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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

September 8-9, 1999
Rockville, Maryland

Closed Session

Members of the National Advisory Council of the Center for Mental Health Services (CMHS) met in closed session to review grant applications and contracts on June 8-9, 1999, at the Parklawn Building, Rockville, Maryland. CMHS Director Bernard S. Arons, M.D., presided.

Open Session

Dr. Arons convened the open meeting at 9:17 a.m. on September 9. Council members in attendance included Frank D. Burgmann, Francis G. Lu, M.D., Donna Mayeux, Richard Nakamura, M.D., Andres Julio Pumariega, M.D., Ian A. Shaffer, M.D., and Karina K. Uldall, M.D. Dr. Arons welcomed to the Council Dr. Nakamura, Deputy Director, National Institute of Mental Health (NIMH).

Approval of Minutes

Members unanimously approved the minutes of the June 1999 CMHS Council meeting. Members were requested to furnish additions or corrections to the Joint SAMHSA Council meeting of June 1999 to Anne Mathews-Younes.

CMHS Director's Report: Celebrating Diversity in the Mental Health System

Dr. Arons introduced the theme of the meeting: growing diversity in the United States as it impacts the mental health system. Population experts predict that within the next 20 to 40 years, ethnic minorities in America, taken together, will become a majority in the population. Among children, ethnic and racial minorities currently are the majority in Hawaii, New Mexico, California, Texas, and the District of Columbia. Dr. Arons discussed recent CMHS projects that foster cultural competence in America's mental health system:

• CMHS has published standards and guidelines for cultural competence in serving four priority populations African American, Hispanic, Asian and Pacific Islander (AAPI), and Native American and currently is developing cultural competence performance measures.
  
  
• In July, CMHS convened an AAPI mental health summit, which brought together AAPI providers, researchers, family members, administrators, and experts on children and youth.
  
  
• Dr. Elzbieta Gozdziak and Capt. John Tuskan provided mental health consultation and technical assistance to Operation Provide Refuge, which facilitated admission and resettlement in the U.S. of 4,500 Kosovar/Albanian refugees.
  
  
• The CMHS Minority Fellowship Program increases the number of minorities able to enter the mental health professions and trains health care professionals to recognize and incorporate race, ethnicity, and culture into their treatment of all patients.
  
  
• The Hispanic Priority Initiative of the Community Action Grant Program brings together CMHS, CSAP, and CSAT to focus on the mental health and substance abuse needs of Hispanic communities.
  
  
• The Circles of Care, just completing its first year of serving Native Americans living on reservations and in urban areas, has been awarded the National Performance Review's (NPR) Hammer Award for converging the expertise and concerns of 13 U.S. government agencies, plus the leadership of several major Indian tribes.

• Surgeon General David Satcher announced a Call to Action to Prevent Suicide. CMHS, in conjunction with others, will convene a group of suicide prevention experts, advocates, and practitioners to develop a national strategy.
  
  
• National Advisor to the President on Mental Health Tipper Gore is working with the Surgeon General on a national media campaign to reduce the stigma of mental illness.
  
  
• The draft Surgeon General's report is expected to be released in late fall/early winter. CMHS will engage the Council as plans develop for a nationwide roll-out.
  
  
• Bills in Congress cover such issues as patients' rights, privacy of medical records, and creation of new opportunities for people with mental illness to return to work.
  
  
• The FY 2000 budget is similar to that of the FY1999 budget, with increases in the block grant and the PATH Program for individuals who are homeless and have a mental illness. The FY 2001 budget is being formulated within the Department; mental health is one of the Secretary's priorities.
  
  
• CMHS, together with the Departments of Education and Justice, will soon award more than $180 million in Safe Schools/Healthy Students initiative grants.
  
  
• The National Mental Health Association and On Our Own of Maryland recognized CMHS for its efforts. NPR awarded the Hammer Award to the Emergency Services Group. Internal awards recognizing CMHS staff are acknowledged in the full Director's Report.
  
  
• A Senate committee has approved a SAMHSA reauthorization proposal with a controversial measure: It would allow religiously oriented organizations that receive grants from SAMHSA for substance abuse programs to require specific religious affiliation for the staff that they hire. This provision already exists in the welfare reform legislation and has not been challenged by the courts.

Discussion. Dr. Arons noted that the President's budget proposal significantly exceeds budget caps agreed to in the past by Congress. Although it appears that money is available, funding the President's

budget would require breaking the budget caps, an action that Members of Congress are reluctant to take. If the budget caps are enforced, cuts in the present appropriation of $16 billion would adversely impact a number of programs. One possible solution is a continuing resolution, which will maintain current funding levels while debate continues or until a long-term budget continuing resolution is worked out. Dr. Nakamura acknowledged NIMH's general agreement with Dr. Aron's perspective.

Refugee Mental Health: Case Study of Kosovar/Albanian Refugees at Fort Dix, New Jersey, Elzbieta Gozdziak, Ph.D., Senior Public Health Advisor, Refugee Mental Health Program, CMHS. Having represented CMHS's Refugee Mental Health Program together with John Tuskan, Dr. Gozdziak described challenging but successful efforts to evaluate and ameliorate mental health problems experienced by Kosovar/Albanian refugees at the Fort Dix resettlement center during May- July 1999. The multiagency (DHHS, State, Justice) cooperative effort also collaborated with the International Organization of Migration, Immigration and Refugee Services of America, American Red Cross, Amnesty International, and other agencies.

The main focus of the medical mission was administrative: conducting the migration health assessment. In addition, the mission was to foster well-being among the refugees, to provide for spiritual and psychosocial needs, and to facilitate speedy resettlement. Lack of cultural competence constituted major stumbling blocks in evaluating and caring for the refugees, and the CMHS staff took on an advocacy role on behalf of the refugee population.

Among the lessons learned was the inappropriateness of the disaster medical response model. A new paradigm is needed in refugee emergency situations, perhaps based on a combat psychiatry model. Dr. Pumariega, noting that a community psychiatrist probably would have been valuable in that setting, suggested that collaborative work be undertaken with the Office of Emergency Preparedness and professional associations on standards for contracting medical personnel for various circumstances. In Dr. Gozdziak's view, individual caregivers varied considerably in their evaluation of the mental health of the refugees, resulting in overidentification of mental cases. She speculated that lack of cultural competence is believed to be the culprit. Ethical issues, particularly regarding confidentiality, posed challenges. The mission reconfirmed that the refugee mental health field is a distinct field that requires understanding of the refugee experience. The importance of spirituality in health prevention and mental health prevention was also demonstrated.

Discussion. The ethical issue of offering placebos for sleeplessness or anxiety was encountered in the medical arena. All medical personnel were American-trained. No advanced mental health screening was performed on the general population because of refugees' legal/immigration limbo and the wish to avoid politicizing the process. Privacy concerns were balanced in the mix of issues. Members discussed the need for standardized protocols to institutionalize the lessons learned and to incorporate flexibility to respond to situations with differing needs.

Council Panel on Cultural Competence: Perspectives from the Field

Overview of CMHS Cultural Competence Activities, Harriet McCombs, Ph.D., Moderator. Dr. McCombs encouraged Council members to engage in CMHS's ongoing leadership role in defining and shaping the field of cultural competence. She noted that CMHS will sponsor a national meeting on the state of cultural competency at the American Psychological Association headquarters. Dr. Lu noted that major professional organizations are now incorporating the issue into their major conferences and publications.

Dr. McCombs identified areas of inquiry that have guided the national discussion on cultural competence: status of current systems, knowledge of proficient practice, standards of practice for holding systems accountable, knowledge development on systems improvement, knowledge dissemination, and know-ledge utilization. Some areas of activity in which the above questions have been raised are human resource development, evaluation and research, quality of service at the individual and service levels, knowledge dissemination, policy, advocacy, and technical assistance.

CMHS has produced a summary of the status of CMHS's projects and also a consumer-oriented report card that evaluates CMHS projects' cultural competence. CMHS recently published Standards and Guidelines (available at mentalhealth.samhsa.gov), a defining document in the field of cultural competence.

CMHS Cultural Competence Standards, Andres Julio Pumariega, M.D. Dr. Pumariega noted that major sectors of American health care have not fully endorsed cultural competence standards, including the managed behavioral health industry, DHHS, health professions, academic and in-training sectors, and professional organizations is a serious issue if American health care is to be relevant to its minority citizens.

Dr. Pumariega discussed how the standard was developed, from its beginnings in Cross and colleagues' monograph, "Towards a Culturally Competent System of Care for Children with Serious Emotional Disturbance." The monograph defined cultural competence in two ways: for the individual, ability to function effectively in the context of cultural differences, and for the organization, a set of congruent practices, skills, attitudes, policies, and structures that come together in a system or agency, or among professionals, to enable that agency or the professionals to work effectively in the context of cultural differences. To achieve this state, an organization must review policies to eliminate discriminatory or differential impact, pursue multidimensional diversity training among staff, and implement service adaptations necessary to be congruent with the values, needs, orientations of the population, staff training, and governance involvement of diverse cultural groups.

Dr. Pumariega described the critical aspects of cultural competence for several provider constellations. For the practitioner, for example, cultural competence includes developing areas of knowledge regarding the populations to be served, including customs, beliefs, health-seeking behaviors, attributions, plus the skills of ethnographic interviewing, linguistics and the use of linguistic supports, alliance building, addressing power differentials, attitudes of advocacy, discrimination, racism, and empowerment.

Dr. Pumariega noted that the challenge posed by managed behavioral health has both advantages and liabilities. Managed behavioral health has had its greatest impact on culturally diverse populations through Medicaid programs, which are characterized by significant percentages of AFDC recipients, disabled populations, and children. The white population is demographically older than the culturally diverse populations, and the straight application from original managed-care principles which were primarily developed in middle-class, well-off populations with inherent support systems can have some problems. Managed care can have arbitrary reductions in benefits, restructuring services away from interagency comprehensive approaches which have served people of color well, relocation of services away from traditional locations, and service providers unfamiliar with cultural values and the multiple needs of the population.

Collaboration among professionals to meld cultural competence principles with managed care principles is projected to further the cultural competence of systems of care. Dr. Pumariega asserted that culturally competent care is more cost-efficient and clinically efficient, and produces more accurate diagnosis and effective treatment, less restrictive community approaches, the ability to integrate spiritual and traditional healing approaches, earlier use of services.

The standards project began with two CMHS-funded conferences on culturally diverse work group issues in managed behavioral health. The National Latino Behavioral Health Work Group (later, Latino Panel) was formed in 1995; within a year, the group developed the cultural competence guidelines in managed care for Latino populations. Soon thereafter, three additional panels were created, an African American Panel, an Asian American Panel, and an American Indian Panel; each developed its own guidelines. Consensus among the panels developed for one set of cultural competence standards for behavioral health across the four underrepresented and underserved populations. Borrowing from each other and also from a contemporaneous effort to develop standards by a California state task group, California standards were published in 1997, and the overall cultural competence standards were published in 1998.

Referring to the Cultural Competence Standards publication, Dr. Pumariega reviewed the components of several specific standards. Their core principles included cultural competence, consumer orientation, community-based systems of care, managed care, and natural support systems to augment mental health services for these populations. The structure addresses systems standards (cultural competence planning, governance, benefit design of health plans, quality monitoring and improvements, and we have actually standards that deal with QA/QI, decision support and MIS, and staff training and development), provider/clinical standards (access standards, triage and assessment, care planning, treatment services, case management, linguistic support and communication, intercultural communication, standards for self-help and for discharge planning).

Dr. Pumariega described the standard for a sufficient cultural competence plan. The plan includes integration of cultural competence throughout the health plan, a needs assessment process to determine the population(s) served and to identify their needs; identification of appropriate service modalities and models in a population-based assessment; determination of appropriate service approaches; identification of community resources and cross-agency systems to integrate support services and delivery; identification of natural supports (such as family, traditional healers, religious organizations, civic groups, etc.), identification of key issues and approaches to assure cultural competence at each level of care; examination of specific cultural competence issues at each level of care; stipulation of staffing patterns and skills as they relate to cultural competence; formal cultural competence assessment tools (such as those published by the Judge Baker Technical Assistance Center); a system of rewards, incentives, or sanctions for cultural competence performance; ongoing monitoring of indicators; equal access, comparability of benefits, outcomes across each level of the system of care; and specific outcomes.

Dr. Pumariega described important features of a number of other standards in health plans, for example:

Community involvement in governance
Interagency and cross-system agreements to look at support services to supplement care offered by the mental health service systems

Quality assurance and improvement teams

Cultural competence as part of the selection of clinicians and other providers

Triage and assessment that evaluate cultural aspects of the individual's mental health

Consultation to provider organizations by minority or cross-cultural mental health specialists to help develop, for example, protocols for access, triage, and assessment

Awareness of the need to address communication style and cross-cultural linguistic and communication support

Dr. Pumariega's active group of standards developers see themselves as ongoing resources for the implementation of these standards around technical assistance. He expressed concern about the possibility of watering standards down or adapting them to the point of nonfunctionality, and welcomed implementation of these standards across trade organizations, professional organizations, and governmental groups.

Cultural Competence Performance Measures, Francis G. Lu, M.D.

Dr. Lu described the project's conceptual framework for domains of cultural competence in mental health service delivery. Participants examined the target population, the population in need and the population in service and related it to the formal mental health system, the informal system (perhaps of indigenous healers), and other systems, such as primary care, that might lead the person into the mental health system. Within the system are services, human resources, and policies and procedures. All the above are related to cultural competence outcomes.

Domains include needs assessment, information exchange, services, human resources, policies and plan, and outcomes. The project participants organized the domains in terms of three levels, administrative, provider network or agency, and individual staff member. They also identified factors of the domains that describe specific areas of concern for which measures of cultural competence are required, and also suggested indicators and measures, plus data sources for each measure.

As described in this logic model, the information lends itself to research on cultural competence; ethnicity, religion, poverty level, language use may be important to gather as part of a research protocol. Dr. Lu noted that the indicators related to developing services include a clear statement about both consumer and family involvement, thus tying the model to many of the initiatives with which CMHS has been involved a long time.

Dr. Lu described the performance measures as the second stage of the rocket, with the potential for pilot studies to serve as a third stage to demonstrate that the measures in fact assess cultural competence.

Discussion. Dr. Nakamura questioned the evidence base of the standards described by the presenters. Acknowledging that the cultural competence standards have not yet been pilot tested, Dr. Pumariega pointed to the literature review's wealth of well-documented research on which the standards are based.

Dr. Shaffer stated his wish to involve his managed care company in a pilot study of selected standards/performance measures. He pointed out the difficulty in translating the theoretical model into operational terms. Dr. McCombs noted that a meeting is planned to discuss operationalizing the cultural competence documents. Dr. Pumariega suggested the importance of assessing cultural competence issues in CMHS program grant evaluations.

Asian American and Pacific Islander Mental Health Summit, Tiffany Ho, M.D. Dr. Ho described the July 1999 summit--convened to provide CMHS with recommendations for the development of policies and programs to address the unmet health needs of AAPI children and adults.

Dr. Ho reported on a series of research findings: AAPI populations experience significant mental health problems; underutilize mental health services except, particularly those with limited English proficiency; exhibit more severe disturbances, such as post-traumatic stress disorder (PTSD); and are more likely to drop out of treatment after initial contact or terminate prematurely from mainstream service settings. Research has also shown that ethnic-specific services reduce premature treatment termination; preliminary findings indicate that AAPI youth were under represented in voluntarily entered treatment, but represented at expected rates in the juvenile justice and alcohol/drug treatment sectors.

Summit participants recommended that CMHS establish an AAPI mental health resource development center to promote and guide culturally competent services for AAPI, and support implementation of cultural competence standards in states and local communities.

In discussing clinical standards, participants expressed concern that certain treatment benefits previously covered (for example, PTSD) are no longer covered when states contract for care; that bilingual, bicultural services providers are lacking; and that enlisting family members and nonclinical staff as translators leads to misdiagnosis and inappropriate treatment of AAPI consumers. Summit participants also recommended that CMHS initiate an AAPI Community Action Grant program to support implementation of promising practices in AAPI communities.

Summit participants also identified consumer issues: Outreach and target prevention messages are needed; support is needed for AAPI consumers to advocate for themselves; consumer self-help groups should advocate to ensure benefit packages, changes in benefits, alterations in services, location of service programs, and changes in providers are congruent with consumer needs. Participants also urged increased support from CMHS and NIMH, as appropriate, for research regarding utilization rates for underserved AAPI subgroups, and to operationalize standards for culturally competent mental health services.

Participants noted that little useful data is available on AAPI children and their families, AAPI children generally are not diagnosed early, and diversity within the AAPI population complicates research designs.

Discussion (cont.). Dr. McCombs summarized the two main trends of the presentations: cultural competence within CMHS and cultural competence in the field regarding systems, providers, and consumers. She invited Council members to address how CMHS can increase its responsiveness.

Dr. Shaffer asserted that certain issues relate more to health care delivery and funding changes than only to cultural competence. The issue of cultural competence in this context connects with the way, for example, benefits and changes to them are described in understandable ways. Dr. McCombs noted that differential responses may be experienced in managed care by different populations, which may prove to be an interesting study.

Dr. Pumariega pointed to the reference in the Cultural Competence Standards document on benefit design. Not only can decisions driven by financial concerns have differential adverse effects across different populations, but these decisions sometimes backfire. For example, when a health plan drops a culturally specific provider, minority consumers find it more difficult to access convenient medical care; symptoms can escalate to the point that they require emergency room admission at a cost far greater to the health plan than if the service had been provided in the community. Dr. Shaffer noted the necessity to educate the payer on how a benefit package impacts the plan's various populations.

Dr. McCombs described the evolution of cultural competence. Dr. Lu underscored the importance of guarding against stereotyping or overgeneralization; caregivers must assess an individual's gender, sexual orientation, religious/spiritual beliefs, etc. Dr. McCombs mentioned Los Angeles County's emerging efforts to collect data to measure ten areas of cultural diversity.

Dr. Pumariega noted that while a number of valid, reliable tools exist to determine if the research undertaken in various grant programs is appropriate for the target population, more tools are needed and dissemination of the existing tools must be expanded. Dr. Uldall suggested interweaving research on such instruments within grants programs.

Dr. Pumariega suggested that CMHS work to demonstrate Cross, Bazron, Dennis and Isaacs's principles and model cultural competence, particularly vis-à-vis other organizations in both the private and public sectors by developing cultural competence policies in each functional area. Dr. Arons acknowledged the value of the suggestion. Dr. Shaffer suggested that CMHS develop model policies that are easily operationalized.

Dr. Shaffer also urged efforts to add cultural competence to the syllabus in professional training programs. Dr. Lu stated that cultural issues are included in the draft 2000 standards for psychiatric residency training, and a white paper is expected based on a CMHS-sponsored conference on the issue. Dr. Lu also suggested strengthening the Minority Fellowship Program across mental health disciplines. Dr. McCombs noted that some of these issues must be resolved on the guild level, a process that is being facilitated by CMHS-sponsored multicultural training conducted by the Georgetown Technical Assistance Center.

Dr. Pumariega stated that the internal CMHS process of modeling cultural competence would be gradual. Council members concurred on the necessity of starting with policies and then moving to implementation in current program activities, such as reviewing the process to provide technical assistance to demonstration programs. Ms. Mayeux urged encouraging the Centers for Medicare and Medicare Services to require cultural competence from states and providers.

Dr. Arons summarized the Council's mandate to concretize and add specifics to CMHS's policies on cultural competence and to demonstrate their importance in the grant review process, particularly regarding applications and performance. He also noted possible resistance from professional groups to pressure to alter their curricula, particularly because of the paucity of research that demonstrates the efficacy of cultural competence in care of specific populations. He identified the possible need for bulleted lists of points to represent the standard of cultural competence in certain areas.

Dr. Pumariega suggested several aspects of care that produce better outcomes when provided in a culturally competent manner, for example, diagnostic services, differential benefits of different forms of psychotherapy, and identifying cross-cultural definitions and preferences of confidentiality. Mr. Burgmann identified the lack of sufficient linguistic skills for optimal cultural competence. Ms. Mayeux noted that mainstream consumer advocates for mental health also should be educated in cultural competence.

National and Medicaid Mental Health Expenditures, Jeffrey Buck, Ph.D., Director, Office of Managed Care, CMHS. Dr. Buck described an ongoing joint project with the Center for Substance Abuse Treatment to develop estimates of national spending for mental health and alcohol and other drug services. Its objective is to compare these estimates longitudinally with the Centers for Medicare and Medicare Service's generally accepted statistics for national health care spending.

Among the study's early 1999 findings are the following:

Total 1996 spending for mental health and substance abuse services equaled $80 billion; mental health spending alone equalled $67 billion.

The specialty sector, psychiatric hospitals, community mental health centers, psychiatrists, psychologists, etc.—accounted for 60 percent of the spending compared with 40 percent for general physicians.

Inpatient services accounted for 40 percent of the spending; outpatient, 60 percent.

The government is the chief payer of services for mental health and substance abuse; the federal government pays slightly more than all state and local sources.

Among public-sector payers other than Medicaid, state and local sources constitute the largest payer, followed closely by Medicaid and then Medicare.

The private insurance industry is the largest private contributor; its contribution is slightly greater than 25 percent.

The public sector pays a larger proportion of mental health costs than it does for general health care.

From 1986 to 1996, overall spending for mental health and substance abuse grew more slowly than spending for general health care. By 1996, mental health and substance abuse spending had dropped nearly a full percentage point to 8.1 percent over the decade, a trend that contradicts the general impression held by the public.

The greatest growth is shown in public-payer spending for overall health care; both that and spending for mental health and substance abuse have also grown at a greater rate than the private side.

The 1997 figures will include new sources of data, will be refined using enhanced methodologies, and will be even more accurate than the 1996 findings.

Dr. Buck noted that following the current round of analysis, project staff will study and report on the theoretical framework for what is driving the changes, including possibly differential growth in the management of services. He compared the CMHS/CSAT project with the Hays Report, a more narrowly focused study of the private sector whose findings complement the current government findings.

Council members urged the projects to focus on cultural competence in future statistical work. Dr. Buck noted that the data sets and the State Medicaid Research Files maintained by the Centers for Medicare and Medicare Services are available for purchase by bona fide researchers.

Consumer Affairs Update

Paolo del Vecchio, M.S.W., Senior Policy Analyst, CMHS. Mr. Del Vecchio updated Council members on CMHS's consumer affairs. CMHS hosted a consumer/practitioner dialogue with mental health nurses; participants made the following recommendations: (1) convene an interdisciplinary practitioner/consumer dialogue; (2) improve nurses' training by involving consumers in various conferences and meetings (as has been done at a recent American Psychological Association conference); (3) replicate dialogues at local and state levels; (4) support an enforceable bill of rights for mental health consumers; and (5) explore a national apology to mental health consumers for their treatment over the past hundred years. A future dialogue is planned with social workers.

CMHS assisted in the Centers for Medicare and Medicare Service's issuance of standards and regulations related to restraint and seclusion for adults, and will cosponsor (with the Centers for Medicare and Medicare Services) meetings on consumer satisfaction teams and hospital monitoring. The National Mental Health Association has produced a CMHS-sponsored monograph analyzing existing practice standards. Two government reports are forthcoming that focus on data collection activities, monitoring, and reporting.

A draft call for nominations to the Consumer Subcommittee and draft nomination review procedures were distributed to Council members for comment. By the end of the year, the final candidates are expected to be reviewed.

The planned theme of the National Consumer Survivor Conference (October 1999, Houston) is cultural diversity and cultural competence. At this meeting, the National People of Color Survivor Network will plan its second summit and a multicultural training institute.

Mr. Del Vecchio noted that CMHS sponsored a delegation of consumers to the World Federation for Mental Health Biennial Congress. He remarked on the passage in New York State of Kendra's Law, which deals with involuntary outpatient commitment; mentioned a Department of Justice report that found that 16 percent of people in jails had a history of mental health service use; and pointed to the need for adequate training for correctional officers vis-à-vis mental health issues.

Iris Hyman described CMHS anti-stigma efforts, including the Surgeon General's Report, White House Anti-Stigma Campaign, SAMHSA-wide Anti-Stigma Work Group, anti-stigma poster kit developed by the Office of External Affairs consumer affairs staff, CMHS-sponsored "Guide to Address Stigma in the Media" developed by the National Stigma Clearinghouse, federal anti-stigma workshops, and support for "It's About Time," a historical project to reclaim forgotten cemeteries on hospital grounds.

Carole Schauer updated Council members on the Consumer Bill of Rights. Short papers will be developed on each element of the document to serve as models. Congress is expected to address the issue shortly.

The Secretary of Health and Human Services is charged with developing regulations on privacy and confidentiality of medical records. SAMHSA is represented on a work group to address the mandate. A DHHS work group on the 1998 National Bioethics Advisory Commission report has made 21 recommendations on how to handle research involving persons with mental disorders that may affect decision-making capacity.

Ms. Schauer described four Supreme Court decisions of interest to the Council. In the Olmstead case, the Court ruled that unjustified institutionalization of people with disabilities is discrimination and violates the Americans With Disabilities Act. DHHS has constituted an Olmstead Working Group to focus on Medicaid and providing technical assistance to the states to help them develop "Olmstead implementation plans." In three employment cases, the Court narrowed the definition of disability under the Americans With Disabilities Act to exclude individuals whose disabilities are correctable, which raises important issues concerning people with treatable conditions such as epilepsy, diabetes, and certain mental disorders.

Discussion. Ms. Mayeux questioned the appropriateness of various reporting vehicles for states to comply with Olmstead documentation requirements. Ms. Schauer responded that SAMHSA will look into the issue. Members discussed the need for linguistically and culturally specific brochures to address stigma. similar to those developed by the National Association of Mental Health for depression.

Public Comment and Adjournment. Time was allocated for public comment; there being none, after thanking staff for their contributions and announcing the next scheduled Council meeting (January 20-21, 2000) Dr. Arons adjourned the meeting at 3:30 p.m.