Flo A. SteinFlo A. Stein, MPH
NC PIC Project Manager
Deputy Director
Division of MH/DD/SAS


Evidence-based Programs and Practices

The mission for the NC PIC is to ensure that all North Carolinians will receive excellent care that is consistent with our scientific understanding of what works whenever they come into contact with the DMHDDSAS system.

To improve the lives of clients during the current era of system transformation, North Carolina must focus on the content and quality of services and supports that are offered. Research has found that even some of the most popular and well disseminated programs are not evidence based and in fact can be counterproductive. The provision of quality services and supports involve fidelity to proven intervention models.

To facilitate guidance in determining the future evidence-based services and supports that will be provided through our public system, the Director of the Division of Mental Health, Developmental Disabilities and Substance Abuse Services has developed the North Carolina Practice Improvement Collaborative (NC PIC). The NC PIC is comprised of representatives of all three disabilities and meets thrice yearly to review and discuss current and emerging best practices for adoption and implementation across the State.

NC PIC Updates

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.

Mental Health First Aid Training in NC

The NC National Alliance on Mental Illness (NAMI) and Mental Health First Aid USA (MHFA) are offering free 8-hour courses on Mental Health First Aid in local communities across the state. The list below identifies the trainings that have been announced thus far although you can find trainings in your area by clicking here. Please note that MHFA has also developed a supplement to the MHFA course for Veterans, Service Members, and their Families and that six individuals in NC have been trained.

Youth Mental Health First Aid* – Washington, NC
Friday, June 13, 2014, 8:00am to 5:30pm
Hampton Inn Washington
2085 W. 15th Street
Washington, NC 27889
Click here to register (deadline May 30, 2014) – Limited space available

Mental Health First Aid – Henderson, NC
Thursday and Friday, June 26 & 27, 2014, 10:00 am to 4:00 pm
Perry Memorial Library – Farm Bureau Room
205 Breckenridge St.
Henderson, NC 27536
To register contact Gina Dement at gina.dement@cardinalinnovations.org

Mental Health First Aid* – Washington, NC
Friday, June 27, 2014, 8:00am to 5:30pm
Hampton Inn Washington
2085 W. 15th Street
Washington, NC 27889
Click here to register (deadline June 6, 2014) – Full, wait list available

Mental Health First Aid for Veterans – Goldsboro, NC
Thursday and Friday, July 10-11, 2014, 10:00 am to 4:00 pm
Goldsboro, NC (Exact location to be determined)
To register contact Gina Dement at gina.dement@cardinalinnovations.org


Scaling up Supported Employment in NC

Individual Placement and Support – Supported Employment (IPS-SE) is an evidence-based intervention that helps individuals with serious mental illness obtain competitive employment in the community.  It is integrated with treatment, and follow-along supports by the treatment agency are ongoing.  Designated by the Substance Abuse and Mental Health Services Administration as one of six evidence-based practices, the Dartmouth Psychiatric Research Center provided the evidence underlying the model and outlined the steps for implementing and evaluating it in a downloadable toolkit.

Since its development in 1996, numerous studies have demonstrated its effectiveness.  In addition, researchers at the US Department of Veterans Affairs (VA) and the Dartmouth Psychiatric Research Center have introduced IPS-SE supported employment on a large-scale basis.  In 2007, Resnick and Rosenheck provided preliminary results on a national dissemination initiative, which included an evaluation of two levels of training.   They found that key elements required by such initiatives include “attention to all levels of the organization, especially top leadership; clear program objectives; investment in training by experienced experts; creation of an open learning community through multiple media; and performance measurement with regular feedback at both the program and client level.”  In 2009, they confirmed these findings and stated that “successful implementation is facilitated by supportive leadership at the local level, familiarity of the mentoring staff with rehabilitation values, and possession of both skill and expertise in leadership and teaching roles.”

Becker and her colleagues (2011) described the dissemination of supported employment in 12 states and the District of Columbia, using a two-tiered learning collaborative.  They found that the learning collaborative not only facilitated “implementation, dissemination, standardization, and sustainability of supported employment”, but is also provided an opportunity for participating mental health and vocational rehabilitation leaders to “share educational programs, implementation and intervention strategies, practice experiences, outcome data, and research projects.”

NC joined the IPS-SE international learning collaborative in July 2013 and received a four-year grant to implement IPS-SE for individuals with serious mental illness and co-occurring disorders in the State.  It currently has about 27 provider agencies offering IPS-SE.  Under the aegis of the NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services and the NC Division of Vocational and Rehabilitation Services, four sites—Easterseals UCP, Meridian Behavioral Health, Monarch of NC, and the UNC Center for Excellence in Community Mental Health—were selected to serve as research sites in partnership with the Dartmouth Psychiatric Research Center.  These providers will collect research data for the Center.


Becker DR, Drake RE, Bond GR, Nawaz S, Haslett WR, Martinez RA. A national mental health learning collaborative on supported employment. Psychiatric Services, 2011,62(7):704-6

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services; NC Division of Vocational and Rehabilitation Services; NC Employment First Technical Assistance Center, and the UNC Center for Excellence in Community Mental Health’s NC ACT Technical Assistance Center. Advancing Recovery, 2014;1.

Resnick SG, Rosenheck RA. Dissemination of supported employment in Department of Veterans Affairs. Journal of Rehabilitation Research and Development, 2007;44(6):867-78

Resnick SG, Rosenheck RA. Scaling up the dissemination of evidence-based mental health practice to large systems and long-term time frames. Psychiatric Services, 2009;60(5):682-5