module and take the course.

Free continuing education credits are available for physicians, nurses, psychologists, social workers, counselors, and marriage and family therapists. For more information, click here.

Students in health career preparatory programs are also advised to take the course. In a recent visit to Duke University, Secretary of Veterans Affairs Bob McDonald met with medical students to promote the VA as an ideal place of employment. The VA is facing an estimated shortage of 28,000 physicians, nurses, other healthcare providers, and administrative staff.

Transitioning Youth with Special Needs

Every developmental age comes with its own challenges. For individuals experiencing mental illness and/or substance use disorders or individuals with intellectual and/or developmental disabilities, these challenges may be greater during the transition to adulthood as services and supports change or become difficult to access.

In 2009, ta North Carolina Institute of Medicine Task Force Transitions for People with Developmental Disabilities issued a report, Successful Transitions for People with Developmental Disabilities outlining the challenges and issuing a set of recommendations. While this report specifically addressed transitions for individuals with developmental disabilities, many of the barriers and solutions are similar.

To provide an idea of how many individuals may be affected in North Carolina, a quick look at the statistics is helpful. About 23.2% or 2,284,750 individuals were under the age of 18 in 2013 . Using recent data, the following statistics can be estimated for the State:

  • • 456,950 teens with a serious mental disorder between the ages of 13-18 (The National Alliance on Mental Illness used an estimate received from the National Institute of Mental Health in 2013 that 20% of adolescents between the ages of 13-18 experience serious mental disorders in a given year – source
  • • 91,390 adolescents needed but did not receive treatment for alcohol use (In 2011, the US Department of Health and Human Services used an estimate from the NC Youth Risk Behavior Survey that 4% of teens needed but did not receive treatment for alcohol use from 1991 to 2011 – source
  • • 91,390 adolescents needed but did not receive treatment for illicit drug use (In 2011, the US Department of Health and Human Services used an estimate from the NC Youth Risk Behavior Survey that 4% of teens needed but did not receive treatment for illicit drug use from 1991 to 2011 – source
  • • 316,895 children between the ages of 3 and 17 with any developmental disability between the years 1997 and 2008 (The US Centers for Disease Control and Prevention estimated that 13.87% of children between the ages of 3 and 17 experience a developmental disability based on data between the years 1997 and 2008 – source

Both the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Disease Control and Prevention (CDC) have promoted the value of early identification and early intervention. SAMHSA discussed the importance of early identification and early intervention of youth experiencing mental illness and/or substance use disorders in a recent issue of The CBHSQ Report. The CDC has also developed resources to encourage early identification and early intervention of developmental disabilities – CDC’s “Learn the Signs. Act Early.” Program, Developmental Disabilities Increasing in US, and Developmental Disabilities Research.


Mental Health in North Carolina

According to 2011-12 data compiled by the Substance Abuse and Mental Health Services Administration (SAMHSA, February 2014), North Carolina fared slightly better in prevalence rates than the US as a whole. For any mental illness in individuals aged 18 and over, NC was at 16.84% in prevalence rates compared to 18.19% for the US. In terms of serious mental illness in individuals aged 18 and over, rates of prevalence were similar, with NC at 3.92% compared to 3.97% for the US. (For additional data on NC, click here.)

NC Treatment Outcomes and Program Performance System (TOPPS) data for FY 2009-10 are aligned with national data, which indicate that behavioral disorders (i.e., attention deficit disorder, oppositional defiant disorder, and conduct disorder) and mood disorders (i.e., major depressive disorder and bipolar disorder) top the list in terms of prevalence rates for those in treatment. The table below indicates the percentage of individuals with specific disorders that were in treatment. Only matched data are reported, for those individuals who had an initial interview and a subsequent interview during treatment. For example, of the 4,332 children receiving mental health treatment in FY 2009-10, 59% were being seen for attention deficit disorder.


To place mental health in a broader context is a three-part series that USA Today ran earlier this summer. An overview of the three-part series is also offered. Each article includes a video—the third one on the criminal justice system makes the case for crisis intervention team training in North Carolina.

  1. Cost of Not Caring: Nowhere to Go: The Final and Human Toll for Neglecting the Mentally Ill
  2. Cost of Not Caring: Stigma Set in Stone: Mentally Ill Suffer in Sick Health System
  3. Mental Illness Cases Swamp Criminal Justice System. On America’s Streets, Police Encounters with People with Mental Illnesses Increasingly Direct Resources Away from Traditional Public Safety Roles

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (February 28, 2014). The NSDUH Report: State Estimates of Adult Mental Illness from the 2011 and 2012 National Surveys on Drug Use and Health. Rockville, MD (downloaded from here).



Suicide in the News

In recent years, the topic of suicide has gained traction in the media due to the high number of veterans who die by suicide. It has been estimated that 22 veterans die by suicide each day or 30.0 per 100,000. This is more shocking when compared to that of their civilian counterparts—14.0 per 100,000. The Action Alliance for Suicide Prevention has estimated that 100 Americans die by suicide a day (see background slide set 1).

Also surprising is the increase in the number of middle age Americans who die by suicide. In 2013, the CDC reported that the rate of suicide in Americans ages 35 to 64 was reported to be 17.6 per 100,000 in 2010. The table below illustrates the high number of male deaths by suicide in the age range of 45 to 59 in the NC in 2010. What is also troubling is the high number of suicides for men age 70 and above.

nc pic table


In general, men tend to die by suicide more frequently than women (19.2 vs. 5.5 per 100,000), and the chart above shows that this national trend is true in NC. Similar to national statistics, women in NC attempt suicide more frequently, with more self injury (NC Division of Public Health, 2013). While suicide is the tenth leading cause of death of all suicides (12.0 per 100,000), it is the third leading cause of death among young people between the ages of 15 and 24 (8.5 per 100,000). In NC, young men between the ages of 20-24 had a rate of 22.58 per 100,000.

Researchers have been studying the role of adverse childhood experiences (ACEs) (i.e., physical, sexual, or psychological abuse; neglect; inadequate supervision; domestic violence; parental separation or divorce; parental substance use; parental mental illness; and parental incarceration before the age of 19) in various physical diseases and mental disorders for nearly 20 years. In 2001, Dube and associates looked specifically at the role of ACES in suicidal behaviors and found that the presence of one or more ACEs significantly increased the risk of death by suicide. Brodsky and Stanley (2008) reviewed the literature and found that early experiences of physical and sexual abuse and parental neglect are risk factors for suicidal behavior in adolescence and adulthood.

In 2007, Belik and co-investigators reported on a national survey, which found that interpersonal traumas and exposure to three or more types of traumatic events were particularly associated with suicidal behaviors. Age of onset analyses indicated that the age of traumatic exposure was earlier than the age at which suicidal behaviors began in the majority of respondents. The results implied that exposure to traumatic events was associated with the incidence of suicidal behaviors above and beyond the effect of sociodemographics, mental disorders, and physical disorders assessed in the survey.

In response to the increase in suicides, the federal government has developed a National Strategy for Suicide Prevention (2012), a collaborative effort of the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Disease Control and Prevention, the National Institutes of Health, the Health Resources and Services Administration, and the Indian Health Service (A copy of the National Strategy may be obtained by clicking here). In addition, SAMHSA has developed suicide prevention toolkits for both seniors and high school students. For middle age Americans, the CDC recommends enhancing social support and community connectedness, improving access to health, mental health and preventive services, and reducing the stigma and barriers associated with seeking help. Other prevention strategies include programs to help those at increased risk of suicide, such as those struggling with financial challenges, job loss, intimate partner problems or violence, stress of caregiving for children and aging parents, substance abuse, major depressive disorders, and serious or chronic health problems.

There is no single cause of suicide. To increase awareness of suicide and suicide prevention, SAMHSA established the Suicide Prevention Resource Center (SPRC). The SPRC hosts a Best Practices Registry, which lists 23 practices. In North Carolina and nationally, a suicide prevention lifeline is also available on a 24/7/365 basis (800-273-8255) for both civilians and veterans (Veterans know it as the Veterans or Military Crisis Line; it is the same telephone number but veterans are routed differently).

In addition to the SAMHSA initiatives, the US Department of Veterans Affairs (VA) and the US Department of Defense collaborated to release a clinical practice guideline, Assessment and Management of Patients at Risk for Suicide in 2013. The Army has developed the ACE (Ask, Care, and Escort) Suicide Intervention Program, which the VA also promotes. For family members, the VA has developed a resource guide, which includes branch-specific websites and resources.

Belik SL, Cox BJ, Stein MB, Asmundson GJ, Sareen J. Traumatic events and suicidal behavior: results from a national mental health survey. Journal of Nervous and Mental Disease, 2007;195(4):342-9.

Brodsky BS, Stanley B. Adverse childhood experiences and suicidal behavior. Psychiatric Clinics of North America, 2008;31(2):223-35.

Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. Journal of the American Medical Association, 2001;286(24):3089-96.

Injury Epidemiology and Surveillance Unit, Injury and Violence Prevention, NC Division of Public Health. The burden of suicide in North Carolina. Raleigh, NC: Division of Public Health, NC Department of Health and Human Services, December 2013




Common Practice Elements

For years, clinicians have been grappling with the issue of what characterizes a successful intervention. In 2005, Chorpita and his colleagues tackled this question by proposing a Distillation and Matching Model (DMM) in which evidence-based practices are distilled into profiles of practice elements. By developing these profiles, treatment providers may select the best intervention for an individual, matching on age, gender, ethnicity, diagnosis, procedures, and other potential variables based on what is included in the manuals. These researchers took the DMM further (Chorpita et al., 2007) by identifying implementation barriers, suggesting potential solutions, and emphasizing the value of the DMM in providing flexibility based on clinical judgment. They clarified that the modular approach does not mean that clinicians can pick and choose the practice elements that they want and introduce them out of sequence—the core elements must still be delivered with fidelity. What it does mean is that clinicians able to individualize the treatment plan so that it addresses multiple problems that a client may have since treatment manuals usually focus on one issue.

In 2009, Chorpital and Daleiden reported on a study in which they applied the DMM to 322 randomized clinical trials for child mental health interventions. After coding on specific practice elements, they found that the treatments arranged themselves in clusters, generally around problem areas such as anxiety, depression, conduct disorders, autism, and trauma. They advanced these findings in 2011, when they noted that they were able to identify the minimum number for treatments for the maximum number of clients in children’s mental health services. Cognitive behavioral therapy was the intervention in over 40% of the treatment groups that did significantly better than the control groups. Lindsey and his colleagues used the same methodology to identify common practice elements in family engagement strategies and found that assessment and accessibility promotion were two practice elements present in at least half of the treatment groups that outperformed a control group (2013).

The result of these studies have implications for treatment providers in North Carolina in that the treatment practices that they adopt should include the common practice elements in successful interventions. National registries such as SAMHSA’s National Registry for Evidence-based Programs and Practices (NREPP); the California Evidence-based Clearinghouse for Child Welfare; and the Model Programs of the Office of Juvenile Justice and Crime Prevention provide practice elements for each of the interventions that they deem to be evidence-based.

Chorpita BF, Becker KD, Daleiden EL. Understanding the common elements of evidence-based practice: Misconceptions and clinical examples. Journal of the American Academy of Child and Adolescent Psychiatry, 2007;46(5):647-52.

Chorpita BF, Bernstein A, Daleiden EL. Empirically guided coordination of multiple evidence-based treatments: An illustration of relevance mapping in children’s mental health services. Journal of Counseling and Clinical Psychology, 2011;79(4):470-80.

Chorpita BF, Daleiden EL. Mapping evidence-based treatments for children and adolescents: Application of the distillation and matching model to 615 treatments from 322 randomized trials. Journal of Counseling and Clinical Psychology, 2009;77(3):566-79.

Chorpita BF, Daleiden EL, Weisz JR. Identifying and selecting the common elements of evidence based interventions: A distillation and matching model. Mental Health Services Research, 2005;7(1):5-20

Lindsey MA, Brandt NE, Becker KD, Lee BR, Barth RP, Daleiden EL, Chorpita BF. Identifying the common elements of treatment engagement interventions in chidlren’s mental health services. Clinical Child and Family Psychology Review, published online December 31, 2013.

Funded wholly or in part by the federal Substance Abuse Prevention and Treatment Block Grant Fund (CFDA #93.959) as a project of the NC Division of Mental Health, Developmental Disabilities & Substance Abuse Services.