Remarks by
A. Kathryn Power, M.Ed.
Director
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
Anxiety Disorders Association of e
America 25th Annual Conference “Anxiety Disorders in Special Populations”
The Future of Mental Health Care in America: Hope for Special Populations
Seattle, WA
March 17, 2005
PowerPoint version
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
[SLIDE 1. Title slide]
Good evening. Congratulations to the Anxiety Disorders Association of America (ADAA) on its 25th silver anniversary. During the past quarter century, the ADAA has made outstanding progress in advancing the understanding and treatment of anxiety disorders. Even your name change in 1990—from the Phobia Society of America to the ADAA—reflects a tremendous shift in how our society views anxiety disorders. We now accept that anxiety disorders are just as diverse and complex as the individuals whose lives are affected by them.
In just 25 years, the ADAA has evolved from a small group of individuals to a nationally recognized and widely respected organization. This is a remarkable achievement that deserves special recognition. Your story is one of vision, determination, and—most important—hope for those who seek recovery from these disorders. Your story also is a story without end, for there is so much more that you must accomplish.
Your 25th anniversary should have a purpose beyond the recognition of a milestone, or a tribute to past and present achievements. This celebration also should challenge you to envision an even better future and to set high goals for how you will achieve it. As the noted inventor Charles Kettering observed, “ High achievement always takes place in the framework of high expectation.”
And so, tonight, I want to acknowledge, with justified pride, your many accomplishments. I also want to urge you to expand your organization’s mission by joining with the Center for Mental Health Services (CMHS)—as well as the National Institute of Mental Health (NIMH)―to help us achieve ours. If we can all leave this conference with a shared commitment to improving mental health care for all Americans, then this anniversary event will be a tremendous success.
About a year ago, I had the privilege of meeting personally with members of the ADAA and NIMH to discuss how our three organizations could work together more closely. What a wonderful opportunity it was for us to learn more about each other’s organization and mission! Many of you will be more familiar with NIMH than with the Substance Abuse and Mental Health Services Administration (SAMHSA) and its Center for Mental Health Services (CMHS). As my noted colleague Dr. Thomas Insel can describe, NIMH is the lead Federal agency for research on mental and behavioral disorders. Through its research mission, NIMH continues to make major scientific discoveries related to mental health.
[SLIDE 2.
Organization chart]
SAMHSA’s mission has a different focus. Our three centers collaborate on promoting mental health as well as on preventing and treating serious mental and substance use disorders among all Americans. Our particular charge is to build resilience and to facilitate recovery for individuals with or at risk for mental illnesses and substance abuse. Many of our programs target specific, underserved populations. For example, we have priority programs that target persons who are homeless or in the criminal justice system. These are population groups with extremely high prevalence rates of serious mental illnesses and substance abuse. Their care often becomes the responsibility of safety-net providers and public health systems. The emphasis we place on meeting the needs of such underserved groups is very much in keeping with the focus of this conference, which is improved mental health care for special populations.
[SLIDE 3.
SAMHSA’s vision]
SAMHSA’s vision is “a life in the community for everyone.” Our vision is based on the underlying principle that people of all ages, genders, and races who have or are at risk for mental and substance use disorders should have the opportunity for a fulfilling life in their communities. This life includes a job and education, a home, and meaningful relationships with family and friends.
Anxiety disorders deny millions of Americans a full life in their communities. These disorders are pervasive across all populations and can be extremely disabling. This is an excerpt from a note posted on the ADAA’s message board. It was written by someone whose panic attacks have worsened progressively over a 5-year period. The person wrote that, “I get so scared driving long distances that I won’t leave my house. . . . When I get [an attack], I’m scared that I will lose control of the car and crash. It’s gotten so bad that I don’t go to work.”
The author of that note is only 24 years old, and should have a lifetime of possibilities ahead of him or her. But what hope does he or she hold for the future? Severe and recurrent panic attacks are crippling this young person’s ability to function adequately in daily life. I hope this individual seeks treatment soon. We know that, with proper treatment, recovery is readily attainable. Clearly, too many people still need to hear the ADAA’s key message: Anxiety disorders are real, serious, and treatable!
I’ve been asked to speak tonight about the future of mental health and what my organization is doing to make a difference. For SAMHSA/CMHS, the briefest response to both topics is three words: mental health transformation. A transformed mental health system is our vision for the future. This vision now has become the guiding force behind the programs we operate, the policies we create, and the new initiatives we undertake.
The concept of mental health transformation originated with a report called Achieving the Promise: Transforming Mental Health Care in America. Copies of this report are available on a table at the back of this room.
[SLIDE 4.
SAMHSA matrix]
You also will find copies of the SAMHSA matrix, which shows that mental health transformation is listed among our priority programs. In fact, we consider transformation so vital to our agency mission to prevent and treat mental and substance use disorders that it has become one of SAMHSA’s four “redwood” programs. Charles Curie, SAMHSA’s administrator, coined this term to emphasize a new program philosophy and direction. Rather than having a thousand short-lived “flowers” bloom, he wants SAMHSA to focus on developing a few major, long-lived initiatives.
[SLIDE 5.
Achieving the Promise]
Achieving the Promise is a critical assessment of our national mental health system, which really is a combination of systems providing and funding public mental health care. These systems include State mental health and substance abuse authorities, Medicaid; Medicare; the judicial, education, and welfare systems; public health; and others responsible for direct health and social services delivery.
Achieving the Promise describes a mental health system in disarray. Services and supports are fragmented, disconnected, and often inadequate. Instead of ready access to quality care, the system presents barriers to recovery. The report recommends nothing less than a fundamental transformation of our Nation’s approach to mental health care.
Achieving the Promise is a national call to action. But this report does more than just reveal the shortcomings of our mental health system. It also looks beyond the system’s faults to its potential. Achieving the Promise presents a vision of a transformed system that is consumer driven, focused on recovery, and capable of building a person’s resilience to face life’s challenges.
[SLIDE 6.
Six goals PAUSE FOR READING]
The report outlines six broad goals and nineteen specific recommendations for a transformed mental health system. This slide shows the six goals.
President Bush’s administration has charged my agency with leading the Federal response for transformation.
[SLIDE 7.
Federal Partners Workgroup]
Together with twenty other Federal departments and agencies, including NIMH, we are implementing a roadmap for change that we call our Federal Action Agenda. Our agenda describes how SAMHSA and our partners will respond to each of the Commission’s six goals and nineteen recommendations. It identifies specific, measurable steps that we will take to motivate, facilitate, and compel change by those involved in mental health care. Our action agenda is an evolving document. Each year, as we make progress, we will develop new agendas and identify new priorities.
The progress we make in achieving these goals and recommendations will improve mental health care for all Americans. Through transformation, individuals with any mental disorder will be able to seek treatment willingly, openly, and with hope in their recovery. Consequently, mental health transformation is where the mission of SAMHSA and the mission of the ADAA intersect. I am asking you, as mental health professionals and as an organization, to consider how you can support transformation as part of your ongoing activities.
[SLIDE 8.
Goal 1 and recommendations]
Consider goal 1. Goal 1 and its recommendations focus on mental health and its relationship to overall health. The mind and the body are inseparable. We cannot treat one effectively without treating the other. As evidence, think about the bodily distress commonly experienced by individuals with post-traumatic stress disorder, or PTSD. Reported symptoms include headaches, gastrointestinal distress, fatigue, immune system problems, dizziness, and chest pains. Primary care doctors may over-treat or inappropriately treat these ailments because they do not realize they are symptoms of an underlying anxiety disorder. We can change this! Transformation is our opportunity to create a health care system that better integrates mental and primary health care.
Goal 1 also addresses ignorance, bias, stigma, and discrimination. Discrimination and stigma have created a social climate that makes it harder for people with mental disorders to find or sustain employment, find a home, obtain health insurance, and gain access to appropriate treatment. Too often, fear of discrimination and its consequences prevents individuals from seeking treatment.
This fear is reflected in the number of people who deny themselves the hope of recovery through treatment. As cited in Mental Health: A Report of the Surgeon General, less than one-third of adults with a diagnosable mental disorder receive mental health services in any given year. The percentage is even lower for specific population groups, such as racial and ethnic minorities, children, persons with physical disabilities, and residents of rural or other medically underserved areas.
The reluctance to seek care by persons with anxiety disorders is astounding. Anxiety disorders are the most common mental illnesses in the United States, affecting 19 million individuals. We all probably know someone with an anxiety disorder; we may even be someone with a disorder. And yet, most individuals with these disorders do not recognize, accept, or want to reveal their disorder. Why?—Because public education about mental illnesses is lacking. Because stigma and discrimination can be a person’s greater fear.
I am very proud of what my agency is doing to eliminate discrimination and stigma.
[SLIDE 9.
ADS Center]
Among our recent initiatives is the Resource Center to Address Discrimination and Stigma, or the ADS Center. The ADS Center helps design programs to reduce discrimination and stigma associated with mental illnesses. Using the most research and information available, the ADS Center helps individuals, organizations, and governments counter discrimination and stigma in their communities, in the workplace, and in the media.
Discrimination, of course, takes many forms. The theme of this conference highlights a form of discrimination that prevents many Americans from receiving adequate mental health care. I’m talking about discrimination that affects the care of special populations―care that is not culturally competent, or is not adapted to gender or age differences, or does not accommodate the unique needs of persons with different sexual orientations.
Discrimination is addressed broadly under goal 3 of Achieving the Promise, which is that disparities of care will be eliminated. How significant are disparities? Several years ago, the Surgeon General released a special mental health supplement on culture, race, and ethnicity. This supplement chronicled striking disparities in mental health services for racial and ethnic minorities in the United States. Compared with whites:
- Minorities have less access to, and availability of, mental health services;
- Minorities are less likely to receive needed mental health services;
- Minorities in treatment often receive a poorer quality of mental health care; and
- Minorities are underrepresented in mental health research.
More recently, in 2004, the Agency for Healthcare Research and Quality released its National Healthcare Disparities Report. This report is the first national comprehensive effort to measure differences in access and use of health care services by various populations. It expanded upon the Surgeon General’s report by also examining care received by women, children, the elderly, and other groups as well as racial and ethnic minorities.
According to this report, we are making progress in eliminating some disparities. For example, a larger percentage of individuals among all population groups and education levels are reporting access to mental health care.
[SLIDE 10.
Comparative bar chart
]
Much work, however, remains to be done. The report also notes that, “In general, racial and ethnic minorities often experience worse access to care and lower quality of preventive, primary, and specialty care.” For women, the report frankly states: “Overall, many women’s health needs are inadequately addressed.”
I highly commend the ADAA for its Women’s Initiative, which is focused on improving mental health care for women. Your recent conference on anxiety disorders among women and your continuing efforts to promote a research agenda focused on women both highlight a serious challenge: We must improve our knowledge base about anxiety disorders and how they affect women and their families.
What we do know about mental illnesses and women justifies greater research in this area. From the time a girl reaches puberty to the time she becomes an older adult, she is twice as likely to have an anxiety disorder as her male counterpart. Women are about twice as likely as men to develop m ajor depression.
SAMHSA, through its population approach, has been focusing on ways to improve mental health care for women. During the past 5 years, we have been identifying, evaluating, and expanding the use of evidence-based practices to treat women who have experienced trauma. Our just-completed Women and Violence Study involved nearly 2,700 women who had histories of mental health and substance use and who had been physically or sexually abused, or both. All of the women in our study were diagnosed with PTSD.
I’m sure you are familiar with the relationship between abuse and anxiety disorders. Thirty-nine percent of women victimized by domestic abuse develop PTSD. Adults who were abused during childhood are almost two-and-a-half times as likely to have phobias and more than ten times as likely to have a panic disorder.
Childhood abuse certainly is linked to many of the mental and substance use disorders experienced by the women enrolled in our Women and Violence Study. This is a story about one of these women, whom I’ll call Kate.
Kate was sexually abused by an older brother from an early age, beaten regularly by her father, and neglected by her mother. As a small child, she tried to hide from the chaos and violence in her home. By the time Kate was a young adult, she was using cocaine, heroin, and LSD as her escape mechanism. She developed serious depression as well as PTSD. When drugs failed to numb her mental anguish, she began to cut herself.
At this point, Kate realized that her life was at risk. Her current mental and substance use disorders, compounded by her traumatic past, threatened her very future. Kate sought help through the SAMHSA-funded WELL project, which is one of the programs we evaluated in our study. WELL is an acronym for Women Embracing Life and Living.
Through a combination of trauma-informed care, medication, and psychotherapy, Kate is in recovery. She now is self-employed, with renewed hope in her future. She has started to recruit community members for a local chapter of a statewide consumer organization for women in recovery.
Kate’s story is one of personal triumph. It also is a story of transformation. Kate received mental health care that was tailored to her co-occurring disorders, her personal history of abuse, and her gender. Her experience demonstrates an important conclusion of our Women and Violence Study―Care that is gender-based and trauma-informed works!
SAMHSA is taking a big step forward on this issue by launching a new National Center on Women, Violence, and Trauma. We also are working with the National Trauma Consortium to plan ways to help States and communities become trauma-informed.
I am very proud of our Women and Violence Study as well as other ways SAMHSA is striving to improve the care of individuals with PTSD and other trauma-related mental illnesses. For the past 3 years, we’ve been working with the U.S. Department of Veterans Affairs National Center for Post-Traumatic Stress Disorder. The military’s expertise in this area is contributing greatly to our knowledge about best-practice interventions following disasters. We’ve also asked the center to evaluate crisis counseling practices and to convene a series of expert panels on trauma assessments and screenings.
In addition, we have built a national consortium of organizations focused on the needs of traumatized children. Our National Child Traumatic Stress Network is a collaboration among 54 universities, community-based mental health centers, hospitals, and clinics. Together, we are working to raise the standard of care and improve access to services for traumatized children, their families, and communities throughout the United States. Early intervention is our best opportunity to ensure that children will be able to reach their full potential in life, with the resilience to face life’s future challenges.
SAMHSA also is looking at a population at the other end of the age spectrum—our older adults. America’s older population is growing. By the year 2010, approximately 40 million Americans will be age sixty-five or older. In fact, every day, 6,000 more Americans turn age 65. More than one-fourth of older adults will have mental health issues, including substance abuse, depression, dementia, and suicidal ideation.
Health professionals working with older adults have long observed a frequent and significant overlap of symptoms of anxiety and depression in this population. A holistic approach to treatment takes on even greater importance for this age group. Depression rates are much higher among older people who experience a physical health problem—12 percent for persons hospitalized for hip fractures or heart disease. In fact, anxiety associated with medical conditions or the use of medications is one of the most common presentations of anxiety in older adults. Symptoms of anxiety also commonly accompany dementia.
SAMHSA supports a portfolio of programs designed to address the barriers that stand between older adults and the quality mental health services they deserve. These barriers include the lack of expertise in screening, assessing, and treating late-life mental disorders as well as the misconception that mental disorders are a “normal” function of aging.
Race, gender, and age are not the only variables affecting the prevalence of mental illnesses and the quality of available care. The Healthy People 2010 companion document on “Lesbian, Gay, Bisexual, and Transgender Health” recognizes that sexual prejudice, sexual orientation discrimination, and antigay violence are stressors affecting the mental health of these groups. Other reports describe the incidence of affective disorders, PTSD, sexual trauma, suicidal ideation and behaviors, eating disorders, and other mental health problems they experience. In seeking treatment, however, gay, lesbian, bisexual, and transgender individuals with mental illnesses will confront at least two forms of stigma and discrimination. Negative social attitudes about their lifestyles can affect the quality of medical care they receive. Again, stigma and discrimination are denying individuals their hope in recovery.
So how do we improve the quality of care received by special populations? Certainly, any future vision of transformed mental health care must include universal access to the best treatments available. This is the answer: evidence-based practices.
As I mentioned earlier, NIMH is the lead Federal agency for research on mental and behavioral disorders. SAMHSA, through its three centers, works to harness the power of scientific discoveries by translating science into services. It is our job to ensure that the most advanced discoveries in mental health care become routinely available at the community level.
In the simplest terms, SAMHSA’s role is to align research, policy, funding, and training to promote better mental health services at the community level. We cannot accomplish these tasks alone. Our success hinges on collaboration among a complex web of partners, including the States that ultimately are responsible for service delivery, consumers and their families, clinicians and researchers such as yourselves, and organizations such as the ADAA.
Our goal is to reduce substantially the time between the discovery of an effective intervention and its use as a common practice. We—together with NIMH—have an ambitious science-to-service initiative to do just that—to strengthen and accelerate the widespread application of effective interventions. Our goal, by the way, reflects goal 5 of Achieving the Promise, which is that excellent mental health care is delivered and research is accelerated.
One important advance is our expansion of SAMHSA’s NREPP—the National Registry of Evidence-based Programs and Practices. NREPP originally was created in 1998 to review and evaluate substance abuse prevention programs. Through NREPP, independent academic researchers use nearly twenty criteria to evaluate nominated programs and practices. Those designated as model, effective, or promising are included in an online national registry.
Last year, we expanded NREPP to also incorporate substance abuse treatment programs, as well as mental health promotion and treatment programs. Note the added focus on promotion of mental health. Mental illnesses create tremendous emotional and financial burdens for affected individuals, their families, and their communities. Promoting health to prevent mental illnesses certainly will be the most effective and humane way to eliminate these burdens.
[SLIDE 11.
NREPP Web site]
NREPP actually serves two functions. The first is science-to-service, or to improve treatment by making evidence-based practices available to providers. The second function is service-to-science. When NREPP reviews a practice, the developer gets feedback on how well the practice conforms with each of the evaluation criteria. We want NREPP to do more than identify effective practices. We also want NREPP to help practices move up the evidence ladder, to increase both efficacy and effectiveness.
Science-to-service is an area where the ADAA and SAMHSA can collaborate to everyone’s benefit. The ADAA serves three distinct groups: researchers, clinicians, and consumers. You can help us promote the use of evidence-based practices among all three. Our objective for NREPP is to increase continuously the number of best practices available. Encourage the researchers you fund to submit new programs and practices to NREPP.
Make clinicians more aware of the resources available to them from SAMHSA by linking your Web site to the NREPP site. In addition, make our evidence-based practices part of your training curriculum for clinicians. The ADAA’s role as a conduit for training gives you enormous power to reach those engaged in direct service provision.
Equally important, continue to reach out to consumers and their families to raise their awareness about treatment options. Educate, empower, and enable them to be informed decisionmakers. There are choices to be made—choices in providers, and programs, and medications. These are choices that should be made by consumers as they make their personal journey toward recovery.
Let me clarify at this point how we define recovery. Recovery does not necessarily mean a “cure.”
[SLIDE 12.
Defining recovery]
Recovery is a process, sometimes lifelong, through which a person achieves independence, self-esteem, and a meaningful life in the community. For some individuals, recovery implies the reduction or complete remission of symptoms. For others, recovery is the ability to live a fulfilling and productive life despite a disorder.
Another way this organization can support mental health transformation is to tell us where transformation needs to go in terms of anxiety disorders. Anxiety disorders are your field of expertise. Tell us how you think the mental health system can better meet the needs of persons who suffer from these disorders. What concrete steps can system providers take to be informed better?
SAMHSA wants the ADAA to be our partner in transforming mental health care. Your membership has tremendous power, experience, and outreach. The research you conduct, the individuals you treat, the trainings you conduct—these all are opportunities to help create a mental health system that is consumer-driven, focused on recovery, and capable of building a person’s resilience to face life’s challenges.
I understand that the ADAA also has an award-winning Web site that receives five million hits per month! That’s five million opportunities a month to engage mental health professionals and the public in achieving the promise of mental health transformation.
Ultimately, mental health transformation is about transforming lives. It’s about our capacity to enable individuals with any mental illness to seek and find the best treatment options available. And it’s about hope—hope in recovery, hope in the future, and hope in a fulfilling life in the community for all Americans.
[SLIDE 13.
Vision]
And so, in observing your 25th anniversary, I urge you to consider how you can work toward the future envisioned by Achieving the Promise. This is a future “when everyone with a mental illness will recover, a future when mental illnesses can be prevented or cured, a future when mental illnesses are detected early, and a future when everyone with a mental illness at any stage of life has access to effective treatment and supports—essentials for living, working, learning, and participating fully in the community .”
Embrace this vision, for as George Washington Carver declared, “ Where there is no vision, there is no hope.” We―through a shared commitment to the vision and the promise of mental health transformation—can provide greater hope in recovery to millions of Americans with mental disorders. Thank you.
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