```

[Senate Hearing 114-719]
[From the U.S. Government Publishing Office]

                                                       S. Hrg. 114-719

 IMPROVING THE FEDERAL RESPONSE TO CHALLENGES IN MENTAL HEALTH CARE IN 
                                AMERICA

=======================================================================

                                HEARING
                                
                                OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                                   ON

EXAMINING IMPROVING THE FEDERAL RESPONSE TO CHALLENGES IN MENTAL HEALTH 
                            CARE IN AMERICA

                               __________

                            JANUARY 20, 2016

                               __________

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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  LAMAR ALEXANDER, Tennessee, Chairman

MICHAEL B. ENZI, Wyoming		PATTY MURRAY, Washington
RICHARD BURR, North Carolina		BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia			BERNARD SANDERS (I), Vermont
RAND PAUL, Kentucky			ROBERT P. CASEY, JR., Pennsylvania
SUSAN COLLINS, Maine			AL FRANKEN, Minnesota
LISA MURKOWSKI, Alaska			MICHAEL F. BENNET, Colorado
MARK KIRK, Illinois			SHELDON WHITEHOUSE, Rhode Island
TIM SCOTT, South Carolina		TAMMY BALDWIN, Wisconsin
ORRIN G. HATCH, Utah			CHRISTOPHER S. MURPHY, Connecticut
PAT ROBERTS, Kansas			ELIZABETH WARREN, Massachusetts
BILL CASSIDY, M.D., Louisiana
                             
                                       

               David P. Cleary, Republican Staff Director

         Lindsey Ward Seidman, Republican Deputy Staff Director

                  Evan Schatz, Minority Staff Director

              John Righter, Minority Deputy Staff Director

                                  (ii)

                            C O N T E N T S

                               __________

                               STATEMENTS

                      WEDNESDAY, JANUARY 20, 2016

                                                                   Page

                           Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, 
  Labor, and Pensions, opening statement.........................     1
Murray, Hon. Patty, a U.S. Senator from the State of Washington..     3
Mikulski, Hon. Barbara, a U.S. Senator from the State of Maryland     5
Collins, Hon. Susan, a U.S. Senator from the State of Maine......    30
Murphy, Hon. Christopher S., a U.S. Senator from the State of 
  Connecticut....................................................    32
Cassidy, Hon. Bill, M.D., a U.S. Senator from the State of 
  Louisiana......................................................    34
Warren, Hon. Elizabeth, a U.S. Senator from the State of 
  Massachusetts..................................................    36
Franken, Hon. Al, a U.S. Senator from the State of Minnesota.....    37
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode 
  Island.........................................................    38

                               Witnesses

Hepburn, Brian M., M.D., Executive Director, National Association 
  of State Mental Health Program Directors, Alexandria, VA.......     7
    Prepared statement...........................................     8
Blake, Penny, RN, CCRN, CEN, Staff RN Emergency Department, 
  Emergency Nurses Association, North Palm Beach, FL.............    11
    Prepared statement...........................................    13
Eaton, William W., Ph.D., Professor, Department of Mental Health, 
  Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.    16
    Prepared statement...........................................    17
Rahim, Hakeem, Ed.M., MA, CEO, Live Breathe LLC, Let's Talk 
  Mental Illness, National Alliance on Mental Illness, Hempstead, 
  NY.............................................................    23
    Prepared statement...........................................    24

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Senator Casey................................................    42
    Senator Baldwin..............................................    42
    Response by Brian Hepburn, M.D. to questions of:
        Senator Isakson..........................................    43
        Senator Murray...........................................    43
        Senator Casey............................................    44
        Senator Whitehouse.......................................    45
        Senator Baldwin..........................................    46
    Response by Penny Blake, RN, CCRN, CEN to questions of:
        Senator Alexander........................................    47
        Senator Casey............................................    48
        Senator Whitehouse.......................................    49
        Senator Baldwin..........................................    50
    Response by William W. Eaton, Ph.D. to question of Senator 
      Whitehouse.................................................    50

                                 (iii)

  

 
 IMPROVING THE FEDERAL RESPONSE TO CHALLENGES IN MENTAL HEALTH CARE IN 
                                AMERICA

                              ----------                              

                      WEDNESDAY, JANUARY 20, 2016

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:01 a.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Lamar 
Alexander, chairman of the committee, presiding.
    Present: Senators Alexander, Murray, Burr, Isakson, 
Collins, Cassidy, Mikulski, Franken, Bennet, Whitehouse, 
Murphy, Baldwin, and Warren.

                 Opening Statement of Senator Alexander

    The Chairman. The Senate Committee on Health, Education, 
Labor, and Pensions will please come to order.
    Senator Murray and I will have an opening statement. Then 
we'll introduce our panel of witnesses. Senator Mikulski will 
introduce the first witness. And then after our witness 
testimony, senators will each have 5 minutes of questions.
    Before we begin today's hearing, I want to briefly mention 
for the information of committee our progress on two or three 
items on our agenda. Yesterday, I announced that we plan to 
hold our first markup on February 9th to consider the first set 
of bipartisan bills aimed at spurring biomedical innovation for 
American patients. Senators and staff have been working 
throughout 2015 on this, on a number of bipartisan pieces of 
legislation.
    The House has completed its work on the 21st Century Cures 
Act. The president has reiterated his support for a precision 
medicine initiative and in the State of the Union address for a 
cancer moonshot. So it's urgent that the Senate finish its work 
and turn into law these ideas that will help virtually every 
American.
    We've also been working for months together on legislation 
to help achieve interoperability of electronic health care 
records for doctors, hospitals, and their patients. We have a 
lot of agreement on what to do about that, and the committee 
will be releasing today a bipartisan staff draft of that 
legislation for public comment.
    This February markup will be the first of three committee 
meetings that have been planned to debate and amend bills as 
the committee moves forward on the goal of modernizing the FDA 
and the NIH to get safe, cutting-edge drugs and devices to 
patients more quickly. The bills that will be considered in 
February have bipartisan co-sponsorship by committee members. 
The same with those that will be considered in April.
    In addition, this year, the committee intends to be busy on 
oversight of the Every Student Succeeds Act. A law that is not 
implemented properly isn't worth the paper it's written on. So 
we'll be spending time on making sure the Department of 
Education implements that the way the Congress wrote it and the 
way the President signed it.
    Of course, we've done a lot of work on reauthorizing Higher 
Education, which expired at the end of last year. We have a 
number of bipartisan proposals that will make it easier and 
simpler for students to attend college and for administrators 
to manage our 6,000 colleges and universities.
    We have a lot that we ought to be able to do this year. One 
of the most important of those items has to do with the mental 
health crisis that we're discussing today. I hope--and Senator 
Murray and I agree on this--that we can move promptly to offer 
bipartisan recommendations on how to address the mental health 
crisis. We've already done a lot of work on it. We passed in 
September the Mental Health Awareness and Improvement Act that 
Senator Murray and I introduced. The Senate passed that in 
December.
    Senator Cassidy and Senator Murphy have introduced 
legislation, and Senator Murray and I are working with them. We 
hope to move promptly to bring a combination of those 
recommendations to the full committee.
    Not everything the Senate may want to do is in our 
jurisdiction. So we're working with Senator Blunt, who, with 
Senator Murray, runs the Health Appropriations Subcommittee, on 
ideas that Senator Blunt has proposed, and we're working with 
Senator Cornyn on issues that the Judiciary Committee is 
considering and with the Finance Committee, which will probably 
have to be involved as well.
    What we want to do is to move promptly in this committee to 
take the things that are within our jurisdiction and have them 
ready for the floor and work in parallel with the other 
committees so the leader can bring them to the floor if he 
chooses to do that.
    The reason there is such interest in the mental health 
crisis today is that about one in five adults had a mental 
health condition in the past year, according to the Mental 
Health Services Administration. That's nearly 10 million adults 
with illnesses such as schizophrenia, bipolar disorder, or 
depression that interferes with a major life activity.
    And 60 percent of adults with mental illness did not 
receive mental health services in 2014. Only about half of 
adolescents with a mental health condition received treatment 
for their condition. Mental health conditions that remain 
untreated can lead to dropping out of school, substance abuse, 
incarceration, unemployment, homelessness, and suicide.
    Suicide is the 10th leading cause of death in the United 
States, and 90 percent of those who die by suicide have an 
underlying mental illness. I hear that from many Tennesseeans. 
Between 2010 and 2012, nearly 21 percent--that's one out of 
five adults in Tennessee--reported having a mental illness. 
Four percent had a serious mental illness. The most recent data 
shows that our rate of suicide reached its highest level in 5 
years a couple of years ago. It was the second leading cause of 
death.
    At our October hearing on mental health, the committee 
heard from administration witnesses about what the Federal 
Government is already doing to address mental illness. Today, 
we look forward to hearing from doctors, nurses, advocates, and 
administrators who work every day with Americans who struggle 
with a mental health condition about how the Federal Government 
can help patients, health care providers, communities, and 
States to better address these issues. We want people to be 
able to take advantage of the most innovative research. We 
heard some about that at our recent hearing, about the RAISE 
study.
    I'm interested to hear how the government can support State 
efforts to implement evidence-based treatment programs. This 
will require modernizing our leading Federal agency for mental 
health. It will require involvement from patients, families, 
communities, health care providers, health departments, law 
enforcement, State partners, and many others who are involved. 
I look forward to hearing from our witnesses about the 
challenges we face and the solutions that they offer.
    Senator Murray.

                  Opening Statement of Senator Murray

    Senator Murray. Thank you very much, Chairman Alexander.
    Thank you to all of our colleagues who are here today. I am 
really glad that we have this opportunity today to continue our 
discussion about ways to improve our mental health care system.
    We have a really incredible group of witnesses today 
joining us to share your expertise and experiences. Thank you 
all for coming.
    As I'm sure all of us do, I hear far too often from 
families in Washington State about loved ones, friends, and 
neighbors who are struggling with mental illness and aren't 
getting the support they need. It is heartbreaking, especially 
because when someone does get treatment and support, it can 
truly make a difference.
    I recently heard from a woman in Seattle, who I will call 
Amanda. She was experiencing mental illness so severe that she 
lived in a dumpster for fear of being abducted by aliens. Case 
managers were able to get her the appropriate medication she 
needed. They also connected her with primary care, housing, and 
supplemental security income benefits. Today, Amanda is 
enrolled in school and pursuing her degree with hopes of full-
time employment. That is quite a change for her.
    My constituent, Jack's, story is similarly powerful. Jack 
is a veteran from King County. He enrolled in outpatient 
support services after he was hospitalized several times for 
attempted suicide. He had serious addiction problems and was 
becoming alienated from his family. But after being connected 
with support, he was able to find recovery, even while he was 
being treated for cancer. He now lives independently and is 
reconnecting with his teenage son.
    Amanda's and Jack's stories show that comprehensive, high-
quality mental health care can truly give someone their life 
back. But, unfortunately, a lot of stories don't end that way. 
In fact, only 63 percent of people with serious mental health 
illness received treatment in the past year.
    I'm going to focus on a few challenges in particular today, 
ones which I believe our witnesses will have a lot to say about 
as well. The first is inadequate access to treatment. Far too 
many communities lack access to mental health professionals. In 
fact, half of all U.S. counties don't have a single 
psychiatrist, psychologist, or social worker. That means for 
many patients and families, it is unclear where to turn for 
help. So we need to make sure communities have access to 
trained professionals who can intervene, treat, and support 
those struggling with mental illness.
    And, in addition to strengthening our mental health 
workforce, we need to make sure that when someone presents in 
crisis, or simply chooses to seek help, there are providers who 
can take them in and meet their needs. No patient should be 
turned away, asked to wait in an emergency room for days, or be 
left out on the street because there isn't an available bed.
    Ms. Blake, I'm sure this is a problem you have seen all too 
often in the ER. I think we can and must do better on this, and 
I'm looking forward to hearing all of your thoughts.
    Another issue I am really eager to talk about today is the 
need to truly integrate mental and physical health care. The 
two stories I shared a minute ago have something especially 
important in common. Amanda didn't just need psychiatric help. 
She needed primary care. Jack needed help with addiction and 
depression, but during the course of his recovery, he also 
needed treatment for cancer.
    The siloes that exist between mental health care and 
physical health care don't match patients' realities, and that 
needs to change. The legislation that Senators Murphy and 
Cassidy have worked on together would take some very important 
steps to better integrate mental and physical health care.
    I am also interested in some innovative steps being taken 
at the State level. For example, in my State, the University of 
Washington has a residency program that allows students focused 
on psychiatry to get experience working in physical health 
settings.
    Dr. Hepburn, I know you are focused on this challenge in 
your work, and I'm grateful that we'll have your insights 
today.
    And, finally, I want to reiterate something I mentioned at 
our last hearing. If we are going to confront the challenges 
I've laid out today and many others within our mental health 
system, we have to break down the barriers that stigma creates 
for those suffering from mental illness. That means 
prioritizing research like Dr. Eaton's, which helps enhance our 
understanding of and ability to effectively treat mental 
illnesses. And it means raising awareness so that those 
struggling don't feel they have to struggle alone.
    Today, nearly one in five people in our country experience 
mental illness in a given year. Far too many of them don't 
receive treatment when they need it, and part of the reason is 
that stigma gets in their way.
    Mr. Rahim, you've worked for over a decade to raise 
awareness and promote understanding of mental health in 
communities across the country. And you've been an inspiration 
to many people who otherwise might not have had the courage to 
seek help. So I want to thank you for your work, and I'm eager 
to hear what you think Congress should do to lend our voices to 
efforts like yours.
    Again, thank you to all of our witnesses who are here 
today. We have a lot of urgent work ahead of us to make sure 
that our families and communities have access to the 
comprehensive, high-quality mental health care they need.
    I look forward, Mr. Chairman, to working on a bipartisan 
effort to strengthen our mental health system and give patients 
and families the opportunity to lead healthy, fulfilling lives.
    Thank you.
    The Chairman. Thank you, Senator Murray.
    We welcome our four witnesses, and I thank you for 
arranging to be here. You all have busy schedules, other things 
to be doing. We're grateful to you for that.
    I'm going to ask Senator Mikulski to introduce one of you 
since she has a conflict which will require her to leave soon.

                     Statement of Senator Mikulski

    Senator Mikulski. Thank you very much, Senator Alexander, 
and I want to thank you for your continuing progress on holding 
hearings on the issue of mental health. I know this is the 
third hearing on the topic, and I want to really salute you and 
Senator Murray for moving in this direction.
    The Subcommittee on Commerce, Justice, Science, and Related 
Agencies of the Committee on Appropriations is holding a 
hearing on President Obama's proposals on gun control, and as 
the vice-chair, I must be at my duty station and will have to 
excuse myself.
    I really wanted to be at this hearing because of the fact 
that I'm a professionally trained social worker. We've been 
working on these issues all of my professional life. This is 
what I live for. This is why I came to the Senate, to listen to 
good people with great ideas on how we can help our people.
    We have two distinguished Marylanders here. One, of course, 
is Dr. Hepburn, who headed up the State of Maryland's Agency on 
Health and Mental Health. He is a University of Maryland 
trained clinician who then went on to try to breathe mental 
health into a bureaucracy and then bring care to our people in 
a State that mandates an affordable budget. So we're going to 
have some great ideas.
    Then we have Dr. Eaton here. Dr. William Eaton is a 
professor of the Department of Mental Health at the famous 
Johns Hopkins Bloomberg School of Public Health. Dr. Eaton is a 
professor there, and he chairs the Department of Mental Health. 
It is the only department-level unit in a school of public 
health in the world. Usually public health thinks about 
vaccinations. What Dr. Eaton thinks about is how we can build 
resilient personalities and do the preventive work.
    He will talk to you today about his work, his research, his 
recommendations. Understanding, I believe, the thrust will be 
that everybody who has a mental health problem needs individual 
treatment, but they live in a social world, and we need to look 
at the social indicators, look at the social epidemiology, and 
how we can strengthen the anchor institutions of the family and 
the school.
    You're going to learn a lot from him. I've already learned 
a lot from him, as I do from listening to the folks at Johns 
Hopkins School of Public Health. I really look forward to where 
we're going on this issue of mental health, in a nutshell.
    When I got out of graduate school, Senator Alexander--I 
actually went to graduate school on a National Institutes of 
Health grant--they were training community mental health social 
workers. President Kennedy led the battle to establish 
community mental health centers, to get rid of the old snake 
pit type mental health hospitals.
    All the practitioners at the table remember that, and, Mr. 
Rahim, I'm sure you've heard stories of that, and we welcome 
you here with your personal courage.
    But maybe it's not that we need new institutions. Maybe we 
have to look at what we thought we were going to do, and we 
never did it. We never followed through on community mental 
health centers. Maybe that's the way to go.
    We never followed through in the aggressive way to enforce 
the Wellstone-Domenici Mental Health Parity Act. Maybe that's 
the way we need to go. And speaking as a social worker, along 
with the nurses, we know that mental health requires a team 
approach, and it is both, of course, the psychiatrists, which 
we need, but it's those of us who are trained in these matters.
    I know my colleagues would never think I had a therapeutic 
personality, but I look forward to working with you in the best 
way possible to advance the ideas that will come forth and how 
we can really meet this crisis that's growing and expanding.
    Thank you very much, Mr. Chairman.
    The Chairman. Thank you, Senator Mikulski.
    We will now hear from our witnesses, and let me present 
them. Again, Dr. Hepburn has been mentioned. He's the Executive 
Director of the National Association of State Mental Health 
Program Directors, which represents mental health service 
delivery systems in all 50 States. He's been a clinical 
associate professor of psychiatry at the University of Maryland 
Medical System for nearly 20 years, and he has cared for 
patients for more than 20 years.
    The second witness is Ms. Penny Blake, a registered nurse 
working in an emergency department in central Florida. She's 
been a nurse for 40 years and has worked in an emergency 
department for 15 years. She chairs the National Advocacy 
Advisory Council for Emergency Nurses.
    Dr. Eaton, who Senator Mikulski mentioned, is a professor 
at the Bloomberg School of Public Health, an expert in his 
field who has written hundreds of articles. Much of his work 
has focused on the co-occurrence of mental health disorders and 
other chronic health issues, like diabetes and heart disease.
    Mr. Hakeem Rahim is the CEO of Live Breathe, an 
organization focused on mental health advocacy and reducing the 
stigma associated with mental health. He brings his own 
invaluable perspective of his own journey of mental illness, 
which began during his freshman year in college.
    We look forward to hearing from the four of you. If you'll 
each try to summarize your remarks in about 5 minutes, that 
will leave more time for the senators to have a conversation 
with you about your testimony.
    Why don't we start with Dr. Hepburn.

   STATEMENT OF BRIAN M. HEPBURN, M.D., EXECUTIVE DIRECTOR, 
NATIONAL ASSOCIATION OF STATE MENTAL HEALTH PROGRAM DIRECTORS, 
                         ALEXANDRIA, VA

    Dr. Hepburn. Thank you very much, Chairman Alexander, 
Ranking Member Murray, and Senator Mikulski. It's hard to think 
of Maryland without Senator Mikulski. Thank you.
    Thank you for the opportunity today to address this 
committee on State services regarding mental illness. Thanks go 
to this committee and its members and other members of the 
Senate and the House who are working to find ways to support, 
strengthen, and augment the country's mental health system.
    I want to especially thank, in addition to the chair and 
ranking member, Senators Cassidy and Murphy and also Senator 
Franken. I also want to congratulate Senator Franken on his 
second grandchild. That's where it all starts, being a good 
grandparent.
    We appreciate the full Congress passing Senator Cardin's 
legislation on IMD Demonstration. Also, we appreciate the 
support from Congress on the First Episode Psychosis Program.
    The organization which I represent, the National 
Association of State Mental Health Program Directors, 
represents the State executives of the Mental Health 
Authorities, representing agencies that have $41 billion in 
public mental health services and deliver services to 7.3 
million people. The mission of NASMHPD is to work with the 
States and partners in order to promote wellness, recovery, and 
resiliency.
    NASMHPD members work to promote prevention and early 
intervention, integration of behavioral health and physical 
health, trauma informed approaches, minimized consumer contact 
with police, develop the workforce, promote supported 
employment, supportive housing, and decrease homelessness, 
support the use of data and health information technology.
    The State Mental Health Authorities vary widely in terms of 
how they're organized. However, they share some common 
functions: planning and coordinating a comprehensive array of 
mental health services, submitting an annual application to the 
Block Grant, educating the public, operating and funding 
inpatient services. This could be with State hospitals, or it 
could be buying inpatient services in the private sector.
    The State Mental Health Authorities work closely with 
SAMHSA, which has been an excellent partner for us. The acting 
administrator, Kana Enomoto, is a respected leader in the 
field. We appreciate having her as a leader and a partner.
    SAMHSA has provided strong leadership in promoting the best 
practices for individuals with severe mental illness. The best 
example of that is the First Episode Psychosis Program. The 
First Episode Psychosis Program started with research. The 
research showed that it was a best practice. NIMH then worked 
with SAMHSA to promote the First Episode Psychosis Program. Its 
implementation is now across the country. It's really an 
excellent way of showing how the Federal Government can work 
with the States and work with providers in order to promote a 
best practice.
    It's important to note that the role of the State Mental 
Health Authorities has changed over the last 30 years. Thirty 
years ago, the States were primarily involved in State 
hospitals. Seventy-five percent of the budget went to State 
hospitals. Now, 75 percent of the budget goes to the community.
    Thirty years ago, the private sector was not really 
addressing issues that are in the public sector. Now, it's hard 
to separate public sector and private sector. When it comes to 
admissions to State hospitals, now, almost all the admissions 
are court related. Almost all the civil admissions were 
previously uninsured individuals going to State hospitals. Now, 
those uninsured individuals get the same care as insured 
individuals, and they go to the private sector.
    I want to say something about the funding for the State 
Mental Health Authorities. Basically, the funding for most 
States is primarily from the States themselves, so that the 
State budget and Medicaid make up for almost all that's spent 
in the budget by the State Mental Health Authority. The Block 
Grant accounts for less than 1 percent of the funding for 
mental health within the States.
    What are some additional actions that Congress and the 
Administration could take to support the State Mental Health 
Authorities? One is, as I indicated, the First Episode 
Psychosis Program, an excellent program. The fact that you've 
agreed to move it from 5 percent to 10 percent is excellent. 
What we would ask is for a change in the methodology. The 
smaller States are not able to move ahead with the First 
Episode Psychosis Program the way the larger States are because 
of the Block Grant methodology.
    A second is to modify the Medicaid Institution of Mental 
Disease exclusion so that IMDs can get paid for taking care of 
individuals with Medicaid who are adults, at least, to start 
with the private sector. In Maryland, we participated with a 
demonstration that showed that the average length of stay in 
the private psychiatric hospitals were 10 days. Cost per 
episode was about the same as for the acute and general 
hospital psychiatric units.
    We would ask to reauthorize the Medicaid Money Follows the 
Person. This has been a very important program in terms of 
helping to keep people----
    The Chairman. Dr. Hepburn, could you wind down your 
testimony, please?
    Dr. Hepburn. Yes, I'm sorry--to keep people out of 
institutions, promoting zero suicide, promoting technology, 
promoting smoking cessation, and supporting mental health and 
addiction parity. And with that, I will stop.
    Thank you very much.
    [The prepared statement of Dr. Hepburn follows:]

               Prepared Statement of Brian Hepburn, M.D.

    Chairman Alexander, Ranking Member Murray, and members of the 
Senate HELP Committee, thank you for the opportunity today to address 
the Senate HELP Committee on State services for individuals with mental 
illness. And our thanks go to this committee and its members, and other 
Members of Congress in the Senate and the House, who are working to 
find ways to support, strengthen, and augment the country's mental 
health care delivery system through legislation. Thanks especially to 
the Chair and Ranking Member for their own Mental Health Awareness and 
Improvement Act, Senators Cassidy and Murphy for their Mental Health 
Reform Act, and Senators Franken and Cornyn for their Comprehensive 
Justice and Mental Health Act. We are also appreciative of the full 
Congress passing Senator Cardin's Improving Access to Emergency 
Psychiatric Care Act and approving the additional moneys provided in 
the fiscal year 2016 budget for the Mental Health Block Grant.
    The organization which I represent, the National Association of 
State Mental Health Program Directors (NASMHPD), represents the State 
executives of the State Mental Health Agencies (SMHAs) responsible for 
the $41 billion public mental health service delivery systems serving 
7.3 million people annually in 50 States, four territories, and the 
District of Columbia.
    Prior to becoming NASMHPD's Executive Director in July 2015, I 
served 13 years as Maryland's Mental Health Program Director. I have 
also been a practicing psychiatrist.
    The NASMHPD mission is to work with States, Federal partners, and 
stakeholders to promote wellness, recovery, and resiliency for 
individuals with mental health conditions or co-occurring mental health 
and substance related disorders across all ages and cultural groups, 
including youth, older persons, veterans and their families, and people 
under court jurisdiction.
    In collaboration with States, Federal partners, and stakeholders, 
NASMHPD works to promote:

    1. Prevention and Early Intervention.
    2. Integration of behavioral health care (both mental health and 
substance abuse disorder treatment) with physical health care.
    3. Trauma-Informed approaches to care across sectors, with 
civilians, veterans, and those in the correctional system.
    4. Models and interventions that minimize contact with police, the 
courts, and correctional facilities.
    5. The development and sustainability of an effective Behavioral 
Health Workforce.
    6. The availability of supportive employment and supportive 
housing, and a reduction in homelessness for individuals with mental 
illness and or addictions. The use of data and Health Information 
Technology to improve the quality of mental health services.

    The SMHAs vary widely in how they are organized within each State 
government, how they pay for and organize their mental health service 
delivery systems, and their fiscal and staffing resources. However, all 
SMHAs share some common functions:

     Planning and coordinating a comprehensive array of mental 
health services with other State government Medicaid, correctional, 
educational, judicial, housing, and employment agencies, as well as 
local health and substance use disorder agencies, to meet the mental 
health treatment needs of individuals in their State;
     submitting an annual comprehensive community Mental Health 
Block Grant (MHBG) plan to the Substance Abuse and Mental Health 
Services Administration (SAMHSA), and monitoring, collecting data, 
evaluating, and reporting to SAMHSA on the performance and outcomes of 
systems funded by the MHBG;
     educating the public about mental illness and supporting 
public health prevention activities for mental health; and
     operating inpatient services units that provide critical 
intensive treatment for individuals with high levels of need or who are 
at risk of harm to themselves or others--including individuals 
involuntarily committed by the courts--in public psychiatric hospitals 
or psychiatric units in general hospitals and/or, increasingly, funding 
inpatient psychiatric services in private psychiatric hospitals or 
psychiatric units of private general hospitals.

    In all of these functions, the SMHAs work closely with SAMHSA, 
which provides needed technical assistance and identifies and funds 
peer-reviewed, evidence-based practices to meet consumer needs. SAMHSA 
has been an excellent partner. Acting Administrator Kana Enomoto is a 
respected leader in the field, with a strong clinical background. We 
appreciate the opportunity to have her as a leader and partner.
    SAMHSA has provided strong leadership in promoting best practices 
for the severely mentally ill. The practices championed by SAMHSA and 
adopted by the States have included crisis services and crisis 
intervention teams and training and peer support services, as well as 
practices aimed at preventing suicide--such as the Zero Suicide 
initiative--and reducing homelessness, helping veterans find mental 
health and other supportive services, and addressing child and 
adolescent mental health through early intervention. In each of these 
programs and practices, SAMHSA and the States focus on promoting a 
recovery-oriented and person-centered system of care that empowers 
consumers in their decisionmaking and enables them to receive services 
in the least restrictive and most integrated setting.
    The role of SMHAs has changed over the past 30 years. They have 
moved from primarily running State hospitals and directly providing 
services to increasingly focusing on community services. Thirty years 
ago, the funding for State hospitals was two-thirds of State mental 
health budgets and community funding was one-third. That has now 
flipped, so that funding for community services is two-thirds and the 
State hospitals are one-third of State mental health budgets. The 
majority of admissions to State hospitals 30 years ago were civil 
admissions of uninsured individuals. Now, most States have moved the 
civil admissions to private hospitals and the State hospitals are 
increasingly used for court-related admissions. In addition, most 
States are now contracting with the private sector to provide the 
direct services in the community.
    It is also worth noting that 60 percent ($24.8 billion) of SMHA 
funding comes from State government revenues. The Federal Medicaid 
program is the second largest payer of SMHA mental health services (29 
percent of SMHA funds, or $11.9 billion), followed by Medicare (1.7 
percent). The MHBG constitutes just 1 percent of SMHA funding. MHBG 
funding--totaling $450.4 million in fiscal year 2015, varies widely by 
State under a consumer-based formula; in fiscal year 2015, State MHBG 
moneys ranged from California's $63.1 million to Wyoming's $535,764.
    Among the effective, evidence-based practices identified and 
promoted by SAMHSA through its National Registry of Evidence-Based 
Programs and Practices (NREPP) are those intended to address First 
Episodes of Psychosis (FEP). Recognizing the demonstrated effectiveness 
of FEP pilots funded by the National Institute for Mental Health (NIMH) 
since 2008 in reducing incidences of untreated mental illness, Congress 
for the first time in fiscal year 2014 designated 5 percent of all MHBG 
moneys--and increased grant funding accordingly--for programs that 
address first episodes of serious mental illness, including projects 
based on NIMH's RAISE (``Recovery After an Initial Schizophrenic 
Episode'') FEP model operating in States such as Connecticut, New York, 
and Maryland. For this fiscal year 2016, Congress has increased the 
block grant set-aside for FEP initiatives to 10 percent, again 
increasing block grant funding to cover the expanded set-aside.
    States have also become increasingly involved in working with 
consumer advocates, peer support workers with lived experience, 
providers, and State insurance divisions to see that insurers comply 
with the Federal mental health and addiction parity mandates enacted in 
2008 and 2010. Full compliance is still a work in progress, but NASMHPD 
is convinced that continuing education and monitoring of insurers by 
providers, consumers, and State agencies should eventually ensure that 
mental health and substance use benefits are subject to no 
restrictions--quantitative or non-quantitative--greater than those 
imposed on surgical and medical benefits.
    As increased MHBG funding continues to be made available to the 
States by Congress, the States should be able to effectively grow their 
FEP services and the other community-based services for which payers 
and payment are scarce, such as crisis services, wraparound services, 
supported housing and supported employment, and ACA enrollment 
outreach. NASMHPD's members are grateful for the assistance provided so 
far, and we look forward to continuing to work with SAMHSA and Congress 
in developing a continuum of evidence-based mental health care and 
services for each community.
    What are some additional actions that Congress and the 
Administration could take to support the State Mental Health 
Authorities?

     Continue to support the set aside for First Episode 
Psychosis programs, but consider changing the allocation methodology so 
that States with smaller consumer populations and thus smaller block 
grants, like Rhode Island, Alaska, Maine, Vermont, Wyoming, North 
Dakota, and Delaware, may receive an amount sufficient to fully 
implement a working FEP program.
     Modify the Medicaid Institution for Mental Disease (IMD) 
exclusion so that IMDs are able to receive Medicaid funding for adults.
     Reauthorize the Medicaid Money Follows the Person program, 
due to expire September 30, which States such as Texas are using to 
help fund behavioral health services for individuals in home- and 
community-based settings.
     Support the Zero Suicide goal. The National Suicide 
Prevention Lifeline, with funding from SAMHSA under the Garrett Lee 
Smith Act, has developed an excellent hotline system across the 
country, linking callers with needed crisis services.
     Encourage the use of technology for mental health through 
reimbursement by Medicaid. As stigma has decreased and more persons are 
seeking mental health services, there is a workforce and access 
problem. Technology such as telehealth may be able to help with both. 
Internet services help to reach underserved rural, urban, and frontier 
areas.
     Support targeted efforts for smoking cessation in persons 
with mental illness. Persons with mental illness die at a much earlier 
age than the general population. This is primarily due to smoking.
     And, finally, support parity by strengthening monitoring 
and enforcement mechanisms.

    Thank you for your attention to and consideration of this 
testimony.

    The Chairman. Thanks, Dr. Hepburn.
    Ms. Blake.

  STATEMENT OF PENNY BLAKE, RN, CCRN, CEN, STAFF RN EMERGENCY 
 DEPARTMENT, EMERGENCY NURSES ASSOCIATION, NORTH PALM BEACH, FL

    Ms. Blake. Chairman Alexander, Ranking Member Murray, and 
members of the committee, thank you for inviting me to testify 
at this important hearing.
    I'm an emergency nurse working full time in the emergency 
department at Good Samaritan Hospital in West Palm Beach. It's 
an acute care community hospital. In addition to the work in 
the emergency department, I'm the chairperson of the Advocacy 
Advisory Council for the Emergency Nurses Association, which is 
the largest professional health care organization dedicated to 
improving emergency care.
    As a registered nurse for almost 40 years, my career has 
been devoted to providing the best possible care to every 
person who comes into our hospital's emergency department. 
Increasingly, this involves treating patients who are suffering 
from mental illnesses.
    The emergency department at my hospital has a capacity of 
32 actual beds which can be expanded if necessary. It serves a 
very diverse community that includes extreme poverty and some 
of the wealthiest neighborhoods in the entire country.
    Since the Federal law prohibits hospitals from turning away 
anyone seeking emergency care, I see practically every kind of 
urgent medical condition. But on a typical shift, at least 10 
percent of our cases involve psychiatric patients.
    The reasons for the surge in mental health patients include 
an increase in drug abuse, veterans returning from Iraq and 
Afghanistan who suffer from PTSD, and the stresses that are 
created by a weak economy and joblessness. But in my view, the 
principal cause is the lack of adequate treatment options and 
resources in the community. Mental health patients often find 
they have nowhere to turn for treatment, so they go to the one 
place, the emergency room, that's guaranteed to be open at all 
times and willing to care for every patient.
    In Florida, a physician or law enforcement officer can 
invoke a State law that allows for the involuntary hold for up 
to 72 hours for a person who is deemed to be a threat to 
themselves or others. After a 72-hour hold is put on the 
patient, the emergency department physician must clear the 
patient of any physical illness, and then the patient is placed 
in a 10 by 10 room until we can find a facility that can accept 
the patient for evaluation by a psychiatrist, because at my 
hospital, we do not have any psychiatrists on staff, and we do 
not have a psychiatric unit.
    So all patients requiring inpatient care must be 
transferred to one of the four psychiatric facilities in Palm 
Beach County. I cannot think of a single time in the past year 
that any of our patients has been accepted immediately when 
that request has been made.
    A mentally ill patient typically stays in our ED between 12 
and 24 hours before they are transferred to a psychiatric care 
facility. However, 2, 3, or even 4 days boarding in the 
emergency department is not unusual. This is also the case in 
other hospitals in Palm Beach County, and the problem is made 
worse by the lack of insurance coverage for people who suffer 
from mental illnesses.
    Our experience is consistent with research conducted by the 
Emergency Nurses Association that found that the average 
boarding time in the emergency department is 18 hours for 
psychiatric patients versus only 4 hours for all other types of 
patients. Inadequate community health services and extended 
boarding times are detrimental both for emergency departments 
and the care received by mental health patients.
    For hospital EDs, mental health patients are both resource 
and personnel intensive. Not only do these patients stay in the 
emergency department much longer than other patients, but they 
often require close supervision by multiple staff and 
personalized medical attention. By necessity, it diverts 
nurses, doctors, and technicians from the treatment of the 
other patients who come through our doors.
    Whenever a patient is placed on a 72-hour hold, we have a 
certain protocol we must follow in order to ensure that 
patient's safety. A security guard in our facility is placed at 
the door. For the patients who are experiencing a mental health 
crisis, the emergency department is far from the ideal place to 
receive care. EDs are chaotic, often loud areas in the 
hospital, and the nurses and physicians are stretched to their 
limits in caring for the other patients.
    Our emergency physicians are understandably reluctant to 
prescribe psychoactive medications for these patients because 
it's not their area of expertise. So if a patient needs 
medication, we usually just give some form of antianxiety 
agent. They don't begin any kind of therapeutic interventions 
because there's no one there with professional psychiatric 
training to help provide it.
    Imagine that you are stressed, anxious, possibly suicidal 
and/or psychotic, perhaps having hallucinations, and you're 
confined to a small space. All your belongings are taken away 
from you so you can't hurt yourself. A guard is at your door, 
and there's constant chaos, noise, and motion. And because of 
the shortage of inpatient beds or community-based treatment and 
psychiatric options, this situation continues for many hours or 
even days.
    Mental health care patients would be better served in 
facilities that have specialized expertise. The most important 
thing that we feel is needed is that communities must have the 
health care infrastructure and funding to provide resources 
needed to keep this population healthy. They need to have 
parity for insurance and the same kind of coverage that people 
with physical illnesses have and a high-quality, community-
based mental health system which would include acute and longer 
term care, access to community mental health clinics, inpatient 
and outpatient treatment, and the availability of 24-hour 
crisis psychiatric care and services that will allow the 
patient to be integrated more fully into society.
    I want to thank you for allowing me the opportunity to 
represent and speak for my fellow emergency nurses. We 
passionately care about providing the best possible care to all 
of our patients, and we strive for them to have the best 
outcomes possible for their illnesses. That includes those who 
are the most vulnerable in our society, the person who is 
suffering from mental illness.
    Thank you.
    [The prepared statement of Ms. Blake follows:]

            Prepared Statement of Penny Blake, RN, CCRN, CEN

                                summary
    Chairman Alexander, Ranking Member Murray, members of the 
committee, thank you for inviting me to testify at this important 
hearing. My name is Penny Blake and I am an emergency nurse working in 
the emergency department at Good Samaritan Medical Center in West Palm 
Beach, FL. I have been a registered nurse for almost 40 years. My 
entire career has been devoted to providing the best possible care to 
every person who comes into my hospital's ED. Increasingly, this 
involves treating patients who are suffering from severe mental 
illnesses and substance abuse.
    Since Federal law prohibits hospitals from turning away anyone 
seeking emergency care, I see practically every kind of urgent medical 
condition imaginable. However, at least 10 percent of our cases involve 
psychiatric patients. This percentage has grown tremendously in the 
past several decades.
    There are multiple reasons for the surge in mental health patients 
coming to hospital emergency departments. However, in my view, the 
principal cause is the lack of adequate treatment options and resources 
in the community. The shortfall in community mental health resources 
often leads to the boarding of psychiatric patients in the emergency 
department.
    In Florida, a physician or law enforcement officer can invoke the 
Baker Act, a State law that allows for the involuntary hold for up to 
72 hours for a person deemed to be a threat to themselves or others. 
The typical length of time that a mentally ill patient stays in our ED 
before being transferred to a Baker Act facility is between 12 and 24 
hours. However, 2, 3, or even 4 days boarding is not unusual. This is 
consistent with research conducted by ENA that found the average 
boarding time for psychiatric patients is 18 hours versus only 4 hours 
for all patients in the ED.
    Inadequate community mental health services and extended boarding 
times are detrimental both for emergency departments and the care 
received by mental health patients. For hospital EDs, mental health 
patients are both resource- and personnel-intensive. By necessity, this 
diverts nurses, doctors and technicians from the treatment of other 
patients.
    For patients experiencing a mental health crisis, the emergency 
department is far from the ideal place to receive care. By their 
nature, EDs are chaotic, often loud areas of the hospital where nurses 
and physicians are regularly stretched to their limits taking care of 
everything from traumatic injuries to heart attacks. In addition, 
specialists in psychiatric care are not always available to see 
patients. Mental health patients would be better served in facilities 
that have the specialized expertise to handle the complex diagnosis and 
treatment of mental illness.
    Our mental health patients and their families deserve better care 
than we currently give them. Most importantly, communities must have 
the health care infrastructure and funding to provide the resources 
needed to keep this population healthy. A high-quality, community-based 
mental health system would include acute and longer term care, access 
to community mental health clinics, inpatient and outpatient treatment, 
the availability of 24-hour crisis psychiatric care and services that 
would allow for integrating the patient more fully into society.
    Thank you for allowing me the opportunity to represent and speak 
for my fellow emergency nurses. We passionately care about providing 
the best possible care to ALL of our patients, and strive for them to 
have the best outcomes possible for their illnesses. This includes 
those who are among the most vulnerable in our society--the person 
suffering from a mental illness.
                                 ______
                                 
                            i. introduction
    Chairman Alexander, Ranking Member Murray, members of the 
committee, thank you for inviting me to testify at this important 
hearing. My name is Penny Blake and I am an emergency nurse working 
full-time in the emergency department at Good Samaritan Medical Center, 
an acute care community hospital in West Palm Beach, FL.
    In addition to my work in the emergency department, I am the 
Chairperson of the Advocacy Advisory Council for the Emergency Nurses 
Association (ENA), the largest professional health care organization 
dedicated to improving emergency nursing care. ENA has 41,000 members 
throughout the United States and around the world. I am also the 
Government Affairs Chair for the Florida Emergency Nurses Association 
and past president of the Palm Beach County chapter of ENA.
ii. the challenges confronting emergency departments in caring for the 
                              mentally ill
    I have been a registered nurse for almost 40 years. The majority of 
that time has been at the bedside in critical care and, for the past 18 
years, in the emergency department. My entire career has been devoted 
to providing the best possible care to every person who comes into my 
hospital's emergency department. Increasingly, this involves treating 
patients who are suffering from severe mental illnesses and substance 
abuse.
    The emergency department at Good Samaritan Medical Center has a 
capacity of 32 actual beds, which can be expanded by utilizing the 
halls and walls when necessary. It serves a very diverse community that 
includes extreme poverty and homelessness, as well as some of the 
wealthiest neighborhoods in the entire country.
    Our patient mix varies depending on the time of day or the day of 
the week. Since Federal law prohibits hospitals from turning away 
anyone seeking emergency care, I see practically every kind of urgent 
medical condition imaginable. However, on a typical shift, at least 10 
percent of our cases involve psychiatric patients. This percentage has 
grown tremendously in the past several decades.
    There are multiple reasons for the surge in mental health patients 
coming to hospital emergency departments. These include an increase in 
drug abuse, the large number of veterans returning from Iraq and 
Afghanistan who suffer from PTSD, and the stresses created by a weak 
economy and joblessness.
    However, in my view, the principal cause is the lack of adequate 
treatment options and resources in the community. Mental health 
patients often find they have nowhere to turn for treatment, so they go 
to the one place--emergency departments--guaranteed to be open at all 
times and willing to care for every patient.
    In my hospital, the shortfall in community mental health resources 
often leads to the boarding of psychiatric patients in the emergency 
department.
    In Florida, a physician or law enforcement officer can invoke the 
Baker Act, which is a State law that allows for the involuntary hold 
for up to 72 hours for a person who is deemed to be a threat to 
themselves or others.
    At Good Samaritan, after a hold is put on a patient, the ED 
physician must clear the patient of any physical illness. The patient 
is then placed in a 10 x 10 room until we can find a facility that can 
accept the patient for evaluation by a psychiatrist to determine if 
continued inpatient treatment is warranted.
    My hospital does not have psychiatrists on staff, nor do we have a 
psychiatric unit. Therefore, all patients requiring inpatient care must 
be transferred to one of the four psychiatric facilities in Palm Beach 
County. I cannot think of a single time in the past year that any of 
our patients has been accepted immediately when the request has been 
made.
    The typical length of time that a mentally ill patient stays in our 
ED before they are transferred to a Baker Act facility is between 12 
and 24 hours. However, 2, 3, or even 4 days boarding in the emergency 
department is not unusual. Based on conversations I have had with 
colleagues, this is also the case in other hospitals throughout the 
Palm Beach County area.
    Last year, I visited the ED at a hospital in the southern part of 
the county. They had 14 patients lined up on stretchers in one of their 
hallway wings, all awaiting placement in inpatient psychiatric 
facilities. I was told that was a typical day for them. This problem is 
made worse by the lack of insurance coverage for people who suffer from 
mental illness.
    My personal observations are consistent with research conducted by 
ENA that found the average boarding time in the emergency department 
for psychiatric patients is 18 hours versus only 4 hours for all 
patients in the ED.
    Inadequate community mental health services and extended boarding 
times are detrimental both for emergency departments and the care 
received by mental health patients.
    For hospital EDs, mental health patients are both resource- and 
personnel-intensive. Not only do these patients stay in the emergency 
department much longer than other patients, but they often require 
close supervision by multiple staff and, if available, personalized 
medical attention. By necessity, this diverts nurses, doctors and 
technicians from the treatment of other patients.
    When a psychiatric patient who is in our emergency department is 
deemed to require invocation of the Baker Act, we have a certain 
protocol we must follow to ensure that patient's safety. The patient is 
assigned to a closed room, their personal belongings are removed, they 
are given a gown and slipper socks, and a security guard is placed 
outside their door, within sight of the patient. We do not have 
designated rooms for psychiatric patients, so we must attempt to modify 
the room they are in to prevent access to articles that might be used 
to harm themselves or others.
    The nurse who is assigned to that pod of rooms assumes the care for 
that patient, along with the other four or five patients who are also 
in that pod. None of the RN's with whom I work has received any in-
depth specialized education in the care of the mentally ill. We all may 
have had some courses during our nursing education, but for many of us, 
that was a long time ago.
    For patients experiencing a mental health crisis, the emergency 
department is far from the ideal place to receive care. By their 
nature, EDs are chaotic, often loud areas of the hospital where nurses 
and physicians are regularly stretched to their limits taking care of 
everything from traumatic injuries to heart attacks.
    In addition, specialists in psychiatric care are not always 
available to see patients in the emergency department. As I discussed 
earlier, this is the case in the hospital where I work.
    Further, our emergency physicians are understandably reluctant to 
prescribe psychoactive medications for these patients, as it is not 
their area of expertise. This usually translates into the patient being 
medicated with some form of anti-anxiety agent, if needed, and then 
kept in the room on a stretcher, only being allowed accompanied trips 
to the bathroom. They receive a blanket, a pillow, a TV with remote 
control and meals. The assigned nurse assesses their vital signs and 
functions every 4 hours or more often as indicated. They do not begin 
therapeutic intervention as there is no one present with professional 
training to begin a therapeutic dialog.
    Imagine being someone who is already stressed, anxious, possibly 
suicidal and/or psychotic, and perhaps having auditory or visual 
hallucinations. Then, you are confined to a small space, all your 
belongings are removed so you cannot hurt yourself, a guard is at your 
door, the lights are on outside the room all the time, and there is 
constant chaos, noise and motion. Further, imagine that because of the 
shortage of inpatient beds or community-based treatment options, this 
situation continues for many hours or even days.
    Although we do everything possible to care for all patients in a 
professional and compassionate manner, mental health patients would be 
better served in facilities that have the specialized expertise to 
handle the complex diagnosis and treatment of mental illness.
    In rare cases, the boarding of mental health patients and the 
subsequent overcrowding can also lead to violence in the ED. Although 
the vast majority of behavioral health patients are no more violent 
than other patients, there is no doubt that lack of treatment can 
exacerbate a stressful situation for these patients.
                    iii. how to improve patient care
    Our mental health patients and their families deserve better care 
than we currently give them. I did an informal poll of my colleagues 
across the country on what they believe are the most important needs 
for the behavioral health patients we see in our EDs. Their views 
exactly reflected mine.
    These patients need access to the most appropriate facility for the 
problem they are having. In most cases, that facility should not be the 
local emergency department.
    Individuals with psychiatric and substance abuse conditions should 
receive prioritization, resources, and treatment based upon clinical 
presentation that is equivalent to that provided for other illnesses 
and injuries.
    Individuals with psychiatric and substance abuse conditions must be 
provided parity with regard to third-party reimbursement.
    Emergency psychiatric services need to utilize a consistent 
practice model, including standardized procedures and protocols, for 
patient care regardless of facility, day of the week, or time of day.
    Most importantly, communities must have the health care 
infrastructure and funding to provide the resources needed to keep this 
population healthy. These resources should include all related 
services. A high-quality, community-based mental health system would 
include acute and longer term care, access to community mental health 
clinics, inpatient and outpatient treatment, the availability of 24-
hour crisis psychiatric care and services that would allow for 
integrating the patient more fully into society.
    Any program should also promote collaboration and communication 
between emergency departments and their respective community agencies 
to effectively coordinate the care of patients with psychiatric and 
substance abuse conditions.
                             iv. conclusion
    Thank you for allowing me the opportunity to represent and speak 
for my fellow emergency nurses. We passionately care about providing 
the best possible care to ALL of our patients, and strive for them to 
have the best outcomes possible for their illnesses. This includes 
those who are among the most vulnerable in our society--the person 
suffering from a mental illness.

    The Chairman. Thank you, Ms. Blake.
    Dr. Eaton.

STATEMENT OF WILLIAM W. EATON, PH.D., PROFESSOR, DEPARTMENT OF 
MENTAL HEALTH, JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH, 
                         BALTIMORE, MD

    Mr. Eaton. Senator Alexander, Senator Murray and members of 
the committee, I think you are doing great work and I 
appreciate the opportunity to speak to you.
    My orientation is from that of epidemiology, especially 
social epidemiology. The first point I wanted to make is, we 
all know somebody who has mental illness of one type or other 
or alcohol or drug abuse, and we feel strongly about this.
    But there has been developed a new metric in the field of 
epidemiology called Disability Adjusted Life Years. That metric 
allows us to compare the disease burden of all the diseases, 
the mental and substance use disorders, as well as cancer, 
stroke, and all the physical diseases. When we do that 
comparison on a population basis using epidemiologic data, it 
clearly shows that mental and substance use disorders are the 
most important category of disease burden, and depression is 
the single most important disease itself in terms of disease 
burden.
    The importance of mental disorders has been recognized many 
times in the past--the surgeon general's report, the New 
Freedom Commission, and so forth. But now we have a metric 
which establishes scientifically that mental and substance use 
disorders are the most important form of disease category.
    One of the reasons for this is that the mental disorders 
begin early in life, and they're slow. You talk to somebody who 
has just had an onset of depressive disorder about it, and it 
turns out it will have started 10 years earlier. And the 
consequences of that depressive disorder will not show up 
sometimes for another 10 years.
    The mental disorders, especially depressive disorder, 
actually predicts onset of stroke, dementia, heart attack, 
diabetes. It predicts it more powerfully than the common risk 
factors that we know. For example, a person with a history of 
depressive disorder has three or four times the risk of a heart 
attack. That's a higher risk than somebody with high blood 
pressure or with a family history of heart disease.
    The point is that the fact these mental disorders start 
early, they take a long time, and the consequences for physical 
illnesses are very strong. We need more research to figure out 
why these consequences are occurring, but also this argues, as 
has been stated, for the integration of primary health care 
with psychiatric care, because now the primary care doctor is 
interested in saving the life of his patient, the way he should 
be, and that means he should screen for depressive disorder and 
other disorders, probably, and learn how to do it. We should 
make that technology available.
    I want to say that there are a range of prevention programs 
for mental and substance use disorders. There are many of them, 
and they have beneficial outcomes, proven years or even decades 
following the intervention. Most of these prevention programs 
are social interventions early in the life course prior to the 
onset of the disorder, so in the school system, for example, or 
even shortly after birth. Those preventive interventions are 
one of the unused resources, I guess I would say.
    As a tiny aside, I would say there have been breakthroughs 
in genetics, especially the so-called methylation issue in 
genetics, which shows that the tendency for a gene to operate 
or not operate is affected by the environment. So in the 
future, we'll be studying the way genes and environment work 
together, and when we study that, we're likely to be oriented 
toward the social environment. The way the social environment 
works together with genetic material is the way that mental 
disorders have their occurrence.
    The failure to help people with severe mental disorders is 
the most glaring problem in our mental health system. And it 
turns out that severe mental illnesses like schizophrenia and 
bipolar disorder--I think perhaps you know this, Senator 
Alexander, but they are associated with a shortened life span 
by even two decades.
    Somebody with schizophrenia will die 20 years earlier. 
They're not dying from schizophrenia. They're dying because 
we're not paying attention to the preventive activities that 
you and I receive, like Valsartan for blood pressure or lipid-
lowering drugs. So that's almost a criminal issue that these 
folks are dying so much earlier, and nobody chooses to be 
schizophrenic. It happens to them. It seems like we owe them 
that.
    Finally, in building programs related to brain research, I 
want to mention that the National Institute of Mental Health 
has lost its focus on public mental health, and also it has 
abandoned what should be its natural interest in diagnostic 
categories. These new programs at the National Institute of 
Mental Health have basically confused a huge range of 
researchers and puzzled the international community. This also 
has vitiated the probability of developing research-based 
prevention programs for mental and substance use disorders.
    From my point of view, the action is preventive 
interventions early in the life course, mostly social.
    Thank you for your time.
    [The prepared statement of Mr. Eaton follows:]

             Prepared Statement of William W. Eaton, Ph.D.

                                summary
    The Senate Hearing on Mental Health is appropriate because it is 
now established; using new and accepted measures of the burden of 
disease, that mental and substance use disorders produce a higher 
burden of disease in the United States than any other category of 
disease. For specific disorders, Major Depression is the single largest 
source of disease burden in the United States, as compared with all 
other diseases; and alcohol use disorders are the fifth largest source 
of disease burden.
    Mental and substance use disorders occurring early in life predict 
later occurrence of important diseases such as diabetes, cardiovascular 
conditions, stroke, and dementia, and severe mental illnesses are 
associated with a dramatically shortened life span.
    There are a range of successful population-based programs for 
preventing mental and substance use disorders. Most of these involve 
social interventions early in the life course.
    Breakthroughs in genetics, including the study of methylation, when 
combined with measures of the environment including the vagaries of 
social life, will offer new opportunities to prevent mental and 
substance use disorders in the future.
    The failure to help people with severe mental disorders of 
psychotic intensity, such as schizophrenia and bipolar disorder, is the 
most glaring problem in the mental health system.
    The National Institute of Mental Health (NIMH) has lost its focus 
on public health and abandoned what should be its central focus on 
accepted diagnostic categories.
    The mental health efforts of the Federal Government would benefit 
by careful consolidation of governmental units such as the NIMH, 
National Institute on Drug Abuse (NIDA), the National Institute on 
Alcohol Abuse and Alcoholism (NIAAA), and perhaps some programs of the 
Substance Abuse and Mental Health Administration (SAMHSA).
                                 ______
                                 
    This testimony is designed to give a brief and selective review of 
important aspects of public health as applied to the mental and 
substance use disorders. The presenter is William W. Eaton, professor 
and former chair of the Department of Mental Health, Bloomberg School 
of Public Health, Johns Hopkins University. The testimony represents 
the opinions of William Eaton and not the viewpoint of the Johns 
Hopkins University.
    It is an opportune time for the U.S. Senate to be conducting 
hearings about mental and substance use because of the growing 
awareness of the importance of this topic. This growing awareness is in 
part due to the creation, about 20 years ago, of an algebra for 
estimating the overall burden of diseases, which allows comparison of 
the burden of diseases such as cancer, which are often fatal, to 
diseases such as depressive disorder, which is impairing and often 
long-lasting, but not as likely to be fatal.\1\ \2\ The new metric--
Disability Adjusted Life Years, or DALYs--is accepted around the globe. 
Combining epidemiologic data on incidence, chronicity, and associated 
mortality for a given disorder, with clinical information about the 
disability associated with a disorder, it is possible to estimate the 
number of Disability Adjusted Life Years experienced by the total world 
population in a year--that is, entire burden of all occurrences of the 
specific disorder in the world, with this metric. As well, the total 
number of DALYs experienced as a result of all diseases in the world 
can be estimated. The broad category of mental and substance use 
disorders were responsible for 7.4 percent of the total disease burden 
experienced in the world in 2010--about the same percentage as the 
category of malignant neoplasms, and less than the 11.9 percent 
explained by the category of cardiovascular and circulatory 
diseases.\2\ In the United States and Canada in 2004, where the effect 
of fatal diseases of infancy and childhood is lessened than in the 
world as whole, the mental and substance use disorders were by far the 
largest contributor to the total burden of disease (about 24 percent of 
the total number of DALYs), compared to any other categories, such as 
cancer (12 percent of total DALYs) or cardiovascular conditions (14 
percent).\3\ For more narrow disease conditions, Unipolar depressive 
disorders were responsible for 8.4 percent of the DALYS in the United 
States and Canada, the largest source compared to all other diseases 
(e.g., ischemic heart disease, responsible for 6.3 percent; 
cerebrovascular disease accounting for 3.9 percent). The fifth most 
important cause in the United States and Canada was alcohol use 
disorders (3.4 percent of all DALYs).
    The importance of mental and substance use disorders has been 
emphasized for many years in prior reports such as the Surgeon 
General's Report in 1999,\4\ the President's New Freedom Commission in 
2003,\5\ and the Institute of Medicine report in 2006 on Improving the 
Quality of Health Care for Mental and Substance-Use Conditions.\6\ 
Since the development of the Burden of Disease metric, the importance 
of mental and substance use disorders has been more firmly established.
    The estimates of DALYs for mental and substance use disorders are 
higher than for other sometimes fatal disorders such as cancer because 
of the lifetime structure of these disorders: the mental and substance 
use disorders start much earlier in life, during childhood and 
adolescence in many cases, and a sizable proportion of the mental and 
substance use disorders endure for many years.\7\ But the estimate may 
actually be biased low, because of the effect the mental and substance 
use disorders have in raising risk for important medical conditions 
such as diabetes, heart disease, stroke, and dementia. For example, a 
person with a history of depressive disorder has about two or three 
times the risk for onset of diabetes, or having a heart attack or 
stroke, as someone who has not had an episode of depressive disorder. 
This enhanced risk associated with depressive disorder is larger than 
many other well-known risk factors, such as a family history of the 
physical condition, or, for heart attack as an example the raised risk 
associated with high blood pressure or high cholesterol. For each of 
these medical conditions this enhanced risk resulting from depressive 
disorder has been replicated in more than five studies.\8\ \9\ \10\ 
There is also enhanced risk for onset of dementia in those with a 
history of depressive disorder, replicated more than five times.\11\ It 
has been estimated that persons with severe mental illness like 
schizophrenia and bipolar disorder have 20 years shorter life span \12\ 
than the general population, probably not caused by their mental 
illness, but rather because the treatment and prevention of other 
chronic medical conditions is ignored.
    There are three important implications of these findings of mental 
to physical comorbidity.

     First, the estimates of disease burden for mental and 
substance use disorders may be biased low because they don't account 
for mental disorders as early sources of physical disorders.
     Second, the possibility exists to lower the risk for the 
physical disorders by successful treatment of the mental disorders. 
Less than half of those with mental and substance use disorders get 
into treatment, in part due to the stigma of mental and substance use 
disorders, in part due to the cost involved, and in part due to the 
difficulty in finding good options for treatment.\13\ This logic 
reflects on the advantages of improving the system of care for mental 
and substance use disorders.
     Third, the health care system will benefit by integrating 
systems of primary health care with systems designed for treatment of 
mental and substance use disorders.

    An aspect of mental and substance use disorders that is not well-
appreciated is that there are many viable techniques for preventing 
their occurrence. The high prevalence of these disorders, their 
comorbidity, and the difficulty of treating them successfully argues 
for population-based prevention programs, which typically are aimed at 
entire populations (``universal interventions'') or populations thought 
to be at high risk for the disorders (``selective interventions''). 
Because the disorders start early in life, it is logical to take 
advantage of prevention programs oriented toward childhood, adolescence 
and young adulthood. These prevention programs typically involve social 
activities of some sort, as opposed to medical interventions that occur 
after onset of disorder. For example:

     The Nurse-Family Partnership Program begins by identifying 
high-risk births and providing assistance to the mothers in the period 
after birth.\14\
     The Good Behavior Game activates a social awareness in 
first graders with strong beneficial effects which last into 
adulthood.\15\
     The Teenscreen program facilitates schools to identify and 
get help for adolescents who may be at risk for suicide.\16\ \17\ \18\
     The Adolescent Depression Awareness Program,\19\ \20\ 
which is information about depressive disorder, designed in a format 
similar to information about other medical illnesses already available 
in the Health curriculum of many High Schools.

    These are examples of successful programs which have been widely 
adopted, but their application could be expanded, and the results would 
be a diminution of the later occurrence of mental and substance use 
disorders. In 1994 the report of the Institute of Medicine Committee on 
Prevention of Mental Disorders concluded that:

          ``There could be no wiser investment in our country than a 
        commitment to foster the prevention of mental disorders and the 
        promotion of mental health through rigorous research with the 
        highest of methodological standards.'' \21\

This statement is still true.
    There have been many advances in understanding the genetics of 
mental and substance use disorders in the last few decades, including 
breakthrough statistical techniques involving large samples of subjects 
(so-called Genome-Wide Association, or GWA, studies).\22\ Although most 
mental and substance use disorders have a moderate or strong tendency 
to be inherited, it is increasingly apparent that the inheritance will 
almost always be very complicated, involving many genes interacting in 
myriad ways. In the last decade it has become clear that the DNA can be 
permanently or temporarily activated, or deactivated, throughout the 
course of life (``methylation'').\23\ The sources of the methylation 
include exposure to toxins, obstetric events, physical illnesses, and 
the vagaries of social life. Therefore, it seems likely that the next 
decade will involve increasing research on the way in which genetic 
background and the biological and social environment interact to change 
the future risk for mental disorder. In turn, these developments are 
likely to inform the design of selective intervention programs.
    The most glaring problem of this Nation with regard to mental and 
substance use disorders is the failure to help people with disorders of 
psychotic intensity (schizophrenia and bipolar disorder), even though 
the deinstitutionalization movement in the early 1960s was supposed to 
free them from the asylums which had been designed originally to 
protect them. People do not choose to have schizophrenia, and it places 
an enormous and unfair burden on them. Since schizophrenia persists in 
the population, generation after generation, even though people with 
schizophrenia have low fertility, it may be that they are carrying the 
genetic burden for the rest of us--that is, the large number of genes 
connected to schizophrenia are healthy and life-preserving for most of 
the population, producing schizophrenia only when the genes combine, 
rarely, in a very particular fashion (an extension of the theory of 
heterozygote advantage \24\ \25\). So, we owe them! Contrary to some 
characterizations, schizophrenia is not progressive in its nature: 
rather, people adapt to the disease over the life course, just as they 
might adapt to having diabetes.\26\ The social environment in which 
they live is strongly associated with their success in adaptation. The 
social environment should be free from stigma, stable, with 
uncomplicated access to medical care, a structured workday, and the 
presence of friends and acquaintances. This structure is the aim of 
many rehabilitation programs, including the well-known clubhouse model, 
which has shown good success in generating stable employment and lower 
health costs.\27\ \28\ \29\ \30\ \31\
    The organization of government efforts to reduce the burden of 
mental disorders has become increasingly complex over the last several 
decades. In the early 1970s the National Institute of Mental Health 
(NIMH), part of the National Institutes of Health, was split into three 
institutes, including the NIMH, the National Institute on Alcohol Abuse 
and Alcoholism (NIAAA), and the National Institute on Drug Abuse 
(NIDA). The Substance Abuse and Mental Health Services Administration 
(SAMHSA) was created in the early 1990s. Many of the programs of these 
four units of the government overlap. For example, there are many 
separate surveys that estimate the use of marijuana or alcohol use in 
young people, some on a yearly basis (Monitoring the Future, funded by 
the NIDA \32\); National Survey of Drug Use and Health (funded by the 
SAMHSA),\33\ the National Epidemiologic Survey of Alcohol and Related 
Conditions (funded by the NIAAA) \33\ and National Comorbidity Survey 
and its replication \34\ \35\ (NCS and NCS--R, funded by the NIMH). 
There are programs on prevention of suicide in the NIMH and the SAMHSA, 
and programs of research on prevention of mental and substance use 
disorders in all four units. One logical consolidation is to combine 
the two units focused on substance use, NIAAA and NIDA, into one 
National Institute on Substance Abuse (``NISA''). There is extensive 
comorbidity between drug and alcohol use disorders,\36\ and many of the 
basic mechanisms of addiction are shared by the two groups of 
disorders, so consolidation would likely strengthen research efforts on 
both these closely related groups of disorders.
    Since the formation of the SAMHSA, the public health aspects of the 
NIH units, especially that of the NIMH, have been diminished 
considerably. Even though the preventive interventions described above 
have a social aspect, the focus of research has been increasingly on 
the brain, missing the opportunity to design and implement effective 
new population-based interventions. Another departure from public 
health at the NIMH is the new disregard for diagnostic categories as a 
focus of research interest,\37\ thereby emasculating the field of 
psychiatric epidemiology, the basic science of public mental health, 
because epidemiology requires an identifiable outcome. As well, the 
study of service systems and treatment research is hampered because 
there is a need for data on diagnoses as outcomes of preventive and 
clinical trials, and effectiveness of treatment systems as recorded in 
medical records. This new focus of the NIMH has puzzled the 
international community.\38\
    Many SAMHSA programs have a public health focus on prevention in 
the population, and on treatment systems. Some of these programs are 
excellent, but others lack a research base. There is relatively little 
focus in SAMHSA programs on disorders of psychotic intensity (described 
above), which, though rare, are the most impairing and most in need of 
attention. It may seem strange, but there is only one epidemiologist at 
the NIMH, and only one psychiatrist at the SAMHSA! It might be useful 
and efficient to combine some programs of the SAMHSA into the two NIH 
units (NIMH and the new NISA mentioned above), to reduce duplication, 
on the one hand, and to ensure that they retain a public health focus, 
on the other hand. This consolidation would generate better ability to 
take advantage of the new developments in gene by environment 
interactions described above, because the programs would be more likely 
to stay abreast of the rapidly developing research advances. It would 
not be appropriate to simply eliminate the SAMHSA because there are so 
many programs and services around the United States that depend on 
SAMHSA for guidance and funding, and there are many productive programs 
in the SAMHSA.
    The consolidation of these programs is a complex task and would 
require the work of a special commission to design the new units and to 
schedule the consolidation. The result would be more advances in useful 
research, more effective treatment systems and prevention programs, and 
more efficient use of funds.

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    The Chairman. Thank you, Dr. Eaton.
    Mr. Rahim.

 STATEMENT OF HAKEEM RAHIM, ED.M., MA, CEO, LIVE BREATHE LLC, 
LET'S TALK MENTAL ILLNESS, NATIONAL ALLIANCE ON MENTAL ILLNESS, 
                         HEMPSTEAD, NY

    Mr. Rahim. Chairman Alexander, Ranking Member Murray, 
members of the Health, Education, Labor, and Pensions 
Committee, Senators Cassidy and Murphy, thank you for taking 
these initial steps to improve the lives of millions impacted 
by mental illness.
    Let me first share my journey with mental illness. It began 
in 1998 as a freshman at Harvard University. Three weeks into 
my first semester, I was struck by my first terrifying panic 
attack. My journey continued when I had my first manic episode 
and second one in the spring of 2000.
    My next 2 weeks were filled with sleepless nights. I 
showered less frequently and ate sporadically. I had visions of 
Jesus, heard cars talking, spoke foreign languages. My parents 
rushed me to a psychiatric hospital, and I was diagnosed with 
bipolar disorder.
    The last 18 years of my life have been defined by mental 
illness. Yet through support, proper treatment, and 
persistence, I have recovered and achieved wellness.
    There are millions of Americans who are thriving in the 
face of mental illness: teachers who rise every morning to face 
their anxiety and their classroom full of students, veterans 
with lingering and visible scars of PTSD who will still provide 
for their families. Many are thriving, but many are not. To 
serve everyone living with mental illness, we must take steps 
to address stigma, access to medication, and peer support.
    In 2012, I began speaking openly about my struggles to 
thousands of individuals with mental illness, their family 
members, law enforcement, faith-based communities, teachers, 
mental health professionals, and students. Since 2013, I have 
been a NAMI Queens/Nassau Let's Talk Mental Illness presenter. 
I have been delivering presentations to students now, and I've 
spoken to more than 20,000 students across this country.
    After one of my middle school presentations, a petite young 
African American girl walked up to me and started sharing that 
she was self-harming. When I asked her if she had told anybody, 
she said, ``No, I have not,'' and then she lowered her 
shoulders. I told her, ``That's OK. Thank you for being brave 
and telling me.'' We walked her over to her school counselor, 
the same school counselor a friend and a family member advised 
her not to go to.
    Because she saw the importance of openly addressing stigma, 
and that school saw the importance of openly addressing stigma, 
the young girl's silence and reticence was dissolved. She was 
able to get the help that she needed.
    Awareness and education is central to ending the shame 
around mental illness. Many parts of S. 1945 address key 
components that will break down the barriers from seeking 
treatment.
    For many, medication is also an integral part of treatment. 
Medication has and continues to play a key role in my life. I 
still take anti-depressants and anti-psychotics every morning. 
They are central to my recovery and wellness. Finding the right 
combination of meds was at times a very harsh task for me. But, 
thankfully, by working with my doctor, I found the right 
combinations.
    The struggle to find the correct medication is an arduous 
task for many. Finding the right medication can literally be 
the difference between life and death. Paul, as I will call 
him, a young man I know, went through 10 different diagnoses, 
electroconvulsive therapy, and at least 50 different 
combinations of medication. Twenty years after his first manic 
episode, however, he is now a mental health advocate. Because 
he had access to medication, he is now helping others work 
toward wellness.
    We must keep medications protected, accessible, and 
affordable to people living with mental illness. Doctors and 
patients must have a choice in finding the right treatment, as 
the wrong treatment can lead to vicious cycles of hospital 
visits, substance abuse, exhausted caregivers, and even death.
    However, medication alone cannot sustain wellness. Another 
key component of this bill is peer support. The power of being 
able to relate to others going through similar experiences 
cannot be understated. The peer support group I have interfaced 
with is the quintessential example of the power of the peer.
    In an email chain in this particular support group, a 
member mentioned that he had relapsed into depression. Within 
an hour, there were responses to his email, one member even 
saying that, ``Hey, I'll come pick you up.'' They truly 
understood the power and emotional strength of that support 
group, and that emotional support can shatter the weighted 
chains of depression. I'm happy to say that this group member 
is doing well, and he's really doing well now.
    Having language codifying what a peer specialist is and 
what peer support looks like is essential to standardizing an 
invaluable component of mental wellness--peer support.
    Mr. Chairman, Ranking Member Murray, and members of the 
HELP Committee, I am testifying as a voice for people living 
with mental illness. My journey does not, however, represent 
the full breadth of experience living with mental illness. My 
presence here today, however, does give a face to millions of 
Americans who are struggling, striving, and thriving in the 
face of mental health conditions.
    Recovery from mental illness should be an option for all. 
Bill 1945 is a pronounced step in that direction, and I deeply 
and respectfully urge this committee to move forward on this 
strong bipartisan bill. And I would say that millions of people 
are depending on a transformation of how we address mental 
illness in America.
    Thank you so much.
    [The prepared statement of Mr. Rahim follows:]

             Prepared Statement of Hakeem Rahim, ED.M., MA

    I thank each of you for inviting me to testify before this 
committee. Moreover I am moved to be able to contribute my voice to an 
issue that has impacted me well over half of my life--mental illness.
    In the spring of 2000, as a sophomore at Harvard University, I was 
hospitalized for 2 weeks in a psychiatric hospital in Queens, NY. While 
hospitalized, I was diagnosed with bipolar disorder. I took time off 
from Harvard and subsequently returned and graduated with honors. After 
receiving my bachelors, I continued on to graduate school at Columbia 
University where I received a dual masters in psychological counseling. 
Currently, I am a mental health speaker, educator and advocate.
    In 2012, I began speaking openly about my struggle with mental 
illness. To date, I have spoken to thousands of individuals with mental 
illness, their family members, law enforcement officials, faith based 
communities, teachers and mental health professionals. Since 2013, I 
have worked with NAMI Queens/Nassau as their Let's Talk Mental Illness 
presenter. In this role, I have spoken to over 20,000 college, high 
school and middle school students, delivering well over 300 
presentations.
    My advocacy work has helped bishops and pastors open up to their 
congregations; helped mothers and fathers better understand their 
children; and people with mental illness better understand their 
conditions. I believe the work I am doing is vital, and saving lives.
    My journey does not encompass the full range of experiences of 
those impacted by mental illness. Living with mental illness is highly 
individualized; even people with the same diagnosis may have completely 
unique experiences. As a mental health speaker, educator and advocate, 
I have been fortunate to hear and see a spectrum of these experiences.
    I have heard from people struggling to find work and housing 
because of barriers due to discrimination related to their mental 
illness; of parents concerned about their loved ones lack of ability to 
access treatment; and of people with mental illness who have been 
incarcerated due to their struggles with symptoms and not because of 
criminal intent.
    Wellness should not be determined by favorable life situations, or 
serendipitous experiences. Rather, recovery from mental illness should 
be supported by established, effective, and easily accessible 
resources.
    For this reason, Mr. Chairman, I and advocacy groups I am 
affiliated with, including NAMI, are very excited about this 
legislation. I support S. 1945, drafted by Senators Cassidy and Murphy 
(members of this committee) and NAMI is a stronger supporter as well.
    Mr. Chairman, Ranking Member Murray and members of the HELP 
Committee, recovery from mental illness should be a real option for all 
people living with mental illness. This bill is a pronounced step in 
this direction. I deeply and respectfully urge this committee to move 
forward with this strong bipartisan bill--millions of Americans are 
depending on a collective shift in how we treat and allow people to 
live their best lives in the face of mental illness.
                                 ______
                                 
    Chairman Alexander, Ranking Member Murray, and Members of the 
Health, Education, Labor and Pensions Committee, I thank each of you 
for inviting me here today to testify before this committee. Moreover I 
am moved to be able to contribute my voice to an issue that has 
impacted me for over half of my life--mental illness.
    My journey with mental illness began in 1998 during my freshman 
year at Harvard University. Three weeks into my first semester, I was 
struck by my first terrifying panic attack. At the time, I could not 
find words to describe the deep terror I felt, but I knew something was 
wrong. My journey continued when I had my first manic episode.
    During the spring of 1999, I roamed the streets of my Long Island, 
NY neighborhood possessed with the delusion that I was a prophet and 
would save the world with my prophecies. Concerned, my parents sent me 
to Grenada to relax and be with family. However, there I plunged into a 
deep depression. I returned to Harvard that fall and struggled with 
anxiety and depression.
    In the spring of 2000, I had a second manic episode. My next 2 
weeks were filled with sleepless nights. I showered less frequently and 
ate sporadically. I had visions of Jesus, heard cars talking and 
``spoke'' foreign languages. This time my parents rushed me to a 
psychiatric hospital. I was hospitalized for 2 weeks in Queens, NY. My 
attending psychiatrist diagnosed me with bipolar disorder and explained 
that I would be on several medications. Upon my release from the 
hospital I met with a Brooklyn-based psychiatrist who end up working 
with me for the next 9 years.
    After adjusting to heavy medication, I returned to Harvard 
University to continue my studies in psychology. However, due to 
cognitive impairment and other complications, I left school. In 2002, I 
returned, refocused and persevered to graduate from Harvard with 
honors. After receiving my bachelors, I continued on to graduate school 
at Columbia University. I received a dual masters in psychological 
counseling, and after worked for several years as a college academic 
advisor. All throughout this journey I have contended with the ups and 
downs of depression, anxiety and complications from medication 
including weight gain and cognitive slowing. Yet through this struggle 
and isolation, I have found ways to thrive and use my pain as a vehicle 
to fuel my work.
    In 2012, I began speaking openly about my struggle with mental 
illness. To date, I have spoken to thousands of individuals with mental 
illness, their family members, law enforcement officials, faith based 
communities, teachers and mental health professionals. Since 2013, I 
have been the NAMI Queens/Nassau Let's Talk Mental Illness presenter. 
In this role, I delivered over 300 presentations to more than 20,000 
college, high school and middle school students.
    My advocacy work has helped bishops and pastors open up to their 
congregations; a mother seek help for her son who was traumatized by 
police brutality and another seek professional help after her daughter, 
an Olympian medalist, died by suicide. I have seen a homeless student, 
beset by anger issues and diagnosed with bipolar disorder, completely 
transform after opening up to her school social worker. Students have 
shared their struggles with me and to adults in their lives because of 
my mental health presentations. I believe this work is vital in saving 
lives.
    My recovery and this work would not be possible if I did not have a 
firm foundation anchored in good mental health and wellness. My life 
has been informed but not limited by my mental illness. I have found 
ways to thrive and attribute my recovery to perseverance, support and 
access. The combination of these three factors has been essential to my 
wellness.
    My wellness has been sustained in part due to a strong support 
network. My family has and continues to play an integral role in 
providing emotional, mental and financial support. Having this 
essential and consistent foundation has aided my recovery in 
innumerable ways. Along with a supportive family structure, upon my 
return to college, I utilized the readily available support structures 
at Harvard, including psychiatric visits and psychotropic medications.
    Medication has played a huge role in my recovery. Daily I still use 
key antipsychotics and antidepressants that aid in my stability. This 
journey to find the right combination of medication has been marked 
with different dosages and combination of drugs, weight gain, cognitive 
impairment and long bouts of abysmal depression and paralyzing anxiety.
    Along with medications, support groups have played a role in my 
recovery; the power of being able to confide in and relate to others 
going through similar experiences cannot be understated. Engaging with 
peers has shown me that even in my darkest times I am not alone. Along 
with peer support groups, programs like NAMI's In Our Own Voice, have 
given me platforms to share my story with communities and other people 
struggling with mental illness. Communities are an essential component 
for wellness, hence I am currently developing an online platform for 
these communities to continue to grow and thrive and for the voices of 
people impacted by mental illness to be heard.
    My journey does not encompass the full range of experiences of 
those impacted by mental illness. Living with mental illness is highly 
individualized; even people with the same diagnosis may have completely 
unique experiences. As a mental health speaker, educator and advocate, 
I have been fortunate to hear and see a spectrum of these experiences.
    Through my personal advocacy and work with NAMI, I have heard from 
many people struggling to find work and housing because of a variety of 
barriers including discrimination related to their mental illness. I 
have spoken to hundreds of people in numerous support groups which have 
included NAMI Family to Family classes and Depression and Bipolar 
Support Alliance peer support group. During these conversations, 
parents have spoken about their struggle to support their loved one, 
whether due to lack of ability to access treatment or because their 
loved one refuses treatment. People with lived experience have shared 
that they are unable to access medication because of insurance issues 
or loved ones with family members who have been incarcerated due to 
their struggles with symptoms and not because of criminal intent. Some 
can point to an experience like mine--full recovery. However many have 
spoken to the other side of this experience.
    Wellness should not be determined by favorable life situations, or 
serendipitous experiences. Rather, recovery from mental illness should 
be supported by established, effective and easily accessible resources. 
I have worked hard to sustain my recovery and wellness living with 
mental illness however; I have had structures that have lent to my 
recovery while many do not.
    For this reason, Mr. Chairman, I and advocacy groups I am 
affiliated with, including NAMI, are very excited about this 
legislation designed to reform our public mental health system--a 
system which should afford wellness for all. S. 1893, the Mental Health 
Awareness Act, is a good start, but given what I have experienced and 
have seen through my advocacy work, more is needed; individuals living 
with mental illness, and families impacted by mental illness need 
assistance sooner than later.
    Both NAMI and I support S. 1945, drafted by Senators Cassidy and 
Murphy (members of this committee). A few of the important provisions 
in S. 1945 that I feel would go a long way toward reforming our mental 
health system and contributing to a better life for people living with 
serious mental illness and their families are:

     Grants to the States to better integrate physical and 
mental health;
     Establishment of a new Assistant Secretary for Mental 
Health and Substance Use at HHS;
     Creation of a new Interagency Serious Mental Illness 
Coordinating Committee and a National Mental Health Policy Laboratory;
     New transparency requirements and stepped up enforcement 
of the Federal mental health parity law;
     New requirements in the Federal Mental Health Block Grant 
program for outreach and engagement to the most difficult to serve.

    Mr. Chairman, Ranking Member Murray and members of the HELP 
Committee, I am aware I am testifying as a voice for people living with 
mental illness. My experience does not represent the full breadth of 
the experience living with mental illness, however my presence here 
does give a face to the millions of people in America struggling, 
striving and thriving with mental health conditions. Recovery from 
mental illness should be a real option for all. This bill is a 
pronounced step in this direction. I deeply and respectfully urge this 
committee to move forward on this strong bipartisan bill--millions of 
Americans are depending on a collective shift in how we treat and allow 
people to live their best lives in the face of mental illness.

    The Chairman. Thank you, Mr. Rahim, and thanks to each of 
you. We'll now have a round of 5-minute questions for senators.
    Mr. Rahim, based on your experience, what advice would you 
have to someone who knows a person who may need help? How do 
you persuade them that they should seek help, whether they're a 
family member, a friend, a student, such as the ones you talked 
about?
    Mr. Rahim. I get that question all the time. I speak at 
support groups, like NAMI Family to Family group, DBSA, and 
that's the billion dollar question, because we can't persuade 
anybody to do anything that they don't want to do.
    The Chairman. What's your approach? What do you do?
    Mr. Rahim. The key thing I say is education. We can't 
change anyone's behavior, but we can change how we respond to 
people. The key thing is educating ourselves, and there are a 
lot of support groups, there are a lot of educational programs 
out there that family members of people, say, students, can 
take, and it can change the way they interact with their 
friends or their loved ones, and thereby helping them 
understand what the loved one is going through.
    When I was in psychosis, nobody could tell me that I was 
going through psychosis. But my parents were fortunate enough 
to bring me to the hospital. Because they changed their way of 
approaching my condition, they were able to get me help.
    The Chairman. Dr. Eaton, what's your experience? How do you 
persuade people who need help to seek help?
    Mr. Eaton. I was going to say one thing that's possible in 
this area is a program in high schools, which would be built 
into the health curriculum. There's typically a health 
curriculum about diseases in high schools, and you can build 
into that curriculum without too much trouble a module on 
depressive disorder, psychosis, so people are aware of these 
and think of them as illnesses just like any other illness. 
That's part of the stigma reduction idea, and they become less 
resistant.
    There are also in high schools screening programs. The Teen 
Screen Program was implemented in thousands of high schools 
around the country, in which you screen high school students, 
oriented a little bit toward depressive disorder. You mentioned 
suicide as being the 10th most important cause of death, but 
for teenagers, it's the 3d most important cause of death. So 
programs in high schools--I guess that's what I'm saying--to 
make people aware of the issues around mental illness.
    The Chairman. You were critical of the focus of NIH on----
    Mr. Eaton. NIMH. Mental Health.
    The Chairman. I mean, the institute that deals with mental 
health.
    Mr. Eaton. Right, National Institute of Mental Health.
    The Chairman. And our committee and the Congress has 
increased funding for that, and there's a bipartisan interest 
in doing more. If you were there, what would your focus be 
going forward?
    Mr. Eaton. I'm completely supportive of more funds for 
mental health, justified by the burden of disease that I 
mentioned. We no longer can apply for grants with diagnostic 
categories as the outcome. It's silly. So I would change that 
orientation.
    SAMHSA is a very important agency, and I think to some 
extent the NIMH has disassociated itself from the public health 
orientation, partly because SAMHSA is there, but SAMHSA doesn't 
have the expertise to do the public health research that the 
NIMH has. So I made a comment--it wasn't here, but in the 
written comments--I worked at SAMHSA for 2 days a week last 
year. There was no psychiatrist there, not even one 
psychiatrist. As I left, one psychiatrist joined the SAMHSA. 
There was only one epidemiologist at the National Institute of 
Mental Health. So that's a failure in public mental health.
    The Chairman. Dr. Hepburn, you mentioned 30 years ago in 
mental health. I was a Governor at that time, and I've noticed 
that change. I just have a minute here, but what advice would 
you have for States based on your experience and perspective 
about what the focus should be as they move ahead with the 
dollars that they have, both State, Federal, and private?
    Dr. Hepburn. I think that that's a basic question that 
commissioners have to deal with on a regular basis, trying to 
take care of as many people as possible, as cost effective as 
possible. And what that means is moving further upstream toward 
prevention and early intervention so that you can take care of 
more people as they start to show symptoms or where they're at 
risk for symptoms.
    One of the problems we had 30 years ago is that we were 
waiting until people had severe mental illness before we 
started treating them. Now, with the public health model, we're 
trying to move further upstream to early intervention. So 
trying to spread the dollars out--we obviously still have to 
take care of the people who are severely mentally ill, but 
trying to get to people earlier, as we are with the First 
Episode Psychosis, and even earlier, trying to deal with kids 
and kids' mental health.
    The Chairman. Thank you, Dr. Hepburn.
    Senator Murray.
    Senator Murray. Thank you, Mr. Chairman.
    Mr. Rahim, thank you so much for sharing your story with 
this committee and for all the work you've been doing with 
people across the country. It's very impressive. Your message 
that people aren't defined by their mental illness is really a 
powerful one, and I appreciate that.
    Mr. Rahim. Thank you.
    Senator Murray. I wanted to ask you as you talk, 
particularly with young people, what are the most common forms 
of stigma that you hear about?
    Mr. Rahim. Some of the most common forms are, I don't want 
my friends to know. I don't want my family members to know. 
Students want to talk about what they're going through, but 
it's their parents that don't want to help them get the help. 
That's the case sometimes.
    Senator Murray. They fear their parents will----
    Mr. Rahim. Yes. They fear that their parents will--
oftentimes, there's maybe a guilt associated around--is my 
child broken, or is my child sick? And sometimes it's the 
parents. When the students come to them, when their daughters 
and sons come to them, they actually want to help, but 
sometimes the parents are reticent and not getting them the 
help that they need. But students--yes, a lot of them are open 
and willing to talk, especially making and putting that 
conversation out there.
    Senator Murray. So having somebody else besides your parent 
to talk to is critically important.
    Mr. Rahim. That's one of the things.
    Senator Murray. Resources in the community that they feel 
comfortable accessing. But I often hear from parents, too, that 
they don't know who to call. My child is telling me they have 
this issue, but they don't know who to call. What do you tell 
them?
    Mr. Rahim. Sometimes there is that bridging the gap between 
what resources are out there and what is actually known. A key 
component is that education component, is what is out there, 
what is available, and knowing that it's OK to seek those 
resources. Your child is not broken. You're not wrong or bad if 
something happens to your child. It's really providing that 
bridge, that knowledge gap, that there are resources, and it's 
OK to use them.
    Senator Murray. Great. Thank you very much.
    Ms. Blake, let me turn to you. The work you do in the 
emergency department is a critical part of our health care 
system. We all know that, and I know the patients that come 
through your door are at the most vulnerable points of their 
lives. Otherwise, they wouldn't be walking in that door.
    So once a patient is stabilized, and we know they need more 
specialized care--we know that there is an acute shortage of 
inpatient psychiatric beds. You referred to that. It's 
certainly a critical issue in my home State. One study ranked 
my State 48th out of 50 on the availability of psychiatric 
treatment beds. We're seeing a lot more press and discussion of 
that in my State right now.
    But I wanted to ask you what happens to a patient in the 
emergency department if there are no psychiatric treatment 
beds? You mentioned this in your opening statement. But what do 
you do?
    Ms. Blake. What we do is essentially keep them there in 
that room. We give them three meals, and they are stuck there 
until we can either find a psychiatric facility that's willing 
to take them or--sometimes if the 72-hour hold has gone over 72 
hours, our emergency room physicians have no choice but to 
allow that patient to go.
    Senator Murray. So they go back out into the community?
    Ms. Blake. They go back out into the community. But, 
generally speaking, what will happen is they will go from our 
hospital to the next hospital that's closest and try to get in 
through that way.
    Senator Murray. If they seek care. Otherwise, they end up 
without it.
    Ms. Blake. Exactly.
    Senator Murray. Dr. Eaton.
    Mr. Eaton. Could I just mention that I spent time in 
Victoria, Australia. They have a linked medical records system. 
So if someone shows up in an emergency room, and they don't 
have a bed in that hospital, they can--they've been doing this 
for decades. They can dial up and find the nearest mental 
hospital bed in the entire province in a few minutes.
    Senator Murray. And do you not have that access?
    Ms. Blake. We do not have that access where I am. In 
preparation for coming for this, I did an informal poll of my 
colleagues throughout the country. This is not a problem just 
in Florida or in Washington. This is every single State in the 
country, and I would say this is the top issue in emergency 
departments right now across the country--is holding onto these 
patients. One hospital in the south part of Palm Beach County I 
visited earlier this year had 14 patients they were holding, 
waiting for psychiatric beds.
    Senator Murray. As Mr. Rahim pointed out, people don't know 
who to ask. Hospitals don't have a place for them to go, and we 
have a huge hole in our system.
    Ms. Blake. Exactly, and it's because there is not enough 
resources out in the community to be able to place these 
people, No. 1, to get them screened and get them into treatment 
programs, but, No. 2, the followup from when they are released 
from that facility, because they're put out back on the 
streets. And if they don't have any place to go to followup, to 
get further treatment, their medications, to have someone that 
they can go to if they're starting to have a problem--so many 
of these people are homeless.
    If they get put back out, they have no place to go. They 
have no resources. They have no insurance. They have no way to 
followup with a physician. They have no way to get their 
medications. So they show up back in our emergency rooms.
    Senator Murray. A vicious cycle.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Murray.
    I have next Senator Collins, Senator Baldwin, Senator 
Cassidy, and Senator Murphy.
    Senator Collins.

                      Statement of Senator Collins

    Senator Collins. Thank you, Mr. Chairman.
    Dr. Hepburn, particularly in rural States like Maine, 
patients with serious mental illness all too often lack access 
to the care that they need. And as I look at Federal policies, 
at times, Federal policies exacerbate the problem of access. We 
still don't treat mental illness the same way we treat physical 
illness in this country from the perspective of Federal 
reimbursement policies and programs, which is pretty stunning 
in this day and age.
    You mentioned that Congress recently passed Senator 
Cardin's bipartisan bill, which I was pleased to be a co-
sponsor of, which extends an important demonstration project 
that helps address the psychiatric bed shortage that Ms. Blake 
has talked about and improve access to critical mental health 
care services and support. Maine is one of the pilot States 
under that program and has already seen very promising results, 
because Federal Medicaid matching payments are being allowed 
for freestanding psychiatric hospitals for certain emergency 
psychiatric cases.
    Similarly, the Cassidy-Murphy bill, which I've co-
sponsored, would go further by lifting the IMD exclusion for 
psychiatric patients with an average length of stay of 20 days 
or fewer. That should help more people get the assistance that 
they need. Could you talk a little bit more about this issue 
and how the restrictions on Medicaid funding to freestanding 
psychiatric hospitals affect access to care?
    Dr. Hepburn. Yes. Thank you for the question. Access is a 
major issue. Following up on the previous discussion, there is 
a culture problem where individuals are expected to go into a 
psychiatric unit or a psychiatric hospital. If somebody is in 
the emergency room for another type of problem and there aren't 
beds for that particular discipline, they put them into another 
open bed in the hospital. There isn't any reason that 
individuals with psychiatric problems couldn't go into a 
medical bed with a sitter, if some hospitals decide to do that. 
That's one answer.
    The second is increased use of technology may be another 
way to reach the rural areas. The third, as you talked about, 
the IMD Demonstration, has shown that private psychiatric 
hospitals have about the same cost per episode as acute general 
hospital psychiatric units.
    Some 30, 40, or 50 years ago, the private psychiatric 
hospitals kept people for months, sometimes years. That has 
changed. The average length of time in a cost per episode is 
about the same. There really is not a good reason from a 
financial standpoint or from a clinical standpoint to 
differentiate between private psychiatric hospitals and acute 
general hospitals with psychiatric units.
    Senator Collins. I think you raise an excellent point in 
your last statement. It says the practices of the past are 
dictating the reimbursements of today despite changed 
circumstances. And as we've talked to the administrators and 
psychiatrists, staff, families, and patients at one of the 
psychiatric hospitals in Maine, which is part of this pilot 
project, they are seeing exactly what you've said.
    They're not keeping people forever. They're not abusing it. 
But they're allowing people to get the care that they need 
because it's being reimbursed for those individuals who are in 
the age span of 19 to 64, I think it is, that now cannot get 
reimbursement.
    Doctor.
    Mr. Eaton. Just another comment. Emerging technology may be 
helpful. So what I was talking about--record linkage in 
Victoria, Australia. That will be coming in the United States. 
We'll be able to link records more easily, probably.
    But also, in Baltimore, 85 percent of people with 
schizophrenia own a cell phone, so there is a way of contacting 
these people. And there are technologies being developed. 
They're not really therapies, but they're locating devices and 
devices to talk. I think that's in our future, also.
    Senator Collins. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Collins.
    Senator Baldwin had to step out to another hearing, so 
we'll go to Senator Murphy.

                      Statement of Senator Murphy

    Senator Murphy. Thank you very much, Mr. Chairman. Thank 
you to you and Senator Murray for taking this issue so 
seriously and for putting us on a path to a bipartisan product 
coming out of this committee and also a path to bring this to 
the floor this year. I think this is one of our opportunities 
in 2016 to be able to move something substantive, something 
bipartisan, something that makes a difference on the floor of 
the Senate.
    I thank all of you for being here today.
    I think we've covered this question of capacity well, and I 
thank Senator Collins for her specific questions related to the 
IMD exclusion.
    But just for a minute, let's think about how this would 
relate to our lives. If we were to bring our child to the 
emergency room around dinner time, and we sat there with our 
child all evening, we sat with our child overnight, and we 
didn't get appropriate care for our child until noon the next 
day, we would call for people's heads at that institution. We 
would be outraged.
    That isn't the outlier when it comes to people being 
admitted to the ER with mental health diagnoses. That's the 
average, and yet we sort of have accepted it as commonplace.
    But there's a reason why that's happening. We've closed 
down 4,000 mental health inpatient beds since 2007 in this 
country. In the last 2 years alone, we went from 91 million 
Americans living in an area that was designated as a mental 
health shortage jurisdiction for outpatient services to 97 
million Americans. So we're going the wrong way in capacity as 
need is increasing. It's no mystery as to why we're hearing 
these stories.
    But as Senator Murray pointed out, another failing of our 
system is the lack of coordination, the fact that we have so 
many people trying to do good things, but they're not talking 
to each other. And for really complex patients, it's often not 
clear who's in charge for a child. Is it the school? Is it the 
mental health clinic? Is it their primary care physician?
    Mr. Rahim, your story was so captivating, and you're so 
courageous to continue to tell it. I wanted to ask you about 
this question of coordination. I wanted to ask you a question 
about the barriers that patients face in trying to find a 
quarterback for their care, the worry that's involved in just 
trying to figure out which provider is the best place to start, 
and where do they eventually go to get the care they need.
    How can we do a better job of coordinating all of the good 
things that are happening in the system so that it's easier for 
patients to navigate?
    Mr. Rahim. I can take a step back and share what happened 
with me about 17 years ago. My parents were able to bring me 
directly to a hospital in Queens. I was in there--and you talk 
about the waiting area being chaotic. I had hallucinations in 
the waiting area. I thought that I saw Jesus and prophets.
    But I was able to get hospitalized that night, and I was 
able to get medication that night, and I was able to get in the 
ward that night, and I spent 2 weeks there. So I think that 
early care, as Dr. Hepburn was talking about, is so critical. 
But I was able to get that in that moment.
    To speak to the larger issue and larger problem, I think 
that having that care--the immediacy of care is so critical. I 
know it was critical for me.
    Senator Murphy. Dr. Eaton, I wanted to explore very quickly 
an issue that you raised, which is this realization that if we 
don't spend money on mental health, we're going to spend money 
somewhere else, and that the fact is that a diabetes diagnosis 
alone doesn't put you in the top 5 percent of spenders in the 
Medicare and Medicaid system, and, in fact, a depression 
diagnosis alone doesn't put you in the top 5 percent of 
spenders. It's the combination of the two.
    And as you point out, if you have depression, if you have a 
mental health diagnosis, you are, frankly, much more likely to 
acquire another major and expensive physical health disorder. 
Can you talk a little bit about the connection between a mental 
health diagnosis and then a very expensive, very burdensome 
physical health diagnosis and why a little bit of spending on 
the mental health side prevents you from spending a lot of 
money on the physical health side?
    Mr. Eaton. I wish I knew more, actually, but that finding, 
depressive disorder predicting to diabetes or stroke or heart 
attack--that's been replicated 10 times. It's unquestionable, 
and, therefore, the logic is very strong that on the one hand, 
treating the mental health disorder will almost certainly lower 
the risk for the physical disorder later on, but also 
preventing the mental--moving upstream, even farther than First 
Episode Psychosis. So if we can identify people at risk for 
psychosis, not in the first episode, or at risk for depressive 
disorder, that will have these downstream consequences.
    And the problem is it's complicated because it takes a long 
time. We haven't done enough longitudinal studies to actually 
understand exactly how depressive disorder contributes to risk 
for stroke. We don't actually know that, and in the United 
States, we don't have the tendency to do these longitudinal 
studies, unfortunately.
    I don't think I've answered the question well. But I guess 
I think we need longitudinal research to actually understand 
how it is that the body and the mind evolves over time from the 
age of 15, when somebody's at risk for suicide or depressive 
disorder, until the age of 45, when they have four times the 
risk of having a heart attack because of that.
    Senator Murphy. Thank you very much, Mr. Chairman.
    The Chairman. Thank you, Senator Murphy.
    Senator Cassidy.

                      Statement of Senator Cassidy

    Senator Cassidy. Thank you all. Tremendous testimony. 
Although this is a topic which is in a sense inherently tragic, 
on the other hand, the fact that Senators Alexander and Murray 
and you all are here gives us some room for happiness, of 
optimism in the midst of this. So thank you all.
    Dr. Eaton, let me ask--you describe in your testimony, 
written and spoken, about the lack of coordination between 
Federal programs. I'm drawing from that that you feel as if 
there needs to be some change in how these programs coordinate, 
or else we'll be spending Federal tax dollars in an ineffective 
way, et cetera. Your thoughts on that?
    Mr. Eaton. In the written testimony--and this is the part 
of it that I know. I do epidemiologic research. There is huge 
redundancy in the epidemiologic research related to mental 
disorders. The NIAAA conducts its own survey. The NIDA conducts 
a survey. The SAMHSA conducts a survey. The NIMH--they're all 
very similar. I use them all----
    Senator Cassidy. In a sense--I don't mean to cut you off. 
It's just that I have limited time. In a sense, it would be 
better to have one person saying, ``You shall do this and you 
shall do that,'' as opposed to everybody deciding on their own 
that this is where we need to go?
    Mr. Eaton. I think it would pay to study the coordination 
of those agencies. But it's a very difficult thing to figure 
out.
    Senator Cassidy. Now, let me also ask--you brought up 
something that Representative Tim Murphy brings up in the House 
consistently on the House of Representatives side, that the 
SAMHSA really has a paucity of psychiatrists.
    Mr. Eaton. They didn't have any when I was there.
    Senator Cassidy. It's kind of amazing that the principal 
agency for addressing psychiatric illness didn't have a 
psychiatrist. Or maybe it's not amazing.
    Mr. Eaton. It is amazing.
    Senator Cassidy. It is amazing. I agree. The epidemiology--
by the way, I told Dr. Hepburn when I saw your testimony 
regarding the need to start basing Federal research on some 
objective criteria as opposed to inertia, using DALYs as one 
example, it was like be still my heart.
    Right now, I think you're talking about the societal cost. 
But do you include the cost of incarceration in your societal 
cost?
    Mr. Eaton. Those DALYs do not include that cost, typically, 
and that's something that I didn't get into in my testimony. 
But, really, incarceration--this is a horrible, horrible 
problem. I think we now think--many of us think of it--that the 
prison and jail system is the de facto mental health system in 
the United States.
    Senator Cassidy. My National Sheriffs Association 
president, who is from Louisiana, or at least past president, 
Greg Champagne, says he is the most active mental health 
provider in his parish.
    Mr. Eaton. Yes. In Cook County, that's true, also. And we 
don't even have a good survey of mental disorders in prisons.
    Senator Cassidy. Let me stop. We've heard testimony, Dr. 
Hepburn, that the right drug is so necessary in order to keep 
somebody in balance. I've learned, though, that when someone 
enters a jail, their medicines may be stopped or may be on 
contract. It will be a drug substituted, et cetera.
    If we don't have some way to divert folks who are mentally 
ill out of the jail, it may be they're going into a setting 
which would make a dad gum ER look calm--super chaotic. But 
either no medicine or a different medicine because it is a 
different--is that a fair statement?
    Dr. Hepburn. Yes, that's one of the big concerns about not 
having a sequential intercept model that helps to keep people 
out of being arrested and out of jail. To the point that you 
made, if somebody comes in on medication and that medication 
isn't continued, then it can have a negative impact on their 
ability to recover.
    Senator Cassidy. Thank you.
    Mr. Rahim, again, great testimony. Tell me, though--the 
fact that you're speaking about peer groups as if it is 
something unique--maybe you're just bragging on the one in 
which you're involved. But I also got a sense from your 
testimony that the model needs to be expanded, that as good as 
it is, we actually don't have peer groups proliferating across 
the country. This happens to be an exception of which you wish 
to speak. Is that fair?
    Mr. Rahim. I know that there are peer groups in the 
country, and I think, knowing the power that----
    Senator Cassidy. Now, there are peer groups. Are they all 
over the place?
    Mr. Rahim. I couldn't say that they're all over the place, 
but I know there are peer groups. Certain organizations, like 
Depression and Bipolar Supporter Alliance--they are based on 
peers and wellness. NAMI does also have peer groups across the 
country. But I do think that that is a key component. If I knew 
that somebody--when I was going through the thick of my 
medication----
    Senator Cassidy. Let me stop you because I'm out of time. 
So, in a sense, anything that would promulgate or increase the 
use of peer groups would probably be a good thing.
    Mr. Rahim. One-hundred percent.
    Senator Cassidy. One-hundred percent. Next, my last 
question. If we could put you in a bottle and sell you, the 
whole world would be better off. But oftentimes those who are 
mentally ill will not take their medicine. And the revolving 
door comes, and they feel well, and they stop taking their 
medicine, and they're back with Ms. Blake.
    What motivated you to take your medicine, and what do you 
recommend for those who do not take their medicine? What would 
you recommend to kind of encourage them to stay on that path of 
recovery?
    Mr. Rahim. Medication does not define who you are. You are 
defined by your experience and not your mental illness. 
Defining mental illness is also how you think about yourself 
and the things that--how you are labeled.
    Senator Cassidy. So the appropriate mind set, No. 1. What 
else?
    Mr. Rahim. No. 1 is appropriate mind set, and No. 2 is in 
finding the right medication, knowing that you'll have to go 
through a combination. There is no one medication that is a 
panacea for mental illness, and that's why more research is 
needed. So know that you have a different combination, know 
that you're not defined by your medication or your mental 
illness, and having the ability to self-report to your doctor.
    Know how the medications are affecting you. Know how 
they're impacting your treatment as well as your body, and know 
that you'll have some sort of response and reaction. I think 
those are key components. One, trial and error. There's going 
to be different combinations. Two, know that it'll have an 
impact on your body. Three, self-report. And, four, know that 
they do not define who you are. Mental illness does not define 
who you are.
    Senator Cassidy. Thank you.
    I yield back. Thank you, Mr. Chairman.
    The Chairman. Thanks, Dr. Cassidy.
    Senator Warren.

                      Statement of Senator Warren

    Senator Warren. Thank you, Mr. Chairman. Today, for most 
insurance plans, mental health parity is the law, but it sure 
doesn't feel that way for people who need help. A 2015 survey 
conducted by the National Alliance on Mental Illness found that 
nearly 50 percent of respondents had been denied coverage for 
mental or behavioral health care, compared with only 14 percent 
denied for physical health care. And I hear way too many 
stories from people in Massachusetts about how hard it is to 
get insurance coverage for the care that they need.
    So let me start here. Dr. Hepburn, what do we really know 
about how many people are being denied services they need, why 
they're being denied, if they are filing complaints, and if 
they ever end up getting the care that they need?
    Dr. Hepburn. It's an important issue. Yesterday, I called 
the Maryland Parity Project because I wanted to get an update. 
What they indicated was that it's very hard for them to know 
what the numbers are, because when people look at how difficult 
it is to submit a request for review, it's so tedious and it's 
so detailed, it's going to take months to years to make a 
difference. So I asked for a recommendation, and they said 
something has to change in the process.
    Senator Warren. Let's talk about that in just a second. 
Let's start with what you're saying here. We just don't have 
even good data on this.
    Dr. Hepburn. No.
    Senator Warren. On any of those four questions.
    Mr. Rahim, if someone had trouble getting insurance 
coverage for mental health services, is there one place that 
anyone in this country could report a problem and get some 
help?
    Mr. Rahim. That, I'm not sure of, and----
    Senator Warren. I think that's the information we need 
right there.
    Mr. Rahim. That's what I'm saying. Being that I'm a mental 
health advocate and I don't know, that's speaks to that.
    Senator Warren. And that's part of the problem we've got. 
You know, it's hard to fix any problem if we don't have 
reliable data. Connecticut created an Office of the Health 
Advocate to try to help people navigate the insurance system 
and assist when they were denied coverage. In 2014, that office 
returned nearly $7 million to consumers. The most frequent 
cases they deal with every year are denials of mental health 
coverage.
    My colleague from Massachusetts, Representative Joe 
Kennedy, introduced the Behavioral Health Coverage Transparency 
Act last month to try to create a patient parity portal to 
provide consumers around the country a one-stop shop for 
information about parity and a central place to submit 
complaints about coverage.
    Let me ask you this, Dr. Hepburn. We'll go back to the 
question about what to do about this. Would a central place for 
people to go with problems about insurance coverage for mental 
health problems help consumers and give regulators better 
information about where to focus their enforcement actions?
    Dr. Hepburn. Absolutely, yes.
    Senator Warren. So this is something that could make a real 
difference----
    Dr. Hepburn. Yes.
    Senator Warren [continuing]. From what you're saying. Good.
    I just want to say as this committee goes forward on mental 
health legislation, I would like to work with you, Chairman 
Alexander and Ranking Member Murray, on making sure that 
consumers have a central place to turn to for help when they 
are denied coverage and a central place where we will get the 
information so that we can enforce the law that's currently on 
the books.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Warren, for the 
suggestion.
    Senator Franken.

                      Statement of Senator Franken

    Senator Franken. Thank you both, the chairman and the 
ranking member, for these series of hearings.
    Dr. Eaton, in your testimony, you talked about the 
importance of preventing mental illness.
    So did you, Dr. Hepburn.
    You, Dr. Eaton, highlight programs such as the Nurse Family 
Partnership Program, which has been effective at identifying 
high risk births and assisting moms after birth. I really do 
believe prevention is important. That's why I authored and 
helped advance the Mental Health in Schools Act, which will 
increase access to mental health services in school settings.
    Dr. Eaton, what percentage of individuals with mental 
illness experience onset before the age of 18?
    Mr. Eaton. It depends on which mental disorder you're 
talking about. But I think probably before 18, for depressive 
disorder, the full fledged disorder is probably 20 percent. But 
the beginnings of it are available--50 percent of the people 
who will have depressive disorder full fledged in their 
lifetime, let's say before the age of 30 or 35, are already 
experiencing symptoms at 15. They would be potentially 
identifiable, depending on if we can get the tools to do that.
    For schizophrenia, it'll be similar. Schizophrenia has much 
more sudden onset right at 18, 20, 25, something like that. But 
the signs of psychosis and especially the negative symptoms are 
there at the age of 15 to 20, I think.
    Senator Franken. I think this is why if we expand and 
enhance mental health services in our schools, we will serve 
ourselves well.
    I want to ask about rural suicides, because a study made by 
the Journal of the American Medical Association shows that 
rural adolescents commit suicide at approximately twice the 
rate as teens in urban areas, and this disparity has just 
increased over time. Between 2004 and 2013, across all 
demographic groups, suicide rates rose by 7 percent in 
metropolitan areas, but by 20 percent in rural areas over the 
same period.
    The research shows that these differences are driven by 
lack of treatment options in rural areas, provider shortages, 
and stigma. As the co-chair of the Senate Rural Health Caucus, 
I find this deeply concerning.
    Dr. Hepburn, you have previously served on the National 
Suicide Prevention Lifeline Advisory Board and now represent 
the State Mental Health Program Directors. Can you explain why 
suicide rates have been driven up so dramatically in rural 
areas?
    Dr. Hepburn. I think you answered it, which is basically 
access issues. One of the things I think is important is to 
look at how we can advance technology to try and get to the 
rural areas. At a time when the Internet is reaching people all 
around the world, there's really not a good excuse for being 
unable to reach kids and young people in the rural areas.
    One of the problems we sometimes get into is the lack of 
payment for those services that are done through tele-mental 
health, and I think that's an important issue that needs to be 
addressed. In this day and age, tele-mental Internet services 
should be made available in the same way that every other 
service is available. And by doing that, we can increase access 
to those kids.
    Senator Franken. Which is one of the reasons we need to 
make sure every area in America has the Internet, because this 
is something I hear when I go to rural Minnesota. I support 
programs that provide financial incentives to mental health 
service providers in rural areas, actually, we just need them 
in this country. We have a provider shortage. Is that not 
right? And would that be helpful?
    Dr. Hepburn. Absolutely. We have a workforce shortage. I 
think I read the other day that the average age for people in 
behavioral health in terms of providers in the workforce is 58. 
So we have to use technology as a way of compensating for that.
    Senator Franken. Thank you all for the work you're doing. I 
think we're beginning to understand how important this is in 
this Congress and in this country, and we've seen some good 
things happen in this Congress, beginning to happen, and I want 
to thank the chairman again and the ranking member.
    The Chairman. Thank you, Senator Franken.
    Senator Whitehouse.

                    Statement of Senator Whitehouse

    Senator Whitehouse. Thank you, Chairman. Following up a 
little bit on Senator Warren's questions, it strikes me that 
one of the victories that we have achieved has been to bring 
mental health out of the shadows and de-stigmatize it. Not 
completely, not as much as it should be, but there have been 
some real victories in that area. And I want to commend my 
former delegation member, Representative Patrick Kennedy of 
Rhode Island, on the work that he did on the Mental Health 
Parity and Addiction Equity Act, which has really helped make 
that the law of the land as opposed to just a good social 
change that we've made.
    But in addition to the problem of trying to get insurance 
coverage, is there not also the underlying problem that our 
infrastructure for mental health treatment was basically built 
during a heavily stigmatized period when very few people came 
forward? So it was designed to address a fraction of the real 
mental health problem.
    I don't know what you all see, but in Rhode Island, we have 
some of the best mental health facilities in the country. 
Butler Hospital and Bradley Hospital are best-in-show, world 
class facilities, and yet they are kind of all there is. And 
you get beyond that, and you get into really difficult 
situations, and, very often, there has to be a crisis before 
somebody can get access and get into the mental health care 
system, not because the insurance company isn't reimbursing it, 
but because there simply isn't adequate coverage, particularly 
in children's mental health.
    I see that as the case in Rhode Island. You all have a 
perspective through your organizations nationally. Do you agree 
that that is a national problem as well?
    [No verbal response.]
    Senator Whitehouse. All heads are nodding, let the record 
reflect.
    Do you want to say something?
    Mr. Rahim. Yes. Senator Franken, so key about schools. When 
I've spoken in 12 different schools, we did a study, a 4-week 
followup. Are students actually going to seek help? Out of 
2,000 students I spoke to, 184 actually went to a school social 
worker, a school psychologist, or a teacher because they said, 
``You know what? It's OK to talk about what I'm going 
through.'' So if they're ready to seek that help, where do they 
go?
    Senator Whitehouse. Where do they go?
    Mr. Rahim. People are ready to talk, especially the young 
people. But where do you go once you're ready for that help? 
That's the question.
    Senator Whitehouse. Our victory in the stigma area has now 
created a problem in the infrastructure area, in my opinion.
    In the Judiciary Committee, we will be considering a bill 
that is jurisdictional to the Judiciary Committee, which is the 
Comprehensive Addiction Recovery Act, which has a great deal of 
overlay with mental health issues, very often self-medication 
as a solution, not a good one, but one that people use when 
they're really facing a mental health problem.
    Could I ask as a question for the record if each of you 
would have a look--I think your organizations are probably 
already aware of the Comprehensive Addiction Recovery Act. If 
you wouldn't mind checking to make sure, and if you have an 
opinion on it, that we have that. The hearing is going to be 
coming up in the next couple of weeks, and I'd love to make 
sure we've got your organization's position on the 
Comprehensive Addiction Recovery Act in our record here that I 
can take there.
    Senator Whitehouse. And then the last question that I have 
has to do with emergency rooms. Ms. Blake, that's your world. 
You live in it. I've spent overnights in our emergency room 
just to witness what takes place in there. There's an enormous 
amount of mental health response that's delivered in the 
emergency room.
    People come in in the middle of the night. What they really 
have is a mental health problem. The police have no place else 
to bring them. They take them to the ER. Now it's your problem, 
and an ER isn't really well suited for dealing with that.
    Could you just comment a little bit more on how big a role 
that task that you've been given plays in your workload and how 
much it is diminishing what else you can do? But I'm also 
interested in the extent to which you feel comfortable that the 
electronic health records that you pull up when you bring that 
person in, or when they come in to you, or when they're brought 
in to you, are accurate and complete as to the mental health 
history of that individual?
    Ms. Blake. Yes, I know what you're asking.
    Senator Whitehouse. I've got a feeling that some of the 
protections we've put in place back when this was heavily 
stigmatized to keep all this information private is actually 
keeping it from getting into electronic health records, so that 
in an ER, you aren't aware of the situation.
    Ms. Blake. Absolutely. I can actually give you an example 
of that. Not too terribly long ago, we had a 26-year-old 
gentleman brought to our emergency room. He was a heroin 
overdose. He was unconscious. We didn't know a lot about him, 
except that he had used heroin, because he responded to Narcan 
when we gave him the Narcan.
    We stabilized him, and in the process of taking care of 
him--I was taking care of him--I got a phone call from a 
gentleman in Virginia who was trying to locate his son who had 
been sent down to our county for treatment and rehab for 
substance abuse, who had walked away from his rehab center. It 
turned out--he gave me the son's name, and it turned out it was 
the patient I was taking care of.
    The problem was I could not tell him because of the HIPAA 
law that we had his son in our emergency room, No. 1, because 
the patient was unconscious and unable to give me permission to 
do so. But it turned out, too, that his son had a mental health 
care issue as well. He was bipolar, and he had been off of his 
medications which was contributing to his problem.
    Now, had we been able to release that information or pull 
that information up somehow, then it might have changed the 
whole way that we treated this patient. But, more importantly, 
it broke my heart to not be able to tell this man that his son 
was safe in the emergency room and was going to be able to 
recover.
    I think maybe if we look at some limited circumstances 
where certain information could be released--and I certainly 
understand the privacy issue, but it would be very helpful, 
because in order to access someone's medical records, you first 
have to get permission from them in order to do so. And someone 
who might be in a mental health care crisis may not have the 
capacity to be considered able to sign permission for it.
    Senator Whitehouse. Thank you. My time has expired, but 
that was a terrific story and a terrific point. Thank you.
    The Chairman. Thank you, Senator Whitehouse.
    Senator Murray, do you have any further comments?
    Senator Murray. Mr. Chairman, I just want to say this has 
been a really important hearing, and I really want to thank all 
of our witnesses today. Clearly, we have a lot of work ahead of 
us.
    We talked about making sure communities have access to 
mental health professionals, integrating the primary care with 
mental health care, prioritizing research, and breaking down 
barriers--continuing to break down barriers that stigma 
creates. That is a full plate, but it is an important one for 
us to tackle, and I look forward to working with you on moving 
this agenda forward.
    The Chairman. Thank you, Senator Murray.
    Ms. Blake, thank you for that story, and Senator Whitehouse 
for bringing that up. Touching HIPAA is like touching an 
electric wire. But maybe that's what we're paid to do 
sometimes. So as we look at our mental health legislation, we 
should consider that story and that circumstance, and given the 
way we work on this committee, perhaps we can help with that.
    If you have a specific suggestion for the kind of exemption 
that that should be, we'd like to have it. Maybe your 
organizations have that kind of----
    Ms. Blake. As chair of the Advocacy Advisory Council, 
that's definitely something we can put on our agenda to discuss 
and see what people----
    The Chairman. We're moving pretty fast here.
    Ms. Blake. We have a meeting today.
    The Chairman. Good.
    Senator Whitehouse. They're faster than us.
    [Laughter.]
    The Chairman. What Senator Murray and I hope to do is to 
move promptly through this committee those issues that are 
within our jurisdiction and do it at the same time that we're 
working with the Finance-Judiciary Committees and with Senator 
Murray and Senator Blunt's Appropriations Subcommittee so that 
we'll be ready to deal with this issue. We have some very good 
work being done.
    I thank you for the testimony today from all four of you.
    The hearing record will remain open for 10 days. Members 
may submit additional information within that time.
    The next hearing of this committee will explore issues 
related to generic drug user fee agreements, and it will be on 
Thursday, January 28th.
    Thank you for being here today. The committee will stand 
adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

                  Prepared Statement of Senator Casey

    Thank you, Chairman Alexander and Ranking Member Murray, 
for continuing with this series of hearings on mental health 
and substance abuse. I know everyone on this committee is well 
aware of the fierce urgency of this subject matter. Although 
the vast majority of individuals with mental illness are not 
violent, recent years have given rise to tragedies that 
highlight the need for our Nation to better address this issue. 
The testimony at the first hearing on mental health, and the 
second hearing focusing on opioid abuse, has been enlightening, 
and will help me and the other members of this committee as we 
decide the best way to move forward on mental health and 
substance abuse issues.
    Mental health is one of the country's most pressing health 
care needs. Nearly one in five adults experiences a mental 
illness in a given year. Left untreated, these conditions can 
destroy lives and tear apart families. The Affordable Care Act 
built on the landmark mental health parity law by including 
mental health and substance abuse services as an essential 
health benefit, and by expanding access to private health 
insurance and Medicaid. We must work to build upon this 
progress by strengthening the behavioral healthcare workforce; 
finding new ways to integrate behavioral health and primary 
care; providing resources for crisis situations; and 
strengthening vulnerable communities. We must make good on the 
promise of insurance parity for mental health and substance 
abuse services, and work to ensure that cutting edge medical 
research into mental health and substance abuse receives 
adequate support and sustained funding.
    Today's hearing will provide insight into how we can 
improve Federal mental health policies. I appreciate the 
opportunity to hear from the witnesses, who will discuss the 
challenges faced by State governments, health care 
professionals, mental health researchers and those that suffer 
from mental health conditions. I look forward to working with 
the Administration, as well as my colleagues on the committee, 
as we use today's testimony to build upon and improve Federal 
mental health policy.

                 Prepared Statement of Senator Baldwin

    Thank you, Chairman and Ranking Member, for holding this 
important hearing. My home State of Wisconsin is experiencing a 
uniquely severe shortage of mental health providers that is 
drastically reducing access to needed care. Over half of our 
counties have been designated as mental health professional 
shortage areas, and estimates show that we would need over 200 
psychiatrists to start addressing this shortage.
    This has particularly devastating consequences for the tens 
of thousands of Wisconsin children who are living with 
untreated mental health issues, forcing parents to wait for 
months to get their child into care, cross the border for care 
in another State, or forgo care altogether.
    Wisconsin health and community leaders are collaborating on 
innovative programs to address these issues, but our kids are 
still in crisis.

 Response by Brian Hepburn, M.D. \1\ to Questions of Senator Isakson, 
 Senator Murray, Senator Casey, Senator Whitehouse, and Senator Baldwin
---------------------------------------------------------------------------

    \1\ Stuart Gordon, NASMHPD's Director of Policy, worked with Dr. 
Hepburn and many individual State mental health directors, in drafting 
the attached responses to questions that we received from HELP 
Committee members.
---------------------------------------------------------------------------
                            senator isakson
    Question. How does SAMHSA interact with other HHS agencies, Federal 
departments, and State agencies concerning the development and 
implementation of mental health policies? What improvements, if any, do 
you think could be made in this area?
    Answer. SAMHSA has a long history of working with the State Mental 
Health Agencies (SMHAs) and Substance Abuse Agencies in developing 
programs through grants, sharing evidence-based practices, and seeking 
input regarding concerns about the upcoming implementation of new 
Federal programs. SAMHSA meets quarterly with advisory committees for 
all divisions at the SAMHSA headquarters, and also meets with those 
advisory committees in aggregate. Acting SAMHSA Administrator Kana 
Enomoto and Center for Mental Health Services Director Paolo del 
Vecchio have both long held close working relationships with the SMHAs, 
relationships founded on trust and a mutual understanding of the 
essentials of providing services to individuals with serious mental 
illness and children and youths with serious emotional distress.
    A recent illustration of that close working relationship is how 
SAMHSA and the National Institute for Mental Health worked closely with 
SMHAs in the implementation of the 10 percent Mental Health Block Grant 
set-aside for treatment of First Episodes of Psychosis. Soon after 
enactment of the set-aside, SAMHSA reached out to the SMHAs to solicit 
input on how the program might best be implemented and then issued 
guidance to lead the way. Over the last 2 years, technical assistance 
has provided in the field and by phone to assist States in adopting the 
most effective, evidence-based approaches to achieve the set-aside's 
goals.
    SAMHSA has specifically provided leadership to our field by:

     involving persons experiencing mental illness in shared 
decisionmaking with their treating providers; 
     promoting the importance of peer services (especially at a 
time when we are facing workforce shortages);
     promoting not just the medical model but also the 
importance of supportive housing and supportive employment in helping 
persons avoid disability;
     promoting integration of physical health care and 
behavioral health; and
     promoting telehealth and the use of health information 
technology to reach more people.

    SAMHSA has been working very closely with officials in the Federal 
Medicaid program over the past few years on such items as developing 
quality measures that can be used across programs, and implementation 
of Section 223 of the Excellence in Mental Health Act conditions for 
participation. The two agencies have also been increasingly finding 
projects on which they can collaborate such as the recent CMCS 
Informational Bulletin on funding early intervention programs under 
Medicaid authorities. SAMHSA provides input into the National Quality 
Forum (NQF) Measures Application Partnership which develops 
recommendations to CMS on quality measures for the Medicaid and 
Medicare programs.
                             senator murray
    Question. In your testimony you discussed the need for adequately 
funded crisis response services. I'm particularly concerned about the 
availability of crisis response services in areas with low population 
density that struggle to maintain services because of the low volume of 
calls. How can the Federal Government support State and local service 
providers to ensure that, when patients are in a time of crisis, they 
always have someone to call?
    Answer. Recently the NASMHPD did a survey on how States fund crisis 
services. Some States pay for crisis services entirely with State 
general funds. Other States use a mixture of State general funds, block 
grant funds, local funds and Medicaid. The percentage of the funds in 
the exact mixture for the individual States varies greatly. The rural 
communities are most vulnerable to not having adequate funding because 
they have a low volume of service utilization and therefore recover 
less reimbursement on a fee-for-service basis. They are also vulnerable 
because they have difficulty recruiting mental health professionals, 
such as psychiatrists. The poorer rural areas are also more vulnerable 
because there are no local funds which could help support their 
efforts.
    The Federal Government could be helpful in resolving the problem in 
the rural areas by:

     providing funding to educate the public in how to assist 
friends and loved ones who are experiencing psychological distress. 
This would include being able to identify when an individual is in 
distress, supporting the individual and knowing where to find services 
for the individual. The goal is to provide the needed intervention as 
early as possible and avoid escalation into a crisis;
     providing adequate funding of the Suicide Lifeline Network 
to ensure individuals in crisis in every community will have someone 
immediately available who is trained in crisis response and 
knowledgeable about the resources available in the immediate 
surrounding community;
     providing greater funding for Crisis Intervention Team 
training of law enforcement personnel and first responders to help 
ensure that situations do not escalate;
     providing flexibility in Medicaid rules so that services 
provided remotely could be reimbursed, residential crisis services 
could be covered, residential crisis services would not be subject to 
the IMD exclusion, and peer services could be compensated.
     providing educational loan repayments for mental health 
professionals working in rural crisis programs;
     providing incentives to mental health professional 
training programs for training those professionals in tele-mental 
health; and
     providing incentives to develop social media applications 
directed toward persons in distress/crisis.
                             senator casey
    Question 1. As a member of the Committee on Finance as well as the 
Health, Education, Labor, and Pensions Committee, I frequently hear 
about the mental health needs of children in the child welfare system, 
and the challenges current and former foster children have in accessing 
the mental health services they need. Does the National Association of 
State Mental Health Program Directors have any recommendations or best 
practices for State Mental Health Agencies for ensuring that the mental 
health needs of current and former foster youth are properly met?
    Answer 1. As an example, Indiana is utilizing a Children's Mental 
Health Initiative to provide services to children who have become 
involved with the Department of Child Services due to their behavioral 
health concerns but do not have the funding for services. Also in 
Indiana, there is the Older Youth Initiative that provides youth with 
mental health services and supports as they approach turning 18 in the 
foster care system to assist in the transition to adulthood and self-
sufficiency.
    The Iowa Department of Human Services (DHS) has developed a 
practice guide, Children in Child Welfare: Mental and Behavioral Health 
Practice Bulletin, which acknowledges up front that most children who 
enter the child welfare system have experienced trauma. Thus, mental 
health screening by licensed mental health providers is one of the 
first steps taken after a child's entry into the State welfare program. 
DHS data show that 88 percent of 359 children reviewed between August 
2007 and October 2007 had their mental health needs assessed and met.
    For a broader look, the Children's Bureau, in collaboration with 
the Georgetown University Center for Child and Human Development and 
through the National Technical Assistance Center for Children's Mental 
Health, has released a series of papers, Integrating Safety, Permanency 
and Well-Being in Child Welfare, describing how a more fully integrated 
and developmentally specific approach in Child Welfare can improve both 
child and system level outcomes. The overview, Integrating Safety, 
Permanency and Well-Being: A view from the Field (Wilson), provides a 
look at the evolution of the child welfare system from the 1970s 
forward. The first paper, A comprehensive Framework for Nurturing the 
Well-Being of Children and Adolescents (Biglan), provides a framework 
for considering the domains and indicators of well-being. The second 
paper, Screening, Assessing, Monitoring Outcomes and Using Evidence-
based Practices to Improve Well-Being of Children in Foster Care 
(Conradi, Landsverk, Wotring), describes a process for delivering 
trauma screening, functional and clinical assessment, evidence based 
interventions and the use of progress monitoring in order to better 
achieve well-being outcomes. The third and final paper, A Case Example 
of the Administration on Children and, Youth and Families' Well-Being 
Framework: KIPP (Akin, Bryson, McDonald, and Wilson) presents a case 
study of the Kansas Intensive Permanency Project and describes how it 
has implemented many of the core aspects of a well-being framework.
    We also recommend a 2006 report co-authored by the Georgetown 
University Center's National Children's Technical Assistance Center, 
NASMHPD's Children Youth and Families Division, and the National 
Association of Public Child Welfare Administrators entitled Financing 
Behavioral Health Services and Supports for Children, Youth and 
Families in the Child Welfare System. That study surveyed 24 States on 
their interagency financing strategies and found that 89 percent of 
child welfare agencies and 83 percent of mental health agencies were 
involved in those strategies. Medicaid was next at 65 percent, and 
juvenile justice at 61 percent. The vast majority of the responding 
States (79 percent) developed partnerships among the involved agencies 
to implement the funding strategies, and most of them (61 percent) 
formalized these partnerships.
    As an aside, NASMHPD's membership is unanimous in supporting the 
Administration's initiative to reduce the inappropriate prescribing of 
psychotropic pharmaceutical agents to kids in the foster care system 
[estimated at more than $3 billion a year]. That money can be better 
and more effectively used to enhance Medicaid financing for therapeutic 
foster care services and other intensive psycho-social interventions 
targeting the 50,000 children with the most serious emotional 
disturbances.

    Question 2. In what ways do State Mental Health Agencies commonly 
work with their State child welfare agencies? Is there anything that 
the Federal Government can do to encourage or promote collaboration 
between State Mental Health Agencies and the child welfare agencies in 
their States?
    Answer 2. SAMHSA's Children Mental Services Program seeks to 
establish ``systems of care'' at the State level to encourage 
collaboration on a multi-agency basis. As noted above, State child 
welfare agencies such as Iowa's recognizes that a child in the system 
has been more than likely to have experienced some level of trauma, and 
thus includes a mental health screening performed by licensed mental 
health and substance use treatment providers in the initial physical 
screening. Other agencies refer youngsters with the most serious 
behavioral health conditions to specialized services provided by 
NASMHPD member agencies.
    A number of legislative modifications to the Children's Mental 
Health Services program should be considered including (i) lengthening 
the average grant cycle under the program (e.g., adding at least 2 
years to promote the sustainability of collaborations), (ii) 
authorizing the Administration's fiscal year 2017 CMHI 10-percent set-
aside proposal for funding prodromal approaches to preventing the onset 
of serious mental illness and the first episode of psychosis, and (iii) 
using the Children's Mental Health Services Program to promote 
demonstrations of approaches such as that used in Iowa--a standard 
mental health/substance use screening and treatment planning protocol 
for all kids entering the foster care system nationwide.
    The Federal Government should also consider providing guidance and 
funding for collaborations toward the mental health needs of children 
and families in need. The Indiana Division of Mental Health and 
Addiction (DMHA) and the Indiana Department of Child Services have 
collaborated to provide intensive home and community-based wraparound 
services for youth and families without funding known as Children's 
Mental Health Initiative. See http://www.in.gov/dcs/3401.htm.
                           senator whitehouse
    Question 1. Along with a bipartisan group of senators including 
Senators Portman, Klobuchar, and Ayotte, I introduced a bill earlier 
this year called the Comprehensive Addiction and Recovery Act (S. 524). 
The bill authorizes a series of grants to States and other eligible 
entities to promote an integrated approach including prevention, 
treatment, law enforcement tools, and recovery support to the substance 
abuse epidemic we are facing across the Nation. Among other things, the 
bill tries to increase screening for, and treatment of, co-occurring 
mental health and substance use disorders in the juvenile and criminal 
justice systems and elsewhere.
    Do you support the objectives set forth in S. 524? How would 
enactment of S. 524 improve your organizations ability to help address 
the opioid abuse epidemic?
    Answer 1. Yes, like our friends at the National Association of 
State Alcohol and Drug Abuse Directors (NASADAD), NASMHPD strongly 
supports S. 524, but would like to see all grants and programs proposed 
within the bill fully funded.

    Question 2. What additional tools might you like to see at your 
disposal to address the overlap between substance abuse and mental 
health issues?
    Answer 2. Perhaps language that clarifies that when grant moneys 
are utilized to treat an individual with a substance use disorder who 
also has a co-occurring mental illness or emotional disorder that may 
be impacting or be impacted by the severity or nature of the co-
occurring disorder, grant moneys under CARA may be utilized to treat 
that co-occurring mental illness or emotional disorder without a 
violation of any SAMHSA program prohibition against the intermingling 
of program funds.
    In a similar vein, in the late 1990s, SAMHSA initiated a dual 
diagnosis program/line-item for individuals with both mental health and 
substance use disorders. It never received much Federal funding, but 
efforts to revive the initiative in that form or some similar form 
other would be well-advised.
                            senator baldwin
    Question 1. Three Wisconsin health systems in the Fox Valley area 
have partnered to create a program, called Catalpa, to help improve 
timely access to mental health care for pediatric patients. This 
program provides crisis care for children and their families within 24 
hours and then regular, followup care, led by a multidisciplinary team 
in the partnership network. At its main center, wait times have dropped 
from 54 days to about 5 days.
    Answer 1. Dr. Hepburn and Ms. Blake, this is just one example of a 
program working to address the mental health services crisis facing our 
children. What steps would you recommend the Federal Government take to 
help solve our mental health provider shortage and improve access for 
children throughout the country?
    NASMHPD is very supportive of the model that Wisconsin is now 
using. However, one of the difficulties has been getting funding for 
programs such as this. They are often funded by State general fund 
dollars which has slowed their expansion. Federal funding would be very 
helpful.
    NASMHPD strongly supports President Obama's fiscal year 2017 budget 
recommendation that a 10 percent set-aside be created in the Children's 
Mental Health Services budget line to fund outreach to and treatment of 
at-risk troubled children before they reach a level of serious mental 
illness or serious emotional distress, and certainly before they 
experience their First Episode Psychosis. Such a program would utilize 
peers, teachers, counselors, and family members to help identify 
troubled youths in the schools and in the community and then invite 
them and their families in for family based cognitive behavioral 
therapy sessions led by licensed providers. This type of program 
addressing behavioral health needs further upstream should reduce the 
need for crisis-focused programs later in childhood development.

    Question 2. Mental health is too often thought of as a separate 
part of the care continuum, resulting in a fragmented mental health 
care delivery system. To begin integrating mental health into primary 
care, our Medical College and Children's Hospital of Wisconsin are 
participating in a State pilot program that offers primary care 
providers daily consultation services with child psychiatrists. Dr. 
Hepburn, how can we encourage more of our health systems and local 
support networks to work together to prioritize mental health and 
integrate these services into our larger delivery system?
    Answer 2. Again, NASMHPD is very supportive of the model that 
Wisconsin is using. The model has been used successfully in 
Massachusetts and in Maryland and we would like to see it spread 
throughout the country. However, as with the first model you mention, 
the difficulty has been getting funding for programs such as this. They 
are often funded by State general fund dollars which has slowed their 
expansion. Federal funding initiatives and also allowing these 
consultations to be paid for by Medicaid would be very helpful.
    An alternative approach might be to utilize telemedicine to help 
pediatricians consult with the 7,000 to 8,000 licensed child 
psychiatrists nationwide.
    The model that seems to NASMHPD to have the greatest promise for 
integrating primary care and behavioral health care for persons of all 
ages is the Health Homes Demonstration Model for persons with chronic 
conditions enacted under Section 2703 of the Affordable Care Act. This 
works particularly well because the statute includes, among the 
conditions considered to be chronic and thus covered under the 
demonstration, persistent mental health conditions and substance use 
disorders. The Health Homes Demonstration requires participation of a 
team of health care professionals that includes physicians and other 
professionals such as a nurse care coordinator, nutritionist, social 
worker, behavioral health professional, or any professionals deemed 
appropriate by the State.
    The home health services provided include comprehensive care 
management, care coordination and health promotion, transitional care 
and followup, patient and family support, community and social support, 
and use of health information technology. While most health homes have 
a primary care provider as the designated lead provider, there is no 
legal reason why a health homes model for pediatrics could not have a 
pediatrician as a designated lead provider and, in fact, pediatricians 
are identified in the list of providers that can so serve.
    In contrast to the mostly hospital-based accountable care 
organizations, the health home team can be free-standing, virtual, or 
based at a hospital, community health center, community mental health 
center, rural clinic, clinical group practice, academic health center, 
or any entity deemed appropriate by the Secretary. Also in contrast to 
the ACO model, behavioral health providers have been active 
participants in the Health Home Demonstration project.

    Response by Penny Blake, RN, CCRN, CEN to Questions of Senator 
   Alexander, Senator Casey, Senator Whitehouse, and Senator Baldwin

                            senator alexander
    Question. During your testimony, you told a story regarding the 
disclosure of protected health information under the Health Information 
Portability and Accountability Act. In that case, you said that you 
were unable to disclose information to a family member of a patient 
when that patient was unable to give consent. However, HIPAA does allow 
disclosure under these types of situations according to the HIPAA 
Privacy Rule at 45 Code of Federal Regulations 164.510. What should the 
Federal Government be doing to clarify situations where disclosure of 
protected health information is permissible under HIPAA? Are there 
specific parts of HIPAA that you feel are too restrictive or unclear?
    Answer. Thank you for highlighting this key issue. Before I begin, 
please let me recap the specifics of the circumstance, given the 
relevance to your question.
    During the hearing, I noted that a 26-year-old gentleman presented 
at our emergency room in Florida, unconscious with a heroin overdose, 
which we ascertained because he responded to Narcan, a narcotics rescue 
agent. After the patient was stabilized, I received a phone call from a 
man in Virginia trying to locate his son, who had been previously 
admitted in the area for addiction treatment but had walked away from 
the facility and was, thus, missing. The caller mentioned his name, but 
due to HIPAA restrictions, I was not able to tell the man that his son 
was in our care due to the HIPAA law.
    In my response, I want to highlight two key issues--(1) lack of 
clarity within HIPAA and our State privacy laws regarding the unique 
protections associated with substance abuse and mental health records, 
and (2) how interoperable health care records could have assisted us in 
treating the patient I described.
    But, first, let me turn to the HIPAA clarity issue. While it is 
correct that 45 CFR  164.510 does specify permitted disclosures to a 
``family member, other relative, or a close personal friend of an 
individual'' in the case of an emergency, such disclosures are limited 
only to ``information directly relevant to such person's involvement 
with the individual's care'' [45 CFR  164.510(b)] \1\ The regulation 
further clarifies [45 CFR  164.510(b)(3)] \2\ that such involvement 
may include ``pick(ing) up filled prescriptions, medical supplies, X-
rays, or other similar forms of protected health information.'' At the 
time that I talked to the parent, the patient was already stable. 
Therefore, the disclosure would not have been to assist with the 
patient's care but to provide ease to a family member. As such, it is 
not clear that such a disclosure is permitted by HIPAA.
    The Emergency Nurses Association Code of Ethics, approved in 
February 2015, was developed as a guide for carrying out emergency 
nursing responsibilities in a manner consistent with quality of care 
and the ethical responsibilities of the profession. Regarding an 
individual's right to privacy and confidentiality, this framework 
states that ``information pertinent to the care and welfare of a 
patient may be divulged to those directly involved in the care of the 
patient.'' \2\
    This matter is further complicated by the Florida statute 
requirements, which are stricter than the Federal HIPAA requirements. 
Specifically, the Florida statute states that ``[p]atient records 
maintained by licensed Florida facilities, including hospitals, are 
confidential and may not be disclosed without patient consent unless 
disclosure occurs to specified persons or in specified circumstances 
(e.g. to physicians for treatment purposes, in response to a court 
subpoena, etc.).'' FL ST  395.3025. Therefore, without the patient's 
consent, I am unable to disclose such records due to Florida law. As a 
result, even if one were to further clarify HIPAA, which is considered 
a Federal floor and not a ceiling, States (like Florida) can continue 
to enact more stringent privacy requirements.
    In direct answer to your question, I have highlighted the key 
issues with respect to the HIPAA requirements--namely, the requirement 
that the information disclosed to family members be limited to that 
which is ``directly relevant to such person's involvement with the 
individual's care.'' This requirement, coupled with more stringent 
State privacy laws, is intended to make disclosure of personal health 
information difficult. But, as my example highlights, sometimes, it 
does not serve all those involved.
    However, in the story I relayed, the patient was brought to the 
emergency department with suspected heroin overdose. Given the unique 
protections associated with substance abuse and mental health records 
under Federal and State law, it became unclear whether or not the 
ability to disclose personal health information without the patient's 
consent was still allowable.
    When I recapped the story before, I only alluded to another key 
component: Had we been able to electronically obtain the patient's 
medical records at the time that he entered the emergency room, it 
could have changed the way we treated him. I understand that the HELP 
Committee is working to promote interoperability, and I hope that you 
will continue to do so.
    ENA urges Congress to clarify situations where disclosure of 
protected health information is permissible including requiring the 
U.S. Department of Health and Human Services (HHS) and State 
departments of health to clarify situations in which disclosures 
without consent are permitted, particularly when mental health or 
substance abuse are the cause for an individual's presentation to the 
emergency department.
    In addition, we urge Congress to require HHS to mandate that 
certified EHR technology include fields for mental health and substance 
abuse diagnoses.
    It would also be helpful if HHS encouraged local and regional 
health information exchanges (HIEs) to include mental health or 
substance abuse diagnoses as required data elements, as this 
information can be critical in emergency situations for treatment 
purposes. While it is our understanding that HHS cannot mandate this, 
it could incentivize this activity by making it a requirement of any 
grant funding for HIEs.
                             cfr references
    1. (b) Standard: uses and disclosures for involvement in the 
individual's care and notification purposes--(1) Permitted uses and 
disclosures. (i) A covered entity may, in accordance with paragraphs 
(b)(2) or (3) of this section, disclose to a family member, other 
relative, or a close personal friend of the individual, or any other 
person identified by the individual, the protected health information 
directly relevant to such person's involvement with the individual's 
care or payment related to the individual's health care.
    2. (b)(3) Limited uses and disclosures when the individual is not 
present. If the individual is not present, or the opportunity to agree 
or object to the use or disclosure cannot practicably be provided 
because of the individual's incapacity or an emergency circumstance, 
the covered entity may, in the exercise of professional judgment, 
determine whether the disclosure is in the best interests of the 
individual and, if so, disclose only the protected health information 
that is directly relevant to the person's involvement with the 
individual's health care. A covered entity may use professional 
judgment and its experience with common practice to make reasonable 
inferences of the individual's best interest in allowing a person to 
act on behalf of the individual to pick up filled prescriptions, 
medical supplies, X-rays, or other similar forms of protected health 
information.
    3. 5. The emergency nurse respects the individual's right to 
privacy and confidentiality. The emergency nurse protects and 
safeguards the privacy of their patients, thus preventing uninvited 
intrusion into the patient's private life, medical history, and current 
condition. Information pertinent to the care and welfare of a patient 
may be divulged to those directly involved in the care of the patient. 
The HIPAA Privacy Rule protects the privacy of patient's health 
information and, even in the event of public scrutiny, emergency nurses 
are mandated to preserve the individual's right to privacy and 
confidentiality. Patient information utilized for peer review, third-
party payments, quality improvement initiatives, or risk management 
processes may be disclosed based on an institution's policies, 
protocols, or legal mandates.
                             senator casey
    Question 1. In your testimony, you discuss the process that Good 
Samaritan Medical Center, and similar hospitals, follow when patients 
present with a mental illness. Is this process different for a child or 
young adult who is admitted with a mental health problem? Do these 
patients have unique needs compared to those of adults with mental 
illnesses, and, if so, should the Federal Government provide any 
additional support or enact any policy changes to help health care 
providers address those needs?
    Answer 1. At my hospital, the process for handling children and 
young adults as compared to other mental health patients is the same. 
Since our hospital does not have a psychiatric unit, we would transfer 
a mental health patient to one of the two hospitals in our area that 
admits patients suffering from an acute mental health issue. In such a 
situation, the patient is first medically cleared by an emergency 
physician in my hospital. The patient must then be accepted by the 
emergency physician of the receiving hospital and is transferred by 
ambulance or law enforcement vehicle to that hospital's emergency 
department until a bed became available in their psychiatric unit.

    Question 2. In your experience, what kind of training do nurses and 
other health care professionals receive regarding the patient privacy 
requirements placed on them by HIPAA? Do you feel that access to 
increased training would be helpful?
    Answer 2. In our facility, we must complete a class annually 
regarding the HIPAA law. The class is taken online in a computerized 
format. Access to more in depth training would be helpful to nurses and 
other health care providers. However, based on discussions with 
colleagues across the United States, I believe the larger problem is 
the lack of clarity in the HIPAA language.
    Additionally, States may have further restrictions on health care 
information, making the situation more complex for providers. Finally, 
hospitals protect mental health records even more stringently. As a 
result, health care providers tend to err on the side of caution when 
asked to divulge information.

                           senator whitehouse
    Question 1. Along with a bipartisan group of senators including 
Senators Portman, Klobuchar, and Ayotte, I introduced a bill earlier 
this year called the Comprehensive Addiction and Recovery Act (S. 524). 
The bill authorizes a series of grants to States and other eligible 
entities to promote an integrated approach--including prevention, 
treatment, law enforcement tools, and recovery support--to the 
substance abuse epidemic we are facing across the Nation. Among other 
things, the bill tries to increase screening for, and treatment of, co-
occurring mental health and substance use disorders in the juvenile and 
criminal justice systems and elsewhere.
    Do you support the objectives set forth in S. 524? How would 
enactment of S. 524 improve your organization's ability to help address 
the opioid abuse epidemic?
    Answer 1. The Emergency Nurses Association (ENA) strongly supports 
the Comprehensive Addiction and Recovery Act. Enactment of S. 524 would 
improve the ability if ENA's 41,000 members to address the opioid abuse 
epidemic in several ways. I will focus on three important provisions 
contained in the legislation.
    First, making naloxone available for use in the first few minutes 
of an opioid overdose by laypersons, law enforcement officers and other 
first responders makes a tremendous difference in the outcome for a 
person who has overdosed. I am proud to say that I helped to get 
legislation passed in Florida last year making naloxone available in 
these circumstances. As a result, patients are now much more likely to 
receive naloxone in the field from first responders. Later, when they 
arrive in the emergency department, we monitor the patients as the 
naloxone wears off and, in most cases, we are able to discharge them 
within several hours. In the past, when patients were much less likely 
to have access to naloxone as soon as they experienced a heroin 
overdose, many suffered brain damage caused by lack of oxygen because 
they had stopped breathing. We would place these patients on 
respirators in ICU for days just to keep them alive. Tragically, even 
some who survived an overdose would continue to suffer from long-term 
cognitive issues.
    Second, the bill authorizing the Centers for Substance Abuse and 
Treatment to award grants to States, units of local government or 
nonprofit organizations located in geographic areas that have a high 
rate of heroin or other opioid abuse to expand treat activities, 
including medication assisted treatment programs, for the treatment of 
addiction in the geographical areas affected. This provision will be of 
great benefit to hospitals. Many of the patients we encounter have no 
place to go for the treatment of their addiction, especially if they do 
not have financial resources for private programs. Providing programs 
in the community that can help them safely withdraw from opioids and 
then manage their ongoing care would not only prevent them from needing 
emergency care, but it would save communities the costs associated with 
emergency medical services or police responding to cases of heroin and 
opioid overdoses.
    Finally, the bill's National Youth Recovery Initiative authorizes 
the Director of Office of National Drug Control Policy to make grants 
to high schools and colleges to provide support to their students who 
are recovering from substance use disorders. This section of the 
legislation would assist both in the prevention of overdoses and 
achieving long-term recovery. This would lessen the burden on hospital 
emergency departments, which are not an optimal place to treat patients 
with substance abuse and often related mental health issues.

    Question 2. What additional tools might you like to see at your 
disposal to address the overlap between substance abuse and mental 
health issues?
    Answer 2. There are several tools that would help to address the 
overlap between substance abuse and mental health issues. One important 
change would be to enhance community-based treatment resources for both 
mental health and substance abuse patients. This will allow emergency 
departments to direct patients and their families to treatment options 
in the local community immediately upon discharge.
    The time after discharge is when patients are most vulnerable and 
most likely to seek treatment for their addiction. Sending them 
directly to a treatment facility or outpatient program greatly 
increases their chances of recovery from their addiction. I have 
several friends and acquaintances who are recovered heroin addicts. 
They all say that they were fortunate to have family that cared enough 
to get them into treatment at a time they were in crisis.
    Also, there is unfortunately still a prejudice by some in the 
health care field toward addicts. Therefore, it is important to educate 
health care providers, as well as the public, that addiction is a 
medical condition that often has a mental health component, and that 
both must be addressed as part of a successful treatment protocol.
                            senator baldwin
    Question. Three Wisconsin health systems in the Fox Valley area 
have partnered to create a program, called Catalpa, to help improve 
timely access to mental health care for pediatric patients. This 
program provides crisis care for children and their families within 24 
hours and then regular, followup care, led by a multidisciplinary team 
in the partnership network. At its main center, wait times have dropped 
from 54 days to about 5 days.
    Dr. Hepburn and Ms. Blake, this is just one example of a program 
working to address the mental health services crisis facing our 
children. What steps would you recommend the Federal Government take to 
help solve our mental health provider shortage and improve access for 
children throughout the country?
    Answer. From your description, Catalpa appears to have all of the 
components for a successful program. Access to emergency and crisis 
intervention immediately with referrals and followup resources are the 
key to a successful community based program. Regarding the mental 
health provider shortage, I would suggest examining the incentives the 
Federal Government has provided to address the ongoing shortage of 
registered nurses. These include the Title VIII Nursing Workforce 
Development programs that make scholarships and loans available to 
nurses and nursing students through a variety of grants. Similar 
programs and incentives could be made available for those embarking on 
a career in mental health and psychiatry.
    In addition, the expanded use of technology should be considered. 
We have a shortage of neurologists in my area, so we use telemedicine 
to evaluate patients for possible interventions for stroke symptoms and 
it works well. Telepsychiatry is in use in some hospitals across the 
United States.
    Also, policymakers should expand the role of nurse practitioners to 
allow them, with proper education and certification, to evaluate 
patients with mental health issues for the need for inpatient 
treatment. Frequently, in my area, we are told that the delay in having 
a patient transferred to a psychiatric facility is due to the 
psychiatrist not being available to review their records and evaluate 
them for intake. Allowing advanced practice registered nurses to review 
and evaluate patients would save both time and money.

 Response by William W. Eaton, Ph.D. to Question of Senator Whitehouse

    Question. Along with a bipartisan group of senators including 
Senators Portman, Klobuchar, and Ayotte, I introduced a bill earlier 
this year called the Comprehensive Addiction and Recovery Act (S. 524). 
The bill authorizes a series of grants to States and other eligible 
entities to promote an integrated approach--including prevention, 
treatment, law enforcement tools, and recovery support--to the 
substance abuse epidemic we are facing across the Nation. Among other 
things, the bill tries to increase screening for, and treatment of, co-
occurring mental health and substance use disorders in the juvenile and 
criminal justice systems and elsewhere.

    Do you support the objectives set forth in S. 524? How would 
enactment of S. 524 improve your organization's ability to help address 
the opioid abuse epidemic?
    What additional tools might you like to see at your disposal to 
address the overlap between substance abuse and mental health issues?
    Answer. I support the objectives set forth in S. 524. Thanks for 
the opportunity to comment.

    [Whereupon, at 11:31 a.m., the hearing was adjourned.]

                                  [all]
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