[Senate Hearing 108-405]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 108-405

 RECOMMENDATIONS TO IMPROVE MENTAL HEALTH CARE IN AMERICA: REPORT FROM 
        THE PRESIDENT'S NEW FREEDOM COMMISSION ON MENTAL HEALTH

=======================================================================

                                HEARING

                               BEFORE THE

       SUBCOMMITTEE ON SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                                   ON

  EXAMINING THE REPORT FROM THE PRESIDENT'S NEW FREEDOM COMMISSION ON 
MENTAL HEALTH RELATING TO RECOMMENDATIONS TO IMPROVE MENTAL HEALTH CARE 
                               IN AMERICA

                               __________

                            NOVEMBER 4, 2003

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions




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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  JUDD GREGG, New Hampshire, Chairman

BILL FRIST, Tennessee                EDWARD M. KENNEDY, Massachusetts
MICHAEL B. ENZI, Wyoming             CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
CHRISTOPHER S. BOND, Missouri        BARBARA A. MIKULSKI, Maryland
MIKE DeWINE, Ohio                    JAMES M. JEFFORDS (I), Vermont
PAT ROBERTS, Kansas                  JEFF BINGAMAN, New Mexico
JEFF SESSIONS, Alabama               PATTY MURRAY, Washington
JOHN ENSIGN, Nevada                  JACK REED, Rhode Island
LINDSEY O. GRAHAM, South Carolina    JOHN EDWARDS, North Carolina
JOHN W. WARNER, Virginia             HILLARY RODHAM CLINTON, New York

                  Sharon R. Soderstrom, Staff Director

      J. Michael Myers, Minority Staff Director and Chief Counsel

                                 ______

       Subcommittee on Substance Abuse and Mental Health Services

                      MIKE DeWINE, Ohio, Chairman

MICHAEL B. ENZI, Wyoming             EDWARD M. KENNEDY, Massachusetts
JEFF SESSIONS, Alabama               JEFF BINGAMAN, New Mexico
JOHN ENSIGN, Nevada                  JACK REED, Rhode Island

                    Karla Carpenter, Staff Director

                  David Nexon, Minority Staff Director

                                  (ii)

  




                            C O N T E N T S

                               __________

                               STATEMENTS

                            NOVEMBER 4, 2003

                                                                   Page
DeWine, Hon. Mike, a U.S. Senator from the State of Ohio.........     1
Kennedy, Hon. Edward M., a U.S. Senator from the State of 
  Massachusetts..................................................     3
Reed, Hon. Jack, a U.S. Senator from the State of Rhode Island...     5
Mayberg, Stephen W., Commissioner, The Presidents New Freedom 
  Commission on Mental Health, Sacramento, CA; and Charles G. 
  Curie, Administrator, Substance Abuse and Mental Health 
  Services Administration, U.S. Department of Health and Human 
  Services, Washington, DC.......................................     6
Appelbaum, M.D., Paul S., Department of Psychiatry, University of 
  Massachusetts Medical School, Worcester, MA; Michael M. Faenza, 
  President and Chief Executive Officer, National Mental Health 
  Association, Washington, DC, on behalf of the Campaign For 
  Mental Health Reform; Carlos Brandenburg, Administrator, Nevada 
  Division of Mental Health and Developmental Services, Carson 
  City, NV; and Ann Buchanan, Cockeysville, MD...................    22

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Stephen W. Mayberg...........................................    36
    Charles G. Curie.............................................    39
    Paul S. Appelbaum, M.D.......................................    41
    Michael Faenza...............................................    64
    Carlos Brandenburg...........................................    66
    Ann Buchanan.................................................    68

                                 (iii)

  

 
 RECOMMENDATIONS TO IMPROVE MENTAL HEALTH CARE IN AMERICA: REPORT FROM 
        THE PRESIDENT'S NEW FREEDOM COMMISSION ON MENTAL HEALTH

                              ----------                              


                       TUESDAY, NOVEMBER 4, 2003

                               U.S. Senate,
 Subcommittee on Substance Abuse and Mental Health 
                                          Services,
of the Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10 a.m., in 
room SD-430, Dirksen Senate Office Building, Senator DeWine 
(chairman of the committee) presiding.
    Present: Senators DeWine, Kennedy, Reed, Murray, and 
Clinton.

                  Opening Statement of Senator DeWine

    Senator DeWine. We welcome all of you today. I certainly 
welcome my colleague, Senator Kennedy, whom I look forward to 
working with closely on these issues particularly as we move 
forward on the reauthorization of the Substance Abuse and 
Mental Health Services Act.
    Today we are meeting to talk about the report and 
recommendations made by the President's New Freedom Commission 
on Mental Health. The findings in this report are certainly 
very important but also very troubling.
    Each year, approximately 5 to 7 percent of adults and 5 to 
9 percent of children experience serious emotional disturbances 
or serious mental illness. These illnesses are a great 
impediment to their daily function. Mental health is 
fundamental to a person's overall physical health and well-
being and is crucial to leading a productive and balanced life.
    Mental illnesses such as depression and schizophrenia are 
illnesses as destructive as cancer or heart disease. Mental 
illness ranks first among illnesses that cause disabilities in 
the United States, Canada, and Western Europe.
    The World Health Organization has reported that suicide 
worldwide causes more deaths each year than war or murder and 
is the leading cause of violent death.
    Despite such staggering statistics, it is apparent that 
there continue to be barriers to treatment for a great number 
of those who suffer from mental illness. In a 1999 report by 
the Surgeon General on the topic of mental health, he said: 
``Research-based capacities to identify, treat, and in some 
instances prevent mental disorders are outpacing the capacities 
of the service system the Nation has in place to deliver mental 
health care to all who could benefit from it.''
    Clearly, this leaves a great number of people with mental 
illness suffering.
    We know that the monetary and emotional toll of mental 
illness is very high in this country. Annually, the indirect 
economic cost of mental illness is around $79 billion, $63 
billion of which is due to lost productivity.
    There is also a tremendous cost to the system for the 
incarceration of mentally ill offenders. Approximately $4 
billion is lost in productivity for the incarcerated who have 
mental illnesses and for the lost time of those who provide 
family care.
    The difficult issues surrounding the incarceration of 
mentally ill offenders are discussed in this report and are 
issues that have been of great concern to me for quite some 
time. In an effort to address this problem, I worked with my 
fellow Ohioan, Congressman Ted Strickland, to introduce the 
Mentally Ill Offender Treatment and Crime Reduction Act, which 
recently passed the Senate. This bill offers grants to create 
and expand mental health courts and also provides training for 
officers in criminal and juvenile justice agencies to help them 
properly identify offenders who may be mentally ill.
    This bill also has received broad bipartisan support. I 
want to thank Senator Kennedy for his work on the bill. And I 
feel it is very important, both to public health and to public 
safety, that we continue to move forward on this bill.
    The report that we are examining today will help us do even 
more here in Congress to help ease the suffering of the 
mentally ill. I look forward to hearing the goals and 
recommendations in this report as well as plans for 
implementation. This report has the potential to be a concrete 
starting point for the Federal Government, the States, and the 
mental health community in reforming the current system.
    On our first panel this morning, I would like to introduce 
Dr. Stephen Mayberg and Administrator Charles Curie. Mr. 
Stephen Mayberg comes to us from the California Department of 
Mental Health, where he serves as director. Dr. Mayberg was 
appointed director in 1993 and was reappointed in 1999. Prior 
to his appointment, he served as director of the Yolo County 
Mental Health Program. He has served as president of the 
California Mental Health Directors Association, president of 
the National Association of State Mental Health Program 
Directors, and president of the NASMHPD Research Institute.
    Administrator Curie is from the Substance Abuse and Mental 
Health Services Administration. He has been gracious enough to 
testify at two previous hearings of this subcommittee, and we 
thank him for doing that.
    Prior to his confirmation as administrator in October 2001, 
Mr. Curie served as deputy secretary for mental health and 
substance abuse services for the Department of Public Welfare 
in Pennsylvania. During his tenure, he established and 
implemented a policy to reduce and ultimately eliminate the use 
of seclusion and restraint practices in the State hospital 
system. This program won the 2000 Innovations in American 
Government Award sponsored by the Harvard University John F. 
Kennedy School of Government, the Ford Foundation, and the 
Council on Excellence in Government.
    Mr. Curie also served as president and CEO of the Helen H. 
Stevens Community Health Center in Carlisle, PA and executive 
director and CEO of the Sandusky Valley Center in Tiffin, OH.
    Let me now turn to Senator Kennedy for introductions of our 
second panel.

                  Opening Statement of Senator Kennedy

    Senator Kennedy. Thank you very much, Mr. Chairman.
    I might just make a brief opening comment, and I want to 
first thank Senator DeWine. He was really responsible for our 
committee developing this Subcommittee on Substance Abuse and 
Mental Health Services because of his long-time interest and 
strong commitment. We are hopeful that in this Congress not 
only will our committee be more involved and active but also 
that the Senate will in terms of our national debate and 
action. So I want to thank him very much for all that he has 
done in developing the subcommittee and also for calling this 
hearing today.
    As the President's Commission reports, our mental health 
system is in crisis and is providing inadequate care. Too many 
people are falling through the cracks and not obtaining the 
care they need. Improving access to mental health care is one 
of the most important health issues facing the Nation. One of 
the saddest examples of the crisis is the emerging issue of 
families giving up custody of their children because mental 
health care and support are not available.
    We have legislation with Senator Grassley and myself, 
cosponsored by more than 77 Members of the Senate, and the 
funding is already in the budget, so we are very hopeful that 
we can get that legislation passed before we adjourn this fall.
    As the report makes clear, the mental health system needs 
far more than simple repair. A broad transformation is needed. 
Mental illness should be treated with the same urgency as other 
medical problems.
    When the President announced the formation of the 
Commission, he urged Congress to enact legislation that would 
provide full parity in health insurance coverage of mental and 
physical illnesses. He emphasized that limits placed on 
benefits are a major barrier to mental health care. Yet the 
legislation needed to bring parity to mental health care is 
still far from enactment.
    It has been 3 years since the ``Mental Health Equitable 
Treatment Act'' was first introduced by Senator Domenici and 
Senator Wellstone. In this Congress, it has broad bipartisan 
support, with 66 Senate cosponsors. The American people should 
not have to wait any longer for this help.
    The bill brings first-class medicine to millions of 
citizens who have been second-class patients for too long. 
Passage of the Paul Wellstone Mental Health Equitable Treatment 
Act should be the first order of business in transforming the 
mental health system in the Nation.
    The crisis in coverage has many harmful consequences. 
Private practitioners are withdrawing from managed care 
networks over concerns about adequate reimbursement, and 
patients are left struggling to find doctors who will treat 
them. Often, patients face a 50 percent copay for mental health 
services compared to the customary 20 percent for physician 
office visits. Many do not get the treatment they need for 
mental disorders because of the higher copayment.
    The report also cites another key barrier--the shortage of 
mental health professionals trained to work with children and 
adolescents particularly in rural areas. Disparities like this 
in mental health services should be eliminated, and early 
mental health screening and assessment should be common 
practice.
    The failure by a patient to obtain treatment can mean years 
of shattered dreams and unfulfilled potential. Americans with 
mental illness deserve health and happiness, too, just as those 
with physical illness.
    One in five Americans will suffer some form of mental 
illness this year, but only one-third of them will receive 
treatment. Millions of our fellow citizens are unnecessarily 
enduring the pain and sadness of seeing a loved one or a friend 
battle illnesses that seize the mind and break the spirit.
    Now is the time for Congress and the administration to take 
action to address the mental health crisis in our Nation. I 
look forward to the important testimony we will hear today and 
to working with my colleagues to achieve the reforms so clearly 
needed.
    I might mention, Mr. Chairman, that we have excellent 
studies that go back to the Carter Administration. Rosalyn 
Carter appeared before this committee and was one of the first 
First Ladies to testify on mental health. She was very 
impressive then, and she continues to maintain a very high 
profile and a great interest in this issue, and I believe she 
was over in the House of Representatives testifying as well. 
She has done an extraordinary job.
    Then, we had the 1999 Surgeon General's report, and now we 
have this report. So it is really coming down to whether we 
have the will to take action.
    I think we have seen the documentation of what is necessary 
and what is needed, analyzing the challenges that we have out 
there in terms of the fragmentation and the failure to reach 
parity. But as we are looking at the failure to reach parity, 
we fail even in the Medicare system, the public system. We have 
not done our job even here in terms of making sure that that 
system is going to have full parity.
    What we are finding out is that the longer we wait--and 
today we are going to hear some excellent testimony--it is 
getting more difficult to develop providers. The numbers are 
shrinking, reimbursement obviously is poor, the paperwork is 
exhaustive, and the gymnastics that doctors have to go through 
in order to treat their patients correctly in terms of getting 
proper treatment for them is wearing on the doctors as well as 
on the patients. Children and the elderly are the most 
vulnerable, and we see that and hear about it time and time 
again, and we have not done what is necessary.
    So I want to thank the chairman. He is a man of resolution 
and determination, I know, and he works to try to see how we 
can work across the span to try to get bipartisan support. We 
want to thank him very much for having this hearing, and we 
commit ourselves to working with the chair and all of the 
members of the committee.
    Just briefly, I want to thank Paul Appelbaum, at the 
University of Massachusetts Medical School. It is a great 
pleasure. He is currently director of the Department of 
Psychiatry at the University of Massachusetts Medical School 
and has been a practicing psychiatrist for 20 years. I want to 
thank him for his commitment to treating the indigent and 
working poor. He has had an extraordinary commitment to that 
over the course of his life.
    He is immediate past president of the American Psychiatric 
Association, where he highlighted the growing problems of 
persons with mental disorders in accessing needed psychiatric 
services both in terms of personnel and facilities. It is a 
very important message for us.
    And I want to thank Ann Buchanan who will be telling us a 
human story. She is enormously courageous, and we look forward 
to her testimony.
    Thank you, Mr. Chairman.
    Senator DeWine. Senator Kennedy, thank you very much.
    Senator Reed?

                   Opening Statement of Senator Reed

    Senator Reed. Thank you very much, Mr. Chairman, and let me 
also commend you, not only for scheduling this hearing but for 
your consistent and determined advocacy for mental health 
issues and so many other issues in the U.S. Senate and the 
United States Congress.
    I want to thank the witnesses for being here. The New 
Freedom Commission is another in a series of reports which 
suggest that our mental health care system is broken and needs 
significant reform. And policymakers at every level--national, 
State, and local--have to be concerned about this system.
    I am particularly disappointed as we begin this hearing 
that we have yet to move on the Paul Wellstone Mental Health 
Parity Act. I think that measure alone would contribute 
significantly to improving the system of mental health care 
throughout the United States.
    We have seen despite our initial efforts to achieve mental 
health parity, the insurance companies have found ways around 
it. What we want to do is find a way so that they can deliver 
care that meets the needs that we see out there in society.
    I think indeed, one of the first steps we should take in 
this reform effort is to pass the pending Paul Wellstone Mental 
Health Parity Act, but as the Commission points out, that is 
not the only step that we can take and must take. In my own 
State of Rhode Island, we have a very, very active group of 
mental health practitioners and support systems, but we still 
have problems. One of the key problems is in the area of 
childhood and adolescent mental health services. We have a 
wonderful hospital, Bradley Hospital, the only psychiatric 
hospital in the Nation to exclusively treat children and 
adolescents with mental illness, and they do a remarkable job. 
Yet that hospital and that system of care for adolescents and 
children is under great pressure and great stress.
    In many cases, we are failing the children of this Nation 
when it comes to providing effective mental health services, 
and that is a problem that we will not only regret, but suffer 
for many decades going forward as these children mature into 
adults.
    Ann Buchanan, as Senator Kennedy pointed out, will tell the 
story of her son Rusty, who experienced the problem of ``aging 
out'' of the system, being in that awkward transition from an 
adolescent mental health care system into the adult system, and 
that transition is difficult and in some places impossible.
    But again, I hope we can rally the support and, as Senator 
Kennedy said, the will to do what increasingly is clear that we 
must do, and that is to fix our mental health care system.
    Thank you, Chairman DeWine.
    Senator DeWine. Thank you, Senator Reed, very much.
    What we will do for all of our witnesses today is follow a 
5-minute rule, and we would like you to condense your testimony 
to 5 minutes. We already have everyone's written testimony, so 
if you could just condense it to 5 minutes, that will give us 
an opportunity to ask some questions.
    Dr. Mayberg, thank you for joining us.

STATEMENTS OF STEPHEN W. MAYBERG, COMMISSIONER, THE PRESIDENT'S 
 NEW FREEDOM COMMISSION ON MENTAL HEALTH, SACRAMENTO, CA; AND 
  CHARLES G. CURIE, ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL 
 HEALTH SERVICES ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND 
                 HUMAN SERVICES, WASHINGTON, DC

    Mr. Mayberg. Thank you, and good morning, Mr. Chairman and 
subcommittee members.
    I am Stephen Mayberg. I have submitted written testimony, 
and I think all of you have clearly articulated many of the 
issues and what brings us to this position. I will speak to you 
from my position as a commissioner on President Bush's New 
Freedom Commission on Mental Health and as director of the 
California Department of Mental Health, arguably the largest 
public mental health system in the United States.
    As you know, there were 15 commissioners on this committee, 
the first group representing States, elected officials, 
constituency groups, family members, and consumers. There were 
seven ex officio members and representatives from Health and 
Human Services as well as HUD, Labor, Education, and Veterans' 
Affairs.
    We were charged with looking at the public and private 
mental health system and the issues that led to the failures in 
our system, or the system in shambles, as we reported in our 
annual report, looking at three particular issues--stigma, 
fragmentation, and the disparities in private insurance between 
health and mental health. We focused in on fragmentation.
    The charge was to complete this in 1 year. We found that 
the work was overwhelming and was more than we could handle in 
a year, but that did not stop us from holding monthly meetings 
and having two field visits, one to Los Angeles and one to 
Chicago.
    We discovered that the issues are tremendously complex and 
not easily articulated in a short period of time. We had 
feedback from the public, from written testimony, expert 
testimony, invited testimony, as well as reading voluminous 
amounts of material. We broke into 16 subcommittees because we 
could not get a handle on that and focused on specific issues 
like children's services, older adult services, the interface 
with the criminal justice system and the interface with the 
physical health system, cultural competence, acute care--all 
kinds of things like that.
    What we came up with after 6 months was that it was in our 
minds true that the system was broken and needed to be 
transformed, not reformed, that services were fragmented for 
children and for adults, and for older adults, services were 
almost nonexistent, and there was a disproportionate amount of 
burden on us in terms of disability and employment of persons 
with serious mental illness.
    In July, we submitted our report with a series of goals and 
recommendations and a vision that mental health needs to be a 
higher priority, that there should be a time in our future when 
mental illness can be prevented or cured, but every American 
deserves access to adequate treatment and support.
    Let me quickly discuss the key goals and recommendations 
that we have made. First, we found that if we are to transform 
mental health care, our programs, from the Federal level to the 
community level, must shift toward consumer and family-driven 
services. Consumer needs and preferences--not bureaucratic 
requirements--must drive the services that they receive. To 
achieve that goal, the Commission recommends specific changes 
in Federal programs and upgraded State responsibility for 
planning effective services.
    Second, we observed that the members of minority groups and 
people in rural areas today have worse access to care. ``Place 
and race'' does matter. Further, they often receive services 
that are not responsive to their needs. As a result, the burden 
of mental illness is heavier for those individuals. The 
Commission urged a commitment, again, from the community up to 
the Federal level to services that are ``culturally 
competent,'' acceptable to and effective for people of varied 
backgrounds.
    The Commission's review further found that too often, 
mental illness is detected late, not early. As a result, 
services frequently focus on helping people live with 
considerable disability rather than on intervening early, which 
nearly always yields better outcomes, with less disability, and 
a better opportunity for meaningful life in the community.
    Thus, we recommend a dynamic shift in care toward a model 
that emphasizes early intervention and disability prevention 
and, as our report stated, ``Early detection, assessment, and 
linkage with treatment and supports can prevent mental health 
problems from compounding and poor life outcomes from 
accumulating.''
    Achieving this goal requires better and more extensive 
engagement in education of first-line health care providers, 
primary care practitioners, but also demands a greater focus on 
mental health care in institutions such as schools, child 
welfare programs, and the criminal and juvenile justice 
systems. The goal is a system of integrated community-based 
care that can screen, identify, and respond to problems early.
    The Commission also noted that a majority of adults, even 
those with the most serious mental illness, want to work but 
are held back by poor access to effective job supports, 
incentives to remain on disability status, and employment 
discrimination. That, too, can be changed.
    We also recognize that there is a gap between what we know 
and what we do, and there is a 15- to 20-year science-to-
service delivery gap. We need to move our system forward where 
we use what we have learned in practice rather than leaving it 
in the journals, and that means changing our incentives to pay 
for that but also changing our training programs to make sure 
that people are educated appropriately in the latest state-of-
the-art, state-of-science, services.
    Finally, we feel that it is incumbent upon us to move into 
the 21st century and use the power of information technology 
more appropriately. We need to look at how to use patient 
records in ways that both protect privacy but use technology so 
that people get appropriate and adequate care and do not have 
to reiterate their issues time and time again.
    We understand that the majority of Americans go to the 
Internet to look up issues of their disease, and we need to be 
able to put that in a usable form for most people when they 
find out that someone in their family or they themselves are 
suffering from a mental illness.
    With these recommendations, our work is done and the work 
of all the rest of our advocates, friends, and policymakers 
begins. We truly believe that we have a blueprint for change. 
We hope that through a series of hearings like this and through 
the advocacy of all those in the mental health community, we 
will be able to achieve that change.
    Thank you very much.
    Senator DeWine. Dr. Mayberg, thank you very much.
    [The prepared statement of Mr. Mayberg may be found in 
additional material.]
    Senator DeWine. Mr. Curie?
    Mr. Curie. Thank you, Mr. Chairman, Senator Kennedy, 
Senator Reed. I am honored to present on the President's New 
Freedom Commission on Mental Health and the administration's 
activities to achieve the goals contained in the Commission 
report.
    I would also like to request that my written statement be 
submitted for the record.
    First, I want to thank my friend and colleague, Steve 
Mayberg, for his contributions to the Commission's work. He is 
a great leader in California, and he was a tremendous leader 
and member of the commission.
    I also want to recognize the leadership demonstrated by 
Michael Hogan, the director for mental health from Ohio, who 
was unable to be with us today, but he was chairman of the 
President's Commission, and Mike's steadfast commitment to do 
what is right for people with mental illness steered the 
Commission through many tough decisions and ultimately led to 
the final report which we are here to discuss today.
    An important context for our work in the Bush 
Administration and the recommendations developed by the 
Commission is the words of people in our service delivery 
systems working to obtain and sustain recovery. In particular, 
the first position I held as a new master's of social work 
graduate in a branch office in Fostoria, OH was working as a 
therapist to help mental health consumers, individuals coming 
out of at that time Tiffin State Hospital to make the 
transition back into the community. This aftercare group 
included consumers who had spent over a decade in the hospital. 
I asked them the question what they needed to make their 
transition successful and what they needed to deal with and 
manage their illness. They never spoke in terms of programs, 
they did not speak in terms of needing a psychiatrist or even a 
social worker, but what they spoke of was that they needed a 
job, a home, and meaningful personal relationships--or, to use 
a direct quote, ``I need a life, a real life; I need a job, a 
home, and a date on the weekend.'' They want a life, a real 
life with its rewards.
    This is the very essence of the recommendations contained 
in the final report of the President's New Freedom Commission. 
It is a privilege to serve President Bush and work for 
Secretary Tommy Thompson, as this is an administration that 
knows treatment works and recovery is real.
    As you may know, SAMHSA has been given the lead role to 
conduct a thorough review and assessment of the final report of 
the President's New Freedom Commission on Mental Health, with 
the goal of implementing appropriate steps to strengthen our 
mental health system.
    The ``Mental Health System Recovery Plan,'' if you will, 
will require the implementation of a ``To Do List'' currently 
being developed by SAMHSA on behalf of the Bush Administration. 
The ``To Do List'' will form an action agenda to achieve 
transformation of mental health care in America. And I am very 
fortunate to have a lead staff person whom I have asked to 
address this internally for developing this action agenda, and 
she is Kathryn Power. Kathryn recently joined SAMHSA as 
director of our Center for Mental Health Services--she is 
standing up behind me--I was going to say we stole Kathryn from 
Rhode Island, but it benefits us greatly, and it is going to 
benefit the Nation greatly. She is working to develop an agenda 
for transformation that is built around the six goals and 19 
recommendations contained in the Commission's report.
    To lead the effort, I have assembled a transformation task 
force. We are already working with relevant Federal agencies to 
determine ways to provide States the flexibility needed and the 
incentive to bring to bear the full force of the resources 
available to meet the needs of people with mental illness.
    Our agenda must be consumer and family-driven, not 
bureaucratically bogged down. Consumers of mental health 
services and their families must stand at the center of the 
system of care. Consumer and family needs must drive the care 
and services that are provided. The result will be more of our 
family members, coworkers, neighbors and friends living that 
rewarding life in their communities that I talked about in the 
beginning of my remarks.
    In closing, we all need to recognize the changes that need 
to be made will not happen overnight. But what we structure, 
what we begin to pull together to develop this ``To Do List'' 
must assure that we keep pressing onward. Developing and 
implementing the action agenda for transformation will be an 
ongoing process. Clearly, our success will depend on our 
ability to span all levels of government and the private sector 
to align and bring to bear the full force of resources 
available. The strategy will be to keep our focus on the needs 
of adults with serious mental illnesses, children with serious 
emotional disturbances and their family members. The goal is to 
make recovery a reality for everyone.
    Thank you for your time and interest in our work, and of 
course, we would be pleased to answer any questions you may 
have at this time.
    [The prepared statement of Mr. Curie may be found in 
additional material.]
    Senator DeWine. Mr. Curie, thank you very much.
    The ``To Do List'' that you are working on, again, when do 
you think that will be completed, and give us some more ideas 
about what you are looking at.
    Mr. Curie. Sure. We have actually begun working on the ``To 
Do List,'' and we anticipate having a first draft of the 
document which describes our activities and immediate plans 
within the next 60 days. And again, we will have ongoing 
discussions with the committee as we are in the process of 
developing that.
    Senator DeWine. And in 60 days, we will be able to see 
that?
    Mr. Curie. Yes, yes. And in fact, what we will be doing in 
the meantime--at this point, some of the things that we are 
actually doing include conducting an inventory of those things 
that already are being implemented and being worked on within 
the Federal Government around the goals of the Commission. For 
example, there is a national suicide prevention plan that has 
been in the process of being developed over the past 3 to 4 
years. We are looking to bring that into an action plan which 
would be relevant to achieving Goal 1, that mental health is 
essential to health and that we raise the awareness of mental 
health in this country, tying it to health, and have a real 
focus on suicide prevention and a multifaceted approach to 
raising the awareness of what mental illness really is and what 
society needs to be doing to begin to address that.
    We are also pulling together a transformation task force in 
which we bring aboard the Federal agencies. Steve mentioned 
those agencies in his testimony. Not only, of course, will 
SAMHSA and HHS, with CMS, be involved with that, the National 
Institutes of Health, NIMH in particular, and ACF, Children and 
Families, within HHS and HRSA, but also HUD, Labor, Education.
    Recovery is going to be framing this ``To Do List.'' If we 
are looking at recovery, that is facilitating the process of 
helping people learn how to manage their illness and be able to 
manage their life and get that life. That is the end game.
    Access to treatment is critical. Access to care is 
critical. Having the latest evidence-based practices and having 
incentives out there which will be part of this ``To Do List'' 
and how we work with financing and Medicaid to do that is going 
to be critical. But along with that, we also want to make sure 
that all the entities--and I did not mention Justice, but 
Justice will also be part of this task force--are helping 
people understand in general, particularly people with serious 
mental illness in their families, that we are here to help them 
build a life, because we also know that that prevents relapse. 
We also know that ultimately, if you attain and sustain 
recovery, you are also overcoming that disability.
    Senator DeWine. Let me move if I could, because we do not 
have much time, to a follow-up to what Senator Reed said in his 
opening statement and that is an area that I think troubles all 
of us, and that is the whole problem with young people who have 
mental health problems. We are going to get into this further 
in this committee--in fact, we are going to hold at least one 
hearing on the whole issue of suicide among young people, and 
we are going to do that fairly shortly in this committee, and I 
think we will probably have another whole hearing just on 
mental health issues of young people--but let me ask both of 
you this. What is in this report that we should know about in 
the whole area of young people's mental health problems? Maybe 
another way of asking the question is, how are we doing as a 
country? How are we doing, what are we not doing, and what do 
we need to do? I am going to ask the second panel the same 
question.
    Mr. Mayberg. We are not doing very well, and the reason we 
are not doing very well is that first, the system is 
fragmented. Parents say to us time and time again, ``We do not 
know where to get care. The system is opaque''----
    Senator DeWine. Where do I go.
    Mr. Mayberg [continuing]. Where do I go, whom to ask--and 
if I do ask somebody, they send me to somebody else, so that 
care is not coordinated.
    We realize that our interventions with children are 
oftentimes many years after they have first exhibited symptoms, 
and by the time we intervene, many, many bad things have 
happened so that they have lost critical developmental 
milestones because they are struggling with the issues of their 
illness.
    We have to provide more active outreach into the schools 
because children are in schools. Most kids are first seen by 
their primary care providers. We need to work out a system 
where our interface with primary care is much better. And we do 
a very, very poor job where our most disturbed kids are. We do 
not do the same kind of active outreach into the child welfare 
system and into the juvenile justice system like we should do.
    So in summary, we are not treating the early end of it or 
the late end of it, and the system is opaque. So our 
recommendation is much more of a public health-type 
recommendation where we need to do earlier intervention, better 
identification, more empowerment of families to be able to move 
the system forward.
    Senator Reed talked about issues of transition and where 
kids move out. We have two distinct systems. When someone 
graduates from our children's mental health system, a whole set 
of new rules and obligations occurs, and we lose them. We have 
invested lots of energy, and then they start all over again in 
the adult system.
    Mr. Curie. I could concur with everything Dr. Mayberg 
shared. Clearly, primary care linkage is critical because kids 
are seen there more frequently than in any mental health 
setting initially; also, school-based--and those are clear 
recommendations. Keeping the child with the family--you brought 
up earlier the issue around custody, and we need to address 
that. Parents should not have to give up custody of their 
children in order to receive mental health services, and we 
need to address that as part of this action plan. It is 
unacceptable.
    Also, a systems of care approach is important. We do have a 
track record through the Center for Mental Health Services of 
SAMHSA in which we have had over the past decade the 
establishment of systems of care which we see better outcomes--
that is, making sure that all child care and child-serving 
agencies within a neighborhood are working to the benefit of a 
child. The reason that children's issues are so complex is 
because you are talking about multiple systems which engage 
children, and we need to make sure there is a consistent way of 
doing that.
    One other example I would give of why early intervention 
and also applying what we know--and I think that with children, 
taking the science of what we know and making sure it is in the 
delivery system is critical. When we talk about people with co-
occurring disorders, and we are seeing now that one out of 
every five adults with an addiction, according to our latest 
household survey, also has a serious mental illness, we now 
know that there is a window of opportunity in those teen years 
that when a mental illness is beginning to emerge, and kids 
begin experimenting with drugs, that is many times the 
beginning of a co-occurring disorder. We can intervene earlier 
and have a full assessment done. If a teenager, for example, is 
presenting himself because he is using drugs, make sure there 
is a full assessment done; is there an emotional disturbance or 
a mental illness involved in that situation? If you intervene 
in that window of opportunity in the teen years, you can give 
an individual years of a life in their twenties because you are 
treating them for the underlying disorder. We need to make sure 
that that is the expectation.
    Senator DeWine. Senator Kennedy?
    Senator Kennedy. Thank you.
    I thank both of you for enormously powerful and distressing 
testimony. Just on this issue of what you call co-occurring 
disorders, what is SAMHSA doing now to try to deal with that?
    Mr. Curie. I am glad you asked that question, Senator. It 
is a top priority for SAMHSA. We submitted approximately a year 
ago a report to Congress on co-occurring disorders which offers 
a 5-year blueprint of how we can begin implementing a 
partnership with States, in particular, a structure which will 
bring the assessment of co-occurring disorders and treatment as 
part of the expectation of what we do.
    We are in the process of awarding grants. This year, we are 
awarding grants to seven States, called our COSG grants, to 
Governors' offices, so that a Governor's office can bring 
together not only the mental health authority and the drug and 
alcohol authority, but the criminal justice authority because 
of the high rate of individuals in the criminal justice system 
with untreated co-occurring disorders.
    We are also providing ongoing technical assistance. We have 
had a National Summit on Co-Occurring Disorders, and we are 
working very actively to raise it with the professional 
associations as well as the State mental health and drug and 
alcohol authorities. We are working in close partnership with 
the National Association of State Drug and Alcohol Directors as 
well as the National Association of State Mental Health Program 
Directors to see to it that States have what they need to 
address this issue.
    And I think for the first time, the most significant thing 
is that we have been able to quantify the issue. The household 
survey that we do each year now has a mental health component, 
and to be able to clearly show that one out of five people with 
an addiction or an abuse dependence problem has a serious 
mental illness--that is not just a mental health diagnosis, 
that is a functional assessment--tells us that it has got to be 
every door being the right door when you come to a treatment 
door, whether that be primary care, whether that be a mental 
health door or a substance abuse door.
    Senator Kennedy. Is this with regard to children; did the 
survey look at children, too?
    Mr. Curie. The household survey does include those 12 to 
17, so we are able to capture the teenage population, yes.
    Senator Kennedy. Let me ask you, Dr. Mayberg, your 
Commission report strongly supports Federal legislation for 
mental health parity; is that correct?
    Mr. Mayberg. That is correct.
    Senator Kennedy. Do they also make a recommendation with 
regard to Medicare, that we ought to do something to address 
that issue?
    Mr. Mayberg. One of the important issues that we looked at 
was the whole issue of financing, and we did make a 
recommendation that any time there are discussions about 
Medicaid reform or Medicare reform, that mental health needs to 
be at the table and not be an afterthought. And there are some 
specific recommendations about particular issues that should be 
addressed when that discussion occurs, such as parity in 
Medicare, such as prescription drug costs.
    Senator Kennedy. Your earlier outline about the 
fragmentation and how families are trying to deal with this and 
are lost in trying to get a handle on it includes stories that 
we hear time and time again, and our failure to try to 
systematize this is one of the great public policy failures, I 
believe. And part of it is getting the framework and second is 
to get the resources out there.
    How can we change the consumer-driven--most mental health 
services are controlled by managed care where choice is 
limited. We run up against this kind of challenge as well. How 
can we deal with this?
    Mr. Mayberg. We have several recommendations for how to 
deal with this. One, with the transformation, States need to 
take a more active role in developing a plan of care, and that 
means not just mental health, because mental health does not 
provide the majority of care for children or for adults, as it 
turns out, so we need to look at ways that States can plan the 
delivery of care, and there need to be some kind of incentives 
to be able to do that, to break down the silos.
    Senator Kennedy. Which States are doing that? Are any of 
them doing that now?
    Mr. Mayberg. None of them is doing that right now.
    Senator Kennedy. Well, this is the challenge you give us--
to try to set an overall framework at the Federal level, but 
you want the flexibility within the States. I do not know what 
we are hearing about how the States are going to use the 
flexibility to try to deal with the range of different issues 
and problems in terms of the prisons, child welfare. We have a 
great debate about health clinics in schools, and the basic 
reason that we do not have health clinics in schools is because 
people are concerned about the distribution of condoms. That is 
basically the reason. And we see what the loss is in terms of 
being able to work--some schools get around this, and I can 
tell you a dozen different schools in Massachusetts where it 
makes an enormous difference. They do have the health clinics, 
because they have worked the arrangements out with the local 
hospitals and so on, and it makes an enormous difference.
    But what can you tell us about how we are going to as a 
society--is it resources, is it public policy? Here we are now. 
You have studied this thing. What are the real roadblocks in 
trying to get through this? We want you to knock hard on our 
door. Is it resources? Is it the willingness to deal with it? 
Is it the entrenched interests? Where does the responsibility 
lie--and if it is with us, we want to hear it.
    Mr. Mayberg. Senator, I will knock hard, and I think you 
addressed all of the issues. Part of it is a comfort with 
status quo. Part of it is a lack of knowledge. Part of it is 
bureaucratic silos that we have where there is an unwillingness 
to think about new ways of doing business. And part of what we 
really are looking at in our consumer and family-driven system 
is that the persons who are most disenfranchised are the 
recipients of service, and the more we can give them 
information and empower them, the more we can hope that there 
can be some pressures from a grassroots point of view to force 
these changes. I think that we make a mistake in our 
bureaucracies from not listening to that grassroots message. It 
certainly was true in California, not listening, that voters 
were feeling disenfranchised. And I think that consumers and 
family members are very disenfranchised right now. The more 
information we can give them, the more they can attack the 
bureaucratic and policy barriers that stop us from delivering 
quality care.
    Senator Kennedy. My time is up, but could I just ask you 
one question. We have a prescription drug bill that is in 
conference now. Can you make any kind of assessment about the 
people who know they have a problem, are trying to get 
prescription drugs for mental health and just cannot get them 
because of income limitations? Can you make a quick assessment? 
As I said, my time is up, but can you tell us now, or do you 
want to submit that?
    Mr. Mayberg. From a quick point of view from my perspective 
of analyzing the pharmacy debt in California, 70 percent of all 
prescriptions written are by primary care--they are not written 
in mental health. So if it is not covered on the formulary, 
they are not going to get the services.
    Half the people that we see are not eligible for Medicaid 
coverage for their medication, and they do not get it on 
Medicare, so many, many people do not get needed medications 
because of insurance or formulary restrictions.
    Senator Kennedy. Thank you very much.
    Thank you, Mr. Chairman.
    Senator DeWine. Senator Reed?
    Senator Reed. Thank you very much, Mr. Chairman, and 
thanks, Charles, for identifying Kathryn Power. I am working on 
one cup of decaffeinated coffee, so I did not recognize her--
and you are right--you did in fact steal her from Rhode Island, 
but it was good for SAMHSA, and we in Rhode Island are making 
do without her. And Bill Emmett who is also here today is from 
Rhode Island, too. He is a long-time advocate for families with 
mental health issues. Thanks, Bill for your work.
    Let me just address a question which you both alluded to 
based on the questions of the chairman and Senator Kennedy, and 
that is, the problem with transitions. In the juvenile justice 
system, you are getting care and then, suddenly, you are 
released, and the good news is that you are out of some type of 
incarceration, but there are no services. We just throw these 
young people, typically young male adults or teenagers, back 
into the same environment, with no support system, after they 
have made some progress. In fact, in a way, it is cruel, 
because they are beginning to learn to adjust and cope, and 
then they are out the door again.
    There is another area of transition, and that is 
increasingly, college students, who may be getting support at 
home, may be receiving health care under the family plan, they 
go off to college, confront a whole different world, and we are 
seeing remarkable rates of suicide among college students.I 
know that NYU is not alone, but in the last several months, 
there have been three major incidents there.
    It seems to me that one of the problems with the system--
and you have alluded to it, and perhaps you can do more--is 
these transitional points and how do we address the 
transitional points where it seems to be really broken.
    Dr. Mayberg first, and then Mr. Curie.
    Mr. Mayberg. Thank you, Senator.
    Part of the difficulties we have in transition have to do 
with the silos that we talked about, the bureaucratic silos, 
and part of it has to do with regulatory and statutory 
limitations that contribute to that. For example, with children 
in the juvenile justice system, if you are ``incarcerated,'' 
you lose your eligibility for Federal participation, so that 
oftentimes, mental health systems drop out and are not engaged 
in doing case management or care management. The person shows 
back up in the neighborhood, and the system is really clueless 
about what is happening.
    The same thing is true in terms of rules that determine 
eligibility for children up to the age of 18, and when they 
move away and go to college, they lose their eligibility. Too 
often, our system becomes driven by funding streams rather than 
by consumer or family needs. So if we look at ways to deliver 
the services instead of following the dollar, we probably are 
going to do a better job.
    Senator Reed. Charles?
    Mr. Curie. I would also add, Senator, that transitions--and 
framing it that way, I think, is very helpful, because you are 
exactly right--that is where many people fall through a crack, 
where the system has failed individuals not only in your 
example of the young person going to college and that being a 
transition and is there going to be coverage for them and 
accessibility of care, but also in the public health sector, 
not only the juvenile justice system, but also the children's 
mental health system. There are States that have very good 
children's mental health systems but still have not mastered 
the transition of that child going into an adult system of 
care.
    I do believe that what the action agenda needs to address 
as far as the recommendations of the Commission is to assure 
that for the first time, we have a coherent, cross-systems 
mental health agenda at the Federal level, with all those 
departments and entities I mentioned earlier at the table in 
agreement that they are going to be giving a consistent message 
to their counterpart agencies at the State level and that we 
put incentives in working with the States and provide the 
assistance so that every State has a cross-systems mental 
health agenda and plan.
    Right now, the only plan that States are required to submit 
around mental health is around the block grant. That is 
submitted from the State mental health authority to SAMHSA. Our 
block grant constitutes less than half a billion dollars across 
the States, while we have Medicaid that is in the mid-$20 
billion, and we have a juvenile justice system and an adult 
justice system that is providing services within the walls and 
getting into mental health and behavioral health care.
    If we can get that aligned and require a real plan from the 
States, that would be profound and I think set the stage to be 
able to deal with the silos and to be able to address 
transitions in ways that we have not been able to address them 
before.
    Senator Reed. Do you need additional statutory authority to 
prompt this comprehensive planning?
    Mr. Curie. We are examining that right now. We believe 
right now that if we use our State incentive grant model that 
we have used for substance abuse prevention and that we are 
using now for co-occurring disorders, award the dollars to the 
Governors' offices, and we are also discussing with NGA, that 
the Governors would be able to bring together those folks. 
Right now, the good news is that within the administration, all 
the agencies that I mentioned earlier have agreed to send not 
only principals but people who are going to roll up their 
sleeves and do the work for each of those agencies to hammer 
out such a plan.
    So if we set the stage and get rolling with it, one goal 
will be how do you institutionalize that long-term.
    Senator Reed. Thank you very much, gentlemen. My time has 
expired.
    Thank you, Mr. Chairman.
    Senator DeWine. Thank you, Senator Reed.
    Senator Murray?
    Senator Murray. Mr. Chairman, thank you very much for 
having this hearing and for all the work of the Commission. I 
think this provides a very good road map for ways that we can 
improve our country's mental health services, and I think it 
clearly identifies some of the significant gaps in access and 
coverage and quality outcomes, and I hope we can use this 
report as a call to action.
    Mr. Chairman, I especially appreciate your focus on 
children, and Senator Reed and Senator Kennedy as well--I think 
all of us are deeply concerned about where that is going--and 
your commitment to hold additional hearings on how we can 
address some of those inequities, and of course, the 
Commission's report as well.
    Senator Reed and Senator Kennedy both mentioned mental 
health parity. It is an issue that has raised its head here a 
number of times. The Commission has addressed it. I think that 
is one of the reasons why young people have trouble getting 
access to mental health care as well, is the mental health 
parity, and if you could just reemphasize for all of us the 
importance of that, I would appreciate it.
    Mr. Curie. Absolutely. The Commission, of course, has some 
very strong statements in its findings that the issue of parity 
is going to be part of the fundamental transformation, that if 
a parity bill passes--and again, the Commission supported the 
President's position on endorsing and supporting parity--it 
will greatly help access, especially those employees who have 
coverage, to make sure that children who have emerging serious 
emotional disturbances can receive the treatment they need.
    We think it is also tied to developing a system that can 
address in an early way interventions as well.
    Also, there is the issue of the data. There are a variety 
of studies now that have come out that have demonstrated that 
those States that have adopted parity have done so in such a 
way that it has been at a minimal cost and yet the benefits, 
which we are still studying, are very encouraging.
    So again, the Commission supports the President's position 
on parity, and we do believe that you pay for it sometime, I 
guess is another way of looking at it, and if you are not 
paying for it early on to do the right type of treatment, the 
costs are even greater economically, but most importantly, 
profoundly, the human cost is tremendous.
    Senator Murray. Thank you, and I appreciate the 
recommendation on that.
    I did want to ask this. The Commission's report does 
address the current geographic inequities in access, and it 
paints a pretty dim picture for our rural communities. I know 
that in my home State of Washington, almost every county has 
been deemed a mental health profession shortage area, so for 
patients, that means that even if we had mental health parity, 
getting access is almost impossible.
    One of the Commission's recommendations is greater access 
or greater use of technology to reduce some of these access 
problems. In Washington, we are working to integrate 
telemedicine into rural communities to expand access to mental 
health treatment.
    There are a lot of difficulties in implementing technology. 
One of them is reimbursement. I would like you to comment on 
how we are going to address that issue, because it seems to be 
one of the blocks that we have in trying to move forward on 
this.
    Mr. Curie. Goal 6, one of the six major goals, is 
technology, and the link to remote areas was made in terms of 
the use of tele-health. Clearly, as part of this action agenda 
that I described earlier, we are going to be looking at 
aligning financial incentives in a way to realize those goals, 
recognizing that in remote areas, we need to take a 
multifaceted approach. We need to look at technology not only 
in terms of linking professional help directly to consumers and 
families but also the use of technology in individuals' lives 
so that individuals can have access to information and care. 
And we have not exploited that opportunity enough and need to 
do that in this process.
    So a major focus will be the alignment of financial 
incentives to determine what are the types of interventions and 
what are the types of tools that individuals need to have 
available to them in order to attain and sustain recovery, so 
that will be a major focus.
    The other thing I might mention is that when it comes to 
the issue of dealing with rural and remote areas, it is also a 
workforce development issue, and we need to look at how to give 
incentives to professionals to live in those areas, have 
partnerships with the academic institutions. It will be a 
multifaceted approach that we are going to have to take.
    Senator Murray. Well, again, specifically, how do you 
recommend providers are reimbursed and host sites reimbursed 
for training and equipment? That seems to be one of the 
barriers to using technology in our rural communities.
    Mr. Curie. I think we need to examine how we begin to look 
at those as being real interventions in ways that we have not 
looked at them before and determine how they can be financed. I 
think we need to examine what are the barriers----
    Senator Murray. So you are not ready to make 
recommendations?
    Mr. Curie. We are still in the process of examining just 
how those recommendations can look, but we are working--I 
cannot say enough good things about CMS and how they were at 
the table throughout the whole Commission, how they committed 
themselves through this action agenda--and we are examining 
ways in which we can align the financing and have the 
incentives in the right place to realize the goals of the 
Commission.
    Senator Murray. Thank you very much, Mr. Chairman.
    Senator DeWine. Thank you.
    Senator Kennedy--excuse me. Senator Clinton?
    Senator Clinton. I would be happy to listen to Senator 
Kennedy. [Laughter.]
    I want to thank the chairman for this important hearing, 
and I do want to thank Senator Kennedy for his lifetime of 
commitment, along with his family, to many of these issues.
    I also really want to congratulate and thank the 
Commission. I think this is a very significant piece of work, 
and my greatest fear is that nothing will come of it. We have 
been down this road before. We deinstitutionalized people. We 
created drug regimens. We have done a lot to try to deal with 
the problem on the margins and in the silos, and your report 
convincingly and movingly illustrates how far we have to go.
    I would hope that you would use this committee, 
particularly people like the chairman and Senator Kennedy, my 
colleagues, Senator Reed and Senator Murray, who have both a 
wealth of experience and a real commitment to try to figure out 
what legislative, regulatory, and appropriations strategies 
will work, because otherwise, I am afraid that we will go down 
the path of sending a lot of money out to Governors' offices, 
telling them to get everybody together, asking them to please 
come up with results, and we will be here 5 years or 6 years or 
7 years, with not much to show for it, and the situation will 
continue to deteriorate.
    So I really do urge you to be very forward-leaning in your 
efforts to try to get the support that you need, and perhaps 
even pick a couple of States and pour everything into them so 
that you can make them laboratories and we can look.
    I know the work that Mr. Curie did on Medicaid managed care 
for substance abuse was excellent work in Pennsylvania, and 
partly because of funding cutbacks and budgetary pressures, a 
lot of that work is not going on elsewhere and has even been 
taking some hits in Pennsylvania. And I know the work that Dr. 
Mayberg did in California was really essential in trying to 
rationalize such a huge system.
    But I can just see what is happening now--as State budgets 
are cut, a lot of the advances that individual States made in 
the nineties are being undercut.
    There are a couple of startling findings or conclusions in 
your report, but one that just really got to me was that the 
very first goal and the very first point you make is about 
suicide and the fact that suicide ranks as the leading cause of 
violent deaths worldwide came as a surprise to me. Amidst all 
of the other priorities that you are talking about, the fact 
that you put that as number one I think says a lot. But what 
can we do--while we are looking at revamping the system, 
creating better transitions, providing better financial 
incentives, is there anything specifically that can be done to 
address suicide, or is it something that is just embedded in 
the whole range of problems, and we really cannot take it out 
and deal with it separately from everything else you are 
recommending?
    Dr. Mayberg?
    Mr. Mayberg. We put that first because it is one that 
actually is something we can do something about. We were 
shocked by our benign neglect of this huge problem. Thirty 
thousand Americans a year die of suicide, and we do not address 
the issue. And clearly, when we focus in on suicide prevention 
programs, the results are dramatic.
    A recent study suggested that just having primary care 
providers asking a person, ``Have you considered suicide?'' 
reduces the suicide rate by 29 percent--one question.
    The Air Force focused in on it and dropped their suicide 
rate by almost 50 percent.
    So just putting it as a priority of our mental health 
system to focus in on this national tragedy--as you said, twice 
as many people die of suicide as of homicide.
    Mr. Curie. I would say the answers to your questions, can 
we do it directly or is it embedded, are ``yes'' and ``yes.'' I 
think there are things that we can do directly, and I think 
Steve has described some of those efforts.
    Also, when you take a look at the other roles--early 
intervention, the linkage to primary health care, having mental 
health programs available in the schools where we can interview 
early--all of these can play a role and have been demonstrated 
in an evidence-based way do play a role in reducing suicide.
    But again, they are not systemic, they are not systemwide, 
and they are not the natural way we are doing things, and much 
of what we need to be doing is making sure that we have early 
intervention available, we have access to care where people 
present themselves, particularly children and youth.
    Also, it is going to take a public-private partnership. The 
private sector has come forward and foundations have come 
forward identifying this as an issue, and I think government 
and the private sector need to come together on both a national 
suicide prevention strategy as well as overall awareness of 
mental health and anticipate that that will be part of our 
action plan, getting that process rolling.
    Also, health classes, education--if we can begin educating 
kids in the health classes about depression and mental illness 
early on, just as we educate them about having a healthy diet, 
I think that stressing that more is going to be another aspect.
    Senator Clinton. I certainly hope we can move on that. I am 
deeply concerned about it.
    I also wanted to ask is it fair to say that in many ways, 
we desintitutionalized during the sixties and seventies, and we 
incarcerated during the eighties and nineties? In looking at 
the numbers just for New York, the Mental Health Association 
shared with me some very frightening statistics. In 1955, there 
were 550,000 people with mental illness in State mental 
hospitals. In 2000, there were 870,000 persons with mental 
illness incarcerated--three-tenths of the population in 1955, 
three-tenths of the population in 2000.
    We shut down a lot of the mental health institutions for 
good reason, we never made good on the promise of community-
based services, and we have essentially used our prisons as the 
mental health institution of last resort.
    What can we do about the prison being the new back ward of 
the mental health system?
    Mr. Mayberg. We refer to this issue as ``trans-
institutionalization.'' We do not think that all of the people 
who went from the State hospital ended up in the criminal 
justice system, but clearly one of the contributing factors has 
been the increase in co-occurring disorders, that the use of 
substances and alcohol combined with mental illness does create 
a situation where we are more apt to come in contact with the 
criminal justice system. So part of it is doing better 
screening up front for co-occurring disorders and also looking 
at some of the incentives to institutionalize. It is a cost-
shift in some ways. It is cheaper in many instances to put 
someone in prison than to put them in a State hospital.
    Senator Clinton. What is the difference in cost, because 
certainly in some of the high-cost States, it is $30,000 to 
$40,000 per prisoner. So what would be the comparable cost?
    Mr. Mayberg. The cost of one of my State hospital beds is 
$110,000 a year, so it is three times as much to be in a State 
hospital. And the cost of being on the street, homeless, when 
you look at all the costs of revolving doors and emergency 
rooms, revolving door and county jails, is probably $30,000 or 
$40,000, too.
    Mr. Curie. I would add that before I left Pennsylvania, we 
did a survey of the State prisons, and this has pretty much 
held up nationally with other prison systems. Eighty percent of 
the individuals in prison had a drug and/or alcohol issue. Over 
50 percent were under the influence at the time of arrest. 
Twelve to 13 percent met the definition of serious mental 
illness. Ninety percent of those individuals had a co-occurring 
substance abuse problem.
    The individuals with mental illness typically are getting 
into trouble and arrested due to a substance abuse or use issue 
into the prisons. Also, we did a study of what we call our 
CHIPS program in Pennsylvania to try to derive real data based 
on what you just shared, Senator Clinton, the notion of are 
people coming out of State hospitals and going to prisons. We 
found that around one to two percent of the individuals who 
came out of State hospitals actually got in trouble with the 
law, but the mushrooming going on in the State prisons, the 
link seemed to be the enforcement of the drug laws, which does 
point out the need for us to be partnering with Justice to 
determine how we can assure access to treatment, because there 
have been many demonstration studies across this country that 
have shown that individuals receive treatment for their 
substance abuse, they recover, and they do not recommit a 
crime, they do not get in trouble with the law, and with the 
high percentage of co-occurring, the same is true--if they 
receive the appropriate treatment, they attain recovery.
    So it is the nexus of public health and public safety, and 
definitely is a focus of the action agenda.
    Senator Clinton. Thank you.
    Thank you, Mr. Chairman.
    Senator DeWine. Let me thank both of you very much, and to 
conclude on an observation, Dr. Mayberg, I was intrigued with 
your exchange with Senator Clinton and your statement that just 
asking the question, ``Have you thought about or contemplated 
suicide?'' will take that rate down is a phenomenal thing. It 
strikes me that the asking of that question by a primary care 
physician or by someone in the military really, though, is 
going beyond the mental health system, or at least in a sense 
is going beyond the mental health system, and maybe that is the 
key.
    I am afraid that sometimes, a primary care physician may 
not think he or she is in the mental health system, and I think 
sometimes people in the military certainly would not think they 
were part of the mental health system. And maybe the key is for 
more people to think they are part of the mental health system, 
and if we can do that, maybe we can accomplish a lot more. It 
is just a thought; I do not know.
    Mr. Mayberg. That is why we put that goal first. We have 
made a fundamental mistake by separating the mind from the 
body; they are integrated, and we need to look at persons as a 
whole and not separate their behavioral health issues out from 
their physical health issues, and it is incumbent upon us as 
mental health professionals to work with the primary care 
system and the school system because they are the case-finders, 
they are the individuals who can make substantive differences 
for us.
    So we really need to change our focus from the tail-end of 
the system to the beginning of the system.
    Senator DeWine. Thank you both very much. We appreciate it.
    Mr. Mayberg. Thank you, Mr. Chairman.
    Mr. Curie. Thank you.
    Senator DeWine. We look forward to working with both of you 
in the future.
    Senator DeWine. Let me ask our second panel to begin coming 
up now, if you will, and I will introduce the second panel as 
you are coming up.
    Senator Kennedy has already introduced Dr. Paul Appelbaum. 
We appreciate you being here with us, Doctor.
    Mr. Michael Faenza is the present CEO of the National 
Mental Health Association, which works to promote mental health 
and prevent mental disorders. He is a social worker by training 
and has spent the last decade on legislative advocacy to 
improve mental health services. He has also spent over 15 years 
providing direct service to children and adults with mental 
disorders. In addition to his service with the National Mental 
Health Association, he also serves on the National Assembly of 
Health and Human Services Organization's board of directors and 
the National Health Council board of directors. He was also a 
member of the planning board for the Surgeon General's Report 
on Mental Health.
    Dr. Carlos Brandenburg is joining us today as a member of 
the NASMHPD and as the administrator of the Nevada Division of 
Mental Health and Developmental Services. Prior to joining the 
Nevada Division of Mental Health in 1995, Dr. Brandenburg 
served as director of forensic services at the Lakes Crossing 
Center for the Mentally Disordered Offender in Reno, NV and as 
a mental health consultant at the Sierra Nevada Job Corps 
Center.
    Dr. Brandenburg has also served as a social worker and 
clinical psychologist.
    Ann Buchanan, our final witness today, is from suburban 
Baltimore and will be sharing with us the story of her son, 
Rusty, who has struggled with depression since the age of 16. 
Her experiences in dealing with treatment centers, support 
systems, and payment plans place her in a unique position to 
comment on the New Freedom Commission's recommendations.
    Mrs. Buchanan, you and your son should certainly be 
commended for your courageousness and perseverance in dealing 
with this debilitating disease, and we thank you for testifying 
today and for joining with us.
    Thank you very much.
    Dr. Appelbaum, we will start with you.

STATEMENTS OF DR. PAUL S. APPELBAUM, DEPARTMENT OF PSYCHIATRY, 
  UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL, WORCESTER, MA; 
   MICHAEL M. FAENZA, PRESIDENT AND CHIEF EXECUTIVE OFFICER, 
 NATIONAL MENTAL HEALTH ASSOCIATION, WASHINGTON, DC, ON BEHALF 
 OF THE CAMPAIGN FOR MENTAL HEALTH REFORM; CARLOS BRANDENBURG, 
      ADMINISTRATOR, NEVADA DIVISION OF MENTAL HEALTH AND 
  DEVELOPMENTAL SERVICES, CARSON CITY, NV; AND ANN BUCHANAN, 
                        COCKEYSVILLE, MD


    Dr. Appelbaum. Thank you, Mr. Chairman.
    I am Paul Appelbaum, M.D., professor and chair of the 
Department of Psychiatry at the University of Massachusetts 
Medical School, where I oversee the largest mental health 
treatment system in central Massachusetts.
    As immediate past president of the American Psychiatric 
Association, I have been deeply involved in efforts to reform 
the system of care for mental disorders and have followed the 
work of the Commission closely. When the Commission declared in 
its interim report that the mental health system is 
``fragmented and in disarray,'' it struck a chord with mental 
health professionals and persons with mental disorders and 
their families across the country.
    Let me tell you about the troubling situation in my home 
State of Massachusetts.
    Imagine that you live in Massachusetts and have become so 
depressed that you cannot work or care for those who rely on 
you, but you are fortunate enough to have health insurance and 
expect not to have trouble finding the treatment you need.
    When you call a general hospital with a large outpatient 
clinic like mine, however, they explain that they must put you 
on a waiting list of weeks to months in duration. With insurers 
paying less than the actual cost of delivering outpatient 
treatment, hospitals have been reducing the size of their 
clinics or closing parts of them altogether, to the point where 
the need for services vast exceeds the supply.
    Perhaps next, you try calling a list of private 
practitioners in the community who, your insurance company 
says, are part of their ``network.'' But many of them tell you 
frankly that they can no longer accept insurance coverage 
because the rates are too low to allow them to survive. They 
can see you only if you pay out-of-pocket for the cost of your 
care. Other clinicians of course do still accept some patients 
with insurance, but they too have waiting lists; if you leave 
your name, they will call you back--when and if an opening 
appears.
    With time passing and no treatment, your condition worsens. 
One morning, you cannot even get out of bed. A worried family 
member brings you to the nearest psychiatric emergency room, 
itself overwhelmed with people like you who have been unable to 
access timely care. Although it is clear by now that you need 
to be hospitalized, you wait 7 hours--about average, you later 
learn--for an empty bed to be found in a hospital 50 miles 
away. You are one of the lucky ones. Other patients, several of 
them adolescents, have been living in the emergency room for 
several days while waiting for a bed. It turns out that 
psychiatric units are notorious money losers in general 
hospitals, with insurers paying somewhere around 70 percent of 
the real costs, and that units have been closing around the 
State and indeed around the Nation for the last decade.
    Your neighbor, with bipolar disorder, who works in a 
minimum wage job without insurance, is in an even tougher spot. 
Community mental health centers are no longer funded by the 
State or the Federal Government to care for uninsured patients 
and are now simply turning them away.
    Since Massachusetts hospitals have to accept uninsured 
patients as a condition of participating in the Medicaid 
program, when your neighbor deteriorates to the point of 
needing to be hospitalized, at least a bed can be found. But as 
it becomes clear that she will need longer-term care in one of 
the few remaining State hospitals, she waits for more than a 
month before the transfer can take place. And once she is 
discharged into the community, the continuum of services that 
she needs--housing, job training, treatment for substance 
abuse--is stretched so thin that there is no guarantee that she 
can access any of them.
    If this were the situation only in Massachusetts, it would 
be a tragedy but might not warrant the attention of this 
committee and the whole Congress. But these scenarios are 
echoed in State after State. Given this, it is no surprise that 
the U.S. Surgeon General's Report on Mental Health cited data 
showing that only 20 percent of persons with mental disorders 
receive any treatment in a given year, and that includes fewer 
than half the persons with such severe disorders as 
schizophrenia and bipolar disorder.
    Hence, the importance of the Commission's call for a 
``fundamental transformation'' of our approach to mental health 
care.
    The recommendations in the Commission's report are, without 
exception, helpful. But to be frank, they fall short of the 
fundamental transformation that is so clearly needed. As 
president of the American Psychiatric Association, I appointed 
a task force to develop a vision of what a genuine system of 
mental health care should be. That report, along with my 
presidential address that lays out some directions we can 
follow, has been provided to the committee.
    In short, I suggest that we need to facilitate the 
integration of treatment for most mental disorders into the 
primary care medical system--a goal that faces numerous 
structural obstacles today. And for our citizens with severe 
and persistent mental disorder, we must reinvigorate the vision 
of President John F. Kennedy, whose Community Mental Health Act 
of 1963 marked the last attempt to construct a nationwide 
mental health system that could care for all of our citizens.
    Finally, while the costs of such a program cannot be 
ignored, it can be funded in substantial part from money now 
spent on jails, homeless shelters, disability payments, and 
other efforts to compensate for the failing of our mental 
health system.
    Thank you for your attention, and I would be pleased to 
respond to the committee's questions.
    Senator DeWine. Thank you very much, Dr. Appelbaum.
    [The prepared statement of Dr. Appelbaum may be found in 
additional material.]
    Senator DeWine. Mr. Faenza?
    Mr. Faenza. Thank you, Mr. Chairman, and a special thanks 
to you, Senator, for your attention to the plight of adults 
with mental illness who are caught in our justice system and 
kids in our juvenile justice system. After 30 years in the 
field, I do not think anything is more important than that 
focus, frankly.
    My name is Michael Faenza, and I am the president and CEO 
of the National Mental Health Association--I have been in that 
job for 10 years--and I am pleased to offer this testimony on 
behalf of the Campaign for Mental Health Reform.
    We are very excited about this Campaign. It is an effort to 
advance new Federal policy to make access, recovery, and 
quality in mental health services the hallmarks of our Nation's 
mental health system, and that idea is to use the Commission 
report, which we are very excited about, as the baseline and 
the lever to do this work.
    The Campaign represents a broad spectrum of mental health 
consumers, families, advocates, professionals, providers, 
States, counties, and communities, and it is rare that we in 
our community have this kind of solidarity with a single 
purpose. We share a commitment to the vision and goals of the 
President's Commission on Mental Health and are eager to work 
with this committee to advance needed reforms.
    I want to say a special recognition for Bob Glover, with 
the National Association of State Mental Health Program 
Directors, whose vision created this Campaign.
    Just a word about myself--I have worked within that 30 
years for years in juvenile justice, public mental health 
services, vocational rehabilitation, and I have lived with 
mental health problems since childhood. Forty years ago, I was 
a kid who was moved from classroom to classroom and expelled 
from schools because of inability to pay attention, was not 
able to play well with others. I had a diagnosis of a bipolar 
disorder as an adult. But I have been blessed to have the same 
psychiatrist for 7 years, who found five medications that 
worked for me, and my 30 years in the field have not led with 
that fact, but I think it informs my testimony.
    A true mental health system must bring many systems to the 
table, as has been noted--public health and primary care are so 
important, as Dr. Appelbaum said; health financing, child 
welfare, education, housing, criminal justice, rehabilitation, 
and employment, to name only the most obvious. And I believe 
that that will not happen without Federal legislation and 
without legislation in the States. It just will not come to be.
    In calling for transformation of mental health care, the 
Commission has given us a vision that we believe truly can be 
reached because the science has transformed our understanding 
of mental illness, given us the tools to diagnose and treat 
most mental disorders. The Commission's message that we can 
build resilience in the recovery from mental illness is a 
realizable goal reflects another transformation in thinking 
about mental illness.
    What is needed now is a policy and budgetary commitment to 
realize dramatic reform in mental health care.
    We do appreciate that there are opportunities for mental 
health reform at all levels of government, and we recognize the 
importance of leadership from the Federal Government--the 
Federal Government--in advancing change administratively. But 
administrative action alone cannot align the inconsistent 
eligibility of requirements of many Federal programs that are 
critical to providing benefits, services, and supports needed 
by many people with mental illness. And administrative measures 
alone cannot overcome the limitations, for example, of Medicare 
mental health benefits, which fail to provide basic parity and 
fail to cover cost-effective services needed to treat chronic 
mental illness.
    This committee in particular can play a vital role in 
crafting needed solutions by giving new policy direction to the 
Substance Abuse and Mental Health Services Administration. With 
revision of its statutory charter, SAMHSA can become a truly 
effective leader of mental health system transformation and 
more closely embrace the principles of public health.
    We hope to work with this committee and provide concrete 
recommendations that will advance the Commission's goals and 
strengthen SAMHSA's hand in helping achieve them.
    I would be remiss in not reinforcing what Senator Clinton 
said, that in my 30 years in the field, this is the worst time 
for mental health. The National Mental Health Association did a 
study several months ago, and there are 23 States that have cut 
back funding for public mental health services. We project that 
within the next few months, 45 States will cut mental health 
services. The numbers of kids with mental health problems in 
juvenile justice settings, adults with mental illness on our 
streets and in our jails--these are numbers that are 
increasing. There is a special irony in what we are talking 
about here today and what is actually happening for people at 
risk and with mental disorders.
    Concretely, the Campaign wants to earmark a number of 
things that we think are important in legislation and action by 
this committee. The first is fostering new financing and 
planning mechanisms to provide effective community-based care 
to children and youth with mental health needs. People with 
mental illness are on the short end of the stick in terms of 
interventions for health status and quality of life in this 
country. Nothing in my experience is as grotesque as our 
neglect of children in this country; it is just shameful.
    Second is fostering mental health promotion and early 
intervention services through school-based mental health care. 
As an example, the Safe Schools, Healthy Students Program is a 
collaboration between SAMHSA, Department of Education, and 
Department of Justice. It is underfunded. It is just pilot 
programs, but it is an example of the kind of integration that 
could happen at the Federal level.
    We need to advance early detection and treatment for mental 
health problems across the age span.
    We need to reduce fragmentation in mental health service 
delivery, including systems for care for children and their 
families. We need to make that more than a concept but real, 
through Federal leadership for the States.
    As mentioned, we need to advance a national strategy for 
suicide; we need to foster integration of health and mental 
health care--that should be a huge priority for SAMHSA; and, as 
mentioned, we need to increase the integration of mental health 
and substance abuse.
    As the President stated in announcing the establishment of 
the Commission, ``Our country must make a commitment.'' That 
commitment will necessarily require, we think, dramatic reforms 
across a range of government programs. A national system in 
shambles requires national Federal leadership a little wary of 
the flexibility of the Sates. When we look at Medicaid reform 
down the road, we need to be sure that we do not pull the rug 
out from under 50 percent of the funding in community mental 
health services.
    We believe it is critical that we embark on this path with 
an appreciation that mental health has long been dramatically 
underfunded relative to the impact of mental disorders on the 
individual and, really, the overall health and quality of life 
of people in this country.
    We urge Congress to make mental health and the 
transformation to a recovery-based system both a legislative 
and a funding priority.
    Again, thank you so much, Mr. Chairman, and I will be 
pleased to answer any questions.
    Senator DeWine. Mr. Faenza, thank you very much.
    [The prepared statement of Mr. Faenza may be found in 
additional material.]
    Senator DeWine. Dr. Brandenburg?
    Dr. Brandenburg. Good morning, Mr. Chairman and members of 
the subcommittee.
    My name is Carlos Brandenburg, and I am the administrator 
of the Division of Mental Health and Developmental Services in 
the State of Nevada.
    I would like to extend my thanks to Chairman DeWine for 
inviting me to testify this morning regarding the State of 
Nevada's experience and efforts in trying to implement the 
President's New Freedom Commission on Mental Health.
    By describing the poor State of the Nation's public mental 
health system, the President's New Freedom Commission provided 
an invaluable service not only for millions of people in this 
country with mental illness and their families, but also for 
those of us responsible for administering the programs that are 
in crisis.
    Nevada, notwithstanding our successes, faces many 
challenges. At the same time, there has never been a more 
hopeful time to take on this challenge, and I am profoundly 
grateful for the opportunity to serve as my State's lead on 
this issue at this particular moment in time.
    Why am I so hopeful? First, we have in the Federal 
Government a true partner. As you indicated this morning, 
Administrator Curie has worked hard within the administration 
to help the President form the Commission, to ensure that it 
was composed of extraordinary people, and to establish for it 
an ambitious and achievable mission.
    Second, as you are hearing today, the advocates who stand 
up for the mental health community here in Washington, DC as 
well as nationwide are organized and prepared to work together 
like never before to help the policymakers make the 
Commission's vision a reality and see to it that the light 
shone on this issue is not dimmed.
    Third, we are witnessing an unprecedented interest on the 
part of Congress, as evidenced by this hearing and the creation 
of this subcommittee.
    Fourth is the good fortune of the State of Nevada itself. 
Nevada was honored that President Bush appointed Nevada State 
Senator Randolph Townsend to serve on the President's Mental 
Health Commission. In order to assist Senator Townsend on this, 
we held numerous task force and focus group meetings throughout 
the State to explore the range of problems and the gaps in 
mental health services in our State. This enabled Senator 
Townsend to bring to the Commission concrete recommendations 
for improvements that could be applied both locally and 
nationally.
    Further, these meetings and focus groups allowed us to 
quantify the degree of unmet need in Nevada and to identify the 
barriers that impede care for people with severe mental 
illness.
    During the 2003 State legislative session, Senator Townsend 
had the foresight to introduce Nevada State Senate Bill 301, a 
copy of which I am submitting along with my testimony. This 
State law created the Nevada Mental Health Plan Implementation 
Commission. The commission is charged explicitly with 
developing an action plan for implementing the recommendations 
and goals of the final report of the President's New Freedom 
Commission on Mental Health. The Nevada Commission must submit 
a report setting forth an action plan to Nevada's Interim 
Finance Committee, its Legislative Committee on Health Care, 
and to Governor Guinn on or before January 1, 2005.
    In all of our deliberations, we are focused on specific 
recommendations, both policy and budgetary, that will turn the 
President's Commission's national goals into concrete, forward 
steps in Nevada.
    The Nevada Commission, in addition to providing an 
organized mechanism to facilitate comprehensive State mental 
health planning and policy development, has also been an 
effective means of keeping the subject of mental health in the 
media cross the State and helping us reduce stigma and increase 
awareness.
    During the course of our meetings, we have been struck by 
the fact that too many Nevadans do not know that mental illness 
can be treated and that recovery is possible. We have learned 
about the large barriers encountered by individuals waiting in 
emergency rooms up to 3 or 4 days before they can be 
hospitalized in our public mental health hospitals. We have 
tremendous work shortages in our rural areas; we are having a 
hard time recruiting and retaining mental health professionals 
to work in rural Nevada. In fact, all the psychiatrists in our 
rural areas are considered ``tourists,'' working mainly out of 
Reno or Las Vegas.
    And more important, we need to be more consumer-involved 
and consumer-friendly in the delivery of services. Nevada for 
the last decade has led the Nation in the rate of suicide. We 
are determined to develop a Statewide suicide prevention 
strategy to work on this problem.
    The Nevada Commission's efforts have been greatly enhanced 
by generous technical support provided by the National 
Association of State Mental Health Program Directors, NASMHPD. 
In conjunction with a grant they received from the Federal 
Substance Abuse and Mental Health Services Administration, 
NASMHPD is enabling us to bring national experts, including 
members of the President's Commission, to our meetings. They 
are providing us with recommendations of best practices and 
programs in other areas of the country that can be implemented 
in Nevada. This assistance has been invaluable.
    Ultimately, our Commission will show Nevada how to change 
the fragmented nature of our mental health delivery system.
    This is the last point that I would like to leave with the 
subcommittee. The ultimate goal of the President's Commission 
and, in turn, the Nevada Commission is ambitious and 
attainable. Indeed, it is calling for system transformation. 
The report of the New Freedom Commission on Mental Health 
identifies the fragmentation of services and financing as 
central barriers to the effective delivery of comprehensive 
mental health services and has called on all levels of 
government to correct this problem by ultimately establishing 
in each ``an extensive and coordinated State system of services 
and supports that work to foster consumer independence and 
their ability to live, work, learn, and participate fully in 
their communities.''
    You have heard about Nevada's commitment in making this 
happen, but neither Nevada nor any other State can do this 
without significant assistance on the part of the Federal 
Government. Specifically, we require Federal assistance to both 
engage in the type of planning envisioned by the Commission and 
to implement those plans, enabling us to fill the tremendous 
gaps in our service delivery systems for those individuals who 
are severely mentally ill.
    Even in Nevada, where we have been uniquely fortunate to 
begin the transformation process, we will not be able to do 
this without Federal funding. We hope that the subcommittee, 
presumably as it begins its efforts to reauthorize SAMHSA and 
its programs, will work closely with the States and the 
Campaign for Mental Health Reform to devise a bold program that 
will provide the support needed to ensure that the vision of 
transformation is realized.
    Thank you.
    Senator DeWine. Thank you.
    [The prepared statement of Mr. Brandenburg may be found in 
additional material.]
    Senator DeWine. Mrs. Buchanan, thank you very much for 
joining us.
    Mrs. Buchanan. Good morning, Chairman DeWine and members of 
the subcommittee.
    I am Ann Buchanan of Cockeysville, MD, and I am proud to be 
here this morning to share with you the story of my son's 
struggle with mental illness and offer some perspectives on 
President Bush's New Freedom Commission on Mental Health. I 
would like to thank you for convening this important hearing 
and inviting the unique perspectives of individuals living with 
mental illness and their families.
    I want to begin by sharing with you the story of my 
family's struggle with mental illness. The story is about my 
22-year-old son, Russell, or Rusty, as we call him. Today Rusty 
is doing better and slowly moving on the difficult but 
uncertain path of recovery. He has a diagnosis of 
schizophrenia. He lives in a residential program at Keypoint in 
Dundalk, MD.
    As a child, Rusty was quite calm, quiet, and a loving child 
with no signs of aggression at all. Today he is participating 
in a program that will help him acquire skills to begin working 
soon. He is making slow but sure progress in his recovery. 
However, it has been a long way back from 4 years ago when 
Rusty turned 18.
    In 1997, our family suffered a devastating loss when my 
husband lost his battle with cancer. Rusty was 16. Shortly 
thereafter, Rusty began showing signs of anger--probably normal 
for a teenager coping with the death of a parent. However, 
these symptoms grew worse and resulted in attacks on me. We 
reached a turning point that eventually resulted in Rusty being 
admitted to an inpatient unit.
    Within a one-year period of time, he was hospitalized three 
times. Things worsened to the point that Rusty had to leave 
high school and eventually was placed at Maryland's Regional 
Institute for Children and Adolescents, RICA, in Baltimore. He 
spent much of 1998 and 1999 at RICA.
    In March of 1999, he was about to turn 18 and was moving 
toward getting his high school diploma. The staff at RICA made 
clear that once Rusty turned 18, he would be an adult and would 
legally have the right to make his own decisions. More 
important, they made clear that once he turned 18, he would no 
longer meet the age criteria, and he would have to transition 
to the adult mental health system.
    Unfortunately, most of the staff at RICA was not familiar 
with how to make this transition. It fell on me to do research 
and make contacts with residential programs in the area. What I 
found was that most programs had long waiting lists for housing 
and residential programs. Those without long waiting lists 
refused to accept him because of his history of aggressive 
behavior. At this point, I was afraid he was going to be sent 
back home to me, which I was very worried about because of his 
prior attacks on me.
    Throughout this period in the spring and summer of 1999, I 
grew increasingly anxious. More important, this uncertainty put 
enormous stress on Rusty and compounded his symptoms. During a 
period when he was trying to finish his high school studies in 
July 1999, just before returning to RICA after a weekend visit 
at home, Rusty attempted suicide by drinking gasoline. This 
resulted in his hospitalization, first in the hospital for his 
medical care, and then to Shepherd Pratt, and eventually a 3-
month stay at Spring Grove Hospital. This is how he entered the 
adult mental health system.
    I remain convinced that had Rusty been able to seamlessly 
transition to a housing program, with a treatment plan 
coordinated by the adult mental health system, many of these 
problems in 1999 could have been avoided. However, we were left 
on our own to manage this transition, not because the staff at 
RICA was uncaring but rather, our struggle stemmed from the 
fact that neither the child and adolescent system nor the adult 
system is held accountable for ensuring that young adults can 
make the transition.
    The sad reality is that thousands of families every year 
face the enormous challenge of having their child ``age out'' 
of adolescent treatment and service programs.
    It should not come as a surprise to anyone that the course 
of mental illness does not magically shift once a child turns 
18, 19, or 20. The symptoms they experience, be it anxiety, 
depression, mania, psychosis or paranoia, do not change to fit 
our mental health system's preexisting definitions about what 
are child and adolescent services versus what are adult 
services.
    In my view, it is disturbing that the separate child-
adolescent and adult systems struggle so mightily to help 
adolescents make the transition into adulthood. This is 
especially the case with children and adolescents with more 
severe mental illnesses who are much more likely to see 
diagnoses of illness stay with them into adulthood.
    Why is the transition so difficult? Children acquire 
certain legal rights when they reach age 18, legal rights that 
can limit the ability of parents and families to get their 
children the help they need. Rules governing eligibility for 
SSI, SSDI, and Medicare and Medicaid shift once a child reaches 
the age of 18, and eligibility for certain treatment and 
residential programs may be compromised once an adolescent 
turns age 18.
    These problems are compounded by complicated and confusing 
rules such as Medicaid spend-down. It is rare to find a public 
agency, whether in the adult or the child system, which will 
pay for case management and other wraparound services that can 
ease this transition for families.
    What must be done to address the complicated issues faced 
by consumers and families dealing with the transition from the 
child-adolescent system to the adult system?
    The White House Commission Report offers some important 
findings and recommendations. As this report notes, funding and 
accountability in our Nation's public mental health system is 
needlessly fragmented and complicated. The Federal Government 
has to begin working with States and localities to provide more 
flexibility while insisting on more accountability for 
achieving outcomes that are tied to recovery. Individualized 
treatment plans for consumers and their families, as proposed 
by this report, would be a major step forward in helping 
families put in place the treatment and support their children 
need before they turn 18 and become adults.
    Better systemwide planning, as this report proposes, is 
critically important and should involve not just public mental 
health agencies but also affordable housing, education, and job 
training.
    Finally, I want to comment on findings and recommendations 
in the report calling for consumers and families to have 
greater control over their own care. While this goal is 
laudable, it will never be achieved without expansion of family 
education and peer support programs to help consumers and 
families learn more about mental illness, treatment system, and 
how to advocate for themselves.
    I am a graduate of the NAMI Family-to-Family Education 
Program. I found it to be enormously helpful in preparing me to 
cope with my son's illness and become an advocate both for his 
recovery and for improvements in the service system in our 
community. I attended the Family-to-Family class when Rusty was 
hospitalized the first time, and it helped me understand and 
make contacts to get me started learning about this illness.
    Thank you for the opportunity to talk today.
    [The prepared statement of Mrs. Buchanan may be found in 
additional material.]
    Senator DeWine. Mrs. Buchanan, thank you very much. Yours 
is a very, very compelling story and I think a story that is 
very instructive for us.
    Senator Kennedy really wanted to be here to hear your 
testimony, and he had another commitment, but he did leave a 
question which I am going to ask on his behalf for you. This is 
Senator Kennedy's question: ``We know that far too many 
children and adolescents, like your son, who need mental health 
services do not receive them. One reason for this is that 
public schools do not do a good job of supporting mental 
health. In your own experience, your son Rusty was forced to 
withdraw from his high school. How could Rusty's school have 
done a better job of helping him so he could have remained in 
school?''
    Mrs. Buchanan. Actually, Rusty was always in the special 
education system of public education, and each year, he would 
have an individual IEP plan drawn up. After he was 
hospitalized, each time he returned to Towson High School, he 
had to go through a review board to see if they felt he was 
safe to return, and they accepted him. One day, he made a 
verbal threat to a student, and then they really questioned 
him. They did psychological testing on him, and Rusty felt that 
he could no longer attend, so they did provide home tutoring 
for him until he could be placed at Hannah Moore School, which 
is for emotionally disturbed children. This was just prior to 
going to RICA. But Hannah Moore was not equipped to handle his 
problems, either, so he went to RICA.
    So more psychological testing and attention--at first, we 
thought Rusty's behavior was typical teenage behavior, being 
argumentative and so on, but it led to much more than that; it 
was deeper. After his father died, he was first treated with 
major depression, but as time went on, I could see that it was 
not just from his father's death, it was more deep-rooted than 
that.
    Senator DeWine. Thank you very much. Senator Kennedy has a 
second question, and I think it does make a good follow-up: 
``From your own experience, what advice do you have for the 
Senate and today's panel about how to help more people like 
your son by successful and have positive outcomes?''
    You have already touched on that a little bit, but is there 
anything else you would like to add?
    Mrs. Buchanan. More education on mental illness needs to be 
addressed. Like many illnesses, people do not want to talk 
about mental illness, but it needs to be brought forth so that 
people are aware of it before it gets too far advanced.
    Senator DeWine. Thank you very much. Your testimony has 
been very, very helpful and certainly has outlined for us in 
very human terms a lot of the problems that we do have.
    Dr. Brandenburg, in your State, how do you currently 
address children's mental health issues, and what kind of help 
would make the most difference for your State? What additional 
help do you need?
    Dr. Brandenburg. The State of Nevada right now has a 
Division of Child and Family Services that provides mental 
health services for children in our State. Like other States, 
our services for children are fragmented. We are having a hard 
time providing mental health services to those individuals who 
are in the child welfare system, those individuals who are in 
the juvenile justice system. So what we are trying to do is get 
a handle on that through a legislative subcommittee, trying to 
find out how to break those various silos.
    Just like Mr. Curie and the subcommittee indicated earlier, 
at the Federal level, you have many different funding streams. 
You have SAMHSA, you have NIMH, you have Justice, all providing 
funds at a different area for different programs. That 
translates itself down to the State level, where we have our 
various silos.
    So what we are trying to do at the State level is break 
down those silos and break down the fragmentation of services, 
because kids are falling through the cracks in our State 
between the time that they go either from juvenile justice into 
the mental health system or from the children's mental health 
services into the adult system.
    Senator DeWine. Thank you.
    Mr. Faenza, you have outlined in your written testimony as 
well as in your oral testimony that ``Among the important 
issues we urge this committee to take up and on which we are 
developing legislative proposals are the following,'' and then 
you give a very brief summary of a number of different 
proposals.
    I take it you are going to develop those further and come 
forward to this committee and Congress with very specific 
legislative proposals; is that correct?
    Mr. Faenza. That is correct. The Campaign partners are 
determined to bring a lot more flesh to the bones of these 
concepts and to very candidly bring those forward. We will also 
be looking with a lot of anticipation to Director Power's game 
plan to respond to the Commission report under SAMHSA. But they 
will be very specific, and there will be a lot of solidarity in 
the community behind those recommendations.
    Senator DeWine. We look forward to reviewing your very 
specific proposals, so we welcome that. We want to encourage 
that.
    Mr. Faenza. Thank you.
    Senator DeWine. When you bring them to the committee and to 
the Congress, we certainly want to take a look at them.
    Mr. Faenza. We will be anxious to do that. Thank you, 
Senator.
    Senator DeWine. Very good.
    Dr. Appelbaum, in your written testimony you state: ``The 
recommendations in the Commission's report are, without 
exception, helpful, but to be frank, they fall short of the 
fundamental transformation that is so clearly needed.'' And 
then you continue on.
    Do you want to give us the highlights of what you are 
talking about? What is lacking?
    Dr. Appelbaum. Senator, the track record of mental health 
policy in this country for the last 25 to 30 years has been to 
address problems of high salience in a piecemeal fashion for a 
short period of time, so we become interested in youth suicide 
or substance abuse by pregnant women or the problems of the 
elderly; we develop a few model programs, we fund them for an 
initial period, and 5 years later, when the focus has shifted 
elsewhere, we allow those programs to be resorbed into the 
residual mental health system.
    The result has been a system that has contracted over time 
and failed to provide a comprehensive approach to mental health 
care.
    What I was suggesting in that comment was that merely to 
continue with a model programs approach such as we have been 
doing condemns us to being, as Senator Clinton suggested, in 
the same place 5 years from now or 10 or 20 years from now.
    The last time we really thought systemically about what it 
would take to address the mental health needs of the American 
people as a whole was in the early 1960's, and we came up with 
what was not a bad plan. We divided the country by State, and 
each area of each State was assigned a catchment area. There 
was a community mental health center designed to be responsible 
within that catchment area for the mental health needs of every 
person who lived there.
    So the question of where you went when you had a mental 
health problem was a nonquestion. You went to the mental health 
center, and it had the responsibility of integrating you into 
the system of care.
    Moreover, when you transitioned from being a child to being 
an adult, there was a place--it was the mental health center--
that had responsibility for making sure that you bridged that 
gap. They were responsible for you when you were 17, and they 
were responsible for you when you were 19.
    It was a terrific concept. In part, the problems that it 
had were problems derived from inadequate funding in the first 
place. The notion was that the Federal Government would provide 
funds to build these centers and then would taper its support 
over a number of years, and that the States or someone would 
pick up the difference. Well, the Federal support indeed was 
tapered and ultimately transitioned to the block grant system 
in roughly 1980, but the State tapered their support 
simultaneously, and nobody picked up the difference.
    So we have a vestige in some areas of the country of this 
community mental health system, but the reality is it is only a 
shell of what it once was.
    Maybe a revitalization of that system is what we need now. 
Maybe there is some other equally comprehensive and integrated 
approach. But it is that kind of thinking that I was suggesting 
we need to engage in.
    Senator DeWine. So, Doctor, if you took a snapshot of where 
we were 10 years ago, 20 years ago, are you saying that we have 
actually regressed?
    Dr. Appelbaum. I am saying that we have actually regressed.
    Senator DeWine. I am seeing a nodding of ``yes'' from Dr. 
Brandenburg, Mr. Faenza, and of course, Dr. Appelbaum. Would 
that be correct? OK.
    Dr. Appelbaum. I was speaking last week, Senator, to a team 
from Summit County in Ohio that had just won a national award 
for an innovative mental health program. I visited Summit 
County 2 years ago and frankly, I thought that in my travels 
around the country, it was one of the finest integrated 
community mental health center-based programs I had seen--the 
kind of model that we could expand around the country. But when 
I talked to the director of mental health services and the 
medical director last week and told them how impressed I had 
been 2 years ago on my visit, they said, ``Well, you might feel 
differently if you came back today,'' that even this model 
program is facing extreme economic stress, and they are 
watching important pieces of it no longer be able to be 
supported.
    So the answer to your question is clearly ``yes.''
    Senator DeWine. That testimony is very troubling, and this 
hearing has been very troubling--but very instructive and, we 
hope, very helpful.
    Are there any additional comments from any of the 
witnesses?
    [No response.]
    Senator DeWine. We thank you all very much.
    The hearing is adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

                Prepared Statement of Stephen W. Mayberg

    Good morning Mr. Chairman and Members of the Subcommittee. I am Dr. 
Stephen W. Mayberg, Director of the California Department of Mental 
Health. I was privileged and honored to have been named by President 
Bush to serve as a member of his 15-member New Freedom Commission on 
Mental Health, under the chairmanship of Ohio Mental Health 
Commissioner Mike Hogan.
    My position as the Director of the California Department of Mental 
Health, the largest State mental health system with a public sector 
budget at almost $3.4 billion and 8,500 employees, gives me a broad 
perspective of the issues and problems facing our public mental health 
system. Even more important, I suspect that a factor in my selection to 
the Commission was my long time advocacy for an accountable, state of 
science and user-friendly mental health system that is responsive to 
the people we serve. I have frequently spoken of a system that produces 
outcomes and is about services, not bureaucracies.
    The public members of the Commission included not only 
representatives of State Government such as I, but also representatives 
from the judicial branch, from mental health services providers, and 
from the ranks of mental health advocates. We were joined by seven ex 
officio Federal members representing not only agencies and offices of 
HHS, but also the Departments of Education, Labor, HUD, and Veterans 
Affairs.
    One of those ex officio members, SAMSHA Administrator Charles 
Curie, is testifying here with me today. He and his agency have been 
charged by the Administration to assess the work of the Commission and 
to lead the transformation of mental health care that its 
recommendations help guide. With his expertise that spans Federal, 
State and local mental health--and his highly effective leadership 
style--evidenced in his remarkable work in Pennsylvania State 
Government to change how mental health services are done there--I feel 
confident that we can accomplish the transformation of today's mental 
health care system And, with your help, we can do it in ways that 
benefit the people the system was intended to serve first and 
foremost--men and women, teens and children and their families living 
today with mental illnesses.
    Quoting the Executive Order that created the Commission, the charge 
to the Commission was ``to recommend improvements [in the U.S. mental 
health system] to enable adults with serious mental illnesses and 
children with severe emotional disturbances to live, work, learn, and 
participate fully in their communities.'' To do so we were asked to 
conduct a comprehensive examination of the U.S. mental health system 
today.
    The challenge was to accomplish that mission within a year. And so 
we have. In July, the result of our work was submitted to the 
President, and to the Nation.

Why The Commission Was Created

    In any given year, about 5-7 percent of adults have a serious 
mental illness. In 2002, for example, SAMHSA's National Survey on Drug 
Use and Health reports that an estimated 17.5 million adults age 18 or 
older, 8.3 percent of all adults, had serious mental illnesses (SMI). A 
similar percentage of children and youth, from 5-9 percent, have a 
serious emotional disturbance in any one year. I'm referring to 
illnesses that not only meet the diagnostic criteria for mental 
illnesses found in the Diagnostic and Statistical Manual of Psychiatry, 
Fourth Edition (the DSM-IV), but illnesses that also substantially 
hinder one or more life's activities like holding a job, getting 
dressed, learning at school, or participating in community activities. 
These are illnesses that rank first among the leading causes of 
disability in the United States, Canada and Western Europe. They also 
are the leading cause of suicide, causing more deaths each year 
worldwide than homicide and war together.
    Mental illnesses cost the Nation an estimated $79 billion annually. 
And the vast majority of that total ($63 billion) reflects loss of 
productivity as a result of these illnesses and another $12 billion in 
mortality costs resulting from premature death. In human terms, the 
losses are nearly incalculable, spanning lost families and homes, lost 
education, lost livelihood, and most of all--lost opportunities.
    Yet, despite the prevalence, the costs, and the clear public health 
imperative, people with these disorders often are untreated or under-
treated. Mental illnesses often have been under reported. Compounding 
the problem, countless individuals in need of services cannot or do not 
receive them. Again, according to the SAMHSA Household Survey, in 2002, 
among adults with serious mental illnesses, 30.5 percent perceived they 
had an unmet need for treatment in the past 12 months.
    Too many Americans including policymakers and administrators, 
program officials and health care providers, for too long did not 
recognize the full public health implications of these devastating 
disorders. And for too long, any efforts to address mental illnesses in 
America have been piecemeal, patchwork affairs.
    President Bush created the Commission because, first and foremost, 
as he stated, ``Americans with mental illness deserve our respect . . . 
and they deserve excellent care.'' He recognized that millions of 
Americans of all ages, both male and female, and of all races and 
ethnicities experience mental illnesses.
    President Bush created the Commission because he recognized that 
mental illnesses, like other chronic illnesses, can be treated 
successfully and that people with mental illnesses can and do recover.
    Perhaps most critically, he recognized, as do an ever-growing 
number of those of us working in the field, that three key obstacles 
keep people with mental illnesses from getting the services they want 
and need:
    1. The stigma that still surrounds these illnesses;
    2. The fragmented mental health care service system; and
    3. Existing treatment and dollar limits for mental health care in 
private health insurance.
    The Commission the President established was asked to address the 
second issue--the fragmented mental health care service delivery 
system, to identify ways to respond and models that work to respond, 
and to make solid recommendations for all levels of government and 
public and private sectors to take action.

The Report's Findings

    To do so, the Commission developed a format to receive public 
comment, hear expert testimony, and to conduct field visits. We 
assessed existing reports and documentation addressing a wide range of 
issues and reached out to experts in science, policy, program 
development, and those experiencing mental illnesses themselves. Our 
open meetings generated voluminous content as well as input from the 
1,000,000 hits on our website.
    The scope of information and issues was, at times, staggering and 
to provide focus we identified 16 areas of concern. Subcommittees of 
the Commission looked at, for example, diverse issues such as 
interfaces between physical health and mental health, criminal justice 
issues, children's and older adult issues, issues of culture, and co-
occurring disorders, as well as numerous other topics.
    The work was prodigious; the information gathered extensive. An 
interim Report issued at the 6-month point in our work helped inform 
the field about where our deliberations were headed and generated still 
further comment and discussion. That interim report clearly stated the 
``system is in a shambles'', care is fragmented for adults and 
children, older adults do not receive adequate care, and we have 
unacceptably high levels of unemployment and disability for persons 
with serious mental illness.
    With tremendous diligence, dedication and work, the Commission 
crafted the Final Report of the President's New Freedom Commission on 
Mental Health. Titled Achieving the Promise: Transforming Mental Health 
Care in America, the report presents the Commission's vision for a 
transformed mental health system for America and provides a roadmap for 
that transformation. The destination is recovery--the essentials for 
living, working, learning, and participating fully in the community--
what SAMHSA Administrator Curie likes to call ``a life in the community 
for everyone.''
    It's a vision that we must realize. During our work, we disclosed 
that today's mental health system unintentionally is focused on 
managing the disabilities associated with mental illnesses rather than 
fostering recovery. That limited approach is a product of 
fragmentation, gaps in care and uneven quality of care when it occurs. 
These system problems frustrate the work of dedicated staff and make it 
much harder for people with mental illnesses and their families to 
access needed care.
    We would reweave today's patchwork system into whole cloth--
strengthened by a focus on resilience and recovery. The approach we 
have recommended will move children, youth, adults and older Americans 
with mental illnesses toward full community participation, instead of 
school failure, institutionalization, long-term disability and 
homelessness.
    The roadmap we have charted focuses on six goals and a series of 
specific recommendations for Federal agencies, States, communities, and 
providers nationwide. Together, working through both the public and 
private sectors, the recommendations leverage resources to their utmost 
to achieve the needed transformation of mental health care.
    The data I have already shared with you underscore the importance 
and urgency of meeting the goals and implementing the recommendations 
the Commission has proposed. As I've already observed, these goals and 
recommendations are drawn not from the Commission members alone, but 
from the experiences of clinicians and administrators, consumers and 
families, policymakers and community-based services programs.

The Goals and Recommendations

    Let me discuss some of the key goals and the recommendations we 
have made to reach them.
    First, we found that if we are to transform mental health care, our 
programs--from the Federal level to the community level--must shift 
toward consumer and family-driven services. Consumers' needs and 
preferences, not bureaucratic requirements, must drive the services 
they receive. To achieve that goal, the commission recommended specific 
changes in Federal programs and upgraded State responsibility for 
planning effective services. Most critically, we stressed the 
importance of placing consumers and their families at the center of 
service decisions.
    Second, we observed that members of minority groups and people in 
rural areas today have worse access to care. Further, they often 
receive services that are not responsive to their needs. As a result, 
the burden of mental illness is heavier for these individuals. The 
Commission urged a commitment, again, from community up to the Federal 
level, to services that are ``culturally competent''--acceptable to and 
effective for people of varied backgrounds.
    The Commission's review further found that, too often, mental 
illness is detected late, not early. As a result, services frequently 
focus on helping people live with considerable disability, rather than 
on intervening early, which nearly always yields better outcomes--less 
disability, and a better opportunity for a meaningful life in the 
community. Thus, we recommended a dynamic shift in care, toward a model 
that emphasizes early intervention and disability prevention. As our 
report stated, ``early detection, assessment, and linkage with 
treatment and supports can prevent mental health problems from 
compounding and poor life outcomes from accumulating . . .''
    Achieving this goal requires better and more extensive engagement 
and education of first-line health care providers--primary care 
practitioners. It also demands a greater focus on mental health care in 
institutions such as schools, child welfare programs, and the criminal 
and juvenile justice systems. The goal is a system of integrated, 
community-based care that can screen, identify, and respond to problems 
early. The Commission also noted that a majority of adults--even those 
with the most serious mental illness--want to work, but are held back 
by poor access to effective job supports, incentives to remain on 
disability status, and employment discrimination. That, too, can be 
changed with thoughtfully designed community-based programs, incentives 
to employers. Most critically, it can be changed by instilling in 
community leaders, employers and educators the knowledge that people 
with mental illnesses can and do recover and that they can be good 
students, workers, and members of their families and communities.
    Acknowledging significant progress in research on mental illnesses, 
the panel urged the elimination of the 15-20 year lag between the 
discovery of effective treatments and their wide use in routine patient 
care. We underscored the need for accelerated and relevant research to 
promote recovery and, ultimately, to cure and prevent mental illnesses 
We also found that while we have gleaned considerable new insights into 
what services and supports are most effective in helping people achieve 
recovery and resilience, these practices find their way into community-
based care far too slowly. Thus, we called for a more effective process 
to make ``evidence-based practices'' the bedrock of service delivery. 
This will require that payers of mental health care reimburse such 
practices, that universities and professional groups support training 
and continuing education in research-validated interventions.
    Finally, we recommended that the mental health system needs to move 
more effectively to harness the power of communications and computer 
technology to improve access to information and to care, and to improve 
quality and accountability. With strong protections for privacy, these 
technologies can improve care in rural areas, help prevent medical 
errors, improve quality and reduce paperwork.
    Throughout the report, the Commission identified private and public 
sector model programs as exemplars of how aspects of mental health care 
have been transformed in selected communities.
    These examples of innovation--across America, across the age span, 
and addressing many needs--illuminate how dramatic change is possible, 
and serve as beacons for the broader improvements recommended by the 
Commission.

In Closing

    With the transmission of our Report, the work of the Commission 
ended. Your work, the work of lawmakers, policymakers, program 
developers, administrators and citizens is just beginning. The 
challenge before you is to move today from the principles we have 
espoused to policy that will guide the transformation of mental health 
care today. It's a challenge to move from paper to practice in the 
community. Change is not easy; but the Commission has provided models 
and pointed the way. It's a challenge that will take thought, resources 
and resolve. But most critically, it's a challenge that must be 
accepted not only here at the Federal level, but also in States and 
communities as well as families and individuals.
    I hope your role as Federal legislators, is to lead by example--to 
lead in breaking through the stigma of mental illnesses, to lead in 
breaking down the silos that keep policy and programs for working 
toward shared solutions, and to lead in the knowledge that, with a 
system that works for them, people with mental illnesses can and will 
recover to lead healthy, contributing lives in their communities as 
parents and partners, workers and students, taxpayers and concerned 
citizens of their Nation.
    I am convinced that, together, we can undertake and realize the 
wholesale transformation of mental health care in America that will be 
measured not in the bureaucratic terms of dollars and cents, but rather 
in outcomes that improve the quality of the lives of people with mental 
illnesses, lives that can and should be lived with dignity, 
productivity and the pursuit of happiness that the founding Fathers 
envisioned for us all.
    Thank you, Mr. Chairman and Members of the Subcommittee, for the 
opportunity to be here and to explore with you what the Commission has 
found and recommended.

                 Prepared Statement of Charles G. Curie

    Mr. Chairman and Members of the Subcommittee, I am honored to 
present on the President's New Freedom Commission on Mental Health and 
the Administration's activities to achieve the goals contained in the 
Commission's final report. First, I want to thank my friend and 
colleague Steve Mayberg for his kind words and his contributions to the 
Commission's work. I also want to recognize the leadership demonstrated 
by Michael Hogan as the Chair of the President's Commission. Mike's is 
steadfast commitment to do what is right for people with mental illness 
steered the commission through many tough decisions and ultimately led 
to the final report which we are here today to discuss.
    An important context for our work in the Bush Administration and 
the recommendations developed by the commission is the words of people 
in our service delivery systems working to obtain and sustain recovery. 
In particular, the first position I held, as a new MSW graduate, was 
working as a therapist to help mental health service consumers make the 
transition from in-patient care in State hospitals back into the 
community.
    This aftercare group included consumers that had spent over a 
decade in the hospital. I asked them what they needed to make their 
transition successful. They didn't say they needed a psychiatrist. They 
didn't say they needed a psychologist. They didn't even say they needed 
a social worker. They didn't say they needed a comprehensive service 
delivery system or evidenced-based practices. They said they need a 
job, a home and meaningful personal relationships or to use a direct 
quote . . .''I need a life--a real life . . . I need a job, a home and 
a date on the weekends.''
    People seeking or in recovery from mental illness need most to feel 
connected. They want a life, a real life with all of its rewards. This 
is the very essence of the recommendations contained in the final 
report of the President's New Freedom Commission on Mental Health.
    It is a privilege to serve President Bush and work for Tommy 
Thompson, our Secretary of the U.S. Department of Health and Human 
Services. This is an Administration that knows treatment works and 
recovery is real!
    In the words of our President, ``Political leaders, health care 
professionals, and all Americans must understand and send this message: 
mental disability is not a scandal--it is an illness. And like physical 
illness, it is treatable, especially when the treatment comes early.'' 
As you have heard the President charged the Commission to study the 
problems and gaps in our current system of treatment, and to make 
concrete recommendations for immediate improvements that will be 
implemented . . . by the federal government, the state government, 
local agencies, as well as public and private health care providers.
    I will not spend a lot of time on the details of the report because 
you have already heard from Steve Mayberg. Instead, I will share a 
little of the ``why'' and the ``what now'' perspectives with you. 
Currently, numerous Federal, State and local government entities 
oversee mental health programs. In fact, the Commission identified over 
40 Federal programs alone.
    One of the largest Federal programs that supports people with 
mental illnesses is not even a health services program. The Social 
Security Administration's (SSA) Supplemental Security Income (SSI) and 
Social Security Disability Income (SSDI) programs paid approximately 
$27 billion in disability payments in 2002 to beneficiaries with mental 
impairments (excluding mental retardation). Persons with mental illness 
represent the fast growing group of persons determined to be disabled 
by SSA.
    At the same time employment is an essential tool for persons with 
mental illnesses to fully participate in their communities. The 
majority of adults with serious mental illness want to work and many 
can work with help. However, many seek disability status to get health 
coverage and to do so, the must either end or limit their employment. 
As a result, many consumers with serious mental illness continue to 
rely on Federal assistance payments in order to have health care 
coverage, even when they have a strong desire to be employed.
    Few mental health planning or Medicaid planning requirements ensure 
States work across State agencies or with mental health constituencies 
to form a single comprehensive mental health plan for the State. 
Consequently, the goals and desired outcomes, the service definitions 
and provider qualifications, and the payment mechanisms and 
organization of mental health care can be very different, depending on 
whether Medicaid, general fund appropriations, or other sources, such 
as schools, Temporary Assistance for Needy Families, local public 
mental health authorities, or juvenile justice systems are the payers 
of services.
    Clearly, more efficient organization and better coordination of 
services and funding streams will assist providers in making sure 
effective treatment is received and that recovery can be realized. And, 
Federal funding sources should be aligned and provide consistent 
direction to States in their planning efforts, taking into account the 
multiple missions of the various funding streams and programs.
    When the President announced the Commission and defined the scope 
of responsibility, he spoke frankly about the poor quality of mental 
health care in this country in terms of its fragmented delivery system. 
He talked about the many points of contact we have with people with 
mental illnesses--all too often this being homeless shelters, criminal 
justice system or welfare system. He talked about missed opportunities 
to diagnosis and treat individuals suffering from mental disorders. 
And, he also acknowledged the difficulty of achieving a diagnosis and 
providing the state of the art care we know can be delivered.
    He spoke of the many Americans who fall through the cracks of our 
current service delivery system and equated that failure with years of 
lost living and of lives entirely lost before help is given--if it is 
ever, in fact, even offered.
    President Bush drew upon the all too often common example of a 14-
year old boy who suffered from severe depression and began 
experimenting with drugs to self-medicate and alleviate his symptoms. 
You are all well too familiar with the shameful scenario of the honor 
student turned drug addict. This young man, like many Americans of all 
ages, slipped through the cracks. And just like him, he wasn't 
diagnosed until age 30 with a bipolar disorder, they wait half their 
lifetime for someone to notice that their behavior wasn't simply a 
matter of poor choices.
    As you may know, SAMHSA has been given the lead role to conduct a 
thorough review and assessment of the final report of the President's 
New Freedom Commission on Mental Health with the goal of implementing 
appropriate steps to strengthen our mental health system. In short, 
President Bush asked the Commission to give the mental health system a 
physical . . . they did. The diagnosis is ``fragmentation and 
disarray.'' The Commission report found the nation's mental health care 
system to be well beyond simple repair. It recommends a wholesale 
transformation that involves consumers and providers, policymakers at 
all levels of government, and both the public and private sectors.
    The ``Mental Health System Recovery Plan'' if you will, will 
require the implementation of the ``To Do List'' currently being 
developed by SAMHSA on behalf of the Bush Administration. The ``To Do 
List'' will form an action agenda to achieve transformation of mental 
health care in America. My lead staff person for developing this action 
agenda is Kathryn Power. Kathryn recently joined SAMHSA as the Director 
of our Center for Mental Health Services. She is working to develop an 
agenda for transformation that is built around the 6 goals and 19 
recommendations contained in the Commission's Report.
    This transformation will require a shift in the beliefs of most 
Americans and will require the nation to expand its paradigm of public 
and personal health care. Everyone from public policymakers to 
consumers and family members must come to understand that mental health 
is a vital an integral part of overall health. Along with this new way 
of thinking, Americans must learn to address mental health disorders 
with the same urgency as other medical problems.
    The report also challenges us to close the 15-20 year lag time it 
takes for new research findings to become part of day-to-day services 
for people with mental illnesses. Waiting for the research to make its 
journey down an already clogged pipeline equates to generations lost in 
the process. Too many Americans are already under-served and many more 
are done a disservice when their quality of life remains poor while 
they wait for the latest research to crawl into their communities.
    The report challenges us to harness the power of health information 
technology to improve the quality of care for people with mental 
illnesses, to improve access to services, and to promote sound 
decision-making by consumers, families, providers, administrators and 
policymakers. And it challenge us to identify better ways to work 
together at the federal, state and local levels to leverage our human 
and economic resources and put them to their best use for children and 
adults living with--or at risk for--mental illnesses. Most of all, the 
report reminds us that mental illness is a treatable illness and that 
recovery is the expectation. As a compassionate nation, we cannot 
afford to lose the opportunity to offer hope to those people fighting 
for their lives to obtain and sustain recovery.
    To lead the effort I have assembled a transformation taskforce. We 
are already working with relevant Federal agencies--to determine ways--
to provide States the flexibility needed and the incentive--to bring to 
bear the full force of the resources available to meet the needs of 
people with mental illnesses. I am counting on the relationship that 
SAMHSA and other Federal Agencies have with our State partners. As we 
move forward, we will work with States to develop an Action Agenda of 
their own. A few states have already begun--Texas, Nevada, Nebraska--to 
name a few.
    The new state agendas must be consumer and family driven--not 
bureaucratically bogged-down. Consumers of mental health services and 
their family members must stand at the center of the system of care. 
Consumer and family needs must drive the care and services that are 
provided. The result will be more of our family members, co-workers, 
neighbors and friends living that rewarding life in their communities 
that I talked about in the beginning of my remarks.
    In closing, we all need to recognize the changes that need to be 
made will not happen over night. Developing and implementing the Action 
Agenda for Transformation will be an ongoing process. Clearly, our 
success will depend on our ability to span all levels of government and 
the private sector to align and bring to bear the full force of 
resources available. The strategy will be to keep our focus on the 
needs of adults with serious mental illnesses, children with serious 
emotional disturbances and their family members. The goal is to make 
recovery a reality for everyone.
    Thank you for your time and interest is our work. I would be 
pleased to answer any questions you may have at this time.

             Prepared Statement of Paul S. Appelbaum, M.D.

    Mr. Chairman and members of the Committee, I am Paul Appelbaum, MD, 
Professor and Chair of the Department of Psychiatry at the University 
of Massachusetts Medical School, where I oversee the largest mental 
health treatment system in Central Massachusetts. As the immediate past 
president of the American Psychiatric Association, I have been deeply 
involved in efforts to reform the system of care for mental disorders, 
and have followed the work of the Commission closely.
    When the Commission declared in its Interim Report that ``the 
mental health delivery system is fragmented and in disarray . . .,'' it 
struck a chord with mental health professionals, persons with mental 
disorders and their family members, across the country. After three 
decades of neglect and progressive defunding, the mental health system 
finds itself mired in crisis. Let me tell you about the troubling 
situation in my home state of Massachusetts.
    Imagine that you live in Massachusetts and have become so depressed 
that you cannot work or care for those who rely on you, or so stricken 
with anxiety that you can no longer leave your house. But you are 
fortunate enough to have health insurance and expect not to have 
trouble finding the treatment you need. When you call a general 
hospital with a large outpatient clinic like mine, however, they 
explain that they will need to put you on a waiting list of weeks to 
months in duration. With insurers paying less than the actual cost of 
delivering outpatient treatment, hospitals have been reducing the size 
of their clinics or closing parts of them altogether, to the point 
where the need for services vastly exceeds the supply.
    Perhaps next you try calling a list of private practitioners in the 
community who, your insurance company says, are part of their 
``network.'' But many of them tell you frankly that they no longer 
accept insurance coverage, because the rates are too low to allow them 
to survive. They can see you only if you pay out of pocket for the 
costs of your care. Other clinicians, of course, do still accept some 
patients with insurance, but they too have waiting lists. If you leave 
your name, they will call you back when--and if--an opening appears.
    With time passing and no treatment, your condition worsens. One 
morning, you cannot even get out of bed. A worried family member brings 
you to the nearest psychiatric emergency room, itself overwhelmed with 
people like you who have been unable to access timely outpatient care. 
Although it's clear by now that you need to be hospitalized, you wait 7 
hours--about average you learn--for an empty bed to be found in a 
hospital 50 miles away. In the emergency room, you are one of the lucky 
ones. Other patients, several of them adolescents, have been living 
there for several days while waiting for a bed. It turns out that 
psychiatric units are notorious money--losers in general hospitals, 
with insurers paying somewhere around 70% of the real costs, and that 
units have been closing around the state for the last decade.
    Your neighbor, with bipolar disorder, who works in a minimum wage 
job without insurance, is in an even tougher spot. Community mental 
health centers are no longer funded by the state to care for uninsured 
patients and are now simply turning them away. Since Massachusetts 
hospitals have to accept uninsured patients at the hospital's expense 
as a condition of participating in the Medicaid program, when she 
deteriorates to the point of needing to be hospitalized, a bed can be 
found. But as it becomes clear that she'll need longer-term care in one 
of the few remaining state hospitals, she waits for more than a month 
before the transfer can take place. And once she's discharged into the 
community, the continuum of services that she needs--housing, job 
training, treatment for substance abuse--is stretched so thin that 
there is no guarantee that she can access any of them.
    If this were the situation only in Massachusetts, it would be a 
tragedy, but might not warrant the attention of this Committee and all 
of Congress. But these scenarios are echoed in state after state. Given 
this, it is no surprise that the US Surgeon General's Report on Mental 
Health cited data showing that only 20% of persons with mental 
disorders receive any treatment in a given year, and that includes 
fewer than half the persons with such severe disorders as schizophrenia 
and bipolar disorder. Hence, the importance of Commissioner Hogan's 
call in the transmittal letter for the Commission's report, for a 
``fundamental transformation'' of our approach to mental health care.
    The recommendations in the Commission's report are, without 
exception, helpful. But to be frank, they fall short of the fundamental 
transformation that is so clearly needed. As president of the American 
Psychiatric Association, I appointed a task force to develop a vision 
of what a genuine system of mental health care should be. That report, 
along with my presidential address that lays out some directions we can 
follow, has been provided to the Committee. In short, I suggest that we 
need to facilitate the integration of treatment for most mental 
disorders into the primary care medical system--a goal that faces 
numerous structural obstacles today. And for our citizens with severe 
and persistent mental disorders, we must reinvigorate the vision of 
President John F. Kennedy, whose Community Mental Health Act of 1963 
marked the last attempt to construct a nationwide mental health system 
that could care for all our of our citizens. And while the costs of 
such a program cannot be ignored, it is likely that they can be funded 
in substantial part from money now spent on jails, homeless shelters, 
disability payments and other efforts to compensate for the failings of 
our mental health system.
    Thank you for your attention and I would be pleased to respond to 
the Committee's questions.















































      Prepared Statement of the Campaign for Mental Health Reform

    Mr. Chairman and Members of the Subcommittee, I am Michael Faenza, 
President and CEO of the National Mental Health Association and I am 
pleased to offer this testimony on behalf of the Campaign for Mental 
Health Reform.
    The Campaign for Mental Health Reform has been organized to advance 
Federal policies to make access, recovery, coherence, and quality in 
mental health services the hallmarks of our nation's mental health 
system. The organizations making up the Campaign represent mental 
health consumers, families, advocates, professionals, providers, 
States, counties, and communities and are dedicated to improving the 
lives of people with mental illnesses and children with mental, 
emotional or behavioral disorders. We welcome the opportunity to 
provide testimony regarding the recommendations of the New Freedom 
Commission on Mental Health. Sharing a common commitment to advancing 
the Commission's vision and goals, we are eager to work with this 
committee to advance needed reforms.
    The Commission report and its recommendations represent an 
important milestone to guide policymakers. Building on the 1999 Report 
of the Surgeon General on Mental Health, the Commission's work offers a 
compelling vision and recommendations on how our nation must address 
mental health that finds broad support in the mental health community. 
We view the Commission's report as a call to action, and applaud the 
commissioners' efforts to beam a national spotlight--albeit for a brief 
year--on a subject that is too often neglected: the needs of adults and 
children with or at risk of mental illness.
    We share a belief that there is a desperate need to transform 
mental health care in the United States. Mental illness takes a 
devastating toll on millions of individuals and their families. It is 
the second leading cause of disability and premature death in our 
country. However, as a country, we have yet to make mental health a 
real priority commensurate with its prevalence, morbidity and 
mortality. Mental health and the state of our public mental health 
delivery system should be matters of real societal concern. Consider, 
for example, that untreated mental illness imposes a cost of some $79 
billion on our economy. As the Commission reported, one of every two 
people who need mental health treatment in our country do not receive 
it. Mr. Chairman, as you know from your years of work on this issue, 
some 16 percent of those in our nation's prisons and jails have a 
mental illness. And as many as 80 percent of the young people in our 
juvenile justice system have a mental or substance use disorder. 
Thirty-thousand Americans die by suicide each year, with mental 
disorders a factor in 90 percent of those instances. The suicide rate 
exceeded the homicide rate this past year as it has for the last 100 
years. Like mental health problems generally, suicide strikes across 
the age span. Suicide is the third leading cause of death among those 
between 10 and 24. Older Americans have the highest rate of suicide of 
any population in the United States, and the suicide rate of that 
population increases with age, with those 65 and older accounting for 
20 percent of all suicide deaths, while comprising only 13 percent of 
the population. The rate of suicide among Native Americans is about 1.7 
times the rate of the nation as a whole. Shocking as they are, these 
statistics alone mask the crushing pain that mental health problems 
cause individuals, their families, and communities. They also represent 
a stark reflection of our failure to make mental health a real 
priority. The Commission ``got it right,'' in our view, when it said 
last year that our nation's failure to prioritize mental health is a 
national tragedy.''
    In fact, government has both underfunded mental health programs and 
failed to address mental health as a cross-cutting issue. As the 
Commission ably documents in highlighting the paralyzing fragmentation 
in mental health service-delivery, mental health is an issue of public 
health, health financing, child welfare, education, housing, criminal 
justice, rehabilitation, and employment, to name only the most obvious.
    In its report, the President's Commission called for a 
transformation of mental health care in America. The goal of 
transformation might seem a novel concept or overblown rhetoric. But 
there is a compelling logic to this vision. Science has transformed 
both our understanding of mental illness, and the tools to diagnose and 
treat most mental illnesses. The Commission's recognition that we can 
build resilience and that recovery from mental illness is a realizable 
goal reflects another transformation in thinking about mental illness. 
But public understanding and attitudes about mental illness are still 
shaped by old stereotypes and stigma. And, with rare exception, State 
and local governments have not been able to bring together the needed 
tools to enable people with mental illnesses to live and participate 
fully in their communities. Although the Commission has provided a 
compelling vision of the elements of a transformed mental health 
system, it has not laid out a roadmap for how the transformation it 
prescribes might be realized.
    The Commission left it to policymakers to answer the question, how 
do we proceed down a road toward real transformation? Administration 
officials have described a process aimed at developing administrative 
measures that would advance the Commission's goals. Mental health 
advocates have been invited to offer recommendations. We welcome that 
invitation and have initiated efforts to meet with pertinent agency 
officials.
    We appreciate that there are opportunities for mental health reform 
at all levels of government and we recognize the importance of 
leadership from the Federal Government in advancing change. But it is 
difficult to conceive that administrative action alone can transform a 
system described as ``in shambles.'' Administrative measures cannot 
align the inconsistent eligibility requirements of the disparate 
Federal programs so critical to meeting the array of benefits, services 
and supports needed by many people with mental illness. Administrative 
measures will not address the anomaly that by law, Medicaid, the 
largest payer of mental health services in the country, treats mental 
health care as an optional service. And administrative measures will 
not alter the fact that Medicare mental health benefits fail to provide 
basic parity between mental health care and care for any other illness 
and fail to cover important, effective services needed to treat chronic 
illness.
    Congress must be a leader in changing a ``system'' that, in the 
Commission's words, ``does not adequately serve millions of people who 
need care.'' The problems pinpointed by the Commission span a range of 
challenges--including scattered and sometimes ineffective programs, 
uncoordinated funding streams, and unmet need--but this committee can 
play a vital role in crafting needed solutions. Importantly, this 
committee's leadership in reauthorizing and giving new policy direction 
to the Substance Abuse and Mental Health Services Administration can 
establish a framework for powerful change.
    We hope to work with this committee and provide concrete 
recommendations for legislation that will advance the Commission's 
goals and strengthen SAMHSA's hand in helping achieve them.
    Among the important issues we urge this committee to take up, and 
on which we are developing legislative proposals, are the following:
     Fostering new financing and planning mechanisms to provide 
effective, family-driven community-based care to children and youth 
with mental health needs;
     Fostering mental health promotion and early intervention 
services through school-based mental health care;
     Advancing early detection and treatment across the age 
span for mental health problems, including co-occurring mental 
illnesses and substance use disorders;
     Reducing fragmentation in mental health service delivery, 
including support and systems of care for children and their families;
     Developing mechanisms to expand, implement, and monitor 
the progress of the national strategy for suicide prevention;
     Fostering greater integration of health and mental health 
care;
     Fully involving mental health consumers and families in 
orienting the mental health care system toward a recovery orientation;
     Developing targeted programs to expand and improve the 
effectiveness of the mental health workforce, including the training of 
racial and ethnic minority mental health professionals to meet the 
needs of increasingly diverse populations; and
     Fostering diversion of juveniles and adults from justice 
systems to improved community-based mental health care systems.
    As this committee moves toward reauthorization efforts, we also 
look forward to working with you, and with the agency, on a significant 
revision in the role of the Substance Abuse and Mental Health Services 
Administration (SAMHSA) within the Federal government. With appropriate 
revision of its statutory ``charter'', SAMHGA can become an even more 
effective focal point for leadership on many of these and other 
important mental health issues, as well as provide leadership to States 
and communities.
    As the President stated in announcing the establishment of a mental 
health commission, ``our country must make a commitment.'' That 
commitment will necessarily require dramatic reforms across a range of 
government programs--among them, Medicaid, Medicare, housing, Social 
Security income support, vocational rehabilitation, education, child 
welfare, and justice. In some instances, we believe Federal programs 
give insufficient attention to the needs of people with or at risk of 
mental illness; most, however, provide important assistance, but with 
their differing objectives, eligibility requirements, and financing 
structures, contribute to the widespread fragmentation in mental health 
service-delivery that is too often both inefficient and ineffective. We 
applaud this subcommittee for giving the Commission's recommendations 
early consideration. But we also hope, Mr. Chairman, that as you review 
the challenges facing children and adults with or at risk of mental 
illness that you will consider urging other committee chairmen to make 
mental health reform a priority that moves us toward cross-system 
coordination and integration, and ultimately the kind of transformation 
the Commission envisioned.
    Finally, Mr. Chairman, it is critical that we embark on this path 
with an appreciation that mental health has long been dramatically 
underfunded relative to the impact mental disorders have on the 
individual, his or her family, the community, and the economy. In 
short, we urge Congress to make mental health and the transformation to 
a recovery-based system both a legislative and a funding priority.

                Prepared Statement of Carlos Brandenburg

    Mr. Chairman and Members of the Subcommittee: My name is Carlos 
Brandenburg, and I am the Administrator of the Division of Mental 
Health and Developmental Services in Nevada's Department of Human 
Resources. I would like to extend my thanks and appreciation to 
Chairman DeWine and the Subcommittee for inviting me to testify this 
morning regarding the State of Nevada's experience and efforts 
pertaining to the final report of the President's New Freedom 
Commission on Mental Health.
    By describing the poor state of the nation's public mental health 
system, the President's New Freedom Commission on Mental Health 
provided an invaluable service not only for the millions of people in 
this country with mental illness and their family members, but also for 
those of us responsible for administering the programs that are in 
crisis. Indeed, the mental health system in Nevada, notwithstanding our 
successes, faces extraordinary difficulties. At the same time, there 
has never been a more hopeful time to take on this challenge, and I am 
profoundly grateful for the opportunity to serve as my State's lead on 
this issue and at this particular point in time.
    Why am I so hopeful?
    Much has already been said about the significance of the goals 
stated by the President's Commission itself, its recommendation that 
mental health be transformed, and its commitment to recovery. The value 
of the Commission's work cannot be overstated, but let me identify 
other critical factors.
    First, we have in the Federal government a true partner. 
Administrator Curie worked hard within the Administration to help the 
President form the Commission, to ensure that it was composed of 
extraordinary people, and to establish for it an ambitious but 
achievable mission.
    Second, as you are hearing today, the advocates who stand up for 
the mental health community in Washington, D.C., are organized and 
prepared to work together like never before. The Campaign for Mental 
Health Reform--today being represented by Mike Faenza of the National 
Mental Health Association--can help policy-makers make the Commission's 
vision a reality and see to it that the light shone on this issue is 
not dimmed.
    Third, we are witnessing unprecedented interest on the part of 
Congress, as evidenced by this hearing and the creation of this 
Subcommittee.
    And, fourth, is the good fortune of the State of Nevada itself. 
Nevada was honored that President Bush appointed Nevada State Senator 
Randolph J. Townsend to serve on the President's Mental Health 
Commission. The Commission's only elected official, Senator Townsend 
has long been a proponent of mental health care. His recent work with 
the Commission has served as a great catalyst for Nevada's current 
efforts to transform mental health in our state.
    In order to assist Senator Townsend in carrying out his duties and 
responsibilities as a commissioner, we held numerous town hall and 
focus group meetings to explore the range of problems and gaps in 
mental health care for Nevadans. This enabled him to bring to the 
Commission concrete recommendations for improvement that could apply 
both locally and nationally. Further, these meetings and focus groups 
allowed us to quantify the degree of unmet need in Nevada and identify 
the barriers that impede care for people with mental illness and 
prepare us for our work ahead--after the work of the Commission was 
done.
    During the 2003 state legislative session, Senator Townsend had the 
foresight to introduce Nevada State Senate Bill 301, a copy of which I 
am submitting along with my testimony. This state law created the 
Nevada Mental Health Plan Implementation Commission. The commission is 
charged explicitly with developing an action plan for implementing the 
recommendations and goals of the final report of the President's New 
Freedom Commission on Mental Health in Nevada.
    The Nevada Commission must submit a report setting forth the action 
plan to Nevada's Interim Finance Committee, its Legislative Committee 
on Health Care, and to Governor Guinn on or before January 1, 2005.
    The Nevada Commission members elected Senator Townsend to serve as 
its Chair. Other members include six state legislators, four state 
agency heads (including myself). The Commission also provides for 
extensive public involvement, including participation by consumers, 
family members, and providers. Our fourth meeting is being held as we 
speak. Needless to say, my colleagues gave me leave to speak with you 
all today. Each meeting is focused on one of the six goals of the final 
report of the presidential commission. Today's meeting is focused on 
ensuring early assessment and treatment of mental disorders, improving 
school-based mental health programs, and the need to provide integrated 
treatment for those with co-occurring mental health and substance abuse 
disorders. In all our deliberations, we focus on specific 
recommendations, both policy and budgetary, that will turn the 
President's Commission's national goals into concrete forward steps in 
Nevada.
    The Nevada Commission, in addition to providing an organized 
mechanism to facilitate comprehensive state mental health planning and 
policy development, has also been an effective means of keeping the 
subject of mental health in the media across the state and helping to 
raise awareness and hopefully reduce stigma. During the course of our 
meetings, we have been struck by the fact that too many Nevadans do not 
know that mental illness can be treated and that recovery is possible. 
We have learned about the large barriers encountered by individuals 
with mental illness who are chronically homeless. We have heard 
compelling testimony about the need for consumer involvement in care 
and the success of various consumer model programs around the country, 
and we have learned some strategies used by other states and locales in 
improving the nearly nonexistent mental health care in rural areas of 
the nation--of course, an issue of particular concern in Nevada.
    The Nevada Commission's efforts have been greatly enhanced by 
generous technical support provided by the National Association of 
State Mental Health Program Directors (NASMHPD) in conjunction with a 
contract with the federal Substance Abuse and Mental Health Services 
Administration (SAMHSA). NASMHPD is enabling us to bring national 
experts, including members of the President's Commission, to our 
meetings. They who are providing us with recommendations of best 
practices and programs in other areas of the country that can be 
implemented in Nevada. This assistance has been invaluable.
    Ultimately our Commission will show Nevada how to change the 
fragmented nature of our mental health delivery system. There are some 
preliminary findings that I can report here today. For example, 
enhanced education about mental illness would greatly improve the 
general public perception of mental illness and also increase the 
understanding that mental illness impacts overall health and that 
mental illness is treatable and recovery is possible. Nevada will also 
focus on implementing a state strategy for suicide prevention.
    But here is the last point I would like to leave with the 
Subcommittee. The ultimate goal of the President's Commission and, in 
turn, the Nevada Commission, is ambitious--attainable, but ambitious. 
Indeed, it is calling for system transformation. The report of the New 
Freedom Commission on Mental Health identifies the fragmentation of 
services and financing as central barriers to the effective delivery of 
comprehensive mental health services and has called on all levels of 
government to correct this problem by ultimately establishing in each 
``an extensive and coordinated State system of services and supports 
that work to foster consumer independence and their ability to live, 
work, learn, and participate fully in their communities.'' 
(Recommendation 2.4). You have heard about Nevada's commitment in 
making this happen. But neither Nevada nor any other state can do this 
without significant assistance on the part of the federal government.
    Specifically, we require federal assistance to both engage in the 
type of planning envisioned by the Commission and to implement those 
plans, enabling us to fill the enormous gaps in care for people with 
mental illnesses. Even in Nevada, where we have been uniquely fortunate 
to begin the transformation process, we will not be able to do it 
without federal funding. We hope that the Subcommittee, presumably as 
it begins its effort to reauthorize SAMHSA and its programs, will work 
closely with the states and the Campaign for Mental Health Reform to 
devise a bold program that will provide the support needed to ensure 
that the vision of transformation is realized.
    Thank you again for inviting me to speak today. I am happy to 
entertain any questions at this time.

                   Prepared Statement of Ann Buchanan

    Chairman DeWine, Senator Kennedy and members of the Subcommittee, I 
am Ann Buchanan of Cockeysville, Maryland. I am proud to be here this 
morning to share with you the story of my son's struggle with mental 
illness and offer some perspectives on President Bush's New Freedom 
Commission on Mental Health. At the outset I would like to thank you 
for convening this important hearing and inviting the unique 
perspectives of individuals living with mental illness and their 
families.
    Before commenting on the final report of the White House Commission 
on Mental Health, I would like to first tell you and members of this 
Subcommittee a little about myself and my family's experience with 
mental illness--a saga that continues to this very day. My son is Rusty 
is now 22 years-old. When Rusty was age 16, he and I suffered 
catastrophic event when his father, my husband, lost his battle with 
cancer. Shortly thereafter, Rusty was diagnosed with depression--
probably not uncommon for a teenage boy coping with the trauma of the 
loss of a father. In 1997, Rusty was hospitalized twice at Shepperd-
Pratt. During this period, Rusty was growing increasingly agitated and 
angry and he physically attacked me twice. Shortly thereafter, he was 
forced to withdraw from Towson High School at age 17 and was enrolled 
at Hannah Moore--a school for troubled adolescents.
    After only three months at Hannah Moore, he was sent to the 
Regional Institute for Children and Adolescents (RICA) in Baltimore. 
RICA is a treatment facility that is part of the Maryland Department of 
Health and Mental Hygene. It includes both residential programs and day 
treatment for adolescents with serious emotional disturbances and other 
mental illnesses. It offers a range of services including psychiatric 
treatment, crisis intervention, behavior modification, special 
education and rehabilitative services.
    After arriving at RICA, Rusty stayed for over a year, and with the 
help of the staff and a supportive environment, graduated high school 
in 1999. While this would normally be an occasion for celebration and 
accomplishment for most families, it was a source of enormous stress 
for Rusty, myself and many of the staff at RICA. Tragically for us the 
spring and summer of 1999 were filled with anxiety and uncertainty as 
Rusty approached his 18th birthday and high school graduation. The sad 
reality is that as he approached what would normally be a period of 
great optimism and promise for most adolescents and their families, 
Rusty and I were dealing with the fact that he was ``aging out'' of the 
child and adolescent mental health system with very little planning and 
stability about the adult system of care he would be entering.
    While the staff at RICA were very caring and responsive, the sad 
reality is that it was rare for them to deal with a young person such 
as Rusty who was receiving a high school diploma. We all knew that a 
date certain was coming when Rusty would no longer be eligible to 
receive services at RICA--again, because of he was rapidly approaching 
the point at which he had ``aged out'' of Maryland's child and 
adolescent system. The stress this placed on Rusty was enormous and in 
the summer of 1999 he attempted suicide.
    I want to reiterate that the staff at RICA were helpful. However, I 
was forced to do most of the work to find a residential placement for 
Rusty. Waiting lists were long and finding a residential placement was 
enormously difficult. All across Maryland, psychiatric hospitals and 
residential programs have been cutting beds and shrinking programs. I 
made applications to 3-4 residential programs. Each had either a long 
waiting list or were unwilling to take him because of his history of 
abusive behavior--the result of his mental illness.
    This period was filled with tremendous anxiety for Rusty and 
myself. RICA said that he had to leave and I felt strongly that it was 
not safe for him to return to my home. He was being denied placement in 
residential programs that could meet his needs or was going to be 
placed on a waiting list that could take months if not years. 
Eventually, he began receiving services from the adult system only 
after the suicide attempt in July 1999 and an involuntary admission to 
Spring Grove Hospital. In other words, only after his symptoms and 
condition had deteriorated to the point that he was a threat to himself 
(and most certainly others) was he able to get the treatment he needed 
from the adult system.
    While our story may be unique, I doubt it is. The sad reality is 
that thousands of families every year face the enormous challenge of 
having their child ``age out'' of adolescent treatment and service 
programs. It should not come as no surprise to anyone that the course 
of mental illness does not magically shift once a child turns 18, 19 or 
20. The symptoms they experience--be it anxiety, depression, mania, 
psychosis or paranoia--do not change to fit our mental health system's 
pre-existing definitions about what are children and adolescent 
services v. what are adult services. In my view, it is disturbing that 
the separate child-adolescent and adult systems struggle so mightily to 
help adolescents make the transition in to adulthood. This is 
especially the case with children and adolescents with more severe 
mental illnesses who are much more likely to see their diagnosis and 
illness stay with them into adulthood.
    What must be done to ensure that meaningful transitional services 
become a reality? First, we need to recognize the shift in legal 
relationships that occurs when the law deems an adolescent to be an 
adult with full legal rights in our society. Rusty acquired specific 
rights once he became an adult. This included certain rights relative 
to his mental illness treatment that did not exist when he was an 
adolescent. At the same time, the genesis of these legal rights should 
in no way obscure the obligation of child-adolescent programs to be 
assertive in ensuring that young people are fully able to access to 
mental illness treatment and services. More importantly, they should 
have an affirmative obligation to ensure that the adult system--whether 
a public mental health authority or a CMHC--is aware of, and is 
prepared to meet the treatment needs of adolescents reaching adult age.
    The child-adolescent and adult mental health systems are 
necessarily separate--on the basis of clinical and legal rationale. 
However, this separation should not extinguish the obligation for both 
to develop a cooperative and collaborative relationship that can foster 
a seamless transition.
    One major challenge for us--and for providers such as RICA--is the 
shift in eligibility for income support and health care entitlements 
that can occur as adolescent becomes a legal adult. In our case, Rusty 
qualified for certain Social Security survivor benefits from his late 
father. Many other adolescents with severe mental illnesses qualify for 
SSI before their 18th birthday. In either case, their access to certain 
programs may often be driven by what Medicare and Medicaid will pay 
for.
    More importantly, for most families, this transition is rarely 
smooth and can involve months, and even years, of uncertainty as to 
which programs they qualify for--this is especially the case with 
respect to state Medicaid ``spend down'' requirements. Moreover, in 
many states eligibility for Medicaid can be tied to participation in a 
specific program. For example, Rusty's eligibility for Medicaid 
currently depends on his continuing to be served in the residential 
program where he lives. If he were to leave (or were forced out), he 
would almost certainly lose eligibility for Medicaid and be left with 
no coverage for prescription medications and only limited coverage for 
outpatient therapy. Note--he would still be able eligible for Medicare; 
however, Medicare does not cover prescription medications and has a 50% 
co-payment requirement for outpatient mental health services. Clearly 
more needs to be done to address the fragmentation in both funding 
streams and eligibility standards for these very complicated programs.
    Our struggle with mental illness continues. Rusty has been 
diagnosed with schizophrenia. Since 1999, he has been in several 
different programs in Maryland, including Alliance in Essex. Currently, 
he resides at Keypoint in Dundalk, in a 3-bedrrom apartment he shares 
with two other consumers. He slowly gaining more independence and has 
begun to ride the MTA on his own. He has also been participating in a 
day treatment program. As part of this, he has begin working in the 
greenhouse at Keypoint in hopes of acquiring skills that will allow him 
to participate in a work program at the local Home Depot.

            THE WHITE HOUSE MENTAL HEALTH COMMISSION REPORT

    I would like to make a few brief observations about President 
Bush's New Freedom Mental Health Commission Report as it relates to my 
own family's experience with mental illness. First, it is important to 
note this report does not contain any specific findings or 
recommendations with respect to services designed to address the 
transition from the child-adolescent system to the adult system. At the 
same time, this report does document the enormous fragmentation that 
remains a serious problem in our public mental health system.
    The report also calls for development of an individualized plan of 
care for both children and adults with mental illness (Recommendation 
2.1). Specifically, the report recommends that such plans should be 
designed to improve service coordination, allow for informed choices 
and help achieve and sustain recovery. I have little doubt that had 
such a plan been in place, Rusty would have been able to make a more 
productive transition into adulthood.
    On a more macro-level, Recommendation 2.2 calls for greater 
involvement of consumers and families in fully orienting the mental 
health system toward recovery. This includes a plea for greater 
engagement of consumers and families in the planning and evaluation of 
services. This is certainly a laudable goal and would certainly help 
make providers (and more importantly) public officials more aware of 
the struggles that adolescents and their families experience when 
children become adults.
    The report also contains a heavy focus on the need for more 
comprehensive state planning (Recommendation 2.4). This is a very 
positive step toward making the transition between the child-adolescent 
and adult system more seamless. As the report notes, such comprehensive 
state planning should allow for more creativity and flexibility with 
respect to eligibility requirements for federal programs, insist on 
more accountability at the state and local level (especially to 
consumers and families) and expand the array of available services. 
Among the requirements that could be an integral part of this new era 
of comprehensive state planning is accountability for ensuring that 
adolescents aging into the adult system (and their families) receive 
assistance in making this often difficult transition. Such transition 
services should include intensive case management and benefit planning.
    Finally, I also want to comment on findings and recommendations in 
the report calling for consumes and families to have a greater control 
over their own care. While this goal is laudable, it will never be 
achieved without expansion of family education and peer support 
programs to help consumers and families learn more about mental 
illness, treatment system and how to advocate for themselves. I am a 
graduate of the NAMI ``Family-to-Family'' Education program. I found it 
to be enormously helpful in preparing me to cope with my son's illness 
and become an advocate both for his recovery and for improvements in 
the service system in our community.
    Likewise, numerous peer support and psycho-education programs for 
both consumers and families have a proven track record of effectiveness 
in promoting recovery real change at the community level. As you and 
your colleagues on this Subcommittee move forward in implementing this 
report, I would urge you to consider the enormous value of programs 
such as ``Family-to-Family'' in moving toward the goals articulated by 
the White House Commission.

                               CONCLUSION

    Chairman DeWine and members of the Subcommittee that you for the 
opportunity to offer this testimony on behalf of myself and millions of 
families living everyday with mental illness.

    [Whereupon, at 11:48 a.m., the subcommittee was adjourned.]

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