CMHS National Advisory Council
Meeting Minutes
U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
National Advisory Council Meeting Minutes
June 20-21, 2002
Gaithersburg, Maryland
Minutes
June 20-21, 2002
Open Session
The National Advisory Council of the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Mental Health Services (CMHS) met in open session at 2:30 p.m. on June 20, 2002, at the Gaithersburg Marriott Washingtonian Center, Gaithersburg, Maryland. CMHS Director Bernard S. Arons, M.D., presided. Council members present over the course of the meeting included Abdul Basit, Ph.D., William R. Beardslee, M.D., Francis G. Lu, M.D., Donna Mayeux, Josie Torralba-Romero, M.S.W., Karina K. Uldall, M.D., Cynthia A. Wainscott, and Stephanie White-Perry, M.D. David Shore, M.D., National Institute of Mental Health (NIMH) liaison member, William Van Stone, M.D. (ex officio), and CMHS Acting Deputy Director Ted Searle also were present.
Approval of Minutes
The Council unanimously approved the minutes of the February 7-8, 2002, CMHS Advisory Council Meeting.
CMHS Director's Report
Dr. Arons highlighted CMHS' activities over the decade since its founding in 1992 with the creation of SAMHSA. He indicated that additional information was available in the written report. He began by noting the CMHS focus on community-based care and the quality and improvement of prevention and treatment of mental health problems in the community. He made the distinction between the mission of CMHS and the research focus of NIMH.
Over the last decade, CMHS has seen consumers become more involved in the mental health system and in advocating for their own services. Consumers have called for more investment in utilization and outcome measurement; a strong voice for children and families; an increase in standards from "best practices" to "evidence-based practices"; (re)integration of persons with mental health disabilities into the community; parity; a shift in the perception of mental illness from a family secret to a public health issue; and the elimination of discrimination and stigma associated with mental illness.
CMHS has consistently led the way on the field's most critical issues. The Children's Program broke new ground by focusing Federal attention on coordinated systems of care for children with serious emotional disturbance (SED). For the first time, a national program provided Federal funds to build the service-delivery infrastructure in partnership with local public and private agencies. Since its inception, the program has served more than 50,000 children and families in 67 communities. In 2002, 13 more communities will be funded. Up to 75 percent of the children served are referred by non-mental health agencies; days of inpatient care have been reduced 40 percent; and 80 percent of the original grantee communities are sustaining programs on their own. Among the lessons learned from the success of the program are the length of the funding (5 to 6 years), the need to increase the funding match required, and the emphasis from day 1 on the awareness that grantees must build their own sustainability. Congress has appropriated $96 million for this program in 2002. Children's services programs incorporate the systems-of-care model, for which evaluation (and accountability) tools have been developed to ensure the fidelity of communities to the program model.
CMHS has taken the lead in serving persons who are homeless and have mental illness and also have a co-occurring substance abuse disorder. The Projects for Assistance in Transition from Homelessness (PATH) program grants are funded at $40 million annually. Almost 400 local organizations have used the PATH program's flexible funds to fill gaps in community services, including outreach, job training, screening and diagnosis, and treatment. The Access to Community Care and Effective Services and Supports (ACCESS) demonstration program has helped more than 7,000 homeless persons. Additionally, the Homeless Programs Branch has held regional policy academies during which policy makers develop State action plans to increase access to mainstream services. In another activity, SAMHSA and the Health Resources and Services Administration (HRSA) have announced a grant program to increase the availability of primary care and mental health services for homeless persons with serious mental illnesses.
CMHS has contributed to the consumer movement by working to identify consumer needs, setting a national agenda, moving the field to address consumer issues, amplifying the voice of consumers at the national level, and offering opportunities for the voices of consumers to be heard at the local level. The CMHS portfolio now includes dialogue meetings between consumers and provider and other groups, support of consumer participation at meetings that address consumer rights and responsibilities, and many activities that consumers have indicated are important, including overcoming discrimination and stigma and self-help and recovery. Consumer Affairs staff has participated in regional and national programs, the completion of SAMHSA's self-examination of program and policy barriers to implementing the Olmstead decision, and preparations for the next dialogue between consumers and members of faith- and consumer-based organizations.
CMHS programs have been implemented in response to emerging issues. These programs include the youth violence prevention initiative that promotes resiliency-building interventions; the jail diversion, managed care, co-occurring disorders, suicide prevention, and childhood trauma programs; the HIV/AIDS cost study; the Protection and Advocacy initiative; and an effort to integrate mental health and primary care.
CMHS has addressed concerns about the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and uniform performance measures, as well as data and record-keeping issues. CMHS has broadened the data focus beyond the public sector with the Mental Health Report Card and plans for an information technology system overhaul to make the Federal system more compatible with the field. Dr. Arons next mentioned some other CMHS program areas. The Center's Emergency Services and Disaster Relief Branch responded to the events of September 11th in partnership with other agencies and organizations. In addition, CMHS has redoubled its crisis response initiatives by forging partnerships for large-scale emergencies, collaborating with the National Association of State Mental Health Program Directors (NASMHPD) to create guidelines for disaster planning, and developing course curricula and training for State mental health authorities. Immediate services grants recently were made to four States for weather-related emergencies. He also noted that the Center's Congressionally mandated clearinghouse educates consumers, mental health professionals, media, and the public about the work of CMHS.
Dr. Arons went on to describe the increase in block grant appropriations from a flat $277 million annually several years ago to $433 million in 2002, more than half of CMHS' total budget. Today, States use block grant funds for in-school mental health programs, services for the elderly, telemedicine for isolated rural populations, jail diversion strategies, and New Freedom Initiative-related coalition strengthening.
Dr. Arons described how, in recent years, mental health has risen in the public's consciousness. In 1999, the first Surgeon General's report on mental health was published, followed by reports on youth violence and on culture, race, and ethnicity. The first-ever White House Conference on Mental Health was held in 1999. Publication of a National Strategy for Suicide Prevention was followed by new funding for a National Suicide Prevention Resource Center. President Bush announced full support for parity in 2002 and formed the President's New Freedom Commission on Mental Health, which will study service delivery for severe mental illness and SED and make recommendations for improvements.
Dr. Arons predicted the following for the next decade: Models that have been proven to be effective will be implemented in many more communities, with improved outcomes and lower costs for additional services that are delivered more efficiently. Better-trained individuals will work in a system more capable of translating research findings into action. SAMHSA and CMHS will make great strides toward creating a mental health system that will better meet the needs of every American.
Discussion
Dr. Lu acknowledged CMHS; achievements under Dr. Arons' leadership, noting especially the award conferred on staff for their work on the Surgeon General's report on culture, race, and ethnicity. In response to Dr. Basit's query on CMHS' future plans, Dr. Arons noted the necessity to reconcile practice in the field with new research knowledge. Emphasis will be placed on employment, consumer-run services, services to individuals who are homeless, services for older adults, criminal justice diversion, and children's services, to name several. Block grants will focus on performance partnerships. Ms. Torralba-Romero highlighted CMHS' lead as a change agent in developing standards for cultural competence. Ms. Wainscott expressed appreciation for CMHS' attention to the consumer voice and introduced the following recommendation.
Recommendation
The CMHS National Advisory Council unanimously urged action on an immediate appointment to the Council of a self-designated consumer who would also serve as the Chair of the Subcommittee on Consumer/Survivor Issues.
Discussion (continued)
The Council also formally expressed its appreciation to CMHS staff for its efforts. Ms. Mayeux noted that staff has helped to move information discussed at Council meetings out into the field for broad use and implementation. Dr. Beardslee acknowledged Dr. Arons' leadership, particularly in listening to the field and in fostering partnerships with other agencies. Dr. Arons noted the importance of Council members' input. He stated that the future will hold increased emphasis on CMHS' relationship with NIMH.
Ms. Wainscott noted that about half the Council members will soon depart, instead of the customary one third. To facilitate continuity and transfer of knowledge, she and other departing members volunteered to serve as a resource to CMHS and its Council. Dr. Arons stated that, when potential new members are in the pipeline, they may be appointed to the Council as consultants before receiving formal approval; this interim time could serve as a training period. Once the new members are formally appointed, CMHS will endeavor to bring former Council members back to orient them.
Ms. Wainscott opened a discussion on the Council's relationship to the President's New Freedom Commission on Mental Health. Ms. Mayeux suggested inviting Chair Michael Hogan to the September Council meeting. Ms. Wainscott proposed a full meeting of the Commission and the CMHS National Advisory Council. Ms. Mayeux recommended including biographies of Council members in the initial written communication to Dr. Hogan. Ms. Wainscott volunteered to represent the Council in inviting Dr. Hogan and, perhaps, other commissioners.
Ms. Romero noted another critical direction for CMHS' future: the challenge of professionals working with monolingual clients. It is not clear whether treatment is effective when it is delivered through an interpreter and what behavioral skills are necessary for both providers and interpreters. Dr. Beardslee urged a focus on ways to leverage the experience of former Council members.
Subcommittee on Consumer/Survivor Issues: Update
Sharon Yokote reported on the June 17-18, 2002, Subcommittee meeting at which members heard presentations on issues related to the use of electroconvulsive therapy (ECT). She noted that the Texas reporting law established significant precedents in the areas of data collection and State reporting on the use of ECT and consumer rights; Texas now has no involuntary ETC. Although Texas has collected data for almost 10 years, little has been analyzed to date. Ms. Yokote noted that some consumer-led ECT research shows more dissatisfaction with the procedure than is widely acknowledged.
Ms. Yokote presented the following recommendation for consideration by the CMHS National Advisory Council:
Recommendation
The CMHS National Advisory Council supports improved and uniform collection and analysis of data regarding electroconvulsive therapy. Attention should be focused on formulating consumer-driven research questions on the issue.
Consumer/Survivor Update (continued)
In response, the Council referred the issue to Dr. Ron Manderscheid to determine what data collection and/or analysis activities would lead to additional knowledge. Ms. Mayeux suggested that Dr. Manderscheid consult with consumers on the Subcommittee and Council to be sure the correct questions are addressed. Dr. Arons suggested that Dr. Manderscheid report to the Council on his findings at a later date. Dr. Beardslee suggested that Dr. Manderscheid examine the NIMH evidence base to date. Dr. Shore stated that considerable data has been gathered on efficacy and safety, and some data is available on memory impairment.
Ms. Yokote reported that Subcommittee members acknowledged Mr. Curie's support for consumer-driven mental health systems, a focus on recovery, and the continued value of the Subcommittee. The Subcommittee agenda for the near future includes the development of a briefing paper on consumer issues and successful consumer-operated models for adoption by the Council and subsequent submission to the President's New Freedom Commission on Mental Health.
The CMHS Subcommittee on Consumer/Survivor Issues recommended that the CMHS National Advisory Council endorse the ten recommendations made by the National Council on Disability in its document "From Privileges to Rights: People Labeled with Psychiatric Disabilities Speak for Themselves," published January 20, 2002. The Council tabled this discussion until the following day.
Public Comment
Time was set aside for public comment, but no speakers appeared.
The meeting adjourned at 4:30 p.m. and reconvened the following day.
Closed Session
The Council met in closed session at 8:30 a.m. on June 21, 2002, to review grant applications. CMHS Director Bernard S. Arons, M.D., presided.
Open Session
Dr. Arons reconvened the open session at 10:45 a.m.
CMHS Activities in Prevention and Early Intervention
Anne Mathews-Younes, Ed.D., Director, Division of Program Development, Special Populations and Projects, CMHS, updated the Council on prevention and early intervention activities and sought the Council's advice on future directions. Dr. Mathews-Younes noted that CMHS' work on resilience began in 1998 when staff member Dr. Nancy Davis conducted a literature review on the status of research and research-based programs to foster resilience. In October 1998, when Congress appropriated $40 million to CMHS to address school violence prevention, CMHS Division Director Mike English already had begun talking with the director of Safe and Drug-Free Schools at the Department of Education and the director of the Office of Juvenile Justice and Delinquency Prevention at the Department of Justice about a joint program to address school violence, using evidence-based interventions, with a comprehensive approach that focused on the healthy development of children. The first Safe Schools/Healthy Students (SS/HS) Guidance for Applicants (GFA) was on the streets in spring 1999. That fall, 54 sites were funded, with 3-year annual grants between $1 million and $3 million. Between 1998 and 2002, the SS/HS portfolio has grown to more than 97 grants, with a total Federal investment of more than $610 million. The School Violence Prevention Initiative has given SAMHSA the occasion to pursue the issue of the prevention of mental and behavioral disorders and the promotion of mental health. SAMHSA Administrator Curie has designated prevention and early intervention as a core program area.
The science of prevention has produced knowledge about epidemiology, malleable risk factors, protective factors at all life span stages, diversity of problem behaviors and disorders, and mental health indicators. Dutch researcher Clemens Hosman has stated that between one and two thousand outcome studies have been published on prevention and promotion in mental health. Examples of successful interventions include David Olds' work with nurse home visitation, Dr. Beardslee's work with children of mothers who are depressed, and a 1998 study of Post- traumatic Stress Disorder (PTSD), which showed that persons who received cognitive-behavioral interventions had an onset rate of more than 8 percent, while people who received supportive counseling had an onset rate of 80 percent. It is CMHS' role to share this type of information. Biopsychosocial research in progress by Dr. McFarland at the University of Maine on prodromal symptomology of psychosis has shown amazing preliminary successes. Regarding systemic bullying prevention, for example, Dan Olweus' intervention that reduces bullying by half when implemented in schools has great significance in light of recent Department of Education and Secret Service findings that many U.S. school shooters had felt bullied, persecuted, or injured prior to the incident of violence.
Dr. Mathews-Younes then described an inventory of projects, including a guide to preventing youth violence, a directory of services and resources for survivors of torture, and a publication on domestic violence. The total Federal investment in SS/HS is more than $610 million. In CMHS' new Building Mentally Healthy Communities initiative, a targeted capacity expansion program, 19 grantees are implementing prevention and early intervention programs that involve consultation with the programs' developers to ensure fidelity to the effective intervention. One of the tasks of a new technical assistance center GFA, The Prevention Coordinating Center, will be to link funded minority grantees to community-based organizations (CBOs) that have not achieved funding.
Council members' input was requested, particularly with reference to accountability, capacity, and effectiveness, on early interventions for psychotic illness, advice on reconvening the original Institute of Medicine (IOM) Prevention Committee, and guidance on joining the Center for Substance Abuse Prevention (CSAP's) National Registry of Effective Prevention Programs.
On the topic of early interventions, biopsychosocial approaches to treat early symptoms of mental illnesses were mentioned and discussed briefly. Preventive interventions discussed included Dr. Richard Price's jobs programs, a psychoeducational intervention for children whose parents have a diagnosis of major depression, and a nurse home visiting program. Dr. Beardslee noted that prevention of major psychoses is still in the beginning stages but that early anxiety disorders may be a good predictor of later depression and substance abuse. He acknowledged that the science base is much stronger than it used to be. Ms. Wainscott noted less insistence among consumers that mental illness cannot be prevented.
Ms. Torralba-Romero observed that, for ethnic communities, the best prevention educators are not mental health providers. Rather, CBOs that engage people in civic celebrations, etc., without stigma, are the best preventionists. She urged CMHS to focus on identifying and training natural community educators to do prevention work, to think of primary prevention programs as a bridge to access disparities in populations, to provide coherent training models, to urge language translation with attention to context, and to empower specific communities to design models on a grassroots basis. She noted that health information on media channels such as radio, which is impersonal by its nature, reaches individuals who neither have access to a practitioner nor time to attend meetings or classes.
Ms. Wainscott observed that consumers' ethical concerns should be taken into consideration in interventions for psychotic illnesses. Dr. Shore stated that a large NIMH program that examines well-designed studies on prevention to be used in the future has provided a clearer picture of which risk factors have held up and which are not causal. He noted that evidence for primary prevention of predominantly chemical disorders, such as autism and bipolar disorders, is weaker or nonexistent, but early intervention appears more promising.
On the issue of revisiting the IOM report, Ms. Wainscott supported including grassroots people and policy makers at the table. Dr. Lu supported that strategy and suggested adding other agencies, such as the Agency for Health Care Research and Quality (AHRQ) and NIMH, as well as behavioral scientists and individuals from private foundations. He asserted that the broader base of support and input would reap greater ripple effects. He urged a focus on cultural competence and disparity reduction and needs related to age, language, gender, and ethnicity.
Dr. Beardslee stated his support for reconvening the IOM group but suggested that the group engage in a strategic planning process in reviewing the science. He also suggested that the group catalog other major reports. He urged undertaking the endeavor in a way that emphasizes quality, careful work over a long period, and an effective use of resources. The question to be asked of other agencies in this process might relate to the structure for evaluating evidence-based programs in their portfolios. Another question is how to implement high-quality treatments widely and with people who are not in the mainstream culture and do not speak the mainstream language. Ms. Wainscott noted the need for efficient program replication in communities for resolving the questions related to program ownership and fidelity and integrity. Dr. Beardslee concurred, noting that NIMH plans to emphasize research-to-practice and back. He noted that the way to counter opposition from people who believe that prevention is not useful is to do high-quality, evidence-based work. Dr. Basit asserted that the jury is still out on whether prevention in all areas of the mental health field works. The emphasis should be on determining areas where the effectiveness of prevention has been shown, identifying areas that have a strong evidence base and those which have little, and deciding which areas to focus on.
Ms. Torralba-Romero observed that the majority of prevention projects in California are city-funded youth programs with little guidance and direction from the field on whether or not the program has been researched. It is important to guide these programs with documented best practices. Some youth programs with prevention components intuitively enhance local cultural factors in keeping children together with their families, but they do not know how to study how well they are doing it. The science has not reached them. Ms. Wainscott noted that convening a meeting of Federal agencies could be part of the IOM reunion meeting. She also noted that information gathering in the Internet age will be more efficient than it was when the original meeting took place in 1994. Ms. Mayeux suggested including NASMHPD in the meeting because of this group's strong interest in children of parents with mental illness.
On the issue of adding a mental health category to SAMHSA/CSAP's registry of evidence-based programs, Ms. Torralba-Romero pointed out that communities do not separate substance abuse needs and issues from mental health/stress issues. Participating in the registry would be an opportunity to influence mutual understanding. Dr. Beardslee suggested using a sequential process that involves consultation with the Society for Prevention Research for definitions and advice on what programs fit into which categories. Dr. Beardslee also noted that it will be important to maintain the integrity of mental health prevention efforts at CMHS while the scientific community is sorting out which powerful risk factors influence which illnesses and the accompanying issues related to job loss, violence, and domestic conflict.
Council members spoke to a number of additional issues. Dr. Mathews-Younes noted that a publication entitled, "The Role of Prevention: A Primer for Mental Health Professionals" will offer mental health clinicians an opportunity to earn CMEs and CEUs. It was written in collaboration with a number of mental health associations from the areas of psychiatry, psychology, social work, and nursing. Ms. Mayeux observed that marketing efforts for the course should be undertaken with all the State organizations related to the four disciplines involved in the original collaboration. Dr. Beardslee suggested that local-level marketing also will be important.
Ms. Wainscott noted that developing the infrastructure and workforce in prevention appears to be aligned with ensuring implementation with fidelity. Credentialing bodies may be a resource for prevention credentialing; such bodies in Ohio and Georgia could identify barriers. Dr. Uldall suggested looking at prevention of medical morbidity for people living with mental illness related to, for example, to tuberculosis, hepatitis C, and HIV. Ms. Torralba-Romero observed that fidelity of programs in ethnic and minority communities has not been studied; she suggested that CMHS identify, study, and publish information on programs with promising practices.
Council members discussed similarities and differences in prevention between substance abuse and mental health. Dr. Lu suggested looking at the prevention of co-occurring disorders. Dr. Beardslee foresees effective integration of the two approaches in the future. He noted the importance of keeping the empirical evidence separate for each disorder, including substance abuse. Dr. Lu suggested a SAMHSA prevention initiative in which mental disorders and substance abuse could be looked at both separately and together, with each area retaining its own science and autonomy, but in which co-occurring disorders and related gaps and strategies could also be examined. Ms. Wainscott observed that a program to create prevention specialists must be carefully structured.
Old Business from Previous Day: Subcommittee on Consumer/Survivor Issues (continued)
The Council unanimously passed the following substitute recommendation proposed by the Subcommittee.
Recommendation
The Center for Mental Health Services National Advisory Council recognizes the National Council on Disability's report, "From Privileges to Rights: People Labeled with Psychiatric Disabilities Speak for Themselves," published January 20, 2002, as a meaningful documentation of consumer concern; and, at the request of the Consumer/Survivor Subcommittee, will use it to inform its understanding of disparities in the treatment of all people with psychiatric disabilities; and accepts the challenge of the Consumer/Survivor Subcommittee to maintain awareness of these public policy recommendations as it advises the CMHS Director.
Council Discussion
Ms. Wainscott acknowledged Dr. Arons' leadership in helping to add three Council recommendations to SAMHSA's policy and program matrix: recovery, the public health model, and the elimination of disparities. Dr. Lu noted that the significant amount of interest demonstrated in training for mental health disparities may warrant an increase in funding for the future. Ms. Torralba-Romero suggested adding this topic to the September meeting agenda.
The meeting adjourned at noon.
Next CMHS National Advisory Council Meeting: September 5-6, 2002
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