[Senate Hearing 113-281]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 113-281
 
         ASSESSING THE STATE OF AMERICA'S MENTAL HEALTH SYSTEM 

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

                                HEARING

                               BEFORE THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                                   ON

         EXAMINING THE STATE OF AMERICA'S MENTAL HEALTH SYSTEM

                               __________

                            JANUARY 24, 2013

                               __________

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

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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                       TOM HARKIN, Iowa, Chairman
BARBARA A. MIKULSKI, Maryland              LAMAR ALEXANDER, Tennessee
PATTY MURRAY, Washington                   MICHAEL B. ENZI, Wyoming
BERNARD SANDERS (I), Vermont               RICHARD BURR, North Carolina
ROBERT P. CASEY, JR., Pennsylvania         JOHNNY ISAKSON, Georgia
KAY R. HAGAN, North Carolina               RAND PAUL, Kentucky
AL FRANKEN, Minnesota                      ORRIN G. HATCH, Utah
MICHAEL F. BENNET, Colorado                PAT ROBERTS, Kansas
SHELDON WHITEHOUSE, Rhode Island           LISA MURKOWSKI, Alaska
TAMMY BALDWIN, Wisconsin                   MARK KIRK, Illinois
CHRISTOPHER S. MURPHY, Connecticut         TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts
                                       
             Pamela J. Smith, Staff Director, Chief Counsel
                 Lauren McFerran, Deputy Staff Director
               David P. Cleary, Republican Staff Director

                                  (ii)


                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                       THURSDAY, JANUARY 24, 2013

                                                                   Page

                           Committee Members

Harkin, Hon. Tom, Chairman, Committee on Health, Education, 
  Labor, and Pensions, opening statement.........................     1
Alexander, Hon. Lamar, a U.S. Senator from the State of 
  Tennessee, opening statement...................................     3
Murray, Hon. Patty, a U.S. Senator from the State of Washington..    21
Enzi, Hon. Michael B., a U.S. Senator from the State of Wyoming..    23
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin..    25
Murkowski, Hon. Lisa, a U.S. Senator from the State of Alaska....    26
Franken, Hon. Al, a U.S. Senator from the State of Minnesota.....    28
Mikulski, Hon. Barbara A., a U.S. Senator from the State of 
  Maryland.......................................................    30
Sanders, Hon. Bernard, a U.S. Senator from the State of Vermont..    31
Warren, Hon. Elizabeth, a U.S. Senator from the State of 
  Massachusetts..................................................    33
Bennet, Hon. Michael F., a U.S. Senator from the State of 
  Colorado.......................................................    35

                           Witnesses--Panel I

Hyde, Pamela, J.D., Administrator, Substance Abuse and Mental 
  Health Services Administration, Rockville, MD..................     5
    Prepared statement...........................................     7
Insel, Thomas, M.D., Director, National Institute of Mental 
  Health at the National Institutes of Health, Bethesda, MD......    13
    Prepared statement...........................................    15

                          Witnesses--Panel II

Hogan, Michael, Ph.D., Former Commissioner, New York State Office 
  of Mental Health, and Chairman, President's New Freedom 
  Commission on Mental Health, Delmar, NY........................    37
    Prepared statement...........................................    38
Vero, Robert N., Ed.D., Chief Executive Officer, Centerstone of 
  Tennessee, Nashville, TN.......................................    44
    Prepared statement...........................................    46
DelGrosso, George, M.A., Executive Director, Colorado Behavioral 
  Health Council, Denver, CO.....................................    52
    Prepared statement...........................................    54
Fricks, Larry, Senior Consultant, National Council for Behavioral 
  Health, Cleveland, GA..........................................    55
    Prepared statement...........................................    57

                                 (iii)

  

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Senator Casey................................................    72
    Response by Pamela Hyde, J.D. to questions of:
        Senator Alexander........................................    72
        Senator Mikulski.........................................    75
        Senator Murray...........................................    77
        Senator Casey............................................    78
        Senator Bennet...........................................    79
        Senator Enzi.............................................    80
    Response by Thomas Insel, M.D. to questions of:
        Senator Alexander........................................    81
        Senator Mikulski.........................................    82
        Senator Casey............................................    83
        Senator Enzi.............................................    84
    Response by Michael Hogan, Ph.D. to questions of:
        Senator Alexander........................................    85
        Senator Mikulski.........................................    85
        Senator Casey............................................    86
        Senator Enzi.............................................    86
    Response by Robert N. Vero, Ed.D. to questions of:
        Senator Alexander........................................    87
        Senator Mikulski.........................................    89
        Senator Casey............................................    90
        Senator Enzi.............................................    92
    Response by George DelGrosso to questions of:
        Senator Alexander........................................    95
        Senator Casey............................................    96
        Senator Enzi.............................................    96
    Response by Larry Fricks to questions of:
        Senator Alexander........................................    98
        Senator Mikulski.........................................    98
        Senator Casey............................................    98
        Senator Enzi.............................................    99



  


         ASSESSING THE STATE OF AMERICA'S MENTAL HEALTH SYSTEM

                              ----------                              


                       THURSDAY, JANUARY 24, 2013

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:02 a.m., in 
Room SD-430, Dirksen Senate Office Building, Hon. Tom Harkin, 
chairman of the committee, presiding.
    Present: Senators Harkin, Mikulski, Murray, Sanders, 
Franken, Bennet, Whitehouse, Baldwin, Murphy, Warren, 
Alexander, Enzi, and Murkowski.

                  Opening Statement of Senator Harkin

    The Chairman. The Senate Committee on Health, Education, 
Labor, and Pensions will please come to order.
    My first order of business this morning is to extend a warm 
welcome to our committee's new members, in alphabetical order, 
Senator Tammy Baldwin, Senator Chris Murphy, Senator Tim Scott, 
and Senator Elizabeth Warren. This is a remarkably talented 
group of freshmen Senators, and we're glad to have them on 
board. I know that some are also over at Senator Kerry's 
hearing to be Secretary of State starting at the same time.
    I also want to salute our new Ranking Member, Senator 
Alexander. He has long been a valuable member of this 
committee. I have appreciated my relationship with the former 
Ranking Member, Senator Enzi, and I look forward to the same 
kind of close collaboration and partnership with my good 
friend, Senator Lamar Alexander.
    Today our committee will examine a range of issues 
surrounding mental healthcare in this country. The tragic 
shooting in Newtown, CT, last month brought the issue of mental 
healthcare to the forefront of public dialog. Many people 
across the Nation, including the President, have said that we 
need to take a long, hard look at access to mental health 
services across the country.
    I am pleased to have this opportunity today to start that 
dialog with my colleagues and our panel of expert witnesses. I 
am told this is the first hearing that this committee of 
jurisdiction has had on this issue since 2007. So it's long 
overdue.
    Certainly, one of the most insidious stereotypes about 
people with mental illness is that they are inherently violent. 
I regret that some of the discussion in the wake of the Newtown 
tragedy has sadly reinforced this stereotype. As my fellow 
committee members know and our witnesses and experts know, 
people with mental illness are much more likely to be the 
victims of violent crimes than they are to be perpetrators of 
acts of violence.
    Mental health conditions are sometimes called the Nation's 
silent epidemic. Mental illness affects one in four Americans 
every year. But, despite its prevalence, there is still a 
stigma attached with mental illness, and that stigma results in 
too many people suffering in silence without access to the care 
that could significantly improve their lives.
    Stigma also can stop workers from requesting and getting 
accommodations that can help them be more productive at work. 
I've known so many instances of people who were afraid to do 
anything because they might lose their job or they wouldn't get 
promoted because of that stigma that's attached.
    Like many other chronic diseases, mental health problems 
often begin at a young age. Experts tell us that half of all 
mental illness is manifested by age 14. However, less than half 
of children with an identified mental health condition receive 
treatment. And the average lag time from the first onset of 
symptoms to receiving treatment is almost a decade. 
Unfortunately, the picture for adults seeking treatment is not 
much better.
    This lack of treatment has huge consequences. Some 30,000 
Americans die by suicide each year. And it's a shocking fact 
that people with serious mental illnesses die significantly 
earlier than Americans overall, often from treatable causes 
like diabetes and smoking related chronic conditions.
    These consequences also spill into other areas. As any 
teacher or school counselor will tell you, a child who is 
struggling with depression, anxiety, or any other mental health 
condition is also likely to struggle academically.
    It's also an issue for our justice system since our prisons 
too often become the dumping ground for people who should be 
receiving mental health and substance abuse counseling instead. 
I have had a number of sheriffs in my own State, as well as 
other States, tell me that their jails are now the de facto 
mental institutions in their States.
    The shame in this is that with access to the right 
treatments and supports, most people with mental illness can 
recover and lead productive and healthy lives. But we need to 
make the critical investments that will enable this to happen. 
So wearing my other hat as the chairman of the Labor, Health 
and Human Services, and Education Appropriations Subcommittee, 
I plan to take a close look at funding opportunities in this 
area through the appropriations process.
    We've made important steps forward in recent years. My 
friend, the late Senator Paul Wellstone, and, again, along with 
my friend, Senator Pete Domenici, fought for years to try to 
enact the Mental Health Parity Act to end the absurd practice 
of treating mental and physical illnesses as two different 
things under health insurance. We finally passed it in 2008.
    However, I am sad to say that it has been 4 years, 4 years 
now, that we do not have any final rules on implementing this 
law. That's a shame. I am told the President said that they 
will be announcing a final rule soon. I don't know what soon 
means, but I hope it means what we generally take it to mean, 
which means soon.
    Another critical step will take place next year when, 
thanks to the Affordable Care Act, some 30 million Americans 
will become eligible for Medicaid or private insurance through 
the healthcare exchanges. Coverage of mental health and 
substance abuse disorder services is 1 of the 10 essential 
benefits required in qualified health plans.
    The insurance expansion here offers both challenges and 
opportunities. Experts predict that the newly insured 
population will have a greater need for mental health coverage 
than the general population. As we think about how to meet this 
need, there is an opportunity to realign our healthcare system 
to better integrate primary care and mental health services. 
And in reading over the testimony last evening of our 
witnesses, many of our witnesses spoke about that, this 
integration of primary care and mental health services.
    This committee, I think, on both sides have been very 
supportive of the expansion of community health centers 
throughout the United States. They've been a great addition. 
They're wonderful primary care providers. But how do we 
integrate mental healthcare services in with those community 
health centers and make sure it's part of primary care?
    President Kennedy signed the Community Mental Health Act of 
1963, 50 years ago, which led to a major shift in mental 
healthcare in this country. People who were warehoused in 
institutions moved back into their communities. But the results 
were mixed. Many people were not able to access the community-
based services and treatments they needed. So as we face major 
new changes in the healthcare landscape, I hope we'll learn 
from these lessons and, as I said, see how we might more fully 
utilize the community health center system in America to 
integrate primary care and mental health services.
    So today we'll hear from a panel of expert witnesses who 
will talk about mental healthcare from a variety of 
perspectives, all with the goal, I hope, of addressing this 
critical but often neglected public health issue. I want to 
reemphasize that in my own words--public health issue.
    So I thank you all for being here. I look forward to your 
testimony, and I'll yield to our Ranking Member, Senator 
Alexander.

                 Opening Statement of Senator Alexander

    Senator Alexander. Thanks, Mr. Chairman. Thanks for your 
courtesy. I look forward to working with you. We've worked well 
together in the past. This is a very important committee with a 
large jurisdiction, and I am delighted to have a chance to be 
the Ranking Member.
    I want to say to Senator Enzi how much I appreciate his 
leadership, and we expect it to continue as time goes along.
    I also want to thank the chairman for having this hearing 
in the way he's having the hearing. We're entering this 
discussion, so far as I'm concerned--and that's my sense of the 
chairman's attitude--with no agenda other than to learn what 
needs to be done. As the chairman said, we haven't had a mental 
health hearing for a while, so I'm here to do a lot of 
listening.
    I was saying to some of the witnesses before the hearing 
that when I was U.S. Education Secretary, I often sat in their 
shoes, and I remember going back and telling the people in the 
Department that I thought I was going to a hearing, but, in 
fact, it was a talking, because the Senators did all the 
talking, and the witnesses did most of the listening. So I hope 
this will be more of a hearing instead of a talking, and I'll 
try to do my best to make it that way.
    It seems to me that the question before us is: Who needs 
help, and who's there to provide the help? If we can hone in on 
that question and see what the Federal Government can do to 
improve our ability to determine who needs help and our ability 
to identify the person or agency whose job it is to provide the 
help, then we will have provided some service.
    It helps to put a face on who needs help. As a former 
Governor, I always look at things from my own background and 
perspective, as I know most of us do. About 22 percent of 
Tennesseans reported having a mental illness last year. That's 
more than a million people. This is according to our State's 
Department of Mental Health. About 5 percent had a severe 
mental illness. That's nearly a quarter of a million 
Tennesseans. So that's a lot of people. About 41,000 
Tennesseans had a major depressive episode.
    The funding that helps meet the needs for that comes in 
some part from the Federal Government. About 22 percent of what 
Tennessee spends, I'm told, is Federal dollars. The rest is 
State dollars. In the community services, State appropriations 
are about 70 percent of the mental health funds. So while the 
Federal Government has a role here, it's a support role and a 
supplementary role, and it's a role that ought to make things 
easier instead of harder.
    In preparing for this, it seems to me that, putting a face 
on the individuals who need help, one group would be a 9-year-
old boy who has always been pleasant but suddenly started 
defying his teachers. His grades slipped, and he didn't want to 
go to Boy Scouts. He didn't want to play with friends. So they 
reached out to a pediatrician who was able to get some 
professional assistance. He was diagnosed with a mood disorder 
and he began to improve with sleeping better. And so it was a 
success story for that 9-year-old boy.
    Another case might be an adolescent, a 17-year-old, who had 
no behavioral issues growing up. He started noticing lights in 
the bathroom. Sounds of water irritated him. He had trouble 
sleeping. He began to hear voices telling him to throw rocks at 
anyone who told him to come down from the roof. And he was 
finally diagnosed with schizophrenia, but only after he had 
multiple episodes.
    Those two boys represent two of the largest groups that 
need help. And I'll be interested in finding out from our 
witnesses how well we're doing in helping them get the help.
    Finally, I'll be especially interested in asking the 
Federal agencies as well as the State and local witnesses who 
are here what we can do at the Federal level to make things 
easier to, No. 1, identify who needs help, and, No. 2, identify 
who can provide the help. Are there administrative things we 
can do? Are there funding things we can do? Are we putting up 
any roadblocks that make it harder for you to provide services? 
If we are, this is the place to identify them and see if we can 
correct them.
    So, Mr. Chairman, I look forward to this. I thank you for 
holding the hearing.
    The Chairman. Thank you very much, Senator Alexander.
    Now we'll turn to our witnesses. We have two panels. On our 
first panel, we'll start with Pamela S. Hyde, the Administrator 
of the Substance Abuse and Mental Health Services 
Administration, obviously known as SAMHSA to all of us. Ms. 
Hyde was nominated by President Obama and confirmed by the U.S. 
Senate in November 2009 as the Administrator of SAMHSA. She is 
an attorney and comes to SAMHSA with more than 30 years of 
experience in management and consulting for public healthcare 
and human service agencies.
    She has 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 health firm. Ms. Hyde is a member of or has served 
as a consultant to many national organizations, including the 
John D. and Catherine T. MacArthur Foundation, the American 
College of Mental Health Administration, the President's New 
Freedom Commission on Mental Health, and the U.S. Department of 
Justice.
    Our second witness on this panel, of course, is no stranger 
to this committee, or at least to my Appropriations 
Subcommittee. Dr. Thomas Insel, who is the Director of the 
National Institute of Mental Health, NIMH, at the National 
Institutes of Health. He has been director since the fall of 
2002. Prior to that, Dr. Insel was a professor of psychiatry at 
Emory University, and there he was the founding director of the 
Center for Behavioral Neuroscience, one of the largest science 
and technology centers funded by the National Science 
Foundation.
    He has published over 250 scientific articles and four 
books, including The Neurobiology of Parental Care in 2003. He 
is a member of the Institute of Medicine, a fellow of the 
American College of Neuropsychopharmacology--there, I said it--
and is a recipient of several awards, including the Outstanding 
Service Award from the U.S. Public Health Service.
    We thank you both for your backgrounds, for what you have 
done in this whole area of mental health both in research and 
practicality. And your statements will be made a part of the 
record in their entirety. We'll start with Ms. Hyde. I would 
ask that you sum it up in 5 to 8 minutes, and then we'll get to 
some questions. Again, welcome.
    Ms. Hyde, please proceed.

STATEMENT OF PAMELA HYDE, J.D., ADMINISTRATOR, SUBSTANCE ABUSE 
    AND MENTAL HEALTH SERVICES ADMINISTRATION, ROCKVILLE, MD

    Ms. Hyde. Thank you, Chairman Harkin and Ranking Member 
Alexander, for holding this hearing today. It's an important 
day.
    You will hear today about the prevalence and burden of 
mental illness and about the critical need in our country for 
understanding, treatment, and support services for those who 
experience mental health conditions. SAMHSA's mission is to 
reduce the impact of both substance abuse and mental illness in 
America's communities, and there is significant overlap between 
those two sets of conditions. They currently exist largely 
outside the mainstream of American healthcare, with different 
histories, structures, funding, incentives, practitioners, and 
even, in some cases, different governing laws.
    It's time that changed. SAMHSA envisions a nation that 
understands and acts on the knowledge that behavioral health is 
really essential to health, that mental and emotional health 
and freedom from substance abuse and addiction are necessary 
for an individual, a family, or a community to be healthy.
    As the Senator said, almost half of all Americans will 
experience symptoms of mental or substance abuse disorders in 
their lifetime, and yet of the over 45 million adults with any 
mental illness in a given year, only 38.5 percent of them 
receive the treatment they need. And of the almost 22 million 
adults with substance abuse disorders, only about 11 percent 
receive the treatment they need. For children and adolescents, 
it's only about one in five that receive the treatment they 
need for diagnosable mental disorders.
    Cost, access, and recognition of the problems are the 
primary reasons this treatment is not received. However, it 
doesn't have to be this way. For most of these conditions, 
prevention works, treatment is effective, and people do, in 
fact, recover. As Senator Harkin said, the Institute of 
Medicine reported in 2009 that half of adult mental illness 
begins before the age of 14 and three-quarters before the age 
of 24.
    We can and must intervene early to address these issues for 
our young people and for our Nation. Behavioral health is a 
public health issue, not a social issue, and it can be tackled 
and addressed in an effective public health approach driven by 
data focused on prevention and supportive policies and services 
that treat and restore to health.
    I'd like to talk about the Affordable Care Act for just a 
minute, because it's going to provide one of the largest 
expansions of mental health and substance abuse coverage in a 
generation by helping over 65 million Americans have access to 
additional behavioral health benefits that they do not have 
now. The ACA has already provided screening for depression, 
suicide risk, and alcohol misuse in many service programs and 
in its quality measures, and it has already provided additional 
coverage opportunities for youth. It will ensure that insurance 
plans offered in the new marketplaces cover mental and 
substance abuse disorders at parity with other benefits and as 
1 of the 10 essential health benefit categories.
    As part of the President's plan to protect our children and 
our communities, he outlines some specific actions and 
initiatives. To help ensure adequate coverage of mental health 
and addiction services, the Administration issued a letter to 
State health officials making it clear that Medicaid expansion 
plans must comply with the parity requirements of the Mental 
Health Parity and Addictions Equity Act of 2008, or what we 
call MHPAEA.
    In addition, the Administration will issue final 
regulations governing how existing health plans that offer 
mental health and addiction services must cover them at parity 
under MHPAEA. The President's initiatives to ensure students 
and young adults receive treatment for mental health issues 
include SAMHSA-led proposals such as a new program called 
Project Aware, which would bring together State officials, 
schools, communities, families, and youth to promote safety, 
prevent violence, and to identify mental and behavioral health 
conditions early and refer young people to treatment. Project 
Aware would also provide mental health first aid training.
    A proposed new grant program, Healthy Transitions, would 
provide a pilot to model innovative State and community-based 
initiatives and strategies supporting young people ages 16 to 
25. Along with HRSA, the President's workforce proposal would 
provide training for more than 5,000 additional mental health 
professionals to serve students and young adults.
    Finally, with the Department of Education, HHS will soon 
launch what we're calling a national dialog on mental health to 
help change the conversation and galvanize action about our 
children's mental health.
    We've come a long way in the prevention, treatment, and 
recovery supports for mental and addictive disorders. But we 
have a long way to go, and we can do better.
    Thank you for your time today, and I'd be very pleased to 
answer any questions that you may have.
    [The prepared statement of Ms. Hyde follows:]
               Prepared Statement of Pamela S. Hyde, J.D.
    Chairman Harkin, Ranking Member Alexander and members of the Senate 
Health, Education, Labor, and Pensions Committee, thank you for 
inviting me to testify at this important hearing on the state of the 
mental health system. I am pleased to testify along with Dr. Insel on 
the state of America's mental health system and to discuss some of the 
initiatives related to mental health included in the President's plan 
to protect our children and our communities.
 the substance abuse and mental health services administration (samhsa)
    As you are aware, the Substance Abuse and Mental Health Services 
Administration's (SAMHSA) mission is to reduce the impact of substance 
abuse and mental illness on America's communities. SAMHSA envisions a 
Nation that acts on the knowledge that:

     Behavioral health is essential for health;
     Prevention works;
     Treatment is effective; and
     People recover from mental and substance use disorders.

    In order to achieve this mission, SAMHSA has identified eight 
Strategic Initiatives to focus the Agency's work on improving lives and 
capitalizing on emerging opportunities. SAMHSA's top Strategic 
Initiatives are: Prevention; Trauma and Justice; Health Reform; 
Military Families; Recovery Supports; Health Information Technology; 
Data, Outcomes and Quality; and Public Awareness and Support.
        prevalence of behavioral health conditions and treatment
    In the wake of the Newtown tragedy, it is important to note that 
behavioral health research and practice over the last 20 years reveal 
that most people who are violent do not have a mental disorder, and 
most people with a mental disorder are not violent.\1\ Studies indicate 
that people with mental illnesses are more likely to be the victims of 
violent attacks than the general population.\2\ In fact, demographic 
variables such as age, gender and socioeconomic status are more 
reliable predictors of violence than mental illness.\3\ These facts are 
important because misconceptions about mental illness can cause 
discrimination and unfairly hamper the recovery of the nearly 20 
percent of all adult Americans who experience a mental illness each 
year.
---------------------------------------------------------------------------
    \1\ Monahan J., Steadman H., Silver E., ET al: Rethinking Risk 
Assessment: The MacArthur Study of Mental Disorder and Violence. New 
York, Oxford University Press, 2001 and Swanson, 1994.
    \2\ Appleby, L., Mortensen, P.B., Dunn, G., & Hiroeh, U. (2001). 
Death by homicide, suicide, and other unnatural causes in people with 
mental illness: a population-based study. The Lancet, 358, 2110-12.
    \3\ Elbogen, E.B., Johnson, S.C. Arch Gen Psychiatry. 2009 
Feb;66(2):152-61. doi: 10.1001/archgenpsychiatry.2008.537.
    The intricate link between violence and mental disorder: results 
from the National Epidemiologic Survey on Alcohol and Related 
Conditions.
---------------------------------------------------------------------------
    It is estimated that almost half of all Americans will experience 
symptoms of a mental health condition--mental illness or addiction--at 
some point in their lives. Yet, today, less than one in five children 
and adolescents with diagnosable mental health problems receive the 
treatment they need.\4\ And according to data from SAMHSA's National 
Survey on Drug Use and Health (NSDUH), only 38 percent of adults with 
diagnosable mental health problems--and only 11 percent of those with 
diagnosable substance use disorders--receive needed treatment.\5\
---------------------------------------------------------------------------
    \4\ Unmet Need for Mental Health Care Among U.S. Children: 
Variation by Ethnicity and Insurance Status.
    Sheryl H. Kataoka, M.D., M.S.H.S.; Lily Zhang, M.S.; Kenneth B. 
Wells, M.D., M.P.H., Am J Psychiatry 2002;159:1548-55. 10.1176/
appi.ajp.159.9.1548.
    \5\ Substance Abuse and Mental Health Services Administration, 
Results from the 2011 National Survey on Drug Use and Health: Mental 
Health Findings, NSDUH Series H-45, HHS Publication No. (SMA) 12-4725. 
Rockville, MD: Substance Abuse and Mental Health Services 
Administration, 2012.
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    With respect to the onset of behavioral health conditions, half of 
all lifetime cases of mental and substance use disorders begin by age 
14 and three-fourths by age 24.\6\ When persons with mental health 
conditions or substance use disorders do not receive the proper 
treatment and supportive services they need, crisis situations can 
arise affecting individuals, families, schools, and communities. We 
need to do more to identify mental health and substance abuse issues 
early and help individuals get the treatment they need before these 
crisis situations develop. And we need to help communities understand 
and implement the prevention approaches we know can be effective in 
stopping issues from developing in the first place.
---------------------------------------------------------------------------
    \6\ Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, 
K.R., & Walters, E.E. (2005). Lifetime prevalence and age-of-onset 
distributions of DSM-IV disorders in the National Comorbidity Survey 
Replication. Archives of General Psychiatry, 62(6), 593-602.
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    The President's announcement includes several important steps to 
help address mental health prevention and treatment. I look forward to 
the opportunity to discuss these with you.
                        mental health financing
    First, however, I will provide some background on mental health 
financing. The National Expenditures for Mental Health Services and 
Substance Abuse Treatment report for 1986-2005 found that $113 billion 
was spent on mental health and $22 billion for substance abuse services 
in 2005. SAMHSA is in the process of updating this data. In 2005, 
spending on mental health services accounted for 6.1 percent of all-
health spending. Public payers accounted for 58 percent of mental 
health spending and 46 percent of all-health spending. Medicaid (28 
percent of mental health spending) and private insurance (27 percent of 
mental health spending) accounted for more than half of mental health 
spending in 2005, followed by other State and local government at 18 
percent, Medicare at 8 percent, out-of-pocket at 12 percent, other 
Federal at 5 percent and other private sources at 3 percent.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    The National Expenditures report also found prescription drugs 
accounted for the largest share of mental health spending in 2005--27 
percent. Mental health drug spending grew by an average of 24 percent a 
year between 1997 and 2001. After 2001, growth slowed dramatically, to 
an average rate of 10 percent a year between 2001 and 2005.
    A key source of funding for services for adults with serious mental 
illness (SMI) and children with severe emotional disturbances (SED) is 
the Community Mental Health Services Block Grant (MHBG), which is a 
flexible funding source that is used by States to provide a range of 
mental health services described in their plans for comprehensive 
community-based mental health services for children with serious 
emotional disturbance and adults with serious mental illness. These 
funds are used to support service delivery through planning, 
administration, evaluation, educational activities, and services. 
Services include rehabilitation services, crisis stabilization and case 
management, peer specialist and consumer-directed services, wrap around 
services for children and families, supported employment and housing, 
jail diversion programs, and services for special populations. The 
State plan is developed in collaboration with the State mental health 
planning councils. Planning Councils' membership is statutorily 
mandated to include consumers, family members of adult and child 
consumers, providers, and representatives of other principal State 
agencies. The fiscal year 2013 President's budget proposed $460 million 
to continue the MHBG.
    SAMHSA also administers the Substance Abuse Prevention and 
Treatment Block Grant (SABG) for the States. The fiscal year 2013 
President's budget proposed $1.4 billion for the SABG, and $400 million 
for primary prevention of substance abuse.
    According to the National Association of State Mental Health 
Program Directors, over the past few years, States and communities have 
significantly reduced funding for mental health and addiction services. 
They estimate that in the last 4 years, States have cut $4.35 billion 
in mental health services, while an additional 700,000 people sought 
help at public mental health facilities during this period.\7\ These 
changes have occurred despite the evidence that early treatment and 
prevention for mental illness and substance use programs can reduce 
health costs, criminal and juvenile justice costs, and educational 
costs, and increase productivity.\8\
---------------------------------------------------------------------------
    \7\ The National Association of State Mental Health Program 
Directors (NASMHPD). Too Significant To Fail: The Importance of State 
Behavioral Health Agencies in the Daily Lives of Americans with Mental 
Illness, for Their Families, and for Their Communities. Alexandria, VA. 
2012.
    \8\ National Research Council. Preventing Mental, Emotional, and 
Behavioral Disorders Among Young People: Progress and Possibilities. 
Washington, DC: The National Academies Press, 2009.
---------------------------------------------------------------------------
    Additionally, investments in these programs and services can help 
reduce physical health costs for those with co-morbid health and 
behavioral health conditions.\9\ Some States have found that providing 
adequate mental health and addiction-treatment benefits can 
dramatically reduce health care costs and Medicaid spending.
---------------------------------------------------------------------------
    \9\ See e.g., Egede, L.E., Zheng, D., & Simpson, K. (2002). 
Comorbid depression is associated with increased health care use and 
expenditures in individuals with diabetes. Diabetes Care, 25(3), 464-
470.
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              advancements and trends in behavioral health
Community-Based Care
    In 1963, President John F. Kennedy signed into law the Mental 
Retardation Facilities and Community Mental Health Centers Construction 
Act. The Act led to a drastic alteration in the delivery of mental 
health services and establishment of more than 750 comprehensive 
community mental health centers throughout the country. This movement 
to community-based services helped to reduce the number of individuals 
with mental illness who were ``warehoused'' in secluded hospitals and 
isolated institutions. Other advancements in the treatment of mental 
illness and the growth of the recovery movement, along with other 
programs such as supportive housing, assertive community treatment 
teams, peer specialists, supportive employment, and social security 
disability payments, have helped provide the services and supports 
necessary for persons with serious mental illness to survive and thrive 
in the community. Experience and research has shown that the goal of 
recovery is exemplified through a life that includes: Health; Home; 
Purpose and Community.\10\ Peers play an important role in recovery 
support and the consumer movement has helped promote not only the idea 
that recovery is possible, but also those consumers should play a key 
role in their recovery. SAMHSA's Recovery Support Initiative partners 
with people in recovery from mental and substance use disorders and 
family members to guide the behavioral health system and promote 
individual-, program-, and system-level approaches that foster health 
and resilience; increase permanent housing, employment, education, and 
other necessary supports; and reduce discriminatory barriers.
---------------------------------------------------------------------------
    \10\ New Freedom Commission on Mental Health, Achieving the 
Promise: Transforming Mental Health Care in America. Final Report. DHHS 
Pub. No. SMA-03-3832. Rockville, MD: 2003.
---------------------------------------------------------------------------
Integration
    Given that behavioral health is essential to an individual's 
overall health, SAMHSA administers the Primary and Behavioral Health 
Care Integration (PBHCI) program. The purpose of the program is to 
improve the physical health status of people with serious mental 
illnesses (SMI) by supporting communities to coordinate and integrate 
primary care services into publicly funded community mental health and 
other community-based behavioral health settings. The program supports 
community-based behavioral health agencies' efforts to build the 
partnerships and infrastructure needed to initiate or expand the 
provision of primary healthcare services for people in treatment for 
SMI and co-occurring SMI and substance use disorders. It is a program 
focused on increasing the health status of individuals based on 
physical or behavioral need. The program encourages structural changes 
in existing systems to accomplish its goals. To date, the program has 
awarded 94 grants and 55 percent of awardees are partnering with at 
least one Federally Qualified Health Center (FQHC). This integration 
results in significant physical and behavioral health gains. PBHCI 
grantees collect data on patients at admission and in followup 
reassessments every 6 months, as well as at discharge when possible. 
Some results that are based on grantee-reported outcome measures from 
February 2010 through January 7, 2013, include:

     Health: The percentage of consumers who rated their 
overall health as positive increased by 20 percent from baseline to 
most recent reassessment (N=3737).
     Tobacco Use: The percentage of consumers who reported they 
were not using tobacco during the past 30 days increased by 6 percent 
from baseline to most recent reassessment (N=3787).
     Illegal Substance Use: The percentage of consumers who 
reported that they were not using an illegal substance during the past 
30 days increased by 12 percent from baseline to most recent 
reassessment (N=3568).
     Blood pressure (categorical): Among 7,493 clients, 18.3 
percent showed improvement, and 16.7 percent are no longer at risk for 
high blood pressure (systolic less than 130, diastolic less than 85).
     BMI: Among 7,120 clients, 45.6 percent showed improvement, 
and 4.8 percent are no longer at risk for being overweight (BMI less 
than 25).

    Service systems that are aligned with patient and client need, 
specifically those providing integrated treatment, produce better 
outcomes for individuals with co-
occurring mental and substance use disorders.\11\ Without integrated 
treatment, one or both disorders may not be addressed properly. Mental 
health and substance abuse authorities across the country are taking 
steps to integrate systems and services, and promote integrated 
behavioral health treatment. Currently, there are 35 States that have a 
combined mental health and substance abuse authority. In addition, at 
least two additional States and the District of Columbia are moving 
toward a single agency.
---------------------------------------------------------------------------
    \11\ Center for Substance Abuse Treatment. Systems Integration. 
COCE Overview Paper 7. DHHS Publication No. (SMA) 07-4295. Rockville, 
MD: Substance Abuse and Mental Health Services Administration, and 
Center for Mental Health Services, 2007.
---------------------------------------------------------------------------
    SAMHSA continues to work with both States and grantees to encourage 
systems collaboration and coordination to develop mental health and 
substance abuse systems that support seamless service delivery. 
SAMHSA's effort to integrate primary care and mental health and 
substance abuse services offers a promising, viable, and efficient way 
of ensuring that people have access to needed behavioral health 
services. Additionally, behavioral health care delivered in a primary 
care setting can help to minimize discrimination and reduce negative 
attitude about seeking services, while increasing opportunities to 
improve overall health outcomes. Leadership supporting this type of 
coordinated quality care requires the support of a strengthened 
behavioral health and primary care delivery system as well as a long-
term policy commitment.
Mental Health Parity and Addiction Equity Act (MHPAEA)
    In 2008, the Paul Wellstone and Pete Domenici Mental Health Parity 
and Addiction Equity Act (MHPAEA) became law. MHPAEA improves access to 
much-needed mental and substance use disorder treatment services 
through more equitable coverage. The law applied to large group health 
plans (sponsored by employers with more than 50 employees) and health 
insurance issuers that offered coverage in the large group market. The 
law requires that plans and issuers that offer coverage for mental 
illness and substance use disorders provide those benefits in a way 
that is no more restrictive than the predominant requirements or 
limitations applied to substantially all medical and surgical benefits 
covered by the plan.
Affordable Care Act
    The Affordable Care Act advances the field of behavioral health by 
expanding access to behavioral health care; growing the country's 
behavioral health workforce; reducing behavioral health disparities; 
and implementing the science of behavioral health promotion.
    While most mental illnesses and addictions are treatable, those 
with mental illness often cannot get needed treatment if they do not 
have health insurance that covers mental health services. The 
Affordable Care Act will provide one of the largest expansions of 
mental health and substance abuse coverage in a generation by extending 
health coverage to over 30 million Americans, including an estimated 6 
to 10 million people with mental illness. It also includes coverage for 
preventive services, including screening for depression and alcohol 
misuse. The Affordable Care Act will also make sure that Americans can 
get the mental health treatment they need by ensuring that insurance 
plans in the new Marketplaces cover mental health and substance abuse 
benefits at parity with other benefits. Beginning in 2014, all new 
small group and individual plans will cover mental health and substance 
use disorder services, including behavioral health treatment.
    Medicaid is already the largest payer of mental health services, 
and the Affordable Care Act will extend Medicaid coverage to as many as 
17 million hardworking Americans.
    SAMHSA's No. 1 strategic initiative is Prevention of Substance 
Abuse and Mental Illness, and the Agency has also been heavily engaged 
in the implementation of the prevention and public health promotion 
provisions of the Affordable Care Act. For example, the National 
Prevention Strategy includes priorities focused on Mental and Emotional 
Well-Being and Preventing Drug Abuse and Excessive Alcohol Use.
                             moving forward
    Moving forward, in the wake of the tragedy in Newtown, CT, the 
Administration is focused on making sure that students and young adults 
get treatment for mental health issues. At the same time, SAMHSA knows 
that a larger national dialogue about mental health in America needs to 
occur and we will be taking steps to foster this dialog.
Parity
    The Administration intends to issue next month the Final Rule on 
defining essential health benefits and implementing requirements for 
new small group and individual plans to cover mental health benefits at 
parity with medical and surgical benefits. In addition, the President 
announced that the Administration is committed to promulgating a MHPAEA 
Final Rule.
    Last week, the Centers for Medicare and Medicaid Services sent a 
State Health Official Letter regarding the applicability of MHPAEA to 
Medicaid non-managed care benchmark and benchmark-equivalent plans 
(referred to in this letter as Medicaid Alternative Benefit plans) as 
described in section 1937 of the Social Security Act (the Act), the 
Children's Health Insurance Programs (CHIP) under title XXI of the Act, 
and Medicaid managed care programs as described in section 1932 of the 
Act.
Reaching Youth and Young Adults
    As I noted earlier, three-quarters of mental illnesses appear by 
the age of 24, yet less than one in five children and adolescents with 
diagnosable mental health and substance use problems receive treatment. 
That is why last week, the President announced initiatives to ensure 
that students and young adults receive treatment for mental health 
issues. Specifically, SAMHSA will take a leadership role in initiatives 
that would:

     Reach 750,000 young people through programs to identify 
mental illness early and refer them to treatment: We need to train 
teachers and other adults who regularly interact with students to 
recognize young people who need help and ensure they are referred to 
mental health services. The Administration is calling for a new 
initiative, Project AWARE (Advancing Wellness and Resilience in 
Education), to provide this training and set up systems to provide 
these referrals. This initiative has two parts:

          Provide ``Mental Health First Aid'' training for 
        teachers: Project AWARE proposes $15 million for training for 
        teachers and other adults who interact with youth to detect and 
        respond to mental illness in children and young adults, 
        including how to encourage adolescents and families 
        experiencing these problems to seek treatment.
          Make sure students with signs of mental illness get 
        referred to treatment: Project AWARE also proposes $40 million 
        to help school districts work with law enforcement, mental 
        health agencies, and other local organizations to assure 
        students with mental health issues or other behavioral issues 
        are referred to and receive the services they need. This 
        initiative builds on strategies that, for over a decade, have 
        proven to improve mental health.

     Support individuals ages 16 to 25 at high risk for mental 
illness: Efforts to help youth and young adults cannot end when a 
student leaves high school. Individuals ages 16 to 25 are at high risk 
for mental illness, substance abuse, and suicide, but they are among 
the least likely to seek help. Even those who received services as a 
child may fall through the cracks when they turn 18. The Administration 
is proposing $25 million for innovative State-based strategies 
supporting young people ages 16 to 25 with mental health or substance 
abuse issues.
     Train more than 5,000 additional mental health 
professionals to serve students and young adults: Experts often cite 
the shortage of mental health service providers as one reason it can be 
hard to access treatment. To help fill this gap, the Administration is 
proposing $50 million to train social workers, counselors, 
psychologists, and other mental health professionals. This would 
provide stipends and tuition reimbursement to train more than 5,000 
mental health professionals serving young people in our schools and 
communities.
National Dialogue
    Finally, we know that it is time to change the conversation about 
mental illness and mental health in America. HHS is working to develop 
a national dialog on the mental and emotional health of our young 
people, engaging parents, peers, and teachers to reduce negative 
attitudes toward people with mental illness, to recognize the warning 
signs, and to enhance access to treatment.
                               conclusion
    Thank you again for this opportunity to discuss the state of 
America's mental health system. I would be pleased to answer any 
questions that you may have.

    The Chairman. Thank you very much, Dr. Hyde.
    Now we'll turn to Dr. Insel. Welcome again and please 
proceed.

 STATEMENT OF THOMAS INSEL, M.D., DIRECTOR, NATIONAL INSTITUTE 
    OF MENTAL HEALTH AT THE NATIONAL INSTITUTES OF HEALTH, 
                          BETHESDA, MD

    Dr. Insel. Thank you, Mr. Chairman and Ranking Member 
Alexander and members of the committee. It's a real honor to be 
here, and it's actually a great pairing to have Administrator 
Hyde and me on the same panel.
    This is essentially going from services to science. So as a 
person coming to you from the National Institute of Mental 
Health and the National Institutes of Health, my role is really 
around the research related to mental illness and thinking 
about how to come up with the science that will lead to better 
diagnostics, better therapeutics, better understanding of what 
you called a silent epidemic, Senator Harkin. And that's 
actually an interesting term for this.
    I know we haven't met for some years to talk about this. So 
it's particularly, for us, important to get this out on the 
agenda. It's clear that in some ways this is a response to this 
tragic event that happened in December in Newtown, CT. And if 
it takes an event like that to focus the Nation's attention on 
the needs of those with mental illness--it's terrible to say 
that, but at least perhaps one of the opportunities that can be 
taken now is to think about how do we do better by those with 
mental illness and how do we make sure that events like this 
don't happen again.
    I'm not going to read my testimony to save time. I think 
both Pam and I are eager to get to your questions. But perhaps 
to preempt some of those questions, let me take just a couple 
of minutes to make some of the points that might help in terms 
of how we think about mental illness, some of the definitions 
and the science as we understand it.
    First of all, when we talk about mental illness, we're 
talking about, as you have already heard, very common 
disorders, depression, PTSD, eating disorders, and there are 
many others. There are about 10 or 12 that we focus on. These 
are real illnesses with real treatments and affect about one in 
five Americans overall, including youth, as we'll say in a 
moment.
    Today, we're probably going to talk mostly about serious 
mental illness. That's a term of art that has to do with those 
people who are truly disabled, often by a psychotic illness. 
That occurs in about, overall, perhaps 1 in 20. So it's not 
quite as common. But it's an important piece of the story that 
we need to talk about, because these are the people who are 
most severely impaired.
    As Pam mentioned and as already mentioned by you, Senator 
Harkin, it's really critical for the committee to understand 
that unlike talking about cancer and diabetes and heart 
disease, when we talk about mental illness, we're talking about 
illnesses that begin early in life. These are, in fact, the 
chronic disorders of young people, and it requires a different 
mindset when you think about how do you detect, how do you 
intervene, how do you make sure that you can make a difference. 
That's one of the reasons why these disorders have the highest 
disability rating or the highest morbidity overall. It's 
because they start early and they tend to be chronic.
    As Pam mentioned, we know these are treatable disorders, 
but there's a significant delay in getting treatment. And even 
in those young people who have these most severe illnesses like 
schizophrenia, on average, the delay between the onset of 
symptoms and when they get diagnosed and treated is somewhere 
between 1 and 2 years, which seems extraordinary because you're 
talking about symptoms that are so disabling and so obvious.
    And it's especially unfortunate, because the lesson we have 
learned from cancer and heart disease, diabetes and AIDS, is 
that the secret to having the best outcomes is early detection 
and early intervention. That's what biomedical research has 
taught us over the last four decades. You have to get there 
early in the process if you want people to have the best 
outcome, and we don't do that here.
    I think one of the things we need to talk about--again, 
going back to your comments, Senator Alexander, about who needs 
help and who's going to be responsible for providing help--is 
why the delay, and how do we do better in making sure that 
people get involved earlier in the process.
    Just a comment about violence and mental illness, because 
it will come up, I think. It's on a lot of people's minds. As 
you've heard already, most violence has nothing to do with 
mental illness, and most people with mental illness are not 
violent. In fact, we generally worry more about people with 
mental illness, especially severe mental illness, being the 
victims, not the perpetrators, of violence, and the science 
certainly supports that.
    There are two conditions where we do need to think about 
this because violence and mental illness will intersect. And 
one of those is the psychotic illnesses like schizophrenia that 
start early in usually adolescents. For people who have not 
received treatment, they are at greater risk for violence, 
either because they are paranoid and may irrationally feel that 
they are under attack, or sometimes because of hallucinations 
or voices telling them to do something horrific, as you 
mentioned with your example, Senator Alexander.
    Far more common, however, is the second issue. It's not 
homicide or violence against others. It's violence against the 
self. Suicide is a far more common problem for people with 
serious mental illness--38,000 suicides in this country each 
year with the most recent data that we have. That's more than 1 
every 15 minutes. Of these, 90 percent involve mental illness. 
By contrast, there are less than 17,000 homicides, with less 
than 5 percent involving mental illness.
    So when we talk about violence and mental illness, when we 
talk about safety and security, when we talk about access to 
means or duty to warn, the bigger problem here is suicide. It's 
protecting the person with mental illness as well as family 
members, peers, and people in the community.
    There's a lot that can be done here. We're not great at 
predicting. It's still more an art than science. And I would 
say that's true, by the way, of heart attack, cancer, as well 
as serious mental illness or violence in those people who are 
affected by these kinds of illnesses.
    But even without being 100 percent certain on the 
predictions at the individual level, we can do a lot toward 
prevention, and you'll hear something about that in the 
conversation today. At NIMH, we've really spent much of our 
investments focusing on the earliest stages of severe mental 
illness and identifying high-risk states before psychosis 
begins, just the way we do today with cancer and heart disease 
and thinking about how to intervene early.
    So I think I will stop there except to say that this is an 
extraordinary time in terms of the science of mental illness. 
We are really in the middle of a revolution because of what 
we're learning about the brain. We do think about each of these 
disorders as brain disorders, and we think about our 
interventions in terms of how they affect individual brain 
circuits.
    We've made tremendous strides over the last 50 years. You 
cited President Kennedy's launching of the Community Mental 
Health Program, which actually began with a special comment to 
Congress on February 5, 1963. So we're almost exactly at the 
50-year anniversary. A lot has happened in that time, but as 
Pam mentioned, we have a long way to go. I look forward to your 
questions about how we can do better going forward.
    Thank you.
    [The prepared statement of Dr. Insel follows:]
                Prepared Statement of Thomas Insel, M.D.
    Mr. Chairman and members of the committee, I am Thomas R. Insel, 
M.D., director of the National Institute of Mental Health (NIMH) at the 
National Institutes of Health, an agency in the Department of Health 
and Human Services. Thank you for this opportunity to present an 
overview of the current state of mental health research at NIMH, with a 
particular focus on our efforts to address serious mental illness, and 
our efforts to discover, develop, and pursue new treatments for these 
brain disorders. In my statement, I will review the scope of mental 
disorders in the United States and their impact on public health, and I 
will outline examples of NIMH's research efforts designed to address 
this challenge.
                 public health burden of mental illness
    The National Institute of Mental Health is the lead Federal agency 
for research on mental disorders, with a mission to transform the 
understanding and treatment of mental illnesses through basic and 
clinical research. The burden of mental illness is enormous. In the 
United States, an estimated 11.4 million American adults (approximately 
4.4 percent of all adults) suffer from a serious mental illness (SMI) 
each year, including conditions such as schizophrenia, bipolar 
disorder, and major depression.\1\ According to a 2004 World Health 
Organization report, neuropsychiatric disorders are the leading cause 
of disability in the United States and Canada, accounting for 28 
percent of all years of life lost to disability and premature mortality 
(Disability Adjusted Life Years or DALYs).\2\ The personal, social and 
economic costs associated with these disorders are tremendous. Suicide 
is the 10th leading cause of death in the United States, accounting for 
the loss of more than 38,000 American lives each year, more than double 
the number of lives lost to homicide.\3\ A cautious estimate places the 
direct and indirect financial costs associated with mental illness in 
the United States at well over $300 billion annually, and it ranks as 
the third most costly medical condition in terms of overall health care 
expenditure, behind only heart conditions and traumatic injury.\4\ \5\ 
Even more concerning, the burden of illness for mental disorders is 
projected to sharply increase, not decrease, over the next 20 years.\6\
---------------------------------------------------------------------------
    \1\ Substance Abuse and Mental Health Services Administration. 
Results from the 2009 National Survey on Drug Use and Health: Mental 
Health Findings (Office of Applied Studies, NSDUH Series H-39, HHS 
Publication No. SMA 10-4609). Rockville, MD: Substance Abuse and Mental 
Health Services Administration, 2010.
    \2\ The World Health Organization. The global burden of disease: 
2004 update, Table A2: Burden of disease in DALYs by cause, sex and 
income group in WHO regions, estimates for 2004. Geneva, Switzerland: 
WHO, 2008.
    \3\ Centers for Disease Control and Prevention, National Center for 
Injury Prevention and Control. Web-based Injury Statistics Query and 
Reporting System (WISQARS): www.cdc.gov/ncipc/wisqars accessed November 
2011.
    \4\ Insel TR. Assessing the economic cost of serious mental 
illness. Am J Psychiatry. 2008 Jun;165(6):663-5.
    \5\ Soni A. The Five Most Costly Conditions, 1996 and 2006: 
Estimates for the U.S. Civilian Noninstitutionalized Population. 
Statistical Brief #248. July 2009. Agency for Healthcare Research and 
Quality, Rockville, MD.
    \6\ Bloom DE, Cafiero ET, Jane-Llopis E, Abrahams-Gessel S, Bloom 
LR, Fathima S, Feigl AB, Gaziano T, Mowafi M, Pandya A, Prettner K, 
Rosenberg L, Seligman B, Stein A, Weinstein C. The Global Economic 
Burden of Non-communicable Diseases. Geneva, Switzerland: World 
Economic Forum, 2011.
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    NIMH-supported research has found that Americans with SMI die 8 
years earlier than the general population.\7\ People with SMI 
experience chronic medical conditions and the risk factors that 
contribute to them more frequently and at earlier ages. There are low 
rates of prevention, detection, and intervention for chronic medical 
conditions and their risk factors among people with SMI, and this 
contributes to significant illness and earlier death. Two-thirds or 
more of adults with SMI smoke \8\; over 40 percent are obese (60 
percent for women) \9\ \10\; and metabolic syndrome is highly 
prevalent, especially in women.\11\ Approximately 5 percent of 
individuals with schizophrenia will die by suicide during their 
lifetime, a rate 50-fold greater than the general population. \12\
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    \7\ Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. 
Understanding excess mortality in persons with mental illness: 17-year 
followup of a nationally representative U.S. survey. Med Care. 2011 
Jun;49(6):599-604.
    \8\ Goff DC, Sullivan LM, McEvoy JP, ET al. A comparison of 10-year 
cardiac risk estimates in schizophrenia patients from the CATIE study 
and matched controls. Schizophrenia Res. 2005;80(1):45-53.
    \9\ Allison DB, Fontaine KR, Heo M, ET al. The distribution of body 
mass index among individuals with and without schizophrenia. J Clin 
Psych. 1999;60(4):215-20.
    \10\ McElroy SL. Correlates of overweight and obesity in 644 
patients with bipolar disorder. J Clin Psych. 2002;63:207-213.
    \11\ McEvoy JP, Meyer JM, Goff DC, ET al. Prevalence of the 
metabolic syndrome in patients with schizophrenia: Baseline results 
from the (CATIE) schizophrenia trial and comparison with national 
estimates from NHANES III. Schizophrenia Res. 2005;80(1):19-32.
    \12\ Hor K. & Taylor M. Suicide and schizophrenia: a systematic 
review of rates and risk factors. J Psychopharmacol. 2010;24(4S): 81-
90.
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          delays in receiving treatment--and the consequences
    According to a study published in 2004, the vast majority (80.1 
percent) of people having any mental disorder eventually make contact 
with a health care professional to receive treatment, although delays 
to seeking care average more than a decade.\13\ Although instances of 
SMI are associated with shorter delays, the average delay was 
nevertheless approximately 5 years--that is 5 years of increased risk 
for using potentially life-threatening, self-administered treatments, 
such as legal or illicit substances, or even death. During an episode 
of psychosis, people can lose touch with reality and experience 
hallucinations and delusions. Research has suggested that persons with 
schizophrenia whose psychotic symptoms are controlled are no more 
violent than those without SMI.\14\ Nonetheless, when untreated 
psychosis is also accompanied by symptoms of paranoia and when it is 
associated with substance abuse, the risk of violence is increased. 
Importantly, the risk of violence is reduced with appropriate 
treatment. Moreover, people with SMI are 11 times more likely than the 
general population to be victims themselves of violence.\15\
---------------------------------------------------------------------------
    \13\ Wang PS, Berglund PA, Olfson M, Kessler RC. Delays in initial 
treatment contact after first onset of a mental disorder. Health Serv 
Res. 2004 Apr;39(2):393-415.
    \14\ Steadman HJ, Mulvey EP, Monahan J, Robbins PC, Appelbaum PS, 
Grisso T, Roth LH, Silver E. Violence by people discharged from acute 
psychiatric inpatient facilities and by others in the same 
neighborhoods. Arch Gen Psychiatry. 1998 May;55(5):393-401.
    \15\ Teplin, LA, McClelland, GM, Abram, KM & Weiner, DA. Crime 
victimization in adults with severe mental illness: comparison with the 
National Crime Victimization Survey. Arch Gen Psychiatry, 2005, 62(8), 
911-921.
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          how nimh is addressing this public health challenge
    In the past, we viewed mental disorders as chronic conditions 
defined by their apparent symptoms, even though behavioral 
manifestations of illness are in fact the last indications--following a 
cascade of subtle brain changes--that something is wrong. We understand 
now that mental disorders are brain disorders, with specific symptoms 
rooted in abnormal patterns of brain activity. Moving forward, NIMH 
aims to support research on earlier diagnosis and quicker delivery of 
appropriate treatment, be it behavioral or pharmacological. NIMH has a 
three-pronged research approach to achieve this aim: (1) optimize early 
treatment to improve the trajectory of illness in people who are 
already experiencing the symptoms of SMI; (2) understand and prevent 
the transition from the pre-symptomatic (prodrome) phase to actual 
illness; and (3) investigate the genetic and biological mechanisms 
underlying SMI in order to understand how, in the future, we can 
preempt illness from ever occurring. Here are examples of NIMH efforts 
on these three fronts:

      (1) In the United States, the delay between a first episode of 
psychosis and onset of treatment ranges from 61 to 166 weeks, with an 
average of 110 weeks.\16\ NIMH seeks to reduce that delay as much as 
possible, through continued support of the Recovery After an Initial 
Schizophrenia Episode (RAISE) project; a large-scale research project 
to explore whether using early and aggressive treatment will reduce the 
symptoms and prevent the gradual deterioration of functioning that is 
characteristic of chronic schizophrenia. The project is currently 
focused on maintaining the quality of the treatment over time, and 
retaining individuals in treatment. Results from initial analyses 
suggest that a RAISE-type intervention would not only produce superior 
clinical outcomes, but will reduce re-hospitalization during the first 
year.
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    \16\ Marshall M, Lewis S, Lockwood A, Drake R, Jones P, Croudace T. 
Association between duration of untreated psychosis and outcome in 
cohorts of first-episode patients. Arch Gen Psychiatry. 2005 Sep 
62:975-83.
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      (2) NIMH is continuing to fund research directed at the prodromal 
phase of schizophrenia, the stage just prior to full psychosis. A 
consortium of eight clinical research centers (North American Prodrome 
Longitudinal Study or NAPLS) are using biological assessments, 
including neuroimaging, electrophysiology, neuro-
cognitive testing, hormonal assays, and genomics, to improve our 
ability to predict who will convert to psychosis, and to develop new 
approaches to pre-emptive intervention.
      (3) For decades, we have known that schizophrenia has a genetic 
component, but different methods for studying genetic changes have led 
to uncertainty about which genes are involved and how they contribute 
to illness. Using a new method to integrate information about illness-
related genes from different types of studies, NIMH-supported 
researchers have identified a network of genes that affect the 
development, structure, and function of brain cells. The researchers 
detected important variations in how these gene-related brain changes 
affected risk for schizophrenia versus other disorders.\17\
---------------------------------------------------------------------------
    \17\ Gilman SR, Chang J, Xu B, Bawa TS, Gogos JA, Karayiorgou M, 
Vitkup D. Diverse types of genetic variation converge on functional 
gene networks involved in schizophrenia. Nat Neurosci. 2012 
Nov;15(12):1723-8.
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            preemption: the future of mental health research
    Research has taught us to detect diseases early and intervene 
quickly to preempt later stages of illness. This year we will avert 1.1 
million deaths from heart disease because we have not waited for a 
heart attack to diagnose and treat coronary artery disease.\18\ The 
100,000 young Americans who will have a first episode of psychosis this 
year will join over 2 million with schizophrenia. Our best hope of 
reducing mortality from this, other SMI, and other brain disorders will 
come from realizing that just like other medical disorders, we need to 
diagnose and intervene before the symptoms become manifest. The health 
of the country cannot wait.
---------------------------------------------------------------------------
    \18\ Vital Statistics of the United States, CDC/National Center for 
Health Statistics. (2011, August). Age-adjusted Death Rates for 
Coronary Heart Disease (CHD). National Heart Lung and Blood Institute. 
Retrieved January 23, 2013, from http://www.nhlbi.nih.gov/news/
spotlight/success/conquering-cardiovascular-disease.html.

    The Chairman. Thank you, Dr. Insel. Now I'll start a round 
of 5-minute questions.
    Ms. Hyde, I just want to focus on the Mental Health Parity 
and Addiction Equity Act signed into law in 2008--a major 
accomplishment. I am concerned because the interim final rule 
published in 2010 left some implementation details unresolved. 
When the Administration publishes a final rule, how will you 
address issues such as the scope of services that must be 
covered so that insurers have the detailed guidance they need 
to implement the law?
    Ms. Hyde. Thank you for the question, Senator Harkin. As 
you know, the interim final rule was published in 2010. Part of 
what was requested from the public was input on several topics. 
That was one. In the meantime, we've issued four or five 
subregulatory guidance frequently asked questions. We've also 
been meeting with stakeholders and with industry, trying to 
understand how the implementation is happening. We are ready to 
produce a final reg, and we're in that process now.
    The Chairman. Thank you.
    Dr. Insel, I have some concerns--I know others have also, 
and I've read a lot about these concerns, and I hear them from 
constituents and other people who talk to me--about the use of 
pharmaceuticals, particularly antipsychotic medications in 
children. What I hear is sometimes a kid acts up and does 
something--get them a drug. Get them some antipsychotic 
medication. What do we currently know about the safety and 
long-term effects of these drugs in kids?
    I've often said children are not just little adults. 
They're different. And what might work in an adult, even if you 
say, ``Well, we'll reduce the dosage,'' that sometimes doesn't 
always correlate. I don't want to practice medicine without a 
license. But, nonetheless, we know that to be a fact. What do 
we currently know about the safety and long-term effects on 
these kids, and what areas require further research and study?
    Dr. Insel. Well, in fact, there is a real concern, because 
the use of antipsychotics in children has gone up markedly over 
the last decade. What we do know is that children are actually 
more sensitive to the side effects, particularly the metabolic 
side effects. And that's a real concern because, often, these 
drugs are used long term.
    So there's an issue. There's a real issue about practice 
and about improving the quality of practice in this regard. And 
I should say that some of this may be related to a reluctance 
for many clinicians to use antidepressants, which are probably 
somewhat safer. But there are concerns about suicide and 
actually violent behavior.
    The curious thing to know here is if you look at the other 
side of this--we're not talking about young children, but when 
we talk about adolescents and the example that Senator 
Alexander used about the 15- or 16-year-old who was beginning 
to hear voices and who's going down this path of psychosis, 
what tends to happen most often is not that people are getting 
over-treated with medications but that they're not getting 
diagnosed and treated at all.
    Specifically, with respect to our concerns about violent 
behavior, we know that treatment reduces that. The most 
important thing you can do if you want to prevent new events 
like this, the ones that we've often talked about over the last 
5 or 6 years, is to ensure that people who are on this path to 
becoming psychotic and paranoid and grandiose and perhaps 
dangerous are treated.
    The risk of violence is fifteenfold higher prior to 
treatment than it is after, and treatment often does involve 
antipsychotic medication. It's not the whole treatment, but it 
is a part of making sure that people who are developing a 
psychotic illness are actually not going to become a risk to 
themselves or others.
    The Chairman. We'll hear testimony later from the next 
panel about approaches such as mind-body connections and things 
like that in terms of perhaps--especially as we get into 
prevention and we start recognizing in young children in school 
and other places certain types of behavior that maybe early 
interventions with family counseling and therapy might be more 
successful than just giving them an antipsychotic drug. Do you 
have any comments on that?
    Dr. Insel. There are only a few reasons to use an 
antipsychotic drug in a young child. Probably the most common 
and the one that is approved by the FDA is in autism, where 
there are forms of irritability and what you might call temper 
tantrums in which children will hurt themselves or hurt 
somebody else, often very young children. And in that case, the 
FDA has approved the use of two different antipsychotic drugs 
to help control that kind of behavior.
    But for the most part, the medications that are approved 
for use in children and the ones that seem to show the greatest 
efficacy are in other classes, particularly for children who 
have, for instance, attention deficit hyperactivity disorder, 
where the psycho-stimulants have been shown over and over again 
over the last four decades to be not only of high efficacy but 
high safety as well. And we know from long-term studies that 
that's helpful.
    So I wouldn't say that in any of these cases medicine is 
the whole answer, but it's often helpful as part of the answer. 
There are lots of other kinds of interventions that are being 
developed and some that still need to be developed that may be 
far more effective beyond medication. So this is just a part of 
the story.
    The Chairman. Thank you very much, Dr. Insel. My time is 
up.
    Ms. Hyde, do you have a short comment?
    Ms. Hyde. I was just going to say that from a population-
based point of view for young children, there are 
interventions, not for people who have been identified with an 
issue, but in classrooms; for example, a program that we 
support called The Good Behavior Game, which has shown a fairly 
remarkable ability to help teachers manage behaviors in 
classrooms, that does have long-term impacts.
    The Chairman. Thank you.
    Senator Alexander.
    Senator Alexander. Thanks, Mr. Chairman.
    Ms. Hyde, it looks like, just looking at Tennessee, that 
maybe a quarter to a third of the funds that are available for 
mental health and substance abuse through the State government 
are Federal dollars. Does that sound about right for the 
country? Is that your experience? Most of it goes through two 
big block grants, or one big one and one smaller one. Is that 
about right?
    Ms. Hyde. Sort of a rule of thumb is somewhere around a 
quarter of the funding for the Nation--I don't know about 
Tennessee, particularly--but is----
    Senator Alexander. Well, for the Nation, that sounds about 
right.
    Ms. Hyde. It sounds about right if you take the Medicaid 
dollars. Each State has a different match, of course, so that 
changes how much is State dollars and how much not. About half 
the dollars that go for behavioral health of the country as a 
whole are public dollars, Federal and State.
    Senator Alexander. Do you regularly consult with the State 
mental health directors about your two block grants and how 
they're administered and how the money is--how you might 
improve the process of applying for that money and make it 
easier for them to help the people who need help?
    Ms. Hyde. Absolutely, Senator. We put out a block grant 
application. It's now a uniform application that makes it 
easier for States to apply for the funding. We go through a 
public process as well as an informal process of asking for 
input from the States and the two State associations that 
represent State agencies in that process.
    Senator Alexander. I have heard that the statutory deadline 
for the two block grants is in the fall, September and October, 
but that you've indicated that you've moved that up to the 
spring, and that's causing some States to have concern about 
being able to get ready for the applications because of the 
legislative sessions, and that there's some confusion about how 
much information is requested, and that if as much is requested 
as it appears to be that it might be burdensome. Have you heard 
that from State directors? And, if so, what are you doing about 
that?
    Ms. Hyde. Thank you, Senator. Interestingly enough, we 
actually changed that date initially in consultation with some 
States. What we were trying to do is push up the date so that 
they could do their planning during their legislative process, 
so that as their legislature decided match moneys, or what we 
call maintenance of effort moneys, it could be tied to the 
block grant dollars. Since the application is not yet out, we 
probably will change that date before the final application 
comes out.
    Senator Alexander. Could I encourage you to take a look at 
that and make sure that it's not a burden on the States?
    Ms. Hyde. Absolutely.
    Senator Alexander. You mentioned the mental health parity 
letter that came out earlier this month. Did the mental health 
parity law apply to Medicaid by its terms, or does it apply to 
Medicaid by the terms of the new healthcare law? Or is the 
letter something that expands the application of mental health 
parity to Medicaid?
    Ms. Hyde. The letter just explains and provides guidance to 
States about how MHPAEA, the Federal law about parity, applies 
to certain portions of the Medicaid program. So Medicaid 
benchmark plans and benchmark equivalent plans, as they're 
called, or alternative plans are subject to MHPAEA whereas the 
basic underlying Medicaid program in the States are subject to 
other laws.
    Senator Alexander. So it shouldn't be any surprise to 
Governors who are evaluating the cost of Medicaid expansion 
that the mental health parity law applies to Medicaid.
    Ms. Hyde. Senator, I don't know if it's a surprise. It, in 
fact, applies to certain portions of it. So part of the reason 
for the letter was to try to describe the differences about 
where it applies and where it might not.
    Senator Alexander. That's helpful. I've heard from a number 
of Governors, who haven't made a decision about Medicaid 
expansion, that it's hard for them to make that decision 
without knowing the added cost of it to the States, as Medicaid 
has grown as a part of State budgets, for example, in our 
State, from 8 percent when I was Governor to 26 percent today. 
So did you detail in your letter what the added cost to the 
Federal Government or States would be as a result of the 
application of mental health parity to Medicaid?
    Ms. Hyde. No. The letter was not about cost, although, as 
Congress went through the process of passing the MHPAEA, or the 
Mental Health Parity and Addictions Equity Act, there was 
significant discussion about cost, and all the studies that 
have occurred have indicated that the cost is negligible. In 
fact, MHPAEA does allow a plan to request an exemption if their 
costs go over a certain amount. So that is part of the MHPAEA 
law.
    Senator Alexander. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Alexander.
    Now, as you know, it has been a tradition or rule of this 
committee that Senators are recognized in order of appearance, 
and I have here Senator Murray and then Senator Enzi--we'll go 
back and forth--and Senator Baldwin, Franken, Murphy, Sanders, 
Mikulski, Whitehouse, and Warren.
    So I would now recognize Senator Murray.

                      Statement of Senator Murray

    Senator Murray. Thank you very much, Mr. Chairman, for 
holding this really important hearing. It is, I think, 
especially important to note that, obviously, the issue of 
Newtown focused everybody on it. But this is an issue that a 
lot of us have been working on for a very long time, yourself 
included, and I think it's a great time to refocus. I think 
it's really important that it's your first hearing, and I 
appreciate that.
    Senator Alexander, I welcome you to the new Ranking Member 
position and look forward to working with you and all of our 
new members. It's great to have you on this committee. There's 
a lot of great talent here.
    Mr. Chairman, I think that we'll really be able to do some 
good things with this committee. So thank you very much, and to 
both of our witnesses as well.
    I did want to go back. Senator Harkin has mentioned it 
several times. But in the President's recently released gun 
violence package, he issued three parity provisions, one 
clarifying parity for Medicaid-managed care plans, one saying 
that a parity provision would be included in the final 
essential health benefits rule, and one that committed to 
issuing the final rule on the Mental Health Parity and 
Addiction Equity Act which you've mentioned.
    But it didn't make clear, and you haven't yet made clear, 
when we're going to actually see that. If these plans are 
supposed to be ready to go into exchange starting in October, 
it's really essential that we see a final rule on this before 
April. So let me go back to the question that Senator Harkin 
asked again and ask you to be specific about a date that we 
will see this final rule in place.
    Ms. Hyde. Thank you, Senator Murray. I think the 
President's proposals indicated that the essential health 
benefits rule would be out next month. We are working on the 
MHPAEA final reg, and it will go through the regulatory process 
and is in that process now. I can't give you a specific final 
date, but we are on it.
    Senator Murray. Will we see it by April?
    Ms. Hyde. I can't tell you precisely what the date is, but 
we are on it now.
    Senator Murray. Well, it is really essential because our 
States are working on these exchanges and they need that 
clarity to move forward. So I can't urge you strongly enough 
that that date is critical.
    Mr. Chairman, one of the issues I have focused a lot on in 
terms of mental health, obviously, is our military families. 
And I just continue to believe we have to do everything we can 
for our veterans and our service members as they transition, 
especially during difficult periods of redeployment and 
returning home, transitioning back into the civilian world.
    But the focus also has to be on the families of these 
veterans, and I'm certain that is the same throughout all of 
mental health, whether you're talking about military or a 
number of the other topics you've been talking about. The 
Mental Health Access Act that we wrote included provisions to 
expand some of the VA mental health services to family members. 
Can you tell me how you've been progressing in implementing the 
military families initiative?
    Ms. Hyde. Yes, Senator. You may recall that the President 
issued an Executive order in the fall asking HHS and DOD and VA 
to collectively work on improving the mental health access for 
service members and veterans. We're actively working on that 
together, the three departments.
    Part of the way we're trying to get at the whole family and 
the whole needs of the individual is looking at partnerships 
between community health centers, community mental health 
centers, and VA organizations. There are times when family 
members cannot access Veterans Administration, but they can 
access that other mental health center down the road, or vice 
versa.
    So we have been trying to look at pilots. The Executive 
order called for us to work on pilots. We're doing that. And 
we've also been meeting with stakeholder groups, and some of 
those stakeholder groups have been families of veterans, 
service organizations, and others giving us their input about 
the best way we can provide that. We have a report due to the 
President by the end of February, so we're actively engaged in 
that process.
    Senator Murray. I'll really look forward to seeing that. 
And Senator Sanders is taking over the Veterans Committee, and 
he has a strong interest in community health centers as well. 
So I know we'll continue to be able to push on that. But I 
think it's really important that we focus on that for our 
military families.
    Dr. Insel, thank you so much for talking about the 
importance of reminding all of us that mental health doesn't 
mean that someone is violent. I think that's really important 
to remember as we go through this. And, of course, we do need 
to focus on that population that has the potential to become 
violent, particularly at the younger ages.
    So, Mr. Chairman, I think that's why this hearing is so 
essential, and I really appreciate and look forward to hearing 
the testimony of the rest of the panels. Thank you.
    The Chairman. Senator Enzi.

                       Statement of Senator Enzi

    Senator Enzi. Thank you, Mr. Chairman, and I want to 
congratulate Senator Alexander, who gave up a leadership 
position on our side in order to be the Ranking Member on this 
committee. It shows his dedication to health and education and 
workplace safety and training and pensions, and I know that 
he'll do an outstanding job. And I appreciate you holding this 
hearing on mental health as the initial one.
    My first question is for Administrator Hyde. I want to know 
more about the coordination and collaboration of agencies at 
the Federal, State, and local levels. Within your appropriate 
role as a Federal agency, what needs to be done to better 
enhance that coordination and collaboration of agencies at the 
Federal, State, and local levels?
    Ms. Hyde. Thank you for that question, Senator. We've 
actually been trying very hard to recognize the relationship 
between States and local communities, because the State often 
will create laws, rules, regs that, of course, the community 
has to respond to. So when we provide grants, for example, to 
our communities, we're trying to say, ``How does this relate to 
your State's plan and direction?''
    Likewise, when we're providing grants to our States, we're 
trying to ask, ``How are you bringing your communities into 
that process?'' So we are, by our grant making, trying to bring 
them together. Through our community block grant application 
process, we're also asking how these things relate to what's 
going on at the community level.
    And then we have been providing significant technical 
assistance, because there's a lot of change going on in the 
health delivery system to both our States and to our provider 
agencies which provide the basic community infrastructure. We 
also have county-based programs that we do a significant amount 
of work with. So we're trying to look at those relationships.
    I, personally, have had the opportunity to work at all of 
these levels, city level, county level, State level, and now 
the Federal level. And sometimes what you feel is where you 
sit, but I understand probably only too well how much those 
relationships matter. So we are working on them significantly.
    Senator Enzi. Thank you, and I look forward to any 
suggestions you might have.
    Dr. Insel, what do we need to do to close the gap between 
research and real-world practice to ensure that evidence-based 
treatments are available in the community service settings?
    Dr. Insel. Thank you. It's a question that we discuss a lot 
at NIH, not just within the mental health arena, but across all 
of the diseases for which we're responsible for providing 
better science. The typical response to your question or the 
typical assumption behind it is that there's this sort of 17-
year gap between a discovery and implementation. What we used 
to talk a lot about was how do you move from research to 
practice.
    Interestingly, I'd say in the last 2 or 3 years, there's 
been a transformation in how we talk about this. And, 
increasingly, we're beginning to say,

          ``You know, how do we move from practice to research? 
        How do we make sure that we have developed not just 
        healthcare systems, but learning healthcare systems, 
        healthcare systems that are involved in the research 
        process itself?''

    At NIH, we've created several efforts to do that involving 
millions of patients through large healthcare systems, like 
Kaiser and many others, in which we are doing research or we're 
doing actual practical trials in these very large groups at a 
much reduced cost. But the advantage of that is that you're 
making discoveries in the place where they will be implemented 
rather than doing it, for instance, in an academic center where 
there may still be a gap to getting it to the community.
    The other piece of that that's so important--and it's 
actually part of a new institute that was formed at NIH--NCATS 
is actually bringing in the community at the get-go and making 
sure that the kinds of questions that are being asked by 
science are going to give you the kinds of answers that people 
in the community are looking for.
    Senator Enzi. Any reinvention is always appreciated. This 
next question is for both of you. What type of oversight or 
financial controls are in place to ensure that Federal funding 
is being used effectively to prevent and treat substance abuse 
use disorders and mental illnesses? What needs to be done? What 
changes are needed?
    Ms. Hyde. I'll start with that question, Senator. For 
almost all of our programs, we do an evaluation of the program 
to see what kind of outcomes we're getting and what the results 
are, and we try to use those evaluation results in how we do 
the next round of program activities. We also provide some of 
the largest amounts of surveillance data in the area of 
behavioral health, both substance abuse and mental health, and 
we're trying increasingly to use that data to help us 
understand where we need to go.
    We're working on something called the National Quality 
Framework, National Behavioral Health Quality Framework, which 
is a second step from the National Quality Strategy that was 
called for in the Affordable Care Act. And in that we will be 
laying out the framework for quality direction for behavioral 
health as a whole at different levels.
    We also, obviously, collect information and data from each 
of our grantees, and we are trying to make some improvements in 
that by streamlining our data collection systems. We have 
multiple systems now that we're trying to put into one that we 
hope is more effective and easier for States and communities to 
report into.
    There's a number of activities that we are going through 
around accountability and evaluation. And we work very well 
with NIMH, NIDA, and NIAAA on the way that their services--or 
the research that they provide and how we can bring it into our 
practices as well.
    Senator Enzi. My apologies. I've used up more than my time. 
If Dr. Insel would answer that in writing--and I'll also be 
adding a question about duplicative programs between all 
agencies.
    Dr. Insel. I look forward to it. Thank you.
    The Chairman. Thank you, Senator Enzi.
    And now Senator Baldwin. Welcome to the committee.

                      Statement of Senator Baldwin

    Senator Baldwin. Thank you, Mr. Chairman. I am really 
delighted to join the committee and very pleased that the first 
hearing in this committee this session is devoted to this 
incredibly important topic.
    Ensuring access to quality and affordable healthcare has 
been and will always continue to be a very high priority of 
mine. And when I say healthcare, I don't distinguish between 
physical health and mental health, because, to me, they should 
be viewed as one and the same. The Mental Health Parity Act and 
the Affordable Care Act both take important steps to make this 
vision a reality. And together those two laws will both expand 
healthcare insurance coverage to millions of previously 
uninsured Americans and increase access to mental healthcare 
for millions more who have health insurance coverage.
    My first question relates to increased access to insurance 
coverage. As we speak, Governors across this country, including 
in my home State of Wisconsin, are grappling with the decision 
of whether to expand Medicaid coverage under the Affordable 
Care Act. In my home State, around 200,000 Wisconsinites could 
gain Medicaid coverage through the Affordable Care Act Medicaid 
expansion should our Governor make that decision.
    Ms. Hyde, I really appreciate the fact that in your 
testimony you pointed out that Medicaid is currently the No. 1 
payer for mental health services in the United States. We know 
that many vulnerable Americans do not currently qualify for 
Medicaid coverage.
    In your opinion, how might States that are grappling with 
this decision or States that are choosing to expand Medicaid 
coverage under the Affordable Care Act improve mental health 
outcomes for their most vulnerable citizens? Or, perhaps 
alternatively, what variation might you expect to see between 
States that choose to expand Medicaid and those that don't with 
regard to treatment of mental illness?
    Ms. Hyde. Thank you, Senator, and welcome.
    Senator Baldwin. Thank you.
    Ms. Hyde. We are very optimistic that as States go through 
their processes that they will come to the decisions to provide 
the opportunities for coverage for their citizens. And in that 
process, obviously, each State looks at its own Medicaid 
program. However, the letter that we just recently put out was 
an attempt to try to help States understand how they should be 
looking at mental health and substance abuse treatment within 
those contexts.
    There are certainly services that we know can work. We are 
working very closely with the Medicaid agency, CMS, our partner 
agency, in putting out informational bulletins on how States 
can use their Medicaid program to increase access and to do 
better for behavioral health. We are working with them to do 
that. We also, frankly, are working on the enrollment and 
eligibility process with the department as a whole, because we 
know that people with behavioral health needs typically, even 
after fuller coverage, have a harder time staying covered.
    We are doing both, trying to get access through enrollment 
and eligibility, trying to get access through the type of 
service or the array of services that might be provided, and 
just trying to provide information to help the States 
understand what's the most effective way to provide these 
services and the kinds of services that are most cost effective 
and most effective for treatment.
    Senator Baldwin. Thank you. One of the ways that we've 
already seen expansion of access to care--and you were talking 
in your testimony today about the barriers being cost and 
access, ET cetera--is the provision in the Affordable Care Act 
that allows young people to stay on their parents' health 
insurance until they're 26, something I am particularly proud 
of because I worked very hard on that in the House Energy and 
Commerce Committee, and we're pleased to see it in the final 
act.
    I'm wondering, especially given that your testimony talks a 
lot about the age of onset of many profound mental illnesses 
being between 16 and 25, whether you're already observing the 
positive impact of that increased level of insuredness for that 
age population, that age cohort.
    Ms. Hyde. Well, we certainly know that both the provision 
to allow young people to stay on their parents' insurance and 
also the provision to prohibit exclusion from preexisting 
conditions both help young people with mental health and 
substance abuse disorders stay on and keep insurance, or be 
able to get access to insurance when they may not have access 
to it otherwise. Millions of young people are covered through 
that process already, and we know--I don't have a specific 
number, but we know that those young people who have these 
disorders are part of that group.
    The Chairman. Thank you, Senator Baldwin.
    Senator Murkowski.

                     Statement of Senator Murkowski

    Senator Murkowski. Thank you, Mr. Chairman, and I join the 
rest of my colleagues in thanking you for calling this hearing 
on an incredibly important subject. I'm told by my staff that 
we haven't had a hearing in the HELP Committee on mental health 
issues since 2007, which is way past time. So thank you for 
your attention to this.
    I have been focused on the issue of suicide for years now 
and, particularly, youth suicide in this country. In my State, 
we have some very troubling statistics, but the one that I find 
most disturbing are our statistics when it comes to youth 
suicide. In the country, the rate of suicide was 11.5 suicides 
per 100,000 people. In Alaska, we're looking at a suicide rate 
of exactly double that, 21.8 suicides per 100,000 people.
    Even worse are our statistics as they relate to our Alaska 
Native young men. Those between the ages of 15 and 24 have the 
highest suicide rate of any demographic in the entire country 
at a rate of 141.6 suicides per 100,000 people per year, and 
this was between 2000 and 2009. For us, it's staggering, and 
it's something that I just find so troubling, that in 
everything that we do, we cannot seem to be making inroads 
here. So I have long been focused on it.
    I just reintroduced, along with Senator Reed, legislation 
that will help to address the youth suicide, and this is the 
Garrett Lee Smith Memorial reauthorization. We've got a good 
group of co-sponsors. What we're seeking to do is to provide a 
focus on youth suicide in several different areas; to provide 
for prevention programs; and also, in addition to providing 
these grants to States and tribal organizations, to provide 
them to colleges and universities as well.
    The question that I have for you as director here is how we 
can do more within our colleges and within our universities to 
provide for identification, early treatment, early intervention 
and the treatment services that might make a difference with 
our young people in our universities. We see these documented 
mental health needs. I'm concerned that we don't have 
sufficient flexibility within the programs that currently exist 
to help address this need. Can you speak to your observations 
and what we could be doing better to address those in our 
colleges and universities?
    Ms. Hyde. Senator, thank you for the question. As you know, 
the surgeon general along with a very strong public-private 
partnership last September put out the surgeon general's 
National Strategy for Suicide Prevention. In that strategy, 
there were several high priority things identified. I don't 
have the time nor the memory to go through all of them at this 
moment. But there were some very key things, like identifying--
even as we've been talking about it in this youth age group 
having--raising awareness.
    Some people know what to look for--having people be able to 
get help better, engaging an aftercare, to use that term, so 
when people do have risk of suicide or they make a suicide 
attempt, then followup to make sure that there's adequate 
followup, because we know that's a high-risk time, providing 
clinical standards so that clinicians know how to do the 
screening, and that includes campus-based programs. We're proud 
to administer the Garrett Lee Smith program, and we are seeing 
great results in terms of raising that awareness.
    Part of the President's proposals also include the idea of 
a mental health first-aid approach in trying to get people more 
aware, especially focused on youth, of what to look for, how to 
get help, how to know someone needs help, and how to help them 
get that.
    Senator Murkowski. Well, I would hope that we could work 
with you on this. Again, this is a key, key issue for us.
    Dr. Insel, let me ask you a quick question. It has been 
noted by my colleague, Senator Baldwin, that the identification 
of mental illness in terms of recognizing what we're dealing 
with--the onset is as early as age 14, and that the early 
identification can really help with improving outcomes. Yet 
most of our primary care providers that are out there are 
probably not adequately prepared to identify mental illness at 
its earliest stages or provide for that appropriate care.
    What can be done? What is the Administration doing to 
support primary care, to improve these training opportunities 
so that we can do that early intervention, that early 
identification?
    Dr. Insel. That's such an important question, Senator, 
because as we talked about earlier in the hearing, the lesson 
that we've learned over and over again in biomedical research 
is that early detection and early intervention give you the 
best outcomes. So we do need to do better at this. And it's 
challenging in this sphere because we do not have biomarkers 
the way we do for heart disease or cancer or many other 
diseases, where we can take a blood test and know who has what 
or who's on the high-risk path to develop something.
    NIMH is invested very heavily in developing just those 
kinds of tests, whether they're cognitive or biological, to 
know who's in a high-risk state. But that's a long-term plan, 
and I don't think we can wait to make sure that there's better 
awareness and better community support. So one of the things 
that you heard--and Pam has already spoken to this--is Project 
Aware, which was announced last week by the President, which is 
an attempt to go out and increase awareness in schools, in 
primary care, and in communities about the challenge that we 
face, the need to be able to detect the earliest signs, at the 
same time recognizing that there are a lot of teenagers who are 
struggling, and we don't want to label every one of them as 
having an illness.
    So you need to be sensitive to getting better and better, 
more precise measures about who really is at risk and knowing 
who to intervene with. So we've got to find the right balance 
here, and, hopefully, science will bring us some better tools 
for that.
    Senator Murkowski. My time has expired. Mr. Chairman, I 
apologize for having gone over. Thank you.
    The Chairman. Thank you, Senator Murkowski.
    And now Senator Franken.

                      Statement of Senator Franken

    Senator Franken. Thank you, Mr. Chairman. Like all the 
members of this committee, we thank you for calling this 
hearing.
    I want to welcome Senator Alexander as our new Ranking 
Member. I look forward to working with you.
    And I want to thank Senator Enzi for his work as the former 
Ranking Member.
    Like everyone on this committee, I was devastated by the 
tragedy in Newtown. And in the wake of this tragedy, there's 
been a new focus on mental health issues, which I've been 
working on for a long time. Paul Wellstone held the seat that I 
hold, and I, too, share the sense of urgency about the rules on 
Wellstone-Domenici being finalized.
    While I'm glad we're focusing on mental health, I think 
it's important not to stigmatize people with mental health 
issues or generalize about the connection between mental 
illness and violent behavior. And I want to thank both of you 
for making that very clear. As Ms. Hyde said in her written 
testimony, most people who are violent do not have a mental 
disorder, and most people with a mental disorder are not 
violent.
    And, Dr. Insel, you said essentially exactly the same 
thing.
    We should make sure that everyone has access to mental and 
behavioral health services that they need, because it will make 
our communities and families and them healthier and happier. 
But, again, I think it's absolutely vital that we not 
stigmatize mental illness in the process. I think that would 
not only be counterproductive but counterfactual.
    In the next week, I'm going to be introducing two bills 
that will expand access to mental health services. I'll be 
introducing the Justice and Mental Health Collaboration Act. 
It's really a reauthorization and an improvement, I hope, upon 
MIOTCRA, and this is about when people with mental health 
issues encounter the criminal justice system. I have seven 
Republican sponsors on that, including Senator Hatch on this 
committee.
    I'm also going to be introducing the Mental Health in 
Schools Act, which dovetails with Project Aware. And this is 
where, Dr. Insel, your testimony, and your testimony, too, Ms. 
Hyde, is so important. And it's about schools identifying and 
treating--giving access to treatment to kids. The statistics 
you mentioned--only one in five of children who have a mental 
health issue get seen or treated.
    My legislation will allow schools to collaborate with 
mental health providers, law enforcement, and other community-
based organizations to provide expanded access to mental 
healthcare for their students. It will also support schools in 
training staff and volunteers to spot warning signs in kids and 
to refer them to the appropriate services. And I'm glad that 
Project Aware has the same kind of focus.
    I want to ask about the evidence in terms of--with the 
caveat that both of you made about not stigmatizing mental 
illness and associating it with violence. If mental health 
issues go untreated, does that increase the chance that someone 
in a subset, a certain subset of a type of mental illness, will 
become more violent, or will there be a higher chance of that?
    Dr. Insel.
    Dr. Insel. Senator Franken, within that narrow band of the 
people we're talking about, which is a small, small segment of 
the population of people with a mental illness, those, for 
instance, who have what we call first episode psychosis--we 
know that the duration of untreated psychosis is related, in 
fact, to the risk for having a violent act. That's been studied 
quite carefully, and there's a real correlation there. So 
closing that gap is one of the things we can do to increase 
safety.
    Senator Franken. So, in a sense, Newtown did prompt this. 
In that very narrow--and that was one of a number of horrific 
occurrences where I think that no one would question that in 
Tucson, Newtown, we're talking about someone who's deranged. 
And had that person been diagnosed, say, in school and had been 
able to get some kind of treatment--there is some kind of 
connection between making sure that we're identifying and 
treating children early on with the tragedy that brought us 
here.
    Dr. Insel. I'm not going to speculate on those individual 
cases because I haven't seen them. But the data, the published 
data, are quite clear that the difference between severely 
violent acts like homicide between those who are untreated and 
those who are treated is fifteenfold. You drop the risk 
fifteenfold with treatment. So it's vital, absolutely vital, 
that we detect earlier and intervene earlier with something 
that's effective.
    Senator Franken. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Franken.
    Let's see. Senator Murphy has left right now.
    Senator Sanders.
    Senator Sanders. I think Senator Mikulski had an 
engagement, and she wanted to ask just one question.
    The Chairman. Absolutely.

                     Statement of Senator Mikulski

    Senator Mikulski. Thank you very much, Senator Sanders. I 
have a meeting with Senator Shelby to help organize the 
Appropriations Committee. And that will take me to the 
questions for Dr. Insel and Dr. Hyde.
    I think what we're hearing today is that effective 
intervention, whether it's autism or chronic schizophrenia--
it's research, it's treatment, and the workforce to make both 
happen. My question to each one of you--if we could just take 
the issue of research and then perhaps of workforce, but 
particularly research.
    Dr. Insel, what will be the consequences of sequester on 
the work of the National Institutes, your National Institute of 
Mental Health? You've talked about this outstanding work that 
you're doing. What will happen?
    Dr. Insel. At this point, what we're looking at is about a 
6.4 percent reduction in the 2013 budget, and, of course, that 
will come, if it happens, sometime in March or April.
    Senator Mikulski. But what are the consequences?
    Dr. Insel. Well, there'll be certain studies that we would 
like to do that are not going to be done at that budget. And 
one of the major projects that we're involved with is actually 
highly relevant to this discussion today, which has to do with 
how do we ensure that we have the kinds of predictors for early 
psychosis. We have a large national study in what we call the 
prodrome that we would like to scale up, and that's probably 
not going to be done if we don't have the funds to expand what 
we're currently doing.
    Senator Mikulski. So there would be others along those 
lines.
    Now, Ms. Hyde, when one looks at the operation under your 
organization, what would be the consequence--and you can't have 
mental health without mental health practitioners, which 
usually goes to training grants, educational grants, actual 
workforce needs, particularly, as you know, at the State and 
local government. Would sequester have any impact on workforce 
issues, and what would they be?
    Ms. Hyde. Senator, I think it goes without saying that we 
all hope that sequester, which was never really intended to 
happen, doesn't happen. But SAMHSA does a lot of technical 
assistance and training, and we provide a lot of materials and 
practice improvement for the workforce. And to the extent that 
we don't have the same number of resources to do that, then 
less of that will certainly be able to be done and less of the 
grants that we put out as well.
    Senator Mikulski. Will it have a direct impact on training?
    Ms. Hyde. Senator, it very well could. Again, we have a 
fairly significant portfolio in providing what I call workplace 
or practice improvement efforts. And that, again, includes 
training, technical assistance, materials, just access to 
resources. So those all take resources to do, and to the extent 
that we have the resources, we do it, and if we don't, then we 
do less of it.
    Senator Mikulski. Well, I get the picture, and we will be 
coming back for more detailed questions on that. But I think 
this looming threat is severe, and I'm sure it has a tremendous 
impact on morale.
    But Senator Sanders yielded his time to me. And, Senator 
Sanders, I appreciate it. I know you're keenly interested in 
that area as well.
    Let me just say one word. The reason I asked about the 
training--I went to graduate school on an NIH grant. When this 
1963 bill was signed for mental health community centers, I was 
a social worker working as a child abuse worker. Because of 
that, at age 27, I was able to go to graduate school and get a 
master's in social work, and I was supposed to specialize in 
community mental health.
    Now, many might not think I have a therapeutic personality. 
But I did learn a lot, and I learned that these scholarships 
and so on make a difference in lives, and the consequences of 
well-trained people and what they then produce in our society I 
know is important.
    Dr. Insel. And we hope your training is successful in the 
appropriations process as well. So thank you for that.
    Senator Mikulski. I intend to be very agitated about a lot 
of things.
    [Laughter.]
    The Chairman. Senator Sanders.

                      Statement of Senator Sanders

    Senator Sanders. Thank you very much, Mr. Chairman. Newtown 
and other events have highlighted the importance of this issue, 
and I very much appreciate you holding this hearing.
    I'm going to approach the issue in a little bit different 
way, Mr. Chairman, than some of our colleagues. The United 
States of America is the only country in the industrialized 
world that does not have a national healthcare system. In my 
view, in the midst of major healthcare crises in this country, 
including 50 million people today without any health 
insurance--hopefully, that number will be significantly reduced 
under the ACA--the reality is that when you don't have a 
system, you're not prioritizing.
    So what that means is not only are we not paying adequate 
attention to mental health, in general, but the disparities 
based on income and where you live are also enormous. Senator 
Murkowski mentioned the problems in rural Alaska with Native 
Americans. What I can tell you--and I want you to deal with 
this for a moment. If I'm making a half a million dollars a 
year, and I'm living in New York City, and my kid has problems, 
the likelihood is I'm going to be able to get reasonably good 
mental health treatment for that kid. That's the likelihood for 
my kid.
    On the other hand, if I live in rural Vermont, and I'm 
making $25,000 a year, you know what? I'm going to have a very 
difficult time accessing the mental healthcare that my kids 
need. And that's true, I suspect, in Tennessee, and I suspect 
that it's true all over America. The reality is, right now, 
that we have a primary healthcare system which is a disaster, 
that whether it is physical illness or--you made the point that 
we do well with mental health when people can access the system 
when they need it.
    In my office, I can tell you we get calls in Vermont where 
family members say, ``I have--my kid, my husband--serious 
problems. I can't find mental health treatment now.'' So let me 
ask you a simple question. If our goal is to make sure that 
mental healthcare is available to all people who need it, how 
many thousands and thousands of mental health practitioners 
does this country need, and how do we get them?
    Dr. Insel, why don't we start with you?
    Dr. Insel. I'm going to turn to my colleague who is just 
completing a workforce estimate, and so she's actually looked 
very carefully at this issue.
    Senator Sanders. Ms. Hyde, how many thousands of mental 
health practitioners do we need?
    Ms. Hyde. We don't have good studies that say how many we 
need. We have lots of data that tell us what we don't have. And 
we have lots of data that give us comparisons between certain 
areas and certain types of practitioners. We are just 
completing a report for Congress on that. It'll be ready soon.
    Senator Sanders. But before we even get to the report--and 
we need good data--tell me, is it fair to say that if I am a 
low-income person living in rural America or urban America, 
today I am going to have a very difficult time finding mental 
healthcare for my loved ones?
    Ms. Hyde. Senator, I was actually going to go right there, 
so thank you for the question. It's not even so much--although, 
clearly, in certain areas of practitioners, we don't have 
enough. But it's also the distribution. I come from New Mexico, 
so we have major rural areas in New Mexico, and there are 
counties in New Mexico that don't have any behavioral health 
practitioners, none, zero. Something like 75 percent of the 
psychiatrists are in what we call the Rio Grande corridor.
    Senator Sanders. Which, let me guess, is probably--not 
knowing anything about--a wealthy----
    Ms. Hyde. It's Albuquerque and Santa Fe, yes.
    Senator Sanders [continuing]. A wealthy area.
    Ms. Hyde. Well, it's more urban, certainly, yes, and where 
the universities are.
    Senator Sanders. We don't have a whole lot of time. So my 
question is if I am a working class person, if I am unemployed 
in this country, is it a fair statement to say, especially if 
I'm living in rural America, that it would be very, very hard 
for me to access affordable mental healthcare in a timely 
manner? Is that a fair statement?
    Ms. Hyde. I think it is fair to say that rural areas have a 
more difficult time. There are clearly programs like community 
mental health centers, like community health centers, that have 
been explicitly set up for that.
    Senator Sanders. Well, I worked very hard--let me just 
interrupt. I'm sorry. I apologize. We don't have a lot of time.
    Ms. Hyde. That's all right.
    Senator Sanders. I worked very hard to double the funding 
of community health centers and triple the funding for the 
National Health Service Corps. I think we made progress. Would 
you agree that we have a long, long way to go to expand even 
beyond where we have gone in recent years?
    Ms. Hyde. I would agree that we need more practitioners, 
absolutely.
    Dr. Insel. And I would add to that that it's not only 
across the board, but there are particular areas of need that 
need attention. One of them is in children, and we've been 
talking a lot about youth needs. Child psychiatry is a way 
underemployed----
    Senator Sanders. Absolutely.
    Dr. Insel [continuing]. And child psychology is incredibly 
important to build the workforce.
    Senator Sanders. All right. Let me just conclude. I think 
it's a class issue, too, Mr. Chairman. I think to some degree 
psychiatry is something that is accessible for urban, upper 
income folks. It is not accessible for low-income rural folks. 
So I think the point that Ms. Hyde made is an important one. We 
have to look at geography, and we have to make sure that mental 
health is available to all people, regardless of their income, 
all over this country.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Sanders. I might just add 
that since I focus so much on prevention and early intervention 
right now, school psychologists--the national average is 1,500 
to 1. The recommended ratio--I don't know recommended by whom--
is 700 to 800 students per psychologist. So we need to double 
that if we're even going to meet the recommended level for kids 
in school.
    Senator Warren, welcome to the committee.

                      Statement of Senator Warren

    Senator Warren. Thank you very much, Mr. Chairman. It's 
good to be here. I want to apologize for coming in late. I have 
the best possible excuse. I was introducing my senior Senator, 
Senator Kerry, to the Senate Foreign Relations Committee. And I 
believe that will not be a recurring event.
    The Chairman. Is that your way of saying soon you will be 
the senior Senator from Massachusetts?
    [Laughter.]
    Senator Warren. Yes, sir, it is. So I thank you.
    I would like to start with my questions in the same place 
that Senator Enzi started. I have a very similar interest in 
the questions about research around evidence-based medicine, 
around accountability, around our funding for research.
    What I'd like to do is just start with you, Dr. Insel, if 
you would, and I'll ask you to do two things for us. The first 
is just paint us a little bit of a picture about what we can do 
with research in the mental health field. If we get some good 
research, what can we learn that we don't know? And would you 
talk just a little bit about what funding levels are doing to 
research?
    Dr. Insel. Thank you for that question. I don't usually get 
an opportunity to talk about this, and I promise I'll do it 
very quickly. But you're asking the question at a critical 
moment in time. We are really, in the case of understanding 
mental illness, where we were in some ways for studying cancer 
20 or 30 years ago. We're just on the cusp of a revolution, and 
it's because we have these extraordinary tools now.
    For the first time, we can approach problems of the mind 
through studying the brain, and that gives us a kind of 
precision that we've never even imagined we could have. The 
reason that's so important is because for behavioral problems, 
whether they're in Parkinson's Disease or Alzheimer's Disease 
or Huntington's Disease, the behavioral symptoms are a very 
late event. Those are the heart attacks. And it's the same 
thing, we believe, for the psychosis and schizophrenia.
    We define these as behavioral disorders. But, in fact, 
they're brain disorders, and the brain changes are probably 
occurring years earlier. And if we want to detect and intervene 
earlier, we're going to have to be able to develop ways to get 
at that, to understand them as brain disorders in the same way 
that we've done now in many other areas of medicine.
    I think where the science is taking us is toward the 
biomarkers. It's toward the fundamental biology. We have not 
been there before. We've had a very simplistic approach to 
this. It is far more complicated. The good news is we've got 
far better tools to be able to unpack this.
    Your question was about the funding. It's a challenge. 
There are lots of questions, lots of things we'd like to 
answer. I'd have to say that for NIMH, the shift has largely 
been to move much of our funding to people who actually 10 
years ago were studying cancer and heart disease who are now 
joining us because they feel that autism and schizophrenia are 
the new frontiers, and these are the places where you're going 
to make the big breakthroughs.
    It's always frustrating because there's, of course, never 
enough funding to support all of the best ideas that come in. 
We try to support about 20 percent of them. So that one in five 
grants gets funded. I hope that I'm smart enough to pick the 
best 20 percent. I'm afraid I'm not, and I think if I could do 
30 percent, I'd probably have a much better hit rate. It's just 
hard to know often. So that's always the challenge. You never 
have the funding you want to do all the science, some of which 
is just spectacular, that's sitting there in front of you.
    Senator Warren. Can I ask you just to expand on that in one 
more dimension, and that is--you described it as your hit rate. 
If you really hit on some of these studies on Alzheimer's, on 
autism, can you just speak briefly about what the financial 
impact will be on the country?
    Dr. Insel. Well, we know that in the case of Alzheimer's 
that if we can just forestall the dementia by a matter of 1 
year or 2 years, which is certainly, I think, within our grasp 
as we've gotten a better understanding of how to predict and 
are now looking at ways to intervene, we're talking about 
billions of dollars that would not have to be spent, which are 
now going into the care of people with dementia.
    It really comes down to a question of do you want to invest 
early, or do you want to pay later, because you don't know 
enough and you're not doing this in a way that's efficient. 
And, unfortunately, I think we've tended to decide that we'll 
pay later, often at a very large premium, instead of making the 
early investments in Alzheimer's, autism, schizophrenia to make 
sure that we come up with better solutions.
    Senator Warren. Thank you very much.
    Ms. Hyde, my time has expired. But if you had a quick 
comment you'd like to add, I'd be grateful.
    Ms. Hyde. The quick comment here is you know, of course, 
that these disorders have profound impacts on our justice 
systems, on our school systems, on our public welfare systems, 
our child welfare systems. There's profound dollars that are 
being spent there because we are not intervening early, because 
we are not providing the kind of supports to the young people 
and their families.
    Senator Warren. Thank you very much.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Warren.
    Senator Bennet.

                      Statement of Senator Bennet

    Senator Bennet. Thank you, Mr. Chairman. I was 
unfortunately on the floor with my senior Senator--there's 
nothing unfortunate about that--on an issue of great importance 
to Colorado, so I missed the testimony. I think I'll refrain 
from asking my questions now. I'll submit something for the 
record if that's OK with you, and I know there's a second 
panel.
    But I want to thank you very much for holding this hearing. 
And I'd like to join Senator Franken in saying how delighted I 
am to see our Ranking Member, Senator Alexander, here and thank 
Senator Enzi also for his work as the former Ranking Member of 
the committee, and, finally, to welcome our new colleagues to 
the committee. It's wonderful to see you here.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Bennet.
    I thank our first panel. Thank you, Dr. Insel, and thank 
you, Ms. Hyde, for being here.
    Now we'll call our second panel, Dr. Michael Hogan, Dr. 
Robert Vero, Mr. George DelGrosso, and Mr. Larry Fricks.
    On our next panel, first, I'll introduce Michael Hogan. Dr. 
Hogan is the former commissioner of the New York State Office 
of Mental Health and chairman of the President's New Freedom 
Commission on Mental Health. In his capacity as the 
commissioner of the New York State Mental Health Office, he 
oversaw New York's $5 billion public mental health system. 
Previously, he served as the director of the Ohio Department of 
Mental Health and Commissioner of the Connecticut Department of 
Mental Health.
    We thank you for being here, Dr. Hogan.
    And for purposes of an introduction, now I'll turn to our 
Ranking Member, Senator Alexander.
    Senator Alexander. Thanks, Mr. Chairman. I am delighted to 
welcome Robert Vero from Centerstone of Tennessee. He's well 
known in our State. He has done work in the behavioral 
healthcare field for a long time, four decades. He's chief 
executive of the company, or nonprofit organization, the 
largest nonprofit community mental health centers. They have 
more than 50 facilities and 160 partnership locations. They 
serve nearly 50,000 people of all ages each year.
    He has a distinguished academic background, which includes 
his work at Peabody College at Vanderbilt. He's a clinician. 
He's active and consulted by many for his expertise in this 
field, and I look forward to his insights about who needs help 
and how we can do a better job of making sure they get that 
help.
    Thank you for being here, Dr. Vero.
    The Chairman. Thank you, Senator Alexander.
    Also for purposes of an introduction, I'll recognize the 
Senator from Colorado, Senator Bennet.
    Senator Bennet. Thank you, Mr. Chairman, and it is a great 
privilege to introduce Mr. George DelGrosso to the committee. 
Mr. DelGrosso currently serves as the chief executive officer 
of the Colorado Behavioral Healthcare Council. The Council is a 
statewide network comprising 28 behavioral health 
organizations. It provides treatment and other services to over 
120,000 Coloradoans each year. Mr. DelGrosso began his career 
as a psychotherapist. He then became a marriage and family 
therapist, and he was promoted to a clinical supervisor and 
program developer before ultimately moving into senior 
management.
    Before leading the Colorado Behavioral Healthcare Council, 
Mr. DelGrosso served as the executive director of Mental Health 
Centers in the San Luis Valley in our State and in Cody, WY. 
Throughout his career, Mr. DelGrosso has worked to improve 
training and to develop integrated treatment approaches to 
mental healthcare. Currently, he is working to expand the 
Mental Health First Aid Program in Colorado to improve 
prevention, early identification, and access to care for those 
suffering from mental illness.
    His decades of experience within the mental healthcare 
system give him a unique perspective on our discussions today. 
And it's in that spirit that I'd like to welcome Mr. DelGrosso 
to the committee, and I look forward to his testimony.
    The Chairman. Thank you, Senator Bennet.
    And now we have also Mr. Larry Fricks, a Senior Consultant 
at the National Council for Behavioral Health. Mr. Fricks is 
also the Director of the Appalachian Consultant Group and 
Deputy Director of the SAMHSA-HRSA Center for Integrated Health 
Solutions. He will share with us his firsthand account of 
recovery from mental illness and substance abuse.
    We thank you for being here, Mr. Fricks.
    As with the last panel, your statements will all be made a 
part of the record in their entirety, and I'll ask you to sum 
up--we'll just go from Dr. Hogan down--in 5 to 7 minutes, so we 
can get to a round of questioning. I'll start with Dr. Hogan.
    I read all your testimonies last night. They're just 
excellent, just excellent, every one of them.
    I remember, Dr. Hogan, you talked about separate but 
unequal, mental health from what we call regular health, I 
guess, or the healthcare system. Welcome and please proceed.

  STATEMENT OF MICHAEL HOGAN, Ph.D., FORMER COMMISSIONER, NEW 
 YORK STATE OFFICE OF MENTAL HEALTH, AND CHAIRMAN, PRESIDENT'S 
      NEW FREEDOM COMMISSION ON MENTAL HEALTH, DELMAR, NY

    Mr. Hogan. Well, thank you, Senator Harkin. I just have to 
start as others have by expressing appreciation on behalf of 
our community to the committee for focusing on this at this 
time. It's been quite a while. But the timing is now, for other 
reasons that I'll explain, and recent events, I think, make it 
the right time to pay this some concern, and we're particularly 
appreciative that this focus happens on Senator Alexander's 
first meeting as Ranking Member.
    I will start my remarks by focusing on something that is 
subtle and often not apparent with respect to mental healthcare 
as provided, and that is to say that the mental health system 
started in asylums run by States without the support or 
involvement of the Federal Government in any way. And to some 
extent, as we focused on a movement from asylum to community, 
there was attention to the locus of care that was being 
transformed.
    But what escaped attention was that care in separate 
programs and systems was still separate. That is changing 
before our eyes right now. And it's changing and accelerating 
in ways that we can't even see because of legislation that has 
already been discussed, first originating in this chamber with 
Senator Wellstone and Senator Domenici, to say that mental 
healthcare had to be a part of healthcare, no longer separate.
    And then second of all, the Affordable Care Act took that 
parity legislation and baked it into all the changes in 
healthcare that are going forward. So we are at a time when 
mental healthcare is increasingly going to be part of 
healthcare, and this raises two major questions for me.
    One of them is: Will we take time and attention to make 
sure that we get mental health right in the mainstream of 
healthcare? We're fumbling at that right now. I want to talk a 
little bit more about that.
    The second is: As we move away from the separate system, 
will we pay enough attention to it and ensure that there is 
sufficient stewardship for it in States and so on--this is 
primarily a State problem--or will we recapitulate the 
institutionalization by walking in another direction that is 
well-intended but that forgets the people with the most serious 
needs?
    Those, it seems to me, are the two major challenges that we 
face. And having said that, I want to just touch on a couple of 
points briefly in that context.
    The first of those has to do with the imperative of trying 
to figure out how we can help primary care providers to deliver 
basic mental healthcare. We're not asking them to do the 
complicated stuff. But most primary care providers with a 
little bit of help can do an excellent job with most of the 
mental health conditions that people walk into their offices 
with, but they can't do it on their own. They've got to have a 
social worker or a nurse or somebody who can spend the time 
with people. Their practice has got to be paid a little for 
that. Medicare still doesn't do that very well.
    We have to take steps toward what's now called integrated 
or collaborative care to make sure that we provide that care in 
primary care. Right now, more people get something for their 
mental health problems in primary care than get it from the 
entire separate mental health system. But it tends to be a day 
late and a dollar short and not to be very effective. Your 
chances of getting a diagnosis with depression if you walk into 
your GP's office are less than 50-50, and your chances of 
getting enough treatment to make a difference are about 15 
percent. But with a little bit of attention, that problem can 
be resolved.
    I won't comment too much on the problem of protecting the 
safety net as we go forward in this transition. But I think 
what I would say is what the committee's attention might be 
focused on, which is whether there are adequate standards for 
mental healthcare, not in SAMHSA, but in CMS as the system goes 
forward. Increasingly, in States right now, when you're 
concerned about mental health, you don't talk to the mental 
health director. You talk to the Medicaid director. And whether 
they have this on their radar screen is sort of a coin flip, 
and Federal standards there would help.
    The committee has already talked significantly about 
children's issues. And Senator Alexander's example of that 17-
year-old with an early psychotic symptom, that Senator 
Murkowski also talked about, is something else that I want to 
comment on.
    We know how to address those problems today and we do not. 
We know how to engage people in care with an early psychotic 
problem as we would, in a sense, in a modern cancer center. 
Family would be welcome. We'd look at a longitudinal plan of 
care. We would stick with people to try to find something that 
was acceptable to them, as opposed to waiting until they 
deteriorate, putting them in a hospital, letting them leave 
with a referral to care. That is just not going to work.
    I have two other points that I've addressed in my written 
testimony, and my time is up. So I won't comment on them, other 
than to say I really want to underline what Senator Murkowski 
has said about the problem of suicide. Administrator Hyde and 
the Surgeon General have really stepped up on this. The 
Department of Defense and Veterans Affairs are moving on this. 
The rest of the Government should pay a little bit more 
attention because it's costing us more lives lost from suicide 
every week than we lost to military suicides in the entire last 
year.
    Thank you.
    [The prepared statement of Mr. Hogan follows:]
             Prepared Statement of Michael F. Hogan, Ph.D.
                                summary
    A decade ago the commission appointed by President George W. Bush 
to review mental health care said ``the mental health services delivery 
system is in shambles.'' Just 10 years later, both problems and 
solutions are clearer. Mental health parity with the ACA moves mental 
health to the mainstream of health care. We must capitalize.
     Integrating mental health care into health care is a big 
opportunity that could easily be missed. Most Americans with mental 
health problems get no treatment. More people are treated in primary 
care than by mental health specialists, but this care is poorly paid 
for and often inadequate. Collaborative care is a proven approach to 
integrated care. It would be timely and very helpful if the committee 
were to track progress toward integrated care.
     Protecting the safety net for individuals with serious 
mental illness is essential as we move to integrate care. While budget 
cuts have been damaging, in many States the mental health safety net is 
better and more focused than it was a quarter century ago. We do not 
yet have national standards for the quality of care for people with 
serious mental illness. Without such standards the transition away from 
expert leadership is risky. We must not repeat the errors of 
deinstitutionalization in the correct and optimistic move to 
integration. More robust national standards for mental health within 
Medicare and Medicaid would help.
     Children's mental health care must be improved. Mental 
health problems have been called ``the major chronic diseases of 
childhood.'' Mental illness usually emerges before young people enter 
high school, but the average lag to treatment is 9 years. Reform 
presents major opportunities. Practical steps include: (1) screening 
for and treating maternal depression, (2) helping pediatrics and child 
mental health programs to provide holistic care, (3) upgrading 
performance standards for child mental health care within health care 
plans and programs, and (4) improving school mental health services 
using only research-tested approaches.
     We must develop a national approach for effective early 
treatment of psychotic illness. Our Nation's approach to helping people 
with psychotic illnesses like schizophrenia is shameful; better 
approaches have been tested in the United States and implemented widely 
in Australia and Great Britain. The committee's attention to this issue 
would have a positive effect.
     Lifelong disability for people with mental illness is 
common, but usually unnecessary. Supported employment for people with 
mental illness is effective but underutilized. The Federal Government, 
with leadership from the Social Security Administration and the Centers 
for Medicare and Medicaid Services can change this and reduce needless 
disability.
     Suicide prevention: Now is the time to act. Deaths by 
suicide in the Armed Forces last year exceeded combat deaths. Sadly, 
this is but the tip of the iceberg; twice as many American lives are 
lost to suicide in the average week than to military suicide during all 
of 2012. The Affordable Care Act offers numerous opportunities to 
incorporate best and effective practices for suicide prevention into 
Medicare and Medicaid, and into reform more broadly. The committee's 
attention could help assure that other Federal agencies beside SAMHSA 
and the Department of Defense are focused on preventing suicide, that 
the National Action Alliance for Suicide Prevention is sustained and 
that the national network of crisis lines that can be reached at 1-800-
273-TALK is strengthened. These steps would be life-saving.
    The mental health community greatly appreciates the committee's 
attention at this crucial time.
                                 ______
                                 
    The mental health community appreciates the attention of the 
committee, and the concern for consumers, families and providers that 
it represents. Mental health needs are substantial, but such attention 
from policymakers is rare.
    What is the state of the mental health system? A decade ago, a 
commission appointed by President George W. Bush to review mental 
health care told the President that despite the efforts of many 
dedicated people ``the Unites States mental health services delivery 
system is in shambles.'' While many of the challenges we addressed 
still exist, problems and solutions are clearer a decade later. I hope 
we can provide you with a helpful picture of them.
    Much has changed, while much appears to remain the same. The 
Nation's mental health system had its origins in the asylums of the 
19th century. While much has been said about the balance between 
institutional and community care, a bigger issue is that for most of 
our history, mental health care has been separate from health care--and 
also unequal. In the best recent study of mental health policy, Richard 
Frank and Sherry Glied assessed whether people with a mental illness 
were better off early in this century than 50 years earlier. They 
answered that question in the name of their monograph: ``Better, but 
not well.'' However, the main insight from their study is that the 
improved well-being of people with a mental illness is not mainly due 
to changes within mental health care. Rather, the well-being of people 
with mental illness improved as they gained access to mainstream 
benefits like health care, disability insurance and housing. 
Improvements within the mental health system, like new treatments, had 
a smaller effect.
    This trend has now accelerated. A major example is legislation 
known by the two outstanding Senators, a political odd couple united by 
concern for mental health, who sponsored it: Pete Dominici and Paul 
Wellstone. The 2007 passage of the Mental Health Equity and Addictions 
Parity Act (MHEAPA) was not about improvements within the mental health 
system. It was about including mental illness care in health care. It 
signaled that a separate and unequal mental health system was not an 
adequate solution.
    Mental health care was also greatly enhanced by passage of the 
Patient Protection and Affordable Care Act (ACA). Building on Dominici-
Wellstone, the ACA included mental health within its changes to health 
care. These two pieces of legislation are game changers for mental 
health. The inclusion of mental health will lead to profound changes 
that will play out over the next generation. Because health care is so 
complex and change is unpredictable, there will be false starts and 
dead ends. But any assessment of the state of America's mental health 
system must begin with a realization that we have begun to take big 
steps away from an approach that was both separate and unequal. The 
major challenges facing us are first whether including mental health in 
health care can be done sensibly, and second whether the portions of 
the mental health safety net that have value can be sustained. 
Inclusion creates big opportunities that we can seize or let slip away. 
In an earlier era of deinstitutionalization, we did not sustain our 
commitments to those most in need during change. Can we get it right 
this time?
    Integrating mental health care into health care. A first major 
challenge for the next decade is to integrate basic mental health care 
into primary care. (Integrating primary medical care into mental health 
centers is also important, but not my major focus here.) We know that 
most Americans with mental health problems get no treatment for these 
problems. We also know that more people are treated by their family 
physician or other primary care practitioner than by mental health 
specialists. The problem is that we have many unmet needs while many 
specialty mental health programs are at capacity. The opportunity 
before us is that health coverage that includes mental health care will 
become available for many Americans. We must use this opportunity to 
provide integrated primary care that includes basic mental health care. 
There is less stigma in visits to primary care. People with a chronic 
illness like diabetes, cancer or hypertension who also have depression 
have health care costs at least 50 percent higher; and good basic 
mental health care reduces overall costs. Improving basic mental health 
care in primary care is a huge need and opportunity.
    It will not occur automatically. Mental health care within primary 
care today is often inadequate. It can be done well, improving health 
and reducing costs, but barriers must be addressed. For example, 
``carved out'' benefits for mental health care can usually be used only 
if a specialist is seen. Across primary care settings that have not 
upgraded to provide integrated care, less than half of the patients 
with a mental health problem get a mental illness diagnosis and 
treatment. Payments and supports for basic mental health care in 
primary care are often lacking, so less than 15 percent of the people 
with depression in primary care get adequate care. As a result, people 
with medical conditions like diabetes or high blood pressure as well as 
a mental health concern have bad health outcomes and higher medical 
costs.
    We have an opportunity to address this problem because many people 
with these conditions will now have insurance that includes mental 
health care, and because practical ways to deliver basic mental health 
care in primary care settings are now well established. The approach, 
known as collaborative care, improves both health and mental health 
outcomes and also reduces total costs. Collaborative care is research 
tested and replicated in many real world clinics. The move to 
integrated care takes work, but its core elements are not complex: 
station a mental health practitioner in the practice, screen for mental 
health problems, measure progress, allow billing for basic mental 
health services like educating patients about managing their depression 
and ensure a psychiatrist or other specialist is available for 
consultation.
    While collaborative care is proven, barriers to integrated care 
like separate benefits that are not available to primary care must be 
addressed. For collaborative care to work, the primary care setting 
must have its costs covered, including the modest additional costs of 
providing integrated care. There are also barriers in Federal 
standards. Medicare still does not pay adequately for the elements of 
collaborative care, despite the terrible burden of depression and other 
mental health challenges for older Americans. National screening 
recommendations are also outdated. They say, in effect, ``If you have 
plenty of resources to treat depression, you ought to screen for it.'' 
This is ridiculous. In my view, removing obstacles to primary care 
treatment of basic mental health problems is a core element of getting 
mental health parity right. It would be timely and very helpful if the 
committee were to track progress toward integrated care.
    Protecting the safety net. While health reform creates 
opportunities to improve care for many Americans, the safety net for 
individuals with the most serious mental illness is very stressed. This 
system, which evolved from State asylums and mental health centers to a 
diverse array of community-based treatment, rehabilitation and support 
services, is directed and managed at the State and sometimes the county 
level. Its financing depends on Medicaid and State general funds. And 
given State budget shortfalls, resources have been cut. The National 
Association of State Mental Health Program Directors (NASMHPD) 
indicates that State mental health funding was reduced by more than $4 
billion between 2009 and 2012.
    While these cuts have been damaging, in many States the mental 
health safety net is stronger than it was a quarter century ago. 
Dedicated providers as well as State and local officials have learned 
what works. For example, we understand that decent, safe and affordable 
housing is a foundation for recovery, and a ``Housing First'' approach 
that first finds homeless mentally ill people a place to live and then 
assists with health and mental health has become a usual approach. We 
understand that people in recovery from mental illness and addiction 
working as ``peer specialists'' play an invaluable role as staff of 
community agencies. Many community mental health agencies are also 
integrating medical services into their mental health clinics, to 
address the co-occurring medical problems of the people they serve. So 
while the mental health safety net is stretched to the limits, it is 
better focused and more relevant than in the past.
    There are threats to the safety net as health reform proceeds. 
Budget cuts have taken their toll, and we hope that as States move past 
budgets depleted by the recession there will not be further deep cuts. 
But there is also a concern about the erosion of informed leadership 
for the safety net system. Within States, as Medicaid has become the 
dominant payer for mental health services, the mantle of leadership is 
swinging away from mental health (and addiction) agencies toward 
Medicaid and Health agencies. A similar trend is occurring at the level 
where health care is managed; there is a movement toward managed care 
and within managed care there is movement from specialty behavioral 
health plans to mainstream managed care. The question is whether we can 
sustain the focus on quality of care for those most in need during this 
transition. We do not yet have national standards for the quality of 
care for people with serious mental illness, so the transition away 
from expert leadership is risky. We failed to maintain focus during an 
earlier era of deinstitutionalization; we must not make this mistake 
again.
    Children's mental health care. Mental health problems have been 
called ``the major chronic diseases of childhood.'' Mental illness 
usually emerges before young people enter high school, but the average 
lag to treatment is 9 years. Only about a quarter of children with 
mental health problems see a mental health professional, and often not 
enough care is delivered to make a difference. At the same time, we are 
scandalized by reports showing increased levels of psychiatric 
medication use among children, often with no adequate counseling to 
supplement or as alternative to medications. We see the results of 
insufficient mental health care in school failure and youth suicide. 
How do we do better?
    While the gaps in children's mental health care are huge there is 
also reason for hope. In part, this is because we know more about what 
works, and what doesn't. We must start applying this knowledge. The 
timing is right if we act as we should; there are opportunities in 
healthcare reform and in calls to improve school mental health care. 
But like improvements to mental health care in primary care, 
improvement will not occur unless steps like these are taken:

     Make screening for and treating maternal depression 
standard for the first 2 years after birth. Maternal depression is 
prevalent, treatable, and can lead to big problems in development of 
the young child if left untreated. Treating mom's depression reduces 
levels of mental health problems for her children by half !
     Help pediatric practices and child mental health programs 
to provide holistic care. Noted columnist David Brooks--scarcely a 
bleeding heart liberal--has written persuasively of the problem of 
children growing up without the ability to ``self-regulate''--to manage 
themselves and their own behavior. These skills can be taught--but only 
if we begin early by providing structured support to young parents. To 
do this, we need to be able to:

          Begin therapy for children without a specific 
        diagnosis--to reduce the chance that a serious diagnosis will 
        be given later.
          Allow comprehensive pediatric practices and child 
        mental health programs to bill for parent training and support 
        for behavior management--to reduce the use of major medication 
        use after the behavior has gotten worse.
          Reimburse and support team-based care in pediatrics 
        including physician attendance at team meetings with families.
          Reimburse pediatric and child mental health programs 
        for care coordination with schools and other agencies; care 
        coordination may be more effective and cost-effective than 
        layering on additional treatments.

     Put better performance standards in place for child mental 
health programs. Right now national standards are limited to ADHD and 
followup after hospitalization. Adolescent depression indicators are 
being developed but are not yet approved or used. What doesn't get 
measured in health care often doesn't get done.
     Do school mental health right. The President's proposals 
following the tragedy in Newtown include significant expansion of 
school mental health. Done right, this could be a significant benefit. 
But we now know more about what is effective, and what isn't. Expanded 
programs should only use proven approaches, such as peer-assisted 
learning, and cognitive behavioral interventions for trauma, adapted 
for schools. Each of these approaches has been linked to improving 
educational outcomes.

    Develop a national approach for effective early treatment of 
psychotic illness. Our Nation's approach to helping people with 
psychotic illnesses like schizophrenia is shameful. Usually, young 
people slip into psychotic illnesses for several years while they--or 
their families--get no help. When they have a ``first psychotic 
break,'' they usually are briefly hospitalized. Almost always, 
medications take the worst of the symptoms away--within days or weeks. 
So then they are discharged with a referral to care and maybe a 
recommendation of a support group. This is woefully, stupidly 
deficient. Having symptoms reduced is not a cure. When people feel 
better, and especially since the drugs have significant side effects, 
they often stop taking them. Relapse is likely. Usually the second 
break is worse. And then the revolving door begins. Often after decades 
people figure out how to manage their illness, but by then they are 
often on permanent disability status, unemployed, and in terrible 
health.
    Some have suggested that the solution to this problem is in going 
backward--not forward--to days when stays in mental hospitals were 
measured in months and years. This is idiotic. There is no research to 
suggest it is effective. It is terribly expensive. Hospitals cannot be 
run (as the old asylums were) on unpaid patient labor. And a civilized 
society cannot detain people on a vague hope they will get better. So 
we will not turn the clock back on mental health care. But we do need a 
modern approach to care for people with psychotic disorders, one that 
replaces both the asylum and the revolving door with continuous team 
treatment like that we provide for people with chronic medical 
problems. Teams delivering First Episode Psychosis (FEP) care have 
figured out how to do this work. It is person-
centered, family-driven, collaborative and recovery-oriented. Staying 
in school or work is encouraged--though adaptations may be needed. It 
is time to implement this approach, as both Australia and Great Britain 
have done. We need not lag behind other nations in this area. Our 
country needs to make modest investments now to develop FEP teams so 
that families anywhere in the State struggling with a young adult who 
is slipping away from sanity can get good care reasonably close to 
home. The committee's attention to this issue could have an enormous 
positive effect.
    Lifelong disability for people with mental illness is usually 
unnecessary. While many of the worst outcomes of serious mental illness 
(e.g. homelessness, comorbid medical illness, incarceration) are 
receiving increased attention, we are failing systematically to help 
people escape poverty and disability. In effective supported employment 
approaches such as Individual Placement with Supports (IPS) a majority 
of adults with serious mental illness find a job. But we generally fail 
to use this effective program. The Nation's Vocational Rehabilitation 
(VR) system is focused on employment for people with disabilities, but 
it is limited in scope and flawed in its approach to helping people 
with mental illness. Most people with serious mental illness never get 
VR services, and among those who do, outcomes are worse than for other 
groups of people with disabilities. Most VR programs do not use IPS 
systematically. Meanwhile, Medicaid does not pay for key components of 
IPS. Because of these cracks between systems, an effective approach is 
usually not made available, and the employment rate among people with 
serious mental illness who are receiving care is, scandalously, about 
15 percent.
    Supplemental Security Income (SSI) and, for those who become 
disabled after working, Social Security Disability Income (SSDI) are 
invaluable lifelines for people with serious disability including 
serious mental illness. But many people with mental illness on SSDI and 
SSI want to work. And most could work--at the very least in part-time 
private sector employment--if IPS was available and if disability was 
not an ``all or nothing'' program.
    I would like to bring to the committee's attention an innovative 
program established by New York State and the Social Security 
Administration to address this problem. It takes advantage of Ticket To 
Work--a well-intended back-to-work incentive program that has never 
reached its potential, largely because of its complexity. The New York 
State Office of Mental Health (OMH) in collaboration with the New York 
Department of Labor and other State agencies serving people with 
disabilities developed a comprehensive employment system for people 
with serious mental illness and other disabilities. Key components 
include: (1) education and counseling on benefits (such as how to 
maintain Medicaid coverage while working, and how to take advantage of 
complex Social Security work incentives); (2) an integrated information 
system that links people to and is built onto the Department of Labor's 
workforce system; and (3) a statewide network of IPS services delivered 
through OMH Personalized Recovery Oriented Services (PROS) programs. 
Via a unique partnership agreement, the Social Security Administration 
has designated this system including all participating consumers and 
providers as a Ticket To Work Employment Network. This arrangement is 
the most systematic statewide approach to employment services and to 
fully using available benefits to support productivity instead of 
poverty and disability.
    I urge the committee's attention to the costs and consequences of 
unnecessary disability for people with serious mental illness, in 
particular to:

     Assuring that Vocational Rehabilitation and Medicaid 
figure out how to make effective Individual Placement with Supports 
services available to all people with serious mental illness who want 
work instead of poverty, and
     How the Social Security/New York partnership can be 
implemented in other States.

    Suicide prevention: Now is the time to act. We are dismayed by 
reports that deaths by suicide in the Armed Forces last year exceeded 
other combat deaths. This concern is surely justified. Yet this is but 
the tip of the iceberg; twice as many American lives are lost to 
suicide in the average week than to military suicide in a year. 
Suicide, which is the tenth leading cause of death--and the third 
leading cause of death among young adults--receives a relatively small 
investment in terms of research and programming than other public 
health problems of its magnitude. We can and we must do more.
    The Administration, to its credit, has begun to focus on suicide 
prevention. In 2010, Secretaries Sebelius and Gates launched the Action 
Alliance on Suicide Prevention, a public-private partnership co-chaired 
by Army Secretary John McHugh and former Senator Gordon Smith. With 
support from the Action Alliance, Surgeon General Regina Benjamin has 
released a comprehensive update of the National Strategy on Suicide 
Prevention, originally released in 2001. Yet more action is needed. 
Suicide prevention activities are scattered and thin. Outside the 
Department of Defense, the only national efforts are the National 
Suicide Prevention Lifeline (1-800-273-TALK), a technical assistance 
center, and the small network of youth and college prevention programs 
funded by the Substance Abuse and Mental Health Services Administration 
under the Garrett Lee Smith Memorial Youth Suicide Prevention Act.
    It is time to do more to fight this needless and often preventable 
form of death. It is claiming the lives of students, soldiers, 
veterans, and Americans of every age and background. Congressional 
action would help advance this cause, as it did with passage of the 
Garrett Lee Smith Act. The Action Alliance is focusing integrating 
state-of-the-science suicide prevention practices into initiatives 
under the Affordable Care Act. We assess that current clinical 
practices in the United States are one to two decades behind the 
research, which demonstrates that effective care, what we call 
``suicide care,'' targeted to patients who are at risk, can 
significantly improve their prognosis. The Affordable Care Act offers 
numerous opportunities to incorporate best and effective practices into 
preventive services offered through Medicare and Medicaid, into 
electronic health records, and into other reform initiatives.
    Suicide prevention is an area where small amounts of money can make 
a difference. The Action Alliance has the potential to bend the curve 
on suicide, but it is funded this year via a time-limited grant from 
SAMHSA. Similarly, the Nation's network of certified crisis lines, 
although linked together by the SAMHSA-funded Lifeline project, is 
mostly funded by State and local-level grants and philanthropy, yet it 
is projected to respond to a million callers this year, a large 
proportion of whom are in utter desperation and on the threshold of 
their own death. Research has conclusively shown that these crisis 
lines are effective and are performing as an indispensable part of the 
Nation's health care system, yet they receive no Federal support. The 
committee's attention could help assure that other Federal agencies do 
more to help, that the National Action Alliance for Suicide Prevention 
is sustained and that the national network of crisis lines is 
strengthened. These steps would be life-saving.
    Conclusion. We thank the committee again for focusing on mental 
health needs and opportunities, and we hope our suggestions are 
relevant and helpful. Some of the issues I discuss do not necessarily 
suggest easy fixes. But mental health concerns are coming out of the 
shadows, at a time of major change in health and mental health care. 
Now is the time to get it right. We face major opportunities to improve 
health care for millions of Americans, but these are opportunities that 
can easily be missed. Similarly, we cannot allow what remains of the 
Nation's mental health system for people with the most serious 
disorders to be dissipated. In an earlier, failed era of 
deinstitutionalization, patients were dumped into unprepared 
communities. This is not the time to dump them again, into 
``mainstream'' arrangements without adequate protections and 
accountabilities. Fixing the mental health system requires more than 
gun control. And it is possible.

    The Chairman. Thank you very much, Dr. Hogan.
    And now we'll turn to Dr. Vero.

 STATEMENT OF ROBERT N. VERO, Ed.D., CHIEF EXECUTIVE OFFICER, 
            CENTERSTONE OF TENNESSEE, NASHVILLE, TN

    Mr. Vero. Thank you, Senator Harkin.
    Thank you, Senator Alexander.
    On behalf of Centerstone and my colleagues in behavioral 
health throughout this country, I again want to echo how much 
we appreciate the attention that community behavioral health 
and healthcare, in general, is receiving as a part of this 
hearing. You know, I hope that what I share will assist this 
committee truly as you seek to gain an understanding of the 
opportunities to address the gaps and barriers that we know 
currently exist in the mental health system.
    It's been echoed several times this morning that we know 
that, recently, our country absolutely suffered the devastating 
loss of 28 precious lives, 20 innocents, 6 courageous teachers 
and administrators, a mentally ill young man who did not get 
the care that he needed, and his mother who did not get the 
care nor the information that she needed. This tragedy, along 
with those in Colorado, Arizona, California, Virginia, and 
others, has thrown a very invaluable spotlight on community 
mental health, mental illness, and this entire discussion.
    To work in this area of community mental health is an 
extraordinary privilege. It's likewise a tremendous 
responsibility. I've been fortunate throughout the last four 
decades to participate in our field from a variety of 
perspectives, as a clinician, as a critical incident responder, 
as a faculty member, as a research collaborator, as a patient, 
and as a CEO. I've seen firsthand what the research shows. 
Mental illness affects everyone, and mental health treatment is 
effective.
    Community mental health centers do a tremendous job for the 
people we serve. We change and save lives, helping to build 
strong, healthy, resilient individuals and strong, healthy, 
resilient communities. There are, however, several significant 
barriers and gaps in the current U.S. mental health system that 
make it difficult for our local agencies to serve as the safety 
net they were intended to serve by President Kennedy more than 
50 years ago.
    Most significant among these is the limited availability of 
quality mental health services for children and youth. Sadly, 
we lack a Federal definition of what services a community 
mental health center should offer. Consequently, many towns and 
cities, especially rural ones, do not have access to a 
continuum of care that covers the life span.
    Since 50 percent of mental illnesses do occur before the 
age of 14, and three out of four people experience the initial 
onset of these illnesses by the time they reach young 
adulthood, the lack of early intervention can have tragic and 
lasting effects. Congress is encouraged to pass language 
similar to that included within the Excellence in Mental Health 
Act, defining that a community behavioral health provider must 
provide a full continuum of services across the life span. In 
particular, we wish to thank Senator Debbie Stabenow and 
Senator Jack Reed for their tireless leadership in this 
critical legislation.
    There are several ways as well to address the barriers to 
providing quality children's services. Thanks to grant funding 
from SAMHSA and the Department of Education, Centerstone has 
been able to deliver home and school-based services within both 
urban and rural areas. These programs have proven clinically 
effective and likewise offset overall educational costs.
    Congress could increase its support of Federal funding to 
effectively deliver prevention and early education services. 
Congress could ensure as well that services to children and 
youth target the entire family. Research shows that programs 
that engage the whole family are the most effective programs. 
Inadequate insurance coverage too often becomes the barrier to 
engaging the entire family.
    Incredibly, not all States, counties, and community mental 
health centers offer formal crisis services, especially those 
services that are delivered 7 days a week, 24 hours a day, 365 
days a year. The Excellence in Mental Health Act would also 
require the provision of these crisis services.
    Technology, which we haven't talked very much about this 
morning, also prevents another barrier. Thanks to the work of 
the Office of the National Coordinator of Health IT and the 
leadership of Senator Sheldon Whitehouse, there have been 
tremendous advances toward creating standardized communication 
guidelines.
    Unfortunately, since community mental health was left out 
of the 2009 HITECH Act, we have not been able to fully benefit 
from these advances. Strong bipartisan bills in both houses of 
Congress like those that have been introduced in the prior 
Congress by Representatives Murphy and Blackburn, and Senators 
Whitehouse and Collins would correct this problem.
    With behavioral health IT, this is what community 
behavioral health would be able to do. We could effectively 
share information for purposes of coordination of care, 
including treatment plans, with primary care providers. We 
would prevent some of the drug-drug interactions that occur 
because of a lack of shared information and, hopefully, prevent 
over-prescribing. We could also effectively track outcomes over 
time.
    There's a great need for integrating physical and 
behavioral healthcare in this Nation. We hear a lot about 
America's fragmented and broken healthcare system. The 
consequence, at best, is costly and, at worst, dangerous and 
too often deadly. People with serious mental illness, on 
average, die 25 years earlier than their non-mentally ill 
contemporaries. Is it because of their mental illness? No. It's 
because of the impact of their comorbid conditions, diabetes, 
cardiovascular disease, as examples.
    Community mental health centers are key to improving 
physical healthcare by simultaneously lowering overall 
healthcare cost. Our expertise in behavior change is part of 
the solution to meet the triple aim of healthcare: reduced 
cost, improved health, and quality outcomes.
    We are grateful that in 2009, SAMHSA launched its Primary 
Care and Behavioral Health Integrated Care Program and since 
has launched 94 programs across the country. Two have happened 
to land at Centerstone, which were very fortunate. The SAMHSA 
initiative seeks to improve the physical health status of 
people with serious mental illness and reduce their total 
healthcare cost by making sure services for behavioral health 
and physical health are provided at the same location.
    We have a substantial and complex task before us. We cannot 
solve these issues alone as providers. This is a moment. This 
is a watershed moment that demands courage and action. Everyone 
in this room shares responsibility for the future of community 
mental health. Community mental health centers stand ready to 
work with you, our elected and representative officials, to 
make a difference in this U.S. mental healthcare system.
    Thank you.
    [The prepared statement of Mr. Vero follows:]
                Prepared Statement of Robert Vero, Ed.D.
                                summary
    Community Mental Health Centers do a tremendous job for the people 
we serve. We change and save lives, helping to build healthy, resilient 
communities. There are, however, several significant barriers and gaps 
in the current U.S. mental health system that make it difficult for our 
local agencies to serve as the safety net envisioned by President 
Kennedy, more than 50 years ago.
    (1) Currently, many towns and cities, especially rural ones, do not 
have access to a continuum of evidence-based services designed for 
children and youth. Since 50 percent of mental illnesses start before 
the age of 14, and 3 out of 4 people experience the initial onset of 
these illnesses by young adulthood, this lack of early intervention can 
have tragic, lasting effects. The Excellence in Mental Health Act would 
require that community mental health centers offer a full continuum of 
care services to children and youth.
    (2) There are funding barriers to ensuring that services to 
children and youth target the entire family. Research shows that 
programs that engage the whole family are most effective. There is 
innovative grant funding from SAMHSA and the Department of Education to 
support communities in adopting evidence-based prevention and early 
intervention services. However, sustainability is often difficult due 
to insurance coverage restrictions and regulations.
    (3) Not all States, counties, and community mental health centers 
offer 24/7 mobile crisis services for children and adults. The 
Excellence in Mental Health Act would also require the provision of 
these crisis services by community mental health centers.
    (4) Since community mental health centers were left out of the 
HITECH Act and are often not included in local and State Health 
Information Exchanges, they currently lack the ability to efficiently 
share information for purposes of coordination of care; prevent over-
prescribing, reduce medication errors; and, effectively track outcomes 
over time. There have been several bipartisan bills introduced, thanks 
to the leadership of Representatives Murphy and Blackburn and Senators 
Whitehouse and Collins, but it has not yet been made into law.
    (5) Currently there is a fragmented health care system for persons 
with mental illness. Community mental health centers are key to 
improving physical health while simultaneously lowering health care 
costs. Our expertise in behavior change is part of the solution to meet 
the triple aim of healthcare--reduced cost, improved health, and 
quality care. SAMHSA's Primary Care and Behavioral Health Care 
Integration program addresses this fragmentation, but true 
sustainability for integrated care requires multifaceted changes from 
community mental health centers, States, managed care plans, and 
Federal regulations.
    Community Mental Health Centers stand ready to work with you to 
improve the mental health system. However, we cannot solve these issues 
alone. We ask for leaders in the public and private sector to work with 
us as we seek to create a new future for mental healthcare.
                                 ______
                                 
    On behalf of Centerstone, I would like to personally thank Senator 
Alexander and Senator Harkin for the opportunity to comment on the 
state of the U.S. Mental Health System from the community mental health 
perspective. I hope what I share will assist the Health, Education, 
Labor, and Pensions Committee as you seek to gain an understanding of 
opportunities to address the gaps and barriers within our mental 
healthcare system.
    To work in the area of community mental health is, without 
question, an extraordinary privilege. It is likewise a tremendous 
responsibility.
    I have been fortunate throughout my career to participate in and 
observe our field from different perspectives--as a clinician, a 
critical incident responder, faculty member, research collaborator, 
client, and as a CEO. I have worked with hoarders whose homes were so 
cluttered that there was no longer safe passage to their beds for rest 
and refrigerators so contaminated that the contents were no longer safe 
to consume. I have worked with people who are so profoundly disturbed 
they've committed despicable and sometimes illegal acts. My role with 
these patients was to quell their psychosis and ensure safety for 
themselves and others. I also have had the responsibility of treating a 
mother's depression and complex grief following the tragic death of her 
preschool-aged child.
    I have seen first-hand what the research shows--mental illness 
truly affects everyone. One in four American adults will have a 
diagnosable mental illness in any given year, and about 1 in 17 adults, 
6 percent of the population, have a serious mental illness.\1\
---------------------------------------------------------------------------
    \1\ Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, 
severity, and comorbidity of twelve-month DSM-IV disorders in the 
National Comorbidity Survey Replication (NCS-R). Archives of General 
Psychiatry, 2005 Jun; 62(6):617-27.
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    As a community mental health center (CMHC), we are entrusted with 
the care of individuals, families, and communities whose lives have 
been impacted by mental illness. As health care leaders, we are called 
upon to work to create a mental healthcare system rooted in compassion, 
scientific understanding, individual recovery and, ultimately, disease 
management, prevention and cure.
    I chose this field nearly four decades ago because I thought that 
effective treatment for mental illness could have an equal or even more 
profound impact on families than treatment for heart disease and 
cancer. In school, I saw my inspired, intelligent friends devastated by 
anxiety, depression and bipolar disorder. I witnessed how trauma could 
weaken even the strongest of my colleagues.
    Over the years, I have found this to be true in my own family as 
well, especially when my 40-year-old cousin, Lisa, took her own life. I 
wish she had been able to ask for help when her pain became unbearable 
because I know there is an alternative to senseless death. Mental 
health treatment is life-saving.
                role of community mental health centers
    Community mental health centers have an incredibly important role 
to help provide effective, high quality care to the children, families, 
and older adults they serve. We help to keep children together with 
their families. We provide a lifeline for people struggling at all 
levels of severity of need, from mild levels of anxiety to acute 
episodes of depression to those contemplating suicide. Our treatment 
services and broad array of services for all ages, work to prevent 
horrible tragedies while helping to build strong, healthy, resilient 
communities. Community mental health centers, as a whole, fill a 
tremendous gap and, moreover, do a tremendous job for the people we 
serve. There are, nevertheless, several significant barriers and gaps 
in the current U.S. mental health system that make it difficult for our 
local agencies to serve as the community safety net they were 
envisioned to be 50 years ago by President Kennedy.
 barriers & gaps in access to high quality child & adolescent services
    One of the biggest barriers is a lack of access to services for 
children and youth. Sadly, due to a lack of a Federal definition of 
what services a community mental center should offer, many towns and 
cities, especially rural ones, do not have access to a safety net 
provider, offering a full continuum of evidence-based services to 
children and youth within a service area. Since 50 percent of mental 
illnesses start before the age of 14, and three out of four people 
develop their condition, including bipolar disorder, depression and 
schizophrenia by young adulthood, this lack of access can have tragic, 
lasting effects.\2\
---------------------------------------------------------------------------
    \2\ Kessler, RC, Berglund, P, Demler, O, ET al. (2005). Lifetime 
prevalence and age-of-onset distributions of DSM-IV disorders in the 
National Comorbidity Survey replication. Archives of General 
Psychiatry, 62, 593-602.
---------------------------------------------------------------------------
    We know from the research that the right care at the right time has 
a huge potential to reduce the occurrence of mental illnesses, the 
severity of those illnesses, and their impact on people's lives. Early 
mental health interventions for young children and families can reduce 
risk factors for mental illness and increase protective factors that 
build resiliency.\3\ If children impacted by multiple traumatic 
experiences do not get the care they need, it can have serious, life-
long consequences.\4\
---------------------------------------------------------------------------
    \3\ National Research Council and Institute of Medicine. (2011) 
Preventing Mental, Emotional, and Behavioral Disorders Among Young 
People: Progress and Possibilities. Committee on the Prevention of 
Mental Disorders and Substance Abuse Among Children, Youth, and Young 
Adults: Research Advances and Promising Interventions. Mary Ellen 
O'Connell, Thomas Boat, and Kenneth E. Warner, Editors. Board on 
Children, Youth, and Families, Division of Behavioral and Social 
Sciences and Education. Washington, DC: National Academies Press.
    \4\ Edwards VJ, Holden GW, Anda RF, Felitti VJ. Experiencing 
multiple forms of childhood maltreatment and adult mental health: 
results from the Adverse Childhood Experiences (ACE) Study. American 
Journal of Psychiatry, 2003;160(8):1453-60.
---------------------------------------------------------------------------
    There are several ways to address this barrier:

     The most permanent fix would be to pass language similar 
to that included within the Excellence in Mental Health Act 
specifically defining that a community mental health center has to 
provide a full continuum of services across the lifespan--including 
early intervention services.
     Grant funding streams that encourage existing centers to 
expand their service continuum and partner with community organizations 
are also helpful. At Centerstone, due to grant funding from SAMHSA and 
the Department of Education, we have been able to offer mental health 
and substance abuse services within rural schools for children and 
youth. We are now co-located in 160 preschools, middle and high schools 
throughout Tennessee, serving as adjunct faculty and providing a 
service to the school, they would likely be unable to deliver without 
our partnership. In addition, we recently were awarded a grant for 
early intervention services for families of infants and toddlers at 
risk for emotional problems.
     Pass Health IT legislation so that community mental health 
centers, especially rural centers, can access telehealth services. With 
a severe and growing national shortage of child, adolescent, and adult 
psychiatrists,\5\ telehealth is one of the key ways to foster improved 
access to services for children and adults with serious mental illness, 
especially in underserved and rural areas.
---------------------------------------------------------------------------
    \5\ American Academy of Child and Adolescent Psychiatry (AACAP). 
(2008) Analysis of American Medical Association Physician Masterfile. 
Washington, DC: American Academy of Child and Adolescent Psychiatry.
---------------------------------------------------------------------------
    Barriers to engaging the whole family in care. For our children, 
the most effective care involves treating the entire family. Over and 
over, my staff, who work with children in schools and other community 
settings, share frustrations and concerns for the children they treat 
because of limited or entirely no access to the child's parents or 
caregivers. So often we detect issues in parents and other people in 
the child's environment, yet we are sometimes hindered in our ability 
to treat the entire family unit due to inadequate insurance coverage.
    There are barriers to treating their uninsured or underinsured 
parents who have their own mental health needs and issues. We need to 
be able to teach parenting skills if we want the child's behavior to 
change. We need to be able to address the parent's depression or 
addiction if we want to make an impact on a child's anxiety, truancy, 
or aggression. A mother is only able to advocate for her child and 
coordinate care if she, herself is healthy and able to cope.
    We are eagerly awaiting further news regarding a decision related 
to Medicaid expansion. It will allow community mental health centers to 
treat the low-income parent's depression, substance use disorder, and/
or other condition that impede effective parenting.
    Research shows that programs that engage the whole family, whether 
teaching parenting skills in a clinic or modeling those skills in a 
home setting is effective in reducing aggression, disruptive and 
antisocial behavior, and preventing substance abuse later in life.\6\ 
With SAMHSA grant funding, Centerstone has been able to implement these 
interventions in different communities in Tennessee, resulting in some 
incredible outcomes. However, sustainability often remains a barrier 
once grant-funding concludes.
---------------------------------------------------------------------------
    \6\ National Research Council and Institute of Medicine. (2011) 
IBID
---------------------------------------------------------------------------
    Gaps between different care providing systems. We hear a lot about 
America's fragmented health care system with current news focusing on 
mental health care. Children with serious emotional disturbances and 
mental disorders and their parents, in order to get the care they need, 
often have multiple providers and interface with multiple agencies 
(i.e. department of children's services, juvenile justice, pediatric 
office, school, mental health center, etc.) The consequence is at best 
costly, and at worst dangerous. Care coordination models have proven 
effective outcomes. We encourage the expansion of these evidence-based 
models.
    There is an opportunity here for greater collaboration and shared 
accountability by mandating mental health and substance abuse services 
be incorporated into the clinical models funded by the Affordable Care 
Act.
                    transitions in young adult care
    Currently, when many adolescents with mental illness reach 
adulthood, they are at risk for experiencing a disruption in care if 
their State's Medicaid plan does not have an eligibility class or 
allowance for an ``aging out'' transition plan. Even though the ACA 
affords insurance coverage for dependents, up to the age of 26 years 
old, on their parent insurance plans, many youth will not have access 
to such coverage. This issue must be addressed as States consider plans 
for Medicaid expansion.
      exclusion of community mental health centers from hitech act
    Thanks to the work of the Office of the National Coordinator for 
Health IT and the leadership of Senator Sheldon Whitehouse, there have 
been tremendous advances toward creating standardized guidelines. 
However, since community mental health centers were left out of the 
2009 HITECH Act, we have not been able to fully benefit from these 
advances. This one barrier sets up roadblocks for the achievement of 
several key goals for our field. If behavioral health were included in 
this Act, we would be positioned to:

     Effectively share information for purposes of coordination 
of care, including treatment plans, with primary providers, integrating 
our work to the benefit of the patient.
     Preventing overprescribing and other consequences of 
failed drug coordination such as drug-drug interaction and/or toxicity.
     Effectively track outcomes over time.

    From the CMHC perspective, I do not know how centers can ensure 
that the care we are providing is what we would want for each of our 
family members without using Health IT tools. The first 25 years I 
spent in this field were with paper records, and I can tell you the 
difference between clinical supervision of paper records and clinical 
supervision using analytics tools is night and day. Thanks to the Ayers 
Foundation and the Joe C Davis Foundation, Centerstone was able to 
develop analytics tools similar to those used by for-profit businesses. 
With these tools, I can hotspot clinics, locations and centers where 
outcomes are lagging and rapidly develop localized quality improvement 
plans. I can ask questions like, ``how many children are we serving in 
foster care and have been prescribed atypical antipsychotic medications 
in the last 3 months,'' or ``how is our HEDIS client engagement metric 
last month compared to last year'' and get the answer in 1 short 
minute.
    As primarily Medicaid providers, most community mental health 
centers exist with very little financial margin, if any. Funding large 
health IT purchases is a luxury most cannot afford. Due to the 
contrary, due to the billions in cuts our field has experienced over 
the last 4 years, some community mental health centers have been forced 
to simply shut their doors while many more have quietly ended programs 
and laid off large numbers of employees.
    Inadequate Health IT capacity impedes the ability of the whole 
field to improve the quality of mental health care. Centers not using 
Health IT are, moreover, unable to use analytics tools to look at 
quality metrics or conduct rapid, targeted quality audits. Most health 
information exchanges do not include community mental health centers, 
and many States have no regulations allowing the sharing of information 
electronically with CMHCs. Systems and processes designed to foster 
provider communications and shared data through electronic means would 
greatly improve health care outcomes and reduce cost.
    Strong bipartisan bills in both houses of Congress would correct 
this problem. H.R. 6043 championed by Representatives Tim Murphy of 
Pennsylvania and Marsha Blackburn of Tennessee and S. 539 introduced by 
Senators Whitehouse and Collins would authorize the participation of 
mental health and addiction providers in the healthcare revolution 
sparked by passage of the HITECH Act in 2009.
    need for formal mental health crisis services in every community
    Not all States, counties, and community mental health centers offer 
formal crisis response services. Whether by telephone, Internet, text 
or in-person, having a system of trained professionals for immediate 
response in the event of a crisis is, simply put, life-saving. I am in 
support of the President's recommendation to increase mental health 
first aid training. I believe that it makes sense for every teacher, 
law enforcement officer, and first responder in the United States to 
know how to detect issues and engage someone to get help. However, we 
need to make sure that as we are training people to seek help when in 
crisis, we have an existing network available to respond to the 
situation and provide evidence-based, outcomes-driven services. It is 
not enough to detect an issue; someone must be able to respond.
    The Excellence in Mental Health Act, as part of its definition for 
what a community mental health center should do, requires that it 
provide crisis services. From my perspective, I know that this service 
not only saves life, it saves dollars, and I encourage this be 
considered vital to the service continuum of mental health safety net 
centers. In 2012, our Tennessee Crisis Call Center handled 18,350 
emergency calls. Our Mobile Crisis therapists provided 6,081 face-to-
face crisis assessments and in doing so prevented over 3,000 mental 
health-related hospitalizations--a huge cost savings for our State 
Medicaid program. Our Mobile Crisis team also aided in the appropriate 
hospitalization of another 3,000 individuals whose acute needs required 
a level of care beyond traditional outpatient services. Although this 
might not have saved Medicaid funds, it likely prevented countless 
tragedies.
    Tennessee's TennCare Director and Deputy Commissioner for the State 
department of Finance and Administration, Darin Gordon as with our 
Commissioner of Mental Health and Substance Abuse Services, Douglas 
Varney should be recognized for their support of a formal, statewide 
Crisis Services program, serving the acute psychiatric needs of all 
Tennesseans.
                        need for integrated care
    The quality and length of life of our patients requires that we 
accurately assess and effectively treat their physical as well as their 
mental health needs. Mental health and physical health are as 
intricately intertwined as the brain is to the body. There is ample 
evidence that the current fragmented system with one part of the health 
care field treating mental illness and one treating physical illness is 
costly and, moreover, ineffective.
    While community mental health services are an extremely small 
percentage when you look at State budgets, mental disorders are one of 
the five most costly conditions in the United States.\7\ Fifty-two 
percent of the Dual Eligible beneficiaries with disabilities have a 
psychiatric illness. Psychiatric illness is found in three of the top 
five most expensive diagnosis dyads.\8\ In a study of the fee for 
service Medi-Cal system in California, when the 11 percent of the Medi-
Cal enrollees with a serious mental illness (SMI) in the study were 
compared with all Medi-Cal enrollees, the SMI group's spending was 3.7 
times higher than the total population ($14,365 per person per year 
compared with $3,914).\9\ They also had a higher prevalence of other 
costly health disorders (diabetes, heart disease, chronic respiratory 
disease).
---------------------------------------------------------------------------
    \7\ Agency for Healthcare Research and Quality (2013). AHRQ Program 
Brief: Mental Health Research Findings. Retrieved on January 19, 2013 
from http://www.ahrq.gov/research/mentalhth.htm.
    \8\ Kronick RG, Bella M, Gilmer TP. (2009) The faces of Medicaid 
III: Refining the portrait of people with multiple chronic conditions. 
Center for Health Care Strategies, Inc.
    \9\ California 1115 Waiver Behavioral Health Technical Work Group. 
(2010). Beneficiary risk management: Prioritizing high risk SMI 
patients for case management/coordination. Presentation by JEN 
Associates, Cambridge, MA.
---------------------------------------------------------------------------
    Nationally, one in eight visits to emergency departments is due to 
mental disorders, a substance use disorder, or both.\10\ All of this 
healthcare, while costly, has not resulted in better outcomes. People 
with serious mental illnesses, on average, die 25 years earlier than 
people without such diagnoses, and this early mortality is primarily 
due to preventable physical health conditions.\11\
---------------------------------------------------------------------------
    \10\ Coffey R, ET al. (2010). Emergency Department Use for Mental 
and Substance Use Disorders. AHRQ.
    \11\ Parks J, Svendsen D, Singer P, Foti ME. (2006). Morbidity and 
Mortality in People with Serious Mental Illness. Alexandria, VA: 
National Association of State Mental Health Program Directors.
---------------------------------------------------------------------------
    Community mental health centers are key to improving physical 
health while simultaneously lowering health care costs. The same skills 
we use to prevent mental health hospitalizations can be used to prevent 
physical health hospitalizations. The same skills our clinicians use to 
promote behavior changes in depressive cognitive thought patterns or 
patients with alcoholism can be used to help our patients quit smoking, 
exercise more, and make healthy food choices. The same nurses in our 
clinics that test for lithium and clozapine blood levels could test for 
hemoglobin A1C levels and draw lipid screens. The same case managers 
that do home visits and check on whether someone with schizophrenia is 
taking their medication and meeting their mental health goals also 
could teach the patient how to take their blood pressure and track 
their weight. Our expertise in behavior change is part of the solution 
to meet the triple aim of healthcare--reduced cost, improved health, 
and quality care. However, reimbursement for these activities varies 
depending on the Medicaid, Medicare and the managed care plan. Most 
CMHCs lack funds for training costs to train our staff, update our 
clinics, and obtain health IT systems that are compatible with primary 
care systems.
    Thankfully, in 2009, SAMHSA launched its Primary Care and Mental 
Health Care Integration (PBHCI) program. This program seeks to improve 
the physical health status of people with serious mental illnesses and 
reduce their total health care costs through integration of services. 
SAMHSA has funded 94 sites nationally, and, in cooperation with HRSA, 
has co-funded a national resource center helping community mental 
health centers like Centerstone and Federally Qualified Health Centers 
and other primary care practices to integrate physical and behavioral 
health care.
    This funding stream has been very welcomed by Centerstone. 
Centerstone of Indiana was part of the second cohort to receive funds. 
My organization, Centerstone of Tennessee, was part of the 5th cohort. 
The biggest barrier to making integrated care sustainable for community 
mental health remains funding restrictions. Thankfully, we have seen 
more openness to lift those restrictions from managed care companies 
and States, and we are hopeful that this will be changing rapidly.
    More direction from CMS (Centers for Medicaid and Medicare 
Services) to States regarding definition of what services can and 
should be provided by mental health organizations might be helpful to 
make sure those restrictions lift. The Primary Care Mental Health Care 
Integration program is most valuable if it is sustainable, and 
sustainability can be achieved by some common sense changes.
            need for adequate and consistent coverage in aca
    Currently, there is no guidance issued ensuring that behavioral 
health has a seat at the table for Accountable Care Organizations (ACO) 
and other care coordination models being adopted across the United 
States. It would be helpful, in the final Affordable Care Act (ACA) 
guidelines, for Congress to set forth instructions for the coverage of 
mental health and substance abuse services in the care and coverage 
models established by the ACA.
                               conclusion
    Recently, our country suffered a devastating loss of 28 precious 
lives--the 20 innocents, the 6 courageous teachers and administrators, 
the life of a mentally ill young man who did not get the care he 
needed, and the life of his mother, who did not get the help and 
information she needed. This tragedy, along with those in Colorado, 
Arizona, California, Virginia, and others has thrown a spotlight on our 
mental health system.
    We have a long way to go to reach the President's vision of 
``making access to mental health care as easy as access to a gun.'' Our 
case managers, therapists, psychiatrists, nurses, researchers, and peer 
counselors are passionate about providing the best mental health care 
possible, and we seek to be part of the solution. However, we cannot 
achieve this solution in isolation. This is a moment that demands 
courage and action. Everyone in this room shares a responsibility for 
the future of mental health. Community mental health centers stand 
ready to work with you to improve the U.S. mental health system.
    Thank you for your time and attention.

    The Chairman. Thank you very much, Dr. Vero. I appreciate 
that.
    Now, Mr. DelGrosso, welcome. Please proceed.

   STATEMENT OF GEORGE DelGROSSO, M.A., EXECUTIVE DIRECTOR, 
         COLORADO BEHAVIORAL HEALTH COUNCIL, DENVER, CO

    Mr. DelGrosso. Thank you, Senators Alexander and Harkin, 
and you, Senator Bennet. You've always been there for us for 
mental health in our State, and I want to thank you for being 
there.
    It's interesting this morning as I hear the discussions 
happening around the room, and I want to share two thoughts 
with you if I might. The first one is I think you may be 
surprised about how many people are watching CSPAN today from 
around the country because they're so excited about the 
opportunity to really discuss this matter in a kind of detail 
that we're really hoping for.
    The second part of it is I'd like to share with you that if 
I could take a video of today and the comments that you all 
were making up there and the comments made down here today, and 
if we could sort of encapsulate it and play it to the public, 
and if that became the public message, we wouldn't have to be 
here today. I think people would be greatly moved by what all 
was brought here today and what you're saying about our area of 
healthcare and how important it is to address it, both mental 
health and substance use disorder.
    Today I've been asked to talk about mental health first 
aid. There were several of you that said, ``Tell us about what 
we might be able to do to intervene or to connect earlier,'' 
and that's what I'll be sharing. But I want to make sure, so I 
don't run out of time, to tell you that there are a couple of 
things that can be done.
    One is that with the shortage of funding that has been in 
the area of mental health and substance use disorder, the 
funding that is available has really been focused on people who 
already have diagnosable conditions or are already 
significantly ill. And we need to ensure that we continue to 
provide care in those areas.
    But what we're having problems with is when we do start 
doing prevention work in both the physical health area and the 
behavioral health area, often the codes and the funding are not 
available. So you have to take it out of your own pocket, in a 
sense, as a provider or the person themselves to try to get 
some of the necessary prevention and early intervention 
services and supports that they need to keep them from getting 
to that point. This is particularly a problem in the area of 
Medicare.
    Today we haven't talked very much about the elderly. And I 
think a lot of people think because somebody is getting old 
that they're going to just naturally be depressed and it's a 
bad thing. But that's really not the reality. Many people are 
aging and doing well, but sometimes there is depression or they 
have substance use disorders just like anybody else, and they 
need the help and the care that they can get to be preventive 
and also to get the treatment.
    Mental health first aid is an area in our State that we 
have a great deal of excitement about because of a couple of 
different reasons. No. 1 is that we saw the opportunity with 
mental health first aid to really get out into our citizenry 
and to be able to talk about mental health itself and increase 
their literacy and their understanding and recognition of the 
signs and symptoms of common mental health diseases like 
bipolar, major depression, PTSD and anxiety disorders, as well 
as substance use disorders.
    But it also provides crisis de-escalation techniques by the 
people who take the class. Just like physical health, first aid 
helps you in order to be able to bandage something or to splint 
if there is a broken leg. And then there's a five-step action 
plan to get persons in psychiatric distress referred to mental 
health providers. It's a very comprehensive program.
    In the wake of the serious summer that we had, we often 
know about Aurora and the shootings there, but we also had two 
major fires in our State this past year, and a lot of people 
lost their homes and there was some loss of life. It was one of 
the most depressing summers we've had in Colorado for a long 
time, and it's a beautiful State to live in.
    One of the things that we found is that by using mental 
health first aid, a lot of people began to reach out more for 
help themselves and to help their family members, and to 
understand more about what's going on with them and what's 
happening in the world around them.
    I'll never forget meeting 1 day with Senator Udall and 
Senator Bennet and talking about the issues around mental 
health. And Senator Udall looked up and said,

          ``What we need is a program to help us to sort of 
        identify things for our family members and friends and 
        in our churches and in our Government, ET cetera, when 
        they need help.''

    And we said, ``Sir, let us tell you about mental health 
first aid,'' and at that point, it became a real charge for us 
in Colorado.
    It's interesting to note that our mental health first aid 
instructors have also done training with the Governor's 
cabinet, department heads and managers at many State agencies. 
And there is a consideration right now that all State employees 
will take mental health first aid. The Department of 
Corrections does this today. They have trainers, and all of 
their corrections officers are being trained.
    I can go on and on about the number of people who have 
received this, but I want to let you know that there's some 
really great news coming out of Washington on this. Last week, 
Representative Ron Barber introduced the Mental Health Aid Act 
of 2013. That's H.R. 274. As you may know, he was wounded in 
the tragic incident in Tucson, and mental health first aid was 
also helpful in their area as they were recovering from their 
tragedy there.
    We have it on good authority and anticipate that there is 
going to be a bill with bipartisan support coming through the 
Senate, and we would really ask that you consider supporting 
this as a committee and providing the funding that we so 
necessarily need in our community.
    Again, I want to thank you so much. What a tremendous 
opportunity to be here today and speak on behalf of this area 
of healthcare. Thanks for your interest.
    [The prepared statement of Mr. DelGrosso follows:]
              Prepared Statement of George DelGrosso, M.A.
                                summary
    George DelGrosso, the CEO of Colorado Behavioral Healthcare Council 
(CBHC) will testify on behalf of CBHC and the National Council for 
Community Behavioral Health Care (NCCBH). His testimony will be an 
overview of Mental Health First Aid (MHFA) a prevention and early 
identification program, that helps parents, family members, teachers, 
law enforcement, and others in the general public to understand and 
better identify someone who may be mentally ill or in mental distress 
and help them get necessary treatment before there are serious 
implications for the person and the community. This evidence-based 
program, similar to First-Aid programs taught by the American Red Cross 
for physical health, focuses on mental health and is available in 
various locations throughout the United States.
    MHFA has proven to also be effective in Colorado to help 
communities cope in the aftermath of two major fire disasters, and a 
shooting in Aurora. CBHC received the NCCBH national award in 2012 for 
its implementation of MHFA instruction throughout most of the 
communities in Colorado.
    Mr. DelGrosso will also briefly discuss additional concerns facing 
community mental health and substance abuse providers the HELP 
Committee may want to consider.
                                 ______
                                 
    Chairman Harkin and Senator Alexander, thanks for giving me the 
opportunity to appear before the Senate HELP Committee on behalf of the 
Colorado Behavioral Healthcare Council and the National Council for 
Behavioral Health. My name is George DelGrosso and I am the Chief 
Executive Officer of the Colorado Behavioral Health Council (CBHC).
    The CBHC is a statewide organization composed of 28 behavioral 
health organizations including all of the 17 Community Mental Health 
Centers, 2 specialty mental health clinics, 4 managed service 
organizations and 5 behavioral health organizations. The latter 
organizations are the management entities throughout the State for 
substance use disorder and the State's Medicaid mental health managed 
care program.
    Our members provide psychiatric care, intensive community-based 
services and addiction treatment to over 120,000 Coloradans each year. 
About 50 percent of our mental health center consumer/patient caseload 
is composed of adults with severe mental illnesses like schizophrenia 
and bipolar disorder. We also serve children with serious mental and 
emotional disturbances referred to us by their families, the Colorado 
juvenile justice, special education and foster care systems.
    I will be devoting the bulk of my testimony today to the Colorado 
Mental Health First Aid program because we believe that it's an 
exciting new public health approach to early identification of mental 
illnesses and other mental health disorders. You will hear other 
witnesses testify today that mental disorders often begin manifesting 
themselves by as early as 14 years of age. According to the American 
Psychiatric Association Diagnostic and Statistical Manual, the first 
obvious symptoms of severe mental illnesses occur between ages 18 and 
24. But, on average, it takes us 8 very long years to begin mental 
health care for these Americans. By the time treatment does begin, the 
costs of mental health care services are higher and their clinical 
effectiveness is reduced.
    That's why both the National Council and the CBHC are so excited 
about Mental Health First Aid. It is an evidence-based practice that 
represents an early intervention and early detection program that--if 
implemented broadly enough--could permit America's community mental 
health providers to help millions of our fellow citizens in psychiatric 
distress. In brief, Mental Health First Aid teaches a diverse array of 
audiences three important sets of skills:

     Recognition of the signs and symptoms of common mental 
illnesses like bipolar disorder, major clinical depression, PTSD and 
anxiety disorders.
     Crisis de-escalation techniques.
     A five step action plan to get persons in psychiatric 
distress referred to mental health providers including local Community 
Mental Health Centers.

In sum, this training is somewhat similar to first aid classes taught 
by local chapters of the Red Cross for physical health conditions.
    In our State, we receive some funding from the Colorado Office of 
Behavioral Health, which is the State mental health authority, and use 
Community Mental Health Center resources to provide Mental Health First 
Aid in various locations through out Colorado. People who want to 
attend a Mental Health First Aid class can log on to a Web site, or 
contact their local mental health center and enroll in classes 
happening in their local communities. All of our Community Mental 
Health Centers have trained Mental Health First Aid instructors.
    As I indicated at the outset, a diverse array of training audiences 
is key to the program's public health approach. For example, Mental 
Health First Aid Instructors have conducted trainings with the State 
Sheriff 's Association and the Colorado Department of Corrections. In 
fact, the DOC has a goal of training all their corrections and parole 
officers.
    The committee might be interested to know that we've trained 
Governor Hickenlooper's cabinet members, department heads, and the 
middle managers at many State agencies. CBHC is currently organizing 
Mental Health First Aid training for all the rabbis in the Denver 
Metropolitan Area. We would also like to extend the training to schools 
districts and institutions of higher education throughout the State. 
The ultimate goal is to increase the understanding of mental health 
issues, help our citizens be able to identify when a friend, co-worker 
or family member is having mental health distress, and help them get 
involved in treatment when it is necessary. Someday we hope to see 
Mental Health First Aid Instruction as common place as physical health 
first aid.
    In all candor, the tragic movie theater shootings in Aurora, CO 
added a strong impetus to all these efforts in Colorado. Indeed, in the 
aftermath of the enormous tragedy at Sandy Hook Elementary School in 
Newtown, CT, there has been an outpouring of bipartisan support for 
improving the mental health care system in this Nation. Voices as 
diverse as the Wall Street Journal editorial page, the libertarian Cato 
Institute, President George W. Bush's former speech writer and, now, 
Vice President Biden's Gun Violence Task Force have all endorsed 
various proposals to enhance mental health care in schools and improve 
services for people with severe mental disorders. In fact, the task 
force explicitly endorsed Mental Health First Aid.
    We note that there is a common policy thread running through all 
these proposals. In some form or fashion, they all endorse ``early 
detection'' of mental illnesses. The National Council and CBHC strongly 
endorse Mental Health First Aid because--from a prevention standpoint--
that is exactly what the program does. It permits us to intervene early 
in the lives of individuals who later may be in desperate need of more 
intensive community-based mental health services.
    Last week, Representative Ron Barber introduced the Mental Health 
Aid Act of 2013 (H.R. 274). Congressman Barber was grievously wounded 
in the tragic Tucson, AZ shooting that almost took the life of former-
Representative Gabrielle Giffords and left six other persons dead 
including a 9-year-old girl. We have it on good authority that Senator 
Mark Begich will soon introduce the companion bill in the U.S. Senate. 
He will be joined by Senator Kelly Ayotte from New Hampshire.
    In a recent letter to Vice President Biden, Congressman Barber 
wrote the following:

          ``I urge you to endorse common-sense, bipartisan proposals 
        like the Mental Health First Aid Act. We have failed to give 
        the mental health care needs of Americans due attention for too 
        long--and we paid too high a price for this neglect.''

    In the perhaps divisive legislative debate to come, we hope that 
the Senate HELP Committee can come together to enact the ``common 
sense, bipartisan proposals'' that Representative Barber referred to in 
his correspondence to the vice president.
    Again, thanks for the opportunity to testify. I am happy to answer 
any questions you may have.

    The Chairman. Thank you, Mr. DelGrosso.
    And now we turn to Mr. Fricks. Welcome and please proceed.

STATEMENT OF LARRY FRICKS, SENIOR CONSULTANT, NATIONAL COUNCIL 
              FOR BEHAVIORAL HEALTH, CLEVELAND, GA

    Mr. Fricks. Thank you, Chairman Harkin and Senator 
Alexander. It's an honor to be here and an honor that we're 
getting this sort of focus on those of us that experience 
mental illness and addiction.
    I'd like to address three topics today: first, the stigma 
and discrimination that surround behavioral health disorders; 
second, the critical role of peer support and a new workforce 
in our country called peer specialists that promote recovery; 
and, third, the importance of whole health. Mind-body has been 
huge in my recovery from bipolar illness. So those are the 
three topics I'd like to address.
    First of all, I am someone recovered from bipolar illness. 
I'm also clean and sober 28 years. And I can tell you and my 
peers can tell you that we fight two battles. We fight the 
illness, but we also fight the stigma. We have a saying in our 
movement: What you believe about mental illness may be more 
disabling than the illness itself. And yet as a society we 
largely remain ignorant about the signs and symptoms of mental 
illness, and we ignore our role as supportive community members 
to help those of us experiencing those illnesses.
    I was hospitalized three times in the mid-1980s. I fall in 
the category of a serious mental illness. I've ridden in the 
back of a deputy's car. It's a very humiliating experience. I 
spent a day in jail because of my psychosis until family and 
friends intervened and got me help, and I attempted suicide. So 
you can see it is humbling to be here today and have a chance 
to talk about this.
    What happens is the stigma is so significant that we often 
internalize it. It takes over our lives. It's not only the 
diagnosis, but it becomes the prognosis that your life is over 
as you've known it. And yet today I live a full and meaningful 
life. I have a wonderful wife and a life in the north Georgia 
mountains. Key to that was learning self-management skills. I 
haven't heard anything about self-management. Those of us in 
recovery know about self-management to stay well. Peer support 
is huge, having somebody that you can relate to, and also 
receiving services.
    Now, the future is mind-body. I just want to say that 
learning about sleep deprivation and its role in bipolar 
illness was huge for my recovery. And it was a former director 
of NIMH, Dr. Fred Goodwin, that introduced me to that. I manage 
my bipolar illness largely by managing my sleep patterns and 
being very careful. I fly almost every week, and I'm very 
careful.
    So this new workforce of certified peer specialists--in 
Georgia, for 13 years, I served on the management team for the 
State Department of Behavioral Health and Developmental 
Disabilities. They're the fastest growing workforce in our 
State. We've trained nearly 1,000. There's probably been 12,000 
trained across the country.
    We focus on what we call strength-based recovery and whole 
health. We're able to deliver services that are Medicaid 
billable if the service is included in the State plan. And 
research on the effectiveness of peer specialists has been so 
positive that in 2007 the Centers for Medicare and Medicaid 
Services issued guidelines for States wanting to bill for peer 
support services, proclaiming them as an evidence-based model 
of care.
    Research shows that we have a unique ability as peer 
specialists to connect with other peers to ignite hope and 
teach skills for recovery, self-management, and promoting whole 
health. However, I would warn you that Medicaid's focus on 
medical necessity makes it tough, because we are strength-based 
and we look at unlocking hope and self-management. So it's a 
little tough to fund under medical necessity. We'd like to see 
more flexible funding for that.
    Peer respite centers are springing up across the country 
staffed by us. If you're feeling early warning signs, you can 
go in. We have three of them in Georgia. You can spend up to 7 
nights surrounded by peers, and it's keeping people out of 
hospitals. We're having tremendous success in Georgia. We're 
under a Department of Justice settlement for deaths in our 
hospitals, so this is a service that we have that is really 
starting to pay off.
    Then addressing this mind-body healthcare, there can be no 
health without mental health. Conversely, we cannot 
successfully care for people with mental health and addiction 
disorders without addressing their co-occurring physical health 
disorders. Research indicates that people with severe mental 
illness in the United States who are served in the public 
healthcare system have an average life expectancy that is 25 
years less than the general public. We've heard that already. 
We're dying in the early 50s, many of us.
    So I just want to thank SAMHSA. They're working to address 
this by providing grants to the community behavioral health 
centers for offering basic primary care screenings and 
coordinating referrals to primary care. As part of the Primary 
Care Behavioral Health Integration Program, nurses, trained 
care managers, peer specialists, and other healthcare 
professionals are now actively working in 94 grantee sites to 
screen patients for weight gain, blood lipid levels, 
cholesterol, teach skills for whole health self-management and 
more.
    And although data is still being collected, early results 
indicate that this program has been successful. It is helping 
people with behavioral health conditions maintain or reduce 
their weight, cholesterol, blood sugar, and other risk factors 
for chronic disease. I strongly urge the committee to support 
this important grant program.
    In closing, I'd like to say that after nearly three decades 
of experience in behavioral health, it has taught me that the 
greatest potential for promoting recovery and whole health 
comes from within the individual, with the support of peers, 
family, and community. My recommendation is to establish and 
support programs that drive this potential, putting the person 
at the center of all services, building on their strengths and 
supports.
    Thank you very much.
    [The prepared statement of Mr. Fricks follows:]
                   Prepared Statement of Larry Fricks
                                summary
    Good morning, and thank you for inviting me to speak at today's 
hearing. I'd like to cover three topics: first, the ongoing stigma and 
discrimination that surround behavioral health disorders; second, the 
critical role of peer support to promote recovery; and third, the 
importance of a whole health approach when it comes to improving our 
healthcare system.
    Allow me to share with you today some of my lived experience of 
recovery from mental illness and substance abuse over the last 28 
years. As anyone who has experienced a mental health or substance use 
condition can tell you, we must fight a battle on two fronts: one 
against the diagnosis itself, and the other against public ignorance. I 
was hospitalized three times in the mid-1980s. When I returned home 
from my last hospitalization I sank into deep despair. I internalized 
the stigma and discrimination experienced from mental illness, growing 
a negative self-image and sense of hopelessness from the prognosis that 
my life was over as I knew it. Yet today, I live a full and meaningful 
life because I was able to learn self-management skills, gain peer 
support, and receive mental health services with a focus on mind-body 
recovery. Members of the committee, I urge you to support public 
education programs that reduce stigma and discrimination by helping 
Americans learn how to reach out and support their friends and family 
members who may be experiencing a behavioral health condition.
    Next, I'd like to share some information about certified peer 
specialists, who use their lived experience and are trained in skills 
to promote strength-based recovery and whole health, delivering 
services that are Medicaid-billable when included in State plans. 
Research on the effectiveness of peer specialists has been so positive 
that in 2007, the Centers for Medicare and Medicaid Services issued 
guidelines for States wanting to bill for peer support services, 
proclaiming them ``an evidence-based model of care.'' Research shows 
peer specialists are unique in their ability to connect with other 
peers to ignite hope and teach skills for recovery, self-management, 
and promoting whole health. However, because Medicaid requires 
``medical necessity'' in documenting illness and symptoms--and peer 
specialists are trained to focus on strengths and supports--we need 
more flexible funding sources to grow the recovery and whole health 
outcomes that peer support services can deliver.
    This brings me to the final point I'd like to discuss: the 
importance of addressing the mind-body connection in healthcare. There 
can be no health without mental health. Conversely, we cannot 
successfully care for people with mental health and addiction disorders 
without addressing their co-occurring physical health disorders. The 
Substance Abuse and Mental Health Services Administration is working to 
address this issue by providing grants to community behavioral health 
centers for offering basic primary care screenings and coordinating 
referrals to primary care. As part of the Primary Care-Behavioral 
Health Integration program, nurses, trained care managers, peer 
specialists, and other healthcare professionals are now actively 
working in 94 grantee sites to screen patients for weight gain, blood 
lipid levels, cholesterol, teach skills for whole health self-
management, and more. Although data is still being collected, early 
results indicate that this program has been successful in helping 
people with behavioral health conditions maintain or reduce their 
weight, cholesterol, blood sugar, and other risk factors for chronic 
disease. I strongly urge the committee to support this important grant 
program.
    In closing, I would like to say that nearly three decades of 
experience in behavioral health has taught me that the greatest 
potential for promoting recovery and whole health comes from within an 
individual, with the support of peers, family and community. My 
recommendation is to establish and support programs that drive this 
potential, putting the person at the center of all services, building 
on their strengths and supports.
                                 ______
                                 
    Good morning. Thank you, Chairman Harkin and Senator Alexander, for 
inviting me to speak at today's hearing. My name is Larry Fricks. I am 
a senior consultant to the National Council for Community Behavioral 
Healthcare and deputy director of the SAMHSA--HRSA Center for 
Integrated Health Solutions. I'd like to cover three topics today: 
first, the ongoing stigma and discrimination that surrounds behavioral 
health disorders and the need for better public education regarding the 
facts about mental illness and addiction; second, the critical role of 
peer support to promote recovery; and third, the importance of a whole 
health approach when it comes to improving our healthcare system.
    As former First Lady Rosalynn Carter said, ``stigma is the most 
damaging factor in the life of anyone who has a mental illness.'' 
Stigma is our biggest challenge.
    Allow me to share with you today some of my lived experience of 
recovery from mental illness and substance abuse over the last 28 
years, focusing on peer support and the skills I learned to self-manage 
my mind-body health. As anyone who has experienced a mental health or 
substance use condition can tell you, we must fight a battle on two 
fronts: one against the diagnosis itself, and the other against public 
ignorance. According to data from the Substance Abuse and Mental Health 
Services Administration (SAMHSA),\1\ one in five Americans will 
experience a mental health issue during any given year. Yet, as a 
society, we largely remain ignorant about the signs and symptoms of 
mental illness, and we ignore our role as supportive community members 
to help people experiencing these illnesses.
---------------------------------------------------------------------------
    \1\ Substance Abuse and Mental Health Services Administration, 
Results from the 2011 National Survey on Drug Use and Health: Mental 
Health Findings, NSDUH Series H-45, HHS Publication No. (SMA) 12-4725. 
Rockville, MD: Substance Abuse and Mental Health Services 
Administration, 2012.
---------------------------------------------------------------------------
    My grandmother, Naomi Brewton, graduated from the top of her class 
in college. But when she gave birth to her youngest son, she suffered 
what was then called a ``nervous breakdown.'' Her father was Dr. 
Brewton, founder of Brewton-Parker College near Vidalia, GA. The stigma 
and ignorance around mental illness prompted the family to secretly 
send her off to North Carolina for treatment. When she returned, she 
was a different person. For all the years that I knew her, she was a 
total recluse, never leaving home.
    My grandmother told great stories and had an infectious laugh that 
I loved, but I was never fully able to understand her life of tormented 
isolation until I was hospitalized three times in the mid-1980s. During 
my last hospitalization, I was kept in seclusion and restrained in my 
bed. When I returned home I sank into deep despair, overwhelmed by 
pending divorce, near financial collapse, and a weight gain of some 60 
pounds from psychiatric medications. I internalized the stigma and 
discrimination experienced from mental illness, growing a negative 
self-image and sense of hopelessness from the prognosis that my life 
was over as I knew it, and thinking that highly society-valued roles 
like work may now be too stressful to consider. Like my grandmother, I 
began to isolate, with suicide becoming an attractive option.
    Mounting research shows that people without a social network of 
support and a sense of meaning and purpose are less resilient against 
illness--mind and body--and often die younger. That's why meaningful 
work and peer support are emerging as huge factors in recovery and 
longevity. But in addition to peer support and gaining meaning and 
purpose from employment, my self-management really strengthened when I 
moved into mind-body resiliency. My life was forever changed after 
hearing a presentation by Dr. Fred Goodwin, former director of the 
National Institute of Mental Health and a specialist in bipolar 
illness. His research showed that restful sleep was a huge factor in 
building resiliency and preventing manic episodes like I had 
experienced. An anchor for my recovery is managing my sleep and 
reducing stress by practicing the Relaxation Response made famous by 
Dr. Herbert Benson at the Benson-Henry Institute for Mind Body Medicine 
at Massachusetts General Hospital. I was fortunate to have a 
psychiatrist who fully supported focusing my recovery around managing 
my sleep and after doing so, changed my medication to help shed much of 
the weight I had gained.
    Today, I live the kind of full and meaningful life that my 
grandmother was denied, because I was able to receive mental health 
services with a focus on recovery and learn self-management skills. We 
have come so far in the fight against stigma, in part because of 
greater public awareness and education about the nature of mental 
illness. You heard from another presenter about a program called Mental 
Health First Aid that teaches a five-step action plan to recognize the 
signs and symptoms of mental illness, respond to a person in crisis, 
and encourage seeking professional help, self-help and other support 
strategies. I am a Mental Health First Aid trainer, which means I teach 
people how to instruct others in becoming certified Mental Health First 
Aiders. I have witnessed first-hand the positive impact that comes from 
people with lived experience of recovery gaining the skills for 
providing support to help others experience a life of recovery from 
mental illness and substance abuse. MHFA attendees also learn about the 
growing awareness of the impact of trauma, especially childhood trauma, 
on mind-body health and why we need trauma-
informed services and supports.
    Members of the committee, I urge you to support Mental Health First 
Aid and other public education programs that help Americans learn how 
to reach out to their friends and family members who may be 
experiencing a behavioral health condition. One bill to this effect has 
already been introduced in the House: The Mental Health First Aid Act 
(H.R. 274). I encourage you to give this bill a hearing when it is 
introduced in the Senate and offer your support when it comes before 
your committee this year.
    Next, I would like to share some information about the newest 
workforce in behavioral health, called certified peer specialists. Peer 
specialists are trained in skills to promote strength-based recovery 
and whole health, delivering services that are Medicaid billable when 
included in State plans. Research on the effectiveness of peers in 
promoting recovery has been so positive that in 2007 the Centers for 
Medicare and Medicaid Services (CMS) issued guidelines for States 
wanting to bill for peer support services, proclaiming them ``an 
evidence-based mental health model of care which consists of a 
qualified peer support provider who assists individuals with their 
recovery from mental illness and substance abuse disorders.'' \2\
---------------------------------------------------------------------------
    \2\ Center for Medicare and Medicaid Services, State Medicaid 
Director Letter #07-011. August 15, 2007.
---------------------------------------------------------------------------
    Peer support specialists have personally addressed stigma and 
discrimination and gained the lived experience to promote recovery and 
support rather than illness and disability. Because of this, peer 
specialists are unique in their ability to connect with other peers to 
ignite hope and teach skills for recovery self-management and promoting 
whole health. According to a 2008 study by Eiken and Campbell,

          ``The growing evidence includes reduced hospitalizations, 
        reduced use of crisis services, improved symptoms, larger 
        social support networks, and improved quality of life, as well 
        as strengthening the recovery of the people providing the 
        services.'' \3\
---------------------------------------------------------------------------
    \3\ Eiken, S., & Campbell, J. (2008). Medicaid coverage of peer 
support for people with mental illness: Available research and State 
example. Published by Thomson Reuters Healthcare. Retrieved from:  
http://cms.hhs.gov/PromisingPractices/downloads/PeerSupport.pdf.

---------------------------------------------------------------------------
Published 2006 research by Davidson ET al., found that

        ``peer providers can increase empowerment, decrease substance 
        abuse, reduce days in the hospital, and increase use of 
        outpatient services, at least as long as long as the peer 
        support continues.'' \4\
---------------------------------------------------------------------------
    \4\ Davidson, L., Chinman, M., Sells, D., & Rowe, M. (2006). Peer 
supports among adults with serious mental illness: A report from the 
field. Schizophrenia Bulletin, 32, 443-450.

---------------------------------------------------------------------------
A 2006 study by Sells, ET al., found

        ``the unique role of trusted peers connecting with each other 
        to foster hope and build on strengths is emerging as a key 
        transformational factor in mental health services.'' \5\
---------------------------------------------------------------------------
    \5\ Sells, D., Davidson, L., Jewell, C., Faizer, P., & Rowe, M. 
(2006). The treatment relationship in peer-based and regular case 
management services for clients with severe mental illnesses. 
Psychiatric Services, 57(8): 1179-84.

    One of the most innovative services beginning to spring up across 
the country are peer respite centers. Georgia funds three of these 
centers and they are proving highly effective at reducing 
hospitalizations, an important outcome the State has pledged to achieve 
under a Department of Justice settlement resulting from deaths in State 
hospitals. In Georgia, if a peer senses early warning signs of possible 
relapse, he or she can spend up to 7 nights at a respite center 
supported by peer specialists promoting mind-body health and self-
management. Georgia also recently received CMS approval for peer 
specialists certified in a new training created by the SAMHSA-HRSA 
Center for Integrated Health Solutions called Whole Health Action 
Management (WHAM) to bill Medicaid for peer whole health and wellness 
services.
    I urge the committee to support including certified peer 
specialists as billable providers under Medicaid, given their effective 
role in supporting their peers in recovery and whole health. However, 
because Medicaid requires ``medical necessity'' documenting illness and 
symptoms and peer specialists are trained to focus on strengths and 
supports, we need more flexible funding sources to grow the recovery 
and whole health outcomes peer support services can deliver.
    This brings me to the final point I'd like to discuss today: the 
importance of addressing the mind-body connection when it comes to 
healthcare.
    There can be no health without mental health. Conversely, we cannot 
successfully care for people with mental health and addiction disorders 
without addressing their co-occurring physical health disorders. 
Research indicates that people with severe mental illness in the United 
States who are served in the public healthcare system have an average 
life expectancy that is 25 years less than the general public. That's 
the same as the overall U.S. life expectancy in 1915, a time before any 
of the healthcare advances that have allowed us to lead steadily longer 
lives over the last century.
    The primary culprits behind this shocking situation are untreated 
but preventable diseases that commonly occur together with mental 
illness and addictions: cardiovascular disease, diabetes, complications 
from smoking and some of the side effects of psychiatric medications 
that cause weight gain and diabetes. Most people receive routine 
preventive care that would help identify these conditions early, make 
lifestyle changes, or receive appropriate medications to ensure they 
are well-controlled. But people with serious mental illness often 
cannot access this preventive care--or even get treatment for their 
other health conditions.
    The Substance Abuse and Mental Health Services Administration is 
working to rectify this problem by providing grants to community 
behavioral health centers for offering basic primary care screenings 
and coordinating referrals to primary care. As part of the Primary 
Care-Behavioral Health Integration program (PBHCI), nurses, trained 
care managers, peer specialists, and other types of healthcare 
professionals are now actively working in 94 grantee sites to screen 
patients for weight gain, blood lipid levels, cholesterol, and more.
    Although data is still being collected, early results indicate that 
this program has been successful in helping people with behavioral 
health conditions maintain or reduce their weight, cholesterol, blood 
sugar, and other risk factors for chronic disease. I strongly urge the 
committee to support this important grant program.
    In closing, I would like to say that nearly three decades of 
experience in behavioral health has taught me that the greatest 
potential for promoting recovery and whole health comes from within an 
individual, with the support of peers, family and community. My 
recommendation is to establish and support programs that drive this 
potential, putting the person at the center of all services, building 
on their strengths and supports.

    The Chairman. Well, thank you, Mr. Fricks. I think your 
testimony really does kind of summarize what we're all here 
about today, and that is providing the kind of interventions 
and early support so that people can successfully deal with an 
illness, just like we deal with every other illness, and you're 
a prime example of that. From my limited experience in this 
area, I couldn't agree with you more that the most important 
element in this comes from within, and how do we build that 
system.
    Peer support is so important. You talked about maybe 
billable hours for providers of peer support. I can tell you 
that it is so extremely important that self-management skills 
need to be taught. A lot of times, this doesn't come from just 
a drug. I think it also recognizes--and I'll get back to Dr. 
Vero on this also--that mental health and physical health are, 
as you said, intricately intertwined, intricately intertwined.
    Now, again, at the risk of practicing medicine without a 
license--but I've been involved in this for almost 30 years now 
from this standpoint in this committee and my other committee--
I think we have more than adequate data to show that so many 
physiological conditions have their genesis in psychological 
conditions. And yet we always attempt to just treat the 
psychological condition, and sometimes that makes it even 
worse.
    We had a hearing on this last year on pain and all the pain 
clinics that have come up all over America. They're treating 
pain. Yet we had one witness, a very distinguished doctor who 
had written a lot of books about this--not everything, you 
can't make everything just total. But the vast majority of 
these pain afflictions has its genesis within psychological 
problems, anxiety, stress, things like that that manifest 
themselves in pain.
    Yet people go to pain clinics to get a shot or to get some 
kind of medicine or to get a back operation or something like 
that that may not be warranted. Again, I'm always cautious to 
say that it's not 100 percent. I'm just saying that the vast 
majority of this--I just don't think we recognize that, this 
intricate intertwine between mental health and physical health.
    Well, I took a lot of my time talking, and I shouldn't. But 
I want to start with Dr. Hogan.
    You talked about getting it right--primary care providers 
providing mental healthcare, moving from a separate system. 
Tell me about the accountable care organizations that are 
springing up. They're going to have the guidelines, you say, 
for what these entities have to provide. But I don't think we 
have any kind of instructions to them.
    Is that what you're suggesting, that we need to instruct 
these accountable care organizations that they also need to 
structure this? They need to structure it?
    Mr. Hogan. Absolutely. They'll learn this sooner or later.
    The Chairman. Well, we can't wait until later.
    Mr. Hogan. Exactly. So, for example, if you have diabetes 
or hypertension or cancer or these other major medical 
problems, and you also have depression, your total medical 
costs are going to go up somewhere between 50 and 75 percent. 
And if you treat the depression, it allows the person, as Larry 
was saying, to be an active player in the management of their 
whole health.
    But you can't hope that their depression goes away. You 
actually have to diagnose it. You have to provide a little 
treatment for it. But the data shows that a relatively small 
investment in providing that mental healthcare in that primary 
care setting--or it might be in the context of an ACO--is going 
to reduce total cost because people are going to be better able 
to take care of themselves.
    The Chairman. Dr. Vero, you mentioned that also in your 
testimony about the accountable care organizations. Do you have 
any elaboration on what Dr. Hogan just said?
    Mr. Vero. I think the other element at play would be our 
expectations for accountability, so let's underscore that. That 
act will allow us to set some clear expectations for 
performance, what is expected in terms of improving those 
healthcare outcomes in the agreement between those accountable 
care organizations and the provider in that provider system. We 
are now beginning to target what are those key healthcare 
indicators on the physical health side, on the behavioral 
health side, that will work together to truly improve overall 
outcomes.
    The Chairman. There's a barrier of insurance coverage. I 
think you mentioned that. In this area around Washington, DC, 
there are very few in-network mental health providers. I 
started looking at that some time ago and wondering why. I have 
good coverage, Blue Cross Blue Shield, all that. But I'm amazed 
at how few are in the network.
    The more I looked at it, they said, ``Well, the 
reimbursement is not good enough.'' Well, I looked at that a 
little bit longer, and then I started thinking and looking at 
the amount of support that taxpayers through Federal programs 
and other programs gave these practitioners when they were 
going through medical school, or when they were then going into 
their specialties, and then when they were going into their 
residencies.
    To be sure, a lot of them accumulated a lot of debt 
themselves that they're paying back. But, again, they got these 
nice guaranteed government loans at low interest rates. So I'm 
just wondering shouldn't we expect a little more of them than 
that they just don't get reimbursed enough by Blue Cross Blue 
Shield so they're out of the network?
    As I think Senator Sanders said, if you have the money and 
you can afford it, you're fine. But you could be actually 
paying a lot in your insurance coverage, still not having the 
coverage for mental health services, and then you've got to pay 
additional out-of-pocket for that. Any thoughts on that?
    Mr. DelGrosso.
    Mr. DelGrosso. Yes, sir. Thank you so much for making that 
comment, because it's something that's, like they say, the 
proverbial elephant that's in the room that people don't often 
talk about. And it's been sort of surprising to me how 
insurance companies have not been able to somehow put together 
the savings on the physical health side if they provide more 
care on the behavioral health side.
    It may be due to the fact that they have short-term 
contracts and don't necessarily look at the long run with it or 
whatever. But I think that what we see is the head is not 
connected to the body and sometimes often is the management and 
the thinking as people go forward. So they look at the physical 
health costs separately from the behavioral health costs.
    One of the real pluses for accountable care organizations 
that you were talking about is the opportunity to bring 
together the funding to put the right service, the right place, 
the right time, and the right cost or right payment that might 
be there. And it brings all four of those pieces together, 
where if you're saving money on the physical health side by 
providing more behavioral health services, you can move that 
money over there as needed and vice versa. So it's really 
important.
    I think the expectation of providing care for people who 
are uninsured has fallen greatly on the Federal Government and 
on our States in their indigent care programs and then their 
Medicaid program. So people end up shifting over to the public 
side because they don't have the behavioral health coverage on 
the physical health side. It's a quagmire, but I think that 
we're on the verge of making some changes that could be very 
helpful for us.
    The Chairman. I just told my staff what you said. We've got 
to work on this. We've got to make sure these accountable care 
organizations have that model and that they fully implement 
that model. And, hopefully, we can, through this committee and 
through the Administration and others, impress upon them the 
necessity of doing so.
    Well, thank you. I've run way, way over my time, and I 
apologize.
    Senator Alexander.
    Senator Alexander. That was very interesting. Thank you, 
Mr. Chairman.
    Well, thanks to the four of you for coming today. I'd like 
to listen to what you have to say, so I'll ask a question and 
then I'll ask each of you to answer. If you could think of one 
thing that the Federal Government could do, that we could do, 
to make it easier for you to spend the money we now spend more 
effectively--the money we spend primarily through the two big 
block grants and through Medicaid is the way I gather that most 
of the Federal money goes to mental health. What would be the 
one thing that we could do that might make it easier for you to 
do that?
    Dr. Vero, if you could start--and I'd like to ask you this 
additional question. You mentioned about the importance of a 
continuum, which makes sense, for a community mental health 
center. Now, you're one of the largest operators of community 
mental health centers. Would that be an additional cost to each 
community mental health center if it did that? If so, who would 
pay for that?
    If the Federal Government were to require that, how much 
would it cost and how much money would we have to appropriate 
for that? Or if we require it without paying for it, which is 
sometimes what we do around here, then who would pay for it?
    Mr. Vero. Senator, I want to first start with an 
acknowledgement of my early service in Tennessee and you in 
your Governor role. We talk about this continuum of care over 
the age span. When you were Governor of Tennessee, we built out 
a statewide therapeutic preschool program. We had therapeutic 
preschools in every single one of our community mental health 
centers across all 95 counties.
    Those schools were there to deal with their most vulnerable 
children with whom we were seeing early indications of the 
onset of severe mental illnesses, those SED children we've 
referenced several times today. So what happened? Very few of 
those programs exist. And I can tell you we are so fortunate at 
Centerstone to still continue that program. But it's not in the 
four-wall classroom any longer because that model was no longer 
affordable.
    Community mental healthcare has been subjected to a horrid 
state of commoditization. It's just a fact. As we move from 
Medicaid programs to managed Medicaid programs, we are part of 
the healthcare system that continues to be looked at as a 
commodity. Our services are minimized oftentimes to their 
smallest view, to the nickel--you know, to the dollar, to the 
quarter, to the nickel for differences in choosing who the 
provider might be, where the contract is, or, more importantly, 
what the service is, what that array of services are.
    As that requirement dropped with that commoditization, 
those preschool programs were lost. We took our preschool 
program and moved it into the community. And here's the good 
news. We were only able to serve about 48 of those children a 
year, because it was a high-cost program and because the 
managed care company had a hard time understanding what its 
role was in addressing the healthcare needs of these children 
while they were also receiving vital educational services.
    One of the things we need to do from that Federal level is 
let's remove these barriers that oftentimes don't allow us to 
bring our systems together--education, criminal justice, mental 
health--in a cooperative way for the sole purpose of addressing 
our healthcare crisis. We spend too long arguing over what part 
of the day education should pay for versus what part of the day 
a managed care company or Medicaid should be paying for. We 
have to address those conversations immediately if we're going 
to make any difference in the conversation that we're having.
    Senator Alexander. Well, I'd like to work with you, and 
I'll ask my staff to followup to get specific examples of how 
to do that. Just out of curiosity, was that part of the Healthy 
Children Initiative that we had in Tennessee back then?
    Mr. Vero. Initially, yes, sir.
    Senator Alexander. Well, I'll tell my wife. That was 30 
years ago. My wife was the head of that, and the deputy of that 
was Marguerite Sallee, who ran America's Promise until recently 
and headed Bright Horizons, the worksite daycare company.
    Now, my time is about up. But if there's one thing that we 
could do that would change existing law or practice to spend 
the money we now spend better--and you can follow that up in 
writing if you'd like to--is there one thing you'd like to 
briefly mention? And that's my last question.
    Mr. DelGrosso. I'd like to make a recommendation that you 
allow that the services that you currently pay for be opened up 
to provide more services at the front end, to provide more 
prevention, early intervention, support peer services like what 
Larry was talking about a little while ago, and to let the 
creativity of this country and how we're moving forward in 
other areas of healthcare to also enter into behavioral 
healthcare and allow us to do the right thing.
    Senator Alexander. Was there any other comment on that?
    Mr. Vero. Senator, if I could add to that, we keep talking 
about access. We've talked about the shortage of psychiatrists, 
especially child and adolescent psychiatrists. We've been 
providing telepsychiatry services since 2002 in the State of 
Tennessee. Those services are getting out to counties where we 
can't hire physicians, where we can't draw those physicians to 
maybe those more rural areas.
    It is 2014 as we sit here today. We need to align our 
payment streams with our current technology. We're not 
permitted in the State of Tennessee--and I know elsewhere 
throughout the country--to provide telecounseling services. I 
can have a psychiatrist talk to a child and interview that 
child and provide services and work alongside a practitioner 
who's sitting next to a child and do medication management. But 
I can't provide counseling services remotely through telehealth 
and get reimbursed.
    It's 2014. We have 12 years of experience on the psychiatry 
side, and we can't seem to move out of the current limitations 
around those services.
    Senator Alexander. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Alexander.
    Senator Franken.
    Senator Franken. Thank you, Mr. Chairman.
    Thank you all for your testimony.
    Dr. Vero, you note in your written testimony that there are 
a number of barriers to access to children's mental health 
services. Specifically, you recommend,

        ``grant funding streams that encourage existing centers 
        to expand their service continuum and partner with 
        community organizations.''

    I mentioned in earlier questioning that I'm introducing a 
bill called The Mental Health in Schools Act, which does that 
exactly by providing grant funds for schools to partner with 
mental health centers and other community-based organizations. 
Can you explain why this is so important to students?
    Mr. Vero. Senator, first, let me thank you for moving that 
bill forward again this year. I think it's rather simple. We 
know that most of the disorders that we see in children are 
first identified, not, as most of us would believe, in the 
office of a pediatrician or their family practitioner, but 
instead by their school teachers, some as early as their 
preschool teachers who see this behavior.
    They're well-trained in normal child development. They 
typically know what is expected of that age group. When they 
see unusual and bizarre behaviors or very, very troubled 
children, they need to bring that to the attention of 
professionals. Your bill is encouraging the same thing. Those 
teachers have the competencies to help us identify those 
children who need early intervention.
    We're in 160 schools currently in Tennessee. Those are 
partnerships that work. I have licensed master's level 
therapists in those schools providing the care that you're 
outlining, that you're addressing. We need to get school-based 
services throughout the country.
    Senator Franken. I was just in Mounds View, MN. We had a 
roundtable there--a couple of roundtables, but one specifically 
on integrating community mental health. And you talk in your 
testimony also about how this is really a family disease or a 
family matter.
    We had three mothers talk, whose kids were turned around 
completely because the school system had integrated their 
system with community health, and they had a mental health 
partner, a professional who took their caseload of a number of 
children. We had one woman there--I think she was 26. She had 
an 8-year-old child who had been completely turned around. She 
was a single mom. She was not a wealthy woman living on Fifth 
Avenue.
    This woman had such a joy in describing her son who had 
been completely turned around. He was diagnosed, I think, with 
Asperger's, and he had been unruly. But once they got ahold of 
it, he's turned around completely. And we had two other moms 
there. This is a family disease.
    Mr. Vero. It is.
    Senator Franken. I wrote two movies like 20 years ago on 
the family disease of alcoholism.
    Thank you, Mr. Fricks, for your testimony. Congratulations 
on 28 years of sobriety.
    When I was doing research for that, I was talking a lot to 
rehab counselors.
    Dr. Hogan, I want to ask you about this--the shocking 
ignorance of general practitioners about alcoholism. The 
teacher is for kids in the school. But the pediatricians--what 
they don't know about this is pretty remarkable. Integrated 
care is so important, and it's something we do pretty well in 
Minnesota. We have accountable care organizations that were 
already accountable care organizations before we wrote 
accountable care organizations into ACA, and they've become 
pioneer ACOs.
    What can you say about the training of doctors in medical 
school that we should be doing that we're not doing? Or have we 
gotten better at that?
    Mr. Hogan. Thank you, Senator. I want to just comment very 
briefly on your point about children and to underline this in a 
way that I think may resonate with Senator Harkin, because he's 
been closely connected to and has followed and help build an 
extraordinary national program of early intervention for young 
people who have got a developmental disability. If you have a 
significant developmental disability, you're basically entitled 
to some support and care for yourself and your family.
    For children with these problems that you're describing and 
that 8-year-old you described who got turned around, we have an 
average wait of 9 years until we find out about it. And these 
are conditions where just a little bit of help is going to 
change that young man's trajectory possibly for the rest of his 
life. So this is of profound importance.
    I'll say two things with respect to your question around 
doctors and their training. One is that training around these 
conditions is--there's too much that they have to cover in 
medical school, and this gets short shrift, period. But it's 
not a problem that can be fixed by training doctors better, 
because the primary care doctor has 7, 8, or 10 minutes.
    The only way that this integrated care can be delivered is 
if one of our types is basically parachuted into that doctor's 
practice. And if the patient does a screen in the waiting room, 
the doctor can then say, ``I see you have concerns about your 
sleeping and you're feeling depressed, and I'd like to ask Ms. 
Jones to come in. She's an expert in that area.'' Ms. Jones can 
then spend the time that it takes to talk through the symptoms, 
to maybe explain the sleep issue that Larry described.
    These programs that go under a rubric of collaborative 
care--the doctor does have to change behavior a little bit, but 
it's got to be a team approach, and the team approach can be 
thwarted by two things. One is if we take the mental health 
benefit--I'm going to argue in a way that may seem reverse. If 
we keep the mental health benefit in a separate insurance plan 
and only pay it to mental health specialists, it's not going to 
help the primary care doctor.
    But if we give it to the mainstream insurance plan and 
don't make them measure it--did you ask about depression, did 
you start people on treatment, did they improve? Unless we do 
that, we can't expect results either. So we're sort of getting 
what we have designed. I'm going to say that parity, as 
important as it is, is, I think, less critical now than 
figuring out how to crack this problem of primary care and 
getting support to the doctors out there that have got 8 
minutes, don't have the training, and don't know how to do this 
stuff.
    Senator Franken. I would just argue that when these 
conditions, the mental health conditions, these addiction 
conditions somatize themselves into other things--I see a lot 
of nodding--that there are primary care physicians who don't 
understand that and don't understand that they're seeing 
something that really comes from something else, something else 
that may be addiction or may be mental health.
    I'm way over my time. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Franken.
    Senator Warren.
    Senator Warren. Thank you, Mr. Chairman.
    Thank you all for being here today. I read your testimony, 
all of it. It was very powerful testimony. Thank you very much.
    The thing I drew out of the testimony, though, is a part we 
haven't talked about, and that is that millions of people who 
have serious mental health issues are not seeking care. And 
you've talked in different ways about why that is so. You're 
all kind of describing a different part of the animal. Mr. 
Fricks talks about stigma and why people don't ask for care.
    We talked about the availability of treatment, 
practitioners, whether or not we've got enough people, how we 
might deal with that with peer specialists, how we might deal 
with that with community healthcare centers and doctors' 
offices. We talked a little bit in the earlier panel about 
research, the importance of research, so we get better 
treatment, how we get better outcomes at lower cost.
    But the one I wanted to focus on in this last opportunity 
to talk is about the cost to the individual. I saw in the 
Kaiser study that 45 percent of those who don't seek care 
indicate that the cost is what deters them, that all those 
other things are there but they feel like they can't afford it, 
that they can't go out of pocket.
    What I'd like to hear from you is about the impact, about 
what that means when people deny care to themselves, to their 
children, to spouses and others in their families, and just 
what happens then. And to describe that either--we can talk 
about it in human terms and we can talk about it in financial 
terms, and in financial terms for the family or for the whole 
system. So I'd be grateful if you'd talk about that.
    Maybe, Mr. Fricks, you'd like to start.
    Mr. Fricks. Well, in rural communities like mine, it's so 
obvious about the stigma, because you'll park out front if you 
go into the public health, but if you've got to go to mental 
health, you try to park around back. You don't want your 
neighbors seeing you going into community mental health. So 
when we integrate, we'll help fix that. Everybody can go 
through the same door and park in the same parking lot.
    But it's hard to explain the devastation that occurs from 
the stigma and the active discrimination. It goes beyond just 
stigma. Of all the disability groups, we're the least employed 
in the country. It bumps 90 percent. And, by the way, 
employment is a huge factor in our recovery when people have 
meaningful work. In housing, we're discriminated against.
    A lot of it is--it's almost a civil rights issue. It's a 
human rights issue. I am hopeful that integration helps that. 
And then families are really torn apart by it, too. I'm very 
fortunate to have had a very supportive family. But the stress 
and strain economically will bust up marriages. It's just a 
fact. I mean, you're right on it. So thanks for your 
acknowledgement of that.
    Senator Warren. Thank you.
    Mr. DelGrosso.
    Mr. DelGrosso. Larry, thanks. You say it so well. I just 
think it's interesting that families would not hesitate to get 
a family member help for appendicitis or any other kind of 
physical health problem that they have, but often have a very 
difficult time reaching out to get the behavioral health and 
the substance abuse disorder treatment that they need.
    The bottom line is that it's often seen as that you have a 
character problem, or you've got a bad mom and dad, or 
something along those lines, rather than the fact that for many 
people, they have a brain disease. There's a lot of education 
yet still to come and a lot of support that we need at several 
levels for people to be able to move forward and raise their 
hand to come out and get help.
    I can also say as a mental health provider all these years 
that we need to stick our head up a little bit, too, and be 
proud of the fact or the area of healthcare that we provide 
care in and that we're not an enigma. Let's take the cloak off 
of this and let's talk about what it really is and how people 
can recover and become remarkable members of our community.
    Senator Warren. With the Chairman's indulgence, could I ask 
you, Dr. Vero, to add your comments briefly, and Dr. Hogan?
    Mr. Vero. Senator, thank you for the question, and I'll 
answer it, I think, from maybe both the human side and the 
financial side. We can't afford not to treat these illnesses 
that we identify, especially those that we identify early. They 
simply get worse. Mental illness is a systemic family disease. 
We know that when we look at addiction disorders, in 
particular, alcohol. There may be one individual in that family 
with an alcohol addiction. That entire family can pick up signs 
and symptoms of that illness, and there's dysfunction 
throughout that family.
    Those same things often occur with people who have severe 
and persistent mental illness. Mental illness is the leading 
cause of disability in the United States. That cost alone 
should alarm us all, and we have to start treating this on the 
front end and not treating it with disability payments.
    Senator Warren. Thank you.
    Dr. Hogan.
    Mr. Hogan. I'll conclude on that same point. At some point 
within the last 10 years, the total cost to society of mental 
illness passed the total cost of cancer and is running second 
to heart disease. But what is striking about those statistics 
is that while the cost of cancer and heart disease is the cost 
of providing care, the cost of mental illness is essentially 
the cost of not providing care.
    It's the cost of years lost of life due to suicide, of 
people not being able to function fully at work, of children 
not graduating because they weren't able to sit in their seat 
long enough, and then it escalated, and then they dropped out 
in high school. So if we could reverse this just a little bit 
and provide effective treatments, maybe we could slip back from 
No. 2 to No. 3 again.
    Senator Warren. Thank you very much.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Warren.
    I just want to thank this panel very much, both for the 
work you do and for the testimony you've offered here today. 
Again, the reason why we wanted to start off this Congress and 
why I wanted to start off this Congress with this kind of 
hearing in this committee was simply for the reasons that many 
of you expressed in one way or the other. And that is, we can't 
really get a handle on a healthcare system in America until we 
get a handle on integrating mental health with physical health. 
And I would lean a little bit more toward Mr. Fricks' side on 
looking at this mind-body connection.
    Dr. Hogan, I appreciate that not every primary care 
practitioner--they've only got 8, 9, or 10 minutes. They've got 
to remember a lot of stuff from medical school and their 
residency training.
    But it does seem to me that a system ought to be built 
where you have a collaboration. I have seen these. They're 
around the country, where if you go in, and you have, 
hopefully, electronic records, and you have some ailment that 
you've come in to see a primary care practitioner about, 
whether it's in a community health center or someplace else, a 
private practice, that there's a collaboration with the primary 
care physician and maybe a physical therapist, a psychiatrist 
or psychologist or maybe both, to take a look at what really is 
affecting this person.
    Is it a physical ailment that requires some physical 
intervention, or is it a physical ailment that's been 
manifested because of a psychological problem that needs to be 
attended to, or is it something else? Is this something where a 
qualified therapist could work with them and their family 
rather than thinking there has to be some prescription for some 
medicine filled out that they go to the drugstore to get?
    It just seems to me that as we're moving ahead with this 
Affordable Care Act and this new regime with all the exchanges 
and everything, we have an opportunity, I hope--and with the 
expansion of the community health centers around America, and 
that's where Dr. Vero--we're going to be in touch with you more 
about what you've done in Tennessee, because I think there's a 
model there for what we're going to do with community health 
centers in the future and how they're integrated into the 
system.
    That's why I think this hearing is so important, because 
you, Dr. Hogan, just said that the cost of mental illness now 
outstripped the cost of cancer in our country, and yet we just 
don't pay attention to it. Hopefully, this will set the stage 
for a lot of good bipartisan work and integration here of this 
committee looking at what we need to do to provide this sort of 
new integrated model in this new healthcare regime that we seem 
to be embarked upon here sometime in the near future.
    I thank you very much. I am certain our staffs or us will 
be in touch with you as we move along here for further 
enlightenment and further suggestions and recommendations that 
you might have.
    Senator Alexander.
    Senator Alexander. I want to thank Senator Harkin for this, 
and I want to thank the witnesses for coming. You made some 
very useful suggestions, and I look forward to following up. If 
I may say it this way, this is a committee on which we can have 
some fairly profound differences of opinion when we're talking 
about new laws, new spending, new policies.
    But it seems to me that a lot of what we fail to do here in 
the Federal Government is look at what we're already doing and 
ask the people who are doing it how we can take the programs 
and the money that we have and make it easier for you to do 
what you need to do. You've given us a long list of things 
today that you have suggested that would improve your ability 
to identify who needs help and identify the person to provide 
the help.
    While we may argue about some things, there's no need to 
argue about those things. We can work together on those things, 
and I would look forward very much to that opportunity, and 
I'll forward to your specific suggestions about the laws, 
regulations, and practices that you think we ought to change. 
And I'll work with Senator Harkin and see if we can do this in 
a bipartisan way.
    The Chairman. Thank you very much, Senator Alexander.
    I request that the record remain open for 10 days for 
members to submit statements and submit additional questions 
for the record.
    With that, thank you all very much. The committee will 
stand adjourned.
    [Additional material follows.]

                          Additional Material

                  Prepared Statement of Senator Casey

    Chairman Harkin, Ranking Member Alexander, I would like to 
thank you for convening this timely hearing to assess the state 
of our Nation's mental health system. It is unfortunate that it 
takes a tragedy on the scale of Sandy Hook, Tucson, Aurora or 
Virginia Tech to refocus our attention on the need for better 
access to mental health services, when one in four adults will 
suffer from a diagnosable mental illness in a given year and 
only 60 percent of people with serious mental illnesses get 
access to the mental health care they need.
    We have made progress in the last few years: we passed the 
mental health parity law, requiring health insurers to cover 
mental health benefits at the same level as other medical 
benefits; we have improved the supports available to our 
veterans suffering from post-traumatic stress disorder as a 
result of a decade of conflict and repeated deployments; and we 
passed the Affordable Care Act, which will increase access to 
all health services, including mental health services.
    Yet the repeated tragedies linked to individuals with 
serious mental illnesses, in addition to the countless 
individual tragedies that don't make the news because they are 
all too common, indicate that we must do more. Millions of 
people across the Nation are facing mental illness every day, 
and are not getting the help they need. In Pennsylvania, there 
were 1,547 suicides in 2010, the most recent year for which 
data are available; that works out to approximately four 
suicides per day (data from the Pennsylvania Department of 
Health).
    We also need to address the stigma that still surrounds 
mental illness. No person should ever be afraid to seek medical 
treatment, including mental health treatment. We all have a 
role to play in educating ourselves and our communities about 
mental illness. Only by being accepting and honest about the 
devastating effect of mental illness can we encourage the 
people bearing this burden to come out of the shadows and seek 
the help they so desperately need.
    I am pleased that President Obama recently committed to 
finalizing the mental health parity regulations and the 
regulations on the essential health benefits and parity 
requirements within the health insurance marketplaces under the 
Affordable Care Act.
    Again, I would like to thank Chairman Harkin and Ranking 
Member Alexander for convening this hearing, and would also 
like to recognize Chairman Harkin for his dedication to this 
issue over many years. I look forward to hearing from our 
witnesses today, and to working with my colleagues on the 
committee and in the Senate to improve our Nation's mental 
health system.

   Response by Pamela Hyde, J.D. to Questions of Senator Alexander, 
 Senator Mikulski, Senator Murray, Senator Casey, Senator Bennet, and 
                              Senator Enzi
                           senator alexander
    Question 1. How have you worked with States and other stakeholders 
to ensure that grants and cooperative agreements administered by SAMHSA 
have been responsive to the needs of local communities and States? What 
are some things that can be done to make things easier for States?
    Answer 1. For all SAMHSA grant programs, States and communities are 
asked to identify the specific need in their local jurisdiction and 
describe how the grant funds would address that need. This is done 
intentionally in order to allow States and communities to prioritize 
funds based on their specific needs.
    SAMHSA also provides technical assistance (TA) to communities and 
States to ensure their needs are met and that the most effective and 
efficient services are being developed. SAMHSA provides TA not only to 
its grantees for the implementation of specific grant programs but also 
to States and communities for larger system-wide change and 
enhancement.

    Question 2. It is my understanding that you are making revisions to 
the Community Mental Health Services Block Grant Application and the 
Substance Abuse Prevention and Treatment (SAPT) Block Grant 
Application, and one of the proposed changes is to move the deadline to 
April 1 for the applications from the statutory requirement of 
September 1 for the Mental Health Block Grant and October 1 for the 
Substance Abuse Block Grant.
    Can you give me a status of the pending application and how you are 
working with States to give them flexibility to submit the application 
given the statutory deadlines of September 1 and October 1, and the 
final applications not having been released?
    Answer 2. The fiscal year 2014-15 Uniform Application which is used 
for the Mental Health Block Grant (MHBG) and the Substance Abuse Block 
Grant (SABG) was published in the Federal Register. We expect the 
Application to be finalized later this year. SAMHSA has communicated to 
the block grant jurisdictions that the statutory deadlines remain the 
same (September 1st for the MHBG and October 1st for the SABG), but has 
encouraged an earlier submission date to allow for the States and 
SAMHSA to enter into a meaningful discussion of the State plan at a 
time when it can still be modified.

    Question 3. Patients and providers alike in rural areas face 
particular challenges with respect to access. What has SAMHSA been 
doing to work with States to improve access in these areas?
    Answer 3. SAMHSA's Block Grants provide flexible funds that States 
can use to provide access to necessary services, including services in 
rural areas. As a component of the application for Block Grant funds, 
States provide an assessment of their strengths and needs of the 
service system and identify unmet service needs and critical gaps.
    In addition, SAMHSA's Grants to Expand Care Coordination through 
the Use of Health Information Technology in Targeted Areas of Need 
(Short Title: TCE-Health IT) leverages technology to enhance and/or 
expand the capacity of substance abuse treatment providers to serve 
persons in treatment who have been underserved because of the lack of 
access to treatment in their immediate community. The lack of access 
may be due to transportation concerns, a limited number of substance 
abuse treatment providers in their community, and/or financial 
constraints. The use of health information technology (HIT), including 
web-based services, smart phones, and behavioral health electronic 
applications (e-apps) expand and/or enhance the ability of providers to 
effectively communicate with persons in treatment and to track and 
manage their health to ensure treatment and services are available 
where and when needed. Grantees use technology that will support 
recovery and resiliency efforts and promote wellness.
    In addition, HHS has been a key participant in the White House 
Rural Council, which was created in June 2011 through an Executive 
order. The Council is a combined effort of the White House Domestic 
Policy Council and the National Economic Council, with the Secretary of 
Agriculture serving as chair and Cabinet Agency heads serving as 
members. The Council works across executive departments, agencies, and 
offices to coordinate development of policy recommendations to promote 
economic prosperity and quality of life in rural America.

    Question 4. The Centers for Disease Control and Prevention (CDC) 
has classified prescription drug abuse an epidemic in the United 
States. In 2011, 2.4 million new individuals began using prescription 
drugs for nonmedical purposes. The widespread nonmedical use of 
prescription drugs has increased the numbers of overdose deaths and 
hospitalizations. In 2008, the CDC found that prescription drug misuse 
and abuse had caused 20,044 deaths and over 1,345,645 emergency room 
visits. In Tennessee, prescription drug abuse is a major problem. Can 
you tell me what role SAMHSA is playing to address prescription drug 
abuse?
    Answer 4. SAMHSA works across the Department of Health and Human 
Services through the Behavioral Health Coordinating Council's (BHCC) 
Prescription Drug Abuse Committee. As a result, SAMHSA has partnerships 
with CDC, Food and Drug Administration (FDA), National Institutes of 
Health, Centers for Medicare & Medicaid Services, the Office of the 
National Coordinator for Health Information Technology (ONC), and the 
Office of the Assistant Secretary for Health aimed at preventing and 
treating prescription drug misuse and abuse. SAMHSA is represented on 
the Office of National Drug Control Policy Interagency Workgroup on 
Prescription Drugs. SAMHSA's strategy to reduce prescription drug abuse 
and assist individuals who misuse or abuse prescription drugs is in 
alignment with the Office of National Drug Control Policy's four-part 
strategy: education for prescribers and the public; prescription 
monitoring; safe drug disposal; and effective enforcement. SAMHSA's 
contract supporting the Annual National Survey on Drug Use and Health 
is an integral part of our national surveillance of non-medical use of 
prescription drugs.
    Education--Current prescribers--SAMHSA has supported the education 
of prescribers for the past several years through formal continuing 
medical education courses and other less formal efforts, e.g., webinars 
hosted by SAMHSA's opioid prescriber clinical support system (PCSS) 
grantee (American Academy of Addiction Psychiatry). SAMHSA has placed a 
priority for these prescribing courses in States with the highest rates 
of opioid-related mortality--e.g., New Mexico and West Virginia. SAMHSA 
is also a participant in the NIH Pain Consortium.
    Future prescription drug prescribers--SAMHSA's SBIRT (Screening, 
Brief Intervention, Referral to Treatment) program is an important tool 
for early identification of persons who might be at risk for opioid 
dependency. SAMHSA's SBIRT Residency grant program addresses future 
prescribers and includes screening for prescription drug abuse, and 
more recently has emphasized the use of State prescription drug 
monitoring programs (PDMPs).
    Prescription monitoring--In 2012, SAMHSA developed a grant program, 
in partnership with ONC and CDC to allow States to increase their 
ability, with appropriate privacy protections, to link PDMPs with other 
electronic health care record systems (physicians' offices, 
pharmacists, hospital emergency departments, and Health Information 
Exchanges). In addition, the grants will be used by States to connect 
their PDMPs to other States to improve interoperability.
    SAMHSA has also partnered with ONC to fund pilots that test secure 
linkages between PDMPs and EHR systems across multiple facilities. Some 
of these pilot programs are also exploring ways to incorporate real-
time PDMP data at points-of-care and dispensing, further streamlining 
these data checks for standard patient care. Finally, SAMHSA staff is 
participating in projects with other agencies to increase the ability 
of PDMPs to identify outbreaks of prescription drug abuse.
    Prevention of Prescription Drug Abuse in the Workplace (PAW) 
Technical Assistance Contract--The PAW program provides technical 
assistance to help local, government and military workplace and 
communities understand the prescription drug abuse problem and reduce 
related problems by stimulating, informing, and supporting employer- 
and community-based prevention/early intervention efforts. The PAW 
educational and technical assistance efforts and resources focus on 
SAMHSA grantees; employers, unions, and other communities; and 
collaborate with partner organizations. PAW educational/technical 
assistance resources include fact sheets, web products, assessment 
tools, presentations, trainings, and literature reviews. Topics such as 
developing specific workplace prescription drug abuse policies; 
integrating prescription abuse messaging into current programs and 
community outreach activities; and prescription drug abuse evaluation 
activities and metrics are addressed.
    Prescription Drug Abuse Treatment--Treatment of opioid dependence/
addiction is a critical element of SAMHSA's strategy and includes 
expanding and improving access to the three FDA-approved medical 
treatments: methadone (regulated by FDA, SAMHSA, and the DEA), 
buprenorphine (SAMHSA works together with the DEA to process waivers to 
enable physicians to prescribe buprenorphine products), and naltrexone, 
both oral and extended release products. SAMHSA has been working with 
other Federal agencies to explore ``telemedicine'' enabling treatment 
in rural settings. SAMHSA is continuously educating providers and 
consumers about these medical treatments through educational efforts, 
the PCSS model referenced above and interactions with the provider 
communities. SAMHSA works with the FDA to ensure that safety of these 
medications is continuously monitored and analyzed. For example, SAMHSA 
convened expert panels and work groups with the FDA to assess the 
safety of methadone in terms of cardiac health; methadone-related 
mortality associated with overdose; buprenorphine and risk of pediatric 
exposure; and diversion of these medications for illicit or 
inappropriate use. SAMHSA convened a similar meeting on developing 
guidelines for the medicine Vivitrol, an injectable medicine designed 
to treat opioid dependence for up to 30 days.
                            senator mikulski
    Question 1. I am a big champion of privacy but with Virginia Tech, 
none of the systems talked with each other. How can we make sure 
privacy is protected and everyone in the system is talking to each 
other when problems arise?
    Answer 1. SAMHSA agrees that it is critical that privacy be 
protected in behavioral health treatment. However, SAMHSA recognizes 
that there are situations and crises that require the sharing of 
information about an individual to other clinicians, to the judiciary, 
to law enforcement or to the National Instant Criminal Background Check 
System (NICS). This balancing of competing interests is essential for 
the health of the individual who presents for behavioral health care 
and for the well-being of society should an individual suffering from a 
behavioral health illness be a threat to themselves or to others.
    On January 16, 2013, President Obama implemented 23 Executive 
Actions to reduce gun violence. Following the release of the 
President's plan, the HHS Office for Civil Rights released a letter to 
the provider community and other interested parties clarifying that the 
Health Insurance Portability and Accountability Act (HIPAA) Privacy 
Rule does not prevent the necessary disclosure of critical information 
about a patient to law enforcement, family members of the patient, or 
to other persons, when the provider believes that patient presents a 
serious danger to himself or to other people.
    Some States have cited concerns about restrictions under HIPAA as a 
reason not to share relevant information on people prohibited from gun 
ownership for mental health reasons. The Administration will begin the 
regulatory process to remove any needless barriers, starting by 
gathering information about the scope and extent of the problem.
    In addition to what HIPAA permits in terms of disclosure, most 
States have laws or court decisions which address, and in many 
instances require, the disclosure of patient information to prevent or 
lessen the risk of harm. Since the classic ruling of Tarasoff v. 
Regents of the University of California (1976), mental health 
professionals in many States have had a legal duty to protect intended 
victims by notifying them and the police of threats of harm. In the 
years since Tarasoff, mental health professionals have generally 
adopted some version of the duty to protect reasonably identifiable 
third parties as a standard of practice. Most behavioral health 
providers are aware of the duty to protect third parties; however, most 
primary care providers are not covered by the Tarasoff principles.
    Subsequent to the Virginia Tech shootings, the Virginia Tech Review 
Panel found that the University believed that communicating their 
concerns about a student with one another or the student's parents was 
prohibited by the Federal laws governing the privacy of health and 
education records. In reality, Federal laws and their State 
counterparts afford ample leeway to share information in potentially 
dangerous situations.
    Furthermore, in the Virginia Tech shooting, the student purchased 
two guns in violation of existing Federal law. The fact that in 2005 he 
had been judged to be a danger to himself made him ineligible to 
purchase a gun under Federal law. The Virginia Tech Review Panel found 
that there was a lack of understanding about what information could be 
shared and by whom. Under the President's gun violence reduction plan 
announced in January, the Department of Justice will invest $20 million 
in fiscal year 2013 to give States stronger incentives to make relevant 
information--including information on persons prohibited from 
possessing firearms for mental health reasons--available to the 
background check system. The Administration is also proposing $50 
million for this purpose in fiscal year 2014, and will look for 
additional ways to ensure that States are doing their part to provide 
relevant information.
    One of SAMHSA's top Strategic Initiatives is health information 
technology. SAMHSA is working closely with the Office of the National 
Coordinator for Health Information Technology to encourage States and 
providers to implement certified electronic health records and to 
promote the exchange of health information using recognized standards. 
One of SAMHSA's main HIT goals is to ensure the secure exchange of 
electronic behavioral health information while protecting the privacy 
rights of individuals.
    Health information exchanges (HIEs) are quickly integrating into 
the healthcare landscape enabling real-time access to patient health 
information from multiple sources. SAMHSA is collaborating with other 
agencies (e.g., veterans agencies, criminal justice, and housing) to 
develop a plan to securely exchange relevant health information while 
complying with Federal and State privacy and confidentiality laws.
    SAMHSA believes that the strategies mentioned above will go a long 
way in making sure that privacy is protected while permitting everyone 
in the system to ``talk to'' each other when problems arise.

    Question 2. What is SAMHSA doing with the Department of Defense to 
prevent suicide across the services and for our veterans?
    Answer 2. SAMHSA has been working with the Department of Defense 
(DOD) on preventing suicide since at least 2000, during the development 
of the first National Strategy for Suicide Prevention (published in 
2001 and revised in 2012). With a strong respect for the respective 
areas of expertise in military culture, medicine, behavioral health, 
and evidence-based practices, the Agency and Department work together 
on a variety of fronts and in a range of initiatives.
    In 2005, the DOD joined the Federal Partners Working Group on 
Suicide Prevention, a mechanism for Federal agencies to increase 
collaboration and coordination in their suicide prevention policies and 
initiatives. DOD and SAMHSA co-chaired the Working Group between 2005 
and 2010, and the acting director of the Defense Suicide Prevention 
Office (DSPO) continues to participate in the Group's monthly calls.
    In 2009, Dr. Richard McKeon, Chief of SAMHSA's Suicide Prevention 
Branch, was selected by then Defense Secretary Gates to be one of seven 
civilian members of the DOD Task Force on the Prevention of Suicide by 
Members of the Armed Forces. Among the recommendations of the Task 
Force was the establishment of a DOD suicide prevention office within 
the Office of the Secretary, a recommendation that was embraced by DOD 
and launched in 2011. SAMHSA continues to work closely with DSPO. 
Currently, SAMHSA is working with DSPO to review suicide prevention 
programs within DOD and develop a methodology to identify best 
practices.
    In 2010, HHS Secretary Kathleen Sebelius and then DOD Secretary 
Robert Gates launched the National Action Alliance for Suicide 
Prevention (``Action Alliance''), a public-private partnership that 
advances the National Strategy for Suicide Prevention. Since its 
inception, the Action Alliance has been co-chaired by Secretary of the 
Army John McHugh and former U.S. Senator Gordon Smith. Among its 14 
active task forces is the Military/Veterans Task Force, which last year 
co-hosted Partners in Care/suicide prevention summits in partnership 
with National Guard State Chaplains in five States. Through this 
initiative more than 400 community clergy were trained to recognize the 
warning signs of suicide among service members, veterans, and their 
families, and more than 200 congregations enlisted in a National Guard-
sponsored Partners in Care program to provide support to National Guard 
members and their families. SAMHSA's grantee for the Suicide Prevention 
Resource Center acts as Secretariat for the Action Alliance, managing 
all operations.
    SAMHSA is the lead HHS agency tasked with implementing the 
President's Executive Order ``Improving Access to Mental Health 
Services for Veterans, Service Members, and Military Families,'' which 
was issued on August 31, 2012. SAMHSA is working closely with both DOD 
and the Department of Veterans Affairs (VA) on the outreach and public 
health aspects of the Order.
    SAMHSA has been a planning partner with DOD and VA for the past 
three DOD/VA Suicide Prevention Conferences, offering the public health 
perspective needed to ensure community involvement in suicide 
prevention.
    Through its Service Members, Veterans, and their Families Policy 
Academies and the ongoing technical assistance it provides after the 
Policy Academies, SAMHSA helps States and territories reach out to 
service members--especially members of the National Guard and 
Reserves--who are transitioning back to civilian life. The form of 
outreach varies across States/territories, but the work is generally 
done through State/Federal/private collaboration (e.g., partnerships 
among State mental health and substance abuse agencies, Joining Forces 
and Joining Community Forces, Yellow Ribbon, VA, Veteran Service 
Organizations, etc.). Additionally, SAMHSA promotes military cultural 
training for community providers, which helps civilian providers better 
understand the military culture and appreciate the impact of deployment 
on both the service member and his/her family. Training also encourages 
providers to screen patients for military and combat experience and to 
make appropriate referrals to Vet Centers (which provide readjustment 
counseling to combat veterans, delivered by combat veterans) and to the 
VA.
    In 2011, SAMHSA provided Applied Suicide Intervention Skills 
Training (ASIST) to 50 National Guard State directors of psychological 
health, and to 20 National Guard State suicide prevention program 
managers. ASIST is a ``gatekeeper'' program that trains individuals to 
recognize warning signs of suicide and to respond appropriately and 
effectively to those signs.
    SAMHSA has worked closely with the VA since 2007 when VA launched 
the Veterans Crisis Line in partnership with SAMHSA and its National 
Suicide Prevention Lifeline. The Veterans Crisis Line is also co-
branded the ``Military Crisis Line,'' and marketing includes both names 
so that Veterans, Reservists, and Service members will feel welcome in 
calling this 24/7 life-saving resource.
    Finally, one of SAMHSA's Government Project Officers in the Suicide 
Prevention Branch provides both Marines and Sailors with suicide 
prevention training. SAMHSA is working with the U.S. Marine Corps to 
extend the current Memorandum of Understanding.

    Question 3. How can we help you to strengthen the mental health 
workforce? Is there anything you need from us?
    Answer 3. As outlined in the President's plan, Now is the Time, the 
Administration is proposing funding to train 5,000 behavioral health 
professionals, particularly those interested in working with school and 
transition-age youth. To achieve this goal the Administration is 
proposing $50 million for a behavioral health workforce program to 
train social workers, counselors, psychologists, and other mental 
health professionals.

    Question 4. Are reforms needed in the substance abuse prevention 
and treatment block grant or community mental health services block 
grant to better meet the needs of patients in our communities?
    Answer 4. We will continue to review the block grant requirements 
as the health care law is implemented and look forward to working with 
Congress to continue to meet the needs of patients in our communities.
                             senator murray
    Question 1. In 2008 this committee, under Chairman Kennedy, helped 
to pass into law the Mental Health Parity and Addiction Equity Act. 
This law, expanded in the recent health care reform legislation, 
requires health insurance to cover both mental and physical health 
equally. As you know, three parity provisions were included in the 
President's recently released gun violence package: one clarifying 
parity for Medicaid managed care plans, one saying a parity provision 
would be included in the final essential health benefits rule, and one 
that ``committed'' to issuing the final rule on the Mental Health 
Parity and Addiction Equity Act, but it did NOT make clear when we 
might expect to see that. If plans are supposed to be ready to go in 
Exchanges starting in October, it is essential that we see a final rule 
no later than April.
    Can you give us a date certain on when the final rule will be 
released?
    Answer 1. The Administration intends to issue the final rule on the 
Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 
Equity Act (MHPAEA) by the end of 2013. To date, the three different 
agencies--HHS, Treasury, and Labor--that have responsibility for these 
rules, have released an Interim Final Rule (IFR) and multiple guidance 
documents, in the form of FAQs and compliance aids, to provide guidance 
on substantive issues necessary for Exchanges to move forward with 
guidance to their Qualified Health Plans.

    Question 2. Parity in scope of services has to be defined in the 
final rule. I have heard reports of plans that are dropping key mental 
health and addiction services like intensive outpatient and residential 
treatment, even if similar services are provided for medical 
conditions, because the law's interim final rule did not address the 
issue of scope of service.
    How will you define parity in scope of services in the final rule 
to ensure that patients are able to access important mental health 
services?
    Answer 2. The Administration is studying this issue very carefully 
and is closely reviewing comments received on the IFR. In addition, we 
are reviewing regulations in States that have enacted parity laws to 
assess how they have treated scope of services and examining how 
private health insurance currently covers and pays for services such as 
intensive outpatient and residential treatment. The Administration has 
also obtained clinical opinions and reviewed literature regarding what 
the analogous services are to residential and intensive outpatient.

    Question 3. The final rule needs to clarify how non-quantitative 
treatment limits apply by setting a quantitative floor. In December 
2011, the Department of Labor, the Department of the Treasury, and the 
Department of Health and Human Services released a set of frequently 
asked questions that aimed to provide additional guidance on these 
treatment limits. These FAQs established that non-quantitative 
treatment limits must be applied ``comparably and no more stringently'' 
to mental health and substance abuse benefits than to medical benefits. 
However, many plans are currently claiming that regulations allow them 
to micro-manage mental health and addiction treatment the same way 
plans manage physical therapy, which makes up less than 1 percent of 
medical benefits. Applying a non-quantitative treatment limit more 
stringently to all behavioral health benefits and only 1 percent of 
medical benefits is not comparable and violates. A quantitative floor 
for non-quantitative treatment limits is needed to clarify these limits 
so that plans do not apply them in a way that violates the Mental 
Health Parity and Addiction Equity Act.
    How do you plan to clarify in the final rule how non-quantitative 
treatment limits apply? Will you include a quantitative floor in the 
final rule?
    Answer 3. The Departments issued a number of FAQs to help clarify 
these issues and will continue to do so through FAQs and the final 
rule. Non-quantitative treatment limits (NQTLs) were the focus of FAQs 
that were released on November 17, 2011. In those FAQs it was explained 
that the quantitative tests outlined in the IFR for determining what 
limits or requirements apply to substantially all medical/surgical 
benefits and what the predominant levels for those financial 
requirements or limits are do not apply to NQTLs. In addition, other 
FAQs clarified that applying standards used for a very limited set of 
medical/surgical benefits, for instance just physical therapy to all 
mental health and substance use disorder benefits, would not be 
permissible (see FAQ #5).

    Question 4. The final rule must require transparent disclosure of 
medical and behavioral criteria so that parity compliance testing may 
be performed. The Parity Implementation Coalition has provided 100 
cases to the Department of Labor and the Department of Health and Human 
Services of plans refusing to provide this essential information. No 
plan, to my knowledge, has ever disclosed these criteria, and there has 
been no enforcement of that requirement that I am aware of in the 4 
years that the law has been out.
    How will you enforce the requirement that health insurance plans to 
disclose medical and behavioral criteria?
    Do you have a plan to retroactively handle the Parity 
Implementation Coalition's complaints about plans refusing to disclose 
criteria over the past 4 years?
    Answer 4. The Department of Labor (DOL) has primary oversight of 
private employer-sponsored group health plans, and States have primary 
oversight of health insurance issuers (with HHS having fallback 
oversight for issuers). During the 2 years (since January 2011) that 
the regulations have been fully in effect for most plans, DOL has been 
committed to ensuring that individuals enrolled in employer-sponsored 
health plans receive mental health and substance use benefits in a 
manner that is compliant with MHPAEA. DOL, for example, has a robust 
investigative program in 10 field offices across the country that 
conduct health plan audits to check for compliance with various Federal 
laws, including MHPAEA. Any concerns or inquires brought to DOL's 
attention are thoroughly evaluated and reviewed, including those 
related to mental health parity. Many of these reviews and audits are 
handled under a voluntary compliance and correction approach, and 
resolved through confidential discussions between DOL and the group 
health plan. In general, for cases involving a group health plan 
providing coverage through a fully insured health insurance product, 
DOL works closely with States and HHS to resolve the issues at the 
health insurance issuer level. HHS regularly works with State insurance 
commissioners to address complaints that have been made about a variety 
of matters related to MHPAEA. Some of these involve disclosure of 
medical necessity criteria, which, as such, are handled confidentially.
                             senator casey
    Question 1. You noted that Medicaid accounts for 28 percent of 
mental health spending. In your experience, are mental health patients 
more vulnerable to Medicaid cuts than patients with physical health 
problems?
    Answer 1. Individuals with mental illnesses tend to have lower 
incomes, higher health care expenditures, and are more likely to be 
enrolled in public insurance programs like Medicaid. Therefore they are 
more susceptible to cuts in the program. When cuts are made to 
Medicaid, it can impact one or more services that the individual is 
relying on.

    Question 2. What kind of impact can even small changes in Medicaid 
spending have on access to mental health services?
    Answer 2. The Administration gives States significant flexibility 
to manage costs and benefits in their programs. CMS continues to work 
closely with States to provide options and tools that make it easier 
for States to make changes in their Medicaid programs to improve care 
and lower costs. In the last 6 months, the Administration has released 
guidance giving States flexibility in structuring payments to better 
incentivize higher-quality and lower-cost care, provided enhanced 
matching funds for health home care coordination services for those 
with chronic illnesses, designed new templates to make it easier to 
submit section 1115 demonstrations and to make it easier for a State to 
adopt selective contracting in the program, and developed a detailed 
tool to help support States interested in extending managed care 
arrangements to long-term services and supports.

    Question 3. Which groups of Medicaid beneficiaries tend to use 
mental health services the most?
    Answer 3. Historically, given the varying types of Medicaid 
coverage levels by State, it has typically been children with serious 
emotional disturbance, and adults who have been found to be disabled 
due to a mental illness that have been most often covered by Medicaid, 
and therefore present in the data as users of service. In addition, 
persons who are dually eligible for Medicare and Medicaid often present 
with complex mental health needs.
                             senator bennet
    Question 1. Most private health insurance does not offer a 
comprehensive mental health or substance use disorder benefit. While 
parity takes an important step by requiring that these areas of health 
care are covered at the same level as physical health care, there is a 
lack of detailed information. Current listings of services under 
essential health benefits do not provide sufficient detail on parity 
with mental health and substance use services that are effective and 
necessary. Consequently, there is concern that expanded Medicaid and 
new products on the Exchanges will not offer the necessary services 
available for patients who need mental health and substance use 
disorder treatment and prevention. Does SAMHSA recommend further 
guidance for States and health plans on the required mental health and 
substance use services that each plan must offer in their essential 
benefit plan? If so, what should that guidance include?
    Answer 1. The Affordable Care Act will provide one of the largest 
expansions of mental health and substance use disorder coverage in a 
generation. Beginning in 2014, under the law, all new small group and 
individual market plans will be required to cover 10 Essential Health 
Benefit categories, including mental health and substance use disorder 
services, and will be required to cover them at parity with medical and 
surgical benefits. The Affordable Care Act builds on MHPAEA (the 
Federal parity law), which requires group health plans and insurers 
that offer mental health and substance use disorder benefits to provide 
coverage that is comparable to coverage for general medical and 
surgical care.
    The Affordable Care Act builds on MHPAEA to extend Federal parity 
protections to 62 million Americans. The parity law aims to ensure that 
when coverage for mental health and substance use conditions is 
provided, it is generally comparable to coverage for medical and 
surgical care. The Affordable Care Act builds on the parity law by 
requiring coverage of mental health and substance use disorder benefits 
for millions of Americans in the individual and small group markets who 
currently lack these benefits, and expanding parity requirements to 
apply to millions of Americans whose coverage did not previously comply 
with those requirements.

    Question 2. Mental Health First Aid has the great potential to 
identify people with emerging mental health issues and substance use 
disorders. In many cases, identification can result in referrals to 
primary care, mental health, and substance use treatment providers. 
Most public and private funding does not pay for early intervention and 
prevention services for people with mental health issues and substance 
use disorders. Often, mental health coverage does not exist until a 
person has a diagnosable condition. By funding prevention and early 
intervention, diagnosis and more expensive treatment may not be 
necessary. What efforts are SAMHSA and NIMH engaged in to promote more 
prevention and early intervention services and to remove restrictions 
that require a higher degree of illness before a person can get needed 
care?
    Answer 2. SAMHSA supports a number of grant programs and 
initiatives that promote more prevention and early intervention 
services. Examples include:

     Linking Actions for Unmet Needs in Children's Health 
(Project LAUNCH): Project LAUNCH is a program that seeks to ensure that 
all young children, especially those at increased risk for developing 
social, emotional, and behavioral problems, receive the supports they 
need to succeed. Project LAUNCH brings together stakeholders to develop 
a vision and a comprehensive strategic plan for promoting the wellness 
of all young children. Project LAUNCH also supports programs for child 
care providers such as Mental Health Consultation, which can address 
behavior problems before they disrupt placements and lead to later 
problems.
     Implementing Evidence-Based Prevention Practices in 
Schools (PPS): The purpose of this program is to prevent aggressive and 
disruptive behavior among young children in the short term and prevent 
antisocial behavior, suicidal ideation, and the use of illicit drugs in 
the longer-term with the additional goal of promoting graduation from 
high school.
     Safe Schools/Healthy Students Initiative (SS/HS): SS/HS is 
a unique collaboration between HHS, the Department of Education, and 
the Department of Justice. SS/HS takes a broad approach, drawing on the 
best practices and the latest thinking in education, justice, social 
services, and mental health to help communities take action, 
recognizing that no single activity can be counted on to prevent 
violence. SS/HS supports local education agencies across the country, 
spanning rural, Tribal, suburban, and urban areas as well as diverse 
racial, ethnic, and economic sectors. It provides grant funds, 
technical assistance, and evaluations of both process and outcome 
(effectiveness) measures. To date, SS/HS has provided services to over 
12 million youth and more than $2 billion in funding and other 
resources to 365 communities in 49 States across the Nation. Outcomes 
of SS/HS grantees suggest that partnership was the key factor in 
success. There was a dramatic 263 percent increase in the number of 
students who received school-based mental health services and an 
astounding 519 percent increase in those receiving community-based 
services. Nearly 80 percent of school staff stated that they were 
better able to detect mental health problems in their students and more 
than 90 percent of school staff reported that they saw reductions in 
alcohol and other drug use among their students.
    The President's gun violence reduction package released in January 
includes $40 million to expand SS/HS through Project AWARE.
     National Center for Mental Health Promotion and Youth 
Violence Prevention (National Center): The National Center provides 
training and technical assistance to support prevention and early 
intervention activities as well as directed TA to Safe Schools/Healthy 
Students and Project LAUNCH grantees. National Center staff work with 
school districts and communities as they plan, implement, and sustain 
initiatives that foster resilience, promote mental health, and prevent 
youth violence and mental and behavioral disorders. Through training, 
national and regional events, teleconferences, online learning, site 
visits, peer exchange, a virtual library, and onsite work, the National 
Center provides culturally competent consultation to serve diverse 
audiences.
     Screening, Brief Intervention and Referral to Treatment 
(SBIRT): SBIRT is a comprehensive, integrated, public health approach 
to the delivery of early intervention and treatment services for 
persons with substance use disorders, as well as those who are at risk 
of developing these disorders. Primary care centers, hospital emergency 
rooms, trauma centers, and other community settings provide 
opportunities for early intervention with at-risk substance users 
before more severe consequences occur.
                              senator enzi
    Question. I am concerned about the significant number of 
duplicative Federal Government programs. Can you tell me what programs 
within your agency are duplicative or could be combined to provide more 
efficient operations? Please describe how you plan to identify unfunded 
and unproven programs that can be eliminated in order to better focus 
resources on those that do work.
    Answer. SAMHSA takes its role as a steward of taxpayer dollars very 
seriously and during this tight budget environment, SAMHSA stretches 
every dollar we have to make the maximum impact. We closely examine our 
portfolio at SAMHSA to find efficiencies and as a result have reduced 
redundancy or duplication. For example, in 2012, SAMHSA consolidated 
three State Technical Assistance (TA) contracts into a single contract. 
This consolidation resulted in both programmatic as well as 
administrative efficiencies. In 2011, several similar consolidations 
took place. SAMHSA constantly evaluates its programs via grantee input 
and data collection. Program adjustments, in scope or focus, are 
directly affected by that data. With the development and implementation 
of the Common Data Platform, program adjustments will be even better 
informed in the future.

   Response by Thomas Insel, M.D. to Questions of Senator Alexander, 
           Senator Mikulski, Senator Casey, and Senator Enzi
                           senator alexander
Early Diagnosis of Mental Disorders
    Question. Much of NIMH's work has the potential to have major 
impacts on the mental health system overall, with the ability to 
diagnose mental disorders earlier and get people, especially young 
children, into effective treatment. Can you provide some examples of 
work that you are doing to diagnose mental disorders earlier?
    Answer. One of the primary objectives of the NIMH Strategic Plan 
\1\ is to chart the course of mental disorders over the lifespan to 
determine when, where, and how to intervene, with the ultimate goal of 
preempting or treating mental disorders and hastening recovery. Mental 
disorders are a group of chronic, changing conditions. The symptoms 
often begin to appear in childhood and adolescence and ebb and flow 
over the course of an individual's life. Behavioral manifestations, 
such as psychosis and depression, are in fact late events in the 
timeline of illnesses that began years earlier.\2\ As with many other 
illnesses, science promises to redefine mental disorders along a 
trajectory moving across stages of risk: from early symptoms, to full 
symptoms or syndromes, to remission, relapse, and recovery. NIMH aims 
to compare trajectories of healthy development to those of mental 
disorders in order to better understand the first instance or instances 
when development moves off course. Doing so will allow us to pinpoint 
the best times and techniques to preempt the onset of symptoms or halt 
and reverse the progression and recurrence of illness. Charting the 
course of mental disorders requires attention to genetic, 
neurobiological, behavioral, experiential, and environmental factors 
that confer a risk of developing a mental disorder.
---------------------------------------------------------------------------
    \1\ http://www.nimh.nih.gov/about/strategic-planning-reports/
index.shtml.
    \2\ Cannon TD, Cadenhead K, Cornblatt B, Woods SW, Addington J, 
Walker E, Seidman LJ, Perkins D, Tsuang M, McGlashan T, Heinssen R. 
Prediction of Psychosis in High Risk Youth: A Multi-Site Longitudinal 
Study in North America. Arch Gen Psychiatry. 2008 Jan;65(1):28-37.
---------------------------------------------------------------------------
    NIMH is supporting considerable research to chart these 
trajectories in order to intervene early. For example, the NIMH-funded 
Neurodevelopmental Genomics project is a landmark study in 
developmental neuropsychology that will bridge our understanding of 
brain and behavioral development for children ages 8 to 21. The study 
began with 10,000 children whose genomic profiles and cognitive 
abilities would be studied, with 1,000 undergoing comprehensive 
neuroimaging throughout brain development. The data are still being 
analyzed, but the study has already provided the first detailed 
reference map of cognitive development across adolescence. This project 
is giving us a picture of the range of development in both brain and 
behavior with which we can map expected trajectories, similar to growth 
charts for height and weight.
    NIMH-supported researchers are also working to identify individuals 
who may develop schizophrenia, a chronic, severe, disabling brain 
disorder that affects more than 2 million Americans age 18 and older in 
a given year.\3\ Although we know from other areas of medicine that 
early detection and early intervention yield the best outcomes, we lack 
the predictive markers for early detection of schizophrenia. Some 
individuals with schizophrenia will experience episodes of psychosis, a 
loss of contact with reality that usually includes false beliefs about 
what is taking place or who one is (delusions) and seeing or hearing 
things that are not there (hallucinations). Most young people have pre-
psychotic symptoms, known as the prodrome, for 2-3 years before the 
onset of psychosis. To enhance early detection and preempt psychosis, 
NIMH is supporting the North American Prodrome Longitudinal Study 
(NAPLS), a consortium of eight clinical research centers studying the 
prodromal phase of schizophrenia. The investigators are using 
biological assessments, including neuroimaging, electrophysiology, 
neurocognitive testing, hormonal assays, and genomics, to improve our 
ability to predict who will convert to psychosis, and to develop new 
approaches to pre-emptive intervention.
---------------------------------------------------------------------------
    \3\ Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, 
Goodwin FK. The de facto mental and addictive disorders service system. 
Epidemiologic Catchment Area prospective 1-year prevalence rates of 
disorders and services. Archives of General Psychiatry. 1993 
Feb;50(2):85-94.
---------------------------------------------------------------------------
    While some do not necessarily consider autism a traditional mental 
health disorder, the Diagnostic and Statistical Manual of Mental 
Disorders (DSM) published by the American Psychiatric Association 
includes Autism Spectrum Disorder. NIMH research has also made great 
advances in the early diagnosis for autism spectrum disorder (ASD). ASD 
is a neurodevelopmental disorder that typically manifests before the 
age of 3 years and is associated with a range of difficulties in social 
interaction, communication, and repetitive behaviors. Early detection 
of ASD may lead to earlier intervention which in turn may lessen, or 
even eliminate, ASD symptoms for some children. Yet identifying the 
earliest signs of ASD has been challenging. However, NIMH supported 
researchers have recently shown that it is possible to detect the 
earliest signs of ASD in 6-month-old infants. The researchers followed 
a group of infants from 3 months to 3 years of age. The infants were 
assessed in their third year of life when some of them were found to 
have ASD. Compared to the typically developing infants, infants later 
diagnosed with ASD showed a decreased ability to pay attention to 
complex social scenes involving people and objects. The researchers 
posit that difficulties in attending to people might precede the 
excessive interest in objects often reported in older children with 
ASD. Thus, some of the first signs of ASD, such as limited visual 
attention to social scenes, may be detectable very early in 
development, well before the emergence of current diagnostic 
features.\4\
---------------------------------------------------------------------------
    \4\ Chawarska K, Macari S, Shic F. Decreased Spontaneous Attention 
to Social Scenes in 6-Month-Old Infants Later Diagnosed with Autism 
Spectrum Disorders. Biological Psychiatry, published online January 10, 
2013.
---------------------------------------------------------------------------
                            senator mikulski
Premature Mortality and Mental Illness
    Question. Are we doing all that we can to reduce premature deaths 
associated with mental illness?
    Answer. Research shows that Americans with serious mental illness 
(SMI) die 8 years earlier than the general population from largely 
preventable or treatable comorbid medical conditions, such as heart 
disease, diabetes, cancer, pulmonary disease, and stroke. \5\ Low rates 
of prevention, detection, and treatment further add to these health 
disparities.
---------------------------------------------------------------------------
    \5\ Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. 
Understanding excess mortality in persons with mental illness: 17-year 
followup of a nationally representative U.S. survey. Med Care. 2011 
Jun;49(6):599-604.
---------------------------------------------------------------------------
    To address this serious public health concern, in 2012, NIMH 
convened the meeting ``Research to Improve Health and Longevity of 
People with Severe Mental Illness,'' in collaboration with the National 
Institute on Diabetes and Digestive and Kidney Diseases (NIDDK), the 
National Heart, Lung, and Blood Institute (NHLBI), the National Cancer 
Institute (NCI), and the National Institute on Drug Abuse (NIDA). The 
meeting brought together the leading researchers on medical 
comorbidities in people with SMI and on prevention and treatment within 
the general population for diabetes, heart disease, tobacco use, and 
drug abuse. They were joined by State policy leaders; advocates for 
people with SMI; leaders of community mental health centers; and 
representatives from key Federal agencies, including the Substance 
Abuse and Mental Health Services Administration (SAMHSA) and the Agency 
for Healthcare Research and Quality (AHRQ). The goal of the meeting was 
to identify critical research gaps and formulate the most pressing 
research questions in order to improve the health and longevity of 
people with SMI. This meeting informed the development of a new funding 
announcement that NIMH will release this year, titled Improving Health 
and Reducing Premature Mortality in People with Severe Mental Illness 
(SMI). The goal of this initiative is to test services interventions 
that specifically target people with SMI or children and youth with 
serious emotional disturbances and modifiable health risk factors that 
are the primary causes of premature mortality in these populations.
    In addition to supporting research to extend longevity by treating 
comorbid medical conditions, NIMH is engaged in numerous suicide 
prevention efforts. Suicide is the 10th leading cause of death in the 
United States, accounting for the loss of more than 38,000 American 
lives each year, more than double the number of lives lost to 
homicide.\6\ The National Strategy for Suicide Prevention \7\--
developed by the National Action Alliance for Suicide Prevention--
emphasizes the importance of research that can help develop effective 
interventions. NIMH co-leads the Research Task Force of the Action 
Alliance, which is developing a detailed research agenda, anticipated 
in 2013, that pledges to provide a roadmap for reducing suicide by 20 
percent in 5 years, and 40 percent or more in 10 years.
---------------------------------------------------------------------------
    \6\ Centers for Disease Control and Prevention, National Center for 
Injury Prevention and Control. Web-based Injury Statistics Query and 
Reporting System (WISQARS): www.cdc.gov/ncipc/wisqars accessed October 
2012.
    \7\ More information at: http://
actionallianceforsuicideprevention.org/NSSP.
---------------------------------------------------------------------------
    The challenge of reducing suicide is especially urgent in the 
military. Recognizing that this is not only a military problem but also 
a national challenge, the Army Study to Assess Risk and Resilience in 
Servicemembers \8\ (Army STARRS) was launched in fiscal year 2009. Army 
STARRS is a 5-year collaborative partnership between the Department of 
the Army, NIMH, and several academic institutions that seeks to 
identify factors that both protect Soldiers' mental health and those 
that put a Soldier's mental health at risk. The ultimate goal of Army 
STARRS is to provide empirical evidence to help the Army develop 
targeted prevention and treatment strategies.
---------------------------------------------------------------------------
    \8\ http://armystarrs.org/.
---------------------------------------------------------------------------
    In fiscal year 2012, Army STARRS reached a number of milestones, 
including establishing survey sites at more than 70 locations around 
the world, surveying more than 100,000 Soldiers, and, with appropriate 
consent, collecting more than 56,000 blood samples. Both the New 
Soldier Study, designed to capture information about experiences 
soldiers bring into the Army, and the All Army Study, which provides a 
snapshot of the Army across ranks and all areas of service, are nearing 
completion. This past year, several new components were launched, and 
Army STARRS established a data enclave that integrates the 
administrative records of the 1.6 million Soldiers who served between 
2004 and 2009. The enclave and its more than 1.1 billion pieces of data 
are part of a massive epidemiological approach to studying the 
complexities of Soldiers' mental health.
    Brain disorders are incredibly complex. The array of paths that 
lead to post-
traumatic stress disorder and suicide are as diverse as the individuals 
affected. Army STARRS has shown that no single approach will yield the 
answers needed to solve these difficult problems. A White House 
Executive order released in August 2012 directs Federal agencies to 
improve coordination and integrate research on mental health and 
suicide prevention strategies.\9\ This Order provides a platform that 
will lead to more robust partnerships, capitalizing on the resources of 
multiple Federal departments and agencies, as well as the intellectual 
power of academic institutions. Army STARRS is an unprecedented example 
of how collaboration both within and outside of government is working 
to improve the lives of Servicemembers and civilians by developing 
better prevention, diagnosis, and treatment strategies. NIMH is also 
working with Marines on a separate effort supported by the Marine Corps 
which is synergistic with the Army STARRS project. This effort is 
advisory, assisting the Marines in making decisions about how to 
proceed with their project, and seeking to bring the Marine study 
investigators into a collaborative working relationship with those 
involved in Army STARRS.
---------------------------------------------------------------------------
    \9\ http://www.whitehouse.gov/the-press-office/2012/08/31/
executive-order-improving-access-mental-health-services-veterans-
service.
---------------------------------------------------------------------------
                             senator casey
Funding for Pediatric Mental Illness
    Question 1. What percentage of your funding goes to research into 
mental illnesses that affect children, or to the early phases of 
illnesses that may not fully manifest until adulthood, but often have 
roots in childhood?
    Answer 1. Approximately 28 percent of the NIMH budget was devoted 
to pediatric research in mental health in fiscal year 2011 (the most 
recent year for which this data is available).
    Regarding the derivation of this percentage: In January 2009, NIH 
implemented a new reporting tool called Research, Condition, and 
Disease Categorization (RCDC). RCDC is a computerized process that NIH 
uses to categorize and report the amount it funded in each of 233 
reported categories of disease, condition, or research area. The 
following table represents data derived from the intersection between 
two RCDC categories: ``pediatric'' and ``mental health'' for fiscal 
year 2011. This table represents NIMH-administered records only. RCDC 
data are publicly available via the NIH RePORT Web site.\10\
---------------------------------------------------------------------------
    \10\ http://report.nih.gov/categorical_spending.aspx.


------------------------------------------------------------------------
                    Number of       Total
                    pediatric     pediatric
   Fiscal year       mental        mental      Total NIMH    Percent of
                     health        health        budget      NIMH budget
                    projects      spending
------------------------------------------------------------------------
2011............        1,144         $414M       $1,475M            28
------------------------------------------------------------------------

Unique Considerations in Pediatric Mental Health Research
    Question 2. Are there unique considerations to conducting mental 
health research with children, as opposed to adults, that are different 
from other types of pediatric research?
    Answer 2. Yes, the unique features of the developing brain 
distinguish pediatric mental health research from other types of 
pediatric research. Advances in our understanding of the molecular, 
structural, and functional aspects of brain development have led to the 
discovery of striking changes that occur in the brain during 
adolescence--changes in the strength and efficiency of communication 
between different parts of the brain, notably in the frontal cortex, 
which is responsible for impulse control and long-range planning. An 
important concept from this research is that the brain does not 
resemble that of an adult until the mid-1920s. Thus, from a 
neuroscience perspective, adolescents are not merely mini-adults. This 
insight suggests that we must address mental illnesses, from ASD to 
schizophrenia, as developmental brain disorders with genetic and 
environmental factors leading to altered circuits and behavior. 
Understanding the causes and nature of malfunctioning brain circuits in 
mental disorders may make earlier diagnosis possible. Interventions 
could then be tailored to address the underlying causes directly and 
quickly, changing the trajectory of these illnesses.
    Children also present challenges with regard to ``self-reporting'' 
in mental health research, which is part of the typical diagnostic 
method. In many cases, young children have limited cognitive capacity 
and ability to convey information about themselves and their 
experience. Furthermore, many mental health issues are associated with 
developmental delays, which also compromise a child's ability to report 
or participate effectively in research. These issues underpin the 
necessity of research to find biological markers for mental disorders. 
Through the PROMIS initiative NIMH has been an active partner in an 
NIH-wide effort to develop validated patient and parent reported 
outcome measures for use in assessment of pain, depressive symptoms, 
and anxiety in children in clinical trials.\11\
---------------------------------------------------------------------------
    \11\ http://www.nihpromis.org/default.
---------------------------------------------------------------------------
    In addition to the complexities of developmental changes, it is 
critical to understand what types of interventions work best for the 
unique needs of pediatric populations and to deliver these 
interventions appropriately. NIMH supports several clinical research 
studies on behavioral interventions, medications, or combination 
treatment approaches. Effectiveness trials are currently comparing 
interventions to treat children and adolescents with anxiety, major 
depression, and ASD. In recent years, NIMH has funded a number of 
studies to understand the benefits and risks of using psychotropic 
medications in children; more research is needed to understand the 
effects of these medications, especially in children under 6 years of 
age. Each child has individual needs, and must be monitored closely 
while taking these medications. Several studies in progress are seeking 
to identify ways of preventing, minimizing, or reversing common adverse 
effects of medications, such as weight gain, during antipsychotic 
treatment. Future research will be on developing safer and more 
effective interventions (both behavioral and pharmacological) that are 
tailored to each child's individual needs and characteristics. Another 
focus will be on preventing the onset of mental illness by intervening 
early among children who are at especially high risk or who have 
initial symptoms, before the full onset of the disorders.
                              senator enzi
Coordination of Federal Programs
    Question. I am concerned about the significant number of 
duplicative Federal Government programs. Can you tell me what programs 
within your agency are duplicative or could be combined to provide more 
efficient operations? Please describe how you plan to identify unfunded 
and unproven programs that can be eliminated in order to better focus 
resources on those that do work.
    Answer. NIH makes every effort to eliminate or amend overlap 
regardless of the funding source prior to awarding research funding. 
NIH's review for potential duplication begins immediately after the 
application is submitted to NIH. Each application is reviewed against 
previous submissions to ensure it is ``new'' with significant and 
substantial changes in content and scope, rather than a resubmission of 
an earlier application. The competitive NIH two-tier review process 
includes scientific and technical review and consideration by an 
advisory council that includes public representatives. Prior to the 
final funding decision, applicants are instructed to submit ``Just-in-
Time'' material, which includes a declaration of current other support 
the applicant is receiving--i.e., all financial resources, whether 
Federal, non-Federal, commercial or institutional, available in direct 
support of an individual's research endeavors, including but not 
limited to research grants, cooperative agreements, contracts, and/or 
institutional awards. Furthermore, NIH investigates three forms of 
overlap: scientific (conceptual); budget (salary, equipment); and 
personnel (over-commitment of time to work on the project). NIH has 
taken and will continue to take steps to exemplify and promote the 
highest level of scientific integrity, public accountability, and 
social responsibility in the conduct of science.
  Response by Michael Hogan, Ph.D. to Questions of Senator Alexander, 
           Senator Mikulski, Senator Enzi, and Senator Casey
                           senator alexander
    Question. I'm interested in making things easier for States as they 
tackle the mental health and substance abuse problems facing 
individuals and families in their communities. What are one or two 
things the Federal Government can do to make the money we now spend 
easier to use and help States in this effort?
    Answer. Crucial to this issue is that most of the Federal funding 
relevant to fighting addiction and mental illness at the State level is 
Medicaid. The block grants administered by SAMHSA (Mental Health, 
Substance Abuse Treatment and Prevention) are relatively minor by 
comparison. SAMHSA has done a pretty good job of making the block grant 
application and review processes simpler. Ability to use prevention 
funds to fight both mental illness and addiction would be a very good 
idea. Addictions constituents resist this on the grounds that not 
enough is done to fight addiction, however many health and behavioral 
problems are linked and good prevention efforts such as effective 
parenting programs help with many problems.
    Medicaid is I think the responsibility of the Finance Committee but 
flexibility in Medicaid would help the States as long as standards for 
and levels of behavioral health treatment were maintained. For example, 
Medicaid should support effective prevention programs.
                            senator mikulski
    Question 1. What barriers still exist with regard to achieving 
parity in mental health and medical benefits for patients with 
Medicaid, CHIP, Medicare, and private insurance?
    Answer 1. As my written testimony indicates, Dominici-Wellstone 
goes very far on this issue. I am confident the Administration's 
admittedly overdue parity regs will be ok. The bigger problem is that 
parity by definition applies to mental health specialists, while the 
biggest mental health access issue is a failure to address mental 
health in primary care. This problem must be addressed. Health plans 
must pay for basic mental health care in primary care. The integrated 
care model known as collaborative care is proven effective in over 40 
research studies, yet Medicare and many private plans do not cover the 
elements of collaborative care. It is also crucial that parity not 
become an unintended barrier to improving ``primary mental health 
care.'' The issue here is the necessity of payment to primary care for 
this work; if the parity benefit goes only to specialists it is self-
defeating. The Massachusetts Medicaid program is implementing an 
innovative approach to address this problem. The DIAMOND collaboration 
in Minnesota is another excellent approach.

    Question 2. I am a big champion of privacy but with Virginia Tech, 
none of the systems talked with each other. How can we make sure 
privacy is protected and everyone in the system is talking to each 
other when problems arise?
    Answer 2. My opinion is the problem is more basic. The Supreme 
Court's Tarasoff standard overrules privacy; if there is a clear risk, 
clinicians are obligated to report/take reasonable steps today. The 
deeper problem (addressed in my written testimony) is that we have no 
national approach to treatment of emergent or ``First Episode 
Psychosis.'' Young people with these problems--and several recent mass 
murderers appear to fit this profile--have no system of care . . . so 
isolated practitioners are left to provide this care on their own. Dr. 
Lisa Dixon (formerly of U. MD., now at Columbia) is developing a 
network of these programs in New York. Dr. Brian Hepburn, the Maryland 
mental health commissioner, is familiar with this work. Oregon has a 
well-developed network. With First Episode Psychosis programs in place, 
there would be an expectation of care coordination and communication 
with college personnel. Absent a network of FEP programs, changes in 
the law will be ineffective.

    Question 3. Are reforms needed in the substance abuse prevention 
and treatment block grant or community mental health services block 
grant to meet the needs of patients in our communities?
    Answer 3. Reforms in these grants are mostly not crucial. They are 
very small components of the behavioral health programs in the States. 
SAMHSA has improved their administration. Improved attention to 
behavioral health in CMS is a much bigger problem. The Obama 
administration has done more here (for example the Health Homes program 
in Medicaid, and consultation with SAMHSA) but this is still not 
adequate. CMS must attend to mental health needs better in both 
Medicare and Medicaid.
                             senator casey
    Question 1. Thank you for sharing your insights and your 
suggestions, both practical and philosophical, about what steps we can 
take to improve our mental health system. I am intrigued by your 
description of First Episode Psychosis care that is being used 
successfully in several other countries. Could you describe this 
approach in greater detail? Are there specific barriers to its adoption 
that we are facing in the United States?
    Answer 1. The First Episode Psychosis approach was implemented 
widely in Australia under the leadership of Dr. Patrick McGorry. In the 
United States, the best developed approach is in Oregon, where about 70 
percent of the State is now covered. A good description of the program 
is available at www.eastcommunity.org. If I may be blunt, the biggest 
obstacle is that we are simply behind the times and the needs of 
patients on this. The fact that we have had a separate mental health 
system that focused on the ``seriously and persistently mentally ill'' 
meant indirectly that young people's mental health in general has been 
neglected. The programs we have could often be called ``late 
intervention.'' There are many barriers to a good approach to FEP, 
including that paying for the required team approach to care may be 
challenged by insurers as excessive. But it is essential. At its core, 
FEP care is a community-based approach similar to care in a modern 
cancer center. It is team-based, family-centered, and holistic. It uses 
a treatment plan consistent with what the patient and family will 
accept, but aims for care that meets the highest and best researched 
standards for effectiveness.

    Question 2. Is there a widespread recognition among primary care 
physicians that treating mental health issues is also an important part 
of treating physical health? How can awareness of this matter be 
improved among primary care physicians?
    Answer 2. Awareness among PCP's is very uneven, but many of them 
know that they are dealing with behavioral issues--especially family 
physicians and pediatricians. The bigger problems are that national 
standards for behavioral care in primary care are inadequate--and 
because we have a separate mental health system, we reserve payment for 
behavioral care to specialists. We need widespread promotion of the 
Collaborative Care model, and an understanding that Medicaid, Medicare 
and commercial payers will cover collaborative care. Evidence shows 
that savings from reduced medical care will more than pay for better 
depression care in primary care.

    Question 3. Have providers developed any innovative ways to stretch 
resources after facing State or Federal budget cuts? Are there any 
models that stand out for successfully operating on reduced funds that 
could be emulated by other providers or local officials?
    Answer 3. In my opinion the major innovation that is needed--and 
now happening--is an emphasis on ``integrated care'' whereby basic 
behavioral and other medical problems are handled by the same team, 
with specialists only called in when problems really require it. This 
is happening in many (but not all) Community Health Centers, in some 
Mental Health Centers (e.g. in Missouri) that are now coordinating 
their consumers' medical care. We have learned that people who have 
major chronic health problems (like diabetes, heart disease) and also 
mental health problems have total health costs that are 30-70 percent 
higher than people with comparable medical illnesses but no depression. 
Integrated continuous care helps them manage their health better, 
reducing hospitalizations and ED visits. In my view, this trend toward 
integration may be part of the reason why recent reports show reduced 
medical inflation.
    There are still many barriers to integration. The Federal 
Government is trying to help, but much more needs to be done. My 
discussion of collaborative care above illustrates this. Medicare still 
does not cover its elements adequately. And the barriers in separate 
mental health and medical plans can prevent responsible integration. Of 
course, there remains a tendency for health plans to depress levels of 
mental health service. Integration with basic requirements for mental 
health services is essential.
                              senator enzi
    Question. What can be done to educate local communities about 
identifying risk factors for mental illness and substance abuse? How do 
we improve access to treatment? What is working and what is not 
working?
    Answer. We must do a better job with prevention. The evidence is 
clear that these problems begin in childhood. For example, maternal 
depression can impair a mother's ability to parent well. If she is 
single with multiple children, the problems are compounded. Treating 
mom's depression reduces levels of mental health problems in her 
children by 50 percent without directly treating the children. Our 
failure to intervene early with children who have moderate levels of 
mental health concerns (that could usually be addressed through parent 
support and training, behavioral services in pre-school and age-
appropriate psychotherapy) leads to use of powerful medications and to 
other expensive interventions later on. As I said in the hearing, we 
have an admirable national early intervention program for kids with 
developmental disabilities, but for kids with emotional challenges we 
wait for years and then often just use meds.
    The single biggest thing we could do in the short term is to make 
sure that basic mental health care is a core element of primary care in 
Medicaid, under State Insurance Exchanges, and in Community Health 
Centers. This early intervention approach can address many health 
problems and is cheaper than specialty care. It is applicable for 
pediatrics and geriatrics. But primary care must have access to 
reimbursement for these basic services known as Collaborative Care.
 Response by Robert N. Vero, Ed.D. to Questions of Senator Alexander, 
           Senator Mikulski, Senator Enzi, and Senator Casey
                           senator alexander
    Question 1. I'm interested in making things easier for States as 
they tackle the mental health and substance abuse problems facing 
individuals and families in their communities. What are one or two 
things the Federal Government can do to make the money we now spend 
easier to use and help States in this effort?
    Answer 1. First, it would be helpful for the Federal Government to 
create a Federal definition for Federally Qualified Behavioral Health 
Centers (FQBHCs). There was a definition for Community Mental Health 
Centers (CMHCs) for more than the first 20 years of their existence, 
but this was lost in the 1980s.\1\ This has resulted, too often, in 
poor outcomes, serious gaps in services from State to State, and the 
growth of mental health agencies that provide only some (or none) of 
the core services necessary for community-based care that still call 
themselves ``community mental health centers'' and, likewise, still 
bill Medicaid and Medicare.\2\ \3\ There is a key provision within the 
Excellence in Mental Health Act that proposes a definition and, 
moreover, delineates the minimally expected array of services.

    \1\ Goldman H & Grob G. (2006). Defining ``mental illness'' in 
mental health policy. Health Affairs. 25(3): 737-49. Retrieved on 
February 21, 2013 from http://content.healthaffairs.org/content/25/3/
737.full.
    \2\ Cummings JR, Wen H, & Druss BG (2013). Improving access to 
mental health services for youth in the United States. Journal of the 
American Medical Association. 309(6): 553-54.
    \3\ Department of Health and Human Services Office of the Inspector 
General. (January 2013) Vulnerabilities in CMHS' and Contractors' 
Activities to Detect and Deter Fraud in Community Mental Health 
Centers. OEI-04-11-00101. Retrieved on February 21, 2013 from https://
oig.hhs.gov/oei/reports/oei-04-11-00101.pdf.
---------------------------------------------------------------------------
    1. If States chose to contract with FQBHCs, they could ensure 
communities are able to access a full continuum of high quality, 
evidence-based, mental health and addiction services. Sadly, most 
current public policies do not hold health providers accountable for 
providing value-based services.\4\
---------------------------------------------------------------------------
    \4\ Lehman AF, Goldman HH, Dixon LB, & Churchill R. (2004). 
Evidence-based mental health treatments and services: Examples to 
inform public policy. New York: Millbank Memorial Fund.
---------------------------------------------------------------------------
    2. The proposed definition would ensure that the provider offers 
mobile (face-to-face) crisis mental health services within their local 
community. This is a proven strategy to deter unnecessary psychiatric 
hospitalizations and prevent community tragedies. While many providers 
currently provide crisis hotlines, their continuum of crisis services 
would be unquestionably strengthened with the addition of mobile crisis 
services. These face-to-face assessments are often invaluable 
interventions, also reducing unwarranted arrests and incarcerations. 
State costs are reduced significantly when there are local teams, 
available 24-hours per day (365 days per year), interfacing with law 
enforcement, hospital emergency departments and concerned family 
members to provide emergency assessment to people in crisis.
    3. Another issue the Federally Qualified Behavioral Health Center 
definition could address is the concern States have with access to 
care. Too often, profit-motivated providers have cherry-picked high-
revenue services, leaving some parts of our communities without access 
to care--especially in rural areas. The current fragmented behavioral 
healthcare system has resulted in only \1/3\ of rural counties and 63 
percent of all U.S. counties having ``at least one mental health 
facility with any special programs for youth with severe emotional 
disturbance'' (Cummings, Wen & Druss, 2013, 553).\5\
---------------------------------------------------------------------------
    \5\ Cummings JR, Wen H, & Druss BG (2013). Improving access to 
mental health services for youth in the United States. Journal of the 
American Medical Association. 309(6): 553-54.
---------------------------------------------------------------------------
    4. States would have access to a source of valuable outcomes data 
for patients being treated in FQBHCs. Currently, many States lack whole 
health (physical and behavioral health) outcomes data from mental 
health and addictions providers regarding key quality metrics that 
would help States determine the value of the services provided.

    Second, it would be helpful for States if community mental health 
centers were included in the HITECH Act. In order for States to 
successfully audit providers, ensure that outcomes are being tracked on 
all persons served, and evaluate the value of care received for its 
citizens, the providers it contracts with need to have access to 
electronic health records, data information exchanges, and other 21st 
century technology tools. With most CMHCs serving a high number of 
Medicaid clients, their operational budgets have very slim margins and, 
consequently, many have not been able to keep pace with the 
technological advancements of the digital age. Within the current 
financial environment, most States lack funds to support providers to 
adopt electronic health records and submit data electronically. Thus, 
this impedes States being able to hold providers accountable for 
adopting Health IT. Inclusion of community mental health centers in the 
HITECH Act would be very valuable--especially given the health risks 
and health costs of the highly fragile populations that they serve.

    Question 2. Centerstone of Tennessee sees approximately 50,000 
patients per year at various facilities and locations. How do your 
multiple partnerships in the community impact outcomes and are these 
partnerships effective?
    Answer 2. Our community partnerships work and are, moreover, key to 
our success in impacting outcomes for the people we serve. Centerstone 
actively partners--depending on the community needs and resources 
available in its counties--with law enforcement, jails, courts, 
hospital emergency departments, physician groups, local NAMI and Mental 
Health America chapters, K-12 public schools, day care agencies, 
preschools, faith-based organizations, universities, researchers, and 
other local and regional non-profit organizations. We believe that 
these partnerships are fundamental and, as such, strengthen our success 
and program outcomes. We strive to be the community partner of choice.
    Without our partnerships with law enforcement, jails and the court 
system, our mobile crisis team would not be so successful in preventing 
unwarranted incarcerations. Without our partnerships with hospital 
emergency departments, physicians, community leaders and parent support 
groups, our mobile crisis team would not be as successful in preventing 
unnecessary hospitalizations or worse, tragedies. Without partnerships 
with preschool administrators and their teachers, our school-based 
services team would not be successful in providing early assessment and 
intervention. These early prevention, assessment and intervention 
programs also importantly enhance the likelihood of a child's future 
academic success. Without partnerships with teachers and principals, we 
couldn't teach techniques to help teachers and students prevent 
bullying, violence, drug use and teen pregnancy. More simply, without 
these community partnerships and collaborations, there would be more 
suspensions and expulsions, and we wouldn't be part of Tennessee's 
rapid success in increasing high school graduation rates.
    Our mobile crisis teams would also be less effective if there were 
not a community relationship in place. For example: an emergency 
department physician could sign a certificate of need (emergency/
involuntary commitment papers for hospitalization) before our staff had 
an opportunity to engage the patient and complete a full crisis 
assessment. When provided the opportunity to conduct a face to face 
assessment, we can typically prevent 50 percent of those encounters 
from resulting in a psychiatric hospitalization.
    Mutual need often defines our community relationship with local law 
enforcement agencies. We depend on them to help us be safe when we 
respond to address a crisis. Likewise, they sometimes need us when they 
respond to a call that requires mental health expertise. Our staff is 
specifically trained to intervene with people in acute psychiatric 
crisis. This can be crisis mitigating and life saving.
    In our communities that have long-standing preschool advisory 
boards, the partnerships are very effective. These boards include 
representation from healthcare providers, child welfare, schools, local 
charitable agencies, and mental healthcare providers. In our new early 
childhood system of care communities, these relationships are now being 
formed, and a governance entity with diverse representation is being 
established. In communities where there is a formal advisory board with 
diverse representation that focuses on infant and early childhood 
services, we have found that there are more cross-referrals and 
communication among service providers which results in better outcomes.
    With regard to mental health services within schools, both 
Centerstone and many of our local school systems are working toward the 
same goal--for the child and the family to be successful and 
functioning. The school approaches this from an academic perspective, 
and we focus on it from a mental health perspective. Both of these 
perspectives are important and make for a strong, successful 
relationship. As part of these partnerships, we provide behavioral 
health services in the school, participate on committees alongside 
school staff, and provide specialized mental health and addictions 
trainings for the school staff that they might not otherwise receive. 
We provide coaching to parents, teachers and administrators, empowering 
them to successfully address behavioral health concerns--from 
disruptive behavior in the classroom to self-injurious behaviors.
    We also have several unconventional community partnerships. One 
such example is with Rocketown--a recreational safe place for 
adolescents in Nashville. We have partnered with them for 3 years, 
bringing counseling and case management to that environment in a very 
unique way. We have counselors there in the afternoons, interacting 
with the staff and intervening with the teens. By being there in the 
teen's environment, we are seen as a member of the Rocketown team, not 
as an outsider. While in other settings, it can sometimes be the parent 
or teacher pushing the teen toward services, but at Rocketown the teens 
are seeking out services for themselves. Being able to access a 
respectful, trusting adult can be life-altering for many of these 
teens. Recently, we helped a child who had been living in a car for 
several weeks. We helped that child get connected with a respite foster 
care placement, long-term counseling, and other services the child 
desperately needed.
    Finally, our community success also relies very heavily on our 
relationships with the many different departments of State government 
within Tennessee, including the Departments of Health, Mental Health 
and Substance Abuse Services; Corrections, and the Department of 
Children's Services. For example, the Tennessee State Department of 
Mental Health and Substance Abuse Services, under the leadership of 
Commissioner Doug Varney, has worked with us and other Tennessee mental 
health agencies to standardize how our mobile crisis teams function and 
to determine what data we collect. These data have helped the State 
make decisions regarding the most impactful places for mobile crisis 
services to be offered. We also work very closely with the Department 
of Children's Services. Our school-based services use the same outcomes 
metrics used by DCS. This common outcomes platform helps ensure the 
success of children in State custody and provides the State with 
valuable performance information on its provider network.
                            senator mikulski
    Question 1. Is any further action needed on the part of Congress to 
help you offer mental health and substance abuse services in schools?
    Answer 1. School-based mental health counselors who provide early 
intervention, prevention services, treatment resources, development of 
peer natural helpers, and coordination of care with other health 
providers have been tremendously effective resources for all children 
and youth, including high-risk age groups. School-based services 
eliminate the barrier that families, including working single parents, 
often have trying to address care for their children with behavioral 
health needs. Without these services, many children would not be able 
to obtain the care they seriously need. Many of the children served by 
school-based services have experienced significant trauma, have 
neurological conditions that require teachers and other caregivers to 
get special training and/or coaching, and are at risk for failing 
academically. Sadly, there is a lack of adequate resources for these 
evidence-based programs. Fortunately, the Mental Health in Schools Act 
would be helpful to ameliorate this issue.
    While Centerstone now provides school-based services in 13 of its 
22 counties in Tennessee, this was not the case 10 years ago. 
Competitive grants initially enabled us to create and then later expand 
this service. Beginning this program required initial startup funds. 
The same is true today; those initial funds enable us to create the 
necessary infrastructure to reach sustainability. As an example: 7 
years ago, we received a 3-year grant to provide school-based services 
in Montgomery County, TN. While the initial grant was to help support 
the services of six staff over the 3 years, once we were able to 
establish the infrastructure and the teachers and administrators 
realized the value of our services, we were able to expand services. We 
currently have 22 school-based staff serving in the Montgomery county 
schools, providing unique access and care for hundreds of children and 
adolescents who might not otherwise be accessing treatment.

    Question 2. What recommendations do you have for improving access 
to services for families with infants and toddlers who are at risk for 
emotional problems?
    Answer 2. There are several things that could be helpful to improve 
access to services for families with infants and toddlers at risk for 
emotional problems. Research has shown the effectiveness of early 
childhood interventions.\6\
---------------------------------------------------------------------------
    \6\ National Research Council. (2009). Preventing Mental, 
Emotional, and Behavioral Disorders Among Young People: Progress and 
Possibilities. Washington, DC: The National Academis Press, 2009.
---------------------------------------------------------------------------
    First of all, it would be helpful if every State's Medicaid program 
could fully implement the Early Periodic Screening Diagnosis and 
Treatment (EPSDT) benefit to improve the mental health of low-income 
children and adolescents. Additionally, we recommend that emphasis on 
Social Emotional development should be included in the EPSDT Program 
with a procedure for additional mental health assessment when delays 
are noted.
    Additionally, it would be helpful for there to be several key 
reimbursement changes related to funding for services for this 
vulnerable population. These include:

     Change the definition of medical necessity for CMS 
services to include early childhood intervention services;
     Providing reimbursement for CMHCs (or FQBHCs if the 
definition exists) to provide consultation in hospital settings like 
the Neo-natal Intensive Care Unit and the Intensive Care Unit. It would 
be helpful for child psychiatrists, mental health nurse practitioners, 
psychiatric case managers, and/or therapists from outside community 
settings to be able to meet with, identify and ultimately intervene 
with high-risk children and their families;
     Ensuring that CMS compensates providers for providing home 
visiting services through maternal, infant and early childhood Home 
Visiting. We have had excellent results in the counties where we 
provide these services, and it would be wonderful to be able to expand 
and sustain these services;
     Reimbursement for services in the home setting. Many 
caregivers and their infants and young children are not able to get to 
clinics for therapy services. We recommend that there be more emphasis 
on providing these services in the home setting;
     Reimbursement for maternal, infant, and early childhood 
parenting classes, especially for at-risk parents with mental health 
and addiction diagnoses, have been proven to have excellent outcomes in 
other countries. It would be helpful to enable CMHCs to be able to 
provide these services; and
     Currently, the trainings that we provide in the community 
are, by and large, uncompensated. It would be wonderful to have 
trainings related to early childhood mental health screenings 
incorporated into the requirements for school, head start, daycare and 
preschool workers. This would help us to be able to intervene earlier.

    It would be helpful for CMS to specifically State that the 
Diagnostic Classification of Mental Health Disorders of Infancy and 
Early Childhood (DC: 0-3R) be accepted by States as an acceptable 
system for diagnosing infants and young children. The DC-0-3R defines 
disorders as they appear in infants and preschoolers. Several States 
have developed crosswalks between the DC: 0-3R and the DSM IV.
    Last, mental health education programs (i.e., schools of social 
work or counseling) should offer training in Infant and Early Childhood 
Mental Health. This is currently not widely available for clinicians, 
and it should be made more available for student therapists who will be 
working with infants, toddlers and their families.
                             senator casey
    Question 1. In your testimony, you noted that 50 percent of mental 
illnesses start before the age of 14. By what age is it usually 
possible for professionals to diagnose some of the more common mental 
illnesses? Can these diagnoses be made by the child's pediatrician, or 
do they require referral to a specialist following the parent or 
pediatrician realizing there is a more serious problem?
    Answer 1. By using the Diagnostic Classification of Mental Health 
Disorders of Infancy and Early Childhood (DC: 0-3R) manual, disorders 
can be identified as early as birth. This classification system 
includes assessment of the family in addition to individual child 
characteristics. Most pediatricians have not received training in the 
DC: 0-3R. It depends on the diagnosis, but around 25 percent of 
lifetime mental illnesses can be identified by school age. \8\
---------------------------------------------------------------------------
    \8\ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807642/.
---------------------------------------------------------------------------
    While some childhood behavioral health diagnoses may be initially 
identified by pediatricians, it is most helpful if the pediatrician 
provides a referral for a behavioral health specialist (whether a child 
psychiatrist or a doctoral or masters-level trained mental health 
clinician) to conduct a more in-depth assessment. For example, ADHD-
like behaviors in a child can be a sign of something else (parental 
depression, dietary issues, abuse at home, need for parenting training, 
exposure to trauma), but ruling these out requires a full psycho-social 
assessment, preferably in the child's home or school environment. 
Pediatricians often lack the time and training for these in-depth 
assessments, and the risk of prescribing an ineffective medication to a 
child that could have harmful side effects is very real. Additionally, 
if there is not a referral to a specialist, the child often does not 
receive access to a broader toolkit of treatment options. A 
pediatrician may only have medication as an option to address 
disruptive child behavior. A behavioral health provider, if they are 
offering a full continuum of research-based services for children, will 
have multiple, highly effective options.
    It is critical to intervene as early as possible when there are 
signs of potential mental health or substance use issues in children 
and youth. Later intervention decreases good outcomes. In early 
childhood, a number of issues are closely tied to the adults in a 
family so intervention for the child often needs to be accompanied by 
or preceded by intervention for the adults. We believe a significant 
role for the child's pediatrician as well as other adults who come into 
contact with a child is to identify the problem or symptom and then to 
refer to a mental health professional. Attention also needs to be given 
to over-diagnosis and excessive medication usage \9\ in the children's 
population, particularly the youngest patients.\10\
---------------------------------------------------------------------------
    \9\ http://www.nytimes.com/2009/12/12/health/
12medicaid.html?pagewanted=all&_r=0.
    \10\ http://psychcentral.com/news/2012/08/15/big-jump-in-
antipsychotic-drugs-prescribed-for-kids/43099.html.

    Question 2. You mentioned that Centerstone has been able to offer 
mental health and substance abuse services within rural schools for 
children and youth. How common is it for community mental health 
centers to coordinate their efforts with teachers, schools, day care, 
or early learning programs? Do you feel that these individuals and 
institutions have the training and resources needed to help community 
mental health centers identify and treat mental illnesses early?
    According to a report published last month by the Journal of the 
American Medical Association, only \1/3\ of rural counties and 63 
percent of all U.S. counties having ``at least one mental health 
facility with any special programs for youth with severe emotional 
disturbance'' (Cummings, Wen & Druss, 2013, 553).\11\ In a brief review 
of PubMed, my staff was not able to find specific information 
previously published regarding the specific question of how common it 
is for CMHCs to coordinate efforts with these different community 
partners. In order to address this need, we created a brief survey for 
providers to complete. This was distributed via e-mail to members of 
the National Council for Community Behavioral Healthcare and the 
National Association for City and County Behavioral Health and 
Developmental Disability Directors.
---------------------------------------------------------------------------
    \11\ Cummings JR, Wen H, & Druss BG (2013). Improving access to 
mental health services for youth in the United States. Journal of the 
American Medical Association. 309(6): 553-54.
---------------------------------------------------------------------------
    This survey was completed by 173 different community mental health 
centers serving 941 counties in 43 States. Here are the results:


------------------------------------------------------------------------
                   Preschools/     In-home
                      Early         early        In-home      Day Care
  K-12 Schools      Learning    intervention  services (5-    Settings
                    Programs     (ages 0-4)        18)
------------------------------------------------------------------------
145.............           89            84           129            48
84%.............          51%           49%           75%           28%
------------------------------------------------------------------------

    As you can see, of the providers that responded to this survey, 
there is great diversity regarding the services offered and the 
locations in which they are provided. Only half of the respondents 
provide early intervention services in the child's home or in 
preschools or in early learning programs. Only \1/4\ provide services 
within day care settings.
    Regarding the question of whether non mental health workers within 
these settings currently have the training and resources needed to help 
identify and treat mental illness early, the answer is largely no. 
There is much work to be done in the area of training for early 
childhood workers in their ability to adequately conduct screening and 
referrals to appropriate services. In our experience, we have found 
that staff in these settings are hungry for this knowledge and make 
excellent use of the training and resources once they receive them.

    Question 3. You noted that disruption of care can be a concern for 
young adults if their State Medicaid plan does not allow for an ``aging 
out'' transition plan to enable them to seek other health insurance or 
a new provider in a timely fashion. How damaging can this be to the 
progress that has been made with treating their mental health problems? 
Are there any notable examples you can provide where this was an issue?
    Centerstone, like many providers, struggles to provide the best 
care possible to this population. We often will keep teens that have 
aged out a little longer in our child-based services because they can 
get lost going into the adult care world and need more contact than the 
typical adult patient. They've gone from a very structured place in 
school with a lot of people checking in on them, to having to handle 
everything on their own. Sadly, with budget cuts, providing these 
largely unreimbursed additional services are tricky to navigate.
    We believe that grants and funding streams to work with this 
population would be very helpful. Often times, even a couple of months 
after we transition services, teens that we've helped get stable on 
their medications and in educational settings drop out of care and 
relapse. We need a different way to transition these youth. It would be 
especially helpful if we could provide comprehensive continuity of care 
programs for young adults with developmental disorders including autism 
spectrum disorders and serious mental illness. Being in a State still 
contemplating Medicaid expansion currently makes transition funding 
difficult. There is a delay time for our State safety net dollars to 
kick in, and there are years of delay for a teen to qualify for 
disability. From our experience and from the research, we know that if 
these teens and young adults could get the right care and have a 
seamless transition, many wouldn't need disability. However, we also 
know that if a young adult goes several years without needed 
medications and treatment, this can have devastating, long-term 
consequences. Continuity of care would be helpful to address this.
    When we asked our staff to provide stories of clients who were 
damaged by the transition process, we received too many to share in 
this format. We have selected the stories of these two young people 
below. All of these young adults needed significant help in making the 
transition from high school into adulthood that we were not able to 
provide to them. These summaries were written by staff who worked with 
these clients, and we have kept them in their own voice.

          ``DE-19 years old (at the time she lost her insurance) with a 
        diagnosis of Major Depression Recurrent. She received therapy, 
        case management and medication management services from us. We 
        were actively providing services when she lost her Tenncare. We 
        attempted to appeal and were unsuccessful. We attempted to try 
        and support her after she lost her insurance. She was arrested 
        a few months after we had to transitioned out of services. She 
        lost her temper (her depression manifested itself as 
        irritability and anger) and got into a ``fight'' with a family 
        member, and the police were called. I still feel that the 
        incident could have been avoided if she could have remained on 
        her medications.''
          ``MT-19 years old (when he contacted us to request services 
        again) with a diagnosis of ADHD and intermittent explosive 
        disorder when he was initially discharged. He called because he 
        was having trouble keeping a job because of his anger, and he 
        had been put out of his mom's home. When we attempted to re-
        open him, we learned he had lost his insurance. We attempted to 
        help him get his insurance set up again, but we were not 
        successful. He was not able to make all the appointments, and 
        we could not send a staff to walk him through the safety-net 
        process. We attempted to provide him with resources that could 
        help.''
                              senator enzi
    Question 1. What can be done to educate local communities about 
identifying risk factors for mental illness and substance abuse? How do 
we improve access to treatment? What is working and what is not 
working?
    Answer 1.
Educating Local Communities
    The Mental Health First Aid bill would be helpful to address the 
need to educate local communities. Mental Health First Aid is 
specifically tailored to educate local key stakeholders to identify 
risk factors for Mental illness and Substance Use Disorders. It would 
be extremely helpful if CMHCs could have access to funding to train law 
enforcement, hospital emergency departments, local civic and social 
service organizations, and other community partners. As a recognized 
service provider Centerstone already has relationships with many of 
these entities and this would be a wonderful service addition to these 
important community relationships.
Improving Access to Treatment
    While education regarding the importance of treatment is important, 
it is not effective if there is not access to treatment. There are 
multiple issues contributing to the overall lack of access to 
behavioral health services. These include, but are not limited to: lack 
of transportation, workforce shortages, lack of a specialized 
workforce, limited use of technology by providers, and funding 
shortages. Currently, many individuals who are poor and over age 18 
have limited access to treatment until they are classified disabled for 
their condition. This is unfortunate since most people with mental 
illness--if they receive the right care at the right time--don't have 
to experience their condition as a life-altering disability. Having a 
system of FQBHCs, as is proposed under the Excellence in Mental Health 
Act, would provide that safety net of care for uninsured and 
underinsured individuals and families--significantly improving access 
to care.
What is Working and Not Working?
    While it is a significant undertaking to improve access to mental 
health and addictions treatment, for everyone in need, we believe 
another huge challenge is improving access to cost effective treatment 
and efficacious care. This is one of the reasons we are pleased that 
the Excellence in Mental Health Act specifically mandates providers to 
use the best evidence-based treatments where available. Lack of 
effective treatments is a challenge in urban and suburban areas as much 
as rural areas. You can see the consequences of people receiving poor 
and/or inadequate care in urban settings as you walk to work. As Dr. 
Bickman, a researcher we have worked with at Vanderbilt University, 
recently highlighted in an op-ed in the 
Tennessean (February 12, 2013), ``ineffective treatment is a quieter 
and unacknowledged crisis that is more pervasive and insidious than 
insufficient access.''
    The good news is that mental health and addictions treatment, if 
done well under the right conditions, has been shown to be extremely 
effective with positive, long-lasting effects that yield enormous 
improvements for families, local communities and society in general. 
However, many providers in the mental health sphere do not currently 
(1) ensure that only evidence-based treatments are used and (2) have 
mechanisms in place to ensure that their treatments are resulting in 
positive outcomes as a result of treatment.
    In his article, Bickman proposes seven steps that he believes 
research shows would fix the ``quality problem'' in the mental health 
system. They are:

     ``Monitoring the quality of services to ensure they are 
working.
     Holding service providers accountable for well-implemented 
evidence-based treatments that show positive outcomes.
     Integrating mental health and primary care following a 
public health model.
     Eliminating services and practices that do not benefit 
clients and that hamper the best efforts of underfunded agencies.
     Improving client and family engagement to lower the high 
client dropout rate in treatment.
     Providing improved education and training so the workforce 
is more capable of adopting modern technological approaches.
     Providing financial incentives to agencies for delivering 
effective services.''

    We support all of these steps, and we believe that the Excellence 
in Mental Health Act would go a long way to enabling these changes to 
occur.
    We also want to emphasize that improving the effectiveness of care 
will be impossible without Health Information Technology. It is nearly 
impossible for providers without Health IT to track outcomes for 
individual patients and assess fidelity to evidence-based practices. 
Lacking providers with Health IT capacity, some States have to, 
unfortunately, make outcomes value decisions based on intermittent 
paper surveys dependent on a small percentage of the total patient 
population served. The efforts that Senator Whitehouse has championed 
regarding expanding coverage for Behavioral Health providers to be 
included in the HITECH Act are foundational to set up a different U.S. 
mental health system.

    Question 2. Can educators, whether in primary schools, secondary 
schools or universities, be trained to identify at-risk children and 
adolescents? What are some important strategies for mental health 
first-aid? How can we ensure students and employees follow through with 
screenings and treatments for mental health and substance abuse?
Training Educators
    We have found in our school-based work that educators can 
definitely be trained to identify at-risk children and adolescents. 
Oftentimes, educators have no difficulty identifying those children who 
are acting out. However, it often takes training to help them learn to 
identify children and adolescents that may be internalizing trauma or 
may be depressed or suicidal. Trainings for school staff have been 
invaluable toward helping us all work together for earlier 
identification of issues. In order to strengthen the education system, 
we believe that it would be valuable for teacher training programs and 
continuing education programs to include basic training in early 
identification.
Strategies for Mental Health First Aid
    We believe that it is important for key community leaders to 
receive training in Mental Health First Aid. It can be incredibly 
helpful to train law enforcement, first responders, emergency 
department personnel, faith community leaders, local business and civic 
leaders, and other community partners. While some community 
organizations have the ability to pay for this training themselves, 
others lack the funds to do so. We support comprehensive Mental Health 
First Aid legislation that will assist us in providing this valuable 
training more broadly in the community. In our experience, the more 
individuals trained in a community to recognize early warning signs and 
refer to effective treatment, the more tragedies we can prevent.
Ensuring Follow-Through With Screenings and Treatment
    Regretfully, due to the complicated current legal system, we cannot 
offer absolute assurance that students and employees will follow 
through with screenings and treatment for mental health and substance 
abuse. In order to address the current gaps in the system, it is most 
likely that some privacy laws would need to be reviewed.
    We do believe that it would be helpful if the common metrics for 
health care service provision that managed care companies and States 
were incentivized for achieving (i.e. from NCQA) included metrics for 
mental health care follow-through and client engagement in services. At 
Centerstone, we have adopted the NCQA HEDIS metric for client 
engagement as an outcome across all of our programs and services. Our 
attention to engagement has helped us have a 44 percent average 
engagement rate for 2012. Unfortunately, there is not a national metric 
regarding engagement for mental health services, but the substance 
abuse client engagement industry average was 15 percent in 2015.\7\ 
There is currently no incentive for achieving excellence in this metric 
within the mental health services delivery system, besides addictions. 
However, we believe that if there were an incentive, more providers 
would improve their client engagement and follow-through. Lack of 
engagement and follow-through with persons with addictions and serious 
mental illnesses can have costly, devastating consequences.
---------------------------------------------------------------------------
    \7\ http://www.ghc.org/about_gh/Quality/hedis-2012.pdf.
---------------------------------------------------------------------------
    We encourage our employees to be creative in helping to ensure 
follow-through. Our mobile crisis staff is able to go to wherever the 
need is--at a workplace, school, home, hospital, or other setting--to 
perform the initial screening. Our school-based staff is able to go 
into homes, workplaces, or wherever the parent wishes to meet in order 
to get the parental consent that is required for screening and any 
follow-up.
    One thing that would be helpful to increase screenings is to ensure 
that school personnel (teachers, administrators, and school resource 
officers) receive training in mental health and addiction warning signs 
and how to take appropriate actions to intervene with high-risk 
children and youth who are exhibiting troubling behaviors. The Mental 
Health First Aid bill could be helpful to achieve this aim.
                                 ______
                                 
     Colorado Behavioral Healthcare Council (CBHC),
                                                Denver, CO.
Kathleen C. Laird,
Majority Health Policy Office.

Hon. Tom Harkin,
Committee on Health, Education, Labor, and Pensions,
U.S. Senate,
Washington, DC 20510.

    Ms. Laird: Thank you for the opportunity to respond to the 
Senator's questions. It is a privilege to share my thoughts on their 
questions. I am inspired by the fact that members of the committee are 
genuinely interested in how to help people who have mental health and 
substance use disorder conditions.
                                 ______
                                 
    Response by George DelGrosso to Questions of Senator Alexander, 
                    Senator Enzi, and Senator Casey
                           senator alexander
    Question. I'm interested in making things easier for States as they 
tackle the mental health and substance abuse problems facing 
individuals and families in their communities. What are one or two 
things the Federal Government can do to make the money we now spend 
easier to use and help States in this effort?
    Answer.
Payment
     The main way that the State of Colorado interacts with the 
Federal Government as it relates to mental health issues is through 
annual plans that it submits for use of the Federal Government mental 
health and substance abuse prevention and treatment block grants from 
SAMHSA, Medicaid, and Medicare. The block grants are important programs 
that fund a range of critical prevention and treatment efforts around 
the country for people who do not have health insurance coverage or are 
under-insured for mental health and substance use disorder coverage.
    Unfortunately, the amount of funding available to each State from 
the block grants is very low. This creates a significant burden on the 
States to try and cover this need. What I have noticed is that with 
reductions in State spending for mental health and substance use 
disorder treatment is one of the first places that cuts are made when 
what is needed most is increased investment in treatment services. Not 
receiving necessary treatment results in more burdens on emergency 
rooms, law enforcement, homelessness, and suicide. In worse case 
scenarios we see more violence toward other people.
    Congress can help in this area by allocating more money to the 
block grants to fund additional evidence-based programs that meet 
communities' needs.
     Medicaid is an important program for people with mental 
health and substance use disorders. Each State has their own plan on 
what they will cover in this area and how they reimburse for services. 
As the Medicaid coverage expansion rolls out in 2014, more people than 
ever before will need mental health and addiction services.
    Congress can help by changing the way treatment providers are paid 
through Medicaid. Currently in most States' payment rates don't cover 
the cost of care. Creating a Federal definition and status for 
Federally Qualified Behavioral Health Centers and allowing those 
entities access to the cost-based reimbursement and mandatory Medicaid 
status that other safety net providers currently receive (as outlined 
in the Excellence in Mental Health Act, S. 274) will go a long way 
toward creating that much-needed expansion of our treatment capacity.
Support Integrated Care
    Research indicates an integrated mental health and substance use 
disorder system, and also integrating care between these two areas and 
physical health care will reduce cost, increase health outcomes, and 
improve access to necessary care. The rules, regulations, and payment 
models in SAMHSA, Medicaid, and Medicare are not aligned together to 
support integrated service delivery at the local level. This 
misalignment creates excess burden on States and providers to try and 
integrate care.
    Congress can help in this area by requiring Federal Agencies to 
align their efforts to develop and implement rules, regulations, and 
payment methodologies that are conducive to integration of health care.
                             senator casey
    Thank you for your explanation of Mental Health First Aid and the 
valuable role it can play in identifying individuals with mental 
illness and referring them to appropriate care.
    Question 1. How long did it take Colorado to establish its Mental 
Health First Aid training program?
    Answer 1. MHFA came to Colorado in 2009, starting with just a 
handful of Instructors participating in the original U.S. pilot. Since 
then, the Colorado Behavioral Healthcare Council, the Colorado Office 
of Behavioral Health, and the statewide network of community mental 
health centers have spearheaded an effort to rollout the program 
statewide. In 2013, our Instructor network will eclipse 200, delivering 
both the adult and youth Mental Health First Aid curricula, as our 
State rapidly approaches the 10,000 mark for Mental Health First Aiders 
certified.

    Question 2. What is the cost to provide Mental Health First Aid 
training?
    Answer 2. There are three primary costs associated with Mental 
Health First Aid that we have encountered.
    (1) Training Mental Health First Aid Instructors (those who will 
deliver the courses in the community) is about $1,500 per Instructor;
    (2) Cost to actually deliver the course in the community 
(participant manuals, training materials, etc.) is $20-25 per 
participant, up to 30 participants per course; and
    (3) Implementation supports to facilitate program dissemination 
(infrastructure, coordination, promotion, ongoing evaluation, etc.) 
should be considered. We are happy to provide the estimated amount 
needed in Colorado, but this would vary across the country.

    Question 3. Is the program designed in such a way that it could be 
easily scaled up. I'm interested in making things easier for States as 
they tackle the mental health and substance abuse problems facing 
individuals and families in their communities.&
    Answer 3. Yes--This is a health education and primary prevention 
program that has the potential to reach a huge population; linking 
people to care, combating stigma, and enhancing mental health and 
substance abuse literacy. Colorado has been able to grow the program 
considerably in a short amount of time and with limited resources, and 
with additional support could expand our efforts exponentially. It is 
important to note that investment in implementation supports is 
critical, as is the case when attempting to take any evidence-based 
program to scale. Having an advisory committee that represents a wide 
range of stakeholders also helps to ensure that expansion keeps a 
bigger vision than just reaching to one or two specific populations. 
The media also is interested in MHFA and its potential. Several 
reporters and news agencies have been involved in our efforts.
                              senator enzi
    Question. What can be done to educate local communities about 
identifying risk factors for mental illness and substance abuse? How do 
we improve access to treatment? What is working and what is not 
working?
    Answer.
Education
    In Colorado we have engaged in a statewide approach to community 
education about mental illness and substance use disorder. Our 
Community Mental Health Centers have a very large investment in Mental 
Health First Aid training. Our State Office of Behavioral Health has 
also provided some funding to aid in this effort. We work 
collaboratively with a broad cross-section of Coloradoans to deliver 
Mental Health First Aid (MHFA), including law enforcement, schools, and 
the faith community.
    Mental Health First Aid is a public education program that can help 
families, communities, educators, law enforcement, primary care 
providers and others to understand mental illnesses, seek timely 
intervention, and save lives. MHFA teaches a five-step action plan to 
help people recognize the symptoms of common mental illnesses and 
addiction disorders; de-escalate crisis situations safely; encourage 
appropriate self-help strategies, and initiate timely referral to 
mental health and substance abuse resources available in the community.
    Congress can help by supporting the Mental Health First Aid Act 
that has been introduced by Senator Begich with bipartisan support. 
This bill authorizes $20 million for training Americans in MHFA to 
improve community education about mental illness and help people get 
access to treatment.
Improving Access to Treatment
    There are many areas to address to improve access to treatment. 
Each State and local community will need to address the following:

    Adequate Coverage: It is important to ensure that public programs 
and private insurance adequately cover mental health and substance use 
disorder treatment. Parity with primary health care is essential.
    Payment Reform: Mental health and substance use services need to be 
paid a fair rate that covers the cost of prevention, intervention, 
treatment and aftercare services. It is important to reimburse mental 
health, substance use, and primary care providers for the services they 
provide.
    Work Force Development: There is a severe shortage of mental health 
and substance use disorder providers, particularly in rural areas and 
in specialties such as child psychiatry. Loan forgiveness programs seem 
to help rural areas attract providers. It is important for colleges and 
universities to provide areas of study for a workforce that will work 
in mental health and substance use disorder care. Today's workforce may 
need credentialing in both mental health and substance use disorder and 
to provide care in primary health care settings. Payment reform will 
also help attract people to this area of health care. Salaries and 
benefits for providers have been historically low compared to people 
who have similar skills and qualifications.
    Use of Technology: There is great potential to provide mental 
health and substance use disorder care thru tele-video and using Web-
based tools. This will increase access of services in rural and 
frontier communities. Plus increase access to specialists, such as 
child psychiatrists and treatment for autism. Some of this care will 
also be provided across State lines. Rules and regulations need to be 
in place to ensure providers can provide care using tele-health beyond 
the usual borders, and to be reimbursed fairly. Some level of 
regulation and credentialing of providers who do care over the Internet 
and standards for compliant connections between providers and patients 
need to be addressed.
What is Working and Not Working
    Integrated Care: It is essential that providers provide care with 
the whole person in mind. Historically, mental health and substance use 
disorder care has been separated from physical health. Evidence clearly 
indicates that if a person has both mental health and substance use 
disorder needs, plus the person has physical health problems they have 
a better chance of recovery at a lower cost if all of their health care 
services are addressed together. Mental health and substance use 
disorder providers need to integrate more physical health services, 
data, and information into their provision of care, and physical health 
providers need to do the same with mental health and substance use 
disorder.
    Managed Care: Colorado's Medicaid mental health program has been 
using managed care since 1995. This program is a full-risk contract. 
The results have been significantly better than a fee for service 
payment model. Access to services has improved, more care is being 
provided in a person's home community, and millions of dollars have 
been saved. A key ingredient to Colorado's success is the opportunity 
for providers and managed care companies to partner together and share 
risk. Models that include risk sharing for both service delivery and 
health outcomes have significant promise to improve health care and 
reduce costs.
    Prevention and early intervention: Most of the funding for mental 
health and substance use disorder is for treatment. This treatment is 
usually provided after a person already has a diagnosed condition. Many 
of these conditions could have been avoided, have less negative impact 
if they had been identified earlier or prevented. Services provided at 
earlier stages are less expensive than higher level care, such as 
hospitalization. It is important to add prevention and early 
intervention services for mental health and substance use disorder in 
public programs and private insurance.
    Evidence-based care: There are a growing number of mental health 
and substance use disorder interventions and treatments that predict 
better outcomes. Providers and payers need to focus on delivering and 
paying for services that have the best chance to improve a person's 
overall health. It is important to focus on the person's outcome of 
treatment than the number of services provided. This will require the 
ability to collect data on a person's progress, and use that 
information in treatment.
            Sincerely,
                                          George DelGrosso,
                                                         CEO, CBHC.
  Response by Larry Fricks to Questions of Senator Alexander, Senator 
               Mikulski, Senator Enzi, and Senator Casey
                           senator alexander
    Question 1. I'm interested in making things easier for States as 
they tackle the mental health and substance abuse problems facing 
individuals and families in their communities. What are one or two 
things the Federal Government can do to make the money we now spend 
easier to use and help States in this effort?
    Answer 1. I think the most important thing the Federal Government 
can do through existing programs is to establish Federally Qualified 
Behavioral Health 
Centers in Medicaid. By putting a definition of these entities into 
Federal law, 
consumers will be assured when they seek care at an FQBHC, that center 
offers a 
comprehensive range of high-quality mental health and addiction 
treatment services. Without a definition, there are currently no 
standards of care and no way to guarantee that all Americans have 
access to the full range of needed services 
regardless of where they live. The Federal Government can also 
encourage States to do more to make use of peer support services in 
their Medicaid programs.

    Question 2. You have experienced the mental health system from many 
different perspectives. What are some of the biggest challenges you've 
experienced?&
    Answer 2. As I mentioned in my testimony, stigma remains a huge 
barrier to people accessing needed mental health services. One of the 
biggest challenges is the ongoing discrimination that people with a 
mental health issue face. We have come a long way in raising public 
awareness of mental illness and addictions and educating people about 
how to reach out and support someone living with these conditions, but 
there is still a long way to go. The Mental Health First Aid Act (S. 
153) is one way that we can help erase stigma. Another important thing 
we can do is improve access to peer services and supports, which were 
vital in my own recovery experience. Peer specialists are trained in 
skills to promote strength-based recovery and whole health, delivering 
services that are Medicaid billable when included in State plans. CMS 
considers them an evidence-based practice, but too many States either 
don't offer peer services through Medicaid or impose stringent medical 
necessity criteria on them that make it difficult for individuals to 
have access to peer specialists through Medicaid.
                            senator mikulski
    Question. Do either the substance abuse prevention and treatment 
block grant or community mental health services block grant need reform 
to best meet the needs of patients in our communities?
    Answer. The block grants are important programs that fund a range 
of critical prevention and treatment efforts around the country. I 
would not say that the block grants need ``reform''--rather, what is 
needed most is increased investment in treatment services. There are 
two ways this can happen: (1) by allocating more money to the block 
grants to fund additional evidence-based programs that meet 
communities' needs; and (2) by changing the way that we reimburse 
treatment providers through Medicaid. As the Medicaid coverage 
expansion rolls out in 2014, more people than ever before will need 
mental health and addiction services. Right now, the community 
behavioral health system is already overburdened and struggling with 
payment rates that don't cover the cost of care. Creating a Federal 
definition and status for Federally Qualified Behavioral Health Centers 
and allowing those entities access to the cost-based reimbursement and 
mandatory Medicaid status that other safety net providers currently 
receive (as outlined in the Excellence in Mental Health Act, S. 274) 
will go a long way toward creating that much-needed expansion of our 
treatment capacity.
                             senator casey
    Question. What kind of barriers did you encounter while attempting 
to find employment when you were struggling with your mental illness? 
Is there a role for private employers to play in helping those with 
mental illness? If so, what do you think is the best way to reach out 
to them?
    Answer. Yes, there is absolutely a role for private employers to 
play. One important thing they can do is to ensure they offer health 
insurance that includes adequate coverage of mental health and 
substance use conditions. A barrier to people who have been on 
disability because of behavioral health conditions re-entering the 
workforce, is uncertainty about whether they will continue to have 
healthcare coverage that meets their needs. Employers should look at 
the scope of coverage they offer to make sure it is comprehensive and 
inclusive of the needs of people with mental illness.
                              senator enzi
    Question. What can be done to educate local communities about 
identifying risk factors for mental illness and substance abuse? How do 
we improve access to treatment? What is working and what is not 
working?
    Answer. Educating local communities about mental illness and 
substance abuse is extremely important. The symptoms of severe mental 
illness often emerge slowly and can be difficult to detect without 
basic information on what to look for. Even when friends and family of 
someone who appears to be developing mental illness can tell that 
something is amiss, they may not know how to intervene or direct the 
person to self-help programs and treatment--which means that all too 
often, those in need of mental health services do not get them until it 
is too late.
    Mental Health First Aid is a public education program that can help 
communities understand mental illnesses, seek timely intervention, and 
save lives. MHFA teaches a five-step action plan to help people 
recognize the symptoms of common mental illnesses and addiction 
disorders; de-escalate crisis situations safely; encourage 
appropriate self-help strategies, and initiate timely referral to 
mental health and substance abuse resources available in the community. 
I am a Mental Health First Aid trainer, which means I teach people how 
to instruct others in becoming certified Mental Health First Aiders. I 
have witnessed first-hand the positive impact that comes from people 
with lived experience of recovery gaining the skills for providing 
support to help others experience a life of recovery from mental 
illness and substance abuse. To that end, I would encourage you to 
support the Mental Health First Aid Act, which authorizes $20 million 
for training Americans in MHFA to improve community education about 
mental illness and help people get access to treatment.

    [Whereupon, at 12:36 p.m., the hearing was adjourned.]

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