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S. HRG. 113–281 

ASSESSING THE STATE OF AMERICA’S MENTAL 

HEALTH SYSTEM 

HEARING 

BEFORE THE

COMMITTEE ON HEALTH, EDUCATION, 

LABOR, AND PENSIONS 

UNITED STATES SENATE 

ONE HUNDRED THIRTEENTH CONGRESS 

FIRST SESSION 

ON

EXAMINING THE STATE OF AMERICA’S MENTAL HEALTH SYSTEM 

JANUARY 24, 2013 

Printed for the use of the Committee on Health, Education, Labor, and Pensions 

( 

Available via the World Wide Web: http://www.gpo.gov/fdsys/ 
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS 

TOM HARKIN, Iowa, Chairman 

BARBARA A. MIKULSKI, Maryland 

PATTY MURRAY, Washington 

BERNARD SANDERS (I), Vermont 

ROBERT P. CASEY, JR., Pennsylvania 

KAY R. HAGAN, North Carolina 

AL FRANKEN, Minnesota 

MICHAEL F. BENNET, Colorado 

SHELDON WHITEHOUSE, Rhode Island 

TAMMY BALDWIN, Wisconsin 

CHRISTOPHER S. MURPHY, Connecticut 

ELIZABETH WARREN, Massachusetts 

LAMAR ALEXANDER, Tennessee 

MICHAEL B. ENZI, Wyoming 

RICHARD BURR, North Carolina 

JOHNNY ISAKSON, Georgia 

RAND PAUL, Kentucky 

ORRIN G. HATCH, Utah 

PAT ROBERTS, Kansas 

LISA MURKOWSKI, Alaska 

MARK KIRK, Illinois 

TIM SCOTT, South Carolina 

PAMELA J. SMITH, Staff Director, Chief Counsel 

LAUREN MCFERRAN, Deputy Staff Director 

DAVID P. CLEARY, Republican Staff Director 

(II) 
C O N T E N T S 

STATEMENTS 

THURSDAY, JANUARY 24, 2013 

Page 

COMMITTEE MEMBERS

Harkin, Hon. Tom, Chairman, Committee on Health, Education, Labor, and 

Pensions, opening statement ............................................................................... 1 

Alexander, Hon. Lamar, a U.S. Senator from the State of Tennessee, opening 

statement .............................................................................................................. 3 

Murray, Hon. Patty, a U.S. Senator from the State of Washington ................... 21 

Enzi, Hon. Michael B., a U.S. Senator from the State of Wyoming .................... 23 

Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin .................. 25 

Murkowski, Hon. Lisa, a U.S. Senator from the State of Alaska ........................ 26 

Franken, Hon. Al, a U.S. Senator from the State of Minnesota .......................... 28 

Mikulski, Hon. Barbara A., a U.S. Senator from the State of Maryland ............ 30 

Sanders, Hon. Bernard, a U.S. Senator from the State of Vermont ................... 31 

Warren, Hon. Elizabeth, a U.S. Senator from the State of Massachusetts ........ 33 

Bennet, Hon. Michael F., a U.S. Senator from the State of Colorado ................. 35 

WITNESSES—PANEL I 

Hyde, Pamela, J.D., Administrator, Substance Abuse and Mental Health 

Services Administration, Rockville, MD ............................................................. 5 

Prepared statement .......................................................................................... 7 

Insel, Thomas, M.D., Director, National Institute of Mental Health at the 

National Institutes of Health, Bethesda, MD .................................................... 13 

Prepared statement .......................................................................................... 15 

WITNESSES—PANEL II 

Hogan, Michael, Ph.D., Former Commissioner, New York State Office of 

Mental Health, and Chairman, President’s New Freedom Commission on 

Mental Health, Delmar, NY ................................................................................ 37 

Prepared statement .......................................................................................... 38 

Vero, Robert N., Ed.D., Chief Executive Officer, Centerstone of Tennessee, 

Nashville, TN ....................................................................................................... 44 

Prepared statement .......................................................................................... 46 

DelGrosso, George, M.A., Executive Director, Colorado Behavioral Health 

Council, Denver, CO ............................................................................................ 52 

Prepared statement .......................................................................................... 54 

Fricks, Larry, Senior Consultant, National Council for Behavioral Health, 

Cleveland, GA ....................................................................................................... 55 

Prepared statement .......................................................................................... 57 

(III) 
Page

IV 

ADDITIONAL MATERIAL 

Statements, articles, publications, letters, etc.: 

Senator Casey ................................................................................................... 72 

Response by Pamela Hyde, J.D. to questions of: 

Senator Alexander ..................................................................................... 72 

Senator Mikulski ....................................................................................... 75 

Senator Murray ......................................................................................... 77 

Senator Casey ............................................................................................ 78 

Senator Bennet .......................................................................................... 79 

Senator Enzi .............................................................................................. 80 

Response by Thomas Insel, M.D. to questions of: 

Senator Alexander ..................................................................................... 81 

Senator Mikulski ....................................................................................... 82 

Senator Casey ............................................................................................ 83 

Senator Enzi .............................................................................................. 84 

Response by Michael Hogan, Ph.D. to questions of: 

Senator Alexander ..................................................................................... 85 

Senator Mikulski ....................................................................................... 85 

Senator Casey ............................................................................................ 86 

Senator Enzi .............................................................................................. 86 

Response by Robert N. Vero, Ed.D. to questions of: 

Senator Alexander ..................................................................................... 87 

Senator Mikulski ....................................................................................... 89 

Senator Casey ............................................................................................ 90 

Senator Enzi .............................................................................................. 92 

Response by George DelGrosso to questions of: 

Senator Alexander ..................................................................................... 95 

Senator Casey ............................................................................................ 96 

Senator Enzi .............................................................................................. 96 

Response by Larry Fricks to questions of: 

Senator Alexander ..................................................................................... 98 

Senator Mikulski ....................................................................................... 98 

Senator Casey ............................................................................................ 98 

Senator Enzi .............................................................................................. 99 
(1) 

ASSESSING THE STATE OF AMERICA’S 

MENTAL HEALTH SYSTEM 

THURSDAY, JANUARY 24, 2013 

U.S. SENATE, 

COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS, 

Washington, DC. 

The committee met, pursuant to notice, at 10:02 a.m., in Room 

SD–430, Dirksen Senate Office Building, Hon. Tom Harkin, chairman of the committee, presiding. 

Present: Senators Harkin, Mikulski, Murray, Sanders, Franken, 

Bennet, Whitehouse, Baldwin, Murphy, Warren, Alexander, Enzi, 

and Murkowski. 

OPENING STATEMENT OF SENATOR HARKIN

The CHAIRMAN. The Senate Committee on Health, Education, 

Labor, and Pensions will please come to order. 

My first order of business this morning is to extend a warm welcome to our committee’s new members, in alphabetical order, Senator Tammy Baldwin, Senator Chris Murphy, Senator Tim Scott, 

and Senator Elizabeth Warren. This is a remarkably talented 

group of freshmen Senators, and we’re glad to have them on board. 

I know that some are also over at Senator Kerry’s hearing to be 

Secretary of State starting at the same time. 

I also want to salute our new Ranking Member, Senator Alexander. He has long been a valuable member of this committee. I 

have appreciated my relationship with the former Ranking Member, Senator Enzi, and I look forward to the same kind of close collaboration and partnership with my good friend, Senator Lamar 

Alexander. 

Today our committee will examine a range of issues surrounding 

mental healthcare in this country. The tragic shooting in Newtown, 

CT, last month brought the issue of mental healthcare to the forefront of public dialog. Many people across the Nation, including the 

President, have said that we need to take a long, hard look at access to mental health services across the country. 

I am pleased to have this opportunity today to start that dialog 

with my colleagues and our panel of expert witnesses. I am told 

this is the first hearing that this committee of jurisdiction has had 

on this issue since 2007. So it’s long overdue. 

Certainly, one of the most insidious stereotypes about people 

with mental illness is that they are inherently violent. I regret that 

some of the discussion in the wake of the Newtown tragedy has 

sadly reinforced this stereotype. As my fellow committee members 
2 

know and our witnesses and experts know, people with mental illness are much more likely to be the victims of violent crimes than 

they are to be perpetrators of acts of violence. 

Mental health conditions are sometimes called the Nation’s silent 

epidemic. Mental illness affects one in four Americans every year. 

But, despite its prevalence, there is still a stigma attached with 

mental illness, and that stigma results in too many people suffering in silence without access to the care that could significantly 

improve their lives. 

Stigma also can stop workers from requesting and getting accommodations that can help them be more productive at work. I’ve 

known so many instances of people who were afraid to do anything 

because they might lose their job or they wouldn’t get promoted because of that stigma that’s attached. 

Like many other chronic diseases, mental health problems often 

begin at a young age. Experts tell us that half of all mental illness 

is manifested by age 14. However, less than half of children with 

an identified mental health condition receive treatment. And the 

average lag time from the first onset of symptoms to receiving 

treatment is almost a decade. Unfortunately, the picture for adults 

seeking treatment is not much better. 

This lack of treatment has huge consequences. Some 30,000 

Americans die by suicide each year. And it’s a shocking fact that 

people with serious mental illnesses die significantly earlier than 

Americans overall, often from treatable causes like diabetes and 

smoking related chronic conditions. 

These consequences also spill into other areas. As any teacher or 

school counselor will tell you, a child who is struggling with depression, anxiety, or any other mental health condition is also likely to 

struggle academically. 

It’s also an issue for our justice system since our prisons too 

often become the dumping ground for people who should be receiving mental health and substance abuse counseling instead. I have 

had a number of sheriffs in my own State, as well as other States, 

tell me that their jails are now the de facto mental institutions in 

their States. 

The shame in this is that with access to the right treatments and 

supports, most people with mental illness can recover and lead productive and healthy lives. But we need to make the critical investments that will enable this to happen. So wearing my other hat as 

the chairman of the Labor, Health and Human Services, and Education Appropriations Subcommittee, I plan to take a close look at 

funding opportunities in this area through the appropriations process. 

We’ve made important steps forward in recent years. My friend, 

the late Senator Paul Wellstone, and, again, along with my friend, 

Senator Pete Domenici, fought for years to try to enact the Mental 

Health Parity Act to end the absurd practice of treating mental 

and physical illnesses as two different things under health insurance. We finally passed it in 2008. 

However, I am sad to say that it has been 4 years, 4 years now, 

that we do not have any final rules on implementing this law. 

That’s a shame. I am told the President said that they will be announcing a final rule soon. I don’t know what soon means, but I 
3 

hope it means what we generally take it to mean, which means 

soon. 

Another critical step will take place next year when, thanks to 

the Affordable Care Act, some 30 million Americans will become eligible for Medicaid or private insurance through the healthcare exchanges. Coverage of mental health and substance abuse disorder 

services is 1 of the 10 essential benefits required in qualified health 

plans. 

The insurance expansion here offers both challenges and opportunities. Experts predict that the newly insured population will 

have a greater need for mental health coverage than the general 

population. As we think about how to meet this need, there is an 

opportunity to realign our healthcare system to better integrate 

primary care and mental health services. And in reading over the 

testimony last evening of our witnesses, many of our witnesses 

spoke about that, this integration of primary care and mental 

health services. 

This committee, I think, on both sides have been very supportive 

of the expansion of community health centers throughout the 

United States. They’ve been a great addition. They’re wonderful 

primary care providers. But how do we integrate mental healthcare 

services in with those community health centers and make sure it’s 

part of primary care? 

President Kennedy signed the Community Mental Health Act of 

1963, 50 years ago, which led to a major shift in mental healthcare 

in this country. People who were warehoused in institutions moved 

back into their communities. But the results were mixed. Many 

people were not able to access the community-based services and 

treatments they needed. So as we face major new changes in the 

healthcare landscape, I hope we’ll learn from these lessons and, as 

I said, see how we might more fully utilize the community health 

center system in America to integrate primary care and mental 

health services. 

So today we’ll hear from a panel of expert witnesses who will 

talk about mental healthcare from a variety of perspectives, all 

with the goal, I hope, of addressing this critical but often neglected 

public health issue. I want to reemphasize that in my own words— 

public health issue. 

So I thank you all for being here. I look forward to your testimony, and I’ll yield to our Ranking Member, Senator Alexander. 

OPENING STATEMENT OF SENATOR ALEXANDER

Senator ALEXANDER. Thanks, Mr. Chairman. Thanks for your 

courtesy. I look forward to working with you. We’ve worked well together in the past. This is a very important committee with a large 

jurisdiction, and I am delighted to have a chance to be the Ranking 

Member. 

I want to say to Senator Enzi how much I appreciate his leadership, and we expect it to continue as time goes along. 

I also want to thank the chairman for having this hearing in the 

way he’s having the hearing. We’re entering this discussion, so far 

as I’m concerned—and that’s my sense of the chairman’s attitude— 

with no agenda other than to learn what needs to be done. As the 
4 

chairman said, we haven’t had a mental health hearing for a while, 

so I’m here to do a lot of listening. 

I was saying to some of the witnesses before the hearing that 

when I was U.S. Education Secretary, I often sat in their shoes, 

and I remember going back and telling the people in the Department that I thought I was going to a hearing, but, in fact, it was 

a talking, because the Senators did all the talking, and the witnesses did most of the listening. So I hope this will be more of a 

hearing instead of a talking, and I’ll try to do my best to make it 

that way. 

It seems to me that the question before us is: Who needs help, 

and who’s there to provide the help? If we can hone in on that 

question and see what the Federal Government can do to improve 

our ability to determine who needs help and our ability to identify 

the person or agency whose job it is to provide the help, then we 

will have provided some service. 

It helps to put a face on who needs help. As a former Governor, 

I always look at things from my own background and perspective, 

as I know most of us do. About 22 percent of Tennesseans reported 

having a mental illness last year. That’s more than a million people. This is according to our State’s Department of Mental Health. 

About 5 percent had a severe mental illness. That’s nearly a quarter of a million Tennesseans. So that’s a lot of people. About 41,000 

Tennesseans had a major depressive episode. 

The funding that helps meet the needs for that comes in some 

part from the Federal Government. About 22 percent of what Tennessee spends, I’m told, is Federal dollars. The rest is State dollars. 

In the community services, State appropriations are about 70 percent of the mental health funds. So while the Federal Government 

has a role here, it’s a support role and a supplementary role, and 

it’s a role that ought to make things easier instead of harder. 

In preparing for this, it seems to me that, putting a face on the 

individuals who need help, one group would be a 9-year-old boy 

who has always been pleasant but suddenly started defying his 

teachers. His grades slipped, and he didn’t want to go to Boy 

Scouts. He didn’t want to play with friends. So they reached out 

to a pediatrician who was able to get some professional assistance. 

He was diagnosed with a mood disorder and he began to improve 

with sleeping better. And so it was a success story for that 9-yearold boy. 

Another case might be an adolescent, a 17-year-old, who had no 

behavioral issues growing up. He started noticing lights in the 

bathroom. Sounds of water irritated him. He had trouble sleeping. 

He began to hear voices telling him to throw rocks at anyone who 

told him to come down from the roof. And he was finally diagnosed 

with schizophrenia, but only after he had multiple episodes. 

Those two boys represent two of the largest groups that need 

help. And I’ll be interested in finding out from our witnesses how 

well we’re doing in helping them get the help. 

Finally, I’ll be especially interested in asking the Federal agencies as well as the State and local witnesses who are here what we 

can do at the Federal level to make things easier to, No. 1, identify 

who needs help, and, No. 2, identify who can provide the help. Are 

there administrative things we can do? Are there funding things 
5 

we can do? Are we putting up any roadblocks that make it harder 

for you to provide services? If we are, this is the place to identify 

them and see if we can correct them. 

So, Mr. Chairman, I look forward to this. I thank you for holding 

the hearing. 

The CHAIRMAN. Thank you very much, Senator Alexander. 

Now we’ll turn to our witnesses. We have two panels. On our 

first panel, we’ll start with Pamela S. Hyde, the Administrator of 

the Substance Abuse and Mental Health Services Administration, 

obviously known as SAMHSA to all of us. Ms. Hyde was nominated 

by President Obama and confirmed by the U.S. Senate in November 2009 as the Administrator of SAMHSA. She is an attorney and 

comes to SAMHSA with more than 30 years of experience in management and consulting for public healthcare and human service 

agencies. 

She has served as a State mental health director, State human 

services director, city housing and human services director, as well 

as CEO of a private, nonprofit-managed behavioral health firm. 

Ms. Hyde is a member of or has served as a consultant to many 

national organizations, including the John D. and Catherine T. 

MacArthur Foundation, the American College of Mental Health Administration, the President’s New Freedom Commission on Mental 

Health, and the U.S. Department of Justice. 

Our second witness on this panel, of course, is no stranger to this 

committee, or at least to my Appropriations Subcommittee. Dr. 

Thomas Insel, who is the Director of the National Institute of Mental Health, NIMH, at the National Institutes of Health. He has 

been director since the fall of 2002. Prior to that, Dr. Insel was a 

professor of psychiatry at Emory University, and there he was the 

founding director of the Center for Behavioral Neuroscience, one of 

the largest science and technology centers funded by the National 

Science Foundation. 

He has published over 250 scientific articles and four books, including The Neurobiology of Parental Care in 2003. He is a member 

of the Institute of Medicine, a fellow of the American College of 

Neuropsychopharmacology—there, I said it—and is a recipient of 

several awards, including the Outstanding Service Award from the 

U.S. Public Health Service. 

We thank you both for your backgrounds, for what you have done 

in this whole area of mental health both in research and practicality. And your statements will be made a part of the record in 

their entirety. We’ll start with Ms. Hyde. I would ask that you sum 

it up in 5 to 8 minutes, and then we’ll get to some questions. 

Again, welcome. 

Ms. Hyde, please proceed. 

STATEMENT OF PAMELA HYDE, J.D., ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION, ROCKVILLE, MD 

Ms. HYDE. Thank you, Chairman Harkin and Ranking Member 

Alexander, for holding this hearing today. It’s an important day. 

You will hear today about the prevalence and burden of mental 

illness and about the critical need in our country for understanding, treatment, and support services for those who experience 
6 

mental health conditions. SAMHSA’s mission is to reduce the impact of both substance abuse and mental illness in America’s communities, and there is significant overlap between those two sets 

of conditions. They currently exist largely outside the mainstream 

of American healthcare, with different histories, structures, funding, incentives, practitioners, and even, in some cases, different 

governing laws. 

It’s time that changed. SAMHSA envisions a nation that understands and acts on the knowledge that behavioral health is really 

essential to health, that mental and emotional health and freedom 

from substance abuse and addiction are necessary for an individual, a family, or a community to be healthy. 

As the Senator said, almost half of all Americans will experience 

symptoms of mental or substance abuse disorders in their lifetime, 

and yet of the over 45 million adults with any mental illness in a 

given year, only 38.5 percent of them receive the treatment they 

need. And of the almost 22 million adults with substance abuse disorders, only about 11 percent receive the treatment they need. For 

children and adolescents, it’s only about one in five that receive the 

treatment they need for diagnosable mental disorders. 

Cost, access, and recognition of the problems are the primary 

reasons this treatment is not received. However, it doesn’t have to 

be this way. For most of these conditions, prevention works, treatment is effective, and people do, in fact, recover. As Senator Harkin 

said, the Institute of Medicine reported in 2009 that half of adult 

mental illness begins before the age of 14 and three-quarters before 

the age of 24. 

We can and must intervene early to address these issues for our 

young people and for our Nation. Behavioral health is a public 

health issue, not a social issue, and it can be tackled and addressed 

in an effective public health approach driven by data focused on 

prevention and supportive policies and services that treat and restore to health. 

I’d like to talk about the Affordable Care Act for just a minute, 

because it’s going to provide one of the largest expansions of mental health and substance abuse coverage in a generation by helping 

over 65 million Americans have access to additional behavioral 

health benefits that they do not have now. The ACA has already 

provided screening for depression, suicide risk, and alcohol misuse 

in many service programs and in its quality measures, and it has 

already provided additional coverage opportunities for youth. It will 

ensure that insurance plans offered in the new marketplaces cover 

mental and substance abuse disorders at parity with other benefits 

and as 1 of the 10 essential health benefit categories. 

As part of the President’s plan to protect our children and our 

communities, he outlines some specific actions and initiatives. To 

help ensure adequate coverage of mental health and addiction services, the Administration issued a letter to State health officials 

making it clear that Medicaid expansion plans must comply with 

the parity requirements of the Mental Health Parity and Addictions Equity Act of 2008, or what we call MHPAEA. 

In addition, the Administration will issue final regulations governing how existing health plans that offer mental health and addiction services must cover them at parity under MHPAEA. The 
7 

1Monahan J., Steadman H., Silver E., ET al: Rethinking Risk Assessment: The MacArthur 

Study of Mental Disorder and Violence. New York, Oxford University Press, 2001 and Swanson, 

1994. 

President’s initiatives to ensure students and young adults receive 

treatment for mental health issues include SAMHSA-led proposals 

such as a new program called Project Aware, which would bring together State officials, schools, communities, families, and youth to 

promote safety, prevent violence, and to identify mental and behavioral health conditions early and refer young people to treatment. 

Project Aware would also provide mental health first aid training. 

A proposed new grant program, Healthy Transitions, would provide a pilot to model innovative State and community-based initiatives and strategies supporting young people ages 16 to 25. Along 

with HRSA, the President’s workforce proposal would provide 

training for more than 5,000 additional mental health professionals 

to serve students and young adults. 

Finally, with the Department of Education, HHS will soon 

launch what we’re calling a national dialog on mental health to 

help change the conversation and galvanize action about our children’s mental health. 

We’ve come a long way in the prevention, treatment, and recovery supports for mental and addictive disorders. But we have a 

long way to go, and we can do better. 

Thank you for your time today, and I’d be very pleased to answer 

any questions that you may have. 

[The prepared statement of Ms. Hyde follows:] 

PREPARED STATEMENT OF PAMELA S. HYDE, J.D. 

Chairman Harkin, Ranking Member Alexander and members of the Senate 

Health, Education, Labor, and Pensions Committee, thank you for inviting me to 

testify at this important hearing on the state of the mental health system. I am 

pleased to testify along with Dr. Insel on the state of America’s mental health system and to discuss some of the initiatives related to mental health included in the 

President’s plan to protect our children and our communities. 

THE SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION (SAMHSA)

As you are aware, the Substance Abuse and Mental Health Services Administration’s (SAMHSA) mission is to reduce the impact of substance abuse and mental illness on America’s communities. SAMHSA envisions a Nation that acts on the 

knowledge that: 

• Behavioral health is essential for health; 

• Prevention works; 

• Treatment is effective; and 

• People recover from mental and substance use disorders. 

In order to achieve this mission, SAMHSA has identified eight Strategic Initiatives to focus the Agency’s work on improving lives and capitalizing on emerging 

opportunities. SAMHSA’s top Strategic Initiatives are: Prevention; Trauma and Justice; Health Reform; Military Families; Recovery Supports; Health Information 

Technology; Data, Outcomes and Quality; and Public Awareness and Support. 

PREVALENCE OF BEHAVIORAL HEALTH CONDITIONS AND TREATMENT

In the wake of the Newtown tragedy, it is important to note that behavioral 

health research and practice over the last 20 years reveal that most people who are 

violent do not have a mental disorder, and most people with a mental disorder are 

not violent.1 Studies indicate that people with mental illnesses are more likely to 
8 

2 Appleby, L., Mortensen, P.B., Dunn, G., & Hiroeh, U. (2001). Death by homicide, suicide, and 

other unnatural causes in people with mental illness: a population-based study. The Lancet, 358, 

2110–12. 3 Elbogen, E.B., Johnson, S.C. Arch Gen Psychiatry. 2009 Feb;66(2):152–61. doi: 10.1001/ 

archgenpsychiatry.2008.537. 

The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. 4 Unmet Need for Mental Health Care Among U.S. Children: Variation by Ethnicity and Insurance Status. 

Sheryl H. Kataoka, M.D., M.S.H.S.; Lily Zhang, M.S.; Kenneth B. Wells, M.D., M.P.H., Am 

J Psychiatry 2002;159:1548–55. 10.1176/appi.ajp.159.9.1548. 5Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H–45, HHS 

Publication No. (SMA) 12–4725. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2012. 6Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., & Walters, E.E. (2005). 

Lifetime prevalence and age-of-onset distributions of DSM–IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–602. 

be the victims of violent attacks than the general population.2 In fact, demographic 

variables such as age, gender and socioeconomic status are more reliable predictors 

of violence than mental illness.3 These facts are important because misconceptions 

about mental illness can cause discrimination and unfairly hamper the recovery of 

the nearly 20 percent of all adult Americans who experience a mental illness each 

year. 

It is estimated that almost half of all Americans will experience symptoms of a 

mental health condition—mental illness or addiction—at some point in their lives. 

Yet, today, less than one in five children and adolescents with diagnosable mental 

health problems receive the treatment they need.4 And according to data from 

SAMHSA’s National Survey on Drug Use and Health (NSDUH), only 38 percent of 

adults with diagnosable mental health problems—and only 11 percent of those with 

diagnosable substance use disorders—receive needed treatment.5

With respect to the onset of behavioral health conditions, half of all lifetime cases 

of mental and substance use disorders begin by age 14 and three-fourths by age 24.6

When persons with mental health conditions or substance use disorders do not receive the proper treatment and supportive services they need, crisis situations can 

arise affecting individuals, families, schools, and communities. We need to do more 

to identify mental health and substance abuse issues early and help individuals get 

the treatment they need before these crisis situations develop. And we need to help 

communities understand and implement the prevention approaches we know can be 

effective in stopping issues from developing in the first place. 

The President’s announcement includes several important steps to help address 

mental health prevention and treatment. I look forward to the opportunity to discuss these with you. 

MENTAL HEALTH FINANCING

First, however, I will provide some background on mental health financing. The 

National Expenditures for Mental Health Services and Substance Abuse Treatment 

report for 1986–2005 found that $113 billion was spent on mental health and $22 

billion for substance abuse services in 2005. SAMHSA is in the process of updating 

this data. In 2005, spending on mental health services accounted for 6.1 percent of 

all-health spending. Public payers accounted for 58 percent of mental health spending and 46 percent of all-health spending. Medicaid (28 percent of mental health 

spending) and private insurance (27 percent of mental health spending) accounted 

for more than half of mental health spending in 2005, followed by other State and 

local government at 18 percent, Medicare at 8 percent, out-of-pocket at 12 percent, 

other Federal at 5 percent and other private sources at 3 percent. 
9 

7The National Association of State Mental Health Program Directors (NASMHPD). Too Significant To Fail: The Importance of State Behavioral Health Agencies in the Daily Lives of Americans with Mental Illness, for Their Families, and for Their Communities. Alexandria, VA. 2012. 

The National Expenditures report also found prescription drugs accounted for the 

largest share of mental health spending in 2005—27 percent. Mental health drug 

spending grew by an average of 24 percent a year between 1997 and 2001. After 

2001, growth slowed dramatically, to an average rate of 10 percent a year between 

2001 and 2005. 

A key source of funding for services for adults with serious mental illness (SMI) 

and children with severe emotional disturbances (SED) is the Community Mental 

Health Services Block Grant (MHBG), which is a flexible funding source that is 

used by States to provide a range of mental health services described in their plans 

for comprehensive community-based mental health services for children with serious 

emotional disturbance and adults with serious mental illness. These funds are used 

to support service delivery through planning, administration, evaluation, educational activities, and services. Services include rehabilitation services, crisis stabilization and case management, peer specialist and consumer-directed services, 

wrap around services for children and families, supported employment and housing, 

jail diversion programs, and services for special populations. The State plan is developed in collaboration with the State mental health planning councils. Planning 

Councils’ membership is statutorily mandated to include consumers, family members of adult and child consumers, providers, and representatives of other principal 

State agencies. The fiscal year 2013 President’s budget proposed $460 million to 

continue the MHBG. 

SAMHSA also administers the Substance Abuse Prevention and Treatment Block 

Grant (SABG) for the States. The fiscal year 2013 President’s budget proposed $1.4 

billion for the SABG, and $400 million for primary prevention of substance abuse. 

According to the National Association of State Mental Health Program Directors, 

over the past few years, States and communities have significantly reduced funding 

for mental health and addiction services. They estimate that in the last 4 years, 

States have cut $4.35 billion in mental health services, while an additional 700,000 

people sought help at public mental health facilities during this period.7 These 

changes have occurred despite the evidence that early treatment and prevention for 
10 

8 National Research Council. Preventing Mental, Emotional, and Behavioral Disorders Among 

Young People: Progress and Possibilities. Washington, DC: The National Academies Press, 2009. 9See e.g., Egede, L.E., Zheng, D., & Simpson, K. (2002). Comorbid depression is associated 

with increased health care use and expenditures in individuals with diabetes. Diabetes Care, 

25(3), 464–470. 10 New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental 

Health Care in America. Final Report. DHHS Pub. No. SMA–03–3832. Rockville, MD: 2003. 

mental illness and substance use programs can reduce health costs, criminal and 

juvenile justice costs, and educational costs, and increase productivity.8

Additionally, investments in these programs and services can help reduce physical 

health costs for those with co-morbid health and behavioral health conditions.9

Some States have found that providing adequate mental health and addiction-treatment benefits can dramatically reduce health care costs and Medicaid spending. 

ADVANCEMENTS AND TRENDS IN BEHAVIORAL HEALTH

Community-Based Care 

In 1963, President John F. Kennedy signed into law the Mental Retardation Facilities and Community Mental Health Centers Construction Act. The Act led to a 

drastic alteration in the delivery of mental health services and establishment of 

more than 750 comprehensive community mental health centers throughout the 

country. This movement to community-based services helped to reduce the number 

of individuals with mental illness who were ‘‘warehoused’’ in secluded hospitals and 

isolated institutions. Other advancements in the treatment of mental illness and the 

growth of the recovery movement, along with other programs such as supportive 

housing, assertive community treatment teams, peer specialists, supportive employment, and social security disability payments, have helped provide the services and 

supports necessary for persons with serious mental illness to survive and thrive in 

the community. Experience and research has shown that the goal of recovery is exemplified through a life that includes: Health; Home; Purpose and Community.10

Peers play an important role in recovery support and the consumer movement has 

helped promote not only the idea that recovery is possible, but also those consumers 

should play a key role in their recovery. SAMHSA’s Recovery Support Initiative 

partners with people in recovery from mental and substance use disorders and family members to guide the behavioral health system and promote individual-, program-, and system-level approaches that foster health and resilience; increase permanent housing, employment, education, and other necessary supports; and reduce 

discriminatory barriers. 

Integration 

Given that behavioral health is essential to an individual’s overall health, 

SAMHSA administers the Primary and Behavioral Health Care Integration 

(PBHCI) program. The purpose of the program is to improve the physical health status of people with serious mental illnesses (SMI) by supporting communities to coordinate and integrate primary care services into publicly funded community mental 

health and other community-based behavioral health settings. The program supports community-based behavioral health agencies’ efforts to build the partnerships 

and infrastructure needed to initiate or expand the provision of primary healthcare 

services for people in treatment for SMI and co-occurring SMI and substance use 

disorders. It is a program focused on increasing the health status of individuals 

based on physical or behavioral need. The program encourages structural changes 

in existing systems to accomplish its goals. To date, the program has awarded 94 

grants and 55 percent of awardees are partnering with at least one Federally Qualified Health Center (FQHC). This integration results in significant physical and behavioral health gains. PBHCI grantees collect data on patients at admission and in 

followup reassessments every 6 months, as well as at discharge when possible. Some 

results that are based on grantee-reported outcome measures from February 2010 

through January 7, 2013, include: 

• Health: The percentage of consumers who rated their overall health as positive 

increased by 20 percent from baseline to most recent reassessment (N=3737). 

• Tobacco Use: The percentage of consumers who reported they were not using 

tobacco during the past 30 days increased by 6 percent from baseline to most recent 

reassessment (N=3787). 

• Illegal Substance Use: The percentage of consumers who reported that they 

were not using an illegal substance during the past 30 days increased by 12 percent 

from baseline to most recent reassessment (N=3568). 
11 

11 Center for Substance Abuse Treatment. Systems Integration. COCE Overview Paper 7. 

DHHS Publication No. (SMA) 07–4295. Rockville, MD: Substance Abuse and Mental Health 

Services Administration, and Center for Mental Health Services, 2007. 

• Blood pressure (categorical): Among 7,493 clients, 18.3 percent showed improvement, and 16.7 percent are no longer at risk for high blood pressure (systolic less 

than 130, diastolic less than 85). 

• BMI: Among 7,120 clients, 45.6 percent showed improvement, and 4.8 percent 

are no longer at risk for being overweight (BMI less than 25). 

Service systems that are aligned with patient and client need, specifically those 

providing integrated treatment, produce better outcomes for individuals with cooccurring mental and substance use disorders.11 Without integrated treatment, one 

or both disorders may not be addressed properly. Mental health and substance 

abuse authorities across the country are taking steps to integrate systems and services, and promote integrated behavioral health treatment. Currently, there are 35 

States that have a combined mental health and substance abuse authority. In addition, at least two additional States and the District of Columbia are moving toward 

a single agency. 

SAMHSA continues to work with both States and grantees to encourage systems 

collaboration and coordination to develop mental health and substance abuse systems that support seamless service delivery. SAMHSA’s effort to integrate primary 

care and mental health and substance abuse services offers a promising, viable, and 

efficient way of ensuring that people have access to needed behavioral health services. Additionally, behavioral health care delivered in a primary care setting can 

help to minimize discrimination and reduce negative attitude about seeking services, while increasing opportunities to improve overall health outcomes. Leadership 

supporting this type of coordinated quality care requires the support of a strengthened behavioral health and primary care delivery system as well as a long-term policy commitment. 

Mental Health Parity and Addiction Equity Act (MHPAEA) 

In 2008, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) became law. MHPAEA improves access to much-needed 

mental and substance use disorder treatment services through more equitable coverage. The law applied to large group health plans (sponsored by employers with 

more than 50 employees) and health insurance issuers that offered coverage in the 

large group market. The law requires that plans and issuers that offer coverage for 

mental illness and substance use disorders provide those benefits in a way that is 

no more restrictive than the predominant requirements or limitations applied to 

substantially all medical and surgical benefits covered by the plan. 

Affordable Care Act 

The Affordable Care Act advances the field of behavioral health by expanding access to behavioral health care; growing the country’s behavioral health workforce; 

reducing behavioral health disparities; and implementing the science of behavioral 

health promotion. 

While most mental illnesses and addictions are treatable, those with mental illness often cannot get needed treatment if they do not have health insurance that 

covers mental health services. The Affordable Care Act will provide one of the largest expansions of mental health and substance abuse coverage in a generation by 

extending health coverage to over 30 million Americans, including an estimated 6 

to 10 million people with mental illness. It also includes coverage for preventive 

services, including screening for depression and alcohol misuse. The Affordable Care 

Act will also make sure that Americans can get the mental health treatment they 

need by ensuring that insurance plans in the new Marketplaces cover mental health 

and substance abuse benefits at parity with other benefits. Beginning in 2014, all 

new small group and individual plans will cover mental health and substance use 

disorder services, including behavioral health treatment. 

Medicaid is already the largest payer of mental health services, and the Affordable Care Act will extend Medicaid coverage to as many as 17 million hardworking 

Americans. 

SAMHSA’s No. 1 strategic initiative is Prevention of Substance Abuse and Mental 

Illness, and the Agency has also been heavily engaged in the implementation of the 

prevention and public health promotion provisions of the Affordable Care Act. For 

example, the National Prevention Strategy includes priorities focused on Mental and 

Emotional Well-Being and Preventing Drug Abuse and Excessive Alcohol Use. 
12 

MOVING FORWARD

Moving forward, in the wake of the tragedy in Newtown, CT, the Administration 

is focused on making sure that students and young adults get treatment for mental 

health issues. At the same time, SAMHSA knows that a larger national dialogue 

about mental health in America needs to occur and we will be taking steps to foster 

this dialog. 

Parity 

The Administration intends to issue next month the Final Rule on defining essential health benefits and implementing requirements for new small group and individual plans to cover mental health benefits at parity with medical and surgical 

benefits. In addition, the President announced that the Administration is committed 

to promulgating a MHPAEA Final Rule. 

Last week, the Centers for Medicare and Medicaid Services sent a State Health 

Official Letter regarding the applicability of MHPAEA to Medicaid non-managed 

care benchmark and benchmark-equivalent plans (referred to in this letter as Medicaid Alternative Benefit plans) as described in section 1937 of the Social Security 

Act (the Act), the Children’s Health Insurance Programs (CHIP) under title XXI of 

the Act, and Medicaid managed care programs as described in section 1932 of the 

Act. 

Reaching Youth and Young Adults 

As I noted earlier, three-quarters of mental illnesses appear by the age of 24, yet 

less than one in five children and adolescents with diagnosable mental health and 

substance use problems receive treatment. That is why last week, the President announced initiatives to ensure that students and young adults receive treatment for 

mental health issues. Specifically, SAMHSA will take a leadership role in initiatives 

that would: 

• Reach 750,000 young people through programs to identify mental illness early and refer them to treatment: We need to train teachers and other 

adults who regularly interact with students to recognize young people who need 

help and ensure they are referred to mental health services. The Administration is 

calling for a new initiative, Project AWARE (Advancing Wellness and Resilience in 

Education), to provide this training and set up systems to provide these referrals. 

This initiative has two parts: 

• Provide ‘‘Mental Health First Aid’’ training for teachers: Project 

AWARE proposes $15 million for training for teachers and other adults who 

interact with youth to detect and respond to mental illness in children and 

young adults, including how to encourage adolescents and families experiencing these problems to seek treatment. 

• Make sure students with signs of mental illness get referred to treatment: Project AWARE also proposes $40 million to help school districts work 

with law enforcement, mental health agencies, and other local organizations 

to assure students with mental health issues or other behavioral issues are 

referred to and receive the services they need. This initiative builds on strategies that, for over a decade, have proven to improve mental health. 

• Support individuals ages 16 to 25 at high risk for mental illness: Efforts 

to help youth and young adults cannot end when a student leaves high school. Individuals ages 16 to 25 are at high risk for mental illness, substance abuse, and suicide, but they are among the least likely to seek help. Even those who received services as a child may fall through the cracks when they turn 18. The Administration 

is proposing $25 million for innovative State-based strategies supporting young people ages 16 to 25 with mental health or substance abuse issues. 

• Train more than 5,000 additional mental health professionals to serve 

students and young adults: Experts often cite the shortage of mental health service providers as one reason it can be hard to access treatment. To help fill this gap, 

the Administration is proposing $50 million to train social workers, counselors, psychologists, and other mental health professionals. This would provide stipends and 

tuition reimbursement to train more than 5,000 mental health professionals serving 

young people in our schools and communities. 

National Dialogue 

Finally, we know that it is time to change the conversation about mental illness 

and mental health in America. HHS is working to develop a national dialog on the 

mental and emotional health of our young people, engaging parents, peers, and 

teachers to reduce negative attitudes toward people with mental illness, to recognize 

the warning signs, and to enhance access to treatment. 
13 

CONCLUSION

Thank you again for this opportunity to discuss the state of America’s mental 

health system. I would be pleased to answer any questions that you may have. 

The CHAIRMAN. Thank you very much, Dr. Hyde. 

Now we’ll turn to Dr. Insel. Welcome again and please proceed. 

STATEMENT OF THOMAS INSEL, M.D., DIRECTOR, NATIONAL 

INSTITUTE OF MENTAL HEALTH AT THE NATIONAL INSTITUTES OF HEALTH, BETHESDA, MD 

Dr. INSEL. Thank you, Mr. Chairman and Ranking Member Alexander and members of the committee. It’s a real honor to be here, 

and it’s actually a great pairing to have Administrator Hyde and 

me on the same panel. 

This is essentially going from services to science. So as a person 

coming to you from the National Institute of Mental Health and 

the National Institutes of Health, my role is really around the research related to mental illness and thinking about how to come 

up with the science that will lead to better diagnostics, better 

therapeutics, better understanding of what you called a silent epidemic, Senator Harkin. And that’s actually an interesting term for 

this. 

I know we haven’t met for some years to talk about this. So it’s 

particularly, for us, important to get this out on the agenda. It’s 

clear that in some ways this is a response to this tragic event that 

happened in December in Newtown, CT. And if it takes an event 

like that to focus the Nation’s attention on the needs of those with 

mental illness—it’s terrible to say that, but at least perhaps one of 

the opportunities that can be taken now is to think about how do 

we do better by those with mental illness and how do we make 

sure that events like this don’t happen again. 

I’m not going to read my testimony to save time. I think both 

Pam and I are eager to get to your questions. But perhaps to preempt some of those questions, let me take just a couple of minutes 

to make some of the points that might help in terms of how we 

think about mental illness, some of the definitions and the science 

as we understand it. 

First of all, when we talk about mental illness, we’re talking 

about, as you have already heard, very common disorders, depression, PTSD, eating disorders, and there are many others. There are 

about 10 or 12 that we focus on. These are real illnesses with real 

treatments and affect about one in five Americans overall, including youth, as we’ll say in a moment. 

Today, we’re probably going to talk mostly about serious mental 

illness. That’s a term of art that has to do with those people who 

are truly disabled, often by a psychotic illness. That occurs in 

about, overall, perhaps 1 in 20. So it’s not quite as common. But 

it’s an important piece of the story that we need to talk about, because these are the people who are most severely impaired. 

As Pam mentioned and as already mentioned by you, Senator 

Harkin, it’s really critical for the committee to understand that unlike talking about cancer and diabetes and heart disease, when we 

talk about mental illness, we’re talking about illnesses that begin 

early in life. These are, in fact, the chronic disorders of young people, and it requires a different mindset when you think about how 
14 

do you detect, how do you intervene, how do you make sure that 

you can make a difference. That’s one of the reasons why these disorders have the highest disability rating or the highest morbidity 

overall. It’s because they start early and they tend to be chronic. 

As Pam mentioned, we know these are treatable disorders, but 

there’s a significant delay in getting treatment. And even in those 

young people who have these most severe illnesses like schizophrenia, on average, the delay between the onset of symptoms and 

when they get diagnosed and treated is somewhere between 1 and 

2 years, which seems extraordinary because you’re talking about 

symptoms that are so disabling and so obvious. 

And it’s especially unfortunate, because the lesson we have 

learned from cancer and heart disease, diabetes and AIDS, is that 

the secret to having the best outcomes is early detection and early 

intervention. That’s what biomedical research has taught us over 

the last four decades. You have to get there early in the process 

if you want people to have the best outcome, and we don’t do that 

here. 

I think one of the things we need to talk about—again, going 

back to your comments, Senator Alexander, about who needs help 

and who’s going to be responsible for providing help—is why the 

delay, and how do we do better in making sure that people get involved earlier in the process. 

Just a comment about violence and mental illness, because it will 

come up, I think. It’s on a lot of people’s minds. As you’ve heard 

already, most violence has nothing to do with mental illness, and 

most people with mental illness are not violent. In fact, we generally worry more about people with mental illness, especially severe mental illness, being the victims, not the perpetrators, of violence, and the science certainly supports that. 

There are two conditions where we do need to think about this 

because violence and mental illness will intersect. And one of those 

is the psychotic illnesses like schizophrenia that start early in usually adolescents. For people who have not received treatment, they 

are at greater risk for violence, either because they are paranoid 

and may irrationally feel that they are under attack, or sometimes 

because of hallucinations or voices telling them to do something 

horrific, as you mentioned with your example, Senator Alexander. 

Far more common, however, is the second issue. It’s not homicide 

or violence against others. It’s violence against the self. Suicide is 

a far more common problem for people with serious mental illness—38,000 suicides in this country each year with the most recent data that we have. That’s more than 1 every 15 minutes. Of 

these, 90 percent involve mental illness. By contrast, there are less 

than 17,000 homicides, with less than 5 percent involving mental 

illness. 

So when we talk about violence and mental illness, when we talk 

about safety and security, when we talk about access to means or 

duty to warn, the bigger problem here is suicide. It’s protecting the 

person with mental illness as well as family members, peers, and 

people in the community. 

There’s a lot that can be done here. We’re not great at predicting. 

It’s still more an art than science. And I would say that’s true, by 

the way, of heart attack, cancer, as well as serious mental illness 
15 

1Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use and Health: Mental Health Findings (Office of Applied Studies, 

NSDUH Series H–39, HHS Publication No. SMA 10–4609). Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 2010. 2The World Health Organization. The global burden of disease: 2004 update, Table A2: Burden of disease in DALYs by cause, sex and income group in WHO regions, estimates for 2004. 

Geneva, Switzerland: WHO, 2008. 

or violence in those people who are affected by these kinds of illnesses. 

But even without being 100 percent certain on the predictions at 

the individual level, we can do a lot toward prevention, and you’ll 

hear something about that in the conversation today. At NIMH, 

we’ve really spent much of our investments focusing on the earliest 

stages of severe mental illness and identifying high-risk states before psychosis begins, just the way we do today with cancer and 

heart disease and thinking about how to intervene early. 

So I think I will stop there except to say that this is an extraordinary time in terms of the science of mental illness. We are really 

in the middle of a revolution because of what we’re learning about 

the brain. We do think about each of these disorders as brain disorders, and we think about our interventions in terms of how they 

affect individual brain circuits. 

We’ve made tremendous strides over the last 50 years. You cited 

President Kennedy’s launching of the Community Mental Health 

Program, which actually began with a special comment to Congress 

on February 5, 1963. So we’re almost exactly at the 50-year anniversary. A lot has happened in that time, but as Pam mentioned, 

we have a long way to go. I look forward to your questions about 

how we can do better going forward. 

Thank you. 

[The prepared statement of Dr. Insel follows:] 

PREPARED STATEMENT OF THOMAS INSEL, M.D. 

Mr. Chairman and members of the committee, I am Thomas R. Insel, M.D., director of the National Institute of Mental Health (NIMH) at the National Institutes 

of Health, an agency in the Department of Health and Human Services. Thank you 

for this opportunity to present an overview of the current state of mental health research at NIMH, with a particular focus on our efforts to address serious mental 

illness, and our efforts to discover, develop, and pursue new treatments for these 

brain disorders. In my statement, I will review the scope of mental disorders in the 

United States and their impact on public health, and I will outline examples of 

NIMH’s research efforts designed to address this challenge. 

PUBLIC HEALTH BURDEN OF MENTAL ILLNESS

The National Institute of Mental Health is the lead Federal agency for research 

on mental disorders, with a mission to transform the understanding and treatment 

of mental illnesses through basic and clinical research. The burden of mental illness 

is enormous. In the United States, an estimated 11.4 million American adults (approximately 4.4 percent of all adults) suffer from a serious mental illness (SMI) each 

year, including conditions such as schizophrenia, bipolar disorder, and major depression.1 According to a 2004 World Health Organization report, neuropsychiatric disorders are the leading cause of disability in the United States and Canada, accounting for 28 percent of all years of life lost to disability and premature mortality (Disability Adjusted Life Years or DALYs).2 The personal, social and economic costs associated with these disorders are tremendous. Suicide is the 10th leading cause of 

death in the United States, accounting for the loss of more than 38,000 American 
16 

3 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS): www.cdc.gov/ncipc/ 

wisqars accessed November 2011. 4 Insel TR. Assessing the economic cost of serious mental illness. Am J Psychiatry. 2008 

Jun;165(6):663–5. 5Soni A. The Five Most Costly Conditions, 1996 and 2006: Estimates for the U.S. Civilian 

Noninstitutionalized Population. Statistical Brief #248. July 2009. Agency for Healthcare Research and Quality, Rockville, MD. 6 Bloom DE, Cafiero ET, Jane ́-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, Feigl AB, 

Gaziano T, Mowafi M, Pandya A, Prettner K, Rosenberg L, Seligman B, Stein A, Weinstein C. 

The Global Economic Burden of Non-communicable Diseases. Geneva, Switzerland: World Economic Forum, 2011. 7Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year followup of a nationally representative U.S. survey. Med Care. 2011 Jun;49(6):599–604. 8Goff DC, Sullivan LM, McEvoy JP, ET al. A comparison of 10-year cardiac risk estimates 

in schizophrenia patients from the CATIE study and matched controls. Schizophrenia Res. 

2005;80(1):45–53. 9 Allison DB, Fontaine KR, Heo M, ET al. The distribution of body mass index among individuals with and without schizophrenia. J Clin Psych. 1999;60(4):215–20. 10McElroy SL. Correlates of overweight and obesity in 644 patients with bipolar disorder. J 

Clin Psych. 2002;63:207–213. 11McEvoy JP, Meyer JM, Goff DC, ET al. Prevalence of the metabolic syndrome in patients 

with schizophrenia: Baseline results from the (CATIE) schizophrenia trial and comparison with 

national estimates from NHANES III. Schizophrenia Res. 2005;80(1):19–32. 12 Hor K. & Taylor M. Suicide and schizophrenia: a systematic review of rates and risk factors. 

J Psychopharmacol. 2010;24(4S): 81–90. 13Wang PS, Berglund PA, Olfson M, Kessler RC. Delays in initial treatment contact after first 

onset of a mental disorder. Health Serv Res. 2004 Apr;39(2):393–415. 14Steadman HJ, Mulvey EP, Monahan J, Robbins PC, Appelbaum PS, Grisso T, Roth LH, Silver E. Violence by people discharged from acute psychiatric inpatient facilities and by others 

in the same neighborhoods. Arch Gen Psychiatry. 1998 May;55(5):393–401. 15Teplin, LA, McClelland, GM, Abram, KM & Weiner, DA. Crime victimization in adults with 

severe mental illness: comparison with the National Crime Victimization Survey. Arch Gen Psychiatry, 2005, 62(8), 911–921. 

lives each year, more than double the number of lives lost to homicide.3 A cautious 

estimate places the direct and indirect financial costs associated with mental illness 

in the United States at well over $300 billion annually, and it ranks as the third 

most costly medical condition in terms of overall health care expenditure, behind 

only heart conditions and traumatic injury.4 5 Even more concerning, the burden of 

illness for mental disorders is projected to sharply increase, not decrease, over the 

next 20 years.6

NIMH-supported research has found that Americans with SMI die 8 years earlier 

than the general population.7 People with SMI experience chronic medical conditions and the risk factors that contribute to them more frequently and at earlier 

ages. There are low rates of prevention, detection, and intervention for chronic medical conditions and their risk factors among people with SMI, and this contributes 

to significant illness and earlier death. Two-thirds or more of adults with SMI 

smoke 8; over 40 percent are obese (60 percent for women) 9 10; and metabolic syndrome is highly prevalent, especially in women.11 Approximately 5 percent of individuals with schizophrenia will die by suicide during their lifetime, a rate 50-fold 

greater than the general population. 12

DELAYS IN RECEIVING TREATMENT—AND THE CONSEQUENCES

According to a study published in 2004, the vast majority (80.1 percent) of people 

having any mental disorder eventually make contact with a health care professional 

to receive treatment, although delays to seeking care average more than a decade.13

Although instances of SMI are associated with shorter delays, the average delay was 

nevertheless approximately 5 years—that is 5 years of increased risk for using potentially life-threatening, self-administered treatments, such as legal or illicit substances, or even death. During an episode of psychosis, people can lose touch with 

reality and experience hallucinations and delusions. Research has suggested that 

persons with schizophrenia whose psychotic symptoms are controlled are no more 

violent than those without SMI.14 Nonetheless, when untreated psychosis is also accompanied by symptoms of paranoia and when it is associated with substance 

abuse, the risk of violence is increased. Importantly, the risk of violence is reduced 

with appropriate treatment. Moreover, people with SMI are 11 times more likely 

than the general population to be victims themselves of violence.15
17 

16Marshall M, Lewis S, Lockwood A, Drake R, Jones P, Croudace T. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients. Arch Gen Psychiatry. 2005 Sep 62:975–83. 17Gilman SR, Chang J, Xu B, Bawa TS, Gogos JA, Karayiorgou M, Vitkup D. Diverse types 

of genetic variation converge on functional gene networks involved in schizophrenia. Nat 

Neurosci. 2012 Nov;15(12):1723–8. 18 Vital Statistics of the United States, CDC/National Center for Health Statistics. (2011, August). Age-adjusted Death Rates for Coronary Heart Disease (CHD). National Heart Lung and 

Blood Institute. Retrieved January 23, 2013, from http://www.nhlbi.nih.gov/news/spotlight/ 

success/conquering-cardiovascular-disease.html. 

HOW NIMH IS ADDRESSING THIS PUBLIC HEALTH CHALLENGE

In the past, we viewed mental disorders as chronic conditions defined by their apparent symptoms, even though behavioral manifestations of illness are in fact the 

last indications—following a cascade of subtle brain changes—that something is 

wrong. We understand now that mental disorders are brain disorders, with specific 

symptoms rooted in abnormal patterns of brain activity. Moving forward, NIMH 

aims to support research on earlier diagnosis and quicker delivery of appropriate 

treatment, be it behavioral or pharmacological. NIMH has a three-pronged research 

approach to achieve this aim: (1) optimize early treatment to improve the trajectory 

of illness in people who are already experiencing the symptoms of SMI; (2) understand and prevent the transition from the pre-symptomatic (prodrome) phase to actual illness; and (3) investigate the genetic and biological mechanisms underlying 

SMI in order to understand how, in the future, we can preempt illness from ever 

occurring. Here are examples of NIMH efforts on these three fronts: 

(1) In the United States, the delay between a first episode of psychosis and 

onset of treatment ranges from 61 to 166 weeks, with an average of 110 weeks.16

NIMH seeks to reduce that delay as much as possible, through continued support 

of the Recovery After an Initial Schizophrenia Episode (RAISE) project; a large-scale 

research project to explore whether using early and aggressive treatment will reduce the symptoms and prevent the gradual deterioration of functioning that is 

characteristic of chronic schizophrenia. The project is currently focused on maintaining the quality of the treatment over time, and retaining individuals in treatment. 

Results from initial analyses suggest that a RAISE-type intervention would not only 

produce superior clinical outcomes, but will reduce re-hospitalization during the first 

year. 

(2) NIMH is continuing to fund research directed at the prodromal phase of 

schizophrenia, the stage just prior to full psychosis. A consortium of eight clinical 

research centers (North American Prodrome Longitudinal Study or NAPLS) are 

using biological assessments, including neuroimaging, electrophysiology, neurocognitive testing, hormonal assays, and genomics, to improve our ability to predict 

who will convert to psychosis, and to develop new approaches to pre-emptive intervention. 

(3) For decades, we have known that schizophrenia has a genetic component, 

but different methods for studying genetic changes have led to uncertainty about 

which genes are involved and how they contribute to illness. Using a new method 

to integrate information about illness-related genes from different types of studies, 

NIMH-supported researchers have identified a network of genes that affect the development, structure, and function of brain cells. The researchers detected important variations in how these gene-related brain changes affected risk for schizophrenia versus other disorders.17

PREEMPTION: THE FUTURE OF MENTAL HEALTH RESEARCH

Research has taught us to detect diseases early and intervene quickly to preempt 

later stages of illness. This year we will avert 1.1 million deaths from heart disease 

because we have not waited for a heart attack to diagnose and treat coronary artery 

disease.18 The 100,000 young Americans who will have a first episode of psychosis 

this year will join over 2 million with schizophrenia. Our best hope of reducing mortality from this, other SMI, and other brain disorders will come from realizing that 

just like other medical disorders, we need to diagnose and intervene before the 

symptoms become manifest. The health of the country cannot wait. 

The CHAIRMAN. Thank you, Dr. Insel. Now I’ll start a round of 

5-minute questions. 

Ms. Hyde, I just want to focus on the Mental Health Parity and 

Addiction Equity Act signed into law in 2008—a major accomplishment. I am concerned because the interim final rule published in 
18 

2010 left some implementation details unresolved. When the Administration publishes a final rule, how will you address issues 

such as the scope of services that must be covered so that insurers 

have the detailed guidance they need to implement the law? 

Ms. HYDE. Thank you for the question, Senator Harkin. As you 

know, the interim final rule was published in 2010. Part of what 

was requested from the public was input on several topics. That 

was one. In the meantime, we’ve issued four or five subregulatory 

guidance frequently asked questions. We’ve also been meeting with 

stakeholders and with industry, trying to understand how the implementation is happening. We are ready to produce a final reg, 

and we’re in that process now. 

The CHAIRMAN. Thank you. 

Dr. Insel, I have some concerns—I know others have also, and 

I’ve read a lot about these concerns, and I hear them from constituents and other people who talk to me—about the use of pharmaceuticals, particularly antipsychotic medications in children. What 

I hear is sometimes a kid acts up and does something—get them 

a drug. Get them some antipsychotic medication. What do we currently know about the safety and long-term effects of these drugs 

in kids? 

I’ve often said children are not just little adults. They’re different. And what might work in an adult, even if you say, ‘‘Well, 

we’ll reduce the dosage,’’ that sometimes doesn’t always correlate. 

I don’t want to practice medicine without a license. But, nonetheless, we know that to be a fact. What do we currently know about 

the safety and long-term effects on these kids, and what areas require further research and study? 

Dr. INSEL. Well, in fact, there is a real concern, because the use 

of antipsychotics in children has gone up markedly over the last 

decade. What we do know is that children are actually more sensitive to the side effects, particularly the metabolic side effects. And 

that’s a real concern because, often, these drugs are used long 

term. 

So there’s an issue. There’s a real issue about practice and about 

improving the quality of practice in this regard. And I should say 

that some of this may be related to a reluctance for many clinicians 

to use antidepressants, which are probably somewhat safer. But 

there are concerns about suicide and actually violent behavior. 

The curious thing to know here is if you look at the other side 

of this—we’re not talking about young children, but when we talk 

about adolescents and the example that Senator Alexander used 

about the 15- or 16-year-old who was beginning to hear voices and 

who’s going down this path of psychosis, what tends to happen 

most often is not that people are getting over-treated with medications but that they’re not getting diagnosed and treated at all. 

Specifically, with respect to our concerns about violent behavior, 

we know that treatment reduces that. The most important thing 

you can do if you want to prevent new events like this, the ones 

that we’ve often talked about over the last 5 or 6 years, is to ensure 

that people who are on this path to becoming psychotic and paranoid and grandiose and perhaps dangerous are treated. 

The risk of violence is fifteenfold higher prior to treatment than 

it is after, and treatment often does involve antipsychotic medica-
19 

tion. It’s not the whole treatment, but it is a part of making sure 

that people who are developing a psychotic illness are actually not 

going to become a risk to themselves or others. 

The CHAIRMAN. We’ll hear testimony later from the next panel 

about approaches such as mind-body connections and things like 

that in terms of perhaps—especially as we get into prevention and 

we start recognizing in young children in school and other places 

certain types of behavior that maybe early interventions with family counseling and therapy might be more successful than just giving them an antipsychotic drug. Do you have any comments on 

that? 

Dr. INSEL. There are only a few reasons to use an antipsychotic 

drug in a young child. Probably the most common and the one that 

is approved by the FDA is in autism, where there are forms of irritability and what you might call temper tantrums in which children will hurt themselves or hurt somebody else, often very young 

children. And in that case, the FDA has approved the use of two 

different antipsychotic drugs to help control that kind of behavior. 

But for the most part, the medications that are approved for use 

in children and the ones that seem to show the greatest efficacy are 

in other classes, particularly for children who have, for instance, 

attention deficit hyperactivity disorder, where the psycho-stimulants have been shown over and over again over the last four decades to be not only of high efficacy but high safety as well. And 

we know from long-term studies that that’s helpful. 

So I wouldn’t say that in any of these cases medicine is the whole 

answer, but it’s often helpful as part of the answer. There are lots 

of other kinds of interventions that are being developed and some 

that still need to be developed that may be far more effective beyond medication. So this is just a part of the story. 

The CHAIRMAN. Thank you very much, Dr. Insel. My time is up. 

Ms. Hyde, do you have a short comment? 

Ms. HYDE. I was just going to say that from a population-based 

point of view for young children, there are interventions, not for 

people who have been identified with an issue, but in classrooms; 

for example, a program that we support called The Good Behavior 

Game, which has shown a fairly remarkable ability to help teachers manage behaviors in classrooms, that does have long-term impacts. 

The CHAIRMAN. Thank you. 

Senator Alexander. 

Senator ALEXANDER. Thanks, Mr. Chairman. 

Ms. Hyde, it looks like, just looking at Tennessee, that maybe a 

quarter to a third of the funds that are available for mental health 

and substance abuse through the State government are Federal 

dollars. Does that sound about right for the country? Is that your 

experience? Most of it goes through two big block grants, or one big 

one and one smaller one. Is that about right? 

Ms. HYDE. Sort of a rule of thumb is somewhere around a quarter of the funding for the Nation—I don’t know about Tennessee, 

particularly—but is—— 

Senator ALEXANDER. Well, for the Nation, that sounds about 

right. 
20 

Ms. HYDE. It sounds about right if you take the Medicaid dollars. 

Each State has a different match, of course, so that changes how 

much is State dollars and how much not. About half the dollars 

that go for behavioral health of the country as a whole are public 

dollars, Federal and State. 

Senator ALEXANDER. Do you regularly consult with the State 

mental health directors about your two block grants and how 

they’re administered and how the money is—how you might improve the process of applying for that money and make it easier for 

them to help the people who need help? 

Ms. HYDE. Absolutely, Senator. We put out a block grant application. It’s now a uniform application that makes it easier for States 

to apply for the funding. We go through a public process as well 

as an informal process of asking for input from the States and the 

two State associations that represent State agencies in that process. 

Senator ALEXANDER. I have heard that the statutory deadline for 

the two block grants is in the fall, September and October, but that 

you’ve indicated that you’ve moved that up to the spring, and that’s 

causing some States to have concern about being able to get ready 

for the applications because of the legislative sessions, and that 

there’s some confusion about how much information is requested, 

and that if as much is requested as it appears to be that it might 

be burdensome. Have you heard that from State directors? And, if 

so, what are you doing about that? 

Ms. HYDE. Thank you, Senator. Interestingly enough, we actually 

changed that date initially in consultation with some States. What 

we were trying to do is push up the date so that they could do their 

planning during their legislative process, so that as their legislature decided match moneys, or what we call maintenance of effort 

moneys, it could be tied to the block grant dollars. Since the application is not yet out, we probably will change that date before the 

final application comes out. 

Senator ALEXANDER. Could I encourage you to take a look at that 

and make sure that it’s not a burden on the States? 

Ms. HYDE. Absolutely. 

Senator ALEXANDER. You mentioned the mental health parity letter that came out earlier this month. Did the mental health parity 

law apply to Medicaid by its terms, or does it apply to Medicaid 

by the terms of the new healthcare law? Or is the letter something 

that expands the application of mental health parity to Medicaid? 

Ms. HYDE. The letter just explains and provides guidance to 

States about how MHPAEA, the Federal law about parity, applies 

to certain portions of the Medicaid program. So Medicaid benchmark plans and benchmark equivalent plans, as they’re called, or 

alternative plans are subject to MHPAEA whereas the basic underlying Medicaid program in the States are subject to other laws. 

Senator ALEXANDER. So it shouldn’t be any surprise to Governors 

who are evaluating the cost of Medicaid expansion that the mental 

health parity law applies to Medicaid. 

Ms. HYDE. Senator, I don’t know if it’s a surprise. It, in fact, applies to certain portions of it. So part of the reason for the letter 

was to try to describe the differences about where it applies and 

where it might not. 
21 

Senator ALEXANDER. That’s helpful. I’ve heard from a number of 

Governors, who haven’t made a decision about Medicaid expansion, 

that it’s hard for them to make that decision without knowing the 

added cost of it to the States, as Medicaid has grown as a part of 

State budgets, for example, in our State, from 8 percent when I 

was Governor to 26 percent today. So did you detail in your letter 

what the added cost to the Federal Government or States would be 

as a result of the application of mental health parity to Medicaid? 

Ms. HYDE. No. The letter was not about cost, although, as Congress went through the process of passing the MHPAEA, or the 

Mental Health Parity and Addictions Equity Act, there was significant discussion about cost, and all the studies that have occurred 

have indicated that the cost is negligible. In fact, MHPAEA does 

allow a plan to request an exemption if their costs go over a certain 

amount. So that is part of the MHPAEA law. 

Senator ALEXANDER. Thank you. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Alexander. 

Now, as you know, it has been a tradition or rule of this committee that Senators are recognized in order of appearance, and I 

have here Senator Murray and then Senator Enzi—we’ll go back 

and forth—and Senator Baldwin, Franken, Murphy, Sanders, Mikulski, Whitehouse, and Warren. 

So I would now recognize Senator Murray. 

STATEMENT OF SENATOR MURRAY

Senator MURRAY. Thank you very much, Mr. Chairman, for holding this really important hearing. It is, I think, especially important to note that, obviously, the issue of Newtown focused everybody on it. But this is an issue that a lot of us have been working 

on for a very long time, yourself included, and I think it’s a great 

time to refocus. I think it’s really important that it’s your first 

hearing, and I appreciate that. 

Senator Alexander, I welcome you to the new Ranking Member 

position and look forward to working with you and all of our new 

members. It’s great to have you on this committee. There’s a lot of 

great talent here. 

Mr. Chairman, I think that we’ll really be able to do some good 

things with this committee. So thank you very much, and to both 

of our witnesses as well. 

I did want to go back. Senator Harkin has mentioned it several 

times. But in the President’s recently released gun violence package, he issued three parity provisions, one clarifying parity for 

Medicaid-managed care plans, one saying that a parity provision 

would be included in the final essential health benefits rule, and 

one that committed to issuing the final rule on the Mental Health 

Parity and Addiction Equity Act which you’ve mentioned. 

But it didn’t make clear, and you haven’t yet made clear, when 

we’re going to actually see that. If these plans are supposed to be 

ready to go into exchange starting in October, it’s really essential 

that we see a final rule on this before April. So let me go back to 

the question that Senator Harkin asked again and ask you to be 

specific about a date that we will see this final rule in place. 
22 

Ms. HYDE. Thank you, Senator Murray. I think the President’s 

proposals indicated that the essential health benefits rule would be 

out next month. We are working on the MHPAEA final reg, and 

it will go through the regulatory process and is in that process now. 

I can’t give you a specific final date, but we are on it. 

Senator MURRAY. Will we see it by April? 

Ms. HYDE. I can’t tell you precisely what the date is, but we are 

on it now. 

Senator MURRAY. Well, it is really essential because our States 

are working on these exchanges and they need that clarity to move 

forward. So I can’t urge you strongly enough that that date is critical. 

Mr. Chairman, one of the issues I have focused a lot on in terms 

of mental health, obviously, is our military families. And I just continue to believe we have to do everything we can for our veterans 

and our service members as they transition, especially during difficult periods of redeployment and returning home, transitioning 

back into the civilian world. 

But the focus also has to be on the families of these veterans, 

and I’m certain that is the same throughout all of mental health, 

whether you’re talking about military or a number of the other topics you’ve been talking about. The Mental Health Access Act that 

we wrote included provisions to expand some of the VA mental 

health services to family members. Can you tell me how you’ve 

been progressing in implementing the military families initiative? 

Ms. HYDE. Yes, Senator. You may recall that the President 

issued an Executive order in the fall asking HHS and DOD and VA 

to collectively work on improving the mental health access for service members and veterans. We’re actively working on that together, 

the three departments. 

Part of the way we’re trying to get at the whole family and the 

whole needs of the individual is looking at partnerships between 

community health centers, community mental health centers, and 

VA organizations. There are times when family members cannot 

access Veterans Administration, but they can access that other 

mental health center down the road, or vice versa. 

So we have been trying to look at pilots. The Executive order 

called for us to work on pilots. We’re doing that. And we’ve also 

been meeting with stakeholder groups, and some of those stakeholder groups have been families of veterans, service organizations, 

and others giving us their input about the best way we can provide 

that. We have a report due to the President by the end of February, so we’re actively engaged in that process. 

Senator MURRAY. I’ll really look forward to seeing that. And Senator Sanders is taking over the Veterans Committee, and he has 

a strong interest in community health centers as well. So I know 

we’ll continue to be able to push on that. But I think it’s really important that we focus on that for our military families. 

Dr. Insel, thank you so much for talking about the importance 

of reminding all of us that mental health doesn’t mean that someone is violent. I think that’s really important to remember as we 

go through this. And, of course, we do need to focus on that population that has the potential to become violent, particularly at the 

younger ages. 
23 

So, Mr. Chairman, I think that’s why this hearing is so essential, 

and I really appreciate and look forward to hearing the testimony 

of the rest of the panels. Thank you. 

The CHAIRMAN. Senator Enzi. 

STATEMENT OF SENATOR ENZI

Senator ENZI. Thank you, Mr. Chairman, and I want to congratulate Senator Alexander, who gave up a leadership position on our 

side in order to be the Ranking Member on this committee. It 

shows his dedication to health and education and workplace safety 

and training and pensions, and I know that he’ll do an outstanding 

job. And I appreciate you holding this hearing on mental health as 

the initial one. 

My first question is for Administrator Hyde. I want to know 

more about the coordination and collaboration of agencies at the 

Federal, State, and local levels. Within your appropriate role as a 

Federal agency, what needs to be done to better enhance that coordination and collaboration of agencies at the Federal, State, and 

local levels? 

Ms. HYDE. Thank you for that question, Senator. We’ve actually 

been trying very hard to recognize the relationship between States 

and local communities, because the State often will create laws, 

rules, regs that, of course, the community has to respond to. So 

when we provide grants, for example, to our communities, we’re 

trying to say, ‘‘How does this relate to your State’s plan and direction?’’ 

Likewise, when we’re providing grants to our States, we’re trying 

to ask, ‘‘How are you bringing your communities into that process?’’ 

So we are, by our grant making, trying to bring them together. 

Through our community block grant application process, we’re also 

asking how these things relate to what’s going on at the community level. 

And then we have been providing significant technical assistance, because there’s a lot of change going on in the health delivery 

system to both our States and to our provider agencies which provide the basic community infrastructure. We also have countybased programs that we do a significant amount of work with. So 

we’re trying to look at those relationships. 

I, personally, have had the opportunity to work at all of these 

levels, city level, county level, State level, and now the Federal 

level. And sometimes what you feel is where you sit, but I understand probably only too well how much those relationships matter. 

So we are working on them significantly. 

Senator ENZI. Thank you, and I look forward to any suggestions 

you might have. 

Dr. Insel, what do we need to do to close the gap between research and real-world practice to ensure that evidence-based treatments are available in the community service settings? 

Dr. INSEL. Thank you. It’s a question that we discuss a lot at 

NIH, not just within the mental health arena, but across all of the 

diseases for which we’re responsible for providing better science. 

The typical response to your question or the typical assumption behind it is that there’s this sort of 17-year gap between a discovery 
24 

and implementation. What we used to talk a lot about was how do 

you move from research to practice. 

Interestingly, I’d say in the last 2 or 3 years, there’s been a 

transformation in how we talk about this. And, increasingly, we’re 

beginning to say, 

‘‘You know, how do we move from practice to research? How 

do we make sure that we have developed not just healthcare 

systems, but learning healthcare systems, healthcare systems 

that are involved in the research process itself?’’ 

At NIH, we’ve created several efforts to do that involving millions of patients through large healthcare systems, like Kaiser and 

many others, in which we are doing research or we’re doing actual 

practical trials in these very large groups at a much reduced cost. 

But the advantage of that is that you’re making discoveries in the 

place where they will be implemented rather than doing it, for instance, in an academic center where there may still be a gap to getting it to the community. 

The other piece of that that’s so important—and it’s actually part 

of a new institute that was formed at NIH—NCATS is actually 

bringing in the community at the get-go and making sure that the 

kinds of questions that are being asked by science are going to give 

you the kinds of answers that people in the community are looking 

for. 

Senator ENZI. Any reinvention is always appreciated. This next 

question is for both of you. What type of oversight or financial controls are in place to ensure that Federal funding is being used effectively to prevent and treat substance abuse use disorders and 

mental illnesses? What needs to be done? What changes are needed? 

Ms. HYDE. I’ll start with that question, Senator. For almost all 

of our programs, we do an evaluation of the program to see what 

kind of outcomes we’re getting and what the results are, and we 

try to use those evaluation results in how we do the next round of 

program activities. We also provide some of the largest amounts of 

surveillance data in the area of behavioral health, both substance 

abuse and mental health, and we’re trying increasingly to use that 

data to help us understand where we need to go. 

We’re working on something called the National Quality Framework, National Behavioral Health Quality Framework, which is a 

second step from the National Quality Strategy that was called for 

in the Affordable Care Act. And in that we will be laying out the 

framework for quality direction for behavioral health as a whole at 

different levels. 

We also, obviously, collect information and data from each of our 

grantees, and we are trying to make some improvements in that 

by streamlining our data collection systems. We have multiple systems now that we’re trying to put into one that we hope is more 

effective and easier for States and communities to report into. 

There’s a number of activities that we are going through around 

accountability and evaluation. And we work very well with NIMH, 

NIDA, and NIAAA on the way that their services—or the research 

that they provide and how we can bring it into our practices as 

well. 
25 

Senator ENZI. My apologies. I’ve used up more than my time. If 

Dr. Insel would answer that in writing—and I’ll also be adding a 

question about duplicative programs between all agencies. 

Dr. INSEL. I look forward to it. Thank you. 

The CHAIRMAN. Thank you, Senator Enzi. 

And now Senator Baldwin. Welcome to the committee. 

STATEMENT OF SENATOR BALDWIN

Senator BALDWIN. Thank you, Mr. Chairman. I am really delighted to join the committee and very pleased that the first hearing in this committee this session is devoted to this incredibly important topic. 

Ensuring access to quality and affordable healthcare has been 

and will always continue to be a very high priority of mine. And 

when I say healthcare, I don’t distinguish between physical health 

and mental health, because, to me, they should be viewed as one 

and the same. The Mental Health Parity Act and the Affordable 

Care Act both take important steps to make this vision a reality. 

And together those two laws will both expand healthcare insurance 

coverage to millions of previously uninsured Americans and increase access to mental healthcare for millions more who have 

health insurance coverage. 

My first question relates to increased access to insurance coverage. As we speak, Governors across this country, including in my 

home State of Wisconsin, are grappling with the decision of whether to expand Medicaid coverage under the Affordable Care Act. In 

my home State, around 200,000 Wisconsinites could gain Medicaid 

coverage through the Affordable Care Act Medicaid expansion 

should our Governor make that decision. 

Ms. Hyde, I really appreciate the fact that in your testimony you 

pointed out that Medicaid is currently the No. 1 payer for mental 

health services in the United States. We know that many vulnerable Americans do not currently qualify for Medicaid coverage. 

In your opinion, how might States that are grappling with this 

decision or States that are choosing to expand Medicaid coverage 

under the Affordable Care Act improve mental health outcomes for 

their most vulnerable citizens? Or, perhaps alternatively, what variation might you expect to see between States that choose to expand Medicaid and those that don’t with regard to treatment of 

mental illness? 

Ms. HYDE. Thank you, Senator, and welcome. 

Senator BALDWIN. Thank you. 

Ms. HYDE. We are very optimistic that as States go through their 

processes that they will come to the decisions to provide the opportunities for coverage for their citizens. And in that process, obviously, each State looks at its own Medicaid program. However, the 

letter that we just recently put out was an attempt to try to help 

States understand how they should be looking at mental health 

and substance abuse treatment within those contexts. 

There are certainly services that we know can work. We are 

working very closely with the Medicaid agency, CMS, our partner 

agency, in putting out informational bulletins on how States can 

use their Medicaid program to increase access and to do better for 

behavioral health. We are working with them to do that. We also, 
26 

frankly, are working on the enrollment and eligibility process with 

the department as a whole, because we know that people with behavioral health needs typically, even after fuller coverage, have a 

harder time staying covered. 

We are doing both, trying to get access through enrollment and 

eligibility, trying to get access through the type of service or the 

array of services that might be provided, and just trying to provide 

information to help the States understand what’s the most effective 

way to provide these services and the kinds of services that are 

most cost effective and most effective for treatment. 

Senator BALDWIN. Thank you. One of the ways that we’ve already seen expansion of access to care—and you were talking in 

your testimony today about the barriers being cost and access, ET 

cetera—is the provision in the Affordable Care Act that allows 

young people to stay on their parents’ health insurance until 

they’re 26, something I am particularly proud of because I worked 

very hard on that in the House Energy and Commerce Committee, 

and we’re pleased to see it in the final act. 

I’m wondering, especially given that your testimony talks a lot 

about the age of onset of many profound mental illnesses being between 16 and 25, whether you’re already observing the positive impact of that increased level of insuredness for that age population, 

that age cohort. 

Ms. HYDE. Well, we certainly know that both the provision to 

allow young people to stay on their parents’ insurance and also the 

provision to prohibit exclusion from preexisting conditions both 

help young people with mental health and substance abuse disorders stay on and keep insurance, or be able to get access to insurance when they may not have access to it otherwise. Millions of 

young people are covered through that process already, and we 

know—I don’t have a specific number, but we know that those 

young people who have these disorders are part of that group. 

The CHAIRMAN. Thank you, Senator Baldwin. 

Senator Murkowski. 

STATEMENT OF SENATOR MURKOWSKI

Senator MURKOWSKI. Thank you, Mr. Chairman, and I join the 

rest of my colleagues in thanking you for calling this hearing on 

an incredibly important subject. I’m told by my staff that we 

haven’t had a hearing in the HELP Committee on mental health 

issues since 2007, which is way past time. So thank you for your 

attention to this. 

I have been focused on the issue of suicide for years now and, 

particularly, youth suicide in this country. In my State, we have 

some very troubling statistics, but the one that I find most disturbing are our statistics when it comes to youth suicide. In the 

country, the rate of suicide was 11.5 suicides per 100,000 people. 

In Alaska, we’re looking at a suicide rate of exactly double that, 

21.8 suicides per 100,000 people. 

Even worse are our statistics as they relate to our Alaska Native 

young men. Those between the ages of 15 and 24 have the highest 

suicide rate of any demographic in the entire country at a rate of 

141.6 suicides per 100,000 people per year, and this was between 

2000 and 2009. For us, it’s staggering, and it’s something that I 
27 

just find so troubling, that in everything that we do, we cannot 

seem to be making inroads here. So I have long been focused on 

it. 

I just reintroduced, along with Senator Reed, legislation that will 

help to address the youth suicide, and this is the Garrett Lee 

Smith Memorial reauthorization. We’ve got a good group of cosponsors. What we’re seeking to do is to provide a focus on youth 

suicide in several different areas; to provide for prevention programs; and also, in addition to providing these grants to States and 

tribal organizations, to provide them to colleges and universities as 

well. 

The question that I have for you as director here is how we can 

do more within our colleges and within our universities to provide 

for identification, early treatment, early intervention and the treatment services that might make a difference with our young people 

in our universities. We see these documented mental health needs. 

I’m concerned that we don’t have sufficient flexibility within the 

programs that currently exist to help address this need. Can you 

speak to your observations and what we could be doing better to 

address those in our colleges and universities? 

Ms. HYDE. Senator, thank you for the question. As you know, the 

surgeon general along with a very strong public-private partnership last September put out the surgeon general’s National Strategy for Suicide Prevention. In that strategy, there were several 

high priority things identified. I don’t have the time nor the memory to go through all of them at this moment. But there were some 

very key things, like identifying—even as we’ve been talking about 

it in this youth age group having—raising awareness. 

Some people know what to look for—having people be able to get 

help better, engaging an aftercare, to use that term, so when people do have risk of suicide or they make a suicide attempt, then 

followup to make sure that there’s adequate followup, because we 

know that’s a high-risk time, providing clinical standards so that 

clinicians know how to do the screening, and that includes campusbased programs. We’re proud to administer the Garrett Lee Smith 

program, and we are seeing great results in terms of raising that 

awareness. 

Part of the President’s proposals also include the idea of a mental health first-aid approach in trying to get people more aware, especially focused on youth, of what to look for, how to get help, how 

to know someone needs help, and how to help them get that. 

Senator MURKOWSKI. Well, I would hope that we could work with 

you on this. Again, this is a key, key issue for us. 

Dr. Insel, let me ask you a quick question. It has been noted by 

my colleague, Senator Baldwin, that the identification of mental illness in terms of recognizing what we’re dealing with—the onset is 

as early as age 14, and that the early identification can really help 

with improving outcomes. Yet most of our primary care providers 

that are out there are probably not adequately prepared to identify 

mental illness at its earliest stages or provide for that appropriate 

care. 

What can be done? What is the Administration doing to support 

primary care, to improve these training opportunities so that we 

can do that early intervention, that early identification? 
28 

Dr. INSEL. That’s such an important question, Senator, because 

as we talked about earlier in the hearing, the lesson that we’ve 

learned over and over again in biomedical research is that early detection and early intervention give you the best outcomes. So we 

do need to do better at this. And it’s challenging in this sphere because we do not have biomarkers the way we do for heart disease 

or cancer or many other diseases, where we can take a blood test 

and know who has what or who’s on the high-risk path to develop 

something. 

NIMH is invested very heavily in developing just those kinds of 

tests, whether they’re cognitive or biological, to know who’s in a 

high-risk state. But that’s a long-term plan, and I don’t think we 

can wait to make sure that there’s better awareness and better 

community support. So one of the things that you heard—and Pam 

has already spoken to this—is Project Aware, which was announced last week by the President, which is an attempt to go out 

and increase awareness in schools, in primary care, and in communities about the challenge that we face, the need to be able to detect the earliest signs, at the same time recognizing that there are 

a lot of teenagers who are struggling, and we don’t want to label 

every one of them as having an illness. 

So you need to be sensitive to getting better and better, more 

precise measures about who really is at risk and knowing who to 

intervene with. So we’ve got to find the right balance here, and, 

hopefully, science will bring us some better tools for that. 

Senator MURKOWSKI. My time has expired. Mr. Chairman, I 

apologize for having gone over. Thank you. 

The CHAIRMAN. Thank you, Senator Murkowski. 

And now Senator Franken. 

STATEMENT OF SENATOR FRANKEN

Senator FRANKEN. Thank you, Mr. Chairman. Like all the members of this committee, we thank you for calling this hearing. 

I want to welcome Senator Alexander as our new Ranking Member. I look forward to working with you. 

And I want to thank Senator Enzi for his work as the former 

Ranking Member. 

Like everyone on this committee, I was devastated by the tragedy in Newtown. And in the wake of this tragedy, there’s been a 

new focus on mental health issues, which I’ve been working on for 

a long time. Paul Wellstone held the seat that I hold, and I, too, 

share the sense of urgency about the rules on Wellstone-Domenici 

being finalized. 

While I’m glad we’re focusing on mental health, I think it’s important not to stigmatize people with mental health issues or generalize about the connection between mental illness and violent behavior. And I want to thank both of you for making that very clear. 

As Ms. Hyde said in her written testimony, most people who are 

violent do not have a mental disorder, and most people with a mental disorder are not violent. 

And, Dr. Insel, you said essentially exactly the same thing. 

We should make sure that everyone has access to mental and behavioral health services that they need, because it will make our 

communities and families and them healthier and happier. But, 
29 

again, I think it’s absolutely vital that we not stigmatize mental illness in the process. I think that would not only be counterproductive but counterfactual. 

In the next week, I’m going to be introducing two bills that will 

expand access to mental health services. I’ll be introducing the Justice and Mental Health Collaboration Act. It’s really a reauthorization and an improvement, I hope, upon MIOTCRA, and this is 

about when people with mental health issues encounter the criminal justice system. I have seven Republican sponsors on that, including Senator Hatch on this committee. 

I’m also going to be introducing the Mental Health in Schools 

Act, which dovetails with Project Aware. And this is where, Dr. 

Insel, your testimony, and your testimony, too, Ms. Hyde, is so important. And it’s about schools identifying and treating—giving access to treatment to kids. The statistics you mentioned—only one 

in five of children who have a mental health issue get seen or 

treated. 

My legislation will allow schools to collaborate with mental 

health providers, law enforcement, and other community-based organizations to provide expanded access to mental healthcare for 

their students. It will also support schools in training staff and volunteers to spot warning signs in kids and to refer them to the appropriate services. And I’m glad that Project Aware has the same 

kind of focus. 

I want to ask about the evidence in terms of—with the caveat 

that both of you made about not stigmatizing mental illness and 

associating it with violence. If mental health issues go untreated, 

does that increase the chance that someone in a subset, a certain 

subset of a type of mental illness, will become more violent, or will 

there be a higher chance of that? 

Dr. Insel. 

Dr. INSEL. Senator Franken, within that narrow band of the people we’re talking about, which is a small, small segment of the population of people with a mental illness, those, for instance, who 

have what we call first episode psychosis—we know that the duration of untreated psychosis is related, in fact, to the risk for having 

a violent act. That’s been studied quite carefully, and there’s a real 

correlation there. So closing that gap is one of the things we can 

do to increase safety. 

Senator FRANKEN. So, in a sense, Newtown did prompt this. In 

that very narrow—and that was one of a number of horrific occurrences where I think that no one would question that in Tucson, 

Newtown, we’re talking about someone who’s deranged. And had 

that person been diagnosed, say, in school and had been able to get 

some kind of treatment—there is some kind of connection between 

making sure that we’re identifying and treating children early on 

with the tragedy that brought us here. 

Dr. INSEL. I’m not going to speculate on those individual cases 

because I haven’t seen them. But the data, the published data, are 

quite clear that the difference between severely violent acts like 

homicide between those who are untreated and those who are 

treated is fifteenfold. You drop the risk fifteenfold with treatment. 

So it’s vital, absolutely vital, that we detect earlier and intervene 

earlier with something that’s effective. 
30 

Senator FRANKEN. Thank you. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Franken. 

Let’s see. Senator Murphy has left right now. 

Senator Sanders. 

Senator SANDERS. I think Senator Mikulski had an engagement, 

and she wanted to ask just one question. 

The CHAIRMAN. Absolutely. 

STATEMENT OF SENATOR MIKULSKI

Senator MIKULSKI. Thank you very much, Senator Sanders. I 

have a meeting with Senator Shelby to help organize the Appropriations Committee. And that will take me to the questions for Dr. 

Insel and Dr. Hyde. 

I think what we’re hearing today is that effective intervention, 

whether it’s autism or chronic schizophrenia—it’s research, it’s 

treatment, and the workforce to make both happen. My question to 

each one of you—if we could just take the issue of research and 

then perhaps of workforce, but particularly research. 

Dr. Insel, what will be the consequences of sequester on the work 

of the National Institutes, your National Institute of Mental 

Health? You’ve talked about this outstanding work that you’re 

doing. What will happen? 

Dr. INSEL. At this point, what we’re looking at is about a 6.4 percent reduction in the 2013 budget, and, of course, that will come, 

if it happens, sometime in March or April. 

Senator MIKULSKI. But what are the consequences? 

Dr. INSEL. Well, there’ll be certain studies that we would like to 

do that are not going to be done at that budget. And one of the 

major projects that we’re involved with is actually highly relevant 

to this discussion today, which has to do with how do we ensure 

that we have the kinds of predictors for early psychosis. We have 

a large national study in what we call the prodrome that we would 

like to scale up, and that’s probably not going to be done if we don’t 

have the funds to expand what we’re currently doing. 

Senator MIKULSKI. So there would be others along those lines. 

Now, Ms. Hyde, when one looks at the operation under your organization, what would be the consequence—and you can’t have 

mental health without mental health practitioners, which usually 

goes to training grants, educational grants, actual workforce needs, 

particularly, as you know, at the State and local government. 

Would sequester have any impact on workforce issues, and what 

would they be? 

Ms. HYDE. Senator, I think it goes without saying that we all 

hope that sequester, which was never really intended to happen, 

doesn’t happen. But SAMHSA does a lot of technical assistance and 

training, and we provide a lot of materials and practice improvement for the workforce. And to the extent that we don’t have the 

same number of resources to do that, then less of that will certainly be able to be done and less of the grants that we put out 

as well. 

Senator MIKULSKI. Will it have a direct impact on training? 

Ms. HYDE. Senator, it very well could. Again, we have a fairly 

significant portfolio in providing what I call workplace or practice 
31 

improvement efforts. And that, again, includes training, technical 

assistance, materials, just access to resources. So those all take resources to do, and to the extent that we have the resources, we do 

it, and if we don’t, then we do less of it. 

Senator MIKULSKI. Well, I get the picture, and we will be coming 

back for more detailed questions on that. But I think this looming 

threat is severe, and I’m sure it has a tremendous impact on morale. 

But Senator Sanders yielded his time to me. And, Senator Sanders, I appreciate it. I know you’re keenly interested in that area as 

well. 

Let me just say one word. The reason I asked about the training—I went to graduate school on an NIH grant. When this 1963 

bill was signed for mental health community centers, I was a social 

worker working as a child abuse worker. Because of that, at age 

27, I was able to go to graduate school and get a master’s in social 

work, and I was supposed to specialize in community mental 

health. 

Now, many might not think I have a therapeutic personality. But 

I did learn a lot, and I learned that these scholarships and so on 

make a difference in lives, and the consequences of well-trained 

people and what they then produce in our society I know is important. 

Dr. INSEL. And we hope your training is successful in the appropriations process as well. So thank you for that. 

Senator MIKULSKI. I intend to be very agitated about a lot of 

things. 

[Laughter.] 

The CHAIRMAN. Senator Sanders. 

STATEMENT OF SENATOR SANDERS

Senator SANDERS. Thank you very much, Mr. Chairman. Newtown and other events have highlighted the importance of this 

issue, and I very much appreciate you holding this hearing. 

I’m going to approach the issue in a little bit different way, Mr. 

Chairman, than some of our colleagues. The United States of 

America is the only country in the industrialized world that does 

not have a national healthcare system. In my view, in the midst 

of major healthcare crises in this country, including 50 million people today without any health insurance—hopefully, that number 

will be significantly reduced under the ACA—the reality is that 

when you don’t have a system, you’re not prioritizing. 

So what that means is not only are we not paying adequate attention to mental health, in general, but the disparities based on 

income and where you live are also enormous. Senator Murkowski 

mentioned the problems in rural Alaska with Native Americans. 

What I can tell you—and I want you to deal with this for a moment. If I’m making a half a million dollars a year, and I’m living 

in New York City, and my kid has problems, the likelihood is I’m 

going to be able to get reasonably good mental health treatment for 

that kid. That’s the likelihood for my kid. 

On the other hand, if I live in rural Vermont, and I’m making $25,000 a year, you know what? I’m going to have a very difficult 

time accessing the mental healthcare that my kids need. And that’s 
32 

true, I suspect, in Tennessee, and I suspect that it’s true all over 

America. The reality is, right now, that we have a primary 

healthcare system which is a disaster, that whether it is physical 

illness or—you made the point that we do well with mental health 

when people can access the system when they need it. 

In my office, I can tell you we get calls in Vermont where family 

members say, ‘‘I have—my kid, my husband—serious problems. I 

can’t find mental health treatment now.’’ So let me ask you a simple question. If our goal is to make sure that mental healthcare is 

available to all people who need it, how many thousands and thousands of mental health practitioners does this country need, and 

how do we get them? 

Dr. Insel, why don’t we start with you? 

Dr. INSEL. I’m going to turn to my colleague who is just completing a workforce estimate, and so she’s actually looked very 

carefully at this issue. 

Senator SANDERS. Ms. Hyde, how many thousands of mental 

health practitioners do we need? 

Ms. HYDE. We don’t have good studies that say how many we 

need. We have lots of data that tell us what we don’t have. And 

we have lots of data that give us comparisons between certain 

areas and certain types of practitioners. We are just completing a 

report for Congress on that. It’ll be ready soon. 

Senator SANDERS. But before we even get to the report—and we 

need good data—tell me, is it fair to say that if I am a low-income 

person living in rural America or urban America, today I am going 

to have a very difficult time finding mental healthcare for my loved 

ones? 

Ms. HYDE. Senator, I was actually going to go right there, so 

thank you for the question. It’s not even so much—although, clearly, in certain areas of practitioners, we don’t have enough. But it’s 

also the distribution. I come from New Mexico, so we have major 

rural areas in New Mexico, and there are counties in New Mexico 

that don’t have any behavioral health practitioners, none, zero. 

Something like 75 percent of the psychiatrists are in what we call 

the Rio Grande corridor. 

Senator SANDERS. Which, let me guess, is probably—not knowing 

anything about—a wealthy—— 

Ms. HYDE. It’s Albuquerque and Santa Fe, yes. 

Senator SANDERS [continuing]. A wealthy area. 

Ms. HYDE. Well, it’s more urban, certainly, yes, and where the 

universities are. 

Senator SANDERS. We don’t have a whole lot of time. So my question is if I am a working class person, if I am unemployed in this 

country, is it a fair statement to say, especially if I’m living in rural 

America, that it would be very, very hard for me to access affordable mental healthcare in a timely manner? Is that a fair statement? 

Ms. HYDE. I think it is fair to say that rural areas have a more 

difficult time. There are clearly programs like community mental 

health centers, like community health centers, that have been explicitly set up for that. 

Senator SANDERS. Well, I worked very hard—let me just interrupt. I’m sorry. I apologize. We don’t have a lot of time. 
33 

Ms. HYDE. That’s all right. 

Senator SANDERS. I worked very hard to double the funding of 

community health centers and triple the funding for the National 

Health Service Corps. I think we made progress. Would you agree 

that we have a long, long way to go to expand even beyond where 

we have gone in recent years? 

Ms. HYDE. I would agree that we need more practitioners, absolutely. 

Dr. INSEL. And I would add to that that it’s not only across the 

board, but there are particular areas of need that need attention. 

One of them is in children, and we’ve been talking a lot about 

youth needs. Child psychiatry is a way underemployed—— 

Senator SANDERS. Absolutely. 

Dr. INSEL [continuing]. And child psychology is incredibly important to build the workforce. 

Senator SANDERS. All right. Let me just conclude. I think it’s a 

class issue, too, Mr. Chairman. I think to some degree psychiatry 

is something that is accessible for urban, upper income folks. It is 

not accessible for low-income rural folks. So I think the point that 

Ms. Hyde made is an important one. We have to look at geography, 

and we have to make sure that mental health is available to all 

people, regardless of their income, all over this country. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Sanders. I might just add 

that since I focus so much on prevention and early intervention 

right now, school psychologists—the national average is 1,500 to 1. 

The recommended ratio—I don’t know recommended by whom—is 

700 to 800 students per psychologist. So we need to double that if 

we’re even going to meet the recommended level for kids in school. 

Senator Warren, welcome to the committee. 

STATEMENT OF SENATOR WARREN

Senator WARREN. Thank you very much, Mr. Chairman. It’s good 

to be here. I want to apologize for coming in late. I have the best 

possible excuse. I was introducing my senior Senator, Senator 

Kerry, to the Senate Foreign Relations Committee. And I believe 

that will not be a recurring event. 

The CHAIRMAN. Is that your way of saying soon you will be the 

senior Senator from Massachusetts? 

[Laughter.] 

Senator WARREN. Yes, sir, it is. So I thank you. 

I would like to start with my questions in the same place that 

Senator Enzi started. I have a very similar interest in the questions about research around evidence-based medicine, around accountability, around our funding for research. 

What I’d like to do is just start with you, Dr. Insel, if you would, 

and I’ll ask you to do two things for us. The first is just paint us 

a little bit of a picture about what we can do with research in the 

mental health field. If we get some good research, what can we 

learn that we don’t know? And would you talk just a little bit about 

what funding levels are doing to research? 

Dr. INSEL. Thank you for that question. I don’t usually get an opportunity to talk about this, and I promise I’ll do it very quickly. 

But you’re asking the question at a critical moment in time. We are 
34 

really, in the case of understanding mental illness, where we were 

in some ways for studying cancer 20 or 30 years ago. We’re just on 

the cusp of a revolution, and it’s because we have these extraordinary tools now. 

For the first time, we can approach problems of the mind 

through studying the brain, and that gives us a kind of precision 

that we’ve never even imagined we could have. The reason that’s 

so important is because for behavioral problems, whether they’re in 

Parkinson’s Disease or Alzheimer’s Disease or Huntington’s Disease, the behavioral symptoms are a very late event. Those are the 

heart attacks. And it’s the same thing, we believe, for the psychosis 

and schizophrenia. 

We define these as behavioral disorders. But, in fact, they’re 

brain disorders, and the brain changes are probably occurring 

years earlier. And if we want to detect and intervene earlier, we’re 

going to have to be able to develop ways to get at that, to understand them as brain disorders in the same way that we’ve done 

now in many other areas of medicine. 

I think where the science is taking us is toward the biomarkers. 

It’s toward the fundamental biology. We have not been there before. We’ve had a very simplistic approach to this. It is far more 

complicated. The good news is we’ve got far better tools to be able 

to unpack this. 

Your question was about the funding. It’s a challenge. There are 

lots of questions, lots of things we’d like to answer. I’d have to say 

that for NIMH, the shift has largely been to move much of our 

funding to people who actually 10 years ago were studying cancer 

and heart disease who are now joining us because they feel that 

autism and schizophrenia are the new frontiers, and these are the 

places where you’re going to make the big breakthroughs. 

It’s always frustrating because there’s, of course, never enough 

funding to support all of the best ideas that come in. We try to support about 20 percent of them. So that one in five grants gets funded. I hope that I’m smart enough to pick the best 20 percent. I’m 

afraid I’m not, and I think if I could do 30 percent, I’d probably 

have a much better hit rate. It’s just hard to know often. So that’s 

always the challenge. You never have the funding you want to do 

all the science, some of which is just spectacular, that’s sitting 

there in front of you. 

Senator WARREN. Can I ask you just to expand on that in one 

more dimension, and that is—you described it as your hit rate. If 

you really hit on some of these studies on Alzheimer’s, on autism, 

can you just speak briefly about what the financial impact will be 

on the country? 

Dr. INSEL. Well, we know that in the case of Alzheimer’s that if 

we can just forestall the dementia by a matter of 1 year or 2 years, 

which is certainly, I think, within our grasp as we’ve gotten a better understanding of how to predict and are now looking at ways 

to intervene, we’re talking about billions of dollars that would not 

have to be spent, which are now going into the care of people with 

dementia. 

It really comes down to a question of do you want to invest early, 

or do you want to pay later, because you don’t know enough and 

you’re not doing this in a way that’s efficient. And, unfortunately, 
35 

I think we’ve tended to decide that we’ll pay later, often at a very 

large premium, instead of making the early investments in Alzheimer’s, autism, schizophrenia to make sure that we come up with 

better solutions. 

Senator WARREN. Thank you very much. 

Ms. Hyde, my time has expired. But if you had a quick comment 

you’d like to add, I’d be grateful. 

Ms. HYDE. The quick comment here is you know, of course, that 

these disorders have profound impacts on our justice systems, on 

our school systems, on our public welfare systems, our child welfare 

systems. There’s profound dollars that are being spent there because we are not intervening early, because we are not providing 

the kind of supports to the young people and their families. 

Senator WARREN. Thank you very much. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Warren. 

Senator Bennet. 

STATEMENT OF SENATOR BENNET

Senator BENNET. Thank you, Mr. Chairman. I was unfortunately 

on the floor with my senior Senator—there’s nothing unfortunate 

about that—on an issue of great importance to Colorado, so I 

missed the testimony. I think I’ll refrain from asking my questions 

now. I’ll submit something for the record if that’s OK with you, and 

I know there’s a second panel. 

But I want to thank you very much for holding this hearing. And 

I’d like to join Senator Franken in saying how delighted I am to 

see our Ranking Member, Senator Alexander, here and thank Senator Enzi also for his work as the former Ranking Member of the 

committee, and, finally, to welcome our new colleagues to the committee. It’s wonderful to see you here. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Bennet. 

I thank our first panel. Thank you, Dr. Insel, and thank you, Ms. 

Hyde, for being here. 

Now we’ll call our second panel, Dr. Michael Hogan, Dr. Robert 

Vero, Mr. George DelGrosso, and Mr. Larry Fricks. 

On our next panel, first, I’ll introduce Michael Hogan. Dr. Hogan 

is the former commissioner of the New York State Office of Mental 

Health and chairman of the President’s New Freedom Commission 

on Mental Health. In his capacity as the commissioner of the New 

York State Mental Health Office, he oversaw New York’s $5 billion 

public mental health system. Previously, he served as the director 

of the Ohio Department of Mental Health and Commissioner of the 

Connecticut Department of Mental Health. 

We thank you for being here, Dr. Hogan. 

And for purposes of an introduction, now I’ll turn to our Ranking 

Member, Senator Alexander. 

Senator ALEXANDER. Thanks, Mr. Chairman. I am delighted to 

welcome Robert Vero from Centerstone of Tennessee. He’s well 

known in our State. He has done work in the behavioral healthcare 

field for a long time, four decades. He’s chief executive of the company, or nonprofit organization, the largest nonprofit community 

mental health centers. They have more than 50 facilities and 160 
36 

partnership locations. They serve nearly 50,000 people of all ages 

each year. 

He has a distinguished academic background, which includes his 

work at Peabody College at Vanderbilt. He’s a clinician. He’s active 

and consulted by many for his expertise in this field, and I look forward to his insights about who needs help and how we can do a 

better job of making sure they get that help. 

Thank you for being here, Dr. Vero. 

The CHAIRMAN. Thank you, Senator Alexander. 

Also for purposes of an introduction, I’ll recognize the Senator 

from Colorado, Senator Bennet. 

Senator BENNET. Thank you, Mr. Chairman, and it is a great 

privilege to introduce Mr. George DelGrosso to the committee. Mr. 

DelGrosso currently serves as the chief executive officer of the Colorado Behavioral Healthcare Council. The Council is a statewide 

network comprising 28 behavioral health organizations. It provides 

treatment and other services to over 120,000 Coloradoans each 

year. Mr. DelGrosso began his career as a psychotherapist. He then 

became a marriage and family therapist, and he was promoted to 

a clinical supervisor and program developer before ultimately moving into senior management. 

Before leading the Colorado Behavioral Healthcare Council, Mr. 

DelGrosso served as the executive director of Mental Health Centers in the San Luis Valley in our State and in Cody, WY. 

Throughout his career, Mr. DelGrosso has worked to improve training and to develop integrated treatment approaches to mental 

healthcare. Currently, he is working to expand the Mental Health 

First Aid Program in Colorado to improve prevention, early identification, and access to care for those suffering from mental illness. 

His decades of experience within the mental healthcare system 

give him a unique perspective on our discussions today. And it’s in 

that spirit that I’d like to welcome Mr. DelGrosso to the committee, 

and I look forward to his testimony. 

The CHAIRMAN. Thank you, Senator Bennet. 

And now we have also Mr. Larry Fricks, a Senior Consultant at 

the National Council for Behavioral Health. Mr. Fricks is also the 

Director of the Appalachian Consultant Group and Deputy Director 

of the SAMHSA–HRSA Center for Integrated Health Solutions. He 

will share with us his firsthand account of recovery from mental 

illness and substance abuse. 

We thank you for being here, Mr. Fricks. 

As with the last panel, your statements will all be made a part 

of the record in their entirety, and I’ll ask you to sum up—we’ll 

just go from Dr. Hogan down—in 5 to 7 minutes, so we can get to 

a round of questioning. I’ll start with Dr. Hogan. 

I read all your testimonies last night. They’re just excellent, just 

excellent, every one of them. 

I remember, Dr. Hogan, you talked about separate but unequal, 

mental health from what we call regular health, I guess, or the 

healthcare system. Welcome and please proceed. 
37 

STATEMENT OF MICHAEL HOGAN, Ph.D., FORMER COMMISSIONER, NEW YORK STATE OFFICE OF MENTAL HEALTH, 

AND CHAIRMAN, PRESIDENT’S NEW FREEDOM COMMISSION 

ON MENTAL HEALTH, DELMAR, NY 

Mr. HOGAN. Well, thank you, Senator Harkin. I just have to start 

as others have by expressing appreciation on behalf of our community to the committee for focusing on this at this time. It’s been 

quite a while. But the timing is now, for other reasons that I’ll explain, and recent events, I think, make it the right time to pay this 

some concern, and we’re particularly appreciative that this focus 

happens on Senator Alexander’s first meeting as Ranking Member. 

I will start my remarks by focusing on something that is subtle 

and often not apparent with respect to mental healthcare as provided, and that is to say that the mental health system started in 

asylums run by States without the support or involvement of the 

Federal Government in any way. And to some extent, as we focused 

on a movement from asylum to community, there was attention to 

the locus of care that was being transformed. 

But what escaped attention was that care in separate programs 

and systems was still separate. That is changing before our eyes 

right now. And it’s changing and accelerating in ways that we can’t 

even see because of legislation that has already been discussed, 

first originating in this chamber with Senator Wellstone and Senator Domenici, to say that mental healthcare had to be a part of 

healthcare, no longer separate. 

And then second of all, the Affordable Care Act took that parity 

legislation and baked it into all the changes in healthcare that are 

going forward. So we are at a time when mental healthcare is increasingly going to be part of healthcare, and this raises two major 

questions for me. 

One of them is: Will we take time and attention to make sure 

that we get mental health right in the mainstream of healthcare? 

We’re fumbling at that right now. I want to talk a little bit more 

about that. 

The second is: As we move away from the separate system, will 

we pay enough attention to it and ensure that there is sufficient 

stewardship for it in States and so on—this is primarily a State 

problem—or will we recapitulate the institutionalization by walking in another direction that is well-intended but that forgets the 

people with the most serious needs? 

Those, it seems to me, are the two major challenges that we face. 

And having said that, I want to just touch on a couple of points 

briefly in that context. 

The first of those has to do with the imperative of trying to figure 

out how we can help primary care providers to deliver basic mental 

healthcare. We’re not asking them to do the complicated stuff. But 

most primary care providers with a little bit of help can do an excellent job with most of the mental health conditions that people 

walk into their offices with, but they can’t do it on their own. 

They’ve got to have a social worker or a nurse or somebody who 

can spend the time with people. Their practice has got to be paid 

a little for that. Medicare still doesn’t do that very well. 

We have to take steps toward what’s now called integrated or 

collaborative care to make sure that we provide that care in pri-
38 

mary care. Right now, more people get something for their mental 

health problems in primary care than get it from the entire separate mental health system. But it tends to be a day late and a dollar short and not to be very effective. Your chances of getting a diagnosis with depression if you walk into your GP’s office are less 

than 50–50, and your chances of getting enough treatment to make 

a difference are about 15 percent. But with a little bit of attention, 

that problem can be resolved. 

I won’t comment too much on the problem of protecting the safety net as we go forward in this transition. But I think what I would 

say is what the committee’s attention might be focused on, which 

is whether there are adequate standards for mental healthcare, not 

in SAMHSA, but in CMS as the system goes forward. Increasingly, 

in States right now, when you’re concerned about mental health, 

you don’t talk to the mental health director. You talk to the Medicaid director. And whether they have this on their radar screen is 

sort of a coin flip, and Federal standards there would help. 

The committee has already talked significantly about children’s 

issues. And Senator Alexander’s example of that 17-year-old with 

an early psychotic symptom, that Senator Murkowski also talked 

about, is something else that I want to comment on. 

We know how to address those problems today and we do not. 

We know how to engage people in care with an early psychotic 

problem as we would, in a sense, in a modern cancer center. Family would be welcome. We’d look at a longitudinal plan of care. We 

would stick with people to try to find something that was acceptable to them, as opposed to waiting until they deteriorate, putting 

them in a hospital, letting them leave with a referral to care. That 

is just not going to work. 

I have two other points that I’ve addressed in my written testimony, and my time is up. So I won’t comment on them, other than 

to say I really want to underline what Senator Murkowski has said 

about the problem of suicide. Administrator Hyde and the Surgeon 

General have really stepped up on this. The Department of Defense 

and Veterans Affairs are moving on this. The rest of the Government should pay a little bit more attention because it’s costing us 

more lives lost from suicide every week than we lost to military 

suicides in the entire last year. 

Thank you. 

[The prepared statement of Mr. Hogan follows:] 

PREPARED STATEMENT OF MICHAEL F. HOGAN, PH.D. 

SUMMARY

A decade ago the commission appointed by President George W. Bush to review 

mental health care said ‘‘the mental health services delivery system is in shambles.’’ 

Just 10 years later, both problems and solutions are clearer. Mental health parity 

with the ACA moves mental health to the mainstream of health care. We must capitalize. 

• Integrating mental health care into health care is a big opportunity that could 

easily be missed. Most Americans with mental health problems get no treatment. 

More people are treated in primary care than by mental health specialists, but this 

care is poorly paid for and often inadequate. Collaborative care is a proven approach 

to integrated care. It would be timely and very helpful if the committee were to 

track progress toward integrated care. 

• Protecting the safety net for individuals with serious mental illness is essential 

as we move to integrate care. While budget cuts have been damaging, in many 
39 

States the mental health safety net is better and more focused than it was a quarter 

century ago. We do not yet have national standards for the quality of care for people 

with serious mental illness. Without such standards the transition away from expert 

leadership is risky. We must not repeat the errors of deinstitutionalization in the 

correct and optimistic move to integration. More robust national standards for mental health within Medicare and Medicaid would help. 

• Children’s mental health care must be improved. Mental health problems have 

been called ‘‘the major chronic diseases of childhood.’’ Mental illness usually 

emerges before young people enter high school, but the average lag to treatment is 

9 years. Reform presents major opportunities. Practical steps include: (1) screening 

for and treating maternal depression, (2) helping pediatrics and child mental health 

programs to provide holistic care, (3) upgrading performance standards for child 

mental health care within health care plans and programs, and (4) improving school 

mental health services using only research-tested approaches. 

• We must develop a national approach for effective early treatment of psychotic 

illness. Our Nation’s approach to helping people with psychotic illnesses like schizophrenia is shameful; better approaches have been tested in the United States and 

implemented widely in Australia and Great Britain. The committee’s attention to 

this issue would have a positive effect. 

• Lifelong disability for people with mental illness is common, but usually unnecessary. Supported employment for people with mental illness is effective but underutilized. The Federal Government, with leadership from the Social Security Administration and the Centers for Medicare and Medicaid Services can change this and 

reduce needless disability. 

• Suicide prevention: Now is the time to act. Deaths by suicide in the Armed 

Forces last year exceeded combat deaths. Sadly, this is but the tip of the iceberg; 

twice as many American lives are lost to suicide in the average week than to military suicide during all of 2012. The Affordable Care Act offers numerous opportunities to incorporate best and effective practices for suicide prevention into Medicare 

and Medicaid, and into reform more broadly. The committee’s attention could help 

assure that other Federal agencies beside SAMHSA and the Department of Defense 

are focused on preventing suicide, that the National Action Alliance for Suicide Prevention is sustained and that the national network of crisis lines that can be 

reached at 1–800–273–TALK is strengthened. These steps would be life-saving. 

The mental health community greatly appreciates the committee’s attention at 

this crucial time. 

The mental health community appreciates the attention of the committee, and the 

concern for consumers, families and providers that it represents. Mental health 

needs are substantial, but such attention from policymakers is rare. 

What is the state of the mental health system? A decade ago, a commission appointed by President George W. Bush to review mental health care told the President that despite the efforts of many dedicated people ‘‘the Unites States mental 

health services delivery system is in shambles.’’ While many of the challenges we 

addressed still exist, problems and solutions are clearer a decade later. I hope we 

can provide you with a helpful picture of them. 

Much has changed, while much appears to remain the same. The Nation’s mental 

health system had its origins in the asylums of the 19th century. While much has 

been said about the balance between institutional and community care, a bigger 

issue is that for most of our history, mental health care has been separate from 

health care—and also unequal. In the best recent study of mental health policy, 

Richard Frank and Sherry Glied assessed whether people with a mental illness 

were better off early in this century than 50 years earlier. They answered that question in the name of their monograph: ‘‘Better, but not well.’’ However, the main insight from their study is that the improved well-being of people with a mental illness is not mainly due to changes within mental health care. Rather, the well-being 

of people with mental illness improved as they gained access to mainstream benefits 

like health care, disability insurance and housing. Improvements within the mental 

health system, like new treatments, had a smaller effect. 

This trend has now accelerated. A major example is legislation known by the two 

outstanding Senators, a political odd couple united by concern for mental health, 

who sponsored it: Pete Dominici and Paul Wellstone. The 2007 passage of the Mental Health Equity and Addictions Parity Act (MHEAPA) was not about improvements within the mental health system. It was about including mental illness care 

in health care. It signaled that a separate and unequal mental health system was 

not an adequate solution. 
40 

Mental health care was also greatly enhanced by passage of the Patient Protection 

and Affordable Care Act (ACA). Building on Dominici-Wellstone, the ACA included 

mental health within its changes to health care. These two pieces of legislation are 

game changers for mental health. The inclusion of mental health will lead to profound changes that will play out over the next generation. Because health care is 

so complex and change is unpredictable, there will be false starts and dead ends. 

But any assessment of the state of America’s mental health system must begin with 

a realization that we have begun to take big steps away from an approach that was 

both separate and unequal. The major challenges facing us are first whether including mental health in health care can be done sensibly, and second whether the portions of the mental health safety net that have value can be sustained. Inclusion 

creates big opportunities that we can seize or let slip away. In an earlier era of deinstitutionalization, we did not sustain our commitments to those most in need during 

change. Can we get it right this time? 

Integrating mental health care into health care. A first major challenge for the 

next decade is to integrate basic mental health care into primary care. (Integrating 

primary medical care into mental health centers is also important, but not my major 

focus here.) We know that most Americans with mental health problems get no 

treatment for these problems. We also know that more people are treated by their 

family physician or other primary care practitioner than by mental health specialists. The problem is that we have many unmet needs while many specialty mental 

health programs are at capacity. The opportunity before us is that health coverage 

that includes mental health care will become available for many Americans. We 

must use this opportunity to provide integrated primary care that includes basic 

mental health care. There is less stigma in visits to primary care. People with a 

chronic illness like diabetes, cancer or hypertension who also have depression have 

health care costs at least 50 percent higher; and good basic mental health care reduces overall costs. Improving basic mental health care in primary care is a huge 

need and opportunity. 

It will not occur automatically. Mental health care within primary care today is 

often inadequate. It can be done well, improving health and reducing costs, but barriers must be addressed. For example, ‘‘carved out’’ benefits for mental health care 

can usually be used only if a specialist is seen. Across primary care settings that 

have not upgraded to provide integrated care, less than half of the patients with 

a mental health problem get a mental illness diagnosis and treatment. Payments 

and supports for basic mental health care in primary care are often lacking, so less 

than 15 percent of the people with depression in primary care get adequate care. 

As a result, people with medical conditions like diabetes or high blood pressure as 

well as a mental health concern have bad health outcomes and higher medical costs. 

We have an opportunity to address this problem because many people with these 

conditions will now have insurance that includes mental health care, and because 

practical ways to deliver basic mental health care in primary care settings are now 

well established. The approach, known as collaborative care, improves both health 

and mental health outcomes and also reduces total costs. Collaborative care is research tested and replicated in many real world clinics. The move to integrated care 

takes work, but its core elements are not complex: station a mental health practitioner in the practice, screen for mental health problems, measure progress, allow 

billing for basic mental health services like educating patients about managing their 

depression and ensure a psychiatrist or other specialist is available for consultation. 

While collaborative care is proven, barriers to integrated care like separate benefits that are not available to primary care must be addressed. For collaborative care 

to work, the primary care setting must have its costs covered, including the modest 

additional costs of providing integrated care. There are also barriers in Federal 

standards. Medicare still does not pay adequately for the elements of collaborative 

care, despite the terrible burden of depression and other mental health challenges 

for older Americans. National screening recommendations are also outdated. They 

say, in effect, ‘‘If you have plenty of resources to treat depression, you ought to 

screen for it.’’ This is ridiculous. In my view, removing obstacles to primary care 

treatment of basic mental health problems is a core element of getting mental 

health parity right. It would be timely and very helpful if the committee were to 

track progress toward integrated care. 

Protecting the safety net. While health reform creates opportunities to improve 

care for many Americans, the safety net for individuals with the most serious mental illness is very stressed. This system, which evolved from State asylums and mental health centers to a diverse array of community-based treatment, rehabilitation 

and support services, is directed and managed at the State and sometimes the county level. Its financing depends on Medicaid and State general funds. And given 

State budget shortfalls, resources have been cut. The National Association of State 
41 

Mental Health Program Directors (NASMHPD) indicates that State mental health 

funding was reduced by more than $4 billion between 2009 and 2012. 

While these cuts have been damaging, in many States the mental health safety 

net is stronger than it was a quarter century ago. Dedicated providers as well as 

State and local officials have learned what works. For example, we understand that 

decent, safe and affordable housing is a foundation for recovery, and a ‘‘Housing 

First’’ approach that first finds homeless mentally ill people a place to live and then 

assists with health and mental health has become a usual approach. We understand 

that people in recovery from mental illness and addiction working as ‘‘peer specialists’’ play an invaluable role as staff of community agencies. Many community mental health agencies are also integrating medical services into their mental health 

clinics, to address the co-occurring medical problems of the people they serve. So 

while the mental health safety net is stretched to the limits, it is better focused and 

more relevant than in the past. 

There are threats to the safety net as health reform proceeds. Budget cuts have 

taken their toll, and we hope that as States move past budgets depleted by the recession there will not be further deep cuts. But there is also a concern about the 

erosion of informed leadership for the safety net system. Within States, as Medicaid 

has become the dominant payer for mental health services, the mantle of leadership 

is swinging away from mental health (and addiction) agencies toward Medicaid and 

Health agencies. A similar trend is occurring at the level where health care is managed; there is a movement toward managed care and within managed care there is 

movement from specialty behavioral health plans to mainstream managed care. The 

question is whether we can sustain the focus on quality of care for those most in 

need during this transition. We do not yet have national standards for the quality 

of care for people with serious mental illness, so the transition away from expert 

leadership is risky. We failed to maintain focus during an earlier era of deinstitutionalization; we must not make this mistake again. 

Children’s mental health care. Mental health problems have been called ‘‘the 

major chronic diseases of childhood.’’ Mental illness usually emerges before young 

people enter high school, but the average lag to treatment is 9 years. Only about 

a quarter of children with mental health problems see a mental health professional, 

and often not enough care is delivered to make a difference. At the same time, we 

are scandalized by reports showing increased levels of psychiatric medication use 

among children, often with no adequate counseling to supplement or as alternative 

to medications. We see the results of insufficient mental health care in school failure 

and youth suicide. How do we do better? 

While the gaps in children’s mental health care are huge there is also reason for 

hope. In part, this is because we know more about what works, and what doesn’t. 

We must start applying this knowledge. The timing is right if we act as we should; 

there are opportunities in healthcare reform and in calls to improve school mental 

health care. But like improvements to mental health care in primary care, improvement will not occur unless steps like these are taken: 

• Make screening for and treating maternal depression standard for the first 2 

years after birth. Maternal depression is prevalent, treatable, and can lead to big 

problems in development of the young child if left untreated. Treating mom’s depression reduces levels of mental health problems for her children by half ! 

• Help pediatric practices and child mental health programs to provide holistic 

care. Noted columnist David Brooks—scarcely a bleeding heart liberal—has written 

persuasively of the problem of children growing up without the ability to ‘‘self-regulate’’—to manage themselves and their own behavior. These skills can be taught— 

but only if we begin early by providing structured support to young parents. To do 

this, we need to be able to: 

• Begin therapy for children without a specific diagnosis—to reduce the chance 

that a serious diagnosis will be given later. 

• Allow comprehensive pediatric practices and child mental health programs to 

bill for parent training and support for behavior management—to reduce the 

use of major medication use after the behavior has gotten worse. 

• Reimburse and support team-based care in pediatrics including physician attendance at team meetings with families. 

• Reimburse pediatric and child mental health programs for care coordination 

with schools and other agencies; care coordination may be more effective and 

cost-effective than layering on additional treatments. 

• Put better performance standards in place for child mental health programs. 

Right now national standards are limited to ADHD and followup after hospitalization. Adolescent depression indicators are being developed but are not yet approved 

or used. What doesn’t get measured in health care often doesn’t get done. 
42 

• Do school mental health right. The President’s proposals following the tragedy 

in Newtown include significant expansion of school mental health. Done right, this 

could be a significant benefit. But we now know more about what is effective, and 

what isn’t. Expanded programs should only use proven approaches, such as peerassisted learning, and cognitive behavioral interventions for trauma, adapted for 

schools. Each of these approaches has been linked to improving educational outcomes. 

Develop a national approach for effective early treatment of psychotic illness. Our 

Nation’s approach to helping people with psychotic illnesses like schizophrenia is 

shameful. Usually, young people slip into psychotic illnesses for several years while 

they—or their families—get no help. When they have a ‘‘first psychotic break,’’ they 

usually are briefly hospitalized. Almost always, medications take the worst of the 

symptoms away—within days or weeks. So then they are discharged with a referral 

to care and maybe a recommendation of a support group. This is woefully, stupidly 

deficient. Having symptoms reduced is not a cure. When people feel better, and especially since the drugs have significant side effects, they often stop taking them. 

Relapse is likely. Usually the second break is worse. And then the revolving door 

begins. Often after decades people figure out how to manage their illness, but by 

then they are often on permanent disability status, unemployed, and in terrible 

health. 

Some have suggested that the solution to this problem is in going backward—not 

forward—to days when stays in mental hospitals were measured in months and 

years. This is idiotic. There is no research to suggest it is effective. It is terribly 

expensive. Hospitals cannot be run (as the old asylums were) on unpaid patient 

labor. And a civilized society cannot detain people on a vague hope they will get 

better. So we will not turn the clock back on mental health care. But we do need 

a modern approach to care for people with psychotic disorders, one that replaces 

both the asylum and the revolving door with continuous team treatment like that 

we provide for people with chronic medical problems. Teams delivering First Episode Psychosis (FEP) care have figured out how to do this work. It is personcentered, family-driven, collaborative and recovery-oriented. Staying in school or 

work is encouraged—though adaptations may be needed. It is time to implement 

this approach, as both Australia and Great Britain have done. We need not lag behind other nations in this area. Our country needs to make modest investments now 

to develop FEP teams so that families anywhere in the State struggling with a 

young adult who is slipping away from sanity can get good care reasonably close 

to home. The committee’s attention to this issue could have an enormous positive 

effect. 

Lifelong disability for people with mental illness is usually unnecessary. While 

many of the worst outcomes of serious mental illness (e.g. homelessness, comorbid 

medical illness, incarceration) are receiving increased attention, we are failing systematically to help people escape poverty and disability. In effective supported employment approaches such as Individual Placement with Supports (IPS) a majority 

of adults with serious mental illness find a job. But we generally fail to use this 

effective program. The Nation’s Vocational Rehabilitation (VR) system is focused on 

employment for people with disabilities, but it is limited in scope and flawed in its 

approach to helping people with mental illness. Most people with serious mental illness never get VR services, and among those who do, outcomes are worse than for 

other groups of people with disabilities. Most VR programs do not use IPS systematically. Meanwhile, Medicaid does not pay for key components of IPS. Because of 

these cracks between systems, an effective approach is usually not made available, 

and the employment rate among people with serious mental illness who are receiving care is, scandalously, about 15 percent. 

Supplemental Security Income (SSI) and, for those who become disabled after 

working, Social Security Disability Income (SSDI) are invaluable lifelines for people 

with serious disability including serious mental illness. But many people with mental illness on SSDI and SSI want to work. And most could work—at the very least 

in part-time private sector employment—if IPS was available and if disability was 

not an ‘‘all or nothing’’ program. 

I would like to bring to the committee’s attention an innovative program established by New York State and the Social Security Administration to address this 

problem. It takes advantage of Ticket To Work—a well-intended back-to-work incentive program that has never reached its potential, largely because of its complexity. 

The New York State Office of Mental Health (OMH) in collaboration with the New 

York Department of Labor and other State agencies serving people with disabilities 

developed a comprehensive employment system for people with serious mental illness and other disabilities. Key components include: (1) education and counseling 

on benefits (such as how to maintain Medicaid coverage while working, and how to 
43 

take advantage of complex Social Security work incentives); (2) an integrated information system that links people to and is built onto the Department of Labor’s 

workforce system; and (3) a statewide network of IPS services delivered through 

OMH Personalized Recovery Oriented Services (PROS) programs. Via a unique partnership agreement, the Social Security Administration has designated this system 

including all participating consumers and providers as a Ticket To Work Employment Network. This arrangement is the most systematic statewide approach to employment services and to fully using available benefits to support productivity instead of poverty and disability. 

I urge the committee’s attention to the costs and consequences of unnecessary disability for people with serious mental illness, in particular to: 

• Assuring that Vocational Rehabilitation and Medicaid figure out how to make 

effective Individual Placement with Supports services available to all people with 

serious mental illness who want work instead of poverty, and 

• How the Social Security/New York partnership can be implemented in other 

States. 

Suicide prevention: Now is the time to act. We are dismayed by reports that 

deaths by suicide in the Armed Forces last year exceeded other combat deaths. This 

concern is surely justified. Yet this is but the tip of the iceberg; twice as many 

American lives are lost to suicide in the average week than to military suicide in 

a year. Suicide, which is the tenth leading cause of death—and the third leading 

cause of death among young adults—receives a relatively small investment in terms 

of research and programming than other public health problems of its magnitude. 

We can and we must do more. 

The Administration, to its credit, has begun to focus on suicide prevention. In 

2010, Secretaries Sebelius and Gates launched the Action Alliance on Suicide Prevention, a public-private partnership co-chaired by Army Secretary John McHugh 

and former Senator Gordon Smith. With support from the Action Alliance, Surgeon 

General Regina Benjamin has released a comprehensive update of the National 

Strategy on Suicide Prevention, originally released in 2001. Yet more action is needed. Suicide prevention activities are scattered and thin. Outside the Department of 

Defense, the only national efforts are the National Suicide Prevention Lifeline (1– 

800–273–TALK), a technical assistance center, and the small network of youth and 

college prevention programs funded by the Substance Abuse and Mental Health 

Services Administration under the Garrett Lee Smith Memorial Youth Suicide Prevention Act. 

It is time to do more to fight this needless and often preventable form of death. 

It is claiming the lives of students, soldiers, veterans, and Americans of every age 

and background. Congressional action would help advance this cause, as it did with 

passage of the Garrett Lee Smith Act. The Action Alliance is focusing integrating 

state-of-the-science suicide prevention practices into initiatives under the Affordable 

Care Act. We assess that current clinical practices in the United States are one to 

two decades behind the research, which demonstrates that effective care, what we 

call ‘‘suicide care,’’ targeted to patients who are at risk, can significantly improve 

their prognosis. The Affordable Care Act offers numerous opportunities to incorporate best and effective practices into preventive services offered through Medicare 

and Medicaid, into electronic health records, and into other reform initiatives. 

Suicide prevention is an area where small amounts of money can make a difference. The Action Alliance has the potential to bend the curve on suicide, but it 

is funded this year via a time-limited grant from SAMHSA. Similarly, the Nation’s 

network of certified crisis lines, although linked together by the SAMHSA-funded 

Lifeline project, is mostly funded by State and local-level grants and philanthropy, 

yet it is projected to respond to a million callers this year, a large proportion of 

whom are in utter desperation and on the threshold of their own death. Research 

has conclusively shown that these crisis lines are effective and are performing as 

an indispensable part of the Nation’s health care system, yet they receive no Federal support. The committee’s attention could help assure that other Federal agencies do more to help, that the National Action Alliance for Suicide Prevention is sustained and that the national network of crisis lines is strengthened. These steps 

would be life-saving. 

Conclusion. We thank the committee again for focusing on mental health needs 

and opportunities, and we hope our suggestions are relevant and helpful. Some of 

the issues I discuss do not necessarily suggest easy fixes. But mental health concerns are coming out of the shadows, at a time of major change in health and mental health care. Now is the time to get it right. We face major opportunities to improve health care for millions of Americans, but these are opportunities that can 

easily be missed. Similarly, we cannot allow what remains of the Nation’s mental 
44 

health system for people with the most serious disorders to be dissipated. In an earlier, failed era of deinstitutionalization, patients were dumped into unprepared communities. This is not the time to dump them again, into ‘‘mainstream’’ arrangements without adequate protections and accountabilities. Fixing the mental health 

system requires more than gun control. And it is possible. 

The CHAIRMAN. Thank you very much, Dr. Hogan. 

And now we’ll turn to Dr. Vero. 

STATEMENT OF ROBERT N. VERO, Ed.D., CHIEF EXECUTIVE 

OFFICER, CENTERSTONE OF TENNESSEE, NASHVILLE, TN 

Mr. VERO. Thank you, Senator Harkin. 

Thank you, Senator Alexander. 

On behalf of Centerstone and my colleagues in behavioral health 

throughout this country, I again want to echo how much we appreciate the attention that community behavioral health and 

healthcare, in general, is receiving as a part of this hearing. You 

know, I hope that what I share will assist this committee truly as 

you seek to gain an understanding of the opportunities to address 

the gaps and barriers that we know currently exist in the mental 

health system. 

It’s been echoed several times this morning that we know that, 

recently, our country absolutely suffered the devastating loss of 28 

precious lives, 20 innocents, 6 courageous teachers and administrators, a mentally ill young man who did not get the care that he 

needed, and his mother who did not get the care nor the information that she needed. This tragedy, along with those in Colorado, 

Arizona, California, Virginia, and others, has thrown a very invaluable spotlight on community mental health, mental illness, and 

this entire discussion. 

To work in this area of community mental health is an extraordinary privilege. It’s likewise a tremendous responsibility. I’ve been 

fortunate throughout the last four decades to participate in our 

field from a variety of perspectives, as a clinician, as a critical incident responder, as a faculty member, as a research collaborator, as 

a patient, and as a CEO. I’ve seen firsthand what the research 

shows. Mental illness affects everyone, and mental health treatment is effective. 

Community mental health centers do a tremendous job for the 

people we serve. We change and save lives, helping to build strong, 

healthy, resilient individuals and strong, healthy, resilient communities. There are, however, several significant barriers and gaps in 

the current U.S. mental health system that make it difficult for our 

local agencies to serve as the safety net they were intended to 

serve by President Kennedy more than 50 years ago. 

Most significant among these is the limited availability of quality 

mental health services for children and youth. Sadly, we lack a 

Federal definition of what services a community mental health center should offer. Consequently, many towns and cities, especially 

rural ones, do not have access to a continuum of care that covers 

the life span. 

Since 50 percent of mental illnesses do occur before the age of 

14, and three out of four people experience the initial onset of these 

illnesses by the time they reach young adulthood, the lack of early 

intervention can have tragic and lasting effects. Congress is encouraged to pass language similar to that included within the Ex-
45 

cellence in Mental Health Act, defining that a community behavioral health provider must provide a full continuum of services 

across the life span. In particular, we wish to thank Senator 

Debbie Stabenow and Senator Jack Reed for their tireless leadership in this critical legislation. 

There are several ways as well to address the barriers to providing quality children’s services. Thanks to grant funding from 

SAMHSA and the Department of Education, Centerstone has been 

able to deliver home and school-based services within both urban 

and rural areas. These programs have proven clinically effective 

and likewise offset overall educational costs. 

Congress could increase its support of Federal funding to effectively deliver prevention and early education services. Congress 

could ensure as well that services to children and youth target the 

entire family. Research shows that programs that engage the whole 

family are the most effective programs. Inadequate insurance coverage too often becomes the barrier to engaging the entire family. 

Incredibly, not all States, counties, and community mental health 

centers offer formal crisis services, especially those services that 

are delivered 7 days a week, 24 hours a day, 365 days a year. The 

Excellence in Mental Health Act would also require the provision 

of these crisis services. 

Technology, which we haven’t talked very much about this morning, also prevents another barrier. Thanks to the work of the Office 

of the National Coordinator of Health IT and the leadership of Senator Sheldon Whitehouse, there have been tremendous advances toward creating standardized communication guidelines. 

Unfortunately, since community mental health was left out of the 

2009 HITECH Act, we have not been able to fully benefit from 

these advances. Strong bipartisan bills in both houses of Congress 

like those that have been introduced in the prior Congress by Representatives Murphy and Blackburn, and Senators Whitehouse and 

Collins would correct this problem. 

With behavioral health IT, this is what community behavioral 

health would be able to do. We could effectively share information 

for purposes of coordination of care, including treatment plans, 

with primary care providers. We would prevent some of the drugdrug interactions that occur because of a lack of shared information 

and, hopefully, prevent over-prescribing. We could also effectively 

track outcomes over time. 

There’s a great need for integrating physical and behavioral 

healthcare in this Nation. We hear a lot about America’s fragmented and broken healthcare system. The consequence, at best, is 

costly and, at worst, dangerous and too often deadly. People with 

serious mental illness, on average, die 25 years earlier than their 

non-mentally ill contemporaries. Is it because of their mental illness? No. It’s because of the impact of their comorbid conditions, 

diabetes, cardiovascular disease, as examples. 

Community mental health centers are key to improving physical 

healthcare by simultaneously lowering overall healthcare cost. Our 

expertise in behavior change is part of the solution to meet the triple aim of healthcare: reduced cost, improved health, and quality 

outcomes. 
46 

We are grateful that in 2009, SAMHSA launched its Primary 

Care and Behavioral Health Integrated Care Program and since 

has launched 94 programs across the country. Two have happened 

to land at Centerstone, which were very fortunate. The SAMHSA 

initiative seeks to improve the physical health status of people with 

serious mental illness and reduce their total healthcare cost by 

making sure services for behavioral health and physical health are 

provided at the same location. 

We have a substantial and complex task before us. We cannot 

solve these issues alone as providers. This is a moment. This is a 

watershed moment that demands courage and action. Everyone in 

this room shares responsibility for the future of community mental 

health. Community mental health centers stand ready to work with 

you, our elected and representative officials, to make a difference 

in this U.S. mental healthcare system. 

Thank you. 

[The prepared statement of Mr. Vero follows:] 

PREPARED STATEMENT OF ROBERT VERO, ED.D. 

SUMMARY

Community Mental Health Centers do a tremendous job for the people we serve. 

We change and save lives, helping to build healthy, resilient communities. There 

are, however, several significant barriers and gaps in the current U.S. mental 

health system that make it difficult for our local agencies to serve as the safety net 

envisioned by President Kennedy, more than 50 years ago. 

(1) Currently, many towns and cities, especially rural ones, do not have access to 

a continuum of evidence-based services designed for children and youth. 

Since 50 percent of mental illnesses start before the age of 14, and 3 out of 4 people 

experience the initial onset of these illnesses by young adulthood, this lack of early 

intervention can have tragic, lasting effects. The Excellence in Mental Health Act 

would require that community mental health centers offer a full continuum of care 

services to children and youth. 

(2) There are funding barriers to ensuring that services to children and youth 

target the entire family. Research shows that programs that engage the whole family are most effective. There is innovative grant funding from SAMHSA and the Department of Education to support communities in adopting evidence-based prevention and early intervention services. However, sustainability is often difficult due to 

insurance coverage restrictions and regulations. 

(3) Not all States, counties, and community mental health centers offer 24/7 mobile crisis services for children and adults. The Excellence in Mental Health 

Act would also require the provision of these crisis services by community mental 

health centers. 

(4) Since community mental health centers were left out of the HITECH Act and 

are often not included in local and State Health Information Exchanges, they 

currently lack the ability to efficiently share information for purposes of coordination of care; prevent over-prescribing, reduce medication errors; and, effectively 

track outcomes over time. There have been several bipartisan bills introduced, 

thanks to the leadership of Representatives Murphy and Blackburn and Senators 

Whitehouse and Collins, but it has not yet been made into law. 

(5) Currently there is a fragmented health care system for persons with mental illness. Community mental health centers are key to improving physical health 

while simultaneously lowering health care costs. Our expertise in behavior change 

is part of the solution to meet the triple aim of healthcare—reduced cost, improved 

health, and quality care. SAMHSA’s Primary Care and Behavioral Health Care Integration program addresses this fragmentation, but true sustainability for integrated care requires multifaceted changes from community mental health centers, 

States, managed care plans, and Federal regulations. 

Community Mental Health Centers stand ready to work with you to improve the 

mental health system. However, we cannot solve these issues alone. We ask for 

leaders in the public and private sector to work with us as we seek to create a new 

future for mental healthcare. 
47 

1Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 

twelve-month DSM–IV disorders in the National Comorbidity Survey Replication (NCS–R). Archives of General Psychiatry, 2005 Jun; 62(6):617–27. 

On behalf of Centerstone, I would like to personally thank Senator Alexander and 

Senator Harkin for the opportunity to comment on the state of the U.S. Mental 

Health System from the community mental health perspective. I hope what I share 

will assist the Health, Education, Labor, and Pensions Committee as you seek to 

gain an understanding of opportunities to address the gaps and barriers within our 

mental healthcare system. 

To work in the area of community mental health is, without question, an extraordinary privilege. It is likewise a tremendous responsibility. 

I have been fortunate throughout my career to participate in and observe our field 

from different perspectives—as a clinician, a critical incident responder, faculty 

member, research collaborator, client, and as a CEO. I have worked with hoarders 

whose homes were so cluttered that there was no longer safe passage to their beds 

for rest and refrigerators so contaminated that the contents were no longer safe to 

consume. I have worked with people who are so profoundly disturbed they’ve committed despicable and sometimes illegal acts. My role with these patients was to 

quell their psychosis and ensure safety for themselves and others. I also have had 

the responsibility of treating a mother’s depression and complex grief following the 

tragic death of her preschool-aged child. 

I have seen first-hand what the research shows—mental illness truly affects everyone. One in four American adults will have a diagnosable mental illness in any 

given year, and about 1 in 17 adults, 6 percent of the population, have a serious 

mental illness.1

As a community mental health center (CMHC), we are entrusted with the care 

of individuals, families, and communities whose lives have been impacted by mental 

illness. As health care leaders, we are called upon to work to create a mental 

healthcare system rooted in compassion, scientific understanding, individual recovery and, ultimately, disease management, prevention and cure. 

I chose this field nearly four decades ago because I thought that effective treatment for mental illness could have an equal or even more profound impact on families than treatment for heart disease and cancer. In school, I saw my inspired, intelligent friends devastated by anxiety, depression and bipolar disorder. I witnessed 

how trauma could weaken even the strongest of my colleagues. 

Over the years, I have found this to be true in my own family as well, especially 

when my 40-year-old cousin, Lisa, took her own life. I wish she had been able to 

ask for help when her pain became unbearable because I know there is an alternative to senseless death. Mental health treatment is life-saving. 

ROLE OF COMMUNITY MENTAL HEALTH CENTERS

Community mental health centers have an incredibly important role to help provide effective, high quality care to the children, families, and older adults they 

serve. We help to keep children together with their families. We provide a lifeline 

for people struggling at all levels of severity of need, from mild levels of anxiety to 

acute episodes of depression to those contemplating suicide. Our treatment services 

and broad array of services for all ages, work to prevent horrible tragedies while 

helping to build strong, healthy, resilient communities. Community mental health 

centers, as a whole, fill a tremendous gap and, moreover, do a tremendous job for 

the people we serve. There are, nevertheless, several significant barriers and gaps 

in the current U.S. mental health system that make it difficult for our local agencies 

to serve as the community safety net they were envisioned to be 50 years ago by 

President Kennedy. 

BARRIERS & GAPS IN ACCESS TO HIGH QUALITY CHILD & ADOLESCENT SERVICES

One of the biggest barriers is a lack of access to services for children and youth. 

Sadly, due to a lack of a Federal definition of what services a community mental 

center should offer, many towns and cities, especially rural ones, do not have access 

to a safety net provider, offering a full continuum of evidence-based services to children and youth within a service area. Since 50 percent of mental illnesses start before the age of 14, and three out of four people develop their condition, including 
48 

2Kessler, RC, Berglund, P, Demler, O, ET al. (2005). Lifetime prevalence and age-of-onset distributions of DSM–IV disorders in the National Comorbidity Survey replication. Archives of General Psychiatry, 62, 593–602. 3 National Research Council and Institute of Medicine. (2011) Preventing Mental, Emotional, 

and Behavioral Disorders Among Young People: Progress and Possibilities. Committee on the 

Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young 

Adults: Research Advances and Promising Interventions. Mary Ellen O’Connell, Thomas Boat, 

and Kenneth E. Warner, Editors. Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education. Washington, DC: National Academies Press. 4 Edwards VJ, Holden GW, Anda RF, Felitti VJ. Experiencing multiple forms of childhood 

maltreatment and adult mental health: results from the Adverse Childhood Experiences (ACE) 

Study. American Journal of Psychiatry, 2003;160(8):1453–60. 5 American Academy of Child and Adolescent Psychiatry (AACAP). (2008) Analysis of American Medical Association Physician Masterfile. Washington, DC: American Academy of Child and 

Adolescent Psychiatry. 6 National Research Council and Institute of Medicine. (2011) IBID 

bipolar disorder, depression and schizophrenia by young adulthood, this lack of access can have tragic, lasting effects.2

We know from the research that the right care at the right time has a huge potential to reduce the occurrence of mental illnesses, the severity of those illnesses, and 

their impact on people’s lives. Early mental health interventions for young children 

and families can reduce risk factors for mental illness and increase protective factors that build resiliency.3 If children impacted by multiple traumatic experiences 

do not get the care they need, it can have serious, life-long consequences.4

There are several ways to address this barrier: 

• The most permanent fix would be to pass language similar to that included 

within the Excellence in Mental Health Act specifically defining that a community mental health center has to provide a full continuum of services across the lifespan—including early intervention services. 

• Grant funding streams that encourage existing centers to expand their service continuum and partner with community organizations are also helpful. At 

Centerstone, due to grant funding from SAMHSA and the Department of Education, 

we have been able to offer mental health and substance abuse services within rural 

schools for children and youth. We are now co-located in 160 preschools, middle and 

high schools throughout Tennessee, serving as adjunct faculty and providing a service to the school, they would likely be unable to deliver without our partnership. 

In addition, we recently were awarded a grant for early intervention services for 

families of infants and toddlers at risk for emotional problems. 

• Pass Health IT legislation so that community mental health centers, especially rural centers, can access telehealth services. With a severe and growing national shortage of child, adolescent, and adult psychiatrists,5 telehealth is one of the 

key ways to foster improved access to services for children and adults with serious 

mental illness, especially in underserved and rural areas. 

Barriers to engaging the whole family in care. For our children, the most 

effective care involves treating the entire family. Over and over, my staff, who work 

with children in schools and other community settings, share frustrations and concerns for the children they treat because of limited or entirely no access to the 

child’s parents or caregivers. So often we detect issues in parents and other people 

in the child’s environment, yet we are sometimes hindered in our ability to treat 

the entire family unit due to inadequate insurance coverage. 

There are barriers to treating their uninsured or underinsured parents who have 

their own mental health needs and issues. We need to be able to teach parenting 

skills if we want the child’s behavior to change. We need to be able to address the 

parent’s depression or addiction if we want to make an impact on a child’s anxiety, 

truancy, or aggression. A mother is only able to advocate for her child and coordinate care if she, herself is healthy and able to cope. 

We are eagerly awaiting further news regarding a decision related to Medicaid expansion. It will allow community mental health centers to treat the low-income parent’s depression, substance use disorder, and/or other condition that impede effective 

parenting. 

Research shows that programs that engage the whole family, whether teaching 

parenting skills in a clinic or modeling those skills in a home setting is effective 

in reducing aggression, disruptive and antisocial behavior, and preventing substance 

abuse later in life.6 With SAMHSA grant funding, Centerstone has been able to implement these interventions in different communities in Tennessee, resulting in 

some incredible outcomes. However, sustainability often remains a barrier once 

grant-funding concludes. 
49 

Gaps between different care providing systems. We hear a lot about America’s fragmented health care system with current news focusing on mental health 

care. Children with serious emotional disturbances and mental disorders and their 

parents, in order to get the care they need, often have multiple providers and interface with multiple agencies (i.e. department of children’s services, juvenile justice, 

pediatric office, school, mental health center, etc.) The consequence is at best costly, 

and at worst dangerous. Care coordination models have proven effective outcomes. 

We encourage the expansion of these evidence-based models. 

There is an opportunity here for greater collaboration and shared accountability 

by mandating mental health and substance abuse services be incorporated into the 

clinical models funded by the Affordable Care Act. 

TRANSITIONS IN YOUNG ADULT CARE

Currently, when many adolescents with mental illness reach adulthood, they are 

at risk for experiencing a disruption in care if their State’s Medicaid plan does not 

have an eligibility class or allowance for an ‘‘aging out’’ transition plan. Even though 

the ACA affords insurance coverage for dependents, up to the age of 26 years old, 

on their parent insurance plans, many youth will not have access to such coverage. 

This issue must be addressed as States consider plans for Medicaid expansion. 

EXCLUSION OF COMMUNITY MENTAL HEALTH CENTERS FROM HITECH ACT

Thanks to the work of the Office of the National Coordinator for Health IT and 

the leadership of Senator Sheldon Whitehouse, there have been tremendous advances toward creating standardized guidelines. However, since community mental 

health centers were left out of the 2009 HITECH Act, we have not been able to fully 

benefit from these advances. This one barrier sets up roadblocks for the achievement of several key goals for our field. If behavioral health were included in this 

Act, we would be positioned to: 

• Effectively share information for purposes of coordination of care, including 

treatment plans, with primary providers, integrating our work to the benefit of the 

patient. 

• Preventing overprescribing and other consequences of failed drug coordination 

such as drug-drug interaction and/or toxicity. 

• Effectively track outcomes over time. 

From the CMHC perspective, I do not know how centers can ensure that the care 

we are providing is what we would want for each of our family members without 

using Health IT tools. The first 25 years I spent in this field were with paper 

records, and I can tell you the difference between clinical supervision of paper 

records and clinical supervision using analytics tools is night and day. Thanks to 

the Ayers Foundation and the Joe C Davis Foundation, Centerstone was able to develop analytics tools similar to those used by for-profit businesses. With these tools, 

I can hotspot clinics, locations and centers where outcomes are lagging and rapidly 

develop localized quality improvement plans. I can ask questions like, ‘‘how many 

children are we serving in foster care and have been prescribed atypical 

antipsychotic medications in the last 3 months,’’ or ‘‘how is our HEDIS client engagement metric last month compared to last year’’ and get the answer in 1 short 

minute. 

As primarily Medicaid providers, most community mental health centers exist 

with very little financial margin, if any. Funding large health IT purchases is a luxury most cannot afford. Due to the contrary, due to the billions in cuts our field has 

experienced over the last 4 years, some community mental health centers have been 

forced to simply shut their doors while many more have quietly ended programs and 

laid off large numbers of employees. 

Inadequate Health IT capacity impedes the ability of the whole field to improve 

the quality of mental health care. Centers not using Health IT are, moreover, unable to use analytics tools to look at quality metrics or conduct rapid, targeted quality audits. Most health information exchanges do not include community mental 

health centers, and many States have no regulations allowing the sharing of information electronically with CMHCs. Systems and processes designed to foster provider communications and shared data through electronic means would greatly improve health care outcomes and reduce cost. 

Strong bipartisan bills in both houses of Congress would correct this problem. 

H.R. 6043 championed by Representatives Tim Murphy of Pennsylvania and Marsha Blackburn of Tennessee and S. 539 introduced by Senators Whitehouse and Collins would authorize the participation of mental health and addiction providers in 

the healthcare revolution sparked by passage of the HITECH Act in 2009. 
50 

7 Agency for Healthcare Research and Quality (2013). AHRQ Program Brief: Mental Health 

Research Findings. Retrieved on January 19, 2013 from http://www.ahrq.gov/research/ 

mentalhth.htm. 8Kronick RG, Bella M, Gilmer TP. (2009) The faces of Medicaid III: Refining the portrait of 

people with multiple chronic conditions. Center for Health Care Strategies, Inc. 9 California 1115 Waiver Behavioral Health Technical Work Group. (2010). Beneficiary risk 

management: Prioritizing high risk SMI patients for case management/coordination. Presentation by JEN Associates, Cambridge, MA. 10 Coffey R, ET al. (2010). Emergency Department Use for Mental and Substance Use Disorders. AHRQ. 11Parks J, Svendsen D, Singer P, Foti ME. (2006). Morbidity and Mortality in People with 

Serious Mental Illness. Alexandria, VA: National Association of State Mental Health Program 

Directors. 

NEED FOR FORMAL MENTAL HEALTH CRISIS SERVICES IN EVERY COMMUNITY

Not all States, counties, and community mental health centers offer formal crisis 

response services. Whether by telephone, Internet, text or in-person, having a system of trained professionals for immediate response in the event of a crisis is, simply put, life-saving. I am in support of the President’s recommendation to increase 

mental health first aid training. I believe that it makes sense for every teacher, law 

enforcement officer, and first responder in the United States to know how to detect 

issues and engage someone to get help. However, we need to make sure that as we 

are training people to seek help when in crisis, we have an existing network available to respond to the situation and provide evidence-based, outcomes-driven services. It is not enough to detect an issue; someone must be able to respond. 

The Excellence in Mental Health Act, as part of its definition for what a community mental health center should do, requires that it provide crisis services. From 

my perspective, I know that this service not only saves life, it saves dollars, and 

I encourage this be considered vital to the service continuum of mental health safety 

net centers. In 2012, our Tennessee Crisis Call Center handled 18,350 emergency 

calls. Our Mobile Crisis therapists provided 6,081 face-to-face crisis assessments and 

in doing so prevented over 3,000 mental health-related hospitalizations—a huge cost 

savings for our State Medicaid program. Our Mobile Crisis team also aided in the 

appropriate hospitalization of another 3,000 individuals whose acute needs required 

a level of care beyond traditional outpatient services. Although this might not have 

saved Medicaid funds, it likely prevented countless tragedies. 

Tennessee’s TennCare Director and Deputy Commissioner for the State department of Finance and Administration, Darin Gordon as with our Commissioner of 

Mental Health and Substance Abuse Services, Douglas Varney should be recognized 

for their support of a formal, statewide Crisis Services program, serving the acute 

psychiatric needs of all Tennesseans. 

NEED FOR INTEGRATED CARE

The quality and length of life of our patients requires that we accurately assess 

and effectively treat their physical as well as their mental health needs. Mental 

health and physical health are as intricately intertwined as the brain is to the body. 

There is ample evidence that the current fragmented system with one part of the 

health care field treating mental illness and one treating physical illness is costly 

and, moreover, ineffective. 

While community mental health services are an extremely small percentage when 

you look at State budgets, mental disorders are one of the five most costly conditions in the United States.7 Fifty-two percent of the Dual Eligible beneficiaries with 

disabilities have a psychiatric illness. Psychiatric illness is found in three of the top 

five most expensive diagnosis dyads.8 In a study of the fee for service Medi-Cal system in California, when the 11 percent of the Medi-Cal enrollees with a serious 

mental illness (SMI) in the study were compared with all Medi-Cal enrollees, the 

SMI group’s spending was 3.7 times higher than the total population ($14,365 per 

person per year compared with $3,914).9 They also had a higher prevalence of other 

costly health disorders (diabetes, heart disease, chronic respiratory disease). 

Nationally, one in eight visits to emergency departments is due to mental disorders, a substance use disorder, or both.10 All of this healthcare, while costly, has 

not resulted in better outcomes. People with serious mental illnesses, on average, 

die 25 years earlier than people without such diagnoses, and this early mortality 

is primarily due to preventable physical health conditions.11

Community mental health centers are key to improving physical health while simultaneously lowering health care costs. The same skills we use to prevent mental 

health hospitalizations can be used to prevent physical health hospitalizations. The 

same skills our clinicians use to promote behavior changes in depressive cognitive 
51 

thought patterns or patients with alcoholism can be used to help our patients quit 

smoking, exercise more, and make healthy food choices. The same nurses in our 

clinics that test for lithium and clozapine blood levels could test for hemoglobin A1C 

levels and draw lipid screens. The same case managers that do home visits and 

check on whether someone with schizophrenia is taking their medication and meeting their mental health goals also could teach the patient how to take their blood 

pressure and track their weight. Our expertise in behavior change is part of the solution to meet the triple aim of healthcare—reduced cost, improved health, and 

quality care. However, reimbursement for these activities varies depending on the 

Medicaid, Medicare and the managed care plan. Most CMHCs lack funds for training costs to train our staff, update our clinics, and obtain health IT systems that 

are compatible with primary care systems. 

Thankfully, in 2009, SAMHSA launched its Primary Care and Mental Health 

Care Integration (PBHCI) program. This program seeks to improve the physical 

health status of people with serious mental illnesses and reduce their total health 

care costs through integration of services. SAMHSA has funded 94 sites nationally, 

and, in cooperation with HRSA, has co-funded a national resource center helping 

community mental health centers like Centerstone and Federally Qualified Health 

Centers and other primary care practices to integrate physical and behavioral 

health care. 

This funding stream has been very welcomed by Centerstone. Centerstone of Indiana was part of the second cohort to receive funds. My organization, Centerstone 

of Tennessee, was part of the 5th cohort. The biggest barrier to making integrated 

care sustainable for community mental health remains funding restrictions. Thankfully, we have seen more openness to lift those restrictions from managed care companies and States, and we are hopeful that this will be changing rapidly. 

More direction from CMS (Centers for Medicaid and Medicare Services) to States 

regarding definition of what services can and should be provided by mental health 

organizations might be helpful to make sure those restrictions lift. The Primary 

Care Mental Health Care Integration program is most valuable if it is sustainable, 

and sustainability can be achieved by some common sense changes. 

NEED FOR ADEQUATE AND CONSISTENT COVERAGE IN ACA

Currently, there is no guidance issued ensuring that behavioral health has a seat 

at the table for Accountable Care Organizations (ACO) and other care coordination 

models being adopted across the United States. It would be helpful, in the final Affordable Care Act (ACA) guidelines, for Congress to set forth instructions for the 

coverage of mental health and substance abuse services in the care and coverage 

models established by the ACA. 

CONCLUSION

Recently, our country suffered a devastating loss of 28 precious lives—the 20 innocents, the 6 courageous teachers and administrators, the life of a mentally ill young 

man who did not get the care he needed, and the life of his mother, who did not 

get the help and information she needed. This tragedy, along with those in Colorado, Arizona, California, Virginia, and others has thrown a spotlight on our mental 

health system. 

We have a long way to go to reach the President’s vision of ‘‘making access to 

mental health care as easy as access to a gun.’’ Our case managers, therapists, psychiatrists, nurses, researchers, and peer counselors are passionate about providing 

the best mental health care possible, and we seek to be part of the solution. However, we cannot achieve this solution in isolation. This is a moment that demands 

courage and action. Everyone in this room shares a responsibility for the future of 

mental health. Community mental health centers stand ready to work with you to 

improve the U.S. mental health system. 

Thank you for your time and attention. 

The CHAIRMAN. Thank you very much, Dr. Vero. I appreciate 

that. 

Now, Mr. DelGrosso, welcome. Please proceed. 
52 

STATEMENT OF GEORGE DelGROSSO, M.A., EXECUTIVE DIRECTOR, COLORADO BEHAVIORAL HEALTH COUNCIL, DENVER, 

CO 

Mr. DELGROSSO. Thank you, Senators Alexander and Harkin, 

and you, Senator Bennet. You’ve always been there for us for mental health in our State, and I want to thank you for being there. 

It’s interesting this morning as I hear the discussions happening 

around the room, and I want to share two thoughts with you if I 

might. The first one is I think you may be surprised about how 

many people are watching CSPAN today from around the country 

because they’re so excited about the opportunity to really discuss 

this matter in a kind of detail that we’re really hoping for. 

The second part of it is I’d like to share with you that if I could 

take a video of today and the comments that you all were making 

up there and the comments made down here today, and if we could 

sort of encapsulate it and play it to the public, and if that became 

the public message, we wouldn’t have to be here today. I think people would be greatly moved by what all was brought here today 

and what you’re saying about our area of healthcare and how important it is to address it, both mental health and substance use 

disorder. 

Today I’ve been asked to talk about mental health first aid. 

There were several of you that said, ‘‘Tell us about what we might 

be able to do to intervene or to connect earlier,’’ and that’s what 

I’ll be sharing. But I want to make sure, so I don’t run out of time, 

to tell you that there are a couple of things that can be done. 

One is that with the shortage of funding that has been in the 

area of mental health and substance use disorder, the funding that 

is available has really been focused on people who already have 

diagnosable conditions or are already significantly ill. And we need 

to ensure that we continue to provide care in those areas. 

But what we’re having problems with is when we do start doing 

prevention work in both the physical health area and the behavioral health area, often the codes and the funding are not available. 

So you have to take it out of your own pocket, in a sense, as a provider or the person themselves to try to get some of the necessary 

prevention and early intervention services and supports that they 

need to keep them from getting to that point. This is particularly 

a problem in the area of Medicare. 

Today we haven’t talked very much about the elderly. And I 

think a lot of people think because somebody is getting old that 

they’re going to just naturally be depressed and it’s a bad thing. 

But that’s really not the reality. Many people are aging and doing 

well, but sometimes there is depression or they have substance use 

disorders just like anybody else, and they need the help and the 

care that they can get to be preventive and also to get the treatment. 

Mental health first aid is an area in our State that we have a 

great deal of excitement about because of a couple of different reasons. No. 1 is that we saw the opportunity with mental health first 

aid to really get out into our citizenry and to be able to talk about 

mental health itself and increase their literacy and their understanding and recognition of the signs and symptoms of common 
53 

mental health diseases like bipolar, major depression, PTSD and 

anxiety disorders, as well as substance use disorders. 

But it also provides crisis de-escalation techniques by the people 

who take the class. Just like physical health, first aid helps you in 

order to be able to bandage something or to splint if there is a broken leg. And then there’s a five-step action plan to get persons in 

psychiatric distress referred to mental health providers. It’s a very 

comprehensive program. 

In the wake of the serious summer that we had, we often know 

about Aurora and the shootings there, but we also had two major 

fires in our State this past year, and a lot of people lost their 

homes and there was some loss of life. It was one of the most depressing summers we’ve had in Colorado for a long time, and it’s 

a beautiful State to live in. 

One of the things that we found is that by using mental health 

first aid, a lot of people began to reach out more for help themselves and to help their family members, and to understand more 

about what’s going on with them and what’s happening in the 

world around them. 

I’ll never forget meeting 1 day with Senator Udall and Senator 

Bennet and talking about the issues around mental health. And 

Senator Udall looked up and said, 

‘‘What we need is a program to help us to sort of identify 

things for our family members and friends and in our churches 

and in our Government, ET cetera, when they need help.’’ 

And we said, ‘‘Sir, let us tell you about mental health first aid,’’ 

and at that point, it became a real charge for us in Colorado. 

It’s interesting to note that our mental health first aid instructors have also done training with the Governor’s cabinet, department heads and managers at many State agencies. And there is a 

consideration right now that all State employees will take mental 

health first aid. The Department of Corrections does this today. 

They have trainers, and all of their corrections officers are being 

trained. 

I can go on and on about the number of people who have received 

this, but I want to let you know that there’s some really great news 

coming out of Washington on this. Last week, Representative Ron 

Barber introduced the Mental Health Aid Act of 2013. That’s H.R. 

274. As you may know, he was wounded in the tragic incident in 

Tucson, and mental health first aid was also helpful in their area 

as they were recovering from their tragedy there. 

We have it on good authority and anticipate that there is going 

to be a bill with bipartisan support coming through the Senate, and 

we would really ask that you consider supporting this as a committee and providing the funding that we so necessarily need in 

our community. 

Again, I want to thank you so much. What a tremendous opportunity to be here today and speak on behalf of this area of 

healthcare. Thanks for your interest. 

[The prepared statement of Mr. DelGrosso follows:] 
54 

PREPARED STATEMENT OF GEORGE DELGROSSO, M.A. 

SUMMARY

George DelGrosso, the CEO of Colorado Behavioral Healthcare Council (CBHC) 

will testify on behalf of CBHC and the National Council for Community Behavioral 

Health Care (NCCBH). His testimony will be an overview of Mental Health First 

Aid (MHFA) a prevention and early identification program, that helps parents, family members, teachers, law enforcement, and others in the general public to understand and better identify someone who may be mentally ill or in mental distress 

and help them get necessary treatment before there are serious implications for the 

person and the community. This evidence-based program, similar to First-Aid programs taught by the American Red Cross for physical health, focuses on mental 

health and is available in various locations throughout the United States. 

MHFA has proven to also be effective in Colorado to help communities cope in 

the aftermath of two major fire disasters, and a shooting in Aurora. CBHC received 

the NCCBH national award in 2012 for its implementation of MHFA instruction 

throughout most of the communities in Colorado. 

Mr. DelGrosso will also briefly discuss additional concerns facing community mental health and substance abuse providers the HELP Committee may want to consider. 

Chairman Harkin and Senator Alexander, thanks for giving me the opportunity 

to appear before the Senate HELP Committee on behalf of the Colorado Behavioral 

Healthcare Council and the National Council for Behavioral Health. My name is 

George DelGrosso and I am the Chief Executive Officer of the Colorado Behavioral 

Health Council (CBHC). 

The CBHC is a statewide organization composed of 28 behavioral health organizations including all of the 17 Community Mental Health Centers, 2 specialty mental 

health clinics, 4 managed service organizations and 5 behavioral health organizations. The latter organizations are the management entities throughout the State 

for substance use disorder and the State’s Medicaid mental health managed care 

program. 

Our members provide psychiatric care, intensive community-based services and 

addiction treatment to over 120,000 Coloradans each year. About 50 percent of our 

mental health center consumer/patient caseload is composed of adults with severe 

mental illnesses like schizophrenia and bipolar disorder. We also serve children with 

serious mental and emotional disturbances referred to us by their families, the Colorado juvenile justice, special education and foster care systems. 

I will be devoting the bulk of my testimony today to the Colorado Mental Health 

First Aid program because we believe that it’s an exciting new public health approach to early identification of mental illnesses and other mental health disorders. 

You will hear other witnesses testify today that mental disorders often begin manifesting themselves by as early as 14 years of age. According to the American Psychiatric Association Diagnostic and Statistical Manual, the first obvious symptoms 

of severe mental illnesses occur between ages 18 and 24. But, on average, it takes 

us 8 very long years to begin mental health care for these Americans. By the time 

treatment does begin, the costs of mental health care services are higher and their 

clinical effectiveness is reduced. 

That’s why both the National Council and the CBHC are so excited about Mental 

Health First Aid. It is an evidence-based practice that represents an early intervention and early detection program that—if implemented broadly enough—could permit America’s community mental health providers to help millions of our fellow citizens in psychiatric distress. In brief, Mental Health First Aid teaches a diverse 

array of audiences three important sets of skills: 

• Recognition of the signs and symptoms of common mental illnesses like bipolar 

disorder, major clinical depression, PTSD and anxiety disorders. 

• Crisis de-escalation techniques. 

• A five step action plan to get persons in psychiatric distress referred to mental 

health providers including local Community Mental Health Centers. 

In sum, this training is somewhat similar to first aid classes taught by local chapters of the Red Cross for physical health conditions. 

In our State, we receive some funding from the Colorado Office of Behavioral 

Health, which is the State mental health authority, and use Community Mental 

Health Center resources to provide Mental Health First Aid in various locations 

through out Colorado. People who want to attend a Mental Health First Aid class 

can log on to a Web site, or contact their local mental health center and enroll in 
55 

classes happening in their local communities. All of our Community Mental Health 

Centers have trained Mental Health First Aid instructors. 

As I indicated at the outset, a diverse array of training audiences is key to the 

program’s public health approach. For example, Mental Health First Aid Instructors 

have conducted trainings with the State Sheriff ’s Association and the Colorado Department of Corrections. In fact, the DOC has a goal of training all their corrections 

and parole officers. 

The committee might be interested to know that we’ve trained Governor 

Hickenlooper’s cabinet members, department heads, and the middle managers at 

many State agencies. CBHC is currently organizing Mental Health First Aid training for all the rabbis in the Denver Metropolitan Area. We would also like to extend 

the training to schools districts and institutions of higher education throughout the 

State. The ultimate goal is to increase the understanding of mental health issues, 

help our citizens be able to identify when a friend, co-worker or family member is 

having mental health distress, and help them get involved in treatment when it is 

necessary. Someday we hope to see Mental Health First Aid Instruction as common 

place as physical health first aid. 

In all candor, the tragic movie theater shootings in Aurora, CO added a strong 

impetus to all these efforts in Colorado. Indeed, in the aftermath of the enormous 

tragedy at Sandy Hook Elementary School in Newtown, CT, there has been an outpouring of bipartisan support for improving the mental health care system in this 

Nation. Voices as diverse as the Wall Street Journal editorial page, the libertarian 

Cato Institute, President George W. Bush’s former speech writer and, now, Vice 

President Biden’s Gun Violence Task Force have all endorsed various proposals to 

enhance mental health care in schools and improve services for people with severe 

mental disorders. In fact, the task force explicitly endorsed Mental Health First Aid. 

We note that there is a common policy thread running through all these proposals. In some form or fashion, they all endorse ‘‘early detection’’ of mental illnesses. The National Council and CBHC strongly endorse Mental Health First Aid 

because—from a prevention standpoint—that is exactly what the program does. It 

permits us to intervene early in the lives of individuals who later may be in desperate need of more intensive community-based mental health services. 

Last week, Representative Ron Barber introduced the Mental Health Aid Act of 

2013 (H.R. 274). Congressman Barber was grievously wounded in the tragic Tucson, 

AZ shooting that almost took the life of former-Representative Gabrielle Giffords 

and left six other persons dead including a 9-year-old girl. We have it on good authority that Senator Mark Begich will soon introduce the companion bill in the U.S. 

Senate. He will be joined by Senator Kelly Ayotte from New Hampshire. 

In a recent letter to Vice President Biden, Congressman Barber wrote the following: 

‘‘I urge you to endorse common-sense, bipartisan proposals like the Mental 

Health First Aid Act. We have failed to give the mental health care needs of 

Americans due attention for too long—and we paid too high a price for this neglect.’’ 

In the perhaps divisive legislative debate to come, we hope that the Senate HELP 

Committee can come together to enact the ‘‘common sense, bipartisan proposals’’ 

that Representative Barber referred to in his correspondence to the vice president. 

Again, thanks for the opportunity to testify. I am happy to answer any questions 

you may have. 

The CHAIRMAN. Thank you, Mr. DelGrosso. 

And now we turn to Mr. Fricks. Welcome and please proceed. 

STATEMENT OF LARRY FRICKS, SENIOR CONSULTANT, NATIONAL COUNCIL FOR BEHAVIORAL HEALTH, CLEVELAND, 

GA 

Mr. FRICKS. Thank you, Chairman Harkin and Senator Alexander. It’s an honor to be here and an honor that we’re getting this 

sort of focus on those of us that experience mental illness and addiction. 

I’d like to address three topics today: first, the stigma and discrimination that surround behavioral health disorders; second, the 

critical role of peer support and a new workforce in our country 

called peer specialists that promote recovery; and, third, the impor-
56 

tance of whole health. Mind-body has been huge in my recovery 

from bipolar illness. So those are the three topics I’d like to address. 

First of all, I am someone recovered from bipolar illness. I’m also 

clean and sober 28 years. And I can tell you and my peers can tell 

you that we fight two battles. We fight the illness, but we also fight 

the stigma. We have a saying in our movement: What you believe 

about mental illness may be more disabling than the illness itself. 

And yet as a society we largely remain ignorant about the signs 

and symptoms of mental illness, and we ignore our role as supportive community members to help those of us experiencing those 

illnesses. 

I was hospitalized three times in the mid-1980s. I fall in the category of a serious mental illness. I’ve ridden in the back of a deputy’s car. It’s a very humiliating experience. I spent a day in jail 

because of my psychosis until family and friends intervened and 

got me help, and I attempted suicide. So you can see it is humbling 

to be here today and have a chance to talk about this. 

What happens is the stigma is so significant that we often internalize it. It takes over our lives. It’s not only the diagnosis, but it 

becomes the prognosis that your life is over as you’ve known it. 

And yet today I live a full and meaningful life. I have a wonderful 

wife and a life in the north Georgia mountains. Key to that was 

learning self-management skills. I haven’t heard anything about 

self-management. Those of us in recovery know about self-management to stay well. Peer support is huge, having somebody that you 

can relate to, and also receiving services. 

Now, the future is mind-body. I just want to say that learning 

about sleep deprivation and its role in bipolar illness was huge for 

my recovery. And it was a former director of NIMH, Dr. Fred Goodwin, that introduced me to that. I manage my bipolar illness largely by managing my sleep patterns and being very careful. I fly almost every week, and I’m very careful. 

So this new workforce of certified peer specialists—in Georgia, 

for 13 years, I served on the management team for the State Department of Behavioral Health and Developmental Disabilities. 

They’re the fastest growing workforce in our State. We’ve trained 

nearly 1,000. There’s probably been 12,000 trained across the country. 

We focus on what we call strength-based recovery and whole 

health. We’re able to deliver services that are Medicaid billable if 

the service is included in the State plan. And research on the effectiveness of peer specialists has been so positive that in 2007 the 

Centers for Medicare and Medicaid Services issued guidelines for 

States wanting to bill for peer support services, proclaiming them 

as an evidence-based model of care. 

Research shows that we have a unique ability as peer specialists 

to connect with other peers to ignite hope and teach skills for recovery, self-management, and promoting whole health. However, I 

would warn you that Medicaid’s focus on medical necessity makes 

it tough, because we are strength-based and we look at unlocking 

hope and self-management. So it’s a little tough to fund under medical necessity. We’d like to see more flexible funding for that. 
57 

Peer respite centers are springing up across the country staffed 

by us. If you’re feeling early warning signs, you can go in. We have 

three of them in Georgia. You can spend up to 7 nights surrounded 

by peers, and it’s keeping people out of hospitals. We’re having tremendous success in Georgia. We’re under a Department of Justice 

settlement for deaths in our hospitals, so this is a service that we 

have that is really starting to pay off. 

Then addressing this mind-body healthcare, there can be no 

health without mental health. Conversely, we cannot successfully 

care for people with mental health and addiction disorders without 

addressing their co-occurring physical health disorders. Research 

indicates that people with severe mental illness in the United 

States who are served in the public healthcare system have an average life expectancy that is 25 years less than the general public. 

We’ve heard that already. We’re dying in the early 50s, many of 

us. 

So I just want to thank SAMHSA. They’re working to address 

this by providing grants to the community behavioral health centers for offering basic primary care screenings and coordinating referrals to primary care. As part of the Primary Care Behavioral 

Health Integration Program, nurses, trained care managers, peer 

specialists, and other healthcare professionals are now actively 

working in 94 grantee sites to screen patients for weight gain, 

blood lipid levels, cholesterol, teach skills for whole health selfmanagement and more. 

And although data is still being collected, early results indicate 

that this program has been successful. It is helping people with behavioral health conditions maintain or reduce their weight, cholesterol, blood sugar, and other risk factors for chronic disease. I 

strongly urge the committee to support this important grant program. 

In closing, I’d like to say that after nearly three decades of experience in behavioral health, it has taught me that the greatest potential for promoting recovery and whole health comes from within 

the individual, with the support of peers, family, and community. 

My recommendation is to establish and support programs that 

drive this potential, putting the person at the center of all services, 

building on their strengths and supports. 

Thank you very much. 

[The prepared statement of Mr. Fricks follows:] 

PREPARED STATEMENT OF LARRY FRICKS

SUMMARY

Good morning, and thank you for inviting me to speak at today’s hearing. I’d like 

to cover three topics: first, the ongoing stigma and discrimination that surround behavioral health disorders; second, the critical role of peer support to promote recovery; and third, the importance of a whole health approach when it comes to improving our healthcare system. 

Allow me to share with you today some of my lived experience of recovery from 

mental illness and substance abuse over the last 28 years. As anyone who has experienced a mental health or substance use condition can tell you, we must fight a 

battle on two fronts: one against the diagnosis itself, and the other against public 

ignorance. I was hospitalized three times in the mid-1980s. When I returned home 

from my last hospitalization I sank into deep despair. I internalized the stigma and 

discrimination experienced from mental illness, growing a negative self-image and 

sense of hopelessness from the prognosis that my life was over as I knew it. Yet 
58 

1Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H–45, HHS 

Publication No. (SMA) 12–4725. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2012. 

today, I live a full and meaningful life because I was able to learn self-management 

skills, gain peer support, and receive mental health services with a focus on mindbody recovery. Members of the committee, I urge you to support public education 

programs that reduce stigma and discrimination by helping Americans learn how 

to reach out and support their friends and family members who may be experiencing a behavioral health condition. 

Next, I’d like to share some information about certified peer specialists, who use 

their lived experience and are trained in skills to promote strength-based recovery 

and whole health, delivering services that are Medicaid-billable when included in 

State plans. Research on the effectiveness of peer specialists has been so positive 

that in 2007, the Centers for Medicare and Medicaid Services issued guidelines for 

States wanting to bill for peer support services, proclaiming them ‘‘an evidencebased model of care.’’ Research shows peer specialists are unique in their ability to 

connect with other peers to ignite hope and teach skills for recovery, self-management, and promoting whole health. However, because Medicaid requires ‘‘medical 

necessity’’ in documenting illness and symptoms—and peer specialists are trained 

to focus on strengths and supports—we need more flexible funding sources to grow 

the recovery and whole health outcomes that peer support services can deliver. 

This brings me to the final point I’d like to discuss: the importance of addressing 

the mind-body connection in healthcare. There can be no health without mental 

health. Conversely, we cannot successfully care for people with mental health and 

addiction disorders without addressing their co-occurring physical health disorders. 

The Substance Abuse and Mental Health Services Administration is working to address this issue by providing grants to community behavioral health centers for offering basic primary care screenings and coordinating referrals to primary care. As 

part of the Primary Care-Behavioral Health Integration program, nurses, trained 

care managers, peer specialists, and other healthcare professionals are now actively 

working in 94 grantee sites to screen patients for weight gain, blood lipid levels, 

cholesterol, teach skills for whole health self-management, and more. Although data 

is still being collected, early results indicate that this program has been successful 

in helping people with behavioral health conditions maintain or reduce their weight, 

cholesterol, blood sugar, and other risk factors for chronic disease. I strongly urge 

the committee to support this important grant program. 

In closing, I would like to say that nearly three decades of experience in behavioral health has taught me that the greatest potential for promoting recovery and 

whole health comes from within an individual, with the support of peers, family and 

community. My recommendation is to establish and support programs that drive 

this potential, putting the person at the center of all services, building on their 

strengths and supports. 

Good morning. Thank you, Chairman Harkin and Senator Alexander, for inviting 

me to speak at today’s hearing. My name is Larry Fricks. I am a senior consultant 

to the National Council for Community Behavioral Healthcare and deputy director 

of the SAMHSA—HRSA Center for Integrated Health Solutions. I’d like to cover 

three topics today: first, the ongoing stigma and discrimination that surrounds behavioral health disorders and the need for better public education regarding the 

facts about mental illness and addiction; second, the critical role of peer support to 

promote recovery; and third, the importance of a whole health approach when it 

comes to improving our healthcare system. 

As former First Lady Rosalynn Carter said, ‘‘stigma is the most damaging factor 

in the life of anyone who has a mental illness.’’ Stigma is our biggest challenge. 

Allow me to share with you today some of my lived experience of recovery from 

mental illness and substance abuse over the last 28 years, focusing on peer support 

and the skills I learned to self-manage my mind-body health. As anyone who has 

experienced a mental health or substance use condition can tell you, we must fight 

a battle on two fronts: one against the diagnosis itself, and the other against public 

ignorance. According to data from the Substance Abuse and Mental Health Services 

Administration (SAMHSA),1 one in five Americans will experience a mental health 

issue during any given year. Yet, as a society, we largely remain ignorant about the 

signs and symptoms of mental illness, and we ignore our role as supportive community members to help people experiencing these illnesses. 
59 

My grandmother, Naomi Brewton, graduated from the top of her class in college. 

But when she gave birth to her youngest son, she suffered what was then called 

a ‘‘nervous breakdown.’’ Her father was Dr. Brewton, founder of Brewton-Parker 

College near Vidalia, GA. The stigma and ignorance around mental illness prompted 

the family to secretly send her off to North Carolina for treatment. When she returned, she was a different person. For all the years that I knew her, she was a 

total recluse, never leaving home. 

My grandmother told great stories and had an infectious laugh that I loved, but 

I was never fully able to understand her life of tormented isolation until I was hospitalized three times in the mid-1980s. During my last hospitalization, I was kept 

in seclusion and restrained in my bed. When I returned home I sank into deep despair, overwhelmed by pending divorce, near financial collapse, and a weight gain 

of some 60 pounds from psychiatric medications. I internalized the stigma and discrimination experienced from mental illness, growing a negative self-image and 

sense of hopelessness from the prognosis that my life was over as I knew it, and 

thinking that highly society-valued roles like work may now be too stressful to consider. Like my grandmother, I began to isolate, with suicide becoming an attractive 

option. 

Mounting research shows that people without a social network of support and a 

sense of meaning and purpose are less resilient against illness—mind and body— 

and often die younger. That’s why meaningful work and peer support are emerging 

as huge factors in recovery and longevity. But in addition to peer support and gaining meaning and purpose from employment, my self-management really strengthened when I moved into mind-body resiliency. My life was forever changed after 

hearing a presentation by Dr. Fred Goodwin, former director of the National Institute of Mental Health and a specialist in bipolar illness. His research showed that 

restful sleep was a huge factor in building resiliency and preventing manic episodes 

like I had experienced. An anchor for my recovery is managing my sleep and reducing stress by practicing the Relaxation Response made famous by Dr. Herbert Benson at the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital. I was fortunate to have a psychiatrist who fully supported focusing 

my recovery around managing my sleep and after doing so, changed my medication 

to help shed much of the weight I had gained. 

Today, I live the kind of full and meaningful life that my grandmother was denied, because I was able to receive mental health services with a focus on recovery 

and learn self-management skills. We have come so far in the fight against stigma, 

in part because of greater public awareness and education about the nature of mental illness. You heard from another presenter about a program called Mental Health 

First Aid that teaches a five-step action plan to recognize the signs and symptoms 

of mental illness, respond to a person in crisis, and encourage seeking professional 

help, self-help and other support strategies. I am a Mental Health First Aid trainer, 

which means I teach people how to instruct others in becoming certified Mental 

Health First Aiders. I have witnessed first-hand the positive impact that comes from 

people with lived experience of recovery gaining the skills for providing support to 

help others experience a life of recovery from mental illness and substance abuse. 

MHFA attendees also learn about the growing awareness of the impact of trauma, 

especially childhood trauma, on mind-body health and why we need traumainformed services and supports. 

Members of the committee, I urge you to support Mental Health First Aid and 

other public education programs that help Americans learn how to reach out to their 

friends and family members who may be experiencing a behavioral health condition. 

One bill to this effect has already been introduced in the House: The Mental Health 

First Aid Act (H.R. 274). I encourage you to give this bill a hearing when it is introduced in the Senate and offer your support when it comes before your committee 

this year. 

Next, I would like to share some information about the newest workforce in behavioral health, called certified peer specialists. Peer specialists are trained in skills 

to promote strength-based recovery and whole health, delivering services that are 

Medicaid billable when included in State plans. Research on the effectiveness of 

peers in promoting recovery has been so positive that in 2007 the Centers for Medicare and Medicaid Services (CMS) issued guidelines for States wanting to bill for 

peer support services, proclaiming them ‘‘an evidence-based mental health model of 
60 

2 Center for Medicare and Medicaid Services, State Medicaid Director Letter #07–011. August 

15, 2007. 3 Eiken, S., & Campbell, J. (2008). Medicaid coverage of peer support for people with mental 

illness: Available research and State example. Published by Thomson Reuters Healthcare. Retrieved from: http://cms.hhs.gov/PromisingPractices/downloads/PeerSupport.pdf. 4Davidson, L., Chinman, M., Sells, D., & Rowe, M. (2006). Peer supports among adults with 

serious mental illness: A report from the field. Schizophrenia Bulletin, 32, 443–450. 5Sells, D., Davidson, L., Jewell, C., Faizer, P., & Rowe, M. (2006). The treatment relationship 

in peer-based and regular case management services for clients with severe mental illnesses. 

Psychiatric Services, 57(8): 1179–84. 

care which consists of a qualified peer support provider who assists individuals with 

their recovery from mental illness and substance abuse disorders.’’ 2

Peer support specialists have personally addressed stigma and discrimination and 

gained the lived experience to promote recovery and support rather than illness and 

disability. Because of this, peer specialists are unique in their ability to connect with 

other peers to ignite hope and teach skills for recovery self-management and promoting whole health. According to a 2008 study by Eiken and Campbell, 

‘‘The growing evidence includes reduced hospitalizations, reduced use of crisis 

services, improved symptoms, larger social support networks, and improved 

quality of life, as well as strengthening the recovery of the people providing the 

services.’’ 3

Published 2006 research by Davidson ET al., found that 

‘‘peer providers can increase empowerment, decrease substance abuse, reduce 

days in the hospital, and increase use of outpatient services, at least as long 

as long as the peer support continues.’’ 4

A 2006 study by Sells, ET al., found 

‘‘the unique role of trusted peers connecting with each other to foster hope and 

build on strengths is emerging as a key transformational factor in mental 

health services.’’ 5

One of the most innovative services beginning to spring up across the country are 

peer respite centers. Georgia funds three of these centers and they are proving highly effective at reducing hospitalizations, an important outcome the State has 

pledged to achieve under a Department of Justice settlement resulting from deaths 

in State hospitals. In Georgia, if a peer senses early warning signs of possible relapse, he or she can spend up to 7 nights at a respite center supported by peer specialists promoting mind-body health and self-management. Georgia also recently received CMS approval for peer specialists certified in a new training created by the 

SAMHSA–HRSA Center for Integrated Health Solutions called Whole Health Action 

Management (WHAM) to bill Medicaid for peer whole health and wellness services. 

I urge the committee to support including certified peer specialists as billable providers under Medicaid, given their effective role in supporting their peers in recovery and whole health. However, because Medicaid requires ‘‘medical necessity’’ documenting illness and symptoms and peer specialists are trained to focus on strengths 

and supports, we need more flexible funding sources to grow the recovery and whole 

health outcomes peer support services can deliver. 

This brings me to the final point I’d like to discuss today: the importance of addressing the mind-body connection when it comes to healthcare. 

There can be no health without mental health. Conversely, we cannot successfully 

care for people with mental health and addiction disorders without addressing their 

co-occurring physical health disorders. Research indicates that people with severe 

mental illness in the United States who are served in the public healthcare system 

have an average life expectancy that is 25 years less than the general public. That’s 

the same as the overall U.S. life expectancy in 1915, a time before any of the 

healthcare advances that have allowed us to lead steadily longer lives over the last 

century. 

The primary culprits behind this shocking situation are untreated but preventable 

diseases that commonly occur together with mental illness and addictions: cardiovascular disease, diabetes, complications from smoking and some of the side effects 

of psychiatric medications that cause weight gain and diabetes. Most people receive 

routine preventive care that would help identify these conditions early, make lifestyle changes, or receive appropriate medications to ensure they are well-controlled. 

But people with serious mental illness often cannot access this preventive care—or 

even get treatment for their other health conditions. 

The Substance Abuse and Mental Health Services Administration is working to 

rectify this problem by providing grants to community behavioral health centers for 

offering basic primary care screenings and coordinating referrals to primary care. 
61 

As part of the Primary Care-Behavioral Health Integration program (PBHCI), 

nurses, trained care managers, peer specialists, and other types of healthcare professionals are now actively working in 94 grantee sites to screen patients for weight 

gain, blood lipid levels, cholesterol, and more. 

Although data is still being collected, early results indicate that this program has 

been successful in helping people with behavioral health conditions maintain or reduce their weight, cholesterol, blood sugar, and other risk factors for chronic disease. I strongly urge the committee to support this important grant program. 

In closing, I would like to say that nearly three decades of experience in behavioral health has taught me that the greatest potential for promoting recovery and 

whole health comes from within an individual, with the support of peers, family and 

community. My recommendation is to establish and support programs that drive 

this potential, putting the person at the center of all services, building on their 

strengths and supports. 

The CHAIRMAN. Well, thank you, Mr. Fricks. I think your testimony really does kind of summarize what we’re all here about 

today, and that is providing the kind of interventions and early 

support so that people can successfully deal with an illness, just 

like we deal with every other illness, and you’re a prime example 

of that. From my limited experience in this area, I couldn’t agree 

with you more that the most important element in this comes from 

within, and how do we build that system. 

Peer support is so important. You talked about maybe billable 

hours for providers of peer support. I can tell you that it is so extremely important that self-management skills need to be taught. 

A lot of times, this doesn’t come from just a drug. I think it also 

recognizes—and I’ll get back to Dr. Vero on this also—that mental 

health and physical health are, as you said, intricately intertwined, 

intricately intertwined. 

Now, again, at the risk of practicing medicine without a license— 

but I’ve been involved in this for almost 30 years now from this 

standpoint in this committee and my other committee—I think we 

have more than adequate data to show that so many physiological 

conditions have their genesis in psychological conditions. And yet 

we always attempt to just treat the psychological condition, and 

sometimes that makes it even worse. 

We had a hearing on this last year on pain and all the pain clinics that have come up all over America. They’re treating pain. Yet 

we had one witness, a very distinguished doctor who had written 

a lot of books about this—not everything, you can’t make everything just total. But the vast majority of these pain afflictions has 

its genesis within psychological problems, anxiety, stress, things 

like that that manifest themselves in pain. 

Yet people go to pain clinics to get a shot or to get some kind 

of medicine or to get a back operation or something like that that 

may not be warranted. Again, I’m always cautious to say that it’s 

not 100 percent. I’m just saying that the vast majority of this—I 

just don’t think we recognize that, this intricate intertwine between 

mental health and physical health. 

Well, I took a lot of my time talking, and I shouldn’t. But I want 

to start with Dr. Hogan. 

You talked about getting it right—primary care providers providing mental healthcare, moving from a separate system. Tell me 

about the accountable care organizations that are springing up. 

They’re going to have the guidelines, you say, for what these enti-
62 

ties have to provide. But I don’t think we have any kind of instructions to them. 

Is that what you’re suggesting, that we need to instruct these accountable care organizations that they also need to structure this? 

They need to structure it? 

Mr. HOGAN. Absolutely. They’ll learn this sooner or later. 

The CHAIRMAN. Well, we can’t wait until later. 

Mr. HOGAN. Exactly. So, for example, if you have diabetes or hypertension or cancer or these other major medical problems, and 

you also have depression, your total medical costs are going to go 

up somewhere between 50 and 75 percent. And if you treat the depression, it allows the person, as Larry was saying, to be an active 

player in the management of their whole health. 

But you can’t hope that their depression goes away. You actually 

have to diagnose it. You have to provide a little treatment for it. 

But the data shows that a relatively small investment in providing 

that mental healthcare in that primary care setting—or it might be 

in the context of an ACO—is going to reduce total cost because people are going to be better able to take care of themselves. 

The CHAIRMAN. Dr. Vero, you mentioned that also in your testimony about the accountable care organizations. Do you have any 

elaboration on what Dr. Hogan just said? 

Mr. VERO. I think the other element at play would be our expectations for accountability, so let’s underscore that. That act will 

allow us to set some clear expectations for performance, what is expected in terms of improving those healthcare outcomes in the 

agreement between those accountable care organizations and the 

provider in that provider system. We are now beginning to target 

what are those key healthcare indicators on the physical health 

side, on the behavioral health side, that will work together to truly 

improve overall outcomes. 

The CHAIRMAN. There’s a barrier of insurance coverage. I think 

you mentioned that. In this area around Washington, DC, there are 

very few in-network mental health providers. I started looking at 

that some time ago and wondering why. I have good coverage, Blue 

Cross Blue Shield, all that. But I’m amazed at how few are in the 

network. 

The more I looked at it, they said, ‘‘Well, the reimbursement is 

not good enough.’’ Well, I looked at that a little bit longer, and then 

I started thinking and looking at the amount of support that taxpayers through Federal programs and other programs gave these 

practitioners when they were going through medical school, or 

when they were then going into their specialties, and then when 

they were going into their residencies. 

To be sure, a lot of them accumulated a lot of debt themselves 

that they’re paying back. But, again, they got these nice guaranteed government loans at low interest rates. So I’m just wondering 

shouldn’t we expect a little more of them than that they just don’t 

get reimbursed enough by Blue Cross Blue Shield so they’re out of 

the network? 

As I think Senator Sanders said, if you have the money and you 

can afford it, you’re fine. But you could be actually paying a lot in 

your insurance coverage, still not having the coverage for mental 
63 

health services, and then you’ve got to pay additional out-of-pocket 

for that. Any thoughts on that? 

Mr. DelGrosso. 

Mr. DELGROSSO. Yes, sir. Thank you so much for making that 

comment, because it’s something that’s, like they say, the proverbial elephant that’s in the room that people don’t often talk about. 

And it’s been sort of surprising to me how insurance companies 

have not been able to somehow put together the savings on the 

physical health side if they provide more care on the behavioral 

health side. 

It may be due to the fact that they have short-term contracts and 

don’t necessarily look at the long run with it or whatever. But I 

think that what we see is the head is not connected to the body 

and sometimes often is the management and the thinking as people 

go forward. So they look at the physical health costs separately 

from the behavioral health costs. 

One of the real pluses for accountable care organizations that 

you were talking about is the opportunity to bring together the 

funding to put the right service, the right place, the right time, and 

the right cost or right payment that might be there. And it brings 

all four of those pieces together, where if you’re saving money on 

the physical health side by providing more behavioral health services, you can move that money over there as needed and vice versa. 

So it’s really important. 

I think the expectation of providing care for people who are uninsured has fallen greatly on the Federal Government and on our 

States in their indigent care programs and then their Medicaid program. So people end up shifting over to the public side because 

they don’t have the behavioral health coverage on the physical 

health side. It’s a quagmire, but I think that we’re on the verge of 

making some changes that could be very helpful for us. 

The CHAIRMAN. I just told my staff what you said. We’ve got to 

work on this. We’ve got to make sure these accountable care organizations have that model and that they fully implement that 

model. And, hopefully, we can, through this committee and through 

the Administration and others, impress upon them the necessity of 

doing so. 

Well, thank you. I’ve run way, way over my time, and I apologize. 

Senator Alexander. 

Senator ALEXANDER. That was very interesting. Thank you, Mr. 

Chairman. 

Well, thanks to the four of you for coming today. I’d like to listen 

to what you have to say, so I’ll ask a question and then I’ll ask 

each of you to answer. If you could think of one thing that the Federal Government could do, that we could do, to make it easier for 

you to spend the money we now spend more effectively—the money 

we spend primarily through the two big block grants and through 

Medicaid is the way I gather that most of the Federal money goes 

to mental health. What would be the one thing that we could do 

that might make it easier for you to do that? 

Dr. Vero, if you could start—and I’d like to ask you this additional question. You mentioned about the importance of a continuum, which makes sense, for a community mental health center. 
64 

Now, you’re one of the largest operators of community mental 

health centers. Would that be an additional cost to each community 

mental health center if it did that? If so, who would pay for that? 

If the Federal Government were to require that, how much would 

it cost and how much money would we have to appropriate for 

that? Or if we require it without paying for it, which is sometimes 

what we do around here, then who would pay for it? 

Mr. VERO. Senator, I want to first start with an acknowledgement of my early service in Tennessee and you in your Governor 

role. We talk about this continuum of care over the age span. When 

you were Governor of Tennessee, we built out a statewide therapeutic preschool program. We had therapeutic preschools in every 

single one of our community mental health centers across all 95 

counties. 

Those schools were there to deal with their most vulnerable children with whom we were seeing early indications of the onset of 

severe mental illnesses, those SED children we’ve referenced several times today. So what happened? Very few of those programs 

exist. And I can tell you we are so fortunate at Centerstone to still 

continue that program. But it’s not in the four-wall classroom any 

longer because that model was no longer affordable. 

Community mental healthcare has been subjected to a horrid 

state of commoditization. It’s just a fact. As we move from Medicaid 

programs to managed Medicaid programs, we are part of the 

healthcare system that continues to be looked at as a commodity. 

Our services are minimized oftentimes to their smallest view, to 

the nickel—you know, to the dollar, to the quarter, to the nickel 

for differences in choosing who the provider might be, where the 

contract is, or, more importantly, what the service is, what that 

array of services are. 

As that requirement dropped with that commoditization, those 

preschool programs were lost. We took our preschool program and 

moved it into the community. And here’s the good news. We were 

only able to serve about 48 of those children a year, because it was 

a high-cost program and because the managed care company had 

a hard time understanding what its role was in addressing the 

healthcare needs of these children while they were also receiving 

vital educational services. 

One of the things we need to do from that Federal level is let’s 

remove these barriers that oftentimes don’t allow us to bring our 

systems together—education, criminal justice, mental health—in a 

cooperative way for the sole purpose of addressing our healthcare 

crisis. We spend too long arguing over what part of the day education should pay for versus what part of the day a managed care 

company or Medicaid should be paying for. We have to address 

those conversations immediately if we’re going to make any difference in the conversation that we’re having. 

Senator ALEXANDER. Well, I’d like to work with you, and I’ll ask 

my staff to followup to get specific examples of how to do that. Just 

out of curiosity, was that part of the Healthy Children Initiative 

that we had in Tennessee back then? 

Mr. VERO. Initially, yes, sir. 

Senator ALEXANDER. Well, I’ll tell my wife. That was 30 years 

ago. My wife was the head of that, and the deputy of that was Mar-
65 

guerite Sallee, who ran America’s Promise until recently and headed Bright Horizons, the worksite daycare company. 

Now, my time is about up. But if there’s one thing that we could 

do that would change existing law or practice to spend the money 

we now spend better—and you can follow that up in writing if 

you’d like to—is there one thing you’d like to briefly mention? And 

that’s my last question. 

Mr. DELGROSSO. I’d like to make a recommendation that you 

allow that the services that you currently pay for be opened up to 

provide more services at the front end, to provide more prevention, 

early intervention, support peer services like what Larry was talking about a little while ago, and to let the creativity of this country 

and how we’re moving forward in other areas of healthcare to also 

enter into behavioral healthcare and allow us to do the right thing. 

Senator ALEXANDER. Was there any other comment on that? 

Mr. VERO. Senator, if I could add to that, we keep talking about 

access. We’ve talked about the shortage of psychiatrists, especially 

child and adolescent psychiatrists. We’ve been providing telepsychiatry services since 2002 in the State of Tennessee. Those services 

are getting out to counties where we can’t hire physicians, where 

we can’t draw those physicians to maybe those more rural areas. 

It is 2014 as we sit here today. We need to align our payment 

streams with our current technology. We’re not permitted in the 

State of Tennessee—and I know elsewhere throughout the country—to provide telecounseling services. I can have a psychiatrist 

talk to a child and interview that child and provide services and 

work alongside a practitioner who’s sitting next to a child and do 

medication management. But I can’t provide counseling services remotely through telehealth and get reimbursed. 

It’s 2014. We have 12 years of experience on the psychiatry side, 

and we can’t seem to move out of the current limitations around 

those services. 

Senator ALEXANDER. Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Alexander. 

Senator Franken. 

Senator FRANKEN. Thank you, Mr. Chairman. 

Thank you all for your testimony. 

Dr. Vero, you note in your written testimony that there are a 

number of barriers to access to children’s mental health services. 

Specifically, you recommend, 

‘‘grant funding streams that encourage existing centers to expand their service continuum and partner with community organizations.’’ 

I mentioned in earlier questioning that I’m introducing a bill 

called The Mental Health in Schools Act, which does that exactly 

by providing grant funds for schools to partner with mental health 

centers and other community-based organizations. Can you explain 

why this is so important to students? 

Mr. VERO. Senator, first, let me thank you for moving that bill 

forward again this year. I think it’s rather simple. We know that 

most of the disorders that we see in children are first identified, 

not, as most of us would believe, in the office of a pediatrician or 

their family practitioner, but instead by their school teachers, some 

as early as their preschool teachers who see this behavior. 
66 

They’re well-trained in normal child development. They typically 

know what is expected of that age group. When they see unusual 

and bizarre behaviors or very, very troubled children, they need to 

bring that to the attention of professionals. Your bill is encouraging 

the same thing. Those teachers have the competencies to help us 

identify those children who need early intervention. 

We’re in 160 schools currently in Tennessee. Those are partnerships that work. I have licensed master’s level therapists in those 

schools providing the care that you’re outlining, that you’re addressing. We need to get school-based services throughout the 

country. 

Senator FRANKEN. I was just in Mounds View, MN. We had a 

roundtable there—a couple of roundtables, but one specifically on 

integrating community mental health. And you talk in your testimony also about how this is really a family disease or a family 

matter. 

We had three mothers talk, whose kids were turned around completely because the school system had integrated their system with 

community health, and they had a mental health partner, a professional who took their caseload of a number of children. We had one 

woman there—I think she was 26. She had an 8-year-old child who 

had been completely turned around. She was a single mom. She 

was not a wealthy woman living on Fifth Avenue. 

This woman had such a joy in describing her son who had been 

completely turned around. He was diagnosed, I think, with 

Asperger’s, and he had been unruly. But once they got ahold of it, 

he’s turned around completely. And we had two other moms there. 

This is a family disease. 

Mr. VERO. It is. 

Senator FRANKEN. I wrote two movies like 20 years ago on the 

family disease of alcoholism. 

Thank you, Mr. Fricks, for your testimony. Congratulations on 28 

years of sobriety. 

When I was doing research for that, I was talking a lot to rehab 

counselors. 

Dr. Hogan, I want to ask you about this—the shocking ignorance 

of general practitioners about alcoholism. The teacher is for kids in 

the school. But the pediatricians—what they don’t know about this 

is pretty remarkable. Integrated care is so important, and it’s 

something we do pretty well in Minnesota. We have accountable 

care organizations that were already accountable care organizations before we wrote accountable care organizations into ACA, and 

they’ve become pioneer ACOs. 

What can you say about the training of doctors in medical school 

that we should be doing that we’re not doing? Or have we gotten 

better at that? 

Mr. HOGAN. Thank you, Senator. I want to just comment very 

briefly on your point about children and to underline this in a way 

that I think may resonate with Senator Harkin, because he’s been 

closely connected to and has followed and help build an extraordinary national program of early intervention for young people who 

have got a developmental disability. If you have a significant developmental disability, you’re basically entitled to some support and 

care for yourself and your family. 
67 

For children with these problems that you’re describing and that 

8-year-old you described who got turned around, we have an average wait of 9 years until we find out about it. And these are conditions where just a little bit of help is going to change that young 

man’s trajectory possibly for the rest of his life. So this is of profound importance. 

I’ll say two things with respect to your question around doctors 

and their training. One is that training around these conditions 

is—there’s too much that they have to cover in medical school, and 

this gets short shrift, period. But it’s not a problem that can be 

fixed by training doctors better, because the primary care doctor 

has 7, 8, or 10 minutes. 

The only way that this integrated care can be delivered is if one 

of our types is basically parachuted into that doctor’s practice. And 

if the patient does a screen in the waiting room, the doctor can 

then say, ‘‘I see you have concerns about your sleeping and you’re 

feeling depressed, and I’d like to ask Ms. Jones to come in. She’s 

an expert in that area.’’ Ms. Jones can then spend the time that 

it takes to talk through the symptoms, to maybe explain the sleep 

issue that Larry described. 

These programs that go under a rubric of collaborative care—the 

doctor does have to change behavior a little bit, but it’s got to be 

a team approach, and the team approach can be thwarted by two 

things. One is if we take the mental health benefit—I’m going to 

argue in a way that may seem reverse. If we keep the mental 

health benefit in a separate insurance plan and only pay it to mental health specialists, it’s not going to help the primary care doctor. 

But if we give it to the mainstream insurance plan and don’t 

make them measure it—did you ask about depression, did you start 

people on treatment, did they improve? Unless we do that, we can’t 

expect results either. So we’re sort of getting what we have designed. I’m going to say that parity, as important as it is, is, I 

think, less critical now than figuring out how to crack this problem 

of primary care and getting support to the doctors out there that 

have got 8 minutes, don’t have the training, and don’t know how 

to do this stuff. 

Senator FRANKEN. I would just argue that when these conditions, 

the mental health conditions, these addiction conditions somatize 

themselves into other things—I see a lot of nodding—that there are 

primary care physicians who don’t understand that and don’t understand that they’re seeing something that really comes from 

something else, something else that may be addiction or may be 

mental health. 

I’m way over my time. Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Franken. 

Senator Warren. 

Senator WARREN. Thank you, Mr. Chairman. 

Thank you all for being here today. I read your testimony, all of 

it. It was very powerful testimony. Thank you very much. 

The thing I drew out of the testimony, though, is a part we 

haven’t talked about, and that is that millions of people who have 

serious mental health issues are not seeking care. And you’ve 

talked in different ways about why that is so. You’re all kind of de-
68 

scribing a different part of the animal. Mr. Fricks talks about stigma and why people don’t ask for care. 

We talked about the availability of treatment, practitioners, 

whether or not we’ve got enough people, how we might deal with 

that with peer specialists, how we might deal with that with community healthcare centers and doctors’ offices. We talked a little bit 

in the earlier panel about research, the importance of research, so 

we get better treatment, how we get better outcomes at lower cost. 

But the one I wanted to focus on in this last opportunity to talk 

is about the cost to the individual. I saw in the Kaiser study that 

45 percent of those who don’t seek care indicate that the cost is 

what deters them, that all those other things are there but they 

feel like they can’t afford it, that they can’t go out of pocket. 

What I’d like to hear from you is about the impact, about what 

that means when people deny care to themselves, to their children, 

to spouses and others in their families, and just what happens 

then. And to describe that either—we can talk about it in human 

terms and we can talk about it in financial terms, and in financial 

terms for the family or for the whole system. So I’d be grateful if 

you’d talk about that. 

Maybe, Mr. Fricks, you’d like to start. 

Mr. FRICKS. Well, in rural communities like mine, it’s so obvious 

about the stigma, because you’ll park out front if you go into the 

public health, but if you’ve got to go to mental health, you try to 

park around back. You don’t want your neighbors seeing you going 

into community mental health. So when we integrate, we’ll help fix 

that. Everybody can go through the same door and park in the 

same parking lot. 

But it’s hard to explain the devastation that occurs from the stigma and the active discrimination. It goes beyond just stigma. Of all 

the disability groups, we’re the least employed in the country. It 

bumps 90 percent. And, by the way, employment is a huge factor 

in our recovery when people have meaningful work. In housing, 

we’re discriminated against. 

A lot of it is—it’s almost a civil rights issue. It’s a human rights 

issue. I am hopeful that integration helps that. And then families 

are really torn apart by it, too. I’m very fortunate to have had a 

very supportive family. But the stress and strain economically will 

bust up marriages. It’s just a fact. I mean, you’re right on it. So 

thanks for your acknowledgement of that. 

Senator WARREN. Thank you. 

Mr. DelGrosso. 

Mr. DELGROSSO. Larry, thanks. You say it so well. I just think 

it’s interesting that families would not hesitate to get a family 

member help for appendicitis or any other kind of physical health 

problem that they have, but often have a very difficult time reaching out to get the behavioral health and the substance abuse disorder treatment that they need. 

The bottom line is that it’s often seen as that you have a character problem, or you’ve got a bad mom and dad, or something 

along those lines, rather than the fact that for many people, they 

have a brain disease. There’s a lot of education yet still to come 

and a lot of support that we need at several levels for people to be 
69 

able to move forward and raise their hand to come out and get 

help. 

I can also say as a mental health provider all these years that 

we need to stick our head up a little bit, too, and be proud of the 

fact or the area of healthcare that we provide care in and that 

we’re not an enigma. Let’s take the cloak off of this and let’s talk 

about what it really is and how people can recover and become remarkable members of our community. 

Senator WARREN. With the Chairman’s indulgence, could I ask 

you, Dr. Vero, to add your comments briefly, and Dr. Hogan? 

Mr. VERO. Senator, thank you for the question, and I’ll answer 

it, I think, from maybe both the human side and the financial side. 

We can’t afford not to treat these illnesses that we identify, especially those that we identify early. They simply get worse. Mental 

illness is a systemic family disease. We know that when we look 

at addiction disorders, in particular, alcohol. There may be one individual in that family with an alcohol addiction. That entire family can pick up signs and symptoms of that illness, and there’s dysfunction throughout that family. 

Those same things often occur with people who have severe and 

persistent mental illness. Mental illness is the leading cause of disability in the United States. That cost alone should alarm us all, 

and we have to start treating this on the front end and not treating 

it with disability payments. 

Senator WARREN. Thank you. 

Dr. Hogan. 

Mr. HOGAN. I’ll conclude on that same point. At some point within the last 10 years, the total cost to society of mental illness 

passed the total cost of cancer and is running second to heart disease. But what is striking about those statistics is that while the 

cost of cancer and heart disease is the cost of providing care, the 

cost of mental illness is essentially the cost of not providing care. 

It’s the cost of years lost of life due to suicide, of people not being 

able to function fully at work, of children not graduating because 

they weren’t able to sit in their seat long enough, and then it escalated, and then they dropped out in high school. So if we could reverse this just a little bit and provide effective treatments, maybe 

we could slip back from No. 2 to No. 3 again. 

Senator WARREN. Thank you very much. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Warren. 

I just want to thank this panel very much, both for the work you 

do and for the testimony you’ve offered here today. Again, the reason why we wanted to start off this Congress and why I wanted 

to start off this Congress with this kind of hearing in this committee was simply for the reasons that many of you expressed in 

one way or the other. And that is, we can’t really get a handle on 

a healthcare system in America until we get a handle on integrating mental health with physical health. And I would lean a little bit more toward Mr. Fricks’ side on looking at this mind-body 

connection. 

Dr. Hogan, I appreciate that not every primary care practitioner—they’ve only got 8, 9, or 10 minutes. They’ve got to remember a lot of stuff from medical school and their residency training. 
70 

But it does seem to me that a system ought to be built where 

you have a collaboration. I have seen these. They’re around the 

country, where if you go in, and you have, hopefully, electronic 

records, and you have some ailment that you’ve come in to see a 

primary care practitioner about, whether it’s in a community 

health center or someplace else, a private practice, that there’s a 

collaboration with the primary care physician and maybe a physical therapist, a psychiatrist or psychologist or maybe both, to take 

a look at what really is affecting this person. 

Is it a physical ailment that requires some physical intervention, 

or is it a physical ailment that’s been manifested because of a psychological problem that needs to be attended to, or is it something 

else? Is this something where a qualified therapist could work with 

them and their family rather than thinking there has to be some 

prescription for some medicine filled out that they go to the drugstore to get? 

It just seems to me that as we’re moving ahead with this Affordable Care Act and this new regime with all the exchanges and everything, we have an opportunity, I hope—and with the expansion 

of the community health centers around America, and that’s where 

Dr. Vero—we’re going to be in touch with you more about what 

you’ve done in Tennessee, because I think there’s a model there for 

what we’re going to do with community health centers in the future 

and how they’re integrated into the system. 

That’s why I think this hearing is so important, because you, Dr. 

Hogan, just said that the cost of mental illness now outstripped the 

cost of cancer in our country, and yet we just don’t pay attention 

to it. Hopefully, this will set the stage for a lot of good bipartisan 

work and integration here of this committee looking at what we 

need to do to provide this sort of new integrated model in this new 

healthcare regime that we seem to be embarked upon here sometime in the near future. 

I thank you very much. I am certain our staffs or us will be in 

touch with you as we move along here for further enlightenment 

and further suggestions and recommendations that you might 

have. 

Senator Alexander. 

Senator ALEXANDER. I want to thank Senator Harkin for this, 

and I want to thank the witnesses for coming. You made some very 

useful suggestions, and I look forward to following up. If I may say 

it this way, this is a committee on which we can have some fairly 

profound differences of opinion when we’re talking about new laws, 

new spending, new policies. 

But it seems to me that a lot of what we fail to do here in the 

Federal Government is look at what we’re already doing and ask 

the people who are doing it how we can take the programs and the 

money that we have and make it easier for you to do what you 

need to do. You’ve given us a long list of things today that you have 

suggested that would improve your ability to identify who needs 

help and identify the person to provide the help. 

While we may argue about some things, there’s no need to argue 

about those things. We can work together on those things, and I 

would look forward very much to that opportunity, and I’ll forward 

to your specific suggestions about the laws, regulations, and prac-
71 

tices that you think we ought to change. And I’ll work with Senator 

Harkin and see if we can do this in a bipartisan way. 

The CHAIRMAN. Thank you very much, Senator Alexander. 

I request that the record remain open for 10 days for members 

to submit statements and submit additional questions for the 

record. 

With that, thank you all very much. The committee will stand 

adjourned. 

[Additional material follows.] 
72 

ADDITIONAL MATERIAL

PREPARED STATEMENT OF SENATOR CASEY

Chairman Harkin, Ranking Member Alexander, I would like to 

thank you for convening this timely hearing to assess the state of 

our Nation’s mental health system. It is unfortunate that it takes 

a tragedy on the scale of Sandy Hook, Tucson, Aurora or Virginia 

Tech to refocus our attention on the need for better access to mental health services, when one in four adults will suffer from a 

diagnosable mental illness in a given year and only 60 percent of 

people with serious mental illnesses get access to the mental health 

care they need. 

We have made progress in the last few years: we passed the 

mental health parity law, requiring health insurers to cover mental 

health benefits at the same level as other medical benefits; we have 

improved the supports available to our veterans suffering from 

post-traumatic stress disorder as a result of a decade of conflict and 

repeated deployments; and we passed the Affordable Care Act, 

which will increase access to all health services, including mental 

health services. 

Yet the repeated tragedies linked to individuals with serious 

mental illnesses, in addition to the countless individual tragedies 

that don’t make the news because they are all too common, indicate 

that we must do more. Millions of people across the Nation are facing mental illness every day, and are not getting the help they 

need. In Pennsylvania, there were 1,547 suicides in 2010, the most 

recent year for which data are available; that works out to approximately four suicides per day (data from the Pennsylvania Department of Health). 

We also need to address the stigma that still surrounds mental 

illness. No person should ever be afraid to seek medical treatment, 

including mental health treatment. We all have a role to play in 

educating ourselves and our communities about mental illness. 

Only by being accepting and honest about the devastating effect of 

mental illness can we encourage the people bearing this burden to 

come out of the shadows and seek the help they so desperately 

need. 

I am pleased that President Obama recently committed to finalizing the mental health parity regulations and the regulations on 

the essential health benefits and parity requirements within the 

health insurance marketplaces under the Affordable Care Act. 

Again, I would like to thank Chairman Harkin and Ranking 

Member Alexander for convening this hearing, and would also like 

to recognize Chairman Harkin for his dedication to this issue over 

many years. I look forward to hearing from our witnesses today, 

and to working with my colleagues on the committee and in the 

Senate to improve our Nation’s mental health system. 

RESPONSE BY PAMELA HYDE, J.D. TO QUESTIONS OF SENATOR ALEXANDER, SENATOR

MIKULSKI, SENATOR MURRAY, SENATOR CASEY, SENATOR BENNET, AND SENATOR

ENZI

SENATOR ALEXANDER

Question 1. How have you worked with States and other stakeholders to ensure 

that grants and cooperative agreements administered by SAMHSA have been re-
73 

sponsive to the needs of local communities and States? What are some things that 

can be done to make things easier for States? 

Answer 1. For all SAMHSA grant programs, States and communities are asked 

to identify the specific need in their local jurisdiction and describe how the grant 

funds would address that need. This is done intentionally in order to allow States 

and communities to prioritize funds based on their specific needs. 

SAMHSA also provides technical assistance (TA) to communities and States to ensure their needs are met and that the most effective and efficient services are being 

developed. SAMHSA provides TA not only to its grantees for the implementation of 

specific grant programs but also to States and communities for larger system-wide 

change and enhancement. 

Question 2. It is my understanding that you are making revisions to the Community Mental Health Services Block Grant Application and the Substance Abuse Prevention and Treatment (SAPT) Block Grant Application, and one of the proposed 

changes is to move the deadline to April 1 for the applications from the statutory 

requirement of September 1 for the Mental Health Block Grant and October 1 for 

the Substance Abuse Block Grant. 

Can you give me a status of the pending application and how you are working 

with States to give them flexibility to submit the application given the statutory 

deadlines of September 1 and October 1, and the final applications not having been 

released? 

Answer 2. The fiscal year 2014–15 Uniform Application which is used for the 

Mental Health Block Grant (MHBG) and the Substance Abuse Block Grant (SABG) 

was published in the Federal Register. We expect the Application to be finalized 

later this year. SAMHSA has communicated to the block grant jurisdictions that the 

statutory deadlines remain the same (September 1st for the MHBG and October 1st 

for the SABG), but has encouraged an earlier submission date to allow for the 

States and SAMHSA to enter into a meaningful discussion of the State plan at a 

time when it can still be modified. 

Question 3. Patients and providers alike in rural areas face particular challenges 

with respect to access. What has SAMHSA been doing to work with States to improve access in these areas? 

Answer 3. SAMHSA’s Block Grants provide flexible funds that States can use to 

provide access to necessary services, including services in rural areas. As a component of the application for Block Grant funds, States provide an assessment of their 

strengths and needs of the service system and identify unmet service needs and critical gaps. 

In addition, SAMHSA’s Grants to Expand Care Coordination through the Use of 

Health Information Technology in Targeted Areas of Need (Short Title: TCE–Health 

IT) leverages technology to enhance and/or expand the capacity of substance abuse 

treatment providers to serve persons in treatment who have been underserved because of the lack of access to treatment in their immediate community. The lack 

of access may be due to transportation concerns, a limited number of substance 

abuse treatment providers in their community, and/or financial constraints. The use 

of health information technology (HIT), including web-based services, smart phones, 

and behavioral health electronic applications (e-apps) expand and/or enhance the 

ability of providers to effectively communicate with persons in treatment and to 

track and manage their health to ensure treatment and services are available where 

and when needed. Grantees use technology that will support recovery and resiliency 

efforts and promote wellness. 

In addition, HHS has been a key participant in the White House Rural Council, 

which was created in June 2011 through an Executive order. The Council is a combined effort of the White House Domestic Policy Council and the National Economic 

Council, with the Secretary of Agriculture serving as chair and Cabinet Agency 

heads serving as members. The Council works across executive departments, agencies, and offices to coordinate development of policy recommendations to promote 

economic prosperity and quality of life in rural America. 

Question 4. The Centers for Disease Control and Prevention (CDC) has classified 

prescription drug abuse an epidemic in the United States. In 2011, 2.4 million new 

individuals began using prescription drugs for nonmedical purposes. The widespread 

nonmedical use of prescription drugs has increased the numbers of overdose deaths 

and hospitalizations. In 2008, the CDC found that prescription drug misuse and 

abuse had caused 20,044 deaths and over 1,345,645 emergency room visits. In Tennessee, prescription drug abuse is a major problem. Can you tell me what role 

SAMHSA is playing to address prescription drug abuse? 
74 

Answer 4. SAMHSA works across the Department of Health and Human Services 

through the Behavioral Health Coordinating Council’s (BHCC) Prescription Drug 

Abuse Committee. As a result, SAMHSA has partnerships with CDC, Food and 

Drug Administration (FDA), National Institutes of Health, Centers for Medicare & 

Medicaid Services, the Office of the National Coordinator for Health Information 

Technology (ONC), and the Office of the Assistant Secretary for Health aimed at 

preventing and treating prescription drug misuse and abuse. SAMHSA is represented on the Office of National Drug Control Policy Interagency Workgroup on 

Prescription Drugs. SAMHSA’s strategy to reduce prescription drug abuse and assist individuals who misuse or abuse prescription drugs is in alignment with the Office of National Drug Control Policy’s four-part strategy: education for prescribers 

and the public; prescription monitoring; safe drug disposal; and effective enforcement. SAMHSA’s contract supporting the Annual National Survey on Drug Use and 

Health is an integral part of our national surveillance of non-medical use of prescription drugs. 

Education—Current prescribers—SAMHSA has supported the education of prescribers for the past several years through formal continuing medical education 

courses and other less formal efforts, e.g., webinars hosted by SAMHSA’s opioid prescriber clinical support system (PCSS) grantee (American Academy of Addiction Psychiatry). SAMHSA has placed a priority for these prescribing courses in States with 

the highest rates of opioid-related mortality—e.g., New Mexico and West Virginia. 

SAMHSA is also a participant in the NIH Pain Consortium. 

Future prescription drug prescribers—SAMHSA’s SBIRT (Screening, Brief Intervention, Referral to Treatment) program is an important tool for early identification 

of persons who might be at risk for opioid dependency. SAMHSA’s SBIRT Residency 

grant program addresses future prescribers and includes screening for prescription 

drug abuse, and more recently has emphasized the use of State prescription drug 

monitoring programs (PDMPs). 

Prescription monitoring—In 2012, SAMHSA developed a grant program, in partnership with ONC and CDC to allow States to increase their ability, with appropriate privacy protections, to link PDMPs with other electronic health care record 

systems (physicians’ offices, pharmacists, hospital emergency departments, and 

Health Information Exchanges). In addition, the grants will be used by States to 

connect their PDMPs to other States to improve interoperability. 

SAMHSA has also partnered with ONC to fund pilots that test secure linkages 

between PDMPs and EHR systems across multiple facilities. Some of these pilot 

programs are also exploring ways to incorporate real-time PDMP data at points-ofcare and dispensing, further streamlining these data checks for standard patient 

care. Finally, SAMHSA staff is participating in projects with other agencies to increase the ability of PDMPs to identify outbreaks of prescription drug abuse. 

Prevention of Prescription Drug Abuse in the Workplace (PAW) Technical Assistance Contract—The PAW program provides technical assistance to help local, government and military workplace and communities understand the prescription drug 

abuse problem and reduce related problems by stimulating, informing, and supporting employer- and community-based prevention/early intervention efforts. The 

PAW educational and technical assistance efforts and resources focus on SAMHSA 

grantees; employers, unions, and other communities; and collaborate with partner 

organizations. PAW educational/technical assistance resources include fact sheets, 

web products, assessment tools, presentations, trainings, and literature reviews. 

Topics such as developing specific workplace prescription drug abuse policies; integrating prescription abuse messaging into current programs and community outreach activities; and prescription drug abuse evaluation activities and metrics are 

addressed. 

Prescription Drug Abuse Treatment—Treatment of opioid dependence/addiction is 

a critical element of SAMHSA’s strategy and includes expanding and improving access to the three FDA-approved medical treatments: methadone (regulated by FDA, 

SAMHSA, and the DEA), buprenorphine (SAMHSA works together with the DEA 

to process waivers to enable physicians to prescribe buprenorphine products), and 

naltrexone, both oral and extended release products. SAMHSA has been working 

with other Federal agencies to explore ‘‘telemedicine’’ enabling treatment in rural 

settings. SAMHSA is continuously educating providers and consumers about these 

medical treatments through educational efforts, the PCSS model referenced above 

and interactions with the provider communities. SAMHSA works with the FDA to 

ensure that safety of these medications is continuously monitored and analyzed. For 

example, SAMHSA convened expert panels and work groups with the FDA to assess 

the safety of methadone in terms of cardiac health; methadone-related mortality associated with overdose; buprenorphine and risk of pediatric exposure; and diversion 

of these medications for illicit or inappropriate use. SAMHSA convened a similar 
75 

meeting on developing guidelines for the medicine Vivitrol, an injectable medicine 

designed to treat opioid dependence for up to 30 days. 

SENATOR MIKULSKI

Question 1. I am a big champion of privacy but with Virginia Tech, none of the 

systems talked with each other. How can we make sure privacy is protected and 

everyone in the system is talking to each other when problems arise? 

Answer 1. SAMHSA agrees that it is critical that privacy be protected in behavioral health treatment. However, SAMHSA recognizes that there are situations and 

crises that require the sharing of information about an individual to other clinicians, 

to the judiciary, to law enforcement or to the National Instant Criminal Background 

Check System (NICS). This balancing of competing interests is essential for the 

health of the individual who presents for behavioral health care and for the wellbeing of society should an individual suffering from a behavioral health illness be 

a threat to themselves or to others. 

On January 16, 2013, President Obama implemented 23 Executive Actions to reduce gun violence. Following the release of the President’s plan, the HHS Office for 

Civil Rights released a letter to the provider community and other interested parties 

clarifying that the Health Insurance Portability and Accountability Act (HIPAA) 

Privacy Rule does not prevent the necessary disclosure of critical information about 

a patient to law enforcement, family members of the patient, or to other persons, 

when the provider believes that patient presents a serious danger to himself or to 

other people. 

Some States have cited concerns about restrictions under HIPAA as a reason not 

to share relevant information on people prohibited from gun ownership for mental 

health reasons. The Administration will begin the regulatory process to remove any 

needless barriers, starting by gathering information about the scope and extent of 

the problem. 

In addition to what HIPAA permits in terms of disclosure, most States have laws 

or court decisions which address, and in many instances require, the disclosure of 

patient information to prevent or lessen the risk of harm. Since the classic ruling 

of Tarasoff v. Regents of the University of California (1976), mental health professionals in many States have had a legal duty to protect intended victims by notifying them and the police of threats of harm. In the years since Tarasoff, mental 

health professionals have generally adopted some version of the duty to protect reasonably identifiable third parties as a standard of practice. Most behavioral health 

providers are aware of the duty to protect third parties; however, most primary care 

providers are not covered by the Tarasoff principles. 

Subsequent to the Virginia Tech shootings, the Virginia Tech Review Panel found 

that the University believed that communicating their concerns about a student 

with one another or the student’s parents was prohibited by the Federal laws governing the privacy of health and education records. In reality, Federal laws and 

their State counterparts afford ample leeway to share information in potentially 

dangerous situations. 

Furthermore, in the Virginia Tech shooting, the student purchased two guns in 

violation of existing Federal law. The fact that in 2005 he had been judged to be 

a danger to himself made him ineligible to purchase a gun under Federal law. The 

Virginia Tech Review Panel found that there was a lack of understanding about 

what information could be shared and by whom. Under the President’s gun violence 

reduction plan announced in January, the Department of Justice will invest $20 

million in fiscal year 2013 to give States stronger incentives to make relevant information—including information on persons prohibited from possessing firearms for 

mental health reasons—available to the background check system. The Administration is also proposing $50 million for this purpose in fiscal year 2014, and will look 

for additional ways to ensure that States are doing their part to provide relevant 

information. 

One of SAMHSA’s top Strategic Initiatives is health information technology. 

SAMHSA is working closely with the Office of the National Coordinator for Health 

Information Technology to encourage States and providers to implement certified 

electronic health records and to promote the exchange of health information using 

recognized standards. One of SAMHSA’s main HIT goals is to ensure the secure exchange of electronic behavioral health information while protecting the privacy 

rights of individuals. 

Health information exchanges (HIEs) are quickly integrating into the healthcare 

landscape enabling real-time access to patient health information from multiple 

sources. SAMHSA is collaborating with other agencies (e.g., veterans agencies, 

criminal justice, and housing) to develop a plan to securely exchange relevant health 
76 

information while complying with Federal and State privacy and confidentiality 

laws. 

SAMHSA believes that the strategies mentioned above will go a long way in making sure that privacy is protected while permitting everyone in the system to ‘‘talk 

to’’ each other when problems arise. 

Question 2. What is SAMHSA doing with the Department of Defense to prevent 

suicide across the services and for our veterans? 

Answer 2. SAMHSA has been working with the Department of Defense (DOD) on 

preventing suicide since at least 2000, during the development of the first National 

Strategy for Suicide Prevention (published in 2001 and revised in 2012). With a 

strong respect for the respective areas of expertise in military culture, medicine, behavioral health, and evidence-based practices, the Agency and Department work together on a variety of fronts and in a range of initiatives. 

In 2005, the DOD joined the Federal Partners Working Group on Suicide Prevention, a mechanism for Federal agencies to increase collaboration and coordination 

in their suicide prevention policies and initiatives. DOD and SAMHSA co-chaired 

the Working Group between 2005 and 2010, and the acting director of the Defense 

Suicide Prevention Office (DSPO) continues to participate in the Group’s monthly 

calls. 

In 2009, Dr. Richard McKeon, Chief of SAMHSA’s Suicide Prevention Branch, was 

selected by then Defense Secretary Gates to be one of seven civilian members of the 

DOD Task Force on the Prevention of Suicide by Members of the Armed Forces. 

Among the recommendations of the Task Force was the establishment of a DOD suicide prevention office within the Office of the Secretary, a recommendation that was 

embraced by DOD and launched in 2011. SAMHSA continues to work closely with 

DSPO. Currently, SAMHSA is working with DSPO to review suicide prevention programs within DOD and develop a methodology to identify best practices. 

In 2010, HHS Secretary Kathleen Sebelius and then DOD Secretary Robert Gates 

launched the National Action Alliance for Suicide Prevention (‘‘Action Alliance’’), a 

public-private partnership that advances the National Strategy for Suicide Prevention. Since its inception, the Action Alliance has been co-chaired by Secretary of the 

Army John McHugh and former U.S. Senator Gordon Smith. Among its 14 active 

task forces is the Military/Veterans Task Force, which last year co-hosted Partners 

in Care/suicide prevention summits in partnership with National Guard State Chaplains in five States. Through this initiative more than 400 community clergy were 

trained to recognize the warning signs of suicide among service members, veterans, 

and their families, and more than 200 congregations enlisted in a National Guardsponsored Partners in Care program to provide support to National Guard members 

and their families. SAMHSA’s grantee for the Suicide Prevention Resource Center 

acts as Secretariat for the Action Alliance, managing all operations. 

SAMHSA is the lead HHS agency tasked with implementing the President’s Executive Order ‘‘Improving Access to Mental Health Services for Veterans, Service 

Members, and Military Families,’’ which was issued on August 31, 2012. SAMHSA 

is working closely with both DOD and the Department of Veterans Affairs (VA) on 

the outreach and public health aspects of the Order. 

SAMHSA has been a planning partner with DOD and VA for the past three DOD/ 

VA Suicide Prevention Conferences, offering the public health perspective needed to 

ensure community involvement in suicide prevention. 

Through its Service Members, Veterans, and their Families Policy Academies and 

the ongoing technical assistance it provides after the Policy Academies, SAMHSA 

helps States and territories reach out to service members—especially members of 

the National Guard and Reserves—who are transitioning back to civilian life. The 

form of outreach varies across States/territories, but the work is generally done 

through State/Federal/private collaboration (e.g., partnerships among State mental 

health and substance abuse agencies, Joining Forces and Joining Community 

Forces, Yellow Ribbon, VA, Veteran Service Organizations, etc.). Additionally, 

SAMHSA promotes military cultural training for community providers, which helps 

civilian providers better understand the military culture and appreciate the impact 

of deployment on both the service member and his/her family. Training also encourages providers to screen patients for military and combat experience and to make 

appropriate referrals to Vet Centers (which provide readjustment counseling to combat veterans, delivered by combat veterans) and to the VA. 

In 2011, SAMHSA provided Applied Suicide Intervention Skills Training (ASIST) 

to 50 National Guard State directors of psychological health, and to 20 National 

Guard State suicide prevention program managers. ASIST is a ‘‘gatekeeper’’ program that trains individuals to recognize warning signs of suicide and to respond 

appropriately and effectively to those signs. 
77 

SAMHSA has worked closely with the VA since 2007 when VA launched the Veterans Crisis Line in partnership with SAMHSA and its National Suicide Prevention 

Lifeline. The Veterans Crisis Line is also co-branded the ‘‘Military Crisis Line,’’ and 

marketing includes both names so that Veterans, Reservists, and Service members 

will feel welcome in calling this 24/7 life-saving resource. 

Finally, one of SAMHSA’s Government Project Officers in the Suicide Prevention 

Branch provides both Marines and Sailors with suicide prevention training. 

SAMHSA is working with the U.S. Marine Corps to extend the current Memorandum of Understanding. 

Question 3. How can we help you to strengthen the mental health workforce? Is 

there anything you need from us? 

Answer 3. As outlined in the President’s plan, Now is the Time, the Administration is proposing funding to train 5,000 behavioral health professionals, particularly 

those interested in working with school and transition-age youth. To achieve this 

goal the Administration is proposing $50 million for a behavioral health workforce 

program to train social workers, counselors, psychologists, and other mental health 

professionals. 

Question 4. Are reforms needed in the substance abuse prevention and treatment 

block grant or community mental health services block grant to better meet the 

needs of patients in our communities? 

Answer 4. We will continue to review the block grant requirements as the health 

care law is implemented and look forward to working with Congress to continue to 

meet the needs of patients in our communities. 

SENATOR MURRAY

Question 1. In 2008 this committee, under Chairman Kennedy, helped to pass into 

law the Mental Health Parity and Addiction Equity Act. This law, expanded in the 

recent health care reform legislation, requires health insurance to cover both mental 

and physical health equally. As you know, three parity provisions were included in 

the President’s recently released gun violence package: one clarifying parity for 

Medicaid managed care plans, one saying a parity provision would be included in 

the final essential health benefits rule, and one that ‘‘committed’’ to issuing the final 

rule on the Mental Health Parity and Addiction Equity Act, but it did NOT make 

clear when we might expect to see that. If plans are supposed to be ready to go in 

Exchanges starting in October, it is essential that we see a final rule no later than 

April. 

Can you give us a date certain on when the final rule will be released? 

Answer 1. The Administration intends to issue the final rule on the Paul 

Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act 

(MHPAEA) by the end of 2013. To date, the three different agencies—HHS, Treasury, and Labor—that have responsibility for these rules, have released an Interim 

Final Rule (IFR) and multiple guidance documents, in the form of FAQs and compliance aids, to provide guidance on substantive issues necessary for Exchanges to 

move forward with guidance to their Qualified Health Plans. 

Question 2. Parity in scope of services has to be defined in the final rule. I have 

heard reports of plans that are dropping key mental health and addiction services 

like intensive outpatient and residential treatment, even if similar services are provided for medical conditions, because the law’s interim final rule did not address 

the issue of scope of service. 

How will you define parity in scope of services in the final rule to ensure that 

patients are able to access important mental health services? 

Answer 2. The Administration is studying this issue very carefully and is closely 

reviewing comments received on the IFR. In addition, we are reviewing regulations 

in States that have enacted parity laws to assess how they have treated scope of 

services and examining how private health insurance currently covers and pays for 

services such as intensive outpatient and residential treatment. The Administration 

has also obtained clinical opinions and reviewed literature regarding what the analogous services are to residential and intensive outpatient. 

Question 3. The final rule needs to clarify how non-quantitative treatment limits 

apply by setting a quantitative floor. In December 2011, the Department of Labor, 

the Department of the Treasury, and the Department of Health and Human Services released a set of frequently asked questions that aimed to provide additional 

guidance on these treatment limits. These FAQs established that non-quantitative 

treatment limits must be applied ‘‘comparably and no more stringently’’ to mental 
78 

health and substance abuse benefits than to medical benefits. However, many plans 

are currently claiming that regulations allow them to micro-manage mental health 

and addiction treatment the same way plans manage physical therapy, which makes 

up less than 1 percent of medical benefits. Applying a non-quantitative treatment 

limit more stringently to all behavioral health benefits and only 1 percent of medical 

benefits is not comparable and violates. A quantitative floor for non-quantitative 

treatment limits is needed to clarify these limits so that plans do not apply them 

in a way that violates the Mental Health Parity and Addiction Equity Act. 

How do you plan to clarify in the final rule how non-quantitative treatment limits 

apply? Will you include a quantitative floor in the final rule? 

Answer 3. The Departments issued a number of FAQs to help clarify these issues 

and will continue to do so through FAQs and the final rule. Non-quantitative treatment limits (NQTLs) were the focus of FAQs that were released on November 17, 

2011. In those FAQs it was explained that the quantitative tests outlined in the IFR 

for determining what limits or requirements apply to substantially all medical/surgical benefits and what the predominant levels for those financial requirements or 

limits are do not apply to NQTLs. In addition, other FAQs clarified that applying 

standards used for a very limited set of medical/surgical benefits, for instance just 

physical therapy to all mental health and substance use disorder benefits, would not 

be permissible (see FAQ #5). 

Question 4. The final rule must require transparent disclosure of medical and behavioral criteria so that parity compliance testing may be performed. The Parity Implementation Coalition has provided 100 cases to the Department of Labor and the 

Department of Health and Human Services of plans refusing to provide this essential information. No plan, to my knowledge, has ever disclosed these criteria, and 

there has been no enforcement of that requirement that I am aware of in the 4 

years that the law has been out. 

How will you enforce the requirement that health insurance plans to disclose 

medical and behavioral criteria? 

Do you have a plan to retroactively handle the Parity Implementation Coalition’s 

complaints about plans refusing to disclose criteria over the past 4 years? 

Answer 4. The Department of Labor (DOL) has primary oversight of private employer-sponsored group health plans, and States have primary oversight of health 

insurance issuers (with HHS having fallback oversight for issuers). During the 2 

years (since January 2011) that the regulations have been fully in effect for most 

plans, DOL has been committed to ensuring that individuals enrolled in employersponsored health plans receive mental health and substance use benefits in a manner that is compliant with MHPAEA. DOL, for example, has a robust investigative 

program in 10 field offices across the country that conduct health plan audits to 

check for compliance with various Federal laws, including MHPAEA. Any concerns 

or inquires brought to DOL’s attention are thoroughly evaluated and reviewed, including those related to mental health parity. Many of these reviews and audits are 

handled under a voluntary compliance and correction approach, and resolved 

through confidential discussions between DOL and the group health plan. In general, for cases involving a group health plan providing coverage through a fully insured health insurance product, DOL works closely with States and HHS to resolve 

the issues at the health insurance issuer level. HHS regularly works with State insurance commissioners to address complaints that have been made about a variety 

of matters related to MHPAEA. Some of these involve disclosure of medical necessity criteria, which, as such, are handled confidentially. 

SENATOR CASEY

Question 1. You noted that Medicaid accounts for 28 percent of mental health 

spending. In your experience, are mental health patients more vulnerable to Medicaid cuts than patients with physical health problems? 

Answer 1. Individuals with mental illnesses tend to have lower incomes, higher 

health care expenditures, and are more likely to be enrolled in public insurance programs like Medicaid. Therefore they are more susceptible to cuts in the program. 

When cuts are made to Medicaid, it can impact one or more services that the individual is relying on. 

Question 2. What kind of impact can even small changes in Medicaid spending 

have on access to mental health services? 

Answer 2. The Administration gives States significant flexibility to manage costs 

and benefits in their programs. CMS continues to work closely with States to provide options and tools that make it easier for States to make changes in their Medicaid programs to improve care and lower costs. In the last 6 months, the Adminis-
79 

tration has released guidance giving States flexibility in structuring payments to 

better incentivize higher-quality and lower-cost care, provided enhanced matching 

funds for health home care coordination services for those with chronic illnesses, designed new templates to make it easier to submit section 1115 demonstrations and 

to make it easier for a State to adopt selective contracting in the program, and developed a detailed tool to help support States interested in extending managed care 

arrangements to long-term services and supports. 

Question 3. Which groups of Medicaid beneficiaries tend to use mental health 

services the most? 

Answer 3. Historically, given the varying types of Medicaid coverage levels by 

State, it has typically been children with serious emotional disturbance, and adults 

who have been found to be disabled due to a mental illness that have been most 

often covered by Medicaid, and therefore present in the data as users of service. In 

addition, persons who are dually eligible for Medicare and Medicaid often present 

with complex mental health needs. 

SENATOR BENNET

Question 1. Most private health insurance does not offer a comprehensive mental 

health or substance use disorder benefit. While parity takes an important step by 

requiring that these areas of health care are covered at the same level as physical 

health care, there is a lack of detailed information. Current listings of services 

under essential health benefits do not provide sufficient detail on parity with mental 

health and substance use services that are effective and necessary. Consequently, 

there is concern that expanded Medicaid and new products on the Exchanges will 

not offer the necessary services available for patients who need mental health and 

substance use disorder treatment and prevention. Does SAMHSA recommend further guidance for States and health plans on the required mental health and substance use services that each plan must offer in their essential benefit plan? If so, 

what should that guidance include? 

Answer 1. The Affordable Care Act will provide one of the largest expansions of 

mental health and substance use disorder coverage in a generation. Beginning in 

2014, under the law, all new small group and individual market plans will be required to cover 10 Essential Health Benefit categories, including mental health and 

substance use disorder services, and will be required to cover them at parity with 

medical and surgical benefits. The Affordable Care Act builds on MHPAEA (the 

Federal parity law), which requires group health plans and insurers that offer mental health and substance use disorder benefits to provide coverage that is comparable to coverage for general medical and surgical care. 

The Affordable Care Act builds on MHPAEA to extend Federal parity protections 

to 62 million Americans. The parity law aims to ensure that when coverage for mental health and substance use conditions is provided, it is generally comparable to 

coverage for medical and surgical care. The Affordable Care Act builds on the parity 

law by requiring coverage of mental health and substance use disorder benefits for 

millions of Americans in the individual and small group markets who currently lack 

these benefits, and expanding parity requirements to apply to millions of Americans 

whose coverage did not previously comply with those requirements. 

Question 2. Mental Health First Aid has the great potential to identify people 

with emerging mental health issues and substance use disorders. In many cases, 

identification can result in referrals to primary care, mental health, and substance 

use treatment providers. Most public and private funding does not pay for early 

intervention and prevention services for people with mental health issues and substance use disorders. Often, mental health coverage does not exist until a person 

has a diagnosable condition. By funding prevention and early intervention, diagnosis and more expensive treatment may not be necessary. What efforts are 

SAMHSA and NIMH engaged in to promote more prevention and early intervention 

services and to remove restrictions that require a higher degree of illness before a 

person can get needed care? 

Answer 2. SAMHSA supports a number of grant programs and initiatives that 

promote more prevention and early intervention services. Examples include: 

• Linking Actions for Unmet Needs in Children’s Health (Project LAUNCH): 

Project LAUNCH is a program that seeks to ensure that all young children, especially those at increased risk for developing social, emotional, and behavioral problems, receive the supports they need to succeed. Project LAUNCH brings together 

stakeholders to develop a vision and a comprehensive strategic plan for promoting 

the wellness of all young children. Project LAUNCH also supports programs for 
80 

child care providers such as Mental Health Consultation, which can address behavior problems before they disrupt placements and lead to later problems. 

• Implementing Evidence-Based Prevention Practices in Schools (PPS): The purpose of this program is to prevent aggressive and disruptive behavior among young 

children in the short term and prevent antisocial behavior, suicidal ideation, and the 

use of illicit drugs in the longer-term with the additional goal of promoting graduation from high school. 

• Safe Schools/Healthy Students Initiative (SS/HS): SS/HS is a unique collaboration between HHS, the Department of Education, and the Department of Justice. 

SS/HS takes a broad approach, drawing on the best practices and the latest thinking in education, justice, social services, and mental health to help communities 

take action, recognizing that no single activity can be counted on to prevent violence. SS/HS supports local education agencies across the country, spanning rural, 

Tribal, suburban, and urban areas as well as diverse racial, ethnic, and economic 

sectors. It provides grant funds, technical assistance, and evaluations of both process and outcome (effectiveness) measures. To date, SS/HS has provided services to 

over 12 million youth and more than $2 billion in funding and other resources to 

365 communities in 49 States across the Nation. Outcomes of SS/HS grantees suggest that partnership was the key factor in success. There was a dramatic 263 percent increase in the number of students who received school-based mental health 

services and an astounding 519 percent increase in those receiving community-based 

services. Nearly 80 percent of school staff stated that they were better able to detect 

mental health problems in their students and more than 90 percent of school staff 

reported that they saw reductions in alcohol and other drug use among their students. 

The President’s gun violence reduction package released in January includes $40 

million to expand SS/HS through Project AWARE. 

• National Center for Mental Health Promotion and Youth Violence Prevention 

(National Center): The National Center provides training and technical assistance 

to support prevention and early intervention activities as well as directed TA to Safe 

Schools/Healthy Students and Project LAUNCH grantees. National Center staff 

work with school districts and communities as they plan, implement, and sustain 

initiatives that foster resilience, promote mental health, and prevent youth violence 

and mental and behavioral disorders. Through training, national and regional 

events, teleconferences, online learning, site visits, peer exchange, a virtual library, 

and onsite work, the National Center provides culturally competent consultation to 

serve diverse audiences. 

• Screening, Brief Intervention and Referral to Treatment (SBIRT): SBIRT is a 

comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as 

those who are at risk of developing these disorders. Primary care centers, hospital 

emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur. 

SENATOR ENZI

Question. I am concerned about the significant number of duplicative Federal Government programs. Can you tell me what programs within your agency are duplicative or could be combined to provide more efficient operations? Please describe how 

you plan to identify unfunded and unproven programs that can be eliminated in 

order to better focus resources on those that do work. 

Answer. SAMHSA takes its role as a steward of taxpayer dollars very seriously 

and during this tight budget environment, SAMHSA stretches every dollar we have 

to make the maximum impact. We closely examine our portfolio at SAMHSA to find 

efficiencies and as a result have reduced redundancy or duplication. For example, 

in 2012, SAMHSA consolidated three State Technical Assistance (TA) contracts into 

a single contract. This consolidation resulted in both programmatic as well as administrative efficiencies. In 2011, several similar consolidations took place. 

SAMHSA constantly evaluates its programs via grantee input and data collection. 

Program adjustments, in scope or focus, are directly affected by that data. With the 

development and implementation of the Common Data Platform, program adjustments will be even better informed in the future. 
81 

1http://www.nimh.nih.gov/about/strategic-planning-reports/index.shtml. 2 Cannon TD, Cadenhead K, Cornblatt B, Woods SW, Addington J, Walker E, Seidman LJ, 

Perkins D, Tsuang M, McGlashan T, Heinssen R. Prediction of Psychosis in High Risk Youth: 

A Multi-Site Longitudinal Study in North America. Arch Gen Psychiatry. 2008 Jan;65(1):28–37. 3 Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto 

mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1- 

year prevalence rates of disorders and services. Archives of General Psychiatry. 1993 

Feb;50(2):85–94. 

RESPONSE BY THOMAS INSEL, M.D. TO QUESTIONS OF SENATOR ALEXANDER, SENATOR MIKULSKI, SENATOR CASEY, AND SENATOR ENZI

SENATOR ALEXANDER

Early Diagnosis of Mental Disorders 

Question. Much of NIMH’s work has the potential to have major impacts on the 

mental health system overall, with the ability to diagnose mental disorders earlier 

and get people, especially young children, into effective treatment. Can you provide 

some examples of work that you are doing to diagnose mental disorders earlier? 

Answer. One of the primary objectives of the NIMH Strategic Plan 1 is to chart 

the course of mental disorders over the lifespan to determine when, where, and how 

to intervene, with the ultimate goal of preempting or treating mental disorders and 

hastening recovery. Mental disorders are a group of chronic, changing conditions. 

The symptoms often begin to appear in childhood and adolescence and ebb and flow 

over the course of an individual’s life. Behavioral manifestations, such as psychosis 

and depression, are in fact late events in the timeline of illnesses that began years 

earlier.2 As with many other illnesses, science promises to redefine mental disorders 

along a trajectory moving across stages of risk: from early symptoms, to full symptoms or syndromes, to remission, relapse, and recovery. NIMH aims to compare trajectories of healthy development to those of mental disorders in order to better understand the first instance or instances when development moves off course. Doing 

so will allow us to pinpoint the best times and techniques to preempt the onset of 

symptoms or halt and reverse the progression and recurrence of illness. Charting 

the course of mental disorders requires attention to genetic, neurobiological, behavioral, experiential, and environmental factors that confer a risk of developing a mental disorder. 

NIMH is supporting considerable research to chart these trajectories in order to 

intervene early. For example, the NIMH-funded Neurodevelopmental Genomics 

project is a landmark study in developmental neuropsychology that will bridge our 

understanding of brain and behavioral development for children ages 8 to 21. The 

study began with 10,000 children whose genomic profiles and cognitive abilities 

would be studied, with 1,000 undergoing comprehensive neuroimaging throughout 

brain development. The data are still being analyzed, but the study has already provided the first detailed reference map of cognitive development across adolescence. 

This project is giving us a picture of the range of development in both brain and 

behavior with which we can map expected trajectories, similar to growth charts for 

height and weight. 

NIMH-supported researchers are also working to identify individuals who may develop schizophrenia, a chronic, severe, disabling brain disorder that affects more 

than 2 million Americans age 18 and older in a given year.3 Although we know from 

other areas of medicine that early detection and early intervention yield the best 

outcomes, we lack the predictive markers for early detection of schizophrenia. Some 

individuals with schizophrenia will experience episodes of psychosis, a loss of contact with reality that usually includes false beliefs about what is taking place or 

who one is (delusions) and seeing or hearing things that are not there (hallucinations). Most young people have pre-psychotic symptoms, known as the prodrome, 

for 2–3 years before the onset of psychosis. To enhance early detection and preempt 

psychosis, NIMH is supporting the North American Prodrome Longitudinal Study 

(NAPLS), a consortium of eight clinical research centers studying the prodromal 

phase of schizophrenia. The investigators are using biological assessments, including neuroimaging, electrophysiology, neurocognitive testing, hormonal assays, and 

genomics, to improve our ability to predict who will convert to psychosis, and to develop new approaches to pre-emptive intervention. 

While some do not necessarily consider autism a traditional mental health disorder, the Diagnostic and Statistical Manual of Mental Disorders (DSM) published 

by the American Psychiatric Association includes Autism Spectrum Disorder. NIMH 

research has also made great advances in the early diagnosis for autism spectrum 

disorder (ASD). ASD is a neurodevelopmental disorder that typically manifests before the age of 3 years and is associated with a range of difficulties in social inter-
82 

4 Chawarska K, Macari S, Shic F. Decreased Spontaneous Attention to Social Scenes in 6- 

Month-Old Infants Later Diagnosed with Autism Spectrum Disorders. Biological Psychiatry, published online January 10, 2013. 5Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year followup of a nationally representative U.S. survey. Med Care. 2011 Jun;49(6):599–604. 6 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS): www.cdc.gov/ncipc/ 

wisqars accessed October 2012. 7More information at: http://actionallianceforsuicideprevention.org/NSSP. 8http://armystarrs.org/. 

action, communication, and repetitive behaviors. Early detection of ASD may lead 

to earlier intervention which in turn may lessen, or even eliminate, ASD symptoms 

for some children. Yet identifying the earliest signs of ASD has been challenging. 

However, NIMH supported researchers have recently shown that it is possible to detect the earliest signs of ASD in 6-month-old infants. The researchers followed a 

group of infants from 3 months to 3 years of age. The infants were assessed in their 

third year of life when some of them were found to have ASD. Compared to the typically developing infants, infants later diagnosed with ASD showed a decreased ability to pay attention to complex social scenes involving people and objects. The researchers posit that difficulties in attending to people might precede the excessive 

interest in objects often reported in older children with ASD. Thus, some of the first 

signs of ASD, such as limited visual attention to social scenes, may be detectable 

very early in development, well before the emergence of current diagnostic features.4

SENATOR MIKULSKI

Premature Mortality and Mental Illness 

Question. Are we doing all that we can to reduce premature deaths associated 

with mental illness? 

Answer. Research shows that Americans with serious mental illness (SMI) die 8 

years earlier than the general population from largely preventable or treatable comorbid medical conditions, such as heart disease, diabetes, cancer, pulmonary disease, and stroke. 5 Low rates of prevention, detection, and treatment further add to 

these health disparities. 

To address this serious public health concern, in 2012, NIMH convened the meeting ‘‘Research to Improve Health and Longevity of People with Severe Mental Illness,’’ in collaboration with the National Institute on Diabetes and Digestive and 

Kidney Diseases (NIDDK), the National Heart, Lung, and Blood Institute (NHLBI), 

the National Cancer Institute (NCI), and the National Institute on Drug Abuse 

(NIDA). The meeting brought together the leading researchers on medical 

comorbidities in people with SMI and on prevention and treatment within the general population for diabetes, heart disease, tobacco use, and drug abuse. They were 

joined by State policy leaders; advocates for people with SMI; leaders of community 

mental health centers; and representatives from key Federal agencies, including the 

Substance Abuse and Mental Health Services Administration (SAMHSA) and the 

Agency for Healthcare Research and Quality (AHRQ). The goal of the meeting was 

to identify critical research gaps and formulate the most pressing research questions 

in order to improve the health and longevity of people with SMI. This meeting informed the development of a new funding announcement that NIMH will release 

this year, titled Improving Health and Reducing Premature Mortality in People with 

Severe Mental Illness (SMI). The goal of this initiative is to test services interventions that specifically target people with SMI or children and youth with serious 

emotional disturbances and modifiable health risk factors that are the primary 

causes of premature mortality in these populations. 

In addition to supporting research to extend longevity by treating comorbid medical conditions, NIMH is engaged in numerous suicide prevention efforts. Suicide is 

the 10th leading cause of death in the United States, accounting for the loss of more 

than 38,000 American lives each year, more than double the number of lives lost 

to homicide.6 The National Strategy for Suicide Prevention 7—developed by the National Action Alliance for Suicide Prevention—emphasizes the importance of research that can help develop effective interventions. NIMH co-leads the Research 

Task Force of the Action Alliance, which is developing a detailed research agenda, 

anticipated in 2013, that pledges to provide a roadmap for reducing suicide by 20 

percent in 5 years, and 40 percent or more in 10 years. 

The challenge of reducing suicide is especially urgent in the military. Recognizing 

that this is not only a military problem but also a national challenge, the Army 

Study to Assess Risk and Resilience in Servicemembers 8 (Army STARRS) was 
83 

9http://www.whitehouse.gov/the-press-office/2012/08/31/executive-order-improving-accessmental-health-services-veterans-service. 10http://report.nih.gov/categoricallspending.aspx. 

launched in fiscal year 2009. Army STARRS is a 5-year collaborative partnership 

between the Department of the Army, NIMH, and several academic institutions that 

seeks to identify factors that both protect Soldiers’ mental health and those that put 

a Soldier’s mental health at risk. The ultimate goal of Army STARRS is to provide 

empirical evidence to help the Army develop targeted prevention and treatment 

strategies. 

In fiscal year 2012, Army STARRS reached a number of milestones, including establishing survey sites at more than 70 locations around the world, surveying more 

than 100,000 Soldiers, and, with appropriate consent, collecting more than 56,000 

blood samples. Both the New Soldier Study, designed to capture information about 

experiences soldiers bring into the Army, and the All Army Study, which provides 

a snapshot of the Army across ranks and all areas of service, are nearing completion. This past year, several new components were launched, and Army STARRS established a data enclave that integrates the administrative records of the 1.6 million 

Soldiers who served between 2004 and 2009. The enclave and its more than 1.1 billion pieces of data are part of a massive epidemiological approach to studying the 

complexities of Soldiers’ mental health. 

Brain disorders are incredibly complex. The array of paths that lead to posttraumatic stress disorder and suicide are as diverse as the individuals affected. 

Army STARRS has shown that no single approach will yield the answers needed 

to solve these difficult problems. A White House Executive order released in August 

2012 directs Federal agencies to improve coordination and integrate research on 

mental health and suicide prevention strategies.9 This Order provides a platform 

that will lead to more robust partnerships, capitalizing on the resources of multiple 

Federal departments and agencies, as well as the intellectual power of academic institutions. Army STARRS is an unprecedented example of how collaboration both 

within and outside of government is working to improve the lives of Servicemembers 

and civilians by developing better prevention, diagnosis, and treatment strategies. 

NIMH is also working with Marines on a separate effort supported by the Marine 

Corps which is synergistic with the Army STARRS project. This effort is advisory, 

assisting the Marines in making decisions about how to proceed with their project, 

and seeking to bring the Marine study investigators into a collaborative working relationship with those involved in Army STARRS. 

SENATOR CASEY

Funding for Pediatric Mental Illness 

Question 1. What percentage of your funding goes to research into mental illnesses that affect children, or to the early phases of illnesses that may not fully 

manifest until adulthood, but often have roots in childhood? 

Answer 1. Approximately 28 percent of the NIMH budget was devoted to pediatric 

research in mental health in fiscal year 2011 (the most recent year for which this 

data is available). 

Regarding the derivation of this percentage: In January 2009, NIH implemented 

a new reporting tool called Research, Condition, and Disease Categorization 

(RCDC). RCDC is a computerized process that NIH uses to categorize and report 

the amount it funded in each of 233 reported categories of disease, condition, or research area. The following table represents data derived from the intersection between two RCDC categories: ‘‘pediatric’’ and ‘‘mental health’’ for fiscal year 2011. 

This table represents NIMH-administered records only. RCDC data are publicly 

available via the NIH RePORT Web site.10

Fiscal year Number of pediatric 

mental health projects 

Total pediatric mental 

health spending Total NIMH budget Percent of NIMH budget 

2011 ....................... 1,144 $414M $1,475M 28 

Unique Considerations in Pediatric Mental Health Research 

Question 2. Are there unique considerations to conducting mental health research 

with children, as opposed to adults, that are different from other types of pediatric 

research? 

Answer 2. Yes, the unique features of the developing brain distinguish pediatric 

mental health research from other types of pediatric research. Advances in our understanding of the molecular, structural, and functional aspects of brain develop-
84 

11http://www.nihpromis.org/default. 

ment have led to the discovery of striking changes that occur in the brain during 

adolescence—changes in the strength and efficiency of communication between different parts of the brain, notably in the frontal cortex, which is responsible for impulse control and long-range planning. An important concept from this research is 

that the brain does not resemble that of an adult until the mid–1920s. Thus, from 

a neuroscience perspective, adolescents are not merely mini-adults. This insight suggests that we must address mental illnesses, from ASD to schizophrenia, as developmental brain disorders with genetic and environmental factors leading to altered 

circuits and behavior. Understanding the causes and nature of malfunctioning brain 

circuits in mental disorders may make earlier diagnosis possible. Interventions 

could then be tailored to address the underlying causes directly and quickly, changing the trajectory of these illnesses. 

Children also present challenges with regard to ‘‘self-reporting’’ in mental health 

research, which is part of the typical diagnostic method. In many cases, young children have limited cognitive capacity and ability to convey information about themselves and their experience. Furthermore, many mental health issues are associated 

with developmental delays, which also compromise a child’s ability to report or participate effectively in research. These issues underpin the necessity of research to 

find biological markers for mental disorders. Through the PROMIS initiative NIMH 

has been an active partner in an NIH-wide effort to develop validated patient and 

parent reported outcome measures for use in assessment of pain, depressive symptoms, and anxiety in children in clinical trials.11

In addition to the complexities of developmental changes, it is critical to understand what types of interventions work best for the unique needs of pediatric populations and to deliver these interventions appropriately. NIMH supports several 

clinical research studies on behavioral interventions, medications, or combination 

treatment approaches. Effectiveness trials are currently comparing interventions to 

treat children and adolescents with anxiety, major depression, and ASD. In recent 

years, NIMH has funded a number of studies to understand the benefits and risks 

of using psychotropic medications in children; more research is needed to understand the effects of these medications, especially in children under 6 years of age. 

Each child has individual needs, and must be monitored closely while taking these 

medications. Several studies in progress are seeking to identify ways of preventing, 

minimizing, or reversing common adverse effects of medications, such as weight 

gain, during antipsychotic treatment. Future research will be on developing safer 

and more effective interventions (both behavioral and pharmacological) that are tailored to each child’s individual needs and characteristics. Another focus will be on 

preventing the onset of mental illness by intervening early among children who are 

at especially high risk or who have initial symptoms, before the full onset of the 

disorders. 

SENATOR ENZI

Coordination of Federal Programs 

Question. I am concerned about the significant number of duplicative Federal Government programs. Can you tell me what programs within your agency are duplicative or could be combined to provide more efficient operations? Please describe how 

you plan to identify unfunded and unproven programs that can be eliminated in 

order to better focus resources on those that do work. 

Answer. NIH makes every effort to eliminate or amend overlap regardless of the 

funding source prior to awarding research funding. NIH’s review for potential duplication begins immediately after the application is submitted to NIH. Each application is reviewed against previous submissions to ensure it is ‘‘new’’ with significant 

and substantial changes in content and scope, rather than a resubmission of an earlier application. The competitive NIH two-tier review process includes scientific and 

technical review and consideration by an advisory council that includes public representatives. Prior to the final funding decision, applicants are instructed to submit 

‘‘Just-in-Time’’ material, which includes a declaration of current other support the 

applicant is receiving—i.e., all financial resources, whether Federal, non-Federal, 

commercial or institutional, available in direct support of an individual’s research 

endeavors, including but not limited to research grants, cooperative agreements, 

contracts, and/or institutional awards. Furthermore, NIH investigates three forms 

of overlap: scientific (conceptual); budget (salary, equipment); and personnel (overcommitment of time to work on the project). NIH has taken and will continue to 

take steps to exemplify and promote the highest level of scientific integrity, public 

accountability, and social responsibility in the conduct of science. 
85 

RESPONSE BY MICHAEL HOGAN, PH.D. TO QUESTIONS OF SENATOR ALEXANDER, 

SENATOR MIKULSKI, SENATOR ENZI, AND SENATOR CASEY

SENATOR ALEXANDER

Question. I’m interested in making things easier for States as they tackle the 

mental health and substance abuse problems facing individuals and families in their 

communities. What are one or two things the Federal Government can do to make 

the money we now spend easier to use and help States in this effort? 

Answer. Crucial to this issue is that most of the Federal funding relevant to fighting addiction and mental illness at the State level is Medicaid. The block grants administered by SAMHSA (Mental Health, Substance Abuse Treatment and Prevention) are relatively minor by comparison. SAMHSA has done a pretty good job of 

making the block grant application and review processes simpler. Ability to use prevention funds to fight both mental illness and addiction would be a very good idea. 

Addictions constituents resist this on the grounds that not enough is done to fight 

addiction, however many health and behavioral problems are linked and good prevention efforts such as effective parenting programs help with many problems. 

Medicaid is I think the responsibility of the Finance Committee but flexibility in 

Medicaid would help the States as long as standards for and levels of behavioral 

health treatment were maintained. For example, Medicaid should support effective 

prevention programs. 

SENATOR MIKULSKI

Question 1. What barriers still exist with regard to achieving parity in mental 

health and medical benefits for patients with Medicaid, CHIP, Medicare, and private insurance? 

Answer 1. As my written testimony indicates, Dominici-Wellstone goes very far 

on this issue. I am confident the Administration’s admittedly overdue parity regs 

will be ok. The bigger problem is that parity by definition applies to mental health 

specialists, while the biggest mental health access issue is a failure to address mental health in primary care. This problem must be addressed. Health plans must pay 

for basic mental health care in primary care. The integrated care model known as 

collaborative care is proven effective in over 40 research studies, yet Medicare and 

many private plans do not cover the elements of collaborative care. It is also crucial 

that parity not become an unintended barrier to improving ‘‘primary mental health 

care.’’ The issue here is the necessity of payment to primary care for this work; if 

the parity benefit goes only to specialists it is self-defeating. The Massachusetts 

Medicaid program is implementing an innovative approach to address this problem. 

The DIAMOND collaboration in Minnesota is another excellent approach. 

Question 2. I am a big champion of privacy but with Virginia Tech, none of the 

systems talked with each other. How can we make sure privacy is protected and 

everyone in the system is talking to each other when problems arise? 

Answer 2. My opinion is the problem is more basic. The Supreme Court’s Tarasoff 

standard overrules privacy; if there is a clear risk, clinicians are obligated to report/ 

take reasonable steps today. The deeper problem (addressed in my written testimony) is that we have no national approach to treatment of emergent or ‘‘First Episode Psychosis.’’ Young people with these problems—and several recent mass murderers appear to fit this profile—have no system of care . . . so isolated practitioners 

are left to provide this care on their own. Dr. Lisa Dixon (formerly of U. MD., now 

at Columbia) is developing a network of these programs in New York. Dr. Brian 

Hepburn, the Maryland mental health commissioner, is familiar with this work. Oregon has a well-developed network. With First Episode Psychosis programs in place, 

there would be an expectation of care coordination and communication with college 

personnel. Absent a network of FEP programs, changes in the law will be ineffective. 

Question 3. Are reforms needed in the substance abuse prevention and treatment 

block grant or community mental health services block grant to meet the needs of 

patients in our communities? 

Answer 3. Reforms in these grants are mostly not crucial. They are very small 

components of the behavioral health programs in the States. SAMHSA has improved their administration. Improved attention to behavioral health in CMS is a 

much bigger problem. The Obama administration has done more here (for example 

the Health Homes program in Medicaid, and consultation with SAMHSA) but this 

is still not adequate. CMS must attend to mental health needs better in both Medicare and Medicaid. 
86 

SENATOR CASEY

Question 1. Thank you for sharing your insights and your suggestions, both practical and philosophical, about what steps we can take to improve our mental health 

system. I am intrigued by your description of First Episode Psychosis care that is 

being used successfully in several other countries. Could you describe this approach 

in greater detail? Are there specific barriers to its adoption that we are facing in 

the United States? 

Answer 1. The First Episode Psychosis approach was implemented widely in Australia under the leadership of Dr. Patrick McGorry. In the United States, the best 

developed approach is in Oregon, where about 70 percent of the State is now covered. A good description of the program is available at www.eastcommunity.org. If 

I may be blunt, the biggest obstacle is that we are simply behind the times and the 

needs of patients on this. The fact that we have had a separate mental health system that focused on the ‘‘seriously and persistently mentally ill’’ meant indirectly 

that young people’s mental health in general has been neglected. The programs we 

have could often be called ‘‘late intervention.’’ There are many barriers to a good 

approach to FEP, including that paying for the required team approach to care may 

be challenged by insurers as excessive. But it is essential. At its core, FEP care is 

a community-based approach similar to care in a modern cancer center. It is teambased, family-centered, and holistic. It uses a treatment plan consistent with what 

the patient and family will accept, but aims for care that meets the highest and best 

researched standards for effectiveness. 

Question 2. Is there a widespread recognition among primary care physicians that 

treating mental health issues is also an important part of treating physical health? 

How can awareness of this matter be improved among primary care physicians? 

Answer 2. Awareness among PCP’s is very uneven, but many of them know that 

they are dealing with behavioral issues—especially family physicians and pediatricians. The bigger problems are that national standards for behavioral care in primary care are inadequate—and because we have a separate mental health system, 

we reserve payment for behavioral care to specialists. We need widespread promotion of the Collaborative Care model, and an understanding that Medicaid, Medicare and commercial payers will cover collaborative care. Evidence shows that savings from reduced medical care will more than pay for better depression care in primary care. 

Question 3. Have providers developed any innovative ways to stretch resources 

after facing State or Federal budget cuts? Are there any models that stand out for 

successfully operating on reduced funds that could be emulated by other providers 

or local officials? 

Answer 3. In my opinion the major innovation that is needed—and now happening—is an emphasis on ‘‘integrated care’’ whereby basic behavioral and other 

medical problems are handled by the same team, with specialists only called in 

when problems really require it. This is happening in many (but not all) Community 

Health Centers, in some Mental Health Centers (e.g. in Missouri) that are now coordinating their consumers’ medical care. We have learned that people who have 

major chronic health problems (like diabetes, heart disease) and also mental health 

problems have total health costs that are 30–70 percent higher than people with 

comparable medical illnesses but no depression. Integrated continuous care helps 

them manage their health better, reducing hospitalizations and ED visits. In my 

view, this trend toward integration may be part of the reason why recent reports 

show reduced medical inflation. 

There are still many barriers to integration. The Federal Government is trying 

to help, but much more needs to be done. My discussion of collaborative care above 

illustrates this. Medicare still does not cover its elements adequately. And the barriers in separate mental health and medical plans can prevent responsible integration. Of course, there remains a tendency for health plans to depress levels of mental health service. Integration with basic requirements for mental health services 

is essential. 

SENATOR ENZI

Question. What can be done to educate local communities about identifying risk 

factors for mental illness and substance abuse? How do we improve access to treatment? What is working and what is not working? 

Answer. We must do a better job with prevention. The evidence is clear that these 

problems begin in childhood. For example, maternal depression can impair a mother’s ability to parent well. If she is single with multiple children, the problems are 
87 

1Goldman H & Grob G. (2006). Defining ‘‘mental illness’’ in mental health policy. Health Affairs. 25(3): 737–49. Retrieved on February 21, 2013 from http://content.healthaffairs.org/content/25/3/737.full. 2 Cummings JR, Wen H, & Druss BG (2013). Improving access to mental health services for 

youth in the United States. Journal of the American Medical Association. 309(6): 553–54. 3Department of Health and Human Services Office of the Inspector General. (January 2013) 

Vulnerabilities in CMHS’ and Contractors’ Activities to Detect and Deter Fraud in Community 

Mental Health Centers. OEI–04–11–00101. Retrieved on February 21, 2013 from https:// 

oig.hhs.gov/oei/reports/oei–04–11–00101.pdf. 4Lehman AF, Goldman HH, Dixon LB, & Churchill R. (2004). Evidence-based mental health 

treatments and services: Examples to inform public policy. New York: Millbank Memorial Fund. 

compounded. Treating mom’s depression reduces levels of mental health problems 

in her children by 50 percent without directly treating the children. Our failure to 

intervene early with children who have moderate levels of mental health concerns 

(that could usually be addressed through parent support and training, behavioral 

services in pre-school and age-appropriate psychotherapy) leads to use of powerful 

medications and to other expensive interventions later on. As I said in the hearing, 

we have an admirable national early intervention program for kids with developmental disabilities, but for kids with emotional challenges we wait for years and 

then often just use meds. 

The single biggest thing we could do in the short term is to make sure that basic 

mental health care is a core element of primary care in Medicaid, under State Insurance Exchanges, and in Community Health Centers. This early intervention approach can address many health problems and is cheaper than specialty care. It is 

applicable for pediatrics and geriatrics. But primary care must have access to reimbursement for these basic services known as Collaborative Care. 

RESPONSE BY ROBERT N. VERO, ED.D. TO QUESTIONS OF SENATOR ALEXANDER, 

SENATOR MIKULSKI, SENATOR ENZI, AND SENATOR CASEY

SENATOR ALEXANDER

Question 1. I’m interested in making things easier for States as they tackle the 

mental health and substance abuse problems facing individuals and families in their 

communities. What are one or two things the Federal Government can do to make 

the money we now spend easier to use and help States in this effort? 

Answer 1. First, it would be helpful for the Federal Government to create a Federal definition for Federally Qualified Behavioral Health Centers 

(FQBHCs). There was a definition for Community Mental Health Centers (CMHCs) 

for more than the first 20 years of their existence, but this was lost in the 1980s.1

This has resulted, too often, in poor outcomes, serious gaps in services from State 

to State, and the growth of mental health agencies that provide only some (or none) 

of the core services necessary for community-based care that still call themselves 

‘‘community mental health centers’’ and, likewise, still bill Medicaid and Medicare.2 3 There is a key provision within the Excellence in Mental Health Act that 

proposes a definition and, moreover, delineates the minimally expected array of 

services. 

1. If States chose to contract with FQBHCs, they could ensure communities are 

able to access a full continuum of high quality, evidence-based, mental health and 

addiction services. Sadly, most current public policies do not hold health providers 

accountable for providing value-based services.4

2. The proposed definition would ensure that the provider offers mobile (faceto-face) crisis mental health services within their local community. This is a 

proven strategy to deter unnecessary psychiatric hospitalizations and prevent community tragedies. While many providers currently provide crisis hotlines, their continuum of crisis services would be unquestionably strengthened with the addition 

of mobile crisis services. These face-to-face assessments are often invaluable interventions, also reducing unwarranted arrests and incarcerations. State costs are reduced significantly when there are local teams, available 24-hours per day (365 days 

per year), interfacing with law enforcement, hospital emergency departments and 

concerned family members to provide emergency assessment to people in crisis. 

3. Another issue the Federally Qualified Behavioral Health Center definition 

could address is the concern States have with access to care. Too often, profit-motivated providers have cherry-picked high-revenue services, leaving some parts of our 

communities without access to care—especially in rural areas. The current fragmented behavioral healthcare system has resulted in only 1⁄3 of rural counties and 

63 percent of all U.S. counties having ‘‘at least one mental health facility with any 
88 

5 Cummings JR, Wen H, & Druss BG (2013). Improving access to mental health services for 

youth in the United States. Journal of the American Medical Association. 309(6): 553–54. 

special programs for youth with severe emotional disturbance’’ (Cummings, Wen & 

Druss, 2013, 553).5

4. States would have access to a source of valuable outcomes data for patients 

being treated in FQBHCs. Currently, many States lack whole health (physical and 

behavioral health) outcomes data from mental health and addictions providers regarding key quality metrics that would help States determine the value of the services provided. 

Second, it would be helpful for States if community mental health centers 

were included in the HITECH Act. In order for States to successfully audit providers, ensure that outcomes are being tracked on all persons served, and evaluate 

the value of care received for its citizens, the providers it contracts with need to 

have access to electronic health records, data information exchanges, and other 21st 

century technology tools. With most CMHCs serving a high number of Medicaid clients, their operational budgets have very slim margins and, consequently, many 

have not been able to keep pace with the technological advancements of the digital 

age. Within the current financial environment, most States lack funds to support 

providers to adopt electronic health records and submit data electronically. Thus, 

this impedes States being able to hold providers accountable for adopting Health IT. 

Inclusion of community mental health centers in the HITECH Act would be very 

valuable—especially given the health risks and health costs of the highly fragile 

populations that they serve. 

Question 2. Centerstone of Tennessee sees approximately 50,000 patients per year 

at various facilities and locations. How do your multiple partnerships in the community impact outcomes and are these partnerships effective? 

Answer 2. Our community partnerships work and are, moreover, key to our success in impacting outcomes for the people we serve. Centerstone actively partners— 

depending on the community needs and resources available in its counties—with 

law enforcement, jails, courts, hospital emergency departments, physician groups, 

local NAMI and Mental Health America chapters, K–12 public schools, day care 

agencies, preschools, faith-based organizations, universities, researchers, and other 

local and regional non-profit organizations. We believe that these partnerships are 

fundamental and, as such, strengthen our success and program outcomes. We strive 

to be the community partner of choice. 

Without our partnerships with law enforcement, jails and the court system, our 

mobile crisis team would not be so successful in preventing unwarranted incarcerations. Without our partnerships with hospital emergency departments, physicians, 

community leaders and parent support groups, our mobile crisis team would not be 

as successful in preventing unnecessary hospitalizations or worse, tragedies. Without partnerships with preschool administrators and their teachers, our school-based 

services team would not be successful in providing early assessment and intervention. These early prevention, assessment and intervention programs also importantly enhance the likelihood of a child’s future academic success. Without partnerships with teachers and principals, we couldn’t teach techniques to help teachers 

and students prevent bullying, violence, drug use and teen pregnancy. More simply, 

without these community partnerships and collaborations, there would be more suspensions and expulsions, and we wouldn’t be part of Tennessee’s rapid success in 

increasing high school graduation rates. 

Our mobile crisis teams would also be less effective if there were not a community 

relationship in place. For example: an emergency department physician could sign 

a certificate of need (emergency/involuntary commitment papers for hospitalization) 

before our staff had an opportunity to engage the patient and complete a full crisis 

assessment. When provided the opportunity to conduct a face to face assessment, 

we can typically prevent 50 percent of those encounters from resulting in a psychiatric hospitalization. 

Mutual need often defines our community relationship with local law enforcement 

agencies. We depend on them to help us be safe when we respond to address a crisis. Likewise, they sometimes need us when they respond to a call that requires 

mental health expertise. Our staff is specifically trained to intervene with people in 

acute psychiatric crisis. This can be crisis mitigating and life saving. 

In our communities that have long-standing preschool advisory boards, the partnerships are very effective. These boards include representation from healthcare 

providers, child welfare, schools, local charitable agencies, and mental healthcare 

providers. In our new early childhood system of care communities, these relationships are now being formed, and a governance entity with diverse representation 
89 

is being established. In communities where there is a formal advisory board with 

diverse representation that focuses on infant and early childhood services, we have 

found that there are more cross-referrals and communication among service providers which results in better outcomes. 

With regard to mental health services within schools, both Centerstone and many 

of our local school systems are working toward the same goal—for the child and the 

family to be successful and functioning. The school approaches this from an academic perspective, and we focus on it from a mental health perspective. Both of 

these perspectives are important and make for a strong, successful relationship. As 

part of these partnerships, we provide behavioral health services in the school, participate on committees alongside school staff, and provide specialized mental health 

and addictions trainings for the school staff that they might not otherwise receive. 

We provide coaching to parents, teachers and administrators, empowering them to 

successfully address behavioral health concerns—from disruptive behavior in the 

classroom to self-injurious behaviors. 

We also have several unconventional community partnerships. One such example 

is with Rocketown—a recreational safe place for adolescents in Nashville. We have 

partnered with them for 3 years, bringing counseling and case management to that 

environment in a very unique way. We have counselors there in the afternoons, 

interacting with the staff and intervening with the teens. By being there in the 

teen’s environment, we are seen as a member of the Rocketown team, not as an outsider. While in other settings, it can sometimes be the parent or teacher pushing 

the teen toward services, but at Rocketown the teens are seeking out services for 

themselves. Being able to access a respectful, trusting adult can be life-altering for 

many of these teens. Recently, we helped a child who had been living in a car for 

several weeks. We helped that child get connected with a respite foster care placement, long-term counseling, and other services the child desperately needed. 

Finally, our community success also relies very heavily on our relationships with 

the many different departments of State government within Tennessee, including 

the Departments of Health, Mental Health and Substance Abuse Services; Corrections, and the Department of Children’s Services. For example, the Tennessee State 

Department of Mental Health and Substance Abuse Services, under the leadership 

of Commissioner Doug Varney, has worked with us and other Tennessee mental 

health agencies to standardize how our mobile crisis teams function and to determine what data we collect. These data have helped the State make decisions regarding the most impactful places for mobile crisis services to be offered. We also work 

very closely with the Department of Children’s Services. Our school-based services 

use the same outcomes metrics used by DCS. This common outcomes platform helps 

ensure the success of children in State custody and provides the State with valuable 

performance information on its provider network. 

SENATOR MIKULSKI

Question 1. Is any further action needed on the part of Congress to help you offer 

mental health and substance abuse services in schools? 

Answer 1. School-based mental health counselors who provide early intervention, 

prevention services, treatment resources, development of peer natural helpers, and 

coordination of care with other health providers have been tremendously effective 

resources for all children and youth, including high-risk age groups. School-based 

services eliminate the barrier that families, including working single parents, often 

have trying to address care for their children with behavioral health needs. Without 

these services, many children would not be able to obtain the care they seriously 

need. Many of the children served by school-based services have experienced significant trauma, have neurological conditions that require teachers and other caregivers 

to get special training and/or coaching, and are at risk for failing academically. 

Sadly, there is a lack of adequate resources for these evidence-based programs. Fortunately, the Mental Health in Schools Act would be helpful to ameliorate this 

issue. 

While Centerstone now provides school-based services in 13 of its 22 counties in 

Tennessee, this was not the case 10 years ago. Competitive grants initially enabled 

us to create and then later expand this service. Beginning this program required 

initial startup funds. The same is true today; those initial funds enable us to create 

the necessary infrastructure to reach sustainability. As an example: 7 years ago, we 

received a 3-year grant to provide school-based services in Montgomery County, TN. 

While the initial grant was to help support the services of six staff over the 3 years, 

once we were able to establish the infrastructure and the teachers and administrators realized the value of our services, we were able to expand services. We currently have 22 school-based staff serving in the Montgomery county schools, pro-
90 

6 National Research Council. (2009). Preventing Mental, Emotional, and Behavioral Disorders 

Among Young People: Progress and Possibilities. Washington, DC: The National Academis 

Press, 2009. 8http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807642/. 

viding unique access and care for hundreds of children and adolescents who might 

not otherwise be accessing treatment. 

Question 2. What recommendations do you have for improving access to services 

for families with infants and toddlers who are at risk for emotional problems? 

Answer 2. There are several things that could be helpful to improve access to 

services for families with infants and toddlers at risk for emotional problems. Research has shown the effectiveness of early childhood interventions.6

First of all, it would be helpful if every State’s Medicaid program could fully implement the Early Periodic Screening Diagnosis and Treatment (EPSDT) benefit to 

improve the mental health of low-income children and adolescents. Additionally, we 

recommend that emphasis on Social Emotional development should be included in 

the EPSDT Program with a procedure for additional mental health assessment 

when delays are noted. 

Additionally, it would be helpful for there to be several key reimbursement 

changes related to funding for services for this vulnerable population. These include: 

• Change the definition of medical necessity for CMS services to include early 

childhood intervention services; 

• Providing reimbursement for CMHCs (or FQBHCs if the definition exists) to 

provide consultation in hospital settings like the Neo-natal Intensive Care Unit and 

the Intensive Care Unit. It would be helpful for child psychiatrists, mental health 

nurse practitioners, psychiatric case managers, and/or therapists from outside community settings to be able to meet with, identify and ultimately intervene with highrisk children and their families; 

• Ensuring that CMS compensates providers for providing home visiting services 

through maternal, infant and early childhood Home Visiting. We have had excellent 

results in the counties where we provide these services, and it would be wonderful 

to be able to expand and sustain these services; 

• Reimbursement for services in the home setting. Many caregivers and their infants and young children are not able to get to clinics for therapy services. We recommend that there be more emphasis on providing these services in the home setting; 

• Reimbursement for maternal, infant, and early childhood parenting classes, especially for at-risk parents with mental health and addiction diagnoses, have been 

proven to have excellent outcomes in other countries. It would be helpful to enable 

CMHCs to be able to provide these services; and 

• Currently, the trainings that we provide in the community are, by and large, 

uncompensated. It would be wonderful to have trainings related to early childhood 

mental health screenings incorporated into the requirements for school, head start, 

daycare and preschool workers. This would help us to be able to intervene earlier. 

It would be helpful for CMS to specifically State that the Diagnostic Classification 

of Mental Health Disorders of Infancy and Early Childhood (DC: 0–3R) be accepted 

by States as an acceptable system for diagnosing infants and young children. The 

DC–0–3R defines disorders as they appear in infants and preschoolers. Several 

States have developed crosswalks between the DC: 0–3R and the DSM IV. 

Last, mental health education programs (i.e., schools of social work or counseling) 

should offer training in Infant and Early Childhood Mental Health. This is currently 

not widely available for clinicians, and it should be made more available for student 

therapists who will be working with infants, toddlers and their families. 

SENATOR CASEY

Question 1. In your testimony, you noted that 50 percent of mental illnesses start 

before the age of 14. By what age is it usually possible for professionals to diagnose 

some of the more common mental illnesses? Can these diagnoses be made by the 

child’s pediatrician, or do they require referral to a specialist following the parent 

or pediatrician realizing there is a more serious problem? 

Answer 1. By using the Diagnostic Classification of Mental Health Disorders of 

Infancy and Early Childhood (DC: 0–3R) manual, disorders can be identified as 

early as birth. This classification system includes assessment of the family in addition to individual child characteristics. Most pediatricians have not received training 

in the DC: 0–3R. It depends on the diagnosis, but around 25 percent of lifetime 

mental illnesses can be identified by school age. 8
91 

9http://www.nytimes.com/2009/12/12/health/12medicaid.html?pagewanted=all&lr=0. 10http://psychcentral.com/news/2012/08/15/big-jump-in-antipsychotic-drugs-prescribed-for-kids/ 

43099.html. 11 Cummings JR, Wen H, & Druss BG (2013). Improving access to mental health services for 

youth in the United States. Journal of the American Medical Association. 309(6): 553–54. 

While some childhood behavioral health diagnoses may be initially identified by 

pediatricians, it is most helpful if the pediatrician provides a referral for a behavioral health specialist (whether a child psychiatrist or a doctoral or masters-level 

trained mental health clinician) to conduct a more in-depth assessment. For example, ADHD-like behaviors in a child can be a sign of something else (parental depression, dietary issues, abuse at home, need for parenting training, exposure to 

trauma), but ruling these out requires a full psycho-social assessment, preferably in 

the child’s home or school environment. Pediatricians often lack the time and training for these in-depth assessments, and the risk of prescribing an ineffective medication to a child that could have harmful side effects is very real. Additionally, if there 

is not a referral to a specialist, the child often does not receive access to a broader 

toolkit of treatment options. A pediatrician may only have medication as an option 

to address disruptive child behavior. A behavioral health provider, if they are offering a full continuum of research-based services for children, will have multiple, 

highly effective options. 

It is critical to intervene as early as possible when there are signs of potential 

mental health or substance use issues in children and youth. Later intervention decreases good outcomes. In early childhood, a number of issues are closely tied to the 

adults in a family so intervention for the child often needs to be accompanied by 

or preceded by intervention for the adults. We believe a significant role for the 

child’s pediatrician as well as other adults who come into contact with a child is 

to identify the problem or symptom and then to refer to a mental health professional. Attention also needs to be given to over-diagnosis and excessive medication 

usage 9 in the children’s population, particularly the youngest patients.10

Question 2. You mentioned that Centerstone has been able to offer mental health 

and substance abuse services within rural schools for children and youth. How common is it for community mental health centers to coordinate their efforts with teachers, schools, day care, or early learning programs? Do you feel that these individuals 

and institutions have the training and resources needed to help community mental 

health centers identify and treat mental illnesses early? 

According to a report published last month by the Journal of the American Medical Association, only 1⁄3 of rural counties and 63 percent of all U.S. counties having 

‘‘at least one mental health facility with any special programs for youth with severe 

emotional disturbance’’ (Cummings, Wen & Druss, 2013, 553).11 In a brief review 

of PubMed, my staff was not able to find specific information previously published 

regarding the specific question of how common it is for CMHCs to coordinate efforts 

with these different community partners. In order to address this need, we created 

a brief survey for providers to complete. This was distributed via e-mail to members 

of the National Council for Community Behavioral Healthcare and the National Association for City and County Behavioral Health and Developmental Disability Directors. 

This survey was completed by 173 different community mental health centers 

serving 941 counties in 43 States. Here are the results: 

K–12 Schools Preschools/Early Learning 

Programs 

In-home early intervention 

(ages 0–4) In-home services (5–18) Day Care Settings 

145 ......................... 89 84 129 48 

84% ....................... 51% 49% 75% 28% 

As you can see, of the providers that responded to this survey, there is great diversity regarding the services offered and the locations in which they are provided. 

Only half of the respondents provide early intervention services in the child’s home 

or in preschools or in early learning programs. Only 1⁄4 provide services within day 

care settings. 

Regarding the question of whether non mental health workers within these settings currently have the training and resources needed to help identify and treat 

mental illness early, the answer is largely no. There is much work to be done in 

the area of training for early childhood workers in their ability to adequately conduct screening and referrals to appropriate services. In our experience, we have 
92 

found that staff in these settings are hungry for this knowledge and make excellent 

use of the training and resources once they receive them. 

Question 3. You noted that disruption of care can be a concern for young adults 

if their State Medicaid plan does not allow for an ‘‘aging out’’ transition plan to enable them to seek other health insurance or a new provider in a timely fashion. How 

damaging can this be to the progress that has been made with treating their mental 

health problems? Are there any notable examples you can provide where this was 

an issue? 

Centerstone, like many providers, struggles to provide the best care possible to 

this population. We often will keep teens that have aged out a little longer in our 

child-based services because they can get lost going into the adult care world and 

need more contact than the typical adult patient. They’ve gone from a very structured place in school with a lot of people checking in on them, to having to handle 

everything on their own. Sadly, with budget cuts, providing these largely unreimbursed additional services are tricky to navigate. 

We believe that grants and funding streams to work with this population would 

be very helpful. Often times, even a couple of months after we transition services, 

teens that we’ve helped get stable on their medications and in educational settings 

drop out of care and relapse. We need a different way to transition these youth. It 

would be especially helpful if we could provide comprehensive continuity of care programs for young adults with developmental disorders including autism spectrum 

disorders and serious mental illness. Being in a State still contemplating Medicaid 

expansion currently makes transition funding difficult. There is a delay time for our 

State safety net dollars to kick in, and there are years of delay for a teen to qualify 

for disability. From our experience and from the research, we know that if these 

teens and young adults could get the right care and have a seamless transition, 

many wouldn’t need disability. However, we also know that if a young adult goes 

several years without needed medications and treatment, this can have devastating, 

long-term consequences. Continuity of care would be helpful to address this. 

When we asked our staff to provide stories of clients who were damaged by the 

transition process, we received too many to share in this format. We have selected 

the stories of these two young people below. All of these young adults needed significant help in making the transition from high school into adulthood that we were 

not able to provide to them. These summaries were written by staff who worked 

with these clients, and we have kept them in their own voice. 

‘‘DE–19 years old (at the time she lost her insurance) with a diagnosis of 

Major Depression Recurrent. She received therapy, case management and medication management services from us. We were actively providing services when 

she lost her Tenncare. We attempted to appeal and were unsuccessful. We attempted to try and support her after she lost her insurance. She was arrested 

a few months after we had to transitioned out of services. She lost her temper 

(her depression manifested itself as irritability and anger) and got into a ‘‘fight’’ 

with a family member, and the police were called. I still feel that the incident 

could have been avoided if she could have remained on her medications.’’ 

‘‘MT–19 years old (when he contacted us to request services again) with a diagnosis of ADHD and intermittent explosive disorder when he was initially discharged. He called because he was having trouble keeping a job because of his 

anger, and he had been put out of his mom’s home. When we attempted to reopen him, we learned he had lost his insurance. We attempted to help him get 

his insurance set up again, but we were not successful. He was not able to make 

all the appointments, and we could not send a staff to walk him through the 

safety-net process. We attempted to provide him with resources that could 

help.’’ 

SENATOR ENZI

Question 1. What can be done to educate local communities about identifying risk 

factors for mental illness and substance abuse? How do we improve access to treatment? What is working and what is not working? 

Answer 1. 

Educating Local Communities 

The Mental Health First Aid bill would be helpful to address the need to educate local communities. Mental Health First Aid is specifically tailored to educate 

local key stakeholders to identify risk factors for Mental illness and Substance Use 

Disorders. It would be extremely helpful if CMHCs could have access to funding to 

train law enforcement, hospital emergency departments, local civic and social service organizations, and other community partners. As a recognized service provider 
93 

Centerstone already has relationships with many of these entities and this would 

be a wonderful service addition to these important community relationships. 

Improving Access to Treatment 

While education regarding the importance of treatment is important, it is not effective if there is not access to treatment. There are multiple issues contributing to 

the overall lack of access to behavioral health services. These include, but are not 

limited to: lack of transportation, workforce shortages, lack of a specialized workforce, limited use of technology by providers, and funding shortages. Currently, 

many individuals who are poor and over age 18 have limited access to treatment 

until they are classified disabled for their condition. This is unfortunate since most 

people with mental illness—if they receive the right care at the right time—don’t 

have to experience their condition as a life-altering disability. Having a system of 

FQBHCs, as is proposed under the Excellence in Mental Health Act, would provide 

that safety net of care for uninsured and underinsured individuals and families— 

significantly improving access to care. 

What is Working and Not Working? 

While it is a significant undertaking to improve access to mental health and addictions treatment, for everyone in need, we believe another huge challenge is improving access to cost effective treatment and efficacious care. This is one of 

the reasons we are pleased that the Excellence in Mental Health Act specifically 

mandates providers to use the best evidence-based treatments where available. Lack 

of effective treatments is a challenge in urban and suburban areas as much as rural 

areas. You can see the consequences of people receiving poor and/or inadequate care 

in urban settings as you walk to work. As Dr. Bickman, a researcher we have 

worked with at Vanderbilt University, recently highlighted in an op-ed in the 

Tennessean (February 12, 2013), ‘‘ineffective treatment is a quieter and 

unacknowledged crisis that is more pervasive and insidious than insufficient access.’’ 

The good news is that mental health and addictions treatment, if done well under 

the right conditions, has been shown to be extremely effective with positive, longlasting effects that yield enormous improvements for families, local communities 

and society in general. However, many providers in the mental health sphere do not 

currently (1) ensure that only evidence-based treatments are used and (2) have 

mechanisms in place to ensure that their treatments are resulting in positive outcomes as a result of treatment. 

In his article, Bickman proposes seven steps that he believes research shows 

would fix the ‘‘quality problem’’ in the mental health system. They are: 

• ‘‘Monitoring the quality of services to ensure they are working. 

• Holding service providers accountable for well-implemented evidence-based 

treatments that show positive outcomes. 

• Integrating mental health and primary care following a public health model. 

• Eliminating services and practices that do not benefit clients and that hamper 

the best efforts of underfunded agencies. 

• Improving client and family engagement to lower the high client dropout rate 

in treatment. 

• Providing improved education and training so the workforce is more capable of 

adopting modern technological approaches. 

• Providing financial incentives to agencies for delivering effective services.’’ 

We support all of these steps, and we believe that the Excellence in Mental 

Health Act would go a long way to enabling these changes to occur. 

We also want to emphasize that improving the effectiveness of care will be impossible without Health Information Technology. It is nearly impossible for providers 

without Health IT to track outcomes for individual patients and assess fidelity to 

evidence-based practices. Lacking providers with Health IT capacity, some States 

have to, unfortunately, make outcomes value decisions based on intermittent paper 

surveys dependent on a small percentage of the total patient population served. The 

efforts that Senator Whitehouse has championed regarding expanding coverage for 

Behavioral Health providers to be included in the HITECH Act are foundational to 

set up a different U.S. mental health system. 

Question 2. Can educators, whether in primary schools, secondary schools or universities, be trained to identify at-risk children and adolescents? What are some important strategies for mental health first-aid? How can we ensure students and employees follow through with screenings and treatments for mental health and substance abuse? 
94 

7http://www.ghc.org/aboutlgh/Quality/hedis–2012.pdf. 

Training Educators 

We have found in our school-based work that educators can definitely be trained 

to identify at-risk children and adolescents. Oftentimes, educators have no difficulty 

identifying those children who are acting out. However, it often takes training to 

help them learn to identify children and adolescents that may be internalizing trauma or may be depressed or suicidal. Trainings for school staff have been invaluable 

toward helping us all work together for earlier identification of issues. In order to 

strengthen the education system, we believe that it would be valuable for teacher 

training programs and continuing education programs to include basic training in 

early identification. 

Strategies for Mental Health First Aid 

We believe that it is important for key community leaders to receive training in 

Mental Health First Aid. It can be incredibly helpful to train law enforcement, first 

responders, emergency department personnel, faith community leaders, local business and civic leaders, and other community partners. While some community organizations have the ability to pay for this training themselves, others lack the funds 

to do so. We support comprehensive Mental Health First Aid legislation that will 

assist us in providing this valuable training more broadly in the community. In our 

experience, the more individuals trained in a community to recognize early warning 

signs and refer to effective treatment, the more tragedies we can prevent. 

Ensuring Follow-Through With Screenings and Treatment 

Regretfully, due to the complicated current legal system, we cannot offer absolute 

assurance that students and employees will follow through with screenings and 

treatment for mental health and substance abuse. In order to address the current 

gaps in the system, it is most likely that some privacy laws would need to be reviewed. 

We do believe that it would be helpful if the common metrics for health care service provision that managed care companies and States were incentivized for achieving (i.e. from NCQA) included metrics for mental health care follow-through and client engagement in services. At Centerstone, we have adopted the NCQA HEDIS 

metric for client engagement as an outcome across all of our programs and services. 

Our attention to engagement has helped us have a 44 percent average engagement 

rate for 2012. Unfortunately, there is not a national metric regarding engagement 

for mental health services, but the substance abuse client engagement industry average was 15 percent in 2015.7 There is currently no incentive for achieving excellence in this metric within the mental health services delivery system, besides addictions. However, we believe that if there were an incentive, more providers would 

improve their client engagement and follow-through. Lack of engagement and follow-through with persons with addictions and serious mental illnesses can have 

costly, devastating consequences. 

We encourage our employees to be creative in helping to ensure follow-through. 

Our mobile crisis staff is able to go to wherever the need is—at a workplace, school, 

home, hospital, or other setting—to perform the initial screening. Our school-based 

staff is able to go into homes, workplaces, or wherever the parent wishes to meet 

in order to get the parental consent that is required for screening and any followup. 

One thing that would be helpful to increase screenings is to ensure that school 

personnel (teachers, administrators, and school resource officers) receive training in 

mental health and addiction warning signs and how to take appropriate actions to 

intervene with high-risk children and youth who are exhibiting troubling behaviors. 

The Mental Health First Aid bill could be helpful to achieve this aim. 
95 

COLORADO BEHAVIORAL HEALTHCARE COUNCIL (CBHC), 

DENVER, CO. 

KATHLEEN C. LAIRD, 

Majority Health Policy Office. 

Hon. TOM HARKIN, 

Committee on Health, Education, Labor, and Pensions, 

U.S. Senate, 

Washington, DC 20510. 

MS. LAIRD: Thank you for the opportunity to respond to the Senator’s questions. 

It is a privilege to share my thoughts on their questions. I am inspired by the fact 

that members of the committee are genuinely interested in how to help people who 

have mental health and substance use disorder conditions. 

RESPONSE BY GEORGE DELGROSSO TO QUESTIONS OF SENATOR ALEXANDER, 

SENATOR ENZI, AND SENATOR CASEY

SENATOR ALEXANDER

Question. I’m interested in making things easier for States as they tackle the 

mental health and substance abuse problems facing individuals and families in their 

communities. What are one or two things the Federal Government can do to make 

the money we now spend easier to use and help States in this effort? 

Answer. 

Payment 

• The main way that the State of Colorado interacts with the Federal Government as it relates to mental health issues is through annual plans that it submits 

for use of the Federal Government mental health and substance abuse prevention 

and treatment block grants from SAMHSA, Medicaid, and Medicare. The block 

grants are important programs that fund a range of critical prevention and treatment efforts around the country for people who do not have health insurance coverage or are under-insured for mental health and substance use disorder coverage. 

Unfortunately, the amount of funding available to each State from the block 

grants is very low. This creates a significant burden on the States to try and cover 

this need. What I have noticed is that with reductions in State spending for mental 

health and substance use disorder treatment is one of the first places that cuts are 

made when what is needed most is increased investment in treatment services. Not 

receiving necessary treatment results in more burdens on emergency rooms, law enforcement, homelessness, and suicide. In worse case scenarios we see more violence 

toward other people. 

Congress can help in this area by allocating more money to the block grants to 

fund additional evidence-based programs that meet communities’ needs. 

• Medicaid is an important program for people with mental health and substance 

use disorders. Each State has their own plan on what they will cover in this area 

and how they reimburse for services. As the Medicaid coverage expansion rolls out 

in 2014, more people than ever before will need mental health and addiction services. 

Congress can help by changing the way treatment providers are paid through Medicaid. Currently in most States’ payment rates don’t cover the cost of care. Creating 

a Federal definition and status for Federally Qualified Behavioral Health Centers 

and allowing those entities access to the cost-based reimbursement and mandatory 

Medicaid status that other safety net providers currently receive (as outlined in the 

Excellence in Mental Health Act, S. 274) will go a long way toward creating that 

much-needed expansion of our treatment capacity. 

Support Integrated Care 

Research indicates an integrated mental health and substance use disorder system, and also integrating care between these two areas and physical health care will 

reduce cost, increase health outcomes, and improve access to necessary care. The 

rules, regulations, and payment models in SAMHSA, Medicaid, and Medicare are 

not aligned together to support integrated service delivery at the local level. This 

misalignment creates excess burden on States and providers to try and integrate 

care. 

Congress can help in this area by requiring Federal Agencies to align their efforts 

to develop and implement rules, regulations, and payment methodologies that are 

conducive to integration of health care. 
96 

SENATOR CASEY

Thank you for your explanation of Mental Health First Aid and the valuable role 

it can play in identifying individuals with mental illness and referring them to appropriate care. 

Question 1. How long did it take Colorado to establish its Mental Health First Aid 

training program? 

Answer 1. MHFA came to Colorado in 2009, starting with just a handful of Instructors participating in the original U.S. pilot. Since then, the Colorado Behavioral 

Healthcare Council, the Colorado Office of Behavioral Health, and the statewide 

network of community mental health centers have spearheaded an effort to rollout 

the program statewide. In 2013, our Instructor network will eclipse 200, delivering 

both the adult and youth Mental Health First Aid curricula, as our State rapidly 

approaches the 10,000 mark for Mental Health First Aiders certified. 

Question 2. What is the cost to provide Mental Health First Aid training? 

Answer 2. There are three primary costs associated with Mental Health First Aid 

that we have encountered. 

(1) Training Mental Health First Aid Instructors (those who will deliver the courses in the community) is about $1,500 per Instructor; 

(2) Cost to actually deliver the course in the community (participant manuals, training materials, etc.) is $20–25 per participant, up to 30 participants per course; 

and 

(3) Implementation supports to facilitate program dissemination (infrastructure, 

coordination, promotion, ongoing evaluation, etc.) should be considered. We are 

happy to provide the estimated amount needed in Colorado, but this would vary 

across the country. 

Question 3. Is the program designed in such a way that it could be easily scaled 

up. I’m interested in making things easier for States as they tackle the mental 

health and substance abuse problems facing individuals and families in their communities.

Answer 3. Yes—This is a health education and primary prevention program that 

has the potential to reach a huge population; linking people to care, combating stigma, and enhancing mental health and substance abuse literacy. Colorado has been 

able to grow the program considerably in a short amount of time and with limited 

resources, and with additional support could expand our efforts exponentially. It is 

important to note that investment in implementation supports is critical, as is the 

case when attempting to take any evidence-based program to scale. Having an advisory committee that represents a wide range of stakeholders also helps to ensure 

that expansion keeps a bigger vision than just reaching to one or two specific populations. The media also is interested in MHFA and its potential. Several reporters 

and news agencies have been involved in our efforts. 

SENATOR ENZI

Question. What can be done to educate local communities about identifying risk 

factors for mental illness and substance abuse? How do we improve access to treatment? What is working and what is not working? 

Answer. 

Education 

In Colorado we have engaged in a statewide approach to community education 

about mental illness and substance use disorder. Our Community Mental Health 

Centers have a very large investment in Mental Health First Aid training. Our 

State Office of Behavioral Health has also provided some funding to aid in this effort. We work collaboratively with a broad cross-section of Coloradoans to deliver 

Mental Health First Aid (MHFA), including law enforcement, schools, and the faith 

community. 

Mental Health First Aid is a public education program that can help families, 

communities, educators, law enforcement, primary care providers and others to understand mental illnesses, seek timely intervention, and save lives. MHFA teaches 

a five-step action plan to help people recognize the symptoms of common mental illnesses and addiction disorders; de-escalate crisis situations safely; encourage appropriate self-help strategies, and initiate timely referral to mental health and substance abuse resources available in the community. 

Congress can help by supporting the Mental Health First Aid Act that has been 

introduced by Senator Begich with bipartisan support. This bill authorizes $20 million for training Americans in MHFA to improve community education about mental 

illness and help people get access to treatment. 
97 

Improving Access to Treatment 

There are many areas to address to improve access to treatment. Each State and 

local community will need to address the following: 

Adequate Coverage: It is important to ensure that public programs and private insurance adequately cover mental health and substance use disorder treatment. Parity with primary health care is essential. 

Payment Reform: Mental health and substance use services need to be paid a fair 

rate that covers the cost of prevention, intervention, treatment and aftercare services. It is important to reimburse mental health, substance use, and primary care 

providers for the services they provide. 

Work Force Development: There is a severe shortage of mental health and substance use disorder providers, particularly in rural areas and in specialties such as 

child psychiatry. Loan forgiveness programs seem to help rural areas attract providers. It is important for colleges and universities to provide areas of study for a 

workforce that will work in mental health and substance use disorder care. Today’s 

workforce may need credentialing in both mental health and substance use disorder 

and to provide care in primary health care settings. Payment reform will also help 

attract people to this area of health care. Salaries and benefits for providers have 

been historically low compared to people who have similar skills and qualifications. 

Use of Technology: There is great potential to provide mental health and substance use disorder care thru tele-video and using Web-based tools. This will increase access of services in rural and frontier communities. Plus increase access to 

specialists, such as child psychiatrists and treatment for autism. Some of this care 

will also be provided across State lines. Rules and regulations need to be in place 

to ensure providers can provide care using tele-health beyond the usual borders, and 

to be reimbursed fairly. Some level of regulation and credentialing of providers who 

do care over the Internet and standards for compliant connections between providers and patients need to be addressed. 

What is Working and Not Working 

Integrated Care: It is essential that providers provide care with the whole person 

in mind. Historically, mental health and substance use disorder care has been separated from physical health. Evidence clearly indicates that if a person has both mental health and substance use disorder needs, plus the person has physical health 

problems they have a better chance of recovery at a lower cost if all of their health 

care services are addressed together. Mental health and substance use disorder providers need to integrate more physical health services, data, and information into 

their provision of care, and physical health providers need to do the same with mental health and substance use disorder. 

Managed Care: Colorado’s Medicaid mental health program has been using managed care since 1995. This program is a full-risk contract. The results have been 

significantly better than a fee for service payment model. Access to services has improved, more care is being provided in a person’s home community, and millions of 

dollars have been saved. A key ingredient to Colorado’s success is the opportunity 

for providers and managed care companies to partner together and share risk. Models that include risk sharing for both service delivery and health outcomes have significant promise to improve health care and reduce costs. 

Prevention and early intervention: Most of the funding for mental health and substance use disorder is for treatment. This treatment is usually provided after a person already has a diagnosed condition. Many of these conditions could have been 

avoided, have less negative impact if they had been identified earlier or prevented. 

Services provided at earlier stages are less expensive than higher level care, such 

as hospitalization. It is important to add prevention and early intervention services 

for mental health and substance use disorder in public programs and private insurance. 

Evidence-based care: There are a growing number of mental health and substance 

use disorder interventions and treatments that predict better outcomes. Providers 

and payers need to focus on delivering and paying for services that have the best 

chance to improve a person’s overall health. It is important to focus on the person’s 

outcome of treatment than the number of services provided. This will require the 

ability to collect data on a person’s progress, and use that information in treatment. 

Sincerely, 

GEORGE DELGROSSO, 

CEO, CBHC. 
98 

RESPONSE BY LARRY FRICKS TO QUESTIONS OF SENATOR ALEXANDER, SENATOR

MIKULSKI, SENATOR ENZI, AND SENATOR CASEY

SENATOR ALEXANDER

Question 1. I’m interested in making things easier for States as they tackle the 

mental health and substance abuse problems facing individuals and families in their 

communities. What are one or two things the Federal Government can do to make 

the money we now spend easier to use and help States in this effort? 

Answer 1. I think the most important thing the Federal Government can do 

through existing programs is to establish Federally Qualified Behavioral Health 

Centers in Medicaid. By putting a definition of these entities into Federal law, 

consumers will be assured when they seek care at an FQBHC, that center offers 

a 

comprehensive range of high-quality mental health and addiction treatment services. Without a definition, there are currently no standards of care and no way to 

guarantee that all Americans have access to the full range of needed services 

regardless of where they live. The Federal Government can also encourage States 

to do more to make use of peer support services in their Medicaid programs. 

Question 2. You have experienced the mental health system from many different 

perspectives. What are some of the biggest challenges you’ve experienced?

Answer 2. As I mentioned in my testimony, stigma remains a huge barrier to people accessing needed mental health services. One of the biggest challenges is the ongoing discrimination that people with a mental health issue face. We have come a 

long way in raising public awareness of mental illness and addictions and educating 

people about how to reach out and support someone living with these conditions, 

but there is still a long way to go. The Mental Health First Aid Act (S. 153) is one 

way that we can help erase stigma. Another important thing we can do is improve 

access to peer services and supports, which were vital in my own recovery experience. Peer specialists are trained in skills to promote strength-based recovery and 

whole health, delivering services that are Medicaid billable when included in State 

plans. CMS considers them an evidence-based practice, but too many States either 

don’t offer peer services through Medicaid or impose stringent medical necessity criteria on them that make it difficult for individuals to have access to peer specialists 

through Medicaid. 

SENATOR MIKULSKI

Question. Do either the substance abuse prevention and treatment block grant or 

community mental health services block grant need reform to best meet the needs 

of patients in our communities? 

Answer. The block grants are important programs that fund a range of critical 

prevention and treatment efforts around the country. I would not say that the block 

grants need ‘‘reform’’—rather, what is needed most is increased investment in treatment services. There are two ways this can happen: (1) by allocating more money 

to the block grants to fund additional evidence-based programs that meet communities’ needs; and (2) by changing the way that we reimburse treatment providers 

through Medicaid. As the Medicaid coverage expansion rolls out in 2014, more people than ever before will need mental health and addiction services. Right now, the 

community behavioral health system is already overburdened and struggling with 

payment rates that don’t cover the cost of care. Creating a Federal definition and 

status for Federally Qualified Behavioral Health Centers and allowing those entities 

access to the cost-based reimbursement and mandatory Medicaid status that other 

safety net providers currently receive (as outlined in the Excellence in Mental 

Health Act, S. 274) will go a long way toward creating that much-needed expansion 

of our treatment capacity. 

SENATOR CASEY

Question. What kind of barriers did you encounter while attempting to find employment when you were struggling with your mental illness? Is there a role for private employers to play in helping those with mental illness? If so, what do you think 

is the best way to reach out to them? 

Answer. Yes, there is absolutely a role for private employers to play. One important thing they can do is to ensure they offer health insurance that includes adequate coverage of mental health and substance use conditions. A barrier to people 

who have been on disability because of behavioral health conditions re-entering the 

workforce, is uncertainty about whether they will continue to have healthcare coverage that meets their needs. Employers should look at the scope of coverage they 
99 

offer to make sure it is comprehensive and inclusive of the needs of people with 

mental illness. 

SENATOR ENZI

Question. What can be done to educate local communities about identifying risk 

factors for mental illness and substance abuse? How do we improve access to treatment? What is working and what is not working? 

Answer. Educating local communities about mental illness and substance abuse 

is extremely important. The symptoms of severe mental illness often emerge slowly 

and can be difficult to detect without basic information on what to look for. Even 

when friends and family of someone who appears to be developing mental illness 

can tell that something is amiss, they may not know how to intervene or direct the 

person to self-help programs and treatment—which means that all too often, those 

in need of mental health services do not get them until it is too late. 

Mental Health First Aid is a public education program that can help communities 

understand mental illnesses, seek timely intervention, and save lives. MHFA teaches a five-step action plan to help people recognize the symptoms of common mental 

illnesses and addiction disorders; de-escalate crisis situations safely; encourage 

appropriate self-help strategies, and initiate timely referral to mental health and 

substance abuse resources available in the community. I am a Mental Health First 

Aid trainer, which means I teach people how to instruct others in becoming certified 

Mental Health First Aiders. I have witnessed first-hand the positive impact that 

comes from people with lived experience of recovery gaining the skills for providing 

support to help others experience a life of recovery from mental illness and substance abuse. To that end, I would encourage you to support the Mental Health 

First Aid Act, which authorizes $20 million for training Americans in MHFA to improve community education about mental illness and help people get access to treatment. 

[Whereupon, at 12:36 p.m., the hearing was adjourned.] 

Æ