[Senate Hearing 113-281]
[From the U.S. Government Publishing Office]
S. Hrg. 113-281
ASSESSING THE STATE OF AMERICA'S MENTAL HEALTH SYSTEM
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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
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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
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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.
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\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.
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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\
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\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.
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\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\
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\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.
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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.
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\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.
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\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.
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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.
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\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.
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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\
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\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\
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\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\
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\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.
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\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\
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\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\
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\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.
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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\
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\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.
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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.
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\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.
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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.
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\6\ National Research Council and Institute of Medicine. (2011)
IBID
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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).
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\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.
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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\
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\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.
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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.
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\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.
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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.
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\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.
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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\
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\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.
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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.
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\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.
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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.
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\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.
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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/.
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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.
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\9\ http://www.whitehouse.gov/the-press-office/2012/08/31/
executive-order-improving-access-mental-health-services-veterans-
service.
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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\
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\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\
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\11\ http://www.nihpromis.org/default.
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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.
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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\
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\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.
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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\
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\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.
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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\
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\6\ National Research Council. (2009). Preventing Mental,
Emotional, and Behavioral Disorders Among Young People: Progress and
Possibilities. Washington, DC: The National Academis Press, 2009.
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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\
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\8\ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807642/.
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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\
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\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.
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\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.
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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.
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\7\ http://www.ghc.org/about_gh/Quality/hedis-2012.pdf.
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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.]