208    From the Schools and Programs of Public Health

MENTAL HEALTH TRAINING IN SCHOOLS OF PUBLIC HEALTH: HISTORY, CURRENT STATUS, AND FUTURE OPPORTUNITIES Elizabeth Reisinger Walker, PhD, MPH, MAT Jennie Kwon, BS Delia L. Lang, PhD, MPH, MA Richard M. Levinson, PhD, MA Benjamin G. Druss, MD, MPH

Mental disorders, which are the leading cause of disability1 and contribute to approximately 8 million deaths worldwide annually,2 are a major public health issue. People with mental disorders die 10–25 years younger than the general population.2,3 Fewer than half of people with mental disorders receive treatment for their condition,4 and often the quality of treatment is substandard.5 To address this challenge, the public health workforce must be capable of developing, implementing, and disseminating programs and policies to prevent mental disorders, increase access to and ensure quality of treatment, and improve quality of life for people with mental disorders. Mental health has been recognized as a crucial aspect of public health training since the mid-1900s, when Johns Hopkins University developed the country’s only department focused on mental health.6 In 1959, a report from a conference entitled Mental Health Teaching in Schools of Public Health acknowledged the need for integrating mental health into the curricula at schools of public health (SPHs) and defining the core knowledge of public mental health.7 In the 1970s, the majority of graduates from SPHs felt that mental health issues were important for their coursework and related to their jobs.8,9 Since the 1970s, the few studies addressing mental health training for public health professionals have focused on emergency preparedness and psychological first aid.10–12 No recent work, to our knowledge, has examined current mental health training in SPHs. This issue warrants revisiting because of recent policy changes and trends in public health. During the past 50 years, the burden and cost of illness has shifted even further from acute to chronic diseases,13 including mental disorders. Mental health is moving into the mainstream of health-care delivery, particularly with implementation of mental health parity and the Affordable Care Act. The mental health workforce is aging and there is a growing shortage of public sector leaders.14 Furthermore, the direction of public health education is evolving to ensure that graduates master

the skills needed to have an impact on major public health issues.15 The Association of Schools and Programs of Public Health (ASPPH) has developed recommendations for reshaping public health programs,16–18 which are being used by the Council on Education for Public Health (CEPH) to revise the criteria for accrediting SPHs.19 Given the relevance of mental health in public health today and the prospective changes in public health education, we assessed mental health courses and programs offered by SPHs. METHODS We conducted a content analysis to assess mental health course and program offerings at SPHs and interviewed key informants to examine mental health training and how graduates use their training in the workforce. Content analysis We examined the websites of all 48 SPHs in the United States certified by CEPH as of January 2014. CEPH is the sole accrediting agency for schools and programs that award degrees in public health (http://ceph. org). From March to May 2014, we used mental healthrelated keywords to search the websites of SPHs and compile descriptions of mental health courses and programs. Courses were included if they were part of degree programs at the master’s or doctoral levels. Two researchers reviewed the course descriptions and compiled the initial codebook.20 The researchers independently coded the course descriptions, regularly discussed the codebook and coding, and updated both as needed. We abstracted the following information for each course: school, course number, title, number of credits, key words in the title and/or description, topical category (mental health, substance use, or both), degree of focus on mental health (primary focus or not), and public health subject area (social and behavioral sciences, biostatistics, epidemiology, global health, health policy and management, maternal and child health, general public health, clinical practice, research, and other). We excluded 22 courses that were not related to mental health because the courses either covered topics and skills not specific to mental health (e.g., longitudinal analysis and latent variables) or focused on the role of a substance in a disease process rather than on mental health implications (e.g., role of alcohol in developing cancer). We ran descriptive statistics at the school level to determine the number and type of courses offered by SPHs and at the course level to assess the degree of focus on mental health and topic. We ran crosstabulations to compare course offerings and school

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size, operationalized as number of graduate students or faculty. Because of skewness, we used the median split for number of courses, number of graduate students, and number of faculty. We conducted all analyses in SPSS® version 21.0.21 Key informant interviews We conducted key informant interviews with faculty members involved in mental health programs or courses at SPHs to gain in-depth information about mental health training.22 Following institutional review board approval, we identified 41 potential key informants from the schools’ websites. We invited 30 potential informants to participate; interviewees were selected to represent schools with and without a mental health program and to have variation across their public health subject area of focus. We conducted 16 interviews from January to March 2015. Recruitment stopped when saturation of themes was reached. Once informed consent was received, interviews took place by telephone and lasted 20–45 minutes. A semi-structured interview guide covered the following topics: mental health training at the interviewee’s school, competencies associated with the training, and application of graduates’ training. All interviews were digitally recorded, de-identified and assigned a unique identifier, and transcribed verbatim by one of the researchers. We used MAXQDA for data management and analysis.23 We analyzed interviews using thematic analysis, a flexible method for identifying, analyzing, and describing patterns, or themes. We developed a codebook based on the interview guide and qualitative data. One researcher coded all 16 transcripts and a second researcher independently coded five transcripts; coding was compared and updated as needed. Emerging themes were reviewed to ensure that the data under each theme were coherent but distinct from other themes.24 We also compared themes based on whether the key informants were from SPHs with or without mental health programs. RESULTS Content analysis Of the 48 SPHs, 45 (93.8%) offered at least one class related to mental health. The median number of mental health-related classes was four (range: 0–63). Larger schools tended to offer more mental health-related courses, when measuring school size by number of graduate students (χ25 9.17, degree of freedom [df] 5 1, p50.002) and by number of faculty (χ2512.02, df51, p50.001).

Most of the 316 mental health-related courses had a primary focus on mental health (n5170, 53.8%); in the rest of the courses, mental health was included as a topic but was not the sole focus (Table 1). A median of two courses (range: 0–40) had a primary focus on mental health. Eight SPHs (16.7%) did not offer any courses with mental health as the primary focus. Larger schools tended to offer more courses with a primary focus on mental health (by number of graduate students: χ254.54, df51, p50.033; by number of faculty: χ258.22, df51, p50.004). Of the 316 mental health-related courses, the course descriptions for 63.0% included mental health-related keywords only, 24.7% included only substance use keywords, and 12.3% included both. Across these categories, courses were equally divided between having a primary focus on mental health and including mental health topics (χ250.66, df52, p50.72). The public health subject area with the greatest frequency of mental health-related courses was social and behavioral sciences (n596), followed by health policy and management (n548), epidemiology (n541), clinical practice (n530), and global health (n528) (Table 1). These courses were usually offered in SPHs that were combined with other health professional schools or offered degrees in social work, health psychology, or family therapy. Seven SPHs (14.6%) offered one or more mental health programs: three had mental health concentrations and degrees, four had certificate programs, and four had pre- and postdoctoral training programs (Table 2). Four schools offered one type of program (either a certificate or training program), two schools offered two types of programs (concentration and training program or concentration and certificate), and one school offered all three types of programs (degrees, certificates, and training programs). Key informant interviews Of the 16 key informants, eight were from six SPHs with a mental health program and eight were from eight SPHs without a mental health program. Most key informants were in departments related to social and behavioral sciences and a few were from epidemiology, global health, or health policy and management departments. Key informants emphasized that mental health training was important for all students because of the heavy global burden of mental disorders, compounded by the relative lack of attention given to it in public health. They described three levels of mental health training: infusion of mental health into the overall curriculum, specialized training for students interested in mental

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210    From the Schools and Programs of Public Health

Table 1. Mental health focus and content of mental health coursework, by public health subject area, at 48 U.S. schools of public health, 2014 Focus on mental health

Public health subject area

Number of Number of Total number of courses with courses with mental health and/ mental health as mental health or substance use the primary focus included in the courses (percent) (percent) course (percent)

Social and behavioral sciences

96 (100)

47 (49)

49 (51)

Biostatistics Environmental health

7 (100) 9 (100)

2 (29) 2 (22)

5 (71) 7 (78)

Epidemiology

41 (100)

27 (66)

14 (34)

Global health

28 (100)

17 (61)

11 (39)

Health policy and management Maternal and child health General public health Clinical practice

48 (100)

28 (58)

20 (42)

17 (100) 23 (100) 30 (100)

7 (41) 12 (52) 18 (60)

10 (59) 11 (48) 12 (40)

8 (100)

6 (75)

2 (25)

9 (100) 316 (100)

4 (44) 170 (54)

5 (56) 146 (46)

Research Other Total

health, and additional training for mental health or other health-care professionals. Key informants identified a strong need for integrating mental health into the curriculum so that all students would have some exposure to mental health content and understand how it relates to and influences their topic of focus. Integration could be achieved through the use of more mental health-related examples and guest lectures by faculty involved in mental health research and programs. Several key informants discussed their current implementation and opportunities for expansion of such practices. Other interviewees mentioned that their schools were transitioning to an integrated core public health curriculum, which could incorporate mental health examples. Training for students with a specific interest in mental health included courses, practica and internships, culminating experiences (e.g., theses and capstones), and research with faculty. This training provides students with a more detailed and sophisticated understanding of mental health issues and prepares them to address these issues after graduation. Several key informants mentioned that mental health courses are offered as electives, attended only by students with a

Common course topics related to mental health and/or substance use Social, cultural, and community factors and mental health; prevention, interventions, and evaluation Statistical methods Impact of environment, emergency preparedness Psychiatric epidemiology, chronic disease epidemiology Emergencies and disasters, preparedness, global program planning Services and policy Women, children, and adolescents Public health approaches Social work practices; diagnosis and assessment; treatment, interventions, and services Research methods, grant and manuscript writing Gerontology and aging, anthropology

strong interest in mental health and/or those with room in their schedule. According to the interviewees, for mental health or other health-care professionals, the main benefit of mental health training is gaining a population-based approach that can be applied to the students’ field. Interviewees mentioned public health skills, such as epidemiology, finding evidence-based practices, and planning and evaluating programs, as valuable competencies for mental health professionals to master. Additionally, interprofessional training offers ­flexibility when the students enter the workforce. One key informant noted: Their choice for employment is much larger in terms of the number and variety of places they can work in .  .  . whether it’s more of a management, programmatic position or [one in which] they can rely on their [master of public health (MPH) degree] for their background in evaluation, planning, and accountability.

The main challenge in offering mental health training was the limited number of faculty available to teach mental health courses and oversee students in practical experiences. The following quote illustrates how the number of faculty can affect training opportunities:

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MPH or MSW/MPH with Concentration in Behavioral Healthe MSPH with Concentration in Behavioral Healthf

DrPH in Mental Healthd 16 hours of concentration coursework (six classes), six hours of electives, supervised field experience, capstone 12 hours of concentration coursework, eight hours of electives, nine hours of research methods coursework, thesis

Master’s-level training in population-based research on prevention, causes, treatment, and consequences of mental disorders

Minimum of 64 credits; 17 required courses in the mental health department (40–41 credits) and six additional elective credits; completion of a final research paper 12 courses (40–41 credits) in mental health; attend grand rounds in the Department of Psychiatry and Behavioral Sciences, School of Medicine for at least two quarters Dissertation relevant to public mental health practice

Graduate Certificate in Translational Research in Adolescent Behavioral Healthk

continued on p. 212

Completion of 15 credits: nine hours of coursework, six Training in translational research, focusing on effective treatment and hours of service learning prevention programs, including how these programs can be adapted for adolescent populations in a variety of settings

Training in psychiatric epidemiology, aimed at physicians, residents, and mental health professionals

Completion of 15 credits

University of South Florida, College of Public Health

Training in current issues in mental health policy, including economic impact of mental and substance disorders and treatments, access to treatment, financing, insurance, and delivery system issues

Minimum of 21 credits (five required courses and at least two elective courses)

Certificate Program in Mental Health Policy, Economics, and Servicesi

Certificate in Psychiatric Epidemiologyj

Training in the causes, prevalence, clinical and behavioral features, and consequences of mental disorders in populations to enhance the epidemiologic expertise of mental health professionals and increase public health professionals’ interest in psychiatric disorders

Minimum of 18 credits in the Department of Mental Health, with an additional five credits in the Department of Epidemiology and six credits in the Department of Biostatistics

Certificate Program in Public Mental Health Researchh

University of Florida, College of Public Health and Health Professions

Johns Hopkins University, Bloomberg School of Public Health

Interdisciplinary training in mental health issues through research and learning experiences, with a focus on epidemiologic burden of mental disorders, determinants of mental health, interventions to promote mental health, and mental health services and policy

Training in needs assessment, research, and evaluation related to mental health and substance use disorders

Training in public health practice and applying behavioral and social science approaches to mental health problems Training in community and family mental health issues with a focus on public mental and substance use services

Doctoral-level training in population-based research on prevention, causes, treatment, and consequences of mental disorders

Training in concepts and methods for studying the genetic and psychosocial factors that contribute to the prevalence, incidence, and outcome of mental disorders

Description and objectives

Nine courses offered that are specific to psychiatric epidemiology

Requirements

Emory University, Certificate in Mental Healthg Minimum of seven credit hours from selected courses, practicum, and culminating project related to public Rollins School of Public mental health Health

Certificates

University of South Florida, College of Public Health

MHS in Mental Healthb

Johns Hopkins University, Bloomberg School of Public Health

PhD in Mental Healthc

Area of Interest in Psychiatric Epidemiology for SM and SDa

Program title

Harvard T.H. Chan School of Public Health

Concentrations and degrees

School

Table 2. Mental health programs, requirements, and objectives at seven U.S. schools of public health, 2014

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Program title

Mental Health Training Programr

Coursework, research

Training in the epidemiology and consequences of drug dependence

Coursework, independent research, presentation of research at scientific conferences, seminars Coursework

Training in applying epidemiologic and statistical methods to psychosocial and psychiatric research

Training in children’s mental health services

Training research to advance the understanding of the causes and consequences of mental disorders, including interventions and evaluations of mental health services and systems of care

Training in epidemiology and biostatistics of psychiatric research, focusing on psychiatric genetics and translation research

Training in epidemiologic methods to investigate and take action regarding the onset, course, and consequences of substance abuse

Training in framework for researching the etiology, course, and consequences of psychiatric disorders

Description and objectives

Coursework, research apprenticeships

Coursework in epidemiology, biostatistics, and psychiatric disorders; field placements; faculty-fellow seminar; additional training Coursework in epidemiology, biostatistics, and substance abuse disorders; field placements; facultyfellow seminar; additional training Coursework, seminars, practicum, independent and collaborative research

Requirements

continued on p. 213

j University of Florida Department of Epidemiology. Certificate in psychiatric epidemiology [cited 2015 Jan 5]. Available from: http://epidemiology.phhp.ufl.edu/about/psychiatricepidemiology-certificate

i Johns Hopkins Bloomberg School of Public Health. Mental health policy, economics and services [cited 2014 Oct 6]. Available from: http://www.jhsph.edu/academics/certificate-programs /certificates-for-hopkins-and-non-degree-students/mental-health-policy-economics-and-services.html

h

Johns Hopkins Bloomberg School of Public Health. Public mental health research [cited 2014 Oct 6]. Available from: http://www.jhsph.edu/academics/certificate-programs/certificates-for-hopkinsand-non-degree-students/public-mental-health-research.html

g

Emory University Center for Behavioral Health Policy Studies. Certificate in mental health program [cited 2014 Jul 19]. Available from: http://cbps.emory.edu/mental-health-certificate-program/ index.html

f

University of South Florida College of Public Health. Behavioral health MSPH [cited 2014 Dec 12]. Available from: https://documents.health.usf.edu/pages/viewpage.action?pageId56095892

e

University of South Florida College of Public Health. Behavioral health MPH [cited 2014 Dec 12]. Available from: https://documents.health.usf.edu/pages/viewpage.action?pageId56095864

d

Johns Hopkins Bloomberg School of Public Health. DrPH in mental health [cited 2014 Oct 6]. Available from: http://www.jhsph.edu/departments/mental-health/prospective-students-and-fellows/ degree-programs/drph-in-mental-health

c

Johns Hopkins Bloomberg School of Public Health. PhD in mental health [cited 2014 Oct 6]. Available from: http://www.jhsph.edu/departments/mental-health/prospective-students-and-fellows/ degree-programs/phd-in-mental-health

b

Johns Hopkins Bloomberg School of Public Health. MHS in mental health [cited 2014 Oct 6]. Available from: http://www.jhsph.edu/departments/mental-health/prospective-students-and-fellows/ degree-programs/mhs-in-mental-health

a

Harvard T.H. Chan School of Public Health. Neuro-psychiatric epidemiology. 2014 [cited 2014 Oct 6]. Available from: http://www.hsph.harvard.edu/npe

Yale University

Psychiatric Epidemiologyo

Johns Hopkins University, Bloomberg School of Public Health

Drug Dependence Epidemiologyp Children’s Mental Health Servicesq

Psychiatric Epidemiology and Biostatisticsn

Substance Abuse Epidemiologym

Psychiatric Epidemiologyl

Harvard University, School of Public Health

Columbia University, Mailman School of Public Health

Training programs (pre- and postdoctoral)

School

Table 2 (continued). Mental health programs, requirements, and objectives at seven U.S. schools of public health, 2014

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Harvard T.H. Chan School of Public Health. Pre and post doctoral fellowships [cited 2014 Oct 6]. Available from: http://www.hsph.harvard.edu/npe/pre-and-post-doctoral-fellowships

MSPH 5 master of science in public health

MSW 5 master of social work

MPH 5 master of public health

DrPH 5 doctor of public health

PhD 5 doctor of philosophy

MHS 5 master of health science

SD 5 doctor of science

SM 5 master of science

r

Yale School of Public Health. Mental health training grant [cited 2014 Oct 6]. Available from: http://publichealth.yale.edu/cde/curriculum/phd_cde/mentalhealth.aspx

q

Johns Hopkins Bloomberg School of Public Health. Children’s mental health services training program [cited 2014 Oct 6]. Available from: http://www.jhsph.edu/departments /mental-health/prospective-students-and-fellows/funding-opportunities/childrens-mental-health-services

p

Johns Hopkins Bloomberg School of Public Health. Drug dependence epidemiology training (DDET) program [cited 2014 Oct 6]. Available from: http://www.jhsph.edu/departments /mental-health/prospective-students-and-fellows/funding-opportunities/drug-dependence

o

Johns Hopkins Bloomberg School of Public Health. Psychiatric epidemiology training (PET) program [cited 2014 Oct 6]. Available from: http://www.jhsph.edu/departments/mental-health /prospective-students-and-fellows/funding-opportunities/psychiatric-epidemiology

n

m Columbia University, Mailman School of Public Health. Substance use epidemiology training program [cited 2014 Oct 6]. Available from: https://www.mailman.columbia.edu/become-student /departments/epidemiology/training-programs/substance-abuse-epidemiology/program

l Columbia University, Mailman School of Public Health. Psychiatric epidemiology training program [cited 2014 Oct 6]. Available from: https://www.mailman.columbia.edu/become-student /departments/epidemiology/training-programs/psychiatric-epidemiology-overview

k

University of South Florida. Translational research in adolescent behavioral health [cited 2015 Feb 17]. Available from: http://www.usf.edu/innovative-education/programs/graduate-certificates /translational-research-in-adolescent-behavioral-health.aspx

Table 2 (continued). Mental health programs, requirements, and objectives at seven U.S. schools of public health, 2014

214    From the Schools and Programs of Public Health

I think it would have to do with faculty hiring. I’m looking over at Health Services and I’m seeing [that] nobody over there is doing mental health because they don’t have anybody who knows it; therefore, their students aren’t [learning about mental health] unless they pop over to Global Health, which some of them do.

This challenge was particularly prominent at SPHs without a mental health program. Key informants identified 10 mental health-related competencies that were important for students to master (Table 3). The competencies were categories and course of mental disorders, determinants, diagnosis and measurement, psychiatric epidemiology, services and health-care systems, interventions, mental health promotion, methods and analysis, prevention, and stigma. Other competencies that were mentioned less frequently included using a public health approach, genetics, and policy. Two mental health competencies, diagnosis and stigma, were most frequently mentioned as being unique from other public health topics. Most key informants discussed the complications that arise from not having laboratory tests to diagnose mental disorders. They wanted students to understand the different methods of diagnosing and measuring mental disorders, as illustrated by the following comment: [Students] need to understand how we define behavioral health conditions; how we diagnose and assess; and what the controversies are . . . and how that might [affect] research, practice, interventions, and policy.

Key informants felt that mental disorders are stigmatized in a way that is different from other health conditions and that students should understand the causes, manifestations, and impact of stigma experienced by people with mental disorders. The following quote addresses the impact of stigma: I think people are not fully appreciative of how much stigma they’re going to encounter. . . . When you have somebody who has a broken leg, they usually want you to fix it for them. When you have somebody who’s depressed, they don’t even want to talk to you.

Interviewees commented that graduates apply their mental health training in a variety of capacities. Many graduates work at health-care or social service organizations, county or state health departments, other government agencies, or advocacy groups. Others work in research at academic institutions or consulting groups. MPH graduates tend to provide research support and project coordination, while doctoral graduates are trained for independent research. A smaller percentage of MPH students pursue further education in public health, a related field, or another health profession.

An overarching theme emphasized the need for graduates to understand the impact of mental health in their work, whether or not their jobs focused on mental health issues. The following quote illustrates a common goal for how students use their mental health training: [I hope that] when students leave, they recognize that they don’t have to be diagnosticians, but they recognize the impact of mental health issues, strengths, and symptoms. . . . They realize that mental health is a factor in what they’re doing in whatever health activities they’re doing.

Key informants mentioned several applications of mental health training in the workforce. First, graduates must understand that mental disorders are common, likely affecting some of the people they serve. Second, they need to acknowledge the role of stigma. Third, they should be able to incorporate mental health into program planning, implementation, and evaluation. DISCUSSION Key informants stated that the majority of students at SPHs may not receive any training in mental health, which is similar to findings reported almost 50 years ago.8,9 Mental health continues to be underrepresented at SPHs, particularly relative to its burden to society. Key informants mentioned several factors that contribute to the lack of attention given to mental health, including mental health not being considered as legitimate a public health topic as other illnesses; the lack of faculty focused on mental health limiting training opportunities; and the traditional means of organizing departments, core competencies, and accreditation requirements leaving little room for requiring mental health training for all students. There may be more room for mental health in the curriculum as a new model of public health education develops, focusing on core content and concentrations that span and go beyond traditional disciplines.17,18,25 Faculty are still defining the goals of mental health training, which echoes this statement from the 1959 conference on mental health teaching: “This essential central core of knowledge . . . must be clarified, so that training programs can be developed which will be pertinent to community needs and which will have an enduring effect upon the trainee.”7 Part of defining mental health training in public health involves bridging public health and clinical models of psychiatry and psychology. Bridging these two disciplines reflects a historical tension between public health—which is focused on prevention, populations, and the impact

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Issues, topics, and skills related to ways of diagnosing and measuring mental disorders

Epidemiology of mental disorders, including prevalence, incidence, and risk/protective factors related to mental disorders in the population

Services, treatment in health-care settings, and access to services

Community-based interventions related to mental health or bringing or translating interventions to a broader population; also includes bringing mental health into other community-based programs

Mental health, wellness, and promotion of I think we need to say a whole lot more about actual mental health promotion and not have courses mental health (as opposed to focusing on mental focused solely on mental illness and the debilitating effects, but how do we actually bring mental health, illness) those protective factors, into populations.

Methods and analysis techniques that are specifically related to or important for mental health

Prevention related to mental health—primary (preventing emergence of mental health problems), secondary (early diagnosis, reduce time to treatment), and tertiary (reducing negative effects of existent mental disorders and comorbidities)

Negative attitudes that people have toward individuals with mental disorders

Diagnosis and measurement

Epidemiology

Health-care system, services, and treatment

Interventions

Mental health promotion

Methods and analysis

Prevention

Stigma

DSM 5 Diagnostic and Statistical Manual

ICD 5 International Classification of Diseases

a Key informants were faculty members at schools of public health involved in mental health programs (eight key informants from six schools) or courses (eight key informants from eight schools). Interviews were conducted by telephone.

[Students should] be able to also understand stigma and the unique role that stigma plays in help seeking for mental health conditions and how we prioritize them.

One of these competencies or issues that I wanted to highlight for [students] is how many of these conditions start in early childhood and adolescence. The opportunities for prevention are significant. There are many things we can do.

First, [students should understand] methodological competencies, which would include reliability and validity, diagnosis and categorization, survey methods related to population surveys, and understanding the limitations of the different approaches from clinic-based surveys, hospital-based surveys, historical data, population-level data, and community sampling.

We expose them to the interventions more from the standpoint that we need to help them become proficient at analyzing those interventions, but also from a translational research standpoint. In other words, how do you get the good programming up to scale and out to the public that needs it?

[Students should have] a basic understanding of what treatments and services are being used for different types of conditions and the extent to which the evidence is robust to support the different services that are being used.

They should be able to talk about the relative prevalence of [mental disorders], whether those prevalences are geographically related or similar across the world; whether they are increasing, decreasing, or staying the same over time; and some of the key risk factors.

It’s important that [students] understand the difference in how to classify or characterize psychopathology, so that [they] understand what utility a diagnosis may have vs. thinking of things as dimensions vs. thinking of things as full spectra. And that they can think about classification systems, such as ICD and DSM, vs. systems that don’t rely on classification, both for clinical purposes but more importantly for research and public health services reasons.

[The class] covers the social epidemiology of mental disorders and who is most likely to get which kinds of disorders, and then it looks at how we can understand those social patterns, the gender differences in disorder, and the social class gradient.

Social, cultural, and environmental determinants of mental health problems; includes health disparities

Determinants

[Students should be] able to identify some clinical features and prevalence information on a selection of specific mental disorders.

Comments from key informants

Types, signs, symptoms, and course of specific mental disorders

Description

Categories and course

Competency

Table 3. Categories and descriptions of mental health competencies that public health students should gain through mental health training: themes from key informant interviews with 16 faculty from U.S. schools of public health, 2015a

216    From the Schools and Programs of Public Health

of social and environmental factors—and medicine, which is individual and cure focused.26 As with public health and medicine, opportunities for collaboration and interprofessional training between public and clinical mental health exist. Key informants repeatedly mentioned the benefits of mental health training for health-care professionals and the potential for collaboration in academic and practice settings. The findings from the content analysis and interviews lead to several key implications. First, mental health can be incorporated into the new structure of public health education. ASPPH calls for SPHs to offer core content and an “in-depth education in concentration areas that are responsive to the interests of students, the strengths of the institution, and the needs of employers.”25 These concentrations can cross the traditional public health disciplinary boundaries. Mental health could form the basis for a concentration, building off of current mental health programs. Second, all students should graduate with basic mental health literacy. Based on the competencies identified by key informants, public mental health literacy includes knowledge of major types of mental disorders, diagnostic and measurement issues, epidemiologic patterns and determinants of mental disorders, effects of stigma, mental health prevention and promotion, and effective interventions and treatments. Exposure to mental health topics can occur through examples and case studies in a variety of courses. Students should be able to apply their knowledge of mental health issues to their public health focus. Finally, mental health training can help develop graduates who can fill gaps and provide leadership in the public sector. The mental health workforce is facing serious shortages, which are expected to increase as more people with mental disorders gain insurance coverage under the Affordable Care Act.14 Graduates with mental health training can develop policies and programs for federal, state, and community mental health agencies, as well as work with nonprofit advocacy organizations. Clinical departments can provide students with interprofessional training, which can lead to job opportunities after graduation. Executive MPH programs can provide training opportunities for leaders in the public mental health sector. Limitations This study was subject to two limitations. First, we included accredited SPHs; MPH programs may also offer mental health courses and have mental healthfocused faculty. Second, we could not verify actual course offerings for all schools because of differences in how course descriptions were posted online.

Therefore, courses did not necessarily represent what was offered in the 2013–2014 school year or what is offered regularly. CONCLUSIONS Mental health is an important aspect of public health training for all students, not only those pursuing a career in the mental health field. Although the issues in mental health training have not changed substantially during the past 50 years, there is an opportunity to bridge mental health and public health in the nation’s SPHs. This research was supported by the National Institute of General Medical Sciences (K12GM00680-05) and the National Institutes of Health (5K24MH07586703). The Institutional Review Board of Emory University approved the study protocols. Elizabeth Reisinger Walker is a postdoctoral fellow in the Department of Health Policy and Management at Emory University Rollins School of Public Health, Atlanta, Georgia. Jennie Kwon was a research assistant in the Department of Health Policy and Management at Emory University Rollins School of Public Health and is currently a medical student at the Medical University of South Carolina, Charleston, South Carolina. Delia Lang is a research associate professor in the Department of Behavioral Sciences and Health Education at Emory University Rollins School of Public Health. Richard Levinson is the Charles Howard Candler Professor and Executive Associate Dean for Academic Affairs at Emory University Rollins School of Public Health. Benjamin Druss is a professor and the Rosalynn Carter Chair in Mental Health in the Department of Health Policy and Management at Emory University Rollins School of Public Health. Address correspondence to: Elizabeth Reisinger Walker, PhD, MPH, MAT, Emory University, Rollins School of Public Health, Department of Health Policy and Management, 1518 Clifton Rd. NE, Atlanta, GA 30322; tel. 404-712-8527; fax 404-727-9198; e-mail . ©2016 Association of Schools and Programs of Public Health

REFERENCES  1. Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet 2013;382:1575-86.  2. Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry 2015;72:334-41.   3. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis 2006;3:A42.   4. Kessler RC, Demler O, Frank RG, Olfson M, Pincus HA, Walters EE, et al. Prevalence and treatment of mental disorders, 1990 to 2003. N Engl J Med 2005;352:2515-23.  5. Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:629-40.   6. Thomas KK. Mental health at the Johns Hopkins School of Public Health: a history of the department. Baltimore: Johns Hopkins University; 2013.

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  7. Columbia University. Mental health teaching in schools of public health: a report based on the work of six pre-conference committees and a national conference held at Arden House, New York, on December 6–11, 1959. New York: Columbia University; 1961.  8. Padilla E, Goldston SE. Exposure to mental health training in schools of public health. Am J Public Health 1973;63:710-4.   9. Padilla E, Goldston SE. Role of schools of public health in the development of mental health manpower. Community Ment Health  J 1974;10:16-23. 10. Hawley SR, Hawley GC, St Romain T, Ablah E. Quantitative impact of mental health preparedness training for public health professionals. Biosecur Bioterror 2007;5:347-52. 11. Parker CL, Barnett DJ, Everly GS Jr, Links JM. Expanding disaster mental health response: a conceptual training framework for public health professionals. Int J Emerg Ment Health 2006;8:101-9. 12. Parker CL, Everly GS Jr, Barnett DJ, Links JM. Establishing evidenceinformed core intervention competencies in psychological first aid for public health personnel. Int J Emerg Ment Health 2006;8:83-92. 13. From the Centers for Disease Control and Prevention. Achievements in public health, 1900–1999: changes in the public health system. JAMA 2000;283:735-8. 14. Hoge MA, Stuart GW, Morris J, Flaherty MT, Paris M Jr, Goplerud E. Mental health and addiction workforce development: federal leadership is needed to address the growing crisis. Health Aff (Millwood) 2013;32:2005-12. 15. Fried LP. Innovating for 21st-century public health education: a case for seizing this moment. Am J Public Health 2015;105 Suppl 1:S5-7.

16. Association of Schools and Programs of Public Health. Framing the future [cited 2015 Apr 22]. Available from: URL: http://www .aspph.org/educate/framing-the-future 17. Petersen DJ, Weist EM. Framing the future by mastering the new public health. J Public Health Manag Pract 2014;20:371-4. 18. Petersen DJ, Finnegan JR Jr, Spencer HC. Anticipating change, sparking innovation: framing the future. Am J Public Health 2015;105 Suppl 1:S46-9. 19. Council on Education for Public Health. Proposed curriculum criteria revisions [cited 2015 Apr 22]. Available from: http://ceph .org/criteria-revision 20. Elo S, Kyngas H. The qualitative content analysis process. J Adv Nurs 2008;62:107-15. 21. IBM Corp. IBM SPSS® Statistics: Version 21.0 for Windows. Armonk (NY): IBM Corp.; 2012. 22. Patton MQ. Qualitative research and evaluation methods. 3rd ed. Thousand Oaks (CA): Sage Publications; 2002. 23. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77-101. 24. VERBI GmbH. MAXQDA: Version 10. Berlin: VERBI GmbH; 2010. 25. Association of Schools and Programs of Public Health. A master of public health degree for the 21st century: key considerations, design features, and critical content of the core. Washington: ASPPH; 2014. 26. Brandt AM, Gardner M. Antagonism and accommodation: interpreting the relationship between public health and medicine in the United States during the 20th century. Am J Public Health 2000;90:707-15.

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Mental Health Training in Schools of Public Health: History, Current Status, and Future Opportunities.

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