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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 7-8, 2000
Rockville, Maryland
Minutes
SEPTEMBER 7, 2000
Closed Session
The National Advisory Council of the Center for Mental Health Services (CMHS) met in closed session at 9:30 a.m. on September 7, 2000, at the Parklawn Building in Rockville, Maryland, to review grant applications. CMHS Director Bernard S. Arons, M.D., presided.
Open Session
The open session was convened by Dr. Arons at 11:05 a.m. Council members in attendance included Abdul Basit, Ph.D., Dolores Subia Bigfoot, Ph.D., Commander Eric J. Getka, Ph.D., Francis G. Lu, M.D., Ruby J. Martinez, R.N., Ph.D., Russell D. Pierce, J.D., Andres Julio Pumariega, M.D., Ian A. Shaffer, M.D., Josie Torralba Romero, M.S.W., David Shore, M.D., (ex officio), Karina K. Uldall, M.D., and Cynthia Wainscott.
Members unanimously approved the minutes of the May 2000 CMHS Advisory Council meeting as submitted. Dr. Arons introduced new Council member Josie Torralba Romero, M.S.W., and CMHS Acting Deputy Director Anna Marsh, Ph.D.
CMHS Director's Report
Dr. Arons told attendees that CMHS is on the verge of an important new stage of its evolution. Several new initiatives will be introduced over the coming year, and Dr. Arons sought input from Council members.
He explained the Knowledge Development and Application (KDA) life cycle, which includes issue definition, knowledge development, synthesis of knowledge of exemplary practices, exchange of exemplary practice information, preparing communities to implement exemplary practice, promoting exemplary practice adoption in communities, and addressing other emerging issues. The goal is to incorporate more scientific knowledge into "real-world" systems.
A major objective of CMHS' new strategy is translation—to ensure that knowledge reaches the target audience. CMHS is asking national organizations to reach their members; to choose the message, media, and format; and to provide feedback. These organizations include the National Association of State Mental Health Program Directors (NASMHPD) and the National Association of Planning Advisory Councils.
The second strategic step is to help grantees achieve self-sufficiency in funding. The funding tools of the past will continue, including Community Action Grants and sustaining grants. Dr. Arons introduced "For the Long Haul: Maintaining Systems of Care Beyond the Federal Investment," a new $2 million Service System Networking Grant Program that will help to develop infrastructure for integrated services for children and adults.
The third step is to set the stage for systems change, to create public interest in emerging KDA findings. To publicize upcoming findings of the Jail Diversion Project, for example, the Department of Justice (DOJ) convened a broad range of judicial system officials to inform them about the project. Subsequently, the Council of State Governments has begun to create a strategy to deal with mental health needs in judicial systems in conjunction with NASMHPD, CMHS, DOJ, and major foundations. CMHS also will publicize findings of the Employment Intervention Demonstration Program at a major conference in May 2001, with tracks for employers and employees. Employers will learn about the advantages of providing mental health services, and consumers will learn about job opportunities and successful approaches to move consumers/survivors into employment. The two groups also will meet for dialogue.
The fourth step in the KDA process is the development of practice guidelines in the areas of assertive community treatment, integrated services for individuals with co-occurring mental and addictive disorders, medication algorithms, medications for specific disorders, medication self-management, supported employment, and family psycho-education. Guidelines will be published for providers, consumers, families, and program administrators.
Discussion. Dr. Arons noted that practice guidelines for prevention services are still under development. Prevention activities include suicide prevention grants, an international conference on prevention, an upcoming prevention White Paper, and a continuing education curriculum for mental health professionals. Dr. Anne Mathews-Younes noted CMHS' extensive work on school violence prevention and its collaborative work with NIMH on prevention science. Ms. Torralba Romero raised the issue of prevention activities currently not being reimbursable under health insurance. Dr. Bigfoot suggested that a discussion of the levels of prevention—primary, secondary, and tertiary—would expand the concept of prevention. Dr. Shaffer urged wide dissemination of the guidelines and help for health care organizations to conduct risk assessments to target individuals for prevention activities.
Ms. Wainscott described Georgia's activities to translate mental health science into practice. She suggested that primary care and other organizations be engaged in the process. Dr. Arons stated that the intent is to approach different organizations with customized messages, for example, to package and disseminate specifically to tribes and tribal councils Circles of Care information on addressing Native American children's services. Dr. Bigfoot suggested that Native American centers in urban areas would be a critical contact for moving this objective forward. Ms. Martinez noted the benefit of including practitioners on research teams, partnering to solve problems in meaningful ways.
Dr. Lu suggested integrating cultural competence in the practice guidelines. He referred to the cultural competence performance measures and final report, CSAT's "Cultural Issues in Substance Abuse Treatment" and "Integrating Treatment with Dual Diagnosis." Dr. Lu cited the inadequacy of attention to cultural competence in the American Psychiatric Practice Guidelines. Dr. Flynn noted CMHS' close relationship with the DOJ's Office for Victims of Crime, which is developing guidelines for mental health services.
Dr. Arons referred Council members to the written Director's Report for details of CMHS' activities since the last meeting. Dr. Anna Marsh welcomed members of the new Subcommittee on Consumer/Survivor Issues.
Public Comment
Dennis Nissim-Sabat of the American Psychological Association urged that training become central to CMHS' role in the future, citing the insufficient numbers of minority mental health professionals. Gilberto Romero of the technical assistance center CONTACT stated that his organization has opened a branch to concentrate on the western states. Other activities include a focus on cultural competency and outreach into Latino communities. He suggested that government agencies should review each other's literature to enhance consistency in the information that is disseminated. Caroline Kaufman of Consumer Research and Evaluation in Pittsburgh stated that she is co-chair of the new organization Public Health Advocate, whose mission is to promote issues concerning public health and the environment.
Administrator's Update
Nelba Chavez, Ph.D., Administrator, SAMHSA, acknowledged the new Subcommittee on Consumer/Survivor Issues and welcomed Dr. Marsh to CMHS. She described the growth in knowledge over the last four years about successful treatment for marijuana dependency. Preliminary results of five treatment models were just announced; treatment episode data (TEDS) shows, over the last two years, a 155 percent increase in numbers of adolescents seeking treatment for marijuana dependence.
Dr. Chavez urged making the Surgeon General's report on mental health as important to the public as was an earlier Surgeon General's report on tobacco. She acknowledged the gains that have been made in the mental health arena, but noted that serious challenges remain. These include: the lack of a system of care that provides services for all individuals who want or need mental health services; the tenacity of the stigma issue; the lack of parity in insurance; and the paucity of culturally sensitive programs. She identified the challenges of evolving health care industry practices, and acknowledged the deficiencies in data collection on mental health.
Dr. Chavez introduced the "Summary of Findings from the 1999 National Household Survey on Drug Abuse," noting that some indications of the treatment gap for substance abuse are evident, but the gap is not known for mental health. Reports on at-risk children and under-age drinking are forthcoming.
Discussion. Council members thanked Dr. Chavez for her leadership and support. She reiterated the Council's charge to set priorities and to advocate for those priorities. She also noted several important dates in 2001: World Health Organization's World Health Day in April, the World Health Organization meeting in Geneva in May on mental health, and the World Health Report on Mental Health in June.
Subcommittee on Consumer/Survivor Issues
Russell J. Pierce, J.D., reported that the Subcommittee has made decisions regarding organizational structure, operating procedures, staff roles, communication, interactions with the Council, and term limits. Three individuals each will serve three-year terms, two-year terms, and one-year terms; persons serving one- and two-year terms will be eligible for reappointment. A pool of 100 applicants will serve as a resource for recruiting new members.
Mr. Pierce presented the Subcommittee's recommendations on "people first" language, use of the phrase "discrimination and stigma" rather than just "stigma," and the conduct of research on the value of the consumer/survivor movement as a resource for recovery and resilience (see discussion below for details). Subcommittee members include: Sylvia Caras, Ph.D., Coordinator of The People Who Net and an advocate for senior and international issues; Caroline Kaufmann, Ph.D., a researcher and consultant focusing on employment and service integration; Sharon Yokote, an advocate and educator working for parity for mental health and substance abuse services, with interests in institutional and Asian American/Pacific Islander issues; Juli Ann Lawrence, Coordinator of ; Donna Preston, an advocate with the Mental Health Association of Southeastern Pennsylvania; and Jon Brock, whose interests include parents with a psychiatric history and child custody and funding for increased education of consumer/survivor leadership. Former CMHS Council Member and Subcommittee Planning Group Member Frank Burgmann spoke about the Subcommittee facilitating the dialogue between the consumer/survivor movement and the Council.
Discussion. The Subcommittee will report regularly to the Council, and meetings for both groups may focus on data collection, co-occurring disorders, and/or mental health of the elderly. Dr. Arons noted that "people first" language coincides with the CMHS and DHHS position, but asked for clarification on the need for the term "discrimination." Regarding research on the contribution of consumers as a resource for recovery and resilience, Dr. Arons noted that the Consumer-Operated Services Program is ongoing and suggested that the Subcommittee help clarify questions to be asked next, and what type of study might best address them. Mr. Pierce asserted that people with mental illness are discriminated against in the same ways as are individuals with certain other disabilities. Ms. Caras noted that "stigma" isolates people with mental illness. Mr. Pierce explained the concept of "people first" language: Say "person who has schizophrenia," not "a schizophrenic." Not to use "people first" language, explained Dr. Kaufmann, tends to dismiss the qualities of a person not captured by their diagnosis, such as sensitivity or the ability to be a parent. Dr. Uldall urged the Council to consider how to retrain the thinking of professionals along these lines.
The Council voted unanimously to implement the following recommendations from the Subcommittee:
- The National Advisory Council of the Center for Mental Health Services support use of "people first" language within mental health research, policies, programs, and professions. By doing so, the Council affirms a similar resolution made by the National Council on Disability.
- Additionally, the Council endorses the use of the phrase "discrimination and stigma" rather than "stigma" alone. The Council believes that "stigma" furthers the isolation and exclusion of people who experience mental illness by creating a special vocabulary.
Members discussed consumer/survivor input. Dr. Uldall noted consumers' contribution to issues of retention and recruitment, and recommended that the government continue to require culturally competent, meaningful consumer/survivor input into research projects. Dr. Bigfoot discussed consumers/survivors with regard to professional development and continuing education. Dr. Pumariega suggested liaison efforts across federal agencies and noted that the Office of Protection against Research Risk is now developing new standards for ethics in investigation. He suggested working with NIMH on training on issues related to the role of consumers/ survivors in research. Dr. Shaffer discussed marketing this issue to the national professional organizations. Ms. Torralba Romero noted the importance of engaging sufficient numbers of consumers. Council members then voted unanimously to accept the following Subcommittee recommendation:
- The National Advisory Council of the Center for Mental Health Services encourages research on the value of the consumer/survivor movement as a resource for recovery and resilience among people who use public mental health services, and encourages the participation of consumers and survivors in the design and implementation of all CMHS-funded research and evaluation. Such participation should be representative of the consumers/survivors in the area that is the subject of the research or evaluation.
Dr. Marsh returned the discussion to training. Mr. Brock suggested using the model of an Office of Consumer Affairs, which exists in about 30 state departments of health, to help bring a focus on consumer/survivor issues into the administration of mental health services and to health care professional schools. Dr. Bigfoot suggested dealing with stigma and discrimination vis-à-vis ethics. Dr. Lu mentioned that the new standards for residency training requirements in psychiatry appear at on the Internet. Professional competencies are a possible vehicle to address the issue of training.
Dr. Kaufmann suggested as a precondition for the use of seclusion and restraint that physicians must have experienced it before being able to authorize it. Dr. Pumariega suggested CMHS funding to supporting consumer advocacy, perhaps bringing the Subcommittee together with bodies that determine accreditation of training programs. The Consumer Affairs staff will take the suggestion under advisement.
Dr. Arons recessed the meeting at 4:00 p.m. The meeting reconvened the following day at 8:35 a.m.
SEPTEMBER 8, 2000
Dr. Arons introduced the "Partners in Recovery: Creating Successful Practitioner-Consumer Alliances" videotape and the "Consumers and Social Workers in Dialogue" report. He acknowledged the contributions of retiring Council members Ian A. Shaffer, M.D., and Dolores Subia Bigfoot, Ph.D.
Mental Health and Juvenile Justice Panel
Pat Shea, M.S.W., M.A., Public Health Advisor, Special Programs Development Branch, CMHS, facilitator, set the context for the panel discussion. She noted the significant co-occurrence of mental illness and delinquency. The Surgeon General has found that in the general population of individuals ages 9-17, approximately 20 percent per year have a mental disorder. Studies show that 55-80 percent of detained youth meet the diagnostic criteria for at least one mental health disorder.
Why This Issue Demands our Attention: Outlining the Mental Health Needs of the Juvenile Justice Population. Linda Teplin, Ph.D., Director, Psycho-Legal Studies Program, Northwestern University Medical School, presented data for the CMHS-funded Northwestern Juvenile Project, the first large-scale longitudinal study of mental health needs and outcomes among delinquent youth.
Dr. Teplin explained that criminal justice studies now focus on children. CMHS is concerned that the detention center has become the poor child's mental hospital because of changes in the mental health system. Welfare reform, reductions in Medicaid, and reduced or nonexistent mental health care in managed care all result in fewer children getting treatment for mental disorders. Poor children, minority children, and children with co-occurring substance abuse are most likely to become involved in the juvenile justice system.
The Northwestern Juvenile Project studies children in Chicago's detention centers: how their mental health needs develop over time, their patterns of service use over time, the kinds of services they receive from which system, how the services impact outcomes, and from which key public health problems (e.g., violence, HIV/AIDS risk, substance abuse) they suffer.
Dr. Teplin described the study's long-standing relationships and cooperative agreements with every agency in the state. She noted the large Latino population is important to study because it is the fastest-growing ethnic minority group and one with disproportionate representation in juvenile justice.
Dr. Teplin noted the need to devise a way to treat children while they are detained, a particular challenge given children's short stays in detention. It is important to link the children with resources in the community, a difficult task because of the stigma associated with arrest and comorbidity. The research underlying the scope of problem will reveal the services needed to treat the kids and to reduce the revolving-door effects of arrest and release.
Current Status of Mental Health Services in Residential Juvenile Justice Facilities, Survey Findings. Ingrid Goldstrom, M.S., Social Science Analyst, Survey and Analysis Branch, CMHS, described some findings of the 1998 Survey of Mental Health Services in Juvenile Justice Systems, to be presented in full in the upcoming Mental Health, United States, 2000. The survey describes a wide range of facilities and the mental health services provided. Ms. Goldstrom indicated that although it may not be appropriate for short-term facilities to provide therapy, screening and evaluation are essential services. The study showed that nearly 50 percent of all juvenile justice facilities providing on-site mental health services do so in conjunction with the mental health system. The study described the percentage of children and adolescents receiving onsite mental health services in facilities providing onsite access to that service, and the percentage of children and adolescents in all juvenile justice facilities receiving service on one day, among other measures.
OJJDP Response to Addressing the Complex Challenges Associated with Serving the Emotionally Disturbed Offender Population. Karen Stern, Ph.D., Social Science Program Specialist, Office of Juvenile Justice and Delinquency Prevention, Department of Justice, gave the OJJDP website address, www.ojjdp.ncjrs.org, for the "Juvenile Offenders and Victims, 1999 National Report."
Dr. Stern noted that the identification of mental health needs and service delivery pose challenges to the juvenile justice system. Some juvenile justice goals, such as community safety and accountability, may conflict with the traditional goals of mental health service delivery; for example, judges might consider only residential, rather than community-based, options for treatment because of the severity of an offense.
OJJDP's early efforts supported state and local efforts to improve services to juveniles. In the mid-1990s, a Mental Health Juvenile Justice Working Group began a strategy to increase understanding of mental health needs of at-risk youth and to prevent future involvement in the juvenile justice system. OJJDP's 17 projects in this area include research on incidence and prevalence of mental illness among juvenile offenders, identification of appropriate screening and assessment protocols, and improvement of services to children and families.
Dr. Stern noted the urgent need for screening and assessment instruments for juvenile justice populations, and OJJDP has funded the National GAINS Center to examine these issues and make recommendations. Gaps in services include lack of programming for offenders in detention and secure corrections, and a lack of reentry or aftercare programming in communities. OJJDP seeks to develop a comprehensive delivery model to address the mental health needs of youth throughout the juvenile justice system. Pending Congressional funding, a demonstration and evaluation project would replicate and evaluate the model at multiple sites.
Promising Community-Based Practices: A Multi-System Approach. Gary DeCarolis M.Ed., Chief, Child, Adolescent, and Family Services Branch, CMHS, discussed systems of care for children with serious emotional disturbance (SED). Mr. DeCarolis presented data from the Comprehensive Community Mental Health Services Program for Children and Their Families, which addresses the mental health needs of children wherever they happen to be. Approximately 14.6 percent of the children are involved in the juvenile justice system. Each youth gets an individualized care plan and is assigned a case manager. After one year, great clinical gains are evident, including improvement in school performance, less failure, and better attendance, plus a decrease in crime and probation, and, for one third of the youth, no further contact with the juvenile justice system.
Mr. DeCarolis described the Wraparound Milwaukee program. Instead of incarceration, a judge enlists project staff to develop an individualized plan of care. The plan, part of the court order, involves a care manager and a range of services and supports in community. Whereas youth once might have gone into juvenile justice facilities, now they stay in the community with intensive services and supports to take care of their mental health needs.
Looking Ahead: NMHA Strategies for Meeting the Broad-Based Needs of Youth with Both Mental Health and Legal Problems. Collie Brown, Senior Director, Justice and Mental Health Center, National Mental Health Association, highlighted NMHA's Justice for Juveniles program. He urged addressing children's disparate problems holistically by creating local systems-of-care infrastructure to address the multiple needs of young people. He urged providing guidance for jurisdictions nationwide to address issues related to the most troubled youth, including the unique problems of adolescent girls in detention facilities, screening and assessment, inadequate cultural competence, and unheard voices of parents and families.
Discussion. Dr. Teplin noted that few studies have been made of resiliency factors, but her study is doing so. One major positive variable is the presence in the youth's life of one adult who cares about them and provides support. Mr. DeCarolis stated that resiliency is a societal issue. The important question is who will divert that person and keep him from the juvenile justice system, not a focus on internal resilience factors. In Dr. Bigfoot's treatment program, the recidivism rate is very low because of court-ordered heavy family involvement. Dr. Stern stated that the new Prospective Study of Serious Juvenile Offenders follows young people in serious trouble by looking at individual, family, community, and societal factors to determine their pathways into and out of justice systems. Mr. Brown stated that programs must reflect the needs of the individual participants in the community, including hours of accessibility.
Dr. Pumariega described a South Carolina epidemiological study of incarcerated youth that found lower use of community and acute mental health services, and higher use of residential services. Dr. Pumariega suggested a multi-site approach to look at rural/urban differences. Existing services may be inadequate for an incarcerated population. Screening should include functional and risk assessments. Many problems are missed, especially for youth of color, including risk of suicide and self-mutilation. A strong transition from residential treatment to community-based treatment is needed, with continuous case management during the transition to the community. South Carolina now develops closer collaboration between juvenile justice and mental health services, with the Village Project serving as a true model of co-location, blended services, work with judges, family advocacy, and outreach to the community. Regional detention centers have become more popular, so families can visit more easily.
CRIPA lawsuits (based on the civil rights of institutionalized persons) are an important method for change, and Dr. Pumariega urged OJJDP to work with defendants' families. He suggested providing technical assistance to providers for defendant states and acknowledged the Bazelon Center's work in CRIPA litigation.
Mr. Brown stated that NMHA is developing ChildWatch to convene teams of legislators, advocates, and others to talk with youth in facilities to gain access to what goes on behind the walls, positive or negative.
Dr. Teplin stated that her research is the first stage in the process of providing adequate services for youth. The research will show how people need to be trained. CMHS' next step is to implement interventions targeted to the problems, and then to implement and evaluate training programs. Ms. Torralba Romero recommended that Mr. DeCarolis look at differential outcomes of success, particularly of children of color, because of lack of sufficient bilingual/ bicultural personnel, infrastructure supports, infrastructure policy, and direction that professional staff require to do the work in the community. Partnerships with judges, school systems, social services, and community advocates are essential.
Dr. Stern cited a recent OJJDP study on offenders under age 12. Some factors that predispose youngsters from birth on to head into the juvenile justice system are mental disorders, diagnoses, and early aggressive behavior. Children often receive services early on, but the services drop off as they reach school age. If services are "too effective," and the child is functioning "too well," the system may withdraw services that are maintaining that level of functioning. Ms. Wainscott suggested documenting the interaction between lack of mental health services in a child's life and the juvenile justice system, to give advocates leverage to insist that a child gets the help he or she needs, including cost-effectiveness information.
Dr. Shaffer urged determining and closing the gap between people needing services and available funding. CMHS should help organizations show a return on investment to get funding. Mr. DeCarolis suggested that few people understand the mental health needs of children, and public awareness campaigns are needed to influence policy and decision makers. Services must be combined with communication and bottom-line thinking. Mr. Pierce suggested that ranking needs is destructive, that helping one become a "dues-paying member of society" should not be an "additional cost." Commander Getka noted the U.S. Navy's stake in this population because the military is often an alternative path for young people leaving the juvenile justice system. The Navy's mental health system traditionally has been a significant exit point for those who do not adapt well, but the culture may be shifting to retention, using prevention and early intervention services to help personnel function better within the military.
Dr. Lu suggested that CMHS investigate initiatives based on the forthcoming Surgeon General's Report on Ethnic Minority Disparities and Mental Health, and the data discussed in Dr. Teplin's report and issues related to adolescent girls and youth of color. Perhaps using a wraparound or system of care approach, Ms. Torralba Romero discussed the key role of county boards of supervisors in providing funding and suggested convening community teams to develop action plans. CBOs that do not bear the stigma of mental health may be useful in organizing. Dr. Shaffer suggested engaging new stakeholders, such as the business community. Mr. Pierce noted that failure to treat substance abuse represents costs to business, and suggested engaging the faith and civil rights communities. Dr. Pumariega suggested a focus on presenting models (e.g., to judges) and on modeling collaboration, and reexamining denial of Medicaid dollars for mental health for youngsters in the juvenile justice system. Dr. Arons invited Council members to submit additional feedback on the issues.
Promotion of Mental Health and the Prevention of Mental and Behavioral Disorders
Anne Mathews-Younes, Ed.D., Chief, Special Programs Development Branch, CMHS, in her introduction of CMHS's prevention focus, explained that CMHS has engaged the science of prevention in its $80 million school violence prevention initiatives.
Nancy Davis, Ed.D., Public Health Advisor, Special Programs Development Branch, CMHS, stated that interest in prevention has been low due to the perception that nothing can be done about mental illness—a historical lack of hard evidence to the contrary—and a false dichotomy that exists between the concepts of prevention and treatment. She asserted that prevention, treatment, rehabilitation, and recovery are inextricably linked, and our society can no longer afford not to fund the whole continuum of services. The World Health Organization and the Harvard School of Public Health's The Global Burden of Disease study demonstrates the need for preventive services. Psychiatric conditions are responsible for almost 11 percent of disease burden worldwide, and psychiatric and neurologic conditions together account for 28 percent of all years lived with a disability. Of the top nine major causes of death per year in U.S., seven are possibly linked to mental and behavioral disorders.
Dr. Davis identified a controversy surrounding prevention: Correlations do not dictate cause and effect. At this point in the research, decreasing risks and increasing protective factors are the best ways to prevent mental and behavioral disorders in the population.
Gail Ritchie, M.S.W., Public Health Advisor, Special Programs Development Branch, CMHS, discussed features of the mental health/mental illness continuum:
- Mental health and mental illness are not mutually exclusive categories, but rather are points on a continuum ranging from positive mental health through mental health problems to serious mental illness.
- Everyone moves back and forth along this continuum, depending on a multitude of biological, psychological, and social factors that change over time.
- A person's need for mental health services and the type of services he or she needs varies according to position on the continuum at any given time.
Ms. Ritchie gave examples of intervention categories that contribute to mental health. These include: enhancing health; primary prevention; early recognition and intervention; treatment; and rehabilitation. The inclusion of mental health promotion as a guiding concept allows for flexibility in the design of mental health services.
Ms. Ritchie discussed the definition of prevention given in the 1994 IOM report entitled "Reducing Risks for Mental Disorders, Frontiers for Prevention Intervention Research." Prevention is classified as those interventions that occur before the onset of the disorder, and they are divided into three categories: universal, select and indicated. Universal interventions target entire populations that are eligible for consideration, selective interventions target a subgroup who have an elevated risk for the development of a disorder, and indicated interventions are reserved for those at the highest risk for the development of a disorder and may exhibit symptoms of a disorder but do not meet the minimum criteria for a diagnosis. The CMHS conceptualization of preventive intervention includes the IOM perspective as well as the expanded definition of prevention outlined in the 1998 NIMH publication, "Priorities for Prevention Research at NIMH, A Report by the National Advisory Mental Health Council Workgroup on Mental Disorders Prevention Research," which includes the prevention of comorbidity, the delay of onset and the prevention of relapse. CMHS also is currently utilizing concepts from Australian mental health colleagues who broaden the definition of prevention to include health promotion.
Ms. Ritchie explained CMHS' legislative mandate to design national goals and to establish national priorities for the prevention of mental illness and promotion of mental health; to encourage and assist local entities and state agencies to achieve the goals and priorities; and to develop and coordinate federal prevention policies and programs, and assure increased focus on prevention of mental illness and the promotion of mental health. CMHS is considering future initiatives related to the promotion of mental health and the prevention of mental and behavioral disorders that are consistent with the recommendations found in the Surgeon General's 1999 Report on Mental Health. These recommendations include increasing the number of evidence-based practices ready to disseminate on a larger scale (perhaps by collaborating with NIMH); training mental health and other professionals to recognize, select, and implement with fidelity effective, evidence-based preventive interventions; and increasing the ability of communities to collaborate with researchers, and vice versa, to implement prevention and promotion interventions effectively.
Discussion. The Council supported convening a national work group to help CMHS develop its promotion and prevention action plan for the next five years. Ms. Wainscott suggested that replicators, communities, consumers, researchers, and providers be included. Mr. Pierce raised the issue of the ability to prevent biologically based mental illness. Dr. Basit asserted that this group could sort out the definition of prevention.
Dr. Davis noted that White Papers will be published this year on promotion, prevention, and resilience for young adults, middle-aged adults, and older adults, throughout the life span. Dr. Uldall broadened the discussion to include the need for prevention of co-occurring medical and mental disorders. Dr. Pumariega noted the desirability of lowering rehospitalization rates. Mr. Pierce emphasized the quality of life that prevention seems to suggest. Ms. Wainscott suggested adding recovery to the fan model. Ms. Torralba Romero and Dr. Lu urged that cultural competence be reflected in CMHS' products and projects.
Shelagh Smith, M.P.H., C.H.E.S., Public Health Advisor, Office of Organization and Financing, CMHS, introduced the new report "Preventive Interventions Under Managed Care: Mental Health and Substance Abuse Services," which identifies, validates, and abstracts 56 effective evidence-based research studies, and provides concise information for purchasers of services to offer in a managed-care plan. The report covers studies in mental health, substance abuse/use, self-care, and cost impact of interventions. The six services recommended are prenatal and infancy home visits; targeted cessation education/ counseling for smokers, especially those who are pregnant; targeted short-term mental heath therapy; self-care education for adults; pre-surgical education with adults; and brief counseling/advice from physicians designed to reduce alcohol use.
Next steps include continuing dissemination of the booklet, downloadable from the website mentalhealth.samhsa.gov/cmhs/managedcare/default.asp, and marketing it to managed care plans. A per member per month (PMPM) cost analysis report is under way for managed care organizations to estimate the cost of providing the six services.
Discussion. Dr. Pumariega suggested distributing the booklet to professional organizations for their work in standards development. He urged including at least secondary preventive interventions in health plans to improve quality of care and suggested working with the Centers for Medicare and Medicare Services and informing the states about the literature on EPSDT lawsuits (available on the Bazelon Center's website). Ms. Torralba Romero asserted the necessity of a link to reimbursement, and suggested that public-health and school-based nursing groups should receive the report. Ms. Ritchie noted that CMHS is sponsoring a training curriculum for a transdisciplinary continuing education course about prevention for mental health practitioners.
Ms. Torralba Romero proposed that the Council work to devise a consistent definition of "integration of cultural competence" and "inclusion of family involvement" in grant applications. The concepts also must be understood by RA and technical assistance staff, and by review panels. Consistency of information is hoped to improve future responses to RAs. Dr. Pumariega noted the need for outreach to potential grantees with clearer guidelines and definitions incorporated into technical assistance. Dr. Arons constituted a work group on the issue, including Drs. Pumariega and Lu, Ms. Torralba Romero, Messrs. Pierce, del Vichy, and Neil Brown, and a grantee or two to be identified.
Mr. Pierce raised the issue of reimbursement for grant reviews. Dr. Arons noted that CMHS will work out a policy.
Dr. Arons reminded the Council of the September 18 conference call for grant reviews and of the next Council meeting, scheduled for January 25-26, 2001. He solicited topic ideas for the next Council meeting. Dr. Arons adjourned the meeting at 12:40 p.m.
[ Advisory Council ]
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