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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
December 3-4, 1998
Washington, D.C.
Closed Session
Members of the National Advisory Council of the Center for Mental Health Services (CMHS) met in closed session for grant application review on the morning of December 3, 1998, at the Georgetown University Conference Center, Washington, D.C. CMHS Director Bernard S. Arons, M.D., presided.
Open Session
Dr. Arons convened the open meeting at 9:35 a.m. and welcomed Dr. Larry Lehmann, the new representative of the Department of Veterans Affairs to the Council, following the departure of Dr. Thomas Horvath. Council members in attendance included Dolores Subia Bigfoot, Ph.D., Frank D. Burgmann, Marshall Forstein, M.D., Eric J. Getka, Ph.D., Rosa Maria Gil, D.S.W., Daniel Gottlieb, Ph.D., Larry Lehmann, M.D., Donna Mayeux, Andres Pumariega, M.D., and David K. Yamakawa, Jr., J.D. Also in attendance were CMHS Deputy Director, Thomas , Ed.D., and Council Executive Secretary Anne Mathews-Younes, Ed.D.
Approval of Minutes
Members unanimously approved the minutes of the September 13-14, 1998, CMHS Council meeting.
CMHS Director's Report
Dr. Arons discussed the following highlights of the written CMHS Director's Report:
- Congress appropriated 14 percent more funding to CMHS for FY1999 than the previous year, with increases in nearly every line item. Block grants for state services received an increase of more than $13 million.
- For FY1999, Congress has appropriated $40 million to fund a CMHS school violence prevention initiative.
- CMHS co-sponsored the first national conference of the Suicide Prevention Advocacy Network, which adopted recommendations for a national strategy to reduce the suicide rate. CMHS, the National Institute of Mental Health (NIMH), the Centers for Disease Control and Prevention, and other Department of Health and Human Services (DHHS) entities will establish a coordinating group to set the strategy in motion.
- CMHS is currently involved in a number of partnerships. These include: (1) with NIMH and other NIH components on the first-ever Surgeon General's Report on Mental Health; (2) with NIMH and the Health Resources and Services Administration (HRSA) on a second-generation HIV/AIDS research program and sponsorship of a meeting that explored the effects of serious parental illness on the mental health of children; (3) with the American Association of Retired Persons (AARP) on a project to prepare the nation to deal with the increasing mental health problems associated with aging and the aging population; and (4) with the Department of Labor on the Presidential Task Force for the Employment of Adults with Disabilities.
- CMHS has been invited to the annual meeting of the American Public Health Association to help its members become more familiar with the programs of CMHS and SAMHSA. The increasing suicide rate has become of primary concern to the entire public health community.
- Dr. Arons has addressed a number of meetings since the Council last convened. These include the first world conference on the mental health needs of those who are deaf and have a mental illness, and a gathering of grant makers in the health field in Texas.
- CMHS has implemented the Starting Early, Starting Smart project. CMHS, SAMHSA, and the Casey Family Foundation support 13 grant sites nationwide to provide early prevention and intervention services for children from birth through age seven. The project also helps local providers explore new funding sources and the feasibility of public-private ventures.
- The Georgetown Technical Assistance Center is developing a monograph for daycare providers faced with mental health problems in a young child or the child's family.
- Examples of ongoing Knowledge Development programs include: (1) consultation with the Social Security Administration resulting in funding 9 projects focusing on elimination of barriers in returning to work for individuals with serious mental illnesses; (2) dialogue with faith community leaders to help them respond to congregants with mental health problems; (3) development of a directory of resources for members of the immigrant population who have been victims of torture in their native countries; and, (4) development of new knowledge about the mental health problems of older Americans, including substance abuse, models for its treatment, and cost impact
- Dr. Arons presented a list to the Council of the grants processed in September that were awarded.
- Dr. Arons summarized information that CMHS has collected to date on youth violence, and solicited advice from the Council on how to structure the program to be supported by the $40 million Congressional appropriation for a violence prevention initiative. The project is expected to focus on violence as a public health concern, rather than solely as a criminal justice issue, and to include public health prevention and interventions strategies, community-based solutions, and data collection on violence-related topics. The effort is expected to be collaborative across agencies, include schools and community-based organizations (CBOs), include use of technology, and provide for dissemination of findings.
Council members discussed the following topics concerning the violence prevention initiative: the need focus on "safety" issues, in addition to violence; ongoing safe-school (e.g., San Francisco Bay area) and community-based initiatives; necessity to consider youth violence beyond the school environment, and to link communities, families, students, and university education departments in planning and implementing activities for the initiative; convening a national meeting on youth violence; and establishing interagency partnerships.
HIV/AIDS Mental Health Services Demonstration Program
In a panel discussion introduced by Melvin Haas, M.D. (Associate Director for Medical Affairs, CMHS), Capt. Elaine Dennis (Senior Health Policy Analyst, CMHS), William E. Schlenger, Ph.D. (Mental and Behavioral Health Program, Research Triangle Institute), and Jennifer Havens, M.D. (Director, Special Needs Clinic, Columbia Presbyterian Hospital), presented an overview of the recently concluded HIV/AIDS Mental Health Services Demonstration Program, a cross-site program conducted in collaboration with NIMH and HRSA.
Dr. Haas described the three components of the project: effective dissemination of findings to the field, intervention/prevention strategies to avoid HIV/AIDS infection, and the HIV/AIDS Treatment Adherence, Health Outcomes, and Associated Costs program. He then delineated the serious funding constraints under which HIV/AIDS programs function within CMHS, limitations that were ameliorated in this project by interagency collaboration.
Capt. Dennis described the goals of the demonstration. These are to: improve access to comprehensive, integrated mental health and support services for people living with and affected by HIV/AIDS; provide services that meet their cultural and social needs and improve the quality of their lives; document empirically the mental health and other service needs of people living with and affected by HIV and the services they receive through this program; and create replicable HIV/AIDS mental health care models. The project integrated service delivery and evaluation.
Dr. Havens described the 11 project sites, which provided traditional mental health treatment, psychiatric evaluation, psychotherapeutic treatment, and individual psychotherapy. Some mental health sites were co-located with medical care, a common HIV/AIDS mental health model.
Dr. Schlenger described the empirical contribution that the program has made to the field of mental health services for people with HIV. During its four-year tenure, the project served 5,500 people at the 11 sites. The people served reflected the racial, gender, social, and economic face of the epidemic; HIV status, sexual orientation, income source, psychiatric disorder, co-occurring substance abuse, and risk behavior were among the demographic variables examined. Very high rates of psychological disorders, including those related to alcohol and substance abuse, were found. More than 100,000 service encounters were recorded for psychotherapy or counseling, psycho-educational support groups, case management, and medication monitoring. Most clients received multiple types of services. Although half of the services were provided by clinicians with advanced degrees, the other half were provided by individuals with less education and experience. The project found that fewer service encounters were recorded in programs co-located with medical services, and that, overall, clinicians spent just under half of their time providing services to clients. A series of monographs on the program's findings is under development.
Dr. Havens described the findings of the project. The needs of the population served, which was primarily minority, economically disadvantaged patients, were consistent across sites. Core mental health services, case management, and concrete services to ameliorate poverty and social disadvantages, are needed as part of the service package for those affected by HIV/AIDS. The need for the services was found to be great. Focus on sustainability of programs beyond the period covered by grants was determined to be a critical consideration, particularly because Medicaid does not adequately support the types of services provided. Only four of these programs are expected to continue.
Dr. Havens also described the investigational agenda of the future: development of a service package with demonstrated efficacy, formulation of practice guidelines for this patient population for dissemination to the field, and advocacy and policy activity focusing on funding of the services.
The panelists concluded their presentation with a brief discussion of the new multi-site HIV/AIDS Treatment Adherence, Health Outcomes, and Cost Project, a collaboration among the National Institute on Drug Abuse (NIDA), and National Institute on Alcohol Abuse and Alcoholism (NIAAA) of the NIH, the Center for Substance Abuse Prevention, NIH, HRSA, and CMHS. Of the eight sites in the project, five conduct treatment interventions and three integrate mental health with other services. Because two-thirds of the funding is earmarked for evaluation, outcome follow-up and efficacy studies are expected to be possible. Dr. Havens emphasized the need for precision in definitions in Guidance for Applicants (GFAs) and for reviewers to understand the project objectives, particularly the research agenda. She also noted some of the advantages of the cooperative agreement mechanism in undertaking a project of this type.
Capt. Dennis described the federal perspective of lessons learned including the need for: five-year programs, federal collaboration, mechanisms to avoid conflict of interest in the GFA and review process, inclusion of evidence of sustainability as a prerequisite for grant approval, and recognition that engagement and retention of patients are costly activities, although not reimbursable ones.
Update from the National Mental Health Association
Michael Faenza, Executive Director of the National Mental Health Association, urged the Council to work toward improving the plight of children in the juvenile justice system who have serious mental health needs and who receive little or no care. He cited as particular problems: the inadequacy of screening and assessment for serious emotional disturbance; the over-representation of youth of color in the juvenile justice system; the lack of capacity of the mental health system to identify children who do not present in terms of established protocols; medical neglect and abuse; and lack of resources to provide adequate care. For some of America's youth, the only way they can gain access to mental health care is to enter the juvenile justice system. Mr. Faenza asserted that without investment in children, …"humanity's most fundamental long-term problems will remain fundamental long-term problems."
Mr. Faenza acknowledged CMHS efforts in the field and expressed hope for additional resources to be applied to this area.
Dr. Pumariega echoed Mr. Faenza's concerns, citing inadequate institutional resources to keep youth safe and healthy. Dr. Gil questioned how prevention programs might help avoid the problems cited by Mr. Faenza.
Ms. Mayeux suggested that judges represent an untapped resource in influencing positive change in this arena. Dr. Pumariega suggested that CMHS might sponsor an educational presentation at a joint annual meeting of the National Association of Juvenile Court Judges and the National Association of District Attorneys.
Mr. Faenza reported considerable interest by the Congressional Black Caucus in mental health issues in the juvenile justice system.
From the Field: An HIV/AIDS Update
Marshall Forstein, M.D., summarized his work as a psychiatrist in Boston and presented his perspective of the HIV/AIDS epidemic vis-a-vis mental health issues to fellow Council members. Because state funding varies greatly and no specific federal funding stream exists for mental health/HIV needs, it is not clear how the mental health system in HIV/AIDS care should be supported. As highlighted by the HIV/AIDS Mental Health Services Demonstration Program, non-licensed caregivers provide considerable mental health services to HIV patients.
Dr. Forstein noted that although some have interpreted the limited success in HIV/AIDS treatment to mean that the epidemic is under control, global demographics disprove this view. In fact, in some developing countries, the birth rate is not expected to keep pace with the death rate from HIV. The world looks to the U.S. for a vaccine and for pharmaceuticals to manage HIV. The etiology of risk-taking behavior, even among those who understand risk in terms of potential HIV/AIDS infection, is not yet fully understood.
Mental health issues surround the difficulty of adherence to treatment regimens; co-location of primary and mental health facilities helps with adherence. Sufficient numbers of mental health professionals are not currently being trained in relation to the numbers of HIV patients projected for the future. Moreover, traditional community-funded support for psychosocial care appears to be diminishing.
Dr. Arons welcomed input from Council members on the role of CMHS vis-a-vis the global implications of the HIV epidemic. Dr. Gil noted that international cooperative efforts have been undertaken.
SAMHSA Administrator's Report
Acting Deputy Administrator Joseph Autry, M.D., presented the update of SAMHSA's activities, including the FY1999 budget and the FY2000 budget process.
Dr. Autry stated that grants planning for 1999 is well underway. Two rounds of review will be conducted, and, in subsequent years, three rounds will be held. In addition, a new practice of open/standing GFAs will be instituted designed to generate new ideas will be instituted.
He noted that Mental Health U.S. 1998 is expected to be issued early in 1999, and that work continues on the Surgeon General's Report on Mental Health. In addition, Dr. Autry noted continuing interest on the part of the White House in the work of the agency.
In the current year, SAMHSA will focus more on disseminating the findings that have been developed by Knowledge, Development, and Application programs.
Dr. Autry and Council members engaged in lively a discussion of the following issues:
- Inclusion of mental health among the ten diseases to be addressed in the closing of cultural gaps. Council members asserted that mental health advocates may not always have the same level of clout with those of other, "more popular" diseases. Dr. Forstein noted that although the decision was purported to have been made to exclude mental illness from the group of ten diseases on the basis of the difficulty in measuring outcomes, measurable outcomes for certain pharmacological and other treatment modalities for mental illness can be discerned.
- Accountability of states for block grant funds. In response to a question from Dr. Gil, Dr. Autry stated that the federal government is moving toward performance-based outcome measures, and that the reauthorization of SAMHSA offers an opportunity to enact more stringent accountability requirements.
- Improved "marketing" of mental health. Joint efforts with staff of organizations with broad constituencies, such as AARP and the National Parent-Teacher Association, including writing a column for their newsletters, were suggested.
- Dialogue with academia on teacher training in multiple disciplines regarding leading-edge research in mental health issues, such as disaster response and treatment guidelines. Council members noted that the curriculum at institutions of higher learning must be updated to reflect current knowledge in the field.
Finally, Dr. Arons noted that the CMHS National Council meeting tentatively scheduled for April is likely to be rescheduled for early June. The meeting was recessed at 4:50 p.m. and reconvened Friday morning, December 4, 1998, at 9:05 a.m. A summary of Friday's discussions follows.
From Idea to Reality: The Development of a GFA and Implementation of a Program Initiative. The Role of the National Advisory Council
In a panel discussion moderated by Dr. Thomas Bornemann, CMHS staff members Drs. Barbara J. Silver, Lawrence Rickards, and Frances Randolph, and SAMHSA's Director of the Division of Extramural Activities, Policy and Review, Ms. Diane McMinamen, discussed the development of a GFA and implementation of a program initiative.
Dr. Rickards described the development process for a GFA. Goals and objectives include: (1) relevance of important issues to the field, (2) potential to advance knowledge in the field, and (3) ability to adequately communicate project requirements.
Dr. Rickards then described the stages of the GFA development process: (1) contemplation of an idea: brainstorming and discussion/feasibility evaluation; (2) concept development: outline of an announcement, conduct literature review, draft, review and revision of a concept paper; (3) GFA development: document draft, review and revision; (4) publication of the funding announcement; and (5) award procedures and negotiations.
Council members raised the following points:
- Dr. Forstein noted that many grantees find it expensive to accept a grant; it is rare in practice for a grant to cover all the costs of conducting the project. The panelists acknowledged awareness of this problem and stated that, aside from making supplements available, they actively seek ways to improve cost estimations and to encourage leveraging funds through the use by cooperative arrangements.
- In addition, Dr. Forstein asserted that because of the subject exclusions inherent in certain research, a disconnect exists between the studies that are needed in the field and the populations that are actually studied. He suggested that state-provided technical assistance programs and capacity building at the local level would enable organizations with important research questions, but few resources, to develop the ability to pursue funding opportunities. He also pointed out that one-year start-up funding is not a viable mechanism unless linkages with other agencies for support have already been established. It might be desirable for GFAs to encourage establishment of these types of linkages.
- Dr. Shon and Dr. Pumariega concurred that the time between idea development at CMHS and funding may be capitalized upon by an interactive process with the field. There should be a continuous feedback loop which not only addresses conflict-of-interest concerns, but also determines key issues and sharpens areas of inquiry. Solicitation of input following wide dissemination of CMHS-developed concept papers and literature reviews could both elicit valuable insights and answer questions in the field about the origin of grant program ideas.
- Ms. Mayeux suggested that CMHS consult state plans, which identify future issues; the plans are an under-used resource for identifying potential .
- Dr. Getka asserted that Council members would welcome involvement during the early stages of a research project. Ms. Mayeux suggested that a portion of a Council meeting each year could be devoted to discussion of current and future issues, and possible review of concept papers. Dr. Forstein suggested that the Council also be considered as an "idea tank."
- Dr. Forstein asserted that coordinating centers have an important potential role to play in technical assistance, particularly in helping organizations determine whether or not they have the expertise to conduct a project described in a GFA and/or to conduct evaluations. Topics might include: how to interpret a GFA; how to partner with an academic center; how to discover which questions may be answerable in a certain environment; and, when and how to subcontract. Dr. Shon suggested the need for developing a more uniform overview for the approach to services research in order to be consistent across the Center, and subsequently communicating this knowledge to the field. Council members also discussed the advantages of a coordinating center conducting the evaluation component of a study.
- Panel members noted that the role of coordinating centers is evolving. Recently one center conducted a training session for all interviewers in a project and subsequently followed up with inter-rater reliability studies.
- Council members suggested that coordinating centers should themselves be evaluated periodically to ensure maximum effectiveness. Dr. Silver asked Council members for feedback on the centers with which they are familiar.
- Dr. Forstein noted that from the applicant's point of view, the coordinating center can be helpful in several ways. One is to teach how to differentiate and organize data to answer both national and local questions. Another is to train and support clinical staff who must administer study-related instruments.
- Dr. Forstein asserted that grants should include financial resources to enable an institution to support the non-reimbursable supervisory and other activities critical to conduct of the study.
Ms. McMinamen described the reviewer selection process. The ideal panel balances field of expertise, geography, ethnicity, gender, and level of experience of the reviewers. Another important dimension considered is distribution of institutional affiliation among academic institutions, CBOs, state/local government, and consumers. Availability of reviewers is a major concern, and last-minute drop-outs are a frequent occurrence. Although there is a formal process, reviewers may also be identified through networking. Many professionals believe the best training for obtaining awards through the GFA process is to serve as a reviewer, thereby learning first-hand the characteristics of a successful application and the dynamics of the review process.
Dr. Rickards noted that the review process is interactive and that applicants are contacted by Program staff to resolve certain issues that might otherwise disqualify them from consideration.
Dr. Forstein pointed out that, for some professionals, it is difficult to spend time on such non-reimbursable activities as serving on a review panel. This is a problem that may impact increasingly on engaging optimally qualified peer reviewers in the GFA process.
Dr. Randolph described the award and post-award process. Although the priority score assigned to an application generally determines whether or not it will be funded, program staff occasionally use the mechanism of "award criteria" to supersede priority scores. This may occur, for example, in order to improve geographical distribution of grantees or to address a priority population. The budget determines how many grants can be funded. Once the selections are approved, negotiations are conducted with the potential grantees regarding their budgets and also to resolve any deficiencies identified by reviewers. Dr. Randolph suggested that the role of the program officer is to make the grantee successful, and that technical assistance is one way to accomplish this.
Consumer Affairs Update
In his update on consumer affairs, Paolo del Vecchio solicited Council input on SAMHSA's role concerning the following issues:
- People of Color Consumer/Survivor Network. New leadership in this population is emerging. At a recent national meeting to examine the impact of health care reform on people-of-color communities and to develop strategies to improve consumers' lives, these leaders identified the need for consumers to obtain information on services and systems, on rights protection, and on ways to impact the development of managed care systems. They also identified the need for networking, ongoing communication, and leadership development. Representatives from the the Centers for Medicare and Medicaid Services ( CMS), the National Mental Health Association, The National Alliance on Mental Illness (NAMI), and the Bazelon Center presented at the meeting, and CMS has expressed interest in continuing the dialogue.
- Consumer Bill of Rights and Responsibilities. Council members were invited to submit specific comments and recommendations concerning SAMHSA's role in the implementation and promotion of the Bill of Rights.
- Consumer Subcommittee of the National Advisory Council. Nominations to the planning group have been received from national mental health consumer/survivor groups. The group, which is expected to be formed within the next six months, will develop a blueprint for action.
- Restraint and Seclusion Issues. Council members were asked to comment on the role of SAMHSA in providing federal leadership on this issue. Congressional hearings are a possibility in the upcoming session.
- Dr. Forstein suggested making available more resources to train staff of state inpatient facilities. In terms of staff training, Dr. Pumariega suggested that the technique of Total Quality Management might be useful. Mr. Yamakawa suggested that federal leadership can be an important catalyst in stimulating necessary reform. Mr. Burgmann suggested that focusing on best practices may bring about positive change. Dr. Arons noted that CMHS can conduct a survey to identify exemplary programs. Mr. Burgmann also suggested sponsoring a consensus conference on restraint and seclusion. Dr. Getka pointed out the usefulness of including a conference presentation on how the best practices were arrived at, step-by-step, in the institutions that use these procedures. Ms. Mayeux suggested that the Surgeon General's Report may be an appropriate place to discuss these issues.
Public Comment
In the segment allotted for public comment, two individuals spoke to the Council:
- Kathy Muscari introduced CONTACT, the new consumer-operated networking technical assistance center in West Virginia. CONTACT works with consumer groups on developing leadership and peer support, supports statewide networks, shares technology, and engages in other activities.
- Irene Lynch described the recent mental health activities of the Allepos Foundation, including testimony before the National Bioethics Advisory Commission, Healthy People 2010, and the National Council on Disability. Ms. Lynch also serves as CEO of the new World Alliance of Mental Patients, a patient registry.
Adjournment
Dr. Arons adjourned the meeting at 11:50 a.m.
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