[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
EXAMINING SAMHSA'S ROLE IN DELIVERING SERVICES TO THE SEVERELY MENTALLY
ILL
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
__________
MAY 22, 2013
__________
Serial No. 113-47
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
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COMMITTEE ON ENERGY AND COMMERCE
FRED UPTON, Michigan
Chairman
RALPH M. HALL, Texas HENRY A. WAXMAN, California
JOE BARTON, Texas Ranking Member
Chairman Emeritus JOHN D. DINGELL, Michigan
ED WHITFIELD, Kentucky Chairman Emeritus
JOHN SHIMKUS, Illinois EDWARD J. MARKEY, Massachusetts
JOSEPH R. PITTS, Pennsylvania FRANK PALLONE, Jr., New Jersey
GREG WALDEN, Oregon BOBBY L. RUSH, Illinois
LEE TERRY, Nebraska ANNA G. ESHOO, California
MIKE ROGERS, Michigan ELIOT L. ENGEL, New York
TIM MURPHY, Pennsylvania GENE GREEN, Texas
MICHAEL C. BURGESS, Texas DIANA DeGETTE, Colorado
MARSHA BLACKBURN, Tennessee LOIS CAPPS, California
Vice Chairman MICHAEL F. DOYLE, Pennsylvania
PHIL GINGREY, Georgia JANICE D. SCHAKOWSKY, Illinois
STEVE SCALISE, Louisiana JIM MATHESON, Utah
ROBERT E. LATTA, Ohio G.K. BUTTERFIELD, North Carolina
CATHY McMORRIS RODGERS, Washington JOHN BARROW, Georgia
GREGG HARPER, Mississippi DORIS O. MATSUI, California
LEONARD LANCE, New Jersey DONNA M. CHRISTENSEN, Virgin
BILL CASSIDY, Louisiana Islands
BRETT GUTHRIE, Kentucky KATHY CASTOR, Florida
PETE OLSON, Texas JOHN P. SARBANES, Maryland
DAVID B. McKINLEY, West Virginia JERRY McNERNEY, California
CORY GARDNER, Colorado BRUCE L. BRALEY, Iowa
MIKE POMPEO, Kansas PETER WELCH, Vermont
ADAM KINZINGER, Illinois BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia PAUL TONKO, New York
GUS M. BILIRAKIS, Florida
BILL JOHNSON, Missouri
BILLY LONG, Missouri
RENEE L. ELLMERS, North Carolina
Subcommittee on Oversight and Investigations
TIM MURPHY, Pennsylvania
Chairman
MICHAEL C. BURGESS, Texas DIANA DeGETTE, Colorado
Vice Chairman Ranking Member
MARSHA BLACKBURN, Tennessee BRUCE L. BRALEY, Iowa
PHIL GINGREY, Georgia BEN RAY LUJAN, New Mexico
STEVE SCALISE, Louisiana EDWARD J. MARKEY, Massachusetts
GREGG HARPER, Mississippi JANICE D. SCHAKOWSKY, Illinois
PETE OLSON, Texas G.K. BUTTERFIELD, North Carolina
CORY GARDNER, Colorado KATHY CASTOR, Florida
H. MORGAN GRIFFITH, Virginia PETER WELCH, Vermont
BILL JOHNSON, Ohio PAUL TONKO, New York
BILLY LONG, Missouri GENE GREEN, Texas
RENEE L. ELLMERS, North Carolina JOHN D. DINGELL, Michigan
JOE BARTON, Texas HENRY A. WAXMAN, California (ex
FRED UPTON, Michigan (ex officio) officio)
C O N T E N T S
----------
Page
Hon. Tim Murphy, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement........................................... 4
Hon. Diana DeGette, a Representative in Congress from the State
of Colorado, opening statement................................. 6
Hon. Fred Upton, a Representative in Congress from the State of
Michigan, opening statement.................................... 7
Prepared statement........................................... 8
Hon. G.K. Butterfield, a Representative in Congress from the
State of North Carolina, opening statement..................... 10
Hon. Henry A. Waxman, a Representative in Congress from the State
of California, prepared statement.............................. 11
Witnesses
Pamela S. Hyde, Administrator, Substance Abuse and Mental Health
Services Administration........................................ 13
Prepared statement........................................... 15
Answers to submitted questions............................... 165
Joseph Bruce, Father of a Son with Severe Mental Illness......... 57
Prepared statement........................................... 61
Answers to submitted questions............................... 202
E. Fuller Torrey, Founder, Treatment Advocacy Center............. 67
Prepared statement........................................... 70
Answers to submitted questions............................... 206
Sally Satel, Resident Scholar, American Enterprise Institute..... 82
Prepared statement........................................... 84
Answers to submitted questions............................... 211
Joseph Parks, III, Chief Clinical Officer, Missouri Department of
Mental Health.................................................. 91
Prepared statement........................................... 94
Answers to submitted questions............................... 213
Submitted Material
Document binder.................................................. 115
EXAMINING SAMHSA'S ROLE IN DELIVERING SERVICES TO THE SEVERELY MENTALLY
ILL
----------
WEDNESDAY, MAY 22, 2013
House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:05 a.m., in
room 2123 of the Rayburn House Office Building, Hon. Tim Murphy
(chairman of the subcommittee) presiding.
Members present: Representatives Murphy, Burgess,
Blackburn, Gingrey, Scalise, Harper, Olson, Gardner, Griffith,
Johnson, Long, Ellmers, Upton (ex officio), DeGette, Braley,
Butterfield, Castor, Tonko, Green, and Waxman (ex officio).
Also present: Representative Cassidy.
Staff present: Karen Christian, Chief Counsel, Oversight;
Brad Grantz, Policy Coordinator, O&I; Brittany Havens,
Legislative Clerk; Robert Horne, Professional Staff Member,
Health; Alan Slobodin, Deputy Chief Counsel, Oversight; Sam
Spector, Counsel, Oversight; Jean Woodrow, Director,
Information Technology; Stacia Cardille, Democratic Deputy
Chief Counsel; Anne Morris Reid, Democratic Professional Staff;
Brian Cohen, Democratic Staff Director for Oversight and
Investigations Subcommittee and Senior Policy Advisor; Stephen
Salsbury, Democratic Special Assistant; and Elizabeth Letter,
Democratic Assistant Press Secretary.
OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Mr. Murphy. Good morning, everyone. I now convene this
morning's hearing entitled ``Examining SAMHSA's Role in
Delivering Services to the Severely Mentally Ill.''
Since I became the Chairman of the Subcommittee on
Oversight and Investigations, shortly after the December 14,
2012, elementary school shootings in Newtown of last year, we
began looking into the federal programs and the resources
devoted to mental health and mental illness. We did so to
ensure federal dollars devoted to mental health are reaching
those individuals with serious mental illness and helping them
obtain the most effective care.
One lesson we must immediately draw from the Newtown
tragedy is that we need to make it our priority to get those
with serious mental illness who are not presently being treated
into sound, evidence-based treatments.
In 2009, the Substance Abuse and Mental Health Services
Administration, otherwise known as SAMHSA, estimates that about
11 million U.S. adults had serious mental illness, and 40
percent of these individuals did not receive treatment. While
the vast majority of individuals with a mental health condition
are nonviolent, director of the National Institute for Mental
Health, Dr. Thomas Insel, told this subcommittee at our March 5
public forum that effective treatments, which include
medication adherence and evidence-based psychosocial
psychotherapy, can reduce the risk of violent behavior 15-fold
in persons with serious mental illness.
Getting these individuals into treatment is a crucial first
task, and SAMHSA, as the federal agency whose mission includes
reducing the impact of mental illness on America's communities,
should be playing a central role in this effort. But based on
our work to date, SAMHSA has not made the treatment of the
seriously mentally ill a priority. In fact, I am afraid serious
mental illness such as schizophrenia and bipolar disorder may
not be a concern at all.
Consider the 2011-2014 SAMHSA strategic plan entitled
``Leading Change.'' SAMHSA continues to think in broad terms
such as ``behavioral'' and ``emotional'' health, promoting such
concepts as ``wellness'' or ``recovery.'' Not once in this
entire 117-page document will you find the words schizophrenia
or bipolar disorder. Nowhere in the written testimony that was
provided to this committee yesterday by the SAMHSA
administrator do those words appear. And nowhere on SAMHSA's
Web site or in their publications can you learn about the
increased risk of violent behavior by persons with untreated
mental illness. It is as if SAMHSA doesn't believe serious
mental illness exists.
If we have learned one thing from the horrible acts
committed by Seung-Hui Cho at Virginia Tech in 2007; Jared
Loughner in Tucson; James Holmes at the Aurora, Colorado,
theater in July 2012; or Adam Lanza, it is this: that
individuals with untreated severe mental illness are a
significant target for self-directed violence, including
suicide or violence against others. In at least 38 of the last
62 mass killings, the perpetrator displayed signs of possible
mental health problems. In so many of these instances, parents
desperately tried to get their mentally ill loved one to help
before the act. Sadly, they failed, oftentimes because the
current system of care for those with serious mental illness is
broken.
Examining what SAMHSA is doing to grapple with this
heartbreaking truth is the main reason we are gathered here
this morning. The Center for Mental Health Services, housed at
SAMHSA, has a budget of approximately $1 billion per year. It
awards most of these funds through a combination of competitive
and formula grants. I am concerned because the Committee has
seen substantial evidence that too many of these grants are
directed to advancing services rooted in unproven social theory
and feel-good fads rather than science. If SAMHSA were to use
an evidence-based approach to identifying how to prioritize its
resources--like other federal agencies do--would their record,
not to mention their strategic initiatives going forward, look
the same as they do now?
For example, in 2012, an annual conference that has been
funded by SAMHSA for many years at which the SAMHSA
administrator herself regularly delivers a keynote, a
conference known as Alternatives, an hour-and-a-half workshop
was held, described as follows: ``Unleash the Beast is a mind/
body fitness program that looks to the animals of the jungle
for wisdom and skills that can benefit our lives in a myriad of
ways. Through animal-inspired movements, behaviors, and
expressions, participants are encouraged to shed layers of
formal conditioning in order to return to their primal
nature.''
While mental and physical health is important, I question
the value of this exercise in advancing the treatment for
mental illness in humans let alone seriously mentally ill, and
I question if there is any scientific merit at all.
I would also ask why SAMHSA provides grant funding year
after year in the millions of dollars in aggregate to
organizations that are outwardly hostile to the sciences of
psychiatry and psychology. These groups openly deny that mental
illness exists, claiming there is nothing out of the ordinary
when an individual hears voices or experiences extreme mental
states, and that these should be celebrated as nature's gift to
mankind, contributing to artistic creativity and human
diversity.
Leaders of these organizations--including at least one of
which SAMHSA has elevated to the status of a ``National
Technical Assistance Center'' and received at least $300,000 in
taxpayer dollars the past year--have actively encouraged
supporters to ``occupy'' the 2012 annual convention of the
American Psychiatric Association, decrying the professional
association's role in developing the Diagnostic and Statistical
Manual of Mental Disorders, otherwise known as the DSM.
``Psychiatric labeling,'' as they say, is ``a pseudoscientific
practice of limited value in helping people recover.''
When SAMHSA-funded organizations are not busy encouraging
those with mental illness to go off their prescribed
medications--and, yes, they do that--or destroying trust
between individuals with serious mental illness, their family
caregivers, and their physicians, these taxpayer-backed groups
are actively lobbying against effective evidence-based
treatment like Assisted Outpatient Treatment--otherwise known
as AOT--laws, a less-restrictive alternative to involuntary
commitment is what AOT is. Numerous academic studies have shown
AOT to be incredibly effective in reducing re-hospitalizations
and re-arrests among, until-then, untreated individuals with
serious mental illness.
As an agency of the U.S. Public Health Service, we expect
SAMHSA's work to be firmly rooted in evidence-based practices
in deed and not just by word, enduring high-level scientific
peer review at the hands of licensed mental health
professionals. Perhaps some of it is and I know some of it is,
but much of it appears to fall far short of such standards.
To get answers to our questions, this morning, we will hear
from Pamela Hyde, the Administrator of SAMHSA since 2009, on
our first panel. On our second panel, we will hear from E.
Fuller Torrey, a psychiatrist and long-time observer of SAMHSA;
Dr. Sally Satel, a member of the National Advisory Council to
SAMHSA's Center for Mental Health Services for 4 years; and Joe
Bruce, a family man from Caratunk, Maine, whose life was
irrevocably changed by one SAMHSA program in particular.
Joe's wife, Amy, was murdered by their son, Will, only
months after being released from a psychiatric hospital where
he had been treated for schizophrenia. Reflecting on this
horrific act several years ago, Will noted that, un-medicated
at the time, he believed he was a clandestine operative under
orders to kill his mother, an Al Qaeda operative. Joe believes
the efforts of a SAMHSA-funded organization obtained his son's
premature release from the hospital without putting in place a
mechanism for ensuring that Will would remain on his
medication. Joe, we extend our condolences to you and your
family, and thank you for sharing your moving story with us
today.
We will also hear from Dr. Joseph Parks, III, Chief
Clinical Officer of the Missouri Department of Mental Health,
who has substantial experience working with SAMHSA grant
funded-projects. And I want to thank all of our witnesses for
being here today.
[The prepared statement of Mr. Murphy follows:]
Prepared statement of Hon. Tim Murphy
Since I became the Chairman of the Subcommittee on
Oversight and Investigations, shortly after the December 14,
2012, elementary school shootings in Newtown, we began looking
into the federal programs and resources devoted to mental
health and mental illness. We did so to ensure federal dollars
devoted to mental health are reaching those individuals with
serious mental illness and helping them obtain the most
effective care.
One lesson we must immediately draw from the Newtown
tragedy is that we need to make it our priority to get those
with serious mental illnesses, who are not presently being
treated, into sound, evidence-based treatments.
In 2009, the Substance Abuse and Mental Health Services
Administration (SAMHSA) estimates that about 11 million U.S.
adults had serious mental illness, and 40 percent of these
individuals did not receive treatment. While the vast majority
of individuals with a mental health condition are nonviolent,
Director of the National Institute for Mental Health, Dr.
Thomas Insel, told this subcommittee at our March 5 public
forum that effective treatments, which include medication
adherence and evidence-based psychosocial therapy, can reduce
the risk of violent behavior fifteen-fold in persons with
serious mental illness.
Getting these individuals into treatment is a crucial first
task and SAMHSA, as the federal agency whose mission includes
reducing the impact of mental illness on America's communities,
should be playing a central role in this effort. But based on
our work to date, SAMHSA has not made the treatment of the
seriously mentally ill a priority. In fact, I'm afraid serious
mental illness such as schizophrenia and bipolar disorder may
not be a concern at all to SAMHSA.
Consider the 2011-2014 SAMHSA strategic plan entitled
``Leading Change.'' SAMHSA continues to think in broad terms of
``behavioral'' and ``emotional'' health, promoting such
concepts as ``wellness'' and ``recovery.'' Not once in this
entire 117 page document will you find the words schizophrenia
or bipolar disorder. Nowhere in the testimony that was provided
to this committee yesterday by the SAMHSA administrator do
those words appear. And nowhere on SAMHSA's web site or in
their publications can you learn about the increased risk of
violent behavior by persons with untreated serious mental
illness.
It's as if SAMHSA doesn't believe serious mental illness
exists.
If we've learned one thing from the horrible acts committed
by Seung-Hui Cho at Virginia Tech in 2007, Jared Loughner in
Tuscon, James Holmes at the Aurora, Colorado, theater in July
2012, or Adam Lanza, it is that the individuals with untreated
severe mental illness are a significant target for self-
directed violence, including suicide, or violence against
others. In at least 38 of the last 62 mass killings, the
perpetrator displayed signs of possible mental health problems.
In so many of these instances, parents desperately tried to get
their mentally ill loved one help before the act. Sadly, they
failed because the current system of care for those with
serious mental illness is broken.
Examining what SAMHSA is doing to grapple with this
heartbreaking truth is the main reason we are gathered here
this morning.
The Center for Mental Health Services, housed at SAMHSA,
has a budget of approximately $1 billion per year. It awards
most of these funds through a combination of competitive and
formula grants. I'm concerned, because the committee has seen
substantial evidence that too many of these grants are directed
to advancing services rooted in unproven social theory and
feel-good fads, rather than science.
If SAMHSA were to use an evidence-based approach to
identifying how to prioritize its resources--like other federal
agencies do--would their record, not to mention their strategic
initiatives going forward, look the same as they do now?
For example, in 2012, an annual conference that has been
funded by SAMHSA for many years--and at which the SAMHSA
administrator regularly delivers a keynote--Alternatives, an
hour and a half workshop was held, described as follows:
Unleash the Beast is a mind/body fitness program that looks
to the animals of the jungle for wisdom and skills that can
benefit our lives in a myriad of ways. Through animal-inspired
movements, behaviors, and expressions, participants are
encouraged to shed layers of formal conditioning in order to
return to their primal nature.
While mental and physical health is important, I question
the value of this exercise in advancing the treatment for
mental illness in humans. And, I question if there is any
scientific merit.
I would also ask why SAMHSA provides grant funding, year
after year--in the millions of dollars in aggregate--to
organizations that are outwardly hostile to the sciences of
psychiatry and psychology. These groups deny that mental
illness exists, claiming there is nothing out-of-the-ordinary
when an individual hears voices or experiences extreme mental
states--and that these should be celebrated as nature's gifts
to mankind, contributing to artistic creativity and human
diversity.
Leaders of these organizations--including at least one of
which SAMHSA has elevated to the status of a ``National
Technical Assistance Center'' and received at least $300,000 in
taxpayer dollars the past year--have actively encouraged
supporters to ``Occupy'' the 2012 annual convention of the
American Psychiatric Association--decrying the professional
association's role in developing the Diagnostic and Statistical
Manual of Mental Disorders, or DSM. ``Psychiatric labeling,''
they say, is ``a pseudoscientific practice of limited value in
helping people recover.''
When SAMHSA-funded organizations are not busy encouraging
those with mental illness to go off their prescribed
medications or destroying trust between individuals with
serious mental illness, their family caregivers, and their
physicians, these taxpayer-backed groups are actively lobbying
against effective evidence-based treatment like Assisted
Outpatient Treatment (AOT) laws--a less restrictive alternative
to involuntary commitment. Numerous academic studies have shown
AOT to be incredibly effective in reducing re-hospitalizations
and re-arrests among, until-then, untreated individuals with
serious mental illness.
As an agency of the U.S. Public Health Service, we expect
SAMHSA's work to be firmly rooted in evidence-based practices,
enduring high-level scientific peer review at the hands of
licensed mental health professionals. Perhaps some of it is but
much of it appears to fall far short of such standards.
To get answers to our questions, this morning we will hear
from Pamela Hyde, the Administrator of SAMHSA since 2009, on
our first panel. On our second panel, we will hear from E.
Fuller Torrey, a psychiatrist and long-time observer of SAMHSA;
Dr. Sally Satel, a member of the National Advisory Council to
SAMHSA's Center for Mental Health Services for four years; and
Joe Bruce, a family man from Caratunk, Maine, whose life was
irrevocably changed by one SAMHSA program in particular.
Joe's wife, Amy, was murdered by their son, Will, only
months after being released from a psychiatric center where he
had been treated for schizophrenia. Reflecting on this horrific
act several years ago, Will noted that, un-medicated at the
time, he believed he was a clandestine operative under orders
to kill his mother, an Al Qaeda operative.
Joe believes the efforts of a SAMHSA-funded organization
obtained his son's premature release from the hospital without
putting in place a mechanism for ensuring that Will would
remain on his medications. Joe--we extend our condolences to
you and your family, and thank you for sharing your moving
story with us today.
We will also hear from Dr. Joseph Parks III, Chief Clinical
Officer of the Missouri Department of Mental Health, who has
substantial experience working with SAMHSA grant funded-
projects. Thank you to all our witnesses today.
# # #
Mr. Murphy. I would now like to give the ranking member an
opportunity to give remarks of her own.
OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF COLORADO
Ms. DeGette. Thank you very much, Mr. Chairman. Your
passion about this issue is evident. We appreciate everything
that you are doing to have these hearings on mental illness and
gun violence. I want to join you in welcoming all of our
witnesses here today and looking forward to hearing your
perspectives on SAMHSA.
As we all know, Congress has directed SAMHSA to provide
services to prevent, treat, and recover from mental health and
substance abuse disorders. The Agency administers a number of
funding streams, including competitive, formula, and block
grant programs. It also collects data on mental illness,
behavioral health, and substance abuse. Chairman Murphy and I
have been working together to identify areas where, on a
bipartisan basis, we can agree to commonsense solutions.
And in his opening statement, the chairman has identified a
number of important issues regarding SAMHSA that we need to
work together to address. Some of those criticisms I think
really do merit this committee's consideration. Other
criticisms that we see out in the world only distract us from
our real purpose, which is to ensure that we identify people
who are living with mental illness before crisis situations
arrive and make sure that they can get the mental health
treatment that they so desperately need.
For example, we will hear that SAMHSA is too focused--
actually, we did hear in the chairman's opening statement that
SAMHSA is too focused on substance abuse programs, not
dedicated to addressing serious mental illness. And in fact,
mental health programs account for 27 percent of SAMHSA's
overall budget in fiscal year 2013 and substance abuse
comprises 68 percent of its budget. And so if this is really a
legitimate problem that is leading towards a lack of addressing
serious mental health issues, then it is Congress'
responsibility to fix that.
Every year, Congress determines through the appropriations
process what SAMHSA spends on mental health versus substance
abuse. And so if Congress wants SAMHSA to focus more on mental
health, we should work together to provide the Agency with more
resources to do so. And I look forward to working with the
chairman and the rest of the members of this committee to make
that happen as the appropriations process develops this spring.
I also would be happy to work with the chairman and
everyone on this committee to ensure that the Agency has the
resources it needs to do the job and that we enact legislation
that guarantees that we actually fund the programs that we
think are important.
Another criticism that we have heard and I agree with it is
that we don't have enough data to know what programs SAMHSA
funds are working well with and what are not, but you will not
find a bigger advocate in Congress for science-based research
than me. I have been fighting for it in every area for decades:
abstinence-only sex education, stem cell research, on and on
and on. And if we want these programs to work, they have to be
science-based.
And so what we need to do is make sure that SAMHSA, States,
and other grantees have clear reporting requirements and
metrics so that in fact we can measure what worked and what
doesn't work and that we can measure progress.
And so I am hoping, Mr. Chairman, that we can work together
on this, too, improving SAMHSA reporting requirements and
figuring out on an evidence-based basis what really works.
Now, I just want to raise one concern about these hearings.
This is the third proceeding on mental health, and for the
third time we don't have a witness appearing to provide the
perspective of people who are living with mental illness. We
discussed this the other day. We keep talking about issues that
affect their daily lives. We keep having providers and family
members and others coming in to talk about people with mental
illness but we haven't had people who have mental illness
directly talk to us, and I think there are people who would be
willing to come forward and talk about their concerns and their
issues, which of these SAMHSA programs work for them, which of
them don't work for them. What about the privacy provisions and
what about the everything, the funding and everything? So I am
hoping in our next hearing we could have a panel of people who
have mental illness to talk about from their perspective what
works and doesn't work.
Finally, as we discuss ways in which SAMHSA invests in the
prevention and treatment of mental illness in this country, I
think that it is important that we do not lose sight of the key
role recently enacted legislation plays in advancing our shared
goal of improving access to mental health services for the
millions of Americans experiencing mental illness.
The Mental Health Parity Act--which Chairman Murphy and I
both cosponsored along with a number of other members of this
committee--ensures that group health plans and ensures offering
mental health and substance use disorder benefits do so in a
manner that is comparable to coverage for general medical and
surgical care. The Affordable Care Act, building on this parity
legislation, will expand mental health and substance use
disorder benefits and parity protections for 62 million
Americans. The implementation of the Affordable Care Act and
continued support of SAMHSA programs that work will go a long
way in ensuring that people with serious mental illness have
access to the treatments they need.
I yield back, Mr. Chairman. Thank you for your comity.
Mr. Murphy. I thank the gentlelady for her comments.
Now turning to the chairman of the full committee for 5
minutes, Mr. Upton.
OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MICHIGAN
Mr. Upton. Well, thank you, Mr. Chairman.
Today, we are here to examine the role of the Substance
Abuse and Mental Health Services Administration (SAMHSA) in
delivering services to the severely mentally ill, and I
certainly appreciate the chairman's interest, passion, and
professional insight regarding this issue.
In the wake of the tragic shootings at Sandy Hook, this
subcommittee has stepped up to examine an important question:
what is the federal government doing to address serious mental
illness? And I commend the chairman for leading this
investigation.
While the vast majority of individuals with a mental health
condition are nonviolent, in March, the Subcommittee learned
from Dr. Tom Insel, Director of the NIH, National Institute of
Mental Health, the important fact that treatment can reduce the
risk of violent behavior 15-fold in persons with serious mental
illness. This morning, we direct our attention to the primary
federal agency responsible for supporting community-based
treatment services for mental illnesses.
With an annual budget of nearly $1 billion, SAMHSA's Center
for Mental Health Services could serve as a key part of the
Federal Government's efforts to address the tragic impacts on
our society of such serious mental illnesses as major
depression, schizophrenia, and bipolar disorder. This includes
connecting these individuals with effective treatments at a
time when 40 percent of adults with serious mental illness
report not receiving any treatment at all. Not doing so
increases the chances that the next James Holmes or the next
Adam Lanza will in fact fall through the cracks.
Unfortunately, I am concerned that SAMHSA may not be
directing those dollars to treat those with the most severe of
mental illnesses. Further, I am also concerned about the
commitment to science and the scientific process--including
psychiatry--displayed by several major grant recipients. We
need to be investing our dollars in the programs with the best
record for treating those who have mental illnesses.
[The prepared statement of Mr. Upton follows:]
Prepared statement of Hon. Fred Upton
Today we are here to examine the role of the Substance
Abuse and Mental Health Services Administration (SAMHSA) in
delivering services to the severely mentally ill. In the wake
of the tragic shootings at Sandy Hook Elementary School in
Newtown, Connecticut, this subcommittee has stepped up to
examine an important question: what is the federal government
doing to address serious mental illness. I commend Chairman
Murphy for leading this investigation.
While the vast majority of individuals with a mental health
condition are nonviolent, in March, the subcommittee learned
from Dr. Tom Insel, Director of the National Institute of
Mental Health, the important fact that treatment can reduce the
risk of violent behavior fifteen-fold in persons with serious
mental illness. This morning, we direct our attention to the
primary federal agency responsible for supporting community-
based treatment services for mental illness.
With an annual budget of approximately $1 billion, SAMHSA's
Center for Mental Health Services could serve as a key part of
the federal government's efforts to address the tragic impacts
on our society of such serious mental illnesses as major
depression, schizophrenia, and bipolar disorder. This includes
connecting these individuals with effective treatments at a
time when 40 percent of adults with serious mental illness
report not receiving any treatment. Not doing so increases the
chances that the next James Holmes, the next Jared Loughner,
and the next Adam Lanza will fall through the cracks.
Unfortunately, I am concerned that SAMHSA may not be
directing those dollars to treat those with the most severe of
mental illnesses. Further, I am also concerned about the
commitment to science and the scientific process--including
psychiatry--displayed by several major grant recipients. We
need to be investing our dollars in the programs with the best
record for treating those who have mental illnesses.
As the experts joining us today, including Doctors Torrey
and Satel will share with us, SAMHSA's programs do very little
for those at the extreme end of the spectrum of mental illness,
who lack awareness of their own condition, who deny that they
have a disorder demanding treatment, and who see no reason to
follow a medication regimen. I want to especially thank our
witness, Joe Bruce, for joining us today to share his family's
tragic story.
I also welcome Administrator Hyde and look forward to
hearing about her agency's plans to address these concerns
about the most vulnerable among our nation's mentally ill.
# # #
Mr. Upton. And at this point I will yield the balance of my
time to Dr. Burgess.
Mr. Burgess. I thank the chairman for yielding.
You know, the recent notorious tragedies have brought to
light the challenges that are faced by those suffering from
mental illness today in the United States. Certainly SAMHSA has
an important role as the point agency to address mental health
issues, but out of their budgets there are questions that have
come up about the lack of oversight and accountability. Is it
in the public's interest to use limited SAMHSA funding to
encourage alternate approaches to treating mental illness? Is
it the best use of their funding to support an organization
that lobbies against programs that encourage proven treatment
methods such as psychiatric medication adherence?
And now, we are going to hear from witnesses in the second
panel who raised serious questions about the use of the funding
to commission oil paintings and providing for an annual staff
musical within the agency. This agency is responsible to use
its resources to ensure that the almost 10 million Americans
with mental illness can be productive members of society. It is
our job on the committee to assess both the successes and the
shortfalls of the Agency to determine where the Agency's
resources can be used most effectively and ensure they are
doing their best job.
I look forward to hearing about that today and I will yield
the balance of the time to Dr. Gingrey.
Mr. Gingrey. I want to thank you again, Mr. Chairman, for
your leadership on this important issue. I want to thank Dr.
Burgess as well and highlight one particular perspective that
is often overlooked: adherence to a planned treatment. All too
often, individuals suffering from mental illness, substance
abuse disorders, or both are under the treatment of a qualified
medical professional. They have been prescribed an appropriate
regimen of medicine, yet they struggle to take their medication
consistently. This results in relapses and, of course, disease
progression. As you know, relapses result in significant
suffering, increased cost to the patient and the healthcare
system, and in some cases, violent, criminal behavior.
Mr. Chairman, as we seek today to highlight the most
efficient use of federal resources for this particular
vulnerable population, I believe that improving adherence,
whether by novel drugs or innovated management of the disease,
is particularly important and I look forward to working with
the Subcommittee to pursue policies particularly at SAMHSA to
ensure the best possible treatment options available to
providers and patients confronting mental illness and substance
abuse in order to improve health and health economic outcomes.
Mr. Chairman, thank you for your patience and I yield back.
Mr. Murphy. The gentleman yields back. I now recognize for
5 minutes Mr. Butterfield.
OPENING STATEMENT OF HON. G.K. BUTTERFIELD, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF NORTH CAROLINA
Mr. Butterfield. Let me thank you, Mr. Chairman, for
yielding time. I thank the ranking member, Ms. DeGette, for her
comments and I want to associate myself with each word that she
uttered a few minutes ago. She is exactly correct.
I thank the chairman of our full committee, Mr. Upton, and
all of you who have a profound interest in the subject.
This is a very, very important subject not just in my
congressional district but throughout the country. Let me say
good morning to the witnesses and thank you so very much for
coming today to be a part of this process.
Funding from the Substance Abuse and Mental Health Services
Administration--and we call it SAMHSA--has helped my State
enormously. It has helped probably every State in the country
but I can speak specifically to my State. For fiscal year 2012
my State of North Carolina received $20 million from Mental
Health Services. And if my colleagues will check, you will see
that there has been significant federal investment with this
population all across the country. It is a good program. It is
a valuable program.
In my congressional district, the Durham County Health
Department, for example, received funds to enhance services and
support available to 16- to 21-year-olds with serious mental
health issues and their families. Also, the Child and Parent
Support Services, Incorporated, in Durham received funds to
assist clinicians working with child welfare and even military
families.
But we continue to see cost-cutting measures like
sequestration and the Ryan budget which endanger important
programs like those in Durham and throughout my State and
throughout the country. There is an article this morning in the
Hill Newspaper that even warns of round two of sequestration.
So many of our citizens think that sequestration was a 1-year
proposition, but it is a 9-year proposition and now we are
getting ready for round two. And Mr. Chairman, we have done
absolutely nothing to fix sequestration. I support full repeal
of sequestration.
Mr. Chairman, the 2013 spending plan that SAMHSA released
earlier this month shows that the sequester will result in cuts
of over $200 million in SAMHSA funding this year, a cut of
almost 6 percent, and next year, it would certainly be more.
Every single SAMHSA program will be affected. Our citizens need
to know that.
Every SAMHSA program will be affected. The Mental Health
Block Grant Program is being cut by $23 million. Children's
mental health services are cut by $6 million. Suicide
prevention funds will be cut; programs to help the mentally ill
people who are homeless will be cut. This will mean fewer
SAMHSA grants and fewer people with access to mental health
services.
Mr. Chairman, we must continue to support those struggling
with mental illness and their families by continuing to
strengthen these very important programs.
At this time, I will yield the balance of my time to the
gentlelady from Florida.
Ms. Castor. Well, I thank my colleague for yielding and I
thank the chairman and the ranking member for calling this very
important hearing.
It is vital that this committee provide oversight of the
mental health services provided by the Federal Government in
partnership with state and locals and for families. What I hear
consistently from families and mental health professionals at
home is simply that the needs so far outstrip the resources
that are available to families and professionals today. That
point was made by Ranking Member DeGette, and she is right.
For example, just yesterday, I had about 10 emergency room
physicians, fairly new doctors, pay a visit up here on Capitol
Hill and our conversation got to the point of what they do
every day when they are confronted with some of our neighbors
who have mental health issues, and they made a point again,
there simply aren't enough places for people to receive
counseling and treatment. They said just what we know, one of
the real problems is the laws say unless someone is a danger to
themselves or to others, they are going to be discharged. And
that is simply not going to help us address the needs of our
families.
This is similar to what I hear from school districts,
teachers, and families and schools. They know when young
children have issues and there are great counselors out there
but significantly not enough to provide the basic treatment and
counseling that they need to make sure that they are healthy
and can succeed in school. So we need to focus on what works in
our community. I hope we will be able to address that today.
The answers are different for the Tampa Bay area than they
are from rural areas across the country, but what we have in
common is that the needs far outstrip the resources available.
And Mr. Chairman, at this time, I would like to ask
unanimous consent to place into the record Ranking Member
Waxman's statement for this hearing today.
Mr. Murphy. Without objection, thank you. We have a copy of
that now. Thank you.
[The prepared statement of Mr. Waxman follows:]
Prepared statement of Hon. Henry A. Waxman
Mr. Chairman, I want to thank our witnesses for coming
today. I appreciate Administrator Hyde being here, and I want
to particularly thank Mr. Bruce for traveling here to share his
tragic story. I appreciate his bravery in joining us. His
story--and those we've heard from other families--is a powerful
reminder of why this Committee needs to act to improve mental
health services and treatment.
Mr. Chairman, I know how important this issue is to you.
And I know that you are serious about improving mental health
care in this country.
But I do worry about our progress. After the tragic Newtown
massacre, I was hopeful about efforts to improve the mental
health care system and make sure that those suffering from
serious mental illnesses received the diagnoses and treatment
that they need.
Six months later, I am much less confident. Since Newtown,
Congress has done nothing to advance mental health proposals.
In fact, we've lost ground.
Last week, the House voted to repeal the Affordable Care
Act--the law that builds on bipartisan mental health parity
efforts to extend mental health and substance use disorder
benefits and parity protections for 62 million Americans.
And we have done nothing to fix sequestration, which
represents a major reversal of progress. Mr. Chairman, the 2013
spending plan that SAMHSA released earlier this month shows
that the sequester will result in cuts of over $200 million in
SAMHSA funding this year--a cut of almost 6%.
Every single SAMHSA program will be affected. The Mental
Health Block Grant program is being cut by $23 million.
Children's Mental Health Services are cut by $6 million.
Suicide prevention funds will be cut. Programs to help mentally
ill people who are homeless will be cut.This will mean fewer
SAMHSA grants and fewer people with access to mental health
services.
According to Mental Health America, the sequester will mean
that more than 1 million children and adults will be at risk of
losing access to any type of public mental health support .
almost 30,000 mentally ill, homeless people will lose access to
primary care referral, housing assistance, and other important
services . more than 11,000 professionals will lose access to
youth suicide prevention training . and more than 1,500 at-risk
youth will not be screened for mental health conditions.
The list goes on and on. These cuts are mindless. They
represent an enormous step backward in our efforts to prevent,
diagnose, and improve treatment for those with mental
illnesses. And they are happening as we speak.
Mr. Chairman, this Committee needs to act. The sequester is
creating a slow-motion crisis for those with mental illnesses,
and we need to work together to end it.
But we should not only end the sequester--we should work
together to strengthen our laws and improve funding so those
suffering from serious mental illnesses are identified, receive
better services, and achieve better outcomes.
This Subcommittee has done important work. Through our
series of briefings, forums, and hearings, we have learned
about what works and what doesn't, and where the funding and
legislative gaps exist in our nation's mental health care
system.
Now, Mr. Chairman, it's time for us to act together, in a
bipartisan way, to fill those gaps and chart a new course in
the provision of mental health services for those in need. I
look forward to working with you and my colleagues to achieve
those goals.
Mr. Murphy. All right. I would now like to introduce the
witness on the first panel for today's hearing. Our first
witness is Pamela Hyde. She was nominated by President Barack
Obama and confirmed by the U.S. Senate in November 2009 as
administrator of the Substance Abuse and Mental Health Services
Administration. Ms. Hyde is an attorney and comes to SAMHSA
with more than 35 years of experience in management and
consulting for public health care and human services agencies.
She served as a state mental health director, state human
services director, city housing and human services director, as
well as CEO of a private nonprofit managed behavioral
healthcare firm.
Welcome today, Ms. Hyde. Now, I will swear you in. As you
are aware, the Committee is holding an investigative hearing.
When doing so, we have the practice of taking testimony under
oath. You have any objections to testifying under oath?
Ms. Hyde. No, sir.
Mr. Murphy. And the chair then advises you that under the
rules of the House and rules of the Committee, you are also
entitled to be advised by counsel. Do you desire to be advised
by counsel during your testimony today?
Ms. Hyde. No, thank you.
Mr. Murphy. You probably can provide that for yourself
then.
In that case, if you would please rise and raise your right
hand, I will swear you in.
[Witness sworn.]
Mr. Murphy. Thank you. You are now under oath and subject
to the penalties set forth in Title XVIII, Section 1001 of the
United States Code. You are now welcome to give a 5-minute
summary of your written statement, Ms. Hyde.
TESTIMONY OF PAMELA S. HYDE, ADMINISTRATOR, SUBSTANCE ABUSE AND
MENTAL HEALTH SERVICES ADMINISTRATION
Ms. Hyde. Thank you, Congressman Murphy and Ranking Member
DeGette, for holding this hearing today. It is an important
conversation and I am sure, as you are aware, you have already
stated you know that SAMHSA's mission is to reduce the impact
of substance abuse and mental illness on America's communities.
I would like to take just a few moments to remind you that
SAMHSA is a small agency with a very big mission. While our
funding is small, we use every opportunity to impact the public
and private funders of mental health services. We collaborate
and influence our sister agencies in HHS and across Federal
Government, and we work with States, tribes, territories,
communities, and stakeholders to help advance the behavioral
health of the Nation.
SAMHSA has many roles. Funding is one of them but it is not
the only one. We also provide leadership and voice for and
about behavioral health issues, and that includes substance
abuse. It also includes mental illness. It includes prevention,
treatment, and recovery. We also do surveillance and data
reporting. We provide funding, as we indicated, and we also
work to improve practice with a number of materials and
trainings, and we look at evidence-based practices, as well as
practices coming to science. And we provide information to the
public in the field, our public awareness and education
responsibility, and we also have some responsibility for
setting standards and regulations in certain areas.
I want to just make a quick comment about mental health
financing because it goes to SAMHSA's role. The mental health
spending for mental illness in our country was only about 6.3
percent of all health spending in 2009. That is far below the
importance of mental health and mental illness in our
healthcare issues. Mental health treatment spending depends
much more on public payers than other kinds of health spending,
about 60 percent of mental health spending compared to 49
percent of all health care spending.
For public spending, Medicaid and Medicare are by far the
largest payers for services, and when you add their 40 percent
to about 26 percent of private insurance, then insurance--
Medicaid, Medicare, and private insurance--accounts for about
2/3 of mental health spending followed by state and local
governments' out-of-pocket spending and then a small portion of
federal spending, and that is where SAMHSA's dollars are. So
our dollars are a fairly small part of that larger overall
effort.
About 29 percent, as it was indicated earlier today, is
SAMHSA's--it is about $3 billion--3 plus billion dollars, about
29 percent of it is for mental health. About 70 percent of it
is for substance abuse. Of our mental health dollars, about 27
percent of our total budget is for mental health services,
about 2 percent, give or take, is for surveillance data, public
awareness, and other kinds of efforts. This distribution
between substance abuse and mental health issues has been about
the same for the last 5 years.
Within the mental health budget of SAMHSA, about half of it
is block grant services, which is specifically for people with
serious mental illness and young people with serious emotional
disturbance, and the balance of SAMHSA's mental health budget
provides support for a range of mental health prevention,
treatment, and recovery support services, all as directed by
Congress. Altogether, SAMHSA's mental health budget is spent on
about--75 to 80 percent of it is spent on adults with SMI or
children with SED, or serious emotional disturbance.
Congress has made significant investments as well in the
prevention, emotional health development, and promotion in
early intervention for mental health issues, and SAMHSA does
administer some of those programs.
In a very short time that I have left, I just want to
highlight a couple of programs. Our Mental Health Block Grant
of course is about half of our mental health spending. It is a
flexible but critical, important part for the States that
primarily serves people with evidence-based approaches who are
not otherwise covered by insurance or other efforts and who--or
the services are not otherwise covered. So Medicaid, Medicare,
private insurance may pay for the basics like medication,
inpatient, those sorts of issues. The Mental Health Block Grant
often supplements those services with other important and
evidence-based approaches.
We also have some approaches such as our Children's Mental
Health Initiative. It is a huge part of our program that has
since 1994 served over 122,000 young people with serious
emotional disorders with great results. We also have a program
at about $43 million that is the National Child Traumatic
Stress Network, and it has been in existence for about 10 years
and has provided evidence-based approaches to dealing with
young people with trauma.
Our Primary and Behavioral Health Integration Program is a
program explicitly focused on the health of adults with serious
mental illness and we have had major improvements in the health
impacts for those individuals in that program. We also have a
program for assistance for transition from homelessness, which
primarily serves adults with serious mental illness or people
with mental illness and co-occurring disorders who are
homeless.
We also have a Youth Violence Prevention Program that
Congress has provided resources for us to work on, and that
federal grant program is designed to prevent violence and
substance abuse among our Nation's youth, schools, and
communities. We do a lot of that work in conjunction with
education. We also have a major program, about $33 million,
called LAUNCH, which is specifically for children aged 0 to 3--
to 8 to try to work on prevention, early intervention.
We also do--and I want to make a point here because of what
is going on in Oklahoma right now that one of the major issues
that SAMHSA works on is disaster response and preparedness. So
whether it is Tucson, Sandy Hook, Aurora, or major disasters
and weather-related emergencies such as Oklahoma, we do a lot
of response.
Mr. Murphy. Sorry. If you could give your wrap-up now.
Ms. Hyde. I think I will end there and let you ask
questions. Thank you very much.
[The prepared statement of Ms. Hyde follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you so much for being here today and for
your work.
I want to just clarify a couple things. I note your
testimony in written and oral states several times that SAMHSA
supports evidence-based programs and practices and even data-
driven solutions. So does this mean SAMHSA requires evidence
and data before making a grant award?
Ms. Hyde. Congressman Murphy, thank you for the question.
Yes, we require in our request for applications we ask
individuals either to use an evidence-based practice that we
have identified or to tell us what approach they propose to use
and to explain to us how they think that it has evidence behind
it or how it is moving into science as they are developing
evidence of it working for them.
Mr. Murphy. Do you use models like NIH has where there are
professionals, experts in the field with advanced degrees who
are the majority of panelists to review grants?
Ms. Hyde. That is correct. We use experts to do those
reviews.
Mr. Murphy. By experts, I mean people with MDs or PhDs who
have the scientific credentials as the majority of panelists in
each grant review?
Ms. Hyde. Each of the grant reviews use people who are
experienced in that area. What their degrees are, I don't have
that in front of me.
Mr. Murphy. Experience, I am talking about the majority of
the panelists. This is a yes or no. Are the majority of
panelists people who have specific advanced training and
academic and professional credentials in those fields versus
just experience?
Ms. Hyde. They have training and experience. I do not have
with me what their degrees are.
Mr. Murphy. I am just asking is the policy of SAMHSA that
the majority of people reviewing grants have advanced degrees
and academic credentials and license credentials in reviewing
these grants?
Ms. Hyde. It is our policy, Congressman, to have
individuals with the experience and----
Mr. Murphy. But that is a no? It sounds like----
Ms. Hyde. I will repeat----
Mr. Murphy [continuing]. That is a no.
Ms. Hyde [continuing]. That I don't have with me and I
don't have the information about what their degrees----
Mr. Murphy. OK. That would be a major issue because that is
a major part of your work. Do you fund competitive or
discretionary grants that are part of the mission of SAMHSA or
do you also fund grants that run diametrically opposed to the
mission of SAMHSA?
Ms. Hyde. I think all of our grants and all of our efforts,
whether grant-based or not, are working toward our mission.
Mr. Murphy. OK. Thank you. What is the evidence that SAMHSA
used to fund an advocacy group that encourages the mentally ill
not to take their medication?
Ms. Hyde. I am sorry, Congressman. Can you repeat the
question?
Mr. Murphy. I just wonder what evidence did you use as the
decision-making process when you fund advocacy groups that
encourages the mentally ill not to take the medication?
Ms. Hyde. I don't think we fund advocacy efforts explicitly
to tell people not to take the medication.
Mr. Murphy. You just told me that you don't fund things
that run counter to your mission, and we will here today from
people who have evidence that SAMHSA does fund organizations
that encourage people not to take their psychiatric medication.
So I am just wondering what the evidence is that SAMHSA relied
upon to fund such a grant.
Ms. Hyde. We fund lots of organizations who have missions
or who have opinions or value bases that may not necessarily
agree with SAMHSA or with the field. What we fund are specific
grants for specific purposes related to the mission of SAMHSA.
Mr. Murphy. I still want to know, and we are going to
continue to pursue this because it is an important issue. And I
note in your testimony you do not even mention the title
psychiatrist, and as I noted in my opening statement, you don't
mention the words bipolar, schizophrenia, or other forms of
severe mental illness to talk about a lot of things. And many
of those things are good, but we are here today to talk about
severe mental illness. Does SAMHSA acknowledge that there was a
scientific evidence basis provided by SAMHSA's sister public
health agencies such as NIH and the FDA that support the
effectiveness of medical treatment for mental illness?
Ms. Hyde. Absolutely, Congressman. We work closely with
NIMH, with NIDA, with NIAAA, with other institutes within NIH,
with FDA, and other agencies and we work hard to take what they
learn from the research and use it in the efforts that we do.
Mr. Murphy. One of those that you fund is the National
Empowerment Center whose director espouses anti-science, anti-
psychiatry views and your agency also funds the alternatives,
which is that in your workshop or symposium which regularly
features workshops and speakers who advised people with serious
mental illness to go off physician-prescribed medication.
And as I said before, your testimony today does not even
mention the psychiatry or get into medication issues. So I once
again want to know where is the evidence that this approach to
treating severe mental illness has any scientific, evidence-
based, data-driven background that would support what you
continue to fund?
Ms. Hyde. Congressman, there are a number of ways to
provide treatment and services, and we fund a number of
conference efforts and others. We do not go inside each
individual presentation to identify whether or not we agree
with each individual----
Mr. Murphy. But you continue to fund it----
Ms. Hyde [continuing]. Presenter----
Mr. Murphy [continuing]. And you oftentimes speak at an
opening or part of those conferences?
Ms. Hyde. Yes, we do, and we fund other conferences for the
American Psychological Association, for ASAM, for other
organizations also that we don't look at every single
presentation----
Mr. Murphy. I mean yes or no, is it medically possible to
prevent the onset of schizophrenia?
Ms. Hyde. I think the biomarkers are not there yet. I think
NIMH is working hard on biomarkers about that. We know that we
can prevent a lot of the salient conditions about schizophrenia
and we know that there are a number of people with
schizophrenia who can in fact get to a point where they are
living without the symptoms of the illness that they first
experienced.
Mr. Murphy. Thank you. Thank you. Ms. DeGette, 5 minutes.
Ms. DeGette. Let try to clear some of this up,
Administrator Hyde. It is not in the mission of SAMHSA to tell
patients not to take their medication, is that correct?
Ms. Hyde. That is correct. We----
Ms. DeGette. OK. So what happens is Congress has mandated
that some of the groups that SAMHSA fund are patient advocacy
groups, correct?
Ms. Hyde. That is correct.
Ms. DeGette. And some of those patient advocacy groups may
in fact tell their people not to take drugs, is that correct?
Ms. Hyde. They very well may.
Ms. DeGette. And that is not SAMHSA's policy; that is those
groups' policy, right?
Ms. Hyde. Those groups may have that policy.
Ms. DeGette. And so really Congress should look at do we
want to be telling SAMHSA to fund patient advocacy groups,
right?
Ms. Hyde. It is certainly a congressional authority and a
congressional program----
Ms. DeGette. The other issue is a great amount of the money
that SAMHSA spends is block granted to the States, is that
right?
Ms. Hyde. That is correct.
Ms. DeGette. And so once those funds go to the State, then
the governors decide how those funds are going to be spent and
SAMHSA doesn't really exercise discretion over the groups that
the States give those block grants to, right?
Ms. Hyde. That is correct. We have a plan that the State
provides to us----
Ms. DeGette. Right.
Ms. Hyde [continuing]. But the State makes that decision.
Ms. DeGette. Right. So that is, again, something else
Congress should look at is do we really want to be just sending
that money to the States without the scientific control of
where those funds go, right?
Ms. Hyde. Correct. And we do ask them to do evidence-based
practices and data-driven processes.
Ms. DeGette. Of course you do. Now, let me ask you this
because you talked quite a bit in depth in your opening about
the percentages of SAMHSA's budget that go to mental health
versus drug control and so on, and that again Congress has made
those requirements on SAMHSA, right?
Ms. Hyde. That is our----
Ms. DeGette. I mean, it is not you that sits there and says
I am going to spend 27 percent of my money on serious mental
health; it is Congress that says that, right?
Ms. Hyde. That is correct.
Ms. DeGette. OK. Now, I read the testimony of the second
panel and some of those witnesses--I am sure you have read it,
too--they have strong criticisms of SAMHSA and I want to ask
you about it. Dr. Torrey says that serious mental illness has a
very low priority at the Agency because in the 3-year planning
document that you have, there is no mention of a number of
conditions. So I want to ask you a question. Does the Agency
have a very low priority for serious mental illness?
Ms. Hyde. No. As I indicated, about 75 to 80 percent of our
mental health dollars go towards substance abuse--I mean,
excuse me--toward serious mental illness and serious emotional
disturbance.
Ms. DeGette. And so why in that document did you not
specifically mention schizophrenia, schizoaffective disorder,
bipolar, severe depression, or obsessive compulsive disorder.
Ms. Hyde. That planning document is about behavioral health
systems and directions that we are taking and it has to do with
developing quality frameworks and developing public awareness
and approaches. It has to do with prevention and a number of
other things. We don't have any references to any diagnoses in
that particular----
Ms. DeGette. Oh, I see. OK. So it is just because of the
nature of that document----
Ms. Hyde. That is correct.
Ms. DeGette [continuing]. Not because there is not an
emphasis. Now, Dr. Torrey also says--and this is a quote from
his testimony--``nobody among SAMHSA's 574 staff has experience
in severe mental illness.'' Is that true?
Ms. Hyde. No.
Ms. DeGette. Why do you say that?
Ms. Hyde. Because we have a number of people ranging from
social work, psychologists, internists and others who work--
have been working in this field for years in these areas, so
they have extensive experience.
Ms. DeGette. And now, is it true that SAMHSA has only
employed one psychiatrist?
Ms. Hyde. We don't employ a lot of psychiatrists. We are
not the direct provider of services like IHS or others. We did
actually just announce this week--we have been working on it
for 2 years--we announced the arrival on June 3 of our chief
medical officer, who is a psychiatrist and will be joining----
Ms. DeGette. So what you saying is because you are not
focusing on actual treatment, you don't feel you necessarily
need people with those credentials for every position?
Ms. Hyde. Not for every position----
Ms. DeGette. OK.
Ms. Hyde [continuing]. Absolutely not.
Ms. DeGette. Now, I want to ask you what is the impact on
SAMHSA's budget by the sequester and what are you anticipating
for fiscal year 2014?
Ms. Hyde. The sequester results in about $168 million
reduction in our programs. It was required that we take it
across all programs so it didn't matter which ones. We had to
take it against all of them. We expect or anticipate that that
will result in about 330,000 less people getting services----
Ms. DeGette. Wow.
Ms. Hyde [continuing]. And the benefits of SAMHSA's
programs. So it will significantly reduce that. For 2014 the
President's budget proposes to undo the sequester and so to
take us back to a point where we have more funding for services
and programs, and he also proposes new funding and services as
a result of what we have learned in our efforts out of the
Sandy Hook effort.
Ms. DeGette. Thank you very much.
Mr. Murphy. I recognize the gentleman from Texas, Dr.
Burgess, for 5 minutes.
Mr. Burgess. I thank the chair for the recognition. I am
sorry I had to step out for a moment. I had a group of doctors
out there I was talking to. But it brings up a good question.
How many people work in your agency?
Ms. Hyde. Congressman Burgess, about 600 people, give or
take.
Mr. Burgess. And of that cadre of 600 individuals, how many
M.D. psychiatrists are working?
Ms. Hyde. We have one. We also have a number of----
Mr. Burgess. I found one on the internet, so good, we are
aligned.
Ms. Hyde. We just announced the arrival on June 3 of our
chief medical officer, which we have been seeking for a couple
years. She arrives and will start and she is a psychiatrist in
addiction psychiatry, board-certified.
Mr. Burgess. So if I have it correct, I mean you are the
mental health agency and substance abuse agency for the entire
country, and up until a week or two ago, you had one
psychiatrist on your staff?
Ms. Hyde. As I said--you might have been out of the room,
but I did say that, yes, we don't do direct services. That is
not what our charge is so we have a number of psychologists,
social workers, counselors, other behavioral health
professionals, addictionologists, and others in addition to
other professions that we need to do our work.
Mr. Burgess. Yes, but just speaking from someone who has
spent a life in clinical practice, I mean, there is no
substitute for that. Yes, I am in a position now where public
policy is all that I think about, but at the same time, it is
that time spent in the clinical practice of medicine that
informs the policy, and your agency, it just strikes me we are
really thin there. Is that a fair assessment?
Ms. Hyde. Given what our charge is and what we do and to be
quite honest with you what we are able to pay, we have had a
difficult time achieving any higher percentages of those
individuals. We do have internists and others who work in other
areas where it requires that kind of clinical expertise in
order to do the program. We have, as I said earlier, a number
of other behavioral health professionals who do work in our
grant programs, and then we have people like statisticians and
accountants and others who do other parts of our programs.
Mr. Burgess. And all those people are important, but again,
I would just submit that there is no substitute for someone who
has spent time in the clinical realm of practicing medicine. I
am not a psychiatrist but I know that because of that time in
clinical medicine, someone who has practiced psychiatry is
going to be invaluable to your agency as far as informing the
policy and one or two folks aren't going to get it in an agency
as large as yours with the enormous footprint that you have in
the country as regards to mental health services.
Now, I accept the part about psychiatrists are expensive. I
have always thought they have been overvalued, but we can get
into that discussion later on. But, you know, you are talking
now about you need to train additional people in the mental
health services, correct, in SAMHSA?
Ms. Hyde. In conjunction with HRSA, that is correct.
Mr. Burgess. And about how many?
Ms. Hyde. The President's proposal for 2014 would produce
about 5,000 more professionals.
Mr. Burgess. And of that 5,000 what is the cohort of
clinical psychiatrists that would be part that?
Ms. Hyde. In that particular cohort, that is not what it is
directed towards. HRSA's programs are directed more toward
those clinical-level individuals.
Mr. Burgess. Well, with all due respect to the President,
he has never practiced clinical medicine either and I think
that is apparent from the state of healthcare in this country
today. But nevertheless, you need to have the expertise of
someone who has accepted the responsibility for diagnosing and
treating patients, following through on a treatment plan, and
lacking that, it is hard to know how to advise you to do your
job better. Without the basic tool, without that basic person
involved at the clinical level, I just don't know how you
deliver on the promise that you are supposed to do.
Now, my understanding is that years and years and years ago
Congress in its wisdom separated out the research side from
what you do, is that correct?
Ms. Hyde. That is correct.
Mr. Burgess. So the research goes on at the National
Institute of Health, but without a clinical psychiatrist on the
staff, it is hard for me to know how you are going to be able
to evaluate those things that are developed by that great
research institution up north of town and make them applicable
to the people who are suffering that you are supposed to be
taking care of.
Ms. Hyde. Well, I have two comments about that, as I said
earlier, we spent a couple of years and finally were able to
recruit a new clinical psychiatrist to be the chief medical
officer to do that kind of consultation. We also work very
closely with Tom Insel and all of his staff at NIMH on issues
about clinical care and about evidence-based practices.
Mr. Burgess. Well, look, the President has announced a big
brain mapping initiative, but without the people there to
deliver the goods, I am afraid it is an empty promise.
Mr. Chairman, thank you. I will yield back.
Mr. Murphy. Mr. Butterfield, you are recognized for 5
minutes.
Mr. Butterfield. Thank you very much, Mr. Chairman. And I
am going to try to get through this very quickly.
Again, thank you for your testimony. Let's talk a little
bit about sequestration. You mentioned it just a few moments
ago. Did I understand you to say that it is had a $168 million
impact on your agency?
Ms. Hyde. That is correct.
Mr. Butterfield. That is in fiscal year 2013?
Ms. Hyde. Correct.
Mr. Butterfield. And what is the projection, if you know,
for 2014 and beyond?
Ms. Hyde. I don't know explicitly. My understanding is that
it would probably result in somewhere like another 2 or 2-1/2
percent reduction but we don't have those numbers finalized.
Mr. Butterfield. And that translates into some 300,000
people or more?
Ms. Hyde. Just for 1 year, correct.
Mr. Butterfield. All right. Now, the House Labor HHS
Appropriations Subcommittee has proposed an 18 percent cut. Are
you aware of that?
Ms. Hyde. I have heard that.
Mr. Butterfield. And that translates into some $624
million. What impact would that proposal have on providing care
to individuals with serious mental health illness?
Ms. Hyde. Well, it would--Congressman, it would have a
profound impact. Just on our agency alone it would have a
profound impact, not to mention on all the other agencies that
provide services.
Mr. Butterfield. The Affordable Care Act has provided young
adults with access to health insurance through their parents'
plans, and that is a good thing, and it will provide people
with access to health insurance in 2014 when the exchanges
actually go into effect. With the full implementation of the
Affordable Care Act in 2014, will it increase the ability of
people to access mental health care?
Ms. Hyde. Absolutely. And about 62 million people will have
access to coverage for mental and substance abuse disorders
that don't have it now by a combination of the Affordable Care
Act and the Mental Health Parity and Addiction Equity Act. And
of those 62 million, we anticipate that about 11 million of
them have mental health and substance abuse issues.
Mr. Butterfield. I am encouraged that SAMHSA has helped
assist disadvantaged communities through discretionary grants.
And as you may know, I represent a rural congressional district
in North Carolina where nearly 1 in 4 people are below the
poverty level. Can you describe for me some of the programs
that SAMHSA has which are effective in addressing mental health
in rural and low-income communities?
Ms. Hyde. Congressman, rural areas, I think, do have higher
levels of--sometimes have higher levels of poverty. They have
often less workforce available, so less people to provide those
services. We have worked hard with HRSA and their rural program
to try to see how we can stretch that workforce, how we can do
telemedicine and other kinds of approaches for rural areas and
then our Mental Health Block Grants obviously provide to the
States dollars that they can use as they see fit. So for States
with a higher rural proportion, they certainly could do that.
I come from the State of New Mexico. I understand the rural
areas out there. And the block grant is an important part of
that effort.
Mr. Butterfield. Thank you. North Carolina is home to more
than 700,000 veterans and has one of the largest veteran
populations in the entire country. Seymour Johnson Air Force
Base in my district and both the Coast Guard station and the
Marines have installations who have supported us. Can you
describe some of the crucial programs that SAMHSA supports for
returning service members and their families?
Ms. Hyde. Thanks for that question. Yes, we have had--in
fact, in that Leading Change document we were just talking
about earlier, military personnel and veterans is a huge
priority for us. We have done everything from Policy Academies,
helping States really get their arms around how they can
provide services for those individuals. We support and work
very closely with the Veterans Administration on suicide
prevention efforts and our international lifeline is tied to
them electronically. We have incorporated military families and
veterans as a priority population within about half of our
funding requests. We have really put a major effort there.
Mr. Butterfield. And can these programs be affected by
sequestration?
Ms. Hyde. Absolutely.
Mr. Butterfield. It is my understanding that SAMHSA
provides support to state mental health agencies on the ground
in the wake of natural disasters. In the last year, my district
was dramatically impacted by two hurricanes. Most recently, we
have seen terrible destruction out in Oklahoma where I was on
Tuesday of last week where the total impact won't be known for
quite some time. Can you describe the important work that
SAMHSA does with the relationship to the storms?
Ms. Hyde. Yes. Our disaster preparedness and response
efforts have become very well-known. To FEMA, to the Red Cross,
and to others we provide a 24/7 disaster distress helpline that
is available anytime there is a major disaster like this. It is
available all over the country but we target it to the area
that is hit. We have all kinds of materials that help people
know how to work through disaster issues and prepare
psychologically for them. We do training and technical
assistance for first responders----
Mr. Butterfield. Let me interrupt you because I am going to
have to get this last question in----
Ms. Hyde. Absolutely.
Mr. Butterfield [continuing]. And it is important. I think
you will agree. It is my understanding that for many insurance
companies, preexisting conditions include any conditions which
a patient has been treated for in the last 6 months. Under the
Affordable Care Act, insurance companies cannot deny coverage
due to preexisting illnesses. Our mental illnesses currently
considered a preexisting condition by insurance companies?
Ms. Hyde. In many insurance companies, they are.
Mr. Butterfield. Once the law is implemented, will more
individuals with mental health issues and now have access to
care under the Act?
Ms. Hyde. Yes.
Mr. Butterfield. Thank you. Thank you, Mr. Chairman.
Mr. Murphy. Thank you. We now recognize the gentlelady from
Tennessee, Mrs. Blackburn, for 5 minutes.
Mrs. Blackburn. Thank you, Mr. Chairman, and we thank you
for being with us today. I want to ask you a little bit about
this Alternatives Conference out in Portland, Oregon. You gave
the keynote address at the conference in October 2012, is that
correct?
Ms. Hyde. That is correct.
Mrs. Blackburn. OK. Would you mind submitting a copy of
your remarks for us? Would that be possible?
Ms. Hyde. Congresswoman, I would be happy to. I don't
usually have prepared text. I usually do overheads but I will
give them to you.
Mrs. Blackburn. OK. That would be awesome. And you all
sponsored that. I have got a copy of the program; I see you all
sponsored this. This is one of your initiatives, correct?
Ms. Hyde. It is one of the many conferences and meetings we
support, that is correct.
Mrs. Blackburn. OK. And I would assume in page 11 of your
written testimony you talk about SAMHSA's stewardship, and
since you brought up the sequestration a couple of times, my
assumption is you are reviewing your sponsorship of such
activities. Would that be right?
Ms. Hyde. We have been reviewing our sponsorship of all
conferences and meetings, and in some cases we are continuing
them but with reduced effort.
Mrs. Blackburn. OK.
Ms. Hyde. In other cases, we are just not doing them at
all.
Mrs. Blackburn. How much did you spend to sponsor this
conference?
Ms. Hyde. You know, I don't have that information in front
of me----
Mrs. Blackburn. Would you submit that to us?
Ms. Hyde [continuing]. But I can get it to you, certainly.
Mrs. Blackburn. OK. I think that would be great because if
you are looking at a 168 million impact to your budget, then I
think that all of these conferences and the programs would be
something that we would want to look at very closely.
One of the hour-and-a-half long workshops from the October
13, 2012, session is titled ``Unleash the Beast: Primal
Movement Workshop.'' It is described in this brochure right
here as follows: ``Unleash the Beast is a mind/body fitness
program that looks to the animals of the jungle for wisdom and
skills that can benefit our lives in a myriad of ways. Through
the animal-inspired movements, behaviors, and expressions,
participants are encouraged to shed layers of formal
conditioning in order to return to their primal nature.'' So is
it true that SAMHSA provided funding for this?
Ms. Hyde. As I indicated, we provide funding for the
conference. That is correct.
Mrs. Blackburn. OK. Are you able to provide us--did you
attend this workshop?
Ms. Hyde. No, ma'am.
Mrs. Blackburn. You did not? OK. Can you give me any idea
of specific examples of such animal-inspired movements,
behaviors, and expressions and discuss what studies where
evidence has shown them to be effective in treating mental
illness and humans?
Ms. Hyde. As I said, I didn't go to that conference or that
particular workshop. I can tell you that things like
meditation, yoga, other kinds of movement is appropriate for--
--
Mrs. Blackburn. So that is animal movement?
Ms. Hyde [continuing]. Developing stress--for releasing and
developing and----
Mrs. Blackburn. That would be animal--let me move on.
Ms. Hyde [continuing]. To manage stress.
Mrs. Blackburn. When did you begin sponsoring the
Alternatives Conference?
Ms. Hyde. I don't remember the first year. We can find out
for you.
Mrs. Blackburn. OK. We would like to know that and I think,
you know, one of your exhibitors here, Mind Freedom
International is one of the groups that had a table there. They
encourage people to come off their meds, and I think we would
be concerned about that.
I also want to know how much money you have spent since the
inception of this Alternatives Conference and in conferences in
general? Let us help you with this budget gap that you have,
and this may be a way to find out. Would you please submit that
to us?
Ms. Hyde. I am sorry. Can you clarify what you would like
to see?
Mrs. Blackburn. Money, how much have you spent on the
Alternatives Conference and how much do you spend on
conferences in total? And do you pay speakers' fees and travel?
Is that covered out of what you are paying?
Ms. Hyde. Congresswoman, it depends on the conference what
we pay for. We have reduced our conference support
significantly----
Mrs. Blackburn. OK. What about scholarships to the
conference? Does SAMHSA cover scholarships to the Alternatives
Conference?
Ms. Hyde. We do sometimes provide----
Mrs. Blackburn. OK. Could you submit that amount to us?
Ms. Hyde [continuing]. Scholarships to this and to other
conferences.
Mrs. Blackburn. OK. And I would assume they are going to
the Unleash the Beast Primal Movement Workshop on taxpayer
funds.
March/April 2011 SAMHSA newsletter highlighted the Agency's
use of art to raise awareness around behavioral health.
Specifically, an award-winning artist, Sam English, was
commissioned for $22,500 to create a painting because of his
familiarity with prevention and recovery populations. What
value--I want you to tell--what value do the American people
obtain from SAMHSA's funding of a piece of artwork such as
this?
Ms. Hyde. We have a responsibility, Congresswoman, to get
the word out about behavioral health to all kinds of
populations. In this case, the tribal populations are very
clear that the way to do that is to use people from their
tribes and nations. This was a tribal----
Mrs. Blackburn. $22,500 for a piece of art?
Ms. Hyde. That number is not correct, but this tribal
leader is actually a person in recovery and has produced
documents and opportunities in the past for other substance
abuse programs.
Mrs. Blackburn. Please submit the correct number.
And I yield back my time.
Mr. Murphy. Thank you. The gentlelady's time expired. I now
go to the gentlelady from California, Ms. Castor, for 5
minutes.
Ms. Castor. Thank you, Mr. Chairman.
I would like to focus your attention on mental health care
for children and teens, particularly in schools because what I
have heard from so many of my school districts at home and the
teachers and parents there is that the schools are a terrific
place to identify the emerging issues for the child's mental
health or it is the teacher on the front line that understands
very well the emotional health of that child day in and day out
and that, you know, many schools are able to maybe have a
guidance counselor or a school psychologist, maybe just part-
time, and they get identified. But there seems to be a real
lack of resources available for the true treatment and
counseling that that student needs. So many of the parents I
hear from, they don't have health insurance or they have a
policy that does not provide it. That is going to get better
under Mental Health Parity and the Affordable Care Act.
But I still think that what I am hearing from back home is
the schools would have the capacity to do more with having
psychiatrists and some counselors available. In your
testimony--and I understand SAMHSA has some oversight or has
oversight of the Safe Schools and Healthy Students Initiative
and also Children's Mental Health Initiative. What I have heard
from folks back home is while they value those dollars, it is
just a drop in the bucket and that resources that were
available in the past just aren't there anymore. Could you
speak to that and give us a summary of the Safe Schools and
Healthy Students Initiative and Children's Mental Health
Initiative?
Ms. Hyde. That is correct. The Safe Schools, Healthy
Students is a very effective program that we have worked with
the Department of Education and the Department of Justice on
over the years. It brings together communities, parents,
schools, and others to make sure that young people are safe.
The program has resulted in great outcomes. We have seen less
violence, more perception of safety, more referrals by about
500 percent, more referrals to behavioral health treatment, so
as people are able to identify young people in need. So it is a
very effective program.
The President has proposed to build on that program in the
fiscal year 2014 budget by Project Aware, which would not only
expand Safe Schools, Healthy Students statewide in some States,
but also add a mental health first aid to help teachers and
parents, first responders, and others identified mental health
issues early.
Ms. Castor. But what is your feeling on or what is your
understanding about the needs? As I mentioned earlier in my
opening statement, the needs are far outstripping the resources
that are available at the local level, state level, and federal
level? Or is it a fact that policymakers simply haven't made
mental health services a priority and haven't provided the
investment that is necessary?
Ms. Hyde. That is absolutely correct. There is not enough.
I started out in my testimony, as you may remember, with saying
that only about 6 percent of health care spending is mental
health, and that is far below what the need is. The President
has proposed additional dollars to do additional workforce and
has also proposed additional dollars to try to implement the
efforts that we have. We also know that the Affordable Care Act
will add a lot more coverage for this, but the workforce needs
to grow to meet that need.
Ms. Castor. How do you collaborate with the Department of
Education? Outside of Safe Schools, Healthy Students, what is
your understanding of what the Department of Education is able
to provide when it comes to mental health care to our schools?
Ms. Hyde. They actually provide a lot of in-school
programs, so they support, as does HRSA and other school-based
health clinics and others. We provide assistance in the
community with the referrals and the connections in the
community-based programs. We work with them to provide the
materials when they need it for evidence-based practices, and
we work to provide training for teachers and others----
Ms. Castor. Does that include the IDEA, Individuals with
Disabilities Education Act?
Ms. Hyde. In some cases, yes, but we are focusing on not
just individuals with identified needs but individuals who
haven't yet been identified. We also provide in-school training
for teachers to try to help manage behaviors in the classroom.
Ms. Castor. Do you really believe when you look at the
needs all across America when it comes to mental health for our
young people that we are even with all of these initiatives we
are really being effective? I mean how do we increase capacity
to serve children and need to really be effective and
integrated in the school-based setting?
Ms. Hyde. Well, I think we need more programs like Safe
Schools, Healthy Students, and more like Project Aware that the
President is proposing. The fact is we just have a significant
under-commitment to mental health and mental illness treatment
and recovery in our country and we need more of that. The
Affordable Care Act will help with that but only as we continue
to build up the workforce to be able to meet those needs.
Ms. Castor. Thank you very much.
Mr. Murphy. Thank you. I now recognize Mr. Olson from Texas
for 5 minutes.
Mr. Olson. I thank the chair and thank him for holding this
very important hearing.
America's mental health problems that lead to violence may
lose control every day in America. The violence doesn't just
happen at Virginia Tech; it doesn't happen in a parking lot in
the Safeway in Tucson, Arizona; it doesn't just happen in a
movie theater in Aurora, Colorado, or at a school in Newtown,
Connecticut. They happen 1.5 miles from my hometown, my home,
my hometown of Sugarland, Texas.
At about 9:00 p.m. on Sunday, April 7, of this year, a 31-
year-old constituent hit the wall. He had been sick for about
13 years and was in the process of moving back home with his
parents. He had been seeking painkillers from doctors but his
doctors did not give him the drugs. He became angry with his
parents and threatened them with a hatchet and a rock.
Terrified, they fled their own home and called 911. The
Sugarland police showed up. The son was barricaded in his
parents' house.
Eventually, he emerged with a rifle, and when he pointed it
at the Sugarland police, he was shot and killed in his front
yard. His parents heard the gunshots that killed their son. And
we can never accept what happened in my hometown of Sugarland,
Texas.
Administrator Hyde, I know that SAMHSA is a small agency.
You have an important role to play. You mentioned earlier this
year in your testimony before the House Appropriations
Committee on children's mental health on March 20 that the
President has directed his Secretaries of Health and Human
Services and Education to foster a national dialogue on mental
health. What if it all is SAMHSA's role in this dialogue being
coordinated with the $130 million in new SAMHSA-led programs
that the President announced on January 16 of 2013? Basically,
how is that money being used in this new initiative?
Ms. Hyde. Congressman, that money that is being proposed is
for fiscal year 2014 so we don't have those funding--that
funding yet. It would require Congress to act for us to have
it.
The description of the incident that you described is a
huge tragedy. These are not things that we want to happen. We
have models out there of mental health and crisis intervention
working with police and we have been working a lot with police
and sheriffs association. We don't have a program specifically
around crisis intervention. I wish we did. It is something we
know that we can do better about but we don't have the funding
to do. States use some of their block grant funds for these
dollars but they don't stretch nearly far enough.
So this is an area where we have some evidence-based
practice and we don't have the resources to put it into place
all over the country as we should.
Mr. Olson. Thank you, ma'am. I will have some questions for
the record but I yield the balance of my time to my colleague
from Texas, Mr. Burgess.
Mr. Burgess. I thank the gentleman from Texas for yielding.
I just had a follow-up question on what Mr. Butterfield was
pursuing on to the effects of the sequester. I mean we hear a
lot about that in this committee and I just have to tell you I
am struck by the fact that it seems that nowhere in the federal
agencies is anyone responsible for the prudent management of
taxpayer money. In private business when you are struck with a
budget reduction, which happens and certainly happened to me
when I ran my practice, the first thing I did was not sacrifice
customer service or sacrifice activities that were central to
the core mission of my business.
And yet, we hear it time and time and time again from the
CDC, from HHS, now from your agency that because of the
sequester you can't perform the functions of your core mission,
and yet there are ancillary activities that are occurring that
consume large amounts of dollars. I mean it is basic Six Sigma
management. You do your core mission first and everything else
is secondary to that. And, you know, we hear stories over and
over again about incompetence of the federal agencies. I would
just urge you to be certain that your number one mission needs
to be fulfilled and everything else comes secondary.
I thank the gentleman for yielding and I will yield back.
Mr. Murphy. I now recognize Mr. Green for 5 minutes.
Mr. Green. Thank you, Mr. Chairman. Administrator, welcome.
I guess because you have a lot of Texans on the committee, you
got my neighbor and Dr. Burgess of North Texas. I have a
district in Houston, and previously, my colleague Ranking
Member DeGette touched on a criticism from our second panel on
your agency, and I would like to pursue that a little bit more.
Dr. Torrey claims that incarceration of mentally ill people
in jails in your presence is not a priority for SAMHSA. One, is
this true? And are incarcerated mentally ill people not your
priority? What agency do you work with that addresses the
concern of this particular population?
Ms. Hyde. Thank you for the question. We do have criminal
justice programs in our budget. We do a lot of work with
Sheriffs Associations, with jail and corrections practitioners.
We have done a significant amount of work with juvenile justice
and interfaced with the Department of Justice on that.
The dollars appropriated for these activities are fairly
small compared to some of the other dollars we have, but to the
limits of our Appropriations, we have done a lot of work in the
criminal justice area both with substance abuse and mental
health.
Mr. Green. I appreciate it. And, well, if you could get me
anything that you have worked on in Texas so I could see it. In
an earlier life I did mental health as an attorney representing
folks and I have worked with our sheriff. I watched last year
as they were trying to divert people in Houston Harris County
from, you know, being incarcerated and literally walk them two
blocks to a federally qualified health clinic that also sets up
an appointment, get them on their meds, looks for housing, and
things like that. So we don't provide most of that funding. It
comes locally, I guess, but it would be good if we could just
provide resources to particularly in urban areas but I know
rural areas have the same problem.
Dr. Satel, another panelist, alleges that SAMHSA's guiding
philosophy of care is the recovery model and its tears policy
away from the needs of those living with serious mental
illnesses. Administrator, can you describe the recovery model
and your views on whether it is an adequate guiding principle
for the Agency?
Ms. Hyde. Thank you, Congressman. The recovery is
important. It is part of what we are about. We do want people
to recover. I think there is an assumption that recovery means
not getting treatment. That is not true. Recovery includes
getting the kind of treatment and services a person needs to
maintain their symptoms as well as their lives.
We separate recovery into four areas: the treatment or
health area; as well as housing to make sure that people don't
end up homeless; and to make sure that they have the social
networks they need to survive in the community; and then that
they have the jobs or the education that they need to make a
living. So we support all of those in the recovery effort
Mr. Green. Well, and I understand recovery is important
but, you know, I consider mental illness something you manage,
too. And, you know, sometimes I am not going to recover from a
heart condition. I may manage my illness and I would hope that
is part of your recovery method, being able to manage that
illness because that was our problem of getting people to
realize their illness and you can manage it and function to
sometimes a higher level instead of being able to recover from
your particular mental illness issue.
One of the issues that came up and Dr. Burgess touched on
it that Dr. Torrey claims your agency spent 22,000 on
commissioning artwork to hang in your offices, and I hope that
was before sequester and it was something you couldn't get out
of, but that is what Members of Congress and O&I Committees are
looking at. And can you explain that expenditure?
Ms. Hyde. You know, Dr. Torrey and I have known each other
for a long, long time. He claims many things, not always that I
agree with. We have an obligation to try to do public awareness
and support. One of the things that we did is some special
approach to try to get information out to tribal communities.
We used a person in recovery from substance abuse and mental
illness who has provided other efforts and other art for
posters which we produced. We produce posters for a lot of
places in a lot of ways, and the combination of those efforts
was what you are referring to. The dollar amount is not correct
but we will be glad, as requested, to provide that to you
later.
Mr. Green. OK. Mr. Chairman, thank you.
Ms. DeGette. Would the gentleman yield?
Mr. Green. I would be glad to yield my last 2 seconds.
Ms. DeGette. And when did the Agency purchase that artwork?
Ms. Hyde. It was a couple of years ago.
Ms. DeGette. So it was before sequester took place?
Ms. Hyde. Absolutely, yes.
Ms. DeGette. And I am going to back up what Mr. Green was
saying and say I am hoping that those kinds of expenditures
aren't being made right now with sequester and other cuts
looming.
Ms. Hyde. I think it is fair to say that we have had to cut
a lot of our public awareness efforts, yes.
Ms. DeGette. Including things like that?
Ms. Hyde. Including things like that.
Ms. DeGette. Thank you. Thank you. I yield back.
Mr. Murphy. Thank you. The gentleman's time has expired. I
now recognize the gentleman from Virginia, Mr. Griffith, for 5
minutes.
Mr. Griffith. Thank you, Mr. Chairman. Thank you for being
here today. Appreciate it.
There is substantial evidence that court-ordered assisted
outpatient treatment can reduce hospitalization and length of
stay, increasing the receipt of psychotropic medications in
intensive case management services, among other improved
policy-relevant outcomes. Does SAMHSA provide financial support
to organizations that oppose efforts to expand court-ordered
outpatient treatment programs nationwide?
Ms. Hyde. Again, we provide resources to organizations that
may have positions that are not consistent or that we don't
necessarily espouse one way or another. So I can't really
answer that question. My guess is that there are probably some
of the organizations that receive some dollars and don't
appreciate that approach.
Mr. Griffith. Because there appears to be some data that
some SAMHSA-supported statewide programs such as the
Pennsylvania Mental Health Consumers Association and the
California Network of Mental Health Clinics actively lobby
against proposed expansion of assisted outpatient treatment in
their home States. And I have to wonder while supporting
prominent skeptics of assisted outpatient treatment, have you
all launched or do you have any plans to launch an assisted
outpatient pilot program to maybe encourage folks to be in
favor of these types of programs?
Ms. Hyde. I am sorry. Let me comment first that no one
using our dollars has the right to use federal dollars for
lobbying. So to the extent there is an organization that we
find that is doing something of that nature, they should be
either using other dollars or not doing it. So----
Mr. Griffith. Yes, ma'am.
Ms. Hyde [continuing]. We don't support that. On the
assisted outpatient treatment, the research that has been shown
for assisted outpatient treatment to be effective also is very
clear that it is the treatment and service that is effective.
So to the extent that, for example, in New York where there was
a major assisted outpatient treatment program and an evaluation
of that program that was extensive, there were also a lot of
new dollars poured into that system to make it work. So to the
extent that the services are there, then assisted outpatient
treatment may be effective for some individuals.
Mr. Griffith. And you certainly don't oppose in those cases
where it is necessary involuntary treatment?
Ms. Hyde. We do not oppose any kind of treatment that is
effective, absolutely not.
Mr. Griffith. OK. And you don't have any problem with
having those folks then put on a list to not be able to
purchase firearms?
Ms. Hyde. I don't have an objection to that. I do have
objection to some of the language that is in the law about
that, but I think everybody is working on that. We are looking
at it, things like mental defective and things of that nature
don't make a lot of sense today, so we do need to revise that
law in some ways.
Mr. Griffith. Well, we certainly need to make sure that
those who have severe mental illnesses with a tendency or
either the individual has a history or the diagnostic area,
that those folks are put on a list so that they can't purchase
firearms lawfully. Wouldn't you agree with that?
Ms. Hyde. I think our department is working with the
Department of Justice on the language around that law, yes.
Mr. Griffith. All right. And if I can be of any assistance
on that, please don't hesitate to contact me because we have
serious concern. I represent the 9th District of Virginia and
the Virginia law had to be changed when I was in the state
legislature because we let Mr. Cho slip through the cracks. And
he had been told by a court to go get help but nobody ever made
sure he got that help. And we had to make sure that we changed
the law because not only did he not get the help but that he
was never placed on the list of folks who weren't able to buy
guns. And so after he was court-ordered to get the help, he
went out and purchased firearms and he wasn't on anybody's list
as a no. So we had to change that law.
I would be happy to help in any way that we can on that.
And in regard to the folks that were doing some lobbying, I
know they are not supposed to and certainly not supposed to use
SAMHSA funds for that, but I have read some reports that
indicate that might be happening, and one of the suggestions is
that Congress could consider giving you all more authority to
regulate those individuals and to regulate patient advocates
both on lobbying and other issues. Would you welcome that
additional responsibility?
Ms. Hyde. Mr. Congressman, if you have any information that
suggests someone is using our dollars to lobby, please let us
know. We will take a look and we will exercise whatever
authority you give us to do the right thing.
Mr. Griffith. All right. I appreciate that as well. These
are very serious issues. I do note that when you were talking
about funding, maybe we need to do something because I noticed
in your written report that you are doing some kind of a study
that indicates folks are using less tobacco, particularly in
your youth programs. And while I certainly don't advocate that
young people be involved in the use of tobacco and recognize
that that is a substance, when we are dealing with serious
mental illness versus tobacco use, I would rather put the money
on serious mental illness. Do we need to put that into the
language of your appropriations or is that something that you
have the power to do?
Ms. Hyde. Well, once again, 70 percent, give or take, of
our dollars are about substance abuse, and tobacco use,
especially among young people, is a substance of abuse and
addiction does cause health issues. About half the deaths----
Mr. Griffith. Can you give me the dollar amounts that you
all use on your tobacco programs?
Ms. Hyde. On tobacco?
Sure.
Mr. Griffith. I would appreciate that. And with that, Mr.
Chairman, I see that my time is up and I yield back.
Mr. Murphy. Thank you. The gentleman from Missouri is now
recognized, Mr. Long, for 5 minutes.
Mr. Long. Thank you, Mr. Chairman.
Thank you, Mr. Chairman. And in full disclosure, Ms. Hyde,
I think it is important that we state for the record that you
and I both lived in Springfield, Missouri, for a while. Is that
correct?
Ms. Hyde. That is correct. I grew up there.
Mr. Long. So did I so welcome to the Committee. Glad to
have you here.
You mentioned earlier that sequestration had cost SAMHSA I
believe $168 million out of the budget?
Ms. Hyde. That is correct.
Mr. Long. And that is a budget of what size?
Ms. Hyde. It is about $3.2 million, 3.3. It depends on the
year. It depends on where--before or after sequester. It is
about $3.4 million, all sources.
Mr. Long. OK. Growing up in Springfield, Missouri, you are
familiar with----
Ms. Hyde. I am sorry. I am sorry. Excuse me, 4 billion. It
is about $4 billion.
Mr. Long. Four billion for SAMHSA?
Ms. Hyde. About $3.4 billion altogether, but remember about
70 percent of that is substance abuse.
Mr. Long. Is what?
Ms. Hyde. Is for substance abuse.
Mr. Long. Substance abuse. There is been a lot of talk
about sequestration today and you are familiar with
Springfield, Missouri, growing up there as I did. And at the
corner of Glenstone and Battlefield, the Barnes & Noble there
you could find myself and my wife and our daughters in there
about 3 nights a week. And I read a lot. And especially in this
occupation we fly out here on Monday and fly home on Friday,
you read a lot. And I am kind of old-fashioned. I don't read
the I whatever Kindles and I-books and things like that. I like
the pages in my hand and all of that. I don't know why but I
just like that.
And so one book that I bought was Bob Woodward of Watergate
fame. He wrote a book last year. It came out September 11, same
day that our consulate was attacked in Benghazi. But anyway, I
can get a picture of it on my iPad. I can't read it on my iPad
that I can get a picture of the book, ``The Price of
Politics.'' And that is pretty good for me, wasn't it?
So I probably bought it on September 12, because I was
anxious to get the book because it was kind of my first 2 years
up here and what went on in Congress and all of the budget
battles we had where we spent 42 percent more than we take in
every day in this town. And no one, as you know in Springfield,
Missouri, where you grew up, where I grew up, you can spend 42
percent more than they take in.
So the book I was anxious because I knew it was going to
walk us through the process and when Speaker Boehner would talk
to the President and Eric Cantor would be involved in back-and-
forth and everything.
So I got a hold of the book, read it, and then I happened
to run into--I was watching Morning Joe one morning and then I
saw Bob Woodward on there being interviewed about a different
topic, and then, as fate would have it, I am walking across the
Hill here and get to a stop sign on a corner and there stands
Bob Woodward, still has his makeup on from Morning Joe. And I
went up to Mr. Woodward and I said, Mr. Woodward, I have got to
tell you. I said I just read your book ``The Price of
Politics'' and loved it. I said I am going to say something to
you--and this is like in November/December last year--and I
said I don't know about the meetings that I wasn't in, but the
meetings that I was in I said it was like you had a tape
recorder in the room. That is how accurate your reporting was.
He said, well, thank you. Thank you very much. And in that book
where we can only assume, I think, that if the reporting was
accurate in the meetings I was in that you would be safe to
assume that the reporting was accurate in the meetings I was
not in.
And I believe--I am not sure but I think it is on page 326
but I don't know how to read a book on my iPad--but I think it
is on page 326 talks about where sequestration came from. Do
you know where it came from, whose idea it was?
Ms. Hyde. Congressman, I think these are issues that are
going on between you and the White House and others and I think
that you should take those questions and comments to them.
Mr. Long. Well, I think that you have used sequestration of
a lot here today and 168 million out of your budget, and, you
know, according to Mr. Woodward who was accurate in the
meetings that I was in, it came from the White House. It came
from the President, sequestration. And now that it has gone
into effect, we have a lot of different agencies coming to us
on a lot of different issues and so I just want to point out
for the record where sequestration came from so that when we
are talking about it in hearings like this, and we may talk
about it later in the second panel today, I just thought that
was important to bring out. And I yield back.
Ms. Hyde. Yes, Mr. Congressman, I think sequestration came
from a number of different drivers and I think it is very clear
that Congress had the authority to make a decision that it
would not go into effect. I think everybody wanted it not to go
into effect. I think everybody assumed to that there would be
another----
Mr. Long. Isn't that kind of--well, I am not going to get
into a discussion with you and I am controlling the time, but I
think it is kind of bad to come up with a law that you are
going to pass thinking it won't go into. And I yield my time
back to the chairman.
Mr. Murphy. The gentleman yields back. His time is expired.
And I now recognize the gentleman from Georgia, Dr. Gingrey,
for 5 minutes.
Mr. Gingrey. Mr. Chairman, thank you very much.
Administrator Hyde, can you understand the criticism leveled by
some against SAMHSA that the Agency's focus on behavioral
health being such a broad and amorphous category has come at
the expense of prioritizing resources for treating those with
serious mental illness?
Ms. Hyde. No, I don't agree with that. And again,
behavioral health is a broad term that we use for both
substance abuse and mental health and mental illness. It is
about prevention, treatment, and recovery. So it is a broad
term. Our budget is about 70 percent substance abuse. The other
part of our budget is about 75 to 80 percent about serious
mental illness and serious emotional disturbance. So no, I
don't understand the criticism.
Mr. Gingrey. Well, in other words, look, to me it has drawn
attention away from the biological basis behind the most
serious of these illnesses focusing instead on environmentally
driven behaviors. One example of this is something called
Leading Change, SAMHSA's plan of action for 2011 through 2014.
In this document of over 100 pages setting out the Agency's
eight core strategic initiatives for the coming years, the word
of schizophrenia or bipolar disorder do not appear at all. Are
these conditions not defined by both the National Institute of
Mental Health and SAMHSA as examples of SMI, serious mental
illnesses?
Ms. Hyde. As I said earlier, the Leading Change document
doesn't have any diagnoses in it. It is not the purpose of that
document. The definition of serious mental illness is different
in different places. Congress has given us a definition in one
place that is different with the NIMH in another place. We
have--each State makes their own definition of it for purposes
of the block grant, so there is lots of different definitions,
and certainly, people with schizophrenia and people with
bipolar disorder are some of the diagnostic categories that
could be a person with serious mental illness. In many cases,
it also includes a function or a history that makes the
individual in need of intensive treatment.
Mr. Gingrey. Well, there is a lot of controversy. I read an
article this weekend in the Wall Street Journal that expanded
there was a lot of coverage of mental illness. Those of you may
be here on the panel or members of the subcommittee may have
read these articles about DSM-V and the concern, you know,
about how in the world, you know, psychiatrists and
psychologists getting away from really the cause of some of
these serious things and just throwing medication at it. Maybe
that is another subject, maybe not.
But according to the National Institute of Health,
schizophrenia affects around 2.5 million Americans while
bipolar disorder affects 5.7 million Americans in this country.
And I am discouraged that it seems to me, Madam Administrator,
it just seems to me that your action plan fails to address both
of these populations of people. In the time remaining, can you
please explain to this committee what if anything SAMHSA has
done in the last 5 years which has impacted treatment for a
patient with one of these diseases if they walk into a typical
community mental health center in an average State, Georgia,
mine; what is it, Missouri? Yours and my friend Mr. Long in
front of me. What happens if a person walks into these
community mental health centers in the average State in this
country, Missouri or Georgia?
Ms. Hyde. We know health centers across the country
frequently are funded by the Mental Health Block Grant, which
SAMHSA administers. They frequently are recipients of SAMHSA
grants. Almost all of them now get Medicaid dollars and
Medicare dollars. Most of them now get private insurance
dollars as well. So as we indicated earlier, \2/3\ of the money
to fund those services come from Medicaid, Medicare, and
private insurance.
The SAMHSA grant that we provide help those community
mental health centers to provide those things that a typical
insurance benefit would not necessarily provide. We provide it
for both a different kind of set of services, evidence-based
practices that are over and above those, and we also provide it
for those individuals who were not covered the moment.
So there is a lot of ways in which if you walk into a
community mental health center, you can bet they are touched by
SAMHSA funding and they certainly may very well be touched as
well by SAMHSA technical assistance, by their training, by our
public education and outreach and awareness. They may use our
data. There is a number of ways in which those community health
centers are touched by us.
Mr. Gingrey. Madam Administrator, that is helpful. Thank
you and I yield back.
Mr. Murphy. Thank you. I now recognize the gentleman from
Iowa, Mr. Braley, for 5 minutes.
Mr. Braley. I want to talk about the Garrett Lee Smith
Suicide Prevention Program, a program that is very personal to
me because I lost my niece to suicide her senior year of high
school, and I am concerned about the proliferation of social
media sites and the amount of information available to
teenagers who are contemplating suicide and who have some of
their concerns reinforced about information provided by those
sites. What are we doing to monitor the traffic on Facebook and
Twitter and other social media sites to be more aggressive in
intervening with young people to prevent them from taking this
most drastic step to end their problems?
Ms. Hyde. It is a great question. We have a relationship
with Google, who actually has allowed us to have our National
Suicide Prevention Hotline be the first thing that comes up.
You know, normally, Google will just do a--it will come up
different every time, but if you Google suicide, it will come
up our lifeline number first.
We also have relationships with Facebook who worked with us
over the release last year of the National Strategy for Suicide
Prevention, which was the Surgeon General's report that was
developed by a public-private partnership that we participated
heavily in. Facebook is one of the partners there and they have
actually--now are monitoring some of the language and some of
the materials or some of the chatter that is going on and
trying then to intervene and allow that individual to know that
there is a way that can reach out. So we have good public-
private partnerships working with entities like that to try to
address some of the issues you have raised.
Mr. Braley. What are we doing to affirmatively promote
information through those platforms to try to counter some of
the misinformation and encouragement that takes place over
those platforms and educate young people to the alternatives
that are available to seek help when they are in such a time of
crisis in their lives?
Ms. Hyde. Again, I think there is a couple of ways. We have
a Garrett Lee Smith, as you know, program that is campus-based.
That is one of the age groups that has a high proportion of
death by suicide and a high proportion of individuals who
either seriously consider or act on those issues. Those grants
help to raise awareness. They help to provide support groups.
They help to provide actually information to faculty and
students. So we have a fairly extensive--again, limited by the
dollars that we have, we have a fairly extensive effort around
that.
We also do a significant amount of public awareness and
support with materials, posters, things to hand out to people.
I have got them in my backpack. I carry them around, signs of
suicide prevention that you can give to anyone who appears to
be talking about that kind of thing. We have also tried to
provide some training for parents and survivors of actual
attempts as well as parents of--or family members of those who
have experienced this. So we do a fair amount of work in that
and we do it with partners. It is not just SAMHSA. It is some
of our stakeholder partners who work on this issue extensively.
Mr. Braley. Thank you. That is all I have.
Mr. Griffith [presiding]. I now recognize the gentlelady
from North Carolina, Mrs. Ellmers.
Mrs. Ellmers. Sorry. Thank you, Mr. Chairman. Thank you,
Ms. Hyde, for being with us today. You know, mental health in
this country is so important and certainly one of the issues
that Oversight and Investigation is taking on with a great
passion. We know that the health care system in this country
needs to be reformed. We know that the mental health system in
this country needs to be improved upon.
And that brings me to my concerns about the way that your
organization is moving forward with hard-earned taxpayer
dollars. I am concerned that there seems to be a lack of
physicians and nurses and social workers that are a part of
your organization, and I have reviewed all of the information
here, and I would like to hit on a couple of very specific
issues, especially with healthcare professionals. I read the
brochure on the Alternatives Conference that you are a part of,
and I don't see anywhere where they discuss continuing
education credits for psychiatrists, for psychologists, for
nurses, for social workers. Is this correct? I mean is there no
program that you are associated with with at least education
and training for these healthcare professionals?
Ms. Hyde. No, that is not correct. Alternatives is just one
thing that we do. We also work with--I gave a keynote at the
American psychiatric nurses Association as well. So there is
lots of different efforts that we do with psychology groups,
social work groups, nursing groups and others to try to----
Mrs. Ellmers. But not for this particular conference that
you do like, again, providing accredited hours of education
training for these individuals?
Ms. Hyde. Not at--I don't believe that is----
Mrs. Ellmers. Through federal dollars?
Ms. Hyde. I would have to check that for you.
Mrs. Ellmers. OK. And if you could provide to our committee
those keynote points that you made at that particular
conference, that would be helpful as well.
Also, some of the other issues, and there again we are
looking at federal dollars that are being spent here. We
discussed the sequester cuts that you have identified as
problematic, and I can certainly understand that as well.
However, I think there are dollars that are being spent here
that aren't necessarily getting to the root of the mental
health issues that we are faced with in this country,
especially with young people.
But also in the document that you have, Leading Change, you
do make very specific reference to suicide, substance abuse,
which obviously definitely falls under your jurisdiction,
depression, PTSD, so you are able to name specific diagnoses.
So this is something that you do not have any difficulty
talking about specific diagnoses, is that correct?
Ms. Hyde. In the right context, absolutely not. We don't
have any problem with that in the----
Mrs. Ellmers. OK. So that is a yes. In your document
Leading Change again, you do not specifically mention
schizophrenia, bipolar disorder. So is that something that you
do not regard as serious mental illness?
Ms. Hyde. Of course we consider those serious mental
illness diagnoses. That document was not a clinically-based
document. It laid out our eight strategic initiatives ranging
from prevention to military families to trauma issues to
quality issues to public awareness and support and to
electronic health records.
Mrs. Ellmers. OK, well----
Ms. Hyde. The nature of that document----
Mrs. Ellmers [continuing]. I would like to hit on one
specific area, though, in relation to those with my 1 minute
that I have left. One of the areas there again getting back to
that document, getting back to schizophrenia and bipolar, do
you believe medication is a proven evidence-based treatment for
these diagnoses?
Ms. Hyde. Absolutely. For most people. There are, however,
a number of people who have those diagnoses for which
medication is still not effective.
Mrs. Ellmers. Well, see, that is one of those curious areas
there because you also are providing funding to organizations
that support and promote taking away medical treatment. Do you
acknowledge that?
Ms. Hyde. We provide funding for entities to do the grants
that we give them to do. Whether or not they espouse other----
Mrs. Ellmers. Well, then, what are the criteria that you
would give a grant if it isn't a treatment that you would
support for mental illness----
Ms. Hyde. The----
Mrs. Ellmers. Ten seconds.
Ms. Hyde. It depends on what the grant is. There is a lot
of different grants that we give for a lot of different
purposes. I would be glad to talk to you offline about that
some more.
Mrs. Ellmers. Well, I would like to see that criteria of
how you qualify an organization that you are giving hard-earned
taxpayer dollars when it is something as serious as mental
health. And if you could provide the criteria or the
application process that would be wonderful so that we can see
who gets this money and how you qualify them. Thank you very
much. I went over and I apologize, Mr. Chairman.
Mr. Griffith. I now recognize the gentleman from
California, Mr. Waxman, for 5 minutes.
Mr. Waxman. Thank you, Mr. Chairman.
I understand there has been a good deal of discussion
regarding the role of Protection and Advocacy Program, and I am
very familiar with this program having worked on the
authorizing statute when I was chairman of the Health and
Environment Subcommittee. The Protection and Advocacy for
Individuals with Mental Illness Act authorized Protection and
Advocacy organizations to, one, protect and advocate for the
rights of people with mental illness; and two, investigate
reports of abuse and neglect in facilities that provide care or
treat people with mental illness.
I know we have heard criticisms about efforts of these
entities in specific cases, but I want to underscore two
points: First, Protection and Advocacy organizations are
designed by their respective States and are acting within the
scope of congressionally mandated activities; and second,
absent their efforts, thousands of individuals would continue
to experience abuse, neglect, and violation of their civil
rights.
For example, in 2011 the PAIMI program supported casework
for approximately 4,000 children and adolescents, nearly 13,000
adults and elderly individuals, and entities receiving funding
resolved over 11,000 complaints. Now, Administrator Hyde, you
also noted that SAMHSA is developing a framework to guide
behavioral health services and programs throughout the country
and to provide a consistent set of measures for use by various
stakeholders. Can you tell us how you expect this framework to
improve accountability for your stakeholders?
Ms. Hyde. Thank you. Yes, we are developing a National
Behavioral Health Quality Framework. It is modeled on the
National Quality Strategy that was required by Congress so we
have been working with the organizations to develop that. It
has six goals, things like safe care, evidence-based care,
effective care, patient-centered care, et cetera. And we are
developing rules and measures with the National Quality Forum
and others to populate what that quality framework might look
like.
Mr. Waxman. Is there anything else you would like to add
with regard to SAMHSA's ongoing accountability efforts?
Ms. Hyde. Yes, thanks for the question. We--every one of
our programs--our grant programs we evaluate. We have
evaluation data. We have one of the highest number of the GPRA,
what we call GPRA or government accountability measures of any
of the agencies. We report that data. We make it available. All
of our grantees are doing that. We also work hard--we are in
the process of revising our data reporting and data collection
activities both for our discretionary grants, as well as for
our block grants to assure that we have the best data possible
available for you all, as well as for the public. So we do a
lot of work in this area. We also do oversight of each of our
grants and then we respond to complaints and investigations and
investigate those when they are brought to our attention.
Mr. Waxman. And even as you are requesting more information
from your grantees, I understand there are instances in which
you lack the authority to require States and other grantees to
report on certain measures, for example, within the Community
Mental Health Services Block Grant. Is that correct?
Ms. Hyde. Well, the block grant is meant to be a flexible
funding stream, so for States--they make different choices
about that. They do provide us information about how they use
those dollars and we do report those back. We also--but we--so
we have limited authority in some ways but I think it was
designed to be a flexible funding stream for each State.
Mr. Waxman. Well, it is a flexible funding stream for each
State but when you try to get information from them and you are
asking them to report on certain measures, are you able to get
the information you need?
Ms. Hyde. To an extent we are and we have just begun a new
effort with the States to try to see how we can collectively
report data better. We all want to improve that so we have data
now. We have information about what the States use the dollars
for----
Mr. Waxman. Yes.
Ms. Hyde [continuing]. But we do want to improve those
data. We are always looking for ways to improve that
accountability for Congress and the public.
Mr. Waxman. I think we can agree that it is important to
make sure there are clear reporting requirements and consistent
measures in place so that we can track progress over time. I
hope that we can work together to support SAMHSA's efforts on
this issue.
And I thank the chair for recognizing me. I yield back the
balance of my time.
Mr. Murphy. I thank the gentleman. I now recognize the
gentleman from Ohio, Mr. Johnson, for 5 minutes.
Mr. Johnson. Thank you, Mr. Chairman. And I appreciate the
opportunity. Thank you, Ms. Hyde, for being here today.
I do have one comment I want to make, though, before I get
into the questions because I was struck by what my colleague
from Missouri mentioned about the idea of sequestration because
that seems to be a hot topic today. We consistently have
administration officials come before our committees to talk
about sequestration and the fact that it is hurting their
ability to do the job that they are assigned to do. However, we
know and it has even been admitted that the idea of
sequestration came from the White House.
I came from the floor just a little bit earlier where our
minority whip talked about or tried to make the case that once
again this was a Republican House idea, which it was not, and
that we have abdicated our leadership because we haven't worked
across the aisle to try and replace the sequestration when in
fact we passed two pieces of legislation in the last Congress
that would replace sequestration, give the Administration the
flexibility that it needed by making more responsible spending
cuts.
So I am a little frustrated with the disingenuousness that
continues to come from the Administration and the agencies that
try to blame sequestration on their inability to do their jobs.
I wonder where that backlash was when the Administration was
putting forth this idea. That is just a comment.
Let me ask you, Ms. Hyde, how our review criteria for
SAMHSA's formula and competitive grant programs developed?
Ms. Hyde. Review criteria come from the RFAs, which is
request for applications. So when we developed the RFAs based
on congressional input and the program design, then we develop
criteria from that about what the applicants have to meet.
There is a checklist that the reviewers have to go through.
They actually have to put the page number of the application of
where the different criteria are in the application. They are
scored and then that scoring drives the decisions about
development. Now, that is sort of the discretionary grants. The
formula grants like block grant and the PME program and others,
those are done by application from the States because each
State is entitled to those dollars so long as their
application----
Mr. Johnson. How do you ensure that SAMHSA grant reviewers
follow the criteria consistently?
Ms. Hyde. As I said, there is a checklist and they have to
identify the page number in the application where they actually
saw the criteria that they are looking for in the grant review.
So there is an extensive documentation about how they reviewed
the criteria and how they--the scoring occurs.
Mr. Johnson. What kind of oversight does SAMHSA perform
over its grantees after the grant is awarded?
Ms. Hyde. Each grantee has a grant project officer. Those
grant project officers provide oversight by visits, by audits
of papers, by technical assistance, and by looking at the
materials that are provided for reporting and overseeing
whether or not those are up to snuff and what they are required
for meeting their grant performance.
Mr. Johnson. How often is this type of oversight performed?
Ms. Hyde. It depends on the situation and depends on how
many grantees there are, what kind they are, whether or not
they are sort of usual grants or new grants. So new grantees
may get additional attention or more oversight than grantees
who have been going for a while, et cetera.
Mr. Johnson. OK. Ms. Hyde, some have called the annual
Alternatives Conference that is funded by SAMHSA to be the
largest anti-psychiatry, anti-treatment meeting in the U.S. In
your view, what is the value that has been obtained for the
American people and more specifically the mentally ill from
these conferences?
Ms. Hyde. Again, this is one event of many that we have
worked with----
Mr. Johnson. But it is paid for by the taxpayers, correct?
Ms. Hyde. It is one event that SAMHSA funds.
Mr. Johnson. But it is paid for by the taxpayers, correct?
Ms. Hyde. Well, SAMHSA uses taxpayer dollars----
Mr. Johnson. There you go.
Ms. Hyde [continuing]. That is correct.
Mr. Johnson. OK.
Ms. Hyde. But it is only one. We have many others. The
effort is to provide information and to provide assistance, for
example, trying to provide help and information about how
people can enroll in coverage to get access to treatment and
services. We provide information there on different types of
treatments and approaches that will help individuals. We try to
develop workforce efforts there. There is a number of
opportunities that we do at that conference, as with many of
the other conferences that we support.
Mr. Johnson. Mr. Chairman, I yield back.
Mr. Murphy. Thank you. I now recognize Mr. Tonko for 5
minutes.
Ms. DeGette. Will the gentleman yield to me just for one
question?
Mr. Tonko. I would.
Ms. DeGette. Thank you. I just want to ask you quickly,
Administrator Hyde, irrespective of whose fault the sequester
was--and I don't think it was my fault because I voted no--but
irrespective if it is the White House or the Congress' fault,
the fact is that the cuts have gone into effect and your agency
still has to administer those cuts, correct?
Ms. Hyde. Correct.
Ms. DeGette. Thank you. Thank you, Mr. Tonko.
Mr. Tonko. Thank you, Ranking Member DeGette. And thank
you, Mr. Chair. Thank you as well to Administrator Hyde for
your testimony here today on the sequestration rundown. I think
one piece was left out that the Democrats in this House
proposed an alternative to sequestration. It was blocked by the
majority in the House.
Like many of my colleagues, I, too, am concerned over
allegations of wasteful spending and the questionable
activities of some SAMHSA grantees. These incidents should and
will continue to receive the utmost scrutiny from this
committee and I applaud the chair's initiative to conduct this
important oversight hearing.
However, I also have significant concerns that the
instincts of some of my colleagues in investigating these
allegations would be to throw the proverbial baby out with the
bathwater resulting in further damage to our Nation's already
reeling mental health system. This is not the right approach.
And according to the National Association of State Mental
Health Program Directors, States have cut at least $4.35
billion in public mental health spending from 2009 to 2012. In
these tough times, federal funding from sources like SAMHSA's
Community Mental Health Sources Block Grant is more important
than ever to ensure that even more individuals do not fall
through the cracks of our fragmented mental health systems.
Administrator Hyde, that being said, I think the two
biggest criticisms lobbied against SAMHSA are its funding of
the Consumer and Consumer-Supporter Technical Assistance
Centers and the Protection and Advocacy for Individuals with
Mental Illness program. Can you tell us what proportion of
SAMHSA's mental health budget in 2013 was spent on these very
programs respectively?
Ms. Hyde. Congressman, I don't have that number off the top
of my head but I can tell you it was miniscule compared to the
overall expenditures. We can get that.
Mr. Tonko. Sure.
Ms. Hyde. We can do the math and get you that information.
Mr. Tonko. Well, according to my information, SAMHSA's 2014
budget request document, the Consumer Technical Assistance
Centers program was funded at a level of 1.9 million and the
Protection and Advocacy for Individuals with Mental Illness
program was funded at 36 million. Together, these programs
would comprise a little more than 3 percent of SAMHSA's $954
million mental health budget in 2013. If you could check on
those numbers, please, Administrator Hyde----
Ms. Hyde. Will do.
Mr. Tonko [continuing]. I would appreciate it and get back
to the Committee. And by contrast, what percentages of SAMHSA's
mental health funding went directly to States to support mental
health treatment services in 2013?
Ms. Hyde. About 48 percent of our mental health dollars
went to States through the block grant program. There are
additional discretionary grant programs that States have
dollars from. Again, we could add up how much of that is
States. Most of our dollars do go towards States.
Mr. Tonko. So when you say most, like a rough percentage
would be?
Ms. Hyde. Again, I don't know how many of our grantees are
States versus communities sitting here, but we can certainly
get you that information.
Mr. Tonko. It appears as though a vast majority of the
dollars are going toward assistance for treatment. Regardless
of how much money is spent on programs such as the Consumer and
Consumer-Supporter Technical Assistance Centers and the
Protection and Advocacy for Individuals with Mental Illness,
these programs should be accountable for spending taxpayer
money wisely. I share the opinions of many on this committee
that grantees should not be able to use federal funds to lobby
against duly enacted state laws. Can you describe what type of
internal safeguards SAMHSA has in place to ensure that these
monies are spent appropriately?
Ms. Hyde. We review the grantee expenditures to assure that
they are being spent on the issues that were identified in
their applications and that the funding allows. If we are--if
someone brings to us an allegation that those dollars are being
spent inappropriately, we investigate that and act accordingly.
Mr. Tonko. Thank you, Administrator Hyde.
In closing, I would just like to point out that many of the
programs that we are scrutinizing here today such as the
Protection and Advocacy for Individuals with Mental Illness
program saw their congressional authorizations expire at the
end of 2003. Simply put, as a Congress, we have been derelict
in our duty to provide proper and continuous oversight to this
agency, and as such, this agency shares in the responsibility
for any failures at SAMHSA.
I would strongly urge my colleagues on both sides of the
aisle to continue this dialogue and to work to enact meaningful
legislation that will provide SAMHSA with the appropriate
congressional guidance it needs to find out what works and what
doesn't and to ensure it is meeting its core mission of serving
individuals with serious mental illness. I stand more than
ready to work on this goal with anyone who will join. And with
that, Mr. Chair, I yield back.
Mr. Murphy. The gentleman yields back. I now recognize the
gentleman from Louisiana, Mr. Cassidy, for 5 minutes.
Mr. Cassidy. Hello, Administrator Hyde.
Ms. Hyde. Hi.
Mr. Cassidy. A couple things. Clearly, we are in a time of
budgetary constraints. You referred to it multiple times, but
on the other hand, that is the new reality. That said, it seems
a luxury to be unfocused in how we are implementing programs. I
had to step out several times, I apologize, but I gathered one
of the things I heard you say is that there are many working
definitions of severe mental illness. Now, truly, this seems
like an area that you, your agency could give guidance as to
what severe mental illness is about.
One example, one of the witnesses on the next panel speaks
about how there is an unbalance in your compendium of care. She
formerly worked with yours, says that of 288 programs listed,
only four would address things pertaining to schizophrenia or
bipolar disease. Now, first, knowing that our money is tight,
why out of 288 programs will we only have four that seem to
directly pertain to what we could all agree would be severe
mental illness?
Ms. Hyde. I don't agree with those numbers. I don't know
exactly where that comes from.
Mr. Cassidy. She is a psychiatrist formerly with SAMHSA.
You can read her testimony but she ballparked it. She goes,
listen, maybe there is a couple I missed. Let's say that there
is 8, there is 12, but out of 288 it seems like 286 should be
related to something that we could all agree was severe mental
illness. Is something wrong with that logic?
Ms. Hyde. The issue of serious mental illness is different
for different purposes. So there is literally congressional
definitions. There is definitions----
Mr. Cassidy. So I am coming back to the fact that knowing
in a time of budgetary constraint, when, by the way, in the
shadow of Sandy Hook I think we are compelled not to accept
that there are a lot of different definitions but to try and
hone down at least in programmatic funding upon something that
if there was a psychiatrist at the Agency in a position of
authority, she would say, wow, this is how we prevent another
Sandy Hook, put our resources there as opposed to a lot of
other things which are more diffuse.
Ms. Hyde. I am not aware of any of SAMHSA's programs that
are targeted to serious mental illness that doesn't include
schizophrenia. It is not just----
Mr. Cassidy. OK. But our point is that there is----
Ms. Hyde [continuing]. Schizophrenia, however----
Mr. Cassidy [continuing]. A maladjustment of the compendium
of care that there is only four programs--let's say for the
sake of argument it is 12 out of 288 that are specifically
focused upon what we could all agree would be serious mental
illness.
Ms. Hyde. I am sorry. I just don't agree with the numbers.
As I told you earlier----
Mr. Cassidy. So if she comes up with that, would you agree
in concept--because her testimony is next--in concept would you
agree that if that is true that that would be an unbalanced
compendium of care?
Ms. Hyde. I don't agree that that is true.
Mr. Cassidy. But if it were true, would you accept that,
just a hypothetical if you can go with me that there really
should be a focus of these programs--in fact, your answer
implies that you think it should be. There should be a focus of
these programs upon those that we can agree would be severe
mental illness?
Ms. Hyde. I think I have said several times there is a
priority on serious mental illness.
Mr. Cassidy. And how do you define priority?
Ms. Hyde. Seventy-five to eighty percent of our funding for
mental health goes to people with serious mental illness or
serious emotional disturbance, which is----
Mr. Cassidy. OK.
Ms. Hyde [continuing]. The name for our children's
programs.
Mr. Cassidy. OK. Now, that said, severely mental ill
patients, I see a lot of these grants go for prevention, but
you can't really prevent paranoid schizophrenia. I mean we
don't know the biologic basis in terms of a prevention
activity.
Ms. Hyde. Actually, there is increasing evidence that we
can prevent the disability related to those psychotic
illnesses, and the earlier we intervene, the more we can have a
positive impact----
Mr. Cassidy. So when you say prevention, you don't
technically mean prevention of the illness; you mean prevention
of the untoward effects of having mental illness.
Ms. Hyde. Prevention has a range of issues in it. From--the
Institute of Medicine has a whole range from primary prevention
all the way up to intervention.
Mr. Cassidy. Is there primary prevention of paranoid
schizophrenia?
Ms. Hyde. No, I don't think we have the ability to do that
at this point.
Mr. Cassidy. So my problem again, in an era of budgetary
constraints, should we be focusing our dollars on that which
actually would prevent another Sandy Hook or should we be more
diffuse? And let me ask you that. Do you agree with that
question?
Ms. Hyde. I think we should do everything we can to prevent
incidents like Sandy Hook.
Mr. Cassidy. So does that mean again yes or no that we
should focus our limited dollars upon those activities not
exclusively but would primarily focus our limited dollars on
those activities that would definitely have the potential to
prevent such an incident like that?
Ms. Hyde. I think that is why the President has proposed
the 2014 budget, several programs that we believe will help
identify that and help----
Mr. Cassidy. And so you do agree that we should focus our
dollars because that is actually not a yes or no answer. And I
don't mean to be confrontational, but that is----
Ms. Hyde. We have no choice as public administrators but to
focus our dollars and we do that every day.
Mr. Cassidy. OK. Great. I am almost out. I yield back.
Mr. Murphy. I thank the gentleman. I just want to point
out, I am looking at a document that SAMHSA put out called
Mental Health: United States 2010. And in that on page 11
SAMHSA does define serious mental illness. Among adults, it is
defined as ``persons 18 or older who currently or at any time
in the past year had a diagnosable mental, behavioral, or
emotional disorder and resulting in substantial impairment in
carrying out major life activities.'' So I am assuming
diagnosable. So you do have a definition. I know we have been
going back-and-forth on that but that is helpful and I should
focus on that.
We have finished our questions but I do want to ask a favor
of you if I can. I know one of the things that you have said
frequently is you are not aware about some of the programs you
fund and you asked for some of our feedback on those. So I have
a personal request. On the next panel a man named Joe Bruce is
going to testify and I know you are very busy, but Mr. Bruce's
testimony, he said he is going through something that no parent
or husband should ever have to experience.
His son William, after being discharged from a mental
health treatment center with the assistance of a representative
from the SAMHSA-funded Protection and Advocacy for Individuals
with Mental Illness program murdered his mother. And it is also
Mr. Bruce's wife, and he murdered her with a hatchet. I believe
his story is very powerful and important and I think it is
important for you to hear what one of the agencies you funded
has done in this instance. So if you can stay just to hear his
5 minutes of testimony, I would be grateful if you could do
that.
And with that, we end this panel and we will prepare the
second panel to come up. Thank you.
Ms. Hyde. Thank you.
Mr. Murphy. I will start to introduce our witnesses as they
are taking their seats. I will introduce the witnesses of the
second panel.
Our first witness is Joseph Bruce, the father of a son who
suffers from severe mental illness. Our second witness is Dr.
E. Fuller Torrey. He is a research psychiatrist specializing in
schizophrenia and bipolar disorder and founded the Treatment
Advocacy Center and executive director of the Stanley Medical
Research Institute, which supports research on schizophrenia
and bipolar disorder. He is also a professor of psychiatry at
the Uniform Services University of the Health Sciences.
Our third witness is Dr. Sally Satel, a psychiatrist
trained at Yale University School of Medicine. Since 2001 she
has been a resident scholar at the American Enterprise
Institute and also continues part-time clinical work in drug
treatment clinics in Washington, D.C.
And our fourth witness is Dr. Joseph Parks. He is the chief
clinical officer at the Missouri Department of Mental Health.
There, he is responsible for clinical standards and quality of
care for persons with mental illness, mental retardation, and
developmental disabilities and alcohol and drug dependence. In
this capacity, he has substantial experience working on SAMHSA-
funded grants.
I will now swear in the witnesses. And you are aware the
Committee is holding an investigative hearing. When doing so,
we have the practice of taking testimony under oath. Do any of
you have any objections to testifying under oath?
All have responded no.
The chair then advises you that under the rules of the
House and the rules of the Committee, you are entitled to be
advised by counsel. Do you desire to be advised by counsel
during your testimony today?
All have said negative.
In that case, if you would please rise, raise your right
hand, I will swear you in.
[Witnesses sworn.]
Mr. Murphy. Let the record show all witnesses have answered
in the affirmative.
You are now under oath and subject to the penalties set
forth in Title XVIII, Section 1001 of the United States Code.
You may now each give a 5-minute summary of your written
statement. I will call upon you first, Mr. Bruce, for your
statement. Thank you for being here.
TESTIMONY OF JOSEPH BRUCE, FATHER OF A SON WITH SEVERE MENTAL
ILLNESS; E. FULLER TORREY, FOUNDER, TREATMENT ADVOCACY CENTER;
SALLY SATEL, RESIDENT SCHOLAR, AMERICAN ENTERPRISE INSTITUTE;
AND JOSEPH PARKS, III, CHIEF CLINICAL OFFICER, MISSOURI
DEPARTMENT OF MENTAL HEALTH
TESTIMONY OF JOSEPH BRUCE
Mr. Bruce. My name is Joe Bruce. I live in Caratunk, Maine.
On February 6----
Mr. Murphy. Pull the microphone real close to you, please.
Thank you.
Mr. Bruce. On February 6, 2006, my son William Bruce, age
24, was involuntarily committed to Riverview Psychiatric Center
in Augusta, Maine. On April 20, 2006, with help from federally
funded patient rights advocates from the Disability Rights
Center of Maine, Will was discharged early from Riverview
without the benefit of any medication.
As is most often the case with severely and persistently
mentally ill persons across the country, Will returned home.
Fears his mother and I had voiced to his doctors that Will
would hurt or kill someone came true. On June 20, 2006, I
returned home to find the body of my wife Amy. Will, in a state
of deep psychosis, had killed her with a hatchet.
Will was advised that without his consent, his parents had
no right to participate in his treatment or have access to his
medical records. Will believed there was nothing wrong with him
and that he was not mentally ill, a condition characteristic of
many persons with severe bipolar disorder or paranoid
schizophrenia, particularly of younger ages such as Will's. He
would not consent to our involvement with his treatment, and
because he was an adult, his mother and I were barred from all
access to his treatment. The doctor's decision to release him,
which resulted in such a tragic outcome, was made without the
benefit of all of Will's history or any input from Amy and me.
After his commitment to Riverview by the criminal court, I
applied to become his guardian. Will was agreeable to this
until, incredibly, a patient advocate told him the guardianship
is a bad idea. It would give your father complete power over
you.
The attending physician, a new doctor, undoubtedly at the
urging of DRCM, refused to provide the evaluation required in
the guardianship application. He told me, I could never
participate in anything that would cause your son to be
considered an incapacitated person. Bear in mind that at this
point in time, Will had been placed in the hospital after being
found incompetent to even stand trial.
Suffice it to say, I finally did become guardian, and I was
able to participate in Will's treatment and to obtain the
medical records of his prior treatments. Until then, I had not
known the role that patient advocates had played in Will's
premature and unmedicated release.
The medical records revealed exactly what the patient
advocates had recklessly done and said to encourage Will to
avoid the treatment he so desperately needed. His doctor had
recorded verbatim what the patient advocates said to Will in
the meetings from which Amy and I had been excluded. The
patient advocate, a Trish Callahan, told the treating doctor
that DRCM regarded Amy and me as a ``negative force in Will's
life.'' Amy and I had never met any of these people or even
heard of Disability Rights of Maine.
In the treatment meetings, she acted like a criminal
defense lawyer. She openly coached Will on how to answer the
doctor's questions so as to get Will the least treatment and
the earliest release. She did this in the face of strongly
contrary evidence of Will's unsuitability for unmedicated
release. She repeatedly pressed for his early release despite
knowing or recklessly disregarding that he was unsuited for it.
DRCM willfully neglected Will's need for treatment, and
their pressure on the doctor to release Will led directly to
Amy's death. But neither the patient advocates nor the DRCM has
ever acknowledged they did anything wrong. They have not
changed their procedures, and Trish Callahan, the advocate who
helped fuel Will's paranoid hostility towards his mother and
contributed to her death, continued to work on the same unit at
Riverview for years afterwards.
Lest anyone believe this is a local, isolated occurrence,
the National Disability Rights Network, responding to the Wall
Street Journal's page 1 article concerning Will's case,
defended the actions of DRCM, and even prepared talking points
to deflect criticism. The patient advocates can do this with
impunity because they are literally accountable to no one. But
my experience with the patient advocates did not end here. I
have come to know the stories of many families, and their
experience with the advocates' surprising approach to these
issues.
Beginning in 2007, I joined with other family members of
some of the most severely mentally ill individuals in the State
of Maine to seek legislative change to laws that had prevented
our loved ones from receiving treatment. We took our concerns
to the lawmakers in the Maine legislature. To the shock of all
of us, we met with fierce lobbying opposition from Disability
Rights Center of Maine. Nonetheless, we were successful in
obtaining helpful legislation in 2007 providing for medication
over objection in appropriate cases. Having failed in the
legislature, the lawyers at DRCM filed a legal action
challenging the law, which thankfully was unsuccessful.
At the time of Amy's death, the courts in Maine only had
two options at a commitment hearing: to place someone in the
hospital or to release them unconditionally. In 2008 and 2009 I
and other family members worked to give the court a third
option, that of releasing an individual into the community on
the condition that he remain on medication. These types of laws
are known as Assisted Outpatient Treatment laws and they have
been opposed across the Nation by PAIMI organizations. Maine
was no exception.
DRCM mounted a well-orchestrated attack on the proposed AOT
law. It was joined in this effort by the Advocacy Initiative
Network of Maine, another SAMHSA-funded organization. Their
campaign included proffering 20 or so consumer witnesses in
opposition to the law, but these consumers were completely
aware of their mental illness, stable on medication and
successfully living in the community, the very goals that the
proposed law was designed to achieve for our loved ones. DRCM
had persuaded them to oppose the law by misrepresenting its
essential provisions. This cynical opposition to the AOT law--
which failed, because the law was ultimately enacted--shocked
me and the families. The incident illustrates the national
policy of the PAIMI program to oppose any form of involuntary
treatment.
The PAIMIs, like DRCM, are so concerned that one person may
be inappropriately treated involuntarily that they seek to
prevent anyone from being medicated. In Will's case, once I
became his guardian, medication over his objection was his
route to recovery.
As another example of DRCM's lobbying influence in this
area, while the Maine families and I were busy working on the
AOT law, DRCM was successful in getting a bill through the
Maine legislature to make it more difficult for families to
become guardians. Becoming a guardian is the only way families
of adult patients can be involved in the treatment of their
loved ones where the patients are unwilling or unable to
consent. Why do PAIMIs want guardianship to be more difficult?
Because guardianship lifts HIPAA secrecy and allows the
guardians into the treatment meetings.
Will is still in Riverview, to which he was committed by
the criminal court. Once he was committed, he got the care he
should have gotten before. Ironically and horribly, Will was
only able to get treatment by killing his mother. We have found
a medication that works. He leaves the hospital frequently on
supervised release with staff or family members. He is being
successfully treated and he is doing extremely well. He now
recognizes that if he had been treated, his mother would still
be alive today. He stated to the Wall Street Journal, ``the
advocates didn't protect me from myself. None of this would
have happened if I had been medicated.''
Tragedy visits families every day. That is a sad fact of
life. But an unbearable aspect of Amy's death is that my own
tax dollars helped make it possible. A retired nurse from
Riverview may have summed it up best. She wrote: ``Mr. Bruce,
your losses didn't happen for reasons other than your family's
misfortune to become involved with the mental health system,
when politics now overrides sound medical decisions.''
Thank you for hearing my testimony. I would be happy to
answer any questions.
[The prepared statement of Mr. Bruce follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Mr. Bruce. And our hearts are with
you and your family. I know you made references to a number of
documents. You ask that these be submitted in the record and
the minority has no objection. We will include these in the
record then. Thank you.
Dr. Torrey, you are recognized next for 5 minutes.
TESTIMONY OF E. FULLER TORREY
Dr. Torrey. Thank you very much.
Mr. Murphy. Microphone on and close to your mouth, please.
Dr. Torrey. Thank you very much, Chairman Murphy, Ms.
DeGette. Very, very important what you are doing. It is not as
sexy as the IRS hearings but it is just as important.
I am here to describe why I think SAMHSA is not only a
failed federal agency but it has been so for 30 years. That is
one of the qualifications I don't like. This is not a new
issue. This is not just something that falls on Ms. Hyde. This
is something that has been going on for 30 years really
unlooked at by Congress in any serious--and so I strongly
commend you for doing what you are doing.
I also want to emphasize that is not a Democratic or
Republican issue. The--SAMHSA has been a failed agency. It was
originally put together under the Bush Administration. It was a
failed agency under the Clinton Administration, under the
George Bush Administration, and it is continuing to be a failed
agency under the Obama Administration. I would like to
illustrate that by six points.
Point number one--and I am emphasizing what they should be
doing compared to what they really are doing. Mass killings are
increasing. We have heard that today. About half of the mass
killers have serious mental illness, mostly schizophrenia,
Seung-Hui Cho, Jared Loughner, James Holmes being only examples
of them. There is no question they are increasing. SAMHSA does
not seem to see this is a--this is not a priority for them at
all.
We have talked about the fact that their 3-year plan has
nothing about these problems but talks completely about
behavioral health problems. A 4-year-old with tantrums having
behavioral health problem, I understand that. A 12-year-old
skipping school has problems. Somebody who goes down and kills
30 first-graders doesn't have a behavioral health problem; he
has a severe mental illness and that should be recognized as
such.
We now know that these are severe mental illnesses. I have
a tremor of my left hand that is an early Parkinson's disease.
This is not a behavioral health problem; this is a brain
disease, just as schizophrenia, bipolar are brain diseases.
These are twins that we looked at many years ago, now showing
the one on the right who has schizophrenia, identical twins,
has larger ventricles. There are now literally hundreds of
studies showing that severe mental illnesses like this are
brain diseases on it. Severe mental illness has been defined
for Congress. It was defined by the mental health NIMH Advisory
Council at the request of Congress in 1994 on it.
SAMHSA does not understand. It has no expertise on severe
mental illness. Its last psychiatrist who had any expertise,
Ken Thompson, left 3 years ago. The one psychiatrist was
retained as an expert only on substance abuse, and the
psychiatrist they just hired only has expertise on substance
abuse, a very good woman but has no expertise on severe mental
illness.
When SAMHSA was asked to bring a psychiatrist to testify
before the Vice President Biden's committee, they brought in
Dr. Daniel Fisher, who doesn't believe schizophrenia exists. He
thinks it is a severe emotional distress, a spiritual
experience. Mr. Cho and Loughner and Holmes were not having a
spiritual experience. They were having a brain disease that
needs treatment.
We have effective treatments. We have medication, we have
assisted outpatient treatment. We know that assisted outpatient
treatment will decrease hospitalizations in several different
studies, decrease homelessness in one study, decreased
victimization, decrease arrests in four studies, decrease
violent behavior in three studies, and saves money in two
studies. We have all kinds of evidence that this is a very
effective treatment for people, especially who don't recognize
that they are sick.
There is no evidence of that at all in SAMHSA, and in fact,
SAMHSA has funded, as you have already heard today, programs,
in my count, 14 States protection and advocacy consumer groups
that have actively opposed the use of outpatient--assisted
outpatient treatment and other effective treatments, including
the States of many members of this committee on it.
Three, there is the issue of the unawareness of illness,
and we know now there is about 20 studies showing the people
who are not aware of their illness have differences in their
brain, those people with schizophrenia on it. We need to pay
attention to that. Instead, what they do is they find
Alternatives Conference, as you have heard. I will answer the
question from the Congressman of Tennessee. We estimate the
cost of a single Alternatives Conference is about $500,000, and
although SAMHSA appears to be feeling that they are short of
money, 2 weeks ago they funded and approved for funding the
conference for this year on it.
Another issue is the shortness of psychiatric beds. SAMHSA
doesn't pay any attention to that but does have an
international office and has an interest in psychiatric beds in
Iraq and held conferences in Cairo and Amman on that.
Severe mental illness in jails and prisons is about
400,000. This is not a priority for SAMHSA. SAMHSA instead is
concerned with putting out reading books, ``Wally Bear and
Friends,'' sticker books, et cetera.
Finally, last but not least, federal money to support
severe mental illnesses are among the fastest-growing items in
the federal budget, including federal funds for psychoses. That
was the most expensive of all the nine chronic diseases, three
times more expensive than the cost of diabetes on it. SAMHSA,
this is not a priority.
In 2010 I asked about several questions about, for example,
why do some States have three times more patients on severe
mental illnesses on SSI and SSDI? SAMHSA had no answers to any
of these questions and did not answer, and the reason why I
know they didn't have any is because they were very busy.
Number one, they were----
Mr. Murphy. The gentleman's time is expired. Can you wrap
up with a final moment? Are you ready to wrap up?
Dr. Torrey. Sorry.
Mr. Murphy. So your time expired. Can you wrap up with
whatever final statements you are going to make on this?
Dr. Torrey. Ten seconds of a video?
Mr. Murphy. Yes.
[Video shown.]
Dr. Torrey. This is what they were spending $80,000 on,
which is their annual songfest that they have in early December
on it. This cost about $80,000 and involved all the members and
was their attempt to bring attention to substance abuse. And my
argument is that people who have $109,000 as an average salary
don't need to be told that substance abuse is a big issue on
it.
Thank you very much. I just want to again emphasize how
important what you are doing is. And if Congress doesn't act at
this point, then we are going to have additional problems under
the next Clinton or the next Bush or the next Obama
Administration.
Mr. Murphy. Thank you.
Dr. Torrey. Thank you.
[The prepared statement of Dr. Torrey follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Dr. Satel, you are recognized for 5 minutes.
TESTIMONY OF SALLY SATEL
Dr. Satel. Thank you, Representatives Murphy, DeGette,
and----
Mr. Murphy. Microphone, and pull it close. Thank you. Press
the button so it is green.
Dr. Satel. Thank you for inviting me to be here today.
Mr. Murphy. It is not on yet. Do you have a green button?
It is lit up?
Dr. Satel. I apologize.
Mr. Murphy. Thank you.
Dr. Satel. Thank you for inviting me to be here today. I am
a resident scholar at the American Enterprise Institute, and as
a psychiatrist, I do some work at a local methadone clinic. And
from 2002 to 2006 I was a member of the National Advisory
Council of the Center for Mental Health Services.
My point today is that SAMHSA does not adequately serve the
sickest individuals despite its statutory mission to do so. To
start with, the Agency has adopted an idiosyncratic
interpretation of its very mission. I am referring to something
called the Recovery Model. The Recovery Model, according to
SAMHSA's definition as its guiding philosophy, is ``a process
of changes through which individuals improve their health and
wellness, live a self-directed life, and strive to reach their
full potential.'' Well, living a self-directed life and
reaching one's full potential is an excellent aspiration and I
try to accomplish that with my patients as well, so I am not
here to criticize the spirit of that model.
What I am here to do is to underscore how inappropriate it
is for the sickest patients. We are talking about individuals
here who are too psychotic to participate in their own self-
directed life, too paranoid, too terrorized by hallucinations,
too lost in delusional thoughts. Fifty percent of them, as Dr.
Torrey just alluded to, don't even recognize they have an
illness, and if they don't have insight into the problem, there
is no way they are going to be able to ``collaborate in
creating a detailed life plan,'' which is part of SAMHSA's
agenda for the mentally ill, or ``determined their own unique
path.''
They are the most vulnerable of CMHS's constituency. They
are the sickest silent minority who languish in back bedrooms
and jail cells and homeless shelters. And CMHS does not hear
from them. Instead, they hear from consumers, which is the
word--politically correct word for patient--consumers who are
able to be directed. They don't hear from the folks who are
most impaired, nor do they hear from their caregivers, the
clinicians who get their hands dirty in the trenches with these
most desperate patients, or even from some of those patients
themselves who, once they are improved, can acknowledge that
mainstream psychiatry has been helpful for them and medications
as well. They don't hear from them. They hear from consumer
survivors who claim to speak for all patients, but obviously
don't do that.
This imbalance has concerned me for years. When I was on
the Advisory Council from 2002 to 2006, we repeatedly were
trying to have some input into the decisions regarding the
grants that were approved but it was clear that we were pretty
much there to rubberstamp those grants. They had already been
approved. We asked repeatedly if we could see them prior to
approval or if we could review them after approval and then
have our assessment be reconsidered, and we were turned away
every time. My colleague--I mentioned a colleague--actually,
his name should appear in my testimony. It is Dr. Jeffrey
Geller, who is a professor at University of Massachusetts, but
he followed me or we overlapped a bit on the Council, and what
he told me was he and fellow members during those years just
gave up at attempts for meaningful input and left in disgust.
Finally, I will turn to the kinds of programs that serve as
a model for the kinds of programs that SAMHSA hopes, states
will enact. This is through--it is a national registry of
evidence-based programs and practices. And here, there is a
striking imbalance. What I mentioned in my testimony was of the
228 programs, four specifically mentioned severe mental illness
in their description. Now, that doesn't mean only four attend
to severe mental illness, but it is striking that even some of
the others who did not mention severe mental illness talked
about patients who were--I will give you one example here--
designed for patients motivated to manage their mental health
issues. Again, these are patients whose psychotic symptoms are
in check. They are not the most disturbed.
And what is also very striking about this registry of
programs is the fact that it pointedly omits AOT, assisted
outpatient treatment. As Dr. Torrey described what those are, I
won't go into it.
Briefly, a word about prevention. No, we cannot enact
primary prevention in the mentally ill, severely mentally ill.
We don't understand the brain mechanisms yet that cause it.
I will end with two recommendations. One would be really to
Administrator Hyde, which is to abandon the Recovery Model that
is the umbrella philosophy and take advice as well from
parents, clinicians, and the sickest but improved patients who
have something constructive to offer. Don't fund groups that
are anti-psychiatry in their agenda. It is like the CDC funding
activists who would tell people with HIV not to take their
antiretrovirals or not to have protected sex. And consider
directing the Secretary to commission an independent review of
the scientific soundness of the studies listed on that registry
about which ones are there and which ones are missing and
should be included.
Thank you very much for your time.
[The prepared statement of Dr. Satel follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Dr. Satel.
Dr. Parks, you are recognized for 5 minutes.
TESTIMONY OF JOSEPH PARKS
Dr. Parks. Good morning. I am Joseph Parks. I want to thank
the chairman and Congresswoman DeGette for the opportunity to
testify today. I am testifying today in my individual capacity
and not on behalf of any organization.
I am a board-certified psychiatrist with specialty training
in emergency psychiatry. I have served as the medical director
for the Missouri Department of Mental Health for 20 years. For
3 years, I was the director of its overall mental health
operation. Throughout my career, I have continued to see
patients and I still see patients on a weekly basis. I have
provided psychiatric service to harmlessly mentally ill persons
in shelters and through assertive community treatment teams.
For the past 12 years I have been the president of the
Medical Director Council of the National Association of State
Mental Health Program Directors, and for the past 3 years, I
have served as director of the Missouri Institute of Mental
Health and professor at the University of Missouri St. Louis.
Through my various roles, I am very familiar with the
SAMHSA Mental Health Block Grant and the Discretionary Grant
programs. These programs are an important contribution to
improving the lives of people with serious mental illness. I
have been a principal investigator for SAMHSA Discretionary
Grants, I have independently evaluated grants through my role
at MIMH, and as Missouri Mental Health Division director, I was
responsible for the execution of the block grant plan.
Although the amounts are modest and inadequate to meet the
overall needs, the SAMHSA Mental Health Block Grant plays an
important role in funding services for uninsured persons and
services that are not payable through Medicaid, particularly in
young adults who are not usually insured when they first become
ill. Block grant funding has been especially critical to keep
in place the full range of activities and services that a
comprehensive state mental health system wants to have,
including early identification and early intervention.
I specifically want to mention to the Committee that SAMHSA
requires us when using the block grant if we are funding
individual activities to spend them on persons with serious
mental illness or children with SED. That is a requirement of
how we use those funds.
Now, SAMHSA discretionary grants play an important role in
implementing new evidence-based practices and improving the
quality of care to people with serious mental illness. A good
example is SAMHSA's Co-Occurring State Incentive Grants--they
were called COSIG--which helped us improve the ability of
community mental health centers and substance abuse treatment
agencies to promptly and effectively serve people who have both
mental illness and substance abuse conditions simultaneously.
This is particularly important with respect to reducing
violence by people with serious mental illness. The
discretionary grants also fund technical assistance. In
Missouri we got technical assistance to reduce the use of
seclusion and restraint in our state hospitals, which reduced
both patient and staff injuries.
Before I turn to policy recommendations, I would like to
acknowledge in light of Oklahoma's tornadoes that SAMHSA gave
significant support when we had tornadoes in Joplin in 2011 in
Representative Long's district. They were instrumental in us
getting care out to those people rapidly.
I want to make the following recommendations for improving
treatment for people with serious mental illness and reducing
violence: first, there is a growing shortage of psychiatrists.
We need a national approach to increase the psychiatric
workforce. Demand for psychiatric services is far outstripping
the ability of the available workforce to supply timely needed
care. Aging psychiatrists are retiring out faster than new
graduates are taking their place. The current estimated gap by
the EPA is about 45,000 psychiatrists short. Patients are not
being seen for months and clinic and hospital psychiatric units
are closing because they can't get the staff. There needs to be
attention here.
Second, I would like to make recommendation for two
specific discretionary grant directions. There should be grants
available to implement mental health first aid training. This
is an early identification, early intervention for mental
illness that is a training with the general public similar to
regular first aid. It is a national--it is being implemented
nationally but it needs more support to roll it out to get
people engaged before they become suicidal or violent.
Third, there needs to be a new round of the COSIG grants.
Substance abuse increases the likelihood that somebody will be
mentally ill significantly. Over half of people with mental
illness have substance abuse problems. We need new grants in
this area.
Regarding mandatory treatment, I would actually recommend
greater support for mental health courts. I have been involved
in providing mandatory treatment through different legal
modalities, including inpatient and outpatient civil
commitment, guardianship in mental health courts in three
different States. In all three States the outpatient--had
outpatient commitment laws and in all three States they were
difficult to implement and used rarely primarily because local
law enforcement doesn't have the resources and doesn't want to
use their officers to follow up on people that are violating
the commitment orders. Also, it is--mental health courts are
more agreeable--are more acceptable to the courts, to law
enforcement, and to the people with mental illness. I think
they would be the best strategy.
Finally, to end my comments, there is an epidemic of
premature death among people with serious mental illness.
Research shows that people in the public mental health system,
most of whom are seriously mentally ill, die an average of 25
years younger--in their mid-50s--than the general population.
This is shorter than the life expectancy of someone with HIV
and on a pier with sub-Saharan Africa. It is an unaddressed
national tragedy.
People with serious mental illness should be federally
designated as a health disparities population and their rates
and causes of death should be monitored annually. HHS and
SAMHSA should develop a national strategy that Congress should
fund specifically for reducing these premature deaths, most of
which are due to chronic medical conditions due to poor care.
We need to promote the integration of behavioral health and
general medical care and promote integrated preventive measures
on both the healthcare side and the mental health side. Nobody
recovers from their mental illness once they are dead of a
heart attack, and that is what is killing our people with
serious mental illness.
Thank you for the opportunity to present my views on these
critical issues. I would be happy to assist the Committee in my
various roles to help you implement solutions and address the
needs of people with mental illness. This deserves national
attention and leadership at all levels. It is greatly
appreciated you holding this hearing.
[The prepared statement of Dr. Parks follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you. I just recognize myself for 5
minutes.
Dr. Parks, you are opposed to assisted outpatient
treatment; you say so in your written and oral testimony? Yes
or no?
Dr. Parks. I think--no, I don't think I can make a yes/no
answer. What I am advising the Committee of is if you wish to
increase access using mandatory methods, I think you will be
more successful and get better implementation if you focus on
mental health courts.
Mr. Murphy. I understand, but with regard to getting
treatment, courts don't provide treatment. Assisted outpatient
treatment is an alternative that has been--we have heard
testimony, read things that have been fought by some of these
advocacy groups funded by SAMHSA.
Dr. Torrey, do you think assisted outpatient treatment,
mandatory assisted outpatient treatment has a value and is
there evidence to prove that?
Dr. Torrey. Obviously, assisted outpatient treatment is a
proven entity at this point. Mental health courts are also good
but it is important to recognize that mental health courts are
merely being used because of the failure of the mental health
treatment system as such. The other problem with mental health
courts is you can't get treatment until you have broken a law,
so if I said to you today we have a very good treatment for
people with diabetes or hypertension but you have to break a
law to get it, you would probably say that I deserve some
treatment.
This is the problem of where we are now that we don't have
any real treatment system out there and we are having to use
the mental health courts. That is a sign of the failure of the
system, not the good part of the system. But they work.
Mr. Murphy. And Mr. Bruce, in your testimony, do you
believe that if your son had been court-ordered to receive
other treatment, inpatient or outpatient, that an outcome could
have been different for him?
Mr. Bruce. There is no question about it. He----
Mr. Murphy. It is on. Just pull it closer. It was on. There
you go. Now, it is off. The green light needs to be on. There
should be a green light on there. Thank you.
Mr. Bruce. My son responded to medication immediately. The
testimony of Dr. Schottky at--a forensic psychiatrist who
evaluated him for his trial talked about the difference between
Will before--when she met him the first time unmedicated and
then when she spoke to him again later after he had started
taking Seroquel, and I knew immediately that he was on
medication because he called me for the first time in 4 months
or so and he was in tears and he said, Dad, I am sick.
And he is--Seroquel was not the right medication for him.
He later began taking Abilify. But I take Will out to lunch in
Augustine, Maine. We go shopping together. He--if you were to
talk to him now, you wouldn't--there is no sign of delusions.
He is able to plan and think. He has problems because of the
length of time that he remained psychotic, but he is--if he had
been on medication in 2006 and had been released from the
hospital on a court order that said he had to remain on his
treatment plan, that would have given him an opportunity for
the medication to work and with the supporting treatment that
is necessary in these kind of programs, I think that he would
be living in a community somewhere probably with a job, and
life would be a lot different for the Bruce family.
Mr. Murphy. Thank you. Real quickly from each of the
doctors I want to ask you a question. In the SAMHSA
administrator's testimony she talked about the 5,000 additional
mental health professionals also requested by the President,
and listed in there to train social workers, counselors,
psychologists, behavioral health professionals, marriage and
family therapists, nurses, and other mental health
professionals. Dr. Torrey, yes or no, do you think this should
also include psychiatrists?
Dr. Torrey. Absolutely. I worked at the National Institute
of Mental Health for many years. I can't conceive of a
federally administered program for people with mental illnesses
that does not include psychiatric input on it.
Mr. Murphy. Dr. Satel, do you think funding should also
increase to get more psychiatrists?
Dr. Satel. Of course.
Mr. Murphy. And Dr. Parks, you already said so?
Dr. Parks. The shortage is more severe for psychiatrists
than the other categories.
Mr. Murphy. Particularly child psychiatrists, I believe.
Dr. Parks. Particularly child psychiatrists, horrible
shortage.
Mr. Murphy. I would just like to conclude with one other
comment. When it comes to court-ordered inpatient or outpatient
treatment, it is extremely important to note that unless a
legal procedure takes place for inpatient or outpatient
treatment by a court proceeding, that person's name does not go
on the National Instant Background Check. Quite frankly, we
don't know how many people should be on that list and the NICS
list is what is used to determine if someone should be
permitted to buy a gun. And while people are advocating whether
or not we should expand registration, my concern is that we may
not be putting people on that list who are at risk of abusing a
weapon for an attack.
I yield now to Ms. DeGette for 5 minutes.
Ms. DeGette. Thank you, Mr. Chairman.
And Mr. Bruce, your experience is heartbreaking and as a
mom, you know, I want to give my deepest condolences to you and
all the issues that you continue to work through to this day.
And I also want to say I think this assisted outpatient
treatment should be a tool that psychiatrists and mental
institutions are allowed to have. Forty-four States allow that
right now.
And, Dr. Parks, maybe you can answer this. I think that in
the block grants that SAMHSA gives to the States, they would be
able to use that money for the assisted outpatient treatment if
they decide to do that, correct?
Dr. Parks. That is correct.
Ms. DeGette. Thank you.
Dr. Parks. And to answer the chairman's question, I do not
oppose assisted outpatient treatment----
Ms. DeGette. You don't oppose it either but----
Dr. Parks. It is difficult.
Ms. DeGette. So in my previous life before I came to
Congress I was a practicing lawyer, and I think everybody kind
of alluded to this, including you, Mr. Bruce, which is if you
are going to get in order for assisted outpatient treatment,
that is going to have to be in order that is given by somebody.
And I think maybe, Dr. Parks, that is what you are talking
about when you talk about these mental health courts. Is that
part of it?
Dr. Parks. Assisted outpatient treatment is a civil court
order and a mental health court is a criminal court order.
Ms. DeGette. OK. So this would be a----
Dr. Parks. But either is a court order in either case.
Ms. DeGette. OK. But it is a court order. And so one thing
I think--and this goes to our whole discussion we are having
today--is that we have just woefully underfunded our entire
mental health system in this country because if you are going
to do a court order, which is appropriate in many cases, then
you have to have the resources to enforce that.
And I have constituents coming in with very similar
stories, Mr. Bruce, to yours. And, you know, one of the things
we have learned in these hearings that we have been doing is
that schizophrenia tends to manifest itself in young men
between the ages of 19 and 25. So that is just the age that
these young men are going off on their own. They are in college
or whatever and they are above 18. And so, you know, the care
providers of the colleges are not required to tell the parents.
So this is the kind of tragedy we are hearing about and we
don't have enough resources in our mental health system to
target people like that and to help them.
Dr. Parks, you are nodding your head. Do you want to----
Dr. Parks. Usually when I go to court to get either a civil
order or to get a criminal condition of probation, it takes
half a day. That means that there is 12 to 16 people I did not
see in clinic because I was taking the time in court.
Psychiatrists' time gets shorter and shorter and this is a
choice agencies face. You know, I only have three----
Ms. DeGette. Right.
Dr. Parks [continuing]. Psychiatrists. Do I do some more
assisted outpatient treatment and tie up their time in
testimony or do I try and just stay away from that?
Ms. DeGette. And there are not enough resources to process
those cases and there is not enough resources to treat the
patients. I had a lady in Denver who said to me that her son,
he became psychotic. He was committed. Then, he was on a 72-
hour hold. He was released and then he came home and he said,
Mom, I think I am going to kill you or myself. And she couldn't
get him the help he needed. And everybody has stories like
this.
I just want to ask you a couple of questions, Dr. Parks,
about the SAMHSA block grant program because a lot of people
have been saying that a lot of SAMHSA's funding is not reaching
people living with serious mental illness issues, and frankly,
that is Congress' fault because of the way we budget it. But
for the money that is used for mental illness as opposed to
drug abuse, you have seen on the ground in Missouri funding
from the SAMHSA Mental Health Block Grant. How much does
Missouri get every year in that block grant?
Dr. Parks. For the block grant we get approximately $7.5
million, a very moderate----
Ms. DeGette. And what percentage of the 7 \1/2\ million
that Missouri gets is used to treat people that don't have
health insurance?
Dr. Parks. About 65 percent goes to people that are
uninsured.
Ms. DeGette. So if they didn't have that money from that
block grant for mental health treatment, where would they be
able to get mental health treatment dollars for your State?
Dr. Parks. Where people usually go, the emergency room.
Ms. DeGette. OK. And how much of SAMHSA's Mental Health
Block Grant is used to treat patients diagnosed with a serious
mental illness?
Dr. Parks. Essentially all of it. There is a small amount
used for suicide prevention that was approved and there is
about 4.5 percent we are allowed to spend on administrative
overhead, much lower than the 20 percent administrative
overhead that commercial insurance is allowed.
Ms. DeGette. So most of it is for serious mental illness?
OK. Thank you very much, Mr. Chairman.
Mr. Murphy. Thank you. I now recognize the gentleman from
Texas, Mr. Olson, for 5 minutes.
Mr. Olson. I thank the chair and welcome to our witnesses.
A very special warm welcome to you, Mr. Bruce. I have seen a
tragedy similar to yours. Two weeks before Christmas in 2003 a
family of four from my church came home from dinner. A mass
gunman was waiting for them. The wife was killed, the younger
son was killed, the husband was severely wounded, and the
oldest son was shot in the arm. The investigation took a course
no one saw coming. Because of an irrational hate, the oldest
son had hired a hitman to kill his family.
I know your situation is different from that situation, but
having talked to the father, I know the courage it takes to
come here and testify. So I thank you for your courage and your
strength to be here today. You will be in my family's thoughts
and prayers.
My question is for Mr. Torrey. Mr. Torrey, your first
witness, you mentioned your 2010 request to SAMHSA for
information, data on why federal costs in mental illness were
increasing so rapidly and their response that there was no
data. Have you received any information to your knowledge that
SAMHSA has begun collecting this type of data? For example, in
your testimony you said what if some States have more than
three times more mentally ill individuals per population on
SSI, supplemental security income, or on Social Security
disability insurance than our States do? What is the percentage
of mentally ill individuals on SSI, SSDI who are not receiving
treatment? What is the percentage of Americans with serious
mental illnesses who are receiving SSI and/or SSDI? And the
answer you got? We have no data. Is that true?
Dr. Torrey. Yes, it is.
Mr. Olson. There is no data?
Dr. Torrey. Yes, that is absolutely correct. And it is
important to realize that we have $140 billion in the mental
health treatment system right now. Everyone says we need more
money. In fact, we have 12 times more, corrected for
population, than we had 60 years ago. I am one of the few
people in Washington who probably says we don't need more
money; what we need to do is spend the money the way we should
be spending it and focus on the seriously mentally ill. Then,
we would have a system that worked.
Mr. Olson. Can you identify any federal barriers as to why
they are not collecting this data?
Dr. Torrey. I would say they are not collecting the data
because they have no interest in these questions. And one of
the things you will learn early in government is you don't ask
questions that you don't want the answers to.
Mr. Olson. This question is one for you again, Dr. Torrey,
and Dr. Satel, if you would please answer this question as
well. How can SAMHSA maximize their resources for those with
severe mental illnesses? Just blanket. I mean how can they do
this because they are missing the target completely? How can
they maximize the resources right here, right now, today? Dr.
Torrey?
Dr. Torrey. Well, there is a whole series of things they
could do. First of all, you could look at the rate that Ms.
Hyde talked about. Seventy percent goes to substance abuse,
thirty percent to seriously mentally ill. I don't know why that
ratio is as it is. It certainly should be at least 50/50 on it.
Secondly, you can specify that SAMHSA must focus its resources
on severe mental illness and report back on a regular basis.
Third, I think a GAO investigation of the discretionary grants,
things like the P and A program and other things is way
overdue.
I have looked at a few of these grants under Freedom of
Information. They really look like they need some light of day
looking at them, and I think that is one of the important
things the Committee could do.
Mr. Olson. Thank you, Dr. Torrey. Dr. Satel?
Dr. Satel. Yes. I would like to mention, though, that when
we are all saying severe mental illness as a large category,
and, yes, it typically refers to bipolar, schizophrenia, the
chronic psychoses, but what we are specifically talking about
is the subset of the severely mentally ill who are so psychotic
that they don't know they are ill and can't cooperate. So even
if a program says it is dedicated for the severely mentally
ill, that doesn't really answer the whole question. It has to
also respond to those who are so sick and so debilitated that
they cannot cooperate with that program. That is an important
difference.
But the more direct answer to your question, what I worry
about in addition to what Dr. Torrey said is the active
sabotage of the best interests of the mentally ill that SAMHSA
underwrites. And again, the PAIMI, maybe if you kept the
protection, I know they do some good things. I know there is
certainly abuse in these institutions and someone needs to be a
watchdog. The advocacy element has become very, very
destructive.
Also, even though there is not much money, as Administrator
Hyde had mentioned that may go to Alternatives Conferences or
consumer survivor groups, that money is leveraged so
efficiently, these folks go out and they lobby state
legislatures and they interfere with the passage of these AOT
laws. I mean they are very efficient. So even if it is a small
amount of money, it can have a much broader effect than many
might expect.
Mr. Olson. Thank you, ma'am. I am out of time. I will
remember the term ``active sabotage.'' Thank you.
Mr. Murphy. Thank you. I now recognize Mr. Griffith from
Virginia for 5 minutes.
Mr. Griffith. Thank you, Mr. Chairman. I appreciate all of
you being here with your testimony and everything that you all
have said. Great concerns about where we are spending our money
and if we are spending it in the right places. I appreciate
that, Dr. Torrey.
I will tell you that the court system is very concerned
about this. I spent 27 years before I came to Congress 2 \1/2\
years ago as a street lawyer as a lot of folks would say, dealt
with families that were dealing with these issues, dealt with
clients who were dealing with these issues. It is seen on a
regular basis in every court across this country.
And I will do a little shout-out for my hometown. They
don't call it a mental health court because that isn't
authorized at this point, but one of our judges has set up a
therapeutic docket specifically because we had sufficient
numbers even in our area of people who are in the criminal
court system who need help. And it may not be that they are
completely out of touch like that subset you are talking about,
Dr. Satel, the severe mental illness, but they have got
significant issues that the court needs to make sure somebody
is dealing with it. If our mental health system isn't going to
do it, the court system has got to try to figure out how to do
it in a just manner. And so I commend Judge Talevi for setting
that up.
Mr. Bruce, in those regards, I would ask you what your
son's condition was like before April 2006 and specifically if
you could tell me, prior to killing his mother, had he had any
contact with the criminal justice system?
Mr. Bruce [continuing]. With the criminal justice system,
but he had been brought to a hospital for evaluation in 2005
after pointing a loaded weapon at two people and coming within
a hair of killing both of them. He was in a state of deep
psychosis. At that time they decided not to send him to a
commitment hearing after he had been on some Thorazine and a
little bit of lithium and had calmed down because they said
that he felt that he didn't meet the standard for involuntary
commitment.
Mr. Griffith. Who said that?
Mr. Bruce. My wife and I waited in the psychiatrist's
office for this commitment hearing to start. She got a call,
said that was the hospital's lawyer and he felt that they
didn't have a case so they weren't sending him to the
commitment hearing. And I said what do you mean, no case? And
she said, well, the standard is imminent danger, which actually
is not the standard in Maine. It poses a likelihood of serious
harm. But anyway, this is what happens when mental health
people are forced to interpret law. I said, well, a couple
weeks ago he almost killed two people. And she said, well, that
was then and this is now. And I said, well, but you told me
that in all likelihood the minute he leaves the hospital he is
going to stop taking these medications which you yourself said
are not even adequate for his disease. She said, how could I go
before a judge and truthfully say that he was in imminent
danger? Just look at him. I mean he was calm. He wasn't
threatening anybody.
Mr. Griffith. Well, what a tragedy and I am sorry for all
the pain and the loss of your wife that you have had to go
through over this.
Mr. Bruce. Thank you.
Mr. Griffith. Do you think at that time he was able to make
decisions for himself that were rational?
Mr. Bruce. No. No.
Mr. Griffith. And you did obtain the guardianship in
February 2007 and he was, I believe you said, found not guilty
by reason of insanity, is that correct----
Mr. Bruce. Yes, sir.
Mr. Griffith [continuing]. At the time of the offense?
Mr. Bruce. Yes.
Mr. Griffith. OK. Well, I hope that we can find some
answers and I appreciate all of you all testifying today.
I do think it is important that we have input at the court
level because us street lawyers see a lot of mental illness in
a lot of our clients and the family members know what is going
on, so they need to be involved. And I have had many cases
where the families kept folks from doing things that they might
otherwise have done that could have caused problems. So I do
appreciate it and appreciate all of your testimony today. Thank
you.
I yield back, Mr. Chairman.
Mr. Murphy. Thank you. The gentleman's time is expired. I
now recognize that Dr. Cassidy of Louisiana for 5 minutes.
Mr. Cassidy. Dr. Parks, for the record, obviously one of my
concerns--I am a doc, too, not a psychiatrist--but one of my
concerns is that some of the SAMHSA money is going for folks
who advocate doing without medications. And yet I have read
from your testimony it seems as if you would reject that. You
firmly seem to believe that medications have a role in the
treatment of serious mental illness.
Dr. Parks. Absolutely. That is correct, Representative.
Mr. Cassidy. Yes. I am told that you are a primary
investigator or a principal investigator on a number of SAMHSA-
type studies?
Dr. Parks. That is correct.
Mr. Cassidy. May I ask what type of studies just quickly?
Dr. Parks. The two that I am currently principal
investigator on, one is suicide prevention on the mental health
side. This has been a 10-year series of grants, many of them
are direct congressional funding. They said spend this on
suicide prevention, particularly with youth, the Garrett Smith
Act.
The second one is out of the CSA, the substance abuse side.
And that is for a brief--that is for screening for excessive
drinking and risky drug use with brief interventions following
an assessment. It is a primary care intervention.
Mr. Cassidy. I have just limited time so I get the----
Dr. Parks. Sorry.
Mr. Cassidy. Do you feel as if your participation in those
grants presents a conflict of interest in your testimony today?
Just asking.
Dr. Parks. I agree it could have the appearance of that. I
am here as an expert.
Mr. Cassidy. I accept that. I mean I can make do. Do you
agree with Dr. Satel and Dr. Satel's statement that it is not
the actual severe, severe mental illness; it is the people with
severe mental illness which is beyond the current reach of
society that seems to be ignored by the funding priorities of
SAMHSA?
Dr. Parks. No, I would not agree by that. That is who we
are spending the block grant money on and that is certainly who
we were treating with the COSIG grants that have now ended.
These are the grants that serve people that have substance
abuse problems and serious mental illness, greatly increasing
their risk of violence. So I would not agree.
Mr. Cassidy. Dr. Satel, how would you----
Dr. Satel. Yes, I would say that I have no question that
Dr. Parks is treating people who have the diagnosis of
schizophrenia and bipolar, and correctly so, but that they are
not in that active phase where they are, again, so profoundly
ill that they cannot even cooperate with your care.
So--but that is the point I am making, again,
distinguishing between--the question isn't does SAMHSA have
programs that serve people with these illnesses; it is, do they
serve them also in the most debilitated phase of that
condition?
Mr. Cassidy. So I gather it was your testimony or Dr.
Torrey's regarding now the efforts seem to be those patients
who actually can participate in their care but the issue is how
do we reach those who cannot participate in their care?
Dr. Satel. Yes, exactly.
Mr. Cassidy. OK. I got that. And you stand by your
statement--you heard me quote your testimony earlier speaking
to Administrator Hyde that there is a--I forget your term, but
there is a relative imbalance in terms of the compendium of
care?
Dr. Satel. Oh, I definitely stand by that. I did clarify it
when you, I think, were out of the room that I mentioned that
there were only four studies that explicitly mentioned severe
mental illness in their description, but, as you also alluded
to, that there were more programs that probably did--or
definitely did attend to them. But again, we are back to that
distinction between those who can cooperate and those who
can't.
Mr. Cassidy. So, Dr. Parks, I respect that you are
frontline. I mean I have worked in a safety net hospital so I
always figure frontline folks have a little bit of street cred.
My impression, though, is that SAMHSA has somewhat lack of
focus. You heard my questioning of the administrator. Would you
disagree with that or do you feel like everything is working
great, no problem, or would you accept what Dr. Torrey says,
what in the heck are we spending $20,000 on an oil painting
for?
Dr. Parks. I have not yet found a governmental agency that
couldn't improve its performance.
Mr. Cassidy. Were you at Charity, by the way, Charity
Hospital?
Dr. Parks. I was at a daughter of Charity.
Mr. Cassidy. OK.
Dr. Parks. I am a Charity alum.
Mr. Cassidy. Yes.
Dr. Parks. That is where I did my internship----
Mr. Cassidy. Yes.
Dr. Parks [continuing]. Wonderful experience. I think the
major problem we have with SAMHSA is they are funding short.
They cannot fund all their priorities adequately. In terms of
the $20,000 painting, I can't support having funded that. That
is $20,000 is very small dollars in the big picture of things.
It is not an excuse to waste it but I think the proper policy
focuses on the big picture dollars.
Mr. Cassidy. And Dr. Torrey, I am sorry, I was out of the
room with other responsibilities but is there anything that you
would--you heard Administrator Hyde kind of contradict some of
your assertions. Just now that I am back in the room, is there
anything you would say to me as regards to her testimony?
Dr. Torrey. Yes, can you repeat that, Dr. Cassidy?
Mr. Cassidy. Yes, her response to my questions in which I
suggested that there was a lack of focus, she seemed to feel as
if there is not. I take it you stand by your assertions that
that indeed there is a lack of focus and even a frivolity as to
some of their spending?
Dr. Torrey. Yes, it is not that there is no worthwhile
programs. In SAMHSA there are some worthwhile programs but they
are relatively few and far between. And I certainly stand by my
statement that not only is severe mental illness not a
priority; it is almost nonexistent.
Mr. Cassidy. OK. I yield back. Thank you.
Mr. Murphy. I thank the gentleman.
And I want to thank all the panelists today and all the
members, both sides of the aisle. It is clear we are all
dedicated to coming up with some answers, a solution.
Unfortunately, it was pointed out this may not have the
publicity of the IRS hearings or Benghazi, but given that 20
percent of people have diagnosable mental illnesses in any
given year and 38,000 people commit suicide I think last year,
750,000 suicide attempts, we all are very concerned. And I
appreciate the dedication of all the members of this committee
in trying to find some answers.
I also want to restate my commitment and everyone's
commitment to science-based evidence for real solutions. Good
intentions do not guarantee good results, and as we move
forward to come up with some solutions, I am pretty sure I
speak for both sides of the aisle when I say that is what we
are going to be looking for, good, effective results will do
this.
Again, I thank everybody and I want to then mention that in
conclusion I remind members they have 10 business days to
submit questions for the record. I ask the witnesses to please
respond promptly to any of the questions. Again, Mr. Bruce, our
prayers and our thoughts are with you and your family and I
thank all the other panelists for this very important hearing
today
And with that, I adjourn.
[Whereupon, at 1:10 p.m., the subcommittee was adjourned.]
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