SAMHSA's FY' 2014 Budget: It is always instructive to review the budget priorities of those federal agencies which address the needs of our profession's beneficiaries. The Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA) noted that her FY' 2014 budget "prioritizes essential investments in mental health and substance abuse infrastructure and innovation as the nation comes to terms with its long-standing neglect of these public health issues. I believe this request reinforces SAMHSA's efforts to help the nation understand and act on the knowledge that behavioral health is essential to health – that emotional health and freedom from substance abuse are necessary for an individual, a family, a community or a nation to be healthy." Her total budget request is $3.572 billion, including $130 million to support the President's plan to protect America's children in the wake of the tragic events of December 14, 2012 in Newtown, Connecticut. Approximately $63 million is targeted for states to work with providers to increase enrollment and to maximize third party reimbursements for substance abuse and mental health services. An additional $21 million is to identify and bring to scale evidence-based practices to promote mental health and to prevent and treat mental illness. Funding is also requested to implement the National Strategy for Suicide Prevention and to begin a new program focused on trauma and women, Grants for Adult Trauma Screening and Brief Intervention. $130 million will ensure young people and the adults who work with them know how to recognize mental illness and find a clear pathway to care. This includes funding for Project AWARE (Advancing Wellness and Resilience in Education), providing Mental Health First Aid training, and fostering comprehensive state-school-community partnerships to prevent violence, promote mental health, and facilitate referrals to treatment.
The Administration firmly believes that individuals and families cannot be healthy without positive mental health, freedom from addiction, and the absence of abuse of substances. Prevention, treatment, and recovery support services for behavioral health are essential components of health service systems and community-wide strategies that work to improve health status and lower costs for individuals, families, businesses, and governments. The presence of substance abuse and mental illness exacerbates the cost of treating co-morbid physical diseases and results in some of the highest disability burdens in the world. SAMHSA's vision – * Behavioral Health is essential for health. *Prevention works. *Treatment is effective. And, * People recover from mental and substance use disorders. Being aware that the sense of shame and secrecy associated with mental illness and addiction prevents too many Americans from seeking help, President Obama directed the Secretaries of the Departments of Health and Human Services and Education to launch a national dialogue about mental illness with young people who have experienced mental illness, members of the faith community, foundations, and school and business leaders. SAMHSA collaborated with public and private partners to facilitate this National Dialogue on Mental Health in order to raise awareness and reduce negative attitudes. APA's Norman Anderson and Give An Hour's Barbara Van Dahlen were invited to participate in this historic White House Conference.
Barbara's Reflections: "On June 3 President Obama held an unprecedented event at the White House: a National Conference on Mental Health. The day-long gathering featured speeches by both the President and Vice President, as well as a series of panels – one of which, moderated by Secretary of Health and Human Services [HHS], Kathleen Sebelius, I had the honor of serving on. The attendees for the conference included members of consumer and advocacy groups, representatives of the major mental health associations (American Psychological Association, American Psychiatric Association, National Association of Social Workers), and several celebrities, including Glenn Close and Bradley Cooper, who came because they care about ending the stigma associated with mental illness. This was a premier event that took months to coordinate. It brought together all of the stakeholders – from within the government and from communities across the country – with the goal of raising our nation's consciousness about the mental health issues that affect one in four Americans. Oddly, while the White House was packed with TV cameras and journalists on June 3, the event itself received very little national coverage…. There has been no follow up and seemingly no interest about an issue that affects us all – directly or indirectly – at some point in our lives. According to the National Institute of Mental Health: * An estimated 26.2% of Americans ages 18 and older – about one in four adults – suffer from a diagnosable mental disorder in a given year. (And) * Mental disorders are the leading cause of disability in the United States and Canada."
One particularly exciting initiative in the SAMHSA budget highlights a program for which Senator Mark Begich introduced the authorizing legislation -- the Mental Health First Aid (MHFA) bill. MHFA helps the public identify, understand, and respond to the signs of mental illness and addiction disorders. Specifically, the program: teaches the warning signs and risk factors for schizophrenia, major clinical depression, panic attacks, anxiety disorders, trauma and other common mental disorders; teaches crisis de-escalation techniques and provides trainees with a 5-step action plan to help individuals in psychiatric crisis connect to professional mental health care. Since violence is not limited to college and school campuses, the audience for the training includes emergency services personnel and other first responders, police, human resource professionals, teachers and school administrators, faith leaders, parents, veterans, etc. Widespread dissemination of the Mental Health First Aid curriculum is expected to reach 750,000 individuals who work with youth, including how to talk to adolescents and families experiencing these problems so they are more willing to seek treatment. SAMHSA funding, combined with that from the Departments of Education and Justice, will be used to support competitive grants with the goal of making schools and communities safer and providing mental health literacy training, along the model of traditional First Aid projects for physical accidents.
Three of SAMHSA's strategic initiatives are closely aligned with APA priorities that Katherine Nordal has discussed at her annual State Leadership Conferences over the past several years. * Ensuring that the behavioral health system (including states, community providers, and peer and prevention specialists) fully participates with the general health care delivery system in the adoption of health information technology (HIT) and interoperable electronic health records (EHRs). * Realizing an integrated data strategy and a national framework for quality improvement in behavioral health care that will inform policy, measure program impact, and lead to improved quality of services and outcomes for individuals, families, and communities. And of special interest to APA President Don Bersoff, * Supporting America's service men and women – active duty, National Guard, Reserve, and veteran – together with their families and communities by leading efforts to ensure that needed behavioral health services are accessible and that outcomes are positive.
Having been supportive of the Minority Fellowship Program (MFP) since its inception in 1973, I was pleased to learn of SAMHSA's request for $5 million to provide stipends to graduate students in order to increase the number of culturally competent behavioral health professionals who would provide direct mental health and/or co-occurring substance abuse services to underserved minority populations. Currently minorities represent 30% of the nation's population and are projected to increase to 40% by 2025; yet only 23% of recent doctorates in psychology, social work, and nursing were awarded to peoples of color. SAMHSA intends to utilize the existing infrastructure of the MFP to expand the focus to support master's level trained behavioral health providers in the fields of psychology, social work, professional counseling, marriage and family therapy, and nursing and thereby increase the number of providers who are available to provide clinical services to the underserved, at-risk children, adolescents, and populations transitioning to adulthood, in an effort to increase access to, and the quality of, behavioral health services for this age group.
Change Always Takes Time: In 2006, the Institute of Medicine (IOM) released its report "Improving the Quality of Health Care for Mental and Substance-Use Conditions." The IOM concluded: "Improving our nation's general health and the quality problems of our general health care system depends upon equally attending to the quality problems in health care for mental and substance-use conditions…. Dealing equally with health care for mental, substance-use, and general health conditions requires a fundamental change in how we as a society and health care system think about and respond to these problems and illnesses. Mental and substance-use problems and illnesses should not be viewed as separate from and unrelated to overall health and general health care." Each year more than 33 million Americans use health care services for their mental and substance-use illness (M/SU). Treatment can be effective. M/SU problems and illnesses occur with a wide array of diagnoses and varied severity, with many people requiring only a short-term intervention to help them cope successfully. However, as with general health care, despite what is known about effective care for M/SU conditions, numerous studies have documented a discrepancy between M/SU care that is known to be effective and the care that is actually delivered. One landmark study demonstrated that people with alcohol dependency were found to receive care consistent with scientific knowledge only about 10.5% of the time. The IOM called on institutions of higher education to "facilitate the development and implementation of core competencies across all M/SU disciplines (and) place much greater emphasis on interdisciplinary didactic and experiential learning and bring together faculty and trainees from their various educational programs" – one of the underlying tenants of the Patient Protection and Affordable Care Act. Similarly, the Secretary of HHS should "provide leadership, strategic development support, and additional funding for research and demonstrations aimed at improving the quality of M/SU health care." The 21stcentury will be an era of patient-centered, interdisciplinary, integrated care which is significantly impacted by the unprecedented advances occurring within the communications and technology fields (i.e., EHRs and comparative effectiveness research) which readily allows cross-diagnostic, cross-population, and cross-provider objective comparisons.
Over the years, I have always wondered why it seems that even beneficial change takes so long to accomplish. Harvey Fineberg, President of the IOM, recently proffered a highly relevant and thoughtful observation in JAMA – "The Paradox of Disease Prevention: Celebrated in Principle, Resisted in Practice." "Why is prevention such a difficult sell? This puzzling question surfaces daily in clinical practice and public health, and it intrudes on policy makers wanting to make scientifically sound, evidence-based policy decisions. Because prevention is so deeply embedded in US culture, the relative neglect of preventive medicine seems paradoxical." This is a critical issue that Senator Inouye and his colleagues grappled with for over four decades. As the treatise notes, there are many possible explanations for prevention's low priority: future success is invisible, there is a lack of clinical drama, the long delay before concrete rewards appear, commercial conflicts of interest, and statistics have little emotional effect upon individual lives. Perhaps the key is that "incentives for prevention are often misaligned in a system designed to treat disease after it occurs. A key policy goal in health reform is to better align financial incentives with superior care, often including prevention. Too often still, the benefits of prevention do not accrue to the payer. Until incentives are aligned with health and not just diagnosis and treatment, true health care reform will be delayed…. In the end, prevention is truly worth the investment to make a difficult sell just a little easier and to put everyone on the road to a healthier future." Yet, as Barbara pointed out after the historic White House event, there is "seemingly no interest about an issue that affects us all – directly or indirectly – at some point in our lives." Without question, the SAMHSA FY' 2014 budget request is most timely.
Transformational Change: This spring, Lt. General Patricia Horoho, U.S. Army Surgeon General, testified before the U.S. House Appropriations Committee describing the Army Medicine story. "Since 1775, America's medical personnel have stood shoulder to shoulder with our fighting troops, received them at home when they returned, and stand ready today when called upon to put their lives on the line to care for our wounded Soldiers. While the wounds of war have been ours to mend and heal during a period of persistent conflict, every day our Soldiers and their Families are kept from injuries, illnesses, and combat wounds through our health promotion and prevention efforts; are treated in state-of-the-art fashion when prevention fails; and are served by an extraordinarily talented medical Force. We are at our best when we operate as part of a Joint Team. It is our collective effort – Army, Air Force, and Navy – that saves lives on the battlefield…. Our Army is charged with being prepared to face tomorrow's challenges, remaining relevant for the future ahead of us.
"The reality is that after more than a decade of war, our Military and our Nation face a time of significant changes and challenges. Army medicine is impacted by both the National healthcare conversation and the direction of the Military Health System…. The Army Medicine 2020 strategy is a Call to Action that contains the vision, strategic imperatives and way ahead for Army Medicine to move from a healthcare system to a System for Health…. By moving from a disease model to a health model, we can impact health on a National level. The health of the military and the health of the Nation are not separate discussions…. This is a Call to Action – Healthcare in the United States is at a turning point, and the Military Health System has an opportunity to lead the Nation away from the status quo.
"In 2012, the Army lost 183 soldiers to suicide. These tragic losses affect all those left behind, including fellow Soldiers, Families, and communities…. We must eliminate the perceived stigma of asking for help. This is not simply an issue isolated to the medical community to recognize and resolve…. Our challenge regarding military suicides is to move forward in a coordinated, multifaceted, and National approach. It will take a team effort…. Army Medicine is advancing a culture shift by encouraging every Professional Soldier to develop a mindset that drives them to optimize their own health in order to improve performance and resiliency. There must be an effective way to change mindsets, not just dictate behaviors. As Army Medicine continues to open the aperture, we must look at where health is truly influenced. Long term success in Army Medicine lies in our ability to effectively impact the 'Lifespace.' It is in the Lifespace where the choices we make impact our lives and our health. We understand the patient healthcare encounter to be an average interaction of 20 minutes, approximately five times a year…. The health of the Total Army is essential for readiness and prevention is the best way to health. Prevention – the early identification and mitigation of health risks through surveillance, education, training, and standardization of best public health practices – is critical to building and sustaining health and resiliency in Army populations and is the foundation for military success.
"Behavioral Health. The longest period of war in our Nation's history has undeniably led to physical, mental and emotional wounds to the men and women serving in the Army – and to their Families. The majority of our Soldiers have maintained resilience during this period. However, the stresses of increased operational tempo are evident in the increased demand for Behavioral Health Services and increased suicide rate…. While physical injuries may be easier to see, 'invisible wounds' such as mild traumatic brain injury, depression, anxiety, and post traumatic stress (PTS) also take a significant toll on our Service Members. And yet, to the individuals who suffer from these wounds, and those who care for them, they are anything but invisible. One of the most challenging areas of wartime medicine is PTS treatment. We have discovered that with the right treatment, most will go on to live productive, fulfilling lives. Military research shows that 15% of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans develop PTS. PTS is treatable; 80% of those with PTS have remained on Active Duty. Army Medicine continues to move the model of behavioral healthcare delivery outside of the brick and mortar MTFs [military treatment facilities] through behavioral health initiatives, such as Embedded Behavioral Health (EBH). We demonstrated success by looking at ways to bring healthcare and education to the foxhole, which allows us to increase accessibility, visibility, and ultimately trust, while decreasing the stigma and time spent away from the unit.
"Behavioral health problems, mild traumatic brain injury, and suicide, while often described as 'invisible wounds of war,' are not unique to a theatre of combat or to the military population – they are National issues. As a Nation, there are opportunities for us to partner and to lead the way in breaking the silence – to encourage those who struggle with behavioral health issues to receive help. The Army and Army Medicine are actively engaged in reducing stigma and upholding our responsibility to raise national awareness regarding mild traumatic brain injury and mental health conditions including PTSD. We anticipate the need for mental health services will only increase in the coming years as the Nation deals with the effects of more than a decade of conflict.
"We must never lose sight of the fact that the most important unit in the Army is the Family unit. Our Families, including those outside of the nuclear family setting, have demonstrated unprecedented strength and resilience, quietly shouldering the burdens of our Nation's wars…. Army Medicine is currently setting the conditions to better understand the Army Family both within and outside of conventional patient care settings. Impacting the Lifespace of our Army Families will not only improve the strength, performance, and readiness of the Soldier, but also establish an example for our Nation on a way forward to improve the health of communities…. Our military families – the children of our men and women in uniform – have a different story to tell compared to their peers outside of the military. I want the story of the military Family to resonate throughout the Nation's history as an example of resilience – demonstrating the powerful impact that can be felt when we invest not only in the Soldier, but in the individuals, old and young, who support our heroes." [General Horoho is the first woman and first non-physician to serve as DoD Surgeon General.]
Reflections on Retirement -- One of Psychology's True Visionaries: "HA! When I decide to retire, I will disappear. I have no desire to hang on past that time. My youngest graduated from medical school Saturday and he is headed to Emory University to begin his seven year neurosurgical residency. My oldest and her husband are both practicing physicians here in town (OB and ID respectively), my middle daughter was awarded her master's degree in nursing two weeks ago and is starting to teach in an RN program locally, and my youngest daughter is a master's degree social worker employed by one of the large general med-surg hospitals locally where she is the ICU/ER social worker. I will simply ride off into the sunset and turn everything over to the next generation (Jim Quillin)." Aloha,
Pat DeLeon, former APA President – Division 29 – August, 2013
