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[Senate Hearing 114-716]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 114-716
 
   MENTAL HEALTH AND SUBSTANCE USE DISORDERS IN AMERICA: PRIORITIES, 
                     CHALLENGES, AND OPPORTUNITIES

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                                   ON

    EXAMINING MENTAL HEALTH AND SUBSTANCE USE DISORDERS IN AMERICA, 
         FOCUSING ON PRIORITIES, CHALLENGES, AND OPPORTUNITIES

                               __________

                            OCTOBER 29, 2015

                               __________

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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

                  Evan Schatz, Minority Staff Director

              John Righter, Minority Deputy Staff Director

                                  (ii)

  

                            C O N T E N T S

                               __________

                               STATEMENTS

                       THURSDAY, OCTOBER 29, 2015

                                                                   Page

                           Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, 
  Labor and Pensions.............................................     1
Murray, Hon. Patty, a U.S. Senator from the State of Washington..     3
Collins, Hon. Susan M., a U.S. Senator from the State of Maine...    28
Franken, Hon. Al, a U.S. Senator from the State of Minnesota.....    29
Cassidy, Hon. Bill, a U.S. Senator from the State of Louisiana...    30
Murphy, Hon. Christopher, a U.S. Senator from the State of 
  Connecticut....................................................    33
Isakson, Hon. Johnny, a U.S. Senator from the State of Georgia...    35
Warren, Hon. Elizabeth, a U.S. Senator from the State of 
  Massachusetts..................................................    36
Scott, Hon. Tim, a U.S. Senator from the State of South Carolina.    38
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin..    40

                               Witnesses

Enomoto, Kana, M.A., Acting Administrator, Substance Abuse and 
  Mental Health Services Administration, Rockville, MD...........     6
    Prepared statement...........................................     8
Macrae, Jim, M.A., M.P.P., Acting Administrator, Health Resources 
  and Services Administration, Rockville, MD.....................    14
    Prepared statement...........................................    16
Insel, Thomas, M.D., Director, National Institute of Mental 
  Health, Bethesda, MD...........................................    19
    Prepared statement...........................................    20

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Response by Kana Enomoto to questions of:
        Senator Enzi.............................................    44
        Senator Isakson..........................................    44
        Senator Hatch............................................    46
        Senator Roberts..........................................    46
        Senator Murray...........................................    51
        Senator Casey............................................    55
        Senator Franken..........................................    55
        Senator Whitehouse.......................................    63
        Senator Warren...........................................    64

                                 (iii)

  

   MENTAL HEALTH AND SUBSTANCE USE DISORDERS IN AMERICA: PRIORITIES, 
                     CHALLENGES, AND OPPORTUNITIES

                              ----------                              

                       THURSDAY, OCTOBER 29, 2015

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:05 a.m. in 
room SD-430, Dirksen Senate Office Building, Hon. Lamar 
Alexander, chairman of the committee, presiding.
    Present: Senators Alexander, Isakson Collins, Scott, 
Cassidy, Murray, Franken, Baldwin, Murphy, 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 is on her way and has suggested that we go 
ahead. She will be here very shortly. She and I will each have 
an opening statement, and then we will introduce our panel of 
witnesses. After our witness testimony, Senators will have 5 
minutes of questions.
    Today, we are discussing the important issue of mental 
health and substance use disorders. Mental illness affects a 
great many Americans. According to a 2013 report from the 
National Survey of Drug Use and Health, nearly one in five 
adults over the age of 26 reported suffering from a mental 
illness. In that same time period, nearly 1 in 10 Americans 
between the age of 12 and 17 reported having at least one major 
depressive episode.
    In Tennessee, about one in five adults reported having a 
mental illness in 2013. That is more than a million Tennesseans 
according to the Tennessee Department of Mental Health and 
Substance Abuse Services. About 5 percent had a severe mental 
illness. That is nearly a quarter of a million Tennesseans. 
About 41,000 Tennesseans had a major depressive episode.
    Already, there is an enormous response to try to help at 
the State level by the private sector and by the Federal 
Government. As a former Governor, I know firsthand that States 
have traditionally been on the forefront with their Departments 
of Mental Health, their treatment facilities, and community-
based services.
    States have had the primary responsibility for behavioral 
health and provide community-based programs that often include 
counseling, case management, social work, and provide 
screening, diagnosis, and treatment for children.
    In the private sector there are many private hospitals, 
nonprofits, mental health professionals, and others working to 
help those in need. Efforts from the private sector totaled 
about $67 billion in 2009 or 39 percent of total dollars spent 
for behavioral health, which includes mental health and 
substance use services. Government spending totaled about $105 
billion in 2009 or 61 percent of total dollars spent, and that 
includes Medicare, Medicaid, and other efforts on the local, 
State, and Federal levels.
    One role the Federal Government plays is through its 
agencies. The Substance Abuse and Mental Health Services 
Administration is an agency within the U.S. Department of 
Health and Human Services. Its role in supporting mental health 
programs is relatively small compared to the responsibility 
that States have and the role of Medicaid, but it is also 
critically important.
    SAMHSA supports States, behavioral health care providers, 
and others by improving the availability and quality of 
prevention and treatment services, collecting behavioral health 
data, and sharing best practices through evidence-based 
initiatives. SAMHSA should be looked at as a leader in the 
field. It receives about $3.5 billion each year through the 
discretionary appropriations process.
    The biggest Government role is the amount of money spent 
through Medicaid, which is a Federal-State partnership. In 
2009, Medicaid spending on behavioral health totaled about $44 
billion, 26 percent of total dollars spent. These Medicaid 
dollars can be used to provide care from community behavioral 
health professionals, inpatient or residential treatment for 
children and seniors with mental illness, and help those with 
severe mental illnesses get the prescription drugs they need.
    In Tennessee last year, State spending for mental health 
and substance use disorder programs and services totaled about 
$555 million. Two hundred and thirty million of that was spent 
on the State's share of Medicaid related to mental health. 
Three hundred and twenty-five million was spent by the State 
Department of Mental Health.
    The Federal Government's Medicare spending also plays a 
role financing 7 percent of total expenditures to treat mental 
illness at about $21 billion a year. These Medicaid dollars 
could help seniors get prescription drugs they need or can be 
used for doctors' appointments, outpatient therapy, and a small 
fraction of inpatient treatment for mental health.
    This Federal support is a significant amount of money. One 
question for today is should we be spending these dollars 
differently? Or should we be spending more dollars, and if so, 
in what ways?
    There are calls for the Federal Government to act 
differently to help those in need and to do more. Twice, the 
Senate Health Committee has passed different versions of the 
Mental Health Awareness and Improvement Act that Senator Murray 
and I have cosponsored once last Congress and again just last 
month. This bipartisan legislation supports suicide prevention 
and intervention programs. It helps train teachers and school 
personnel to recognize and understand mental illness, works to 
reduce the stigma against those struggling with mental illness, 
and helps children recover from traumatic events. I hope the 
Mental Health Awareness and Improvement Act will be passed by 
the Senate and become law this Congress.
    Other Senators are also tackling the issue of how to 
improve mental health treatment. Senators Cassidy and Murphy 
have a mental health bill they introduced in August. Senator 
Franken has introduced a couple of pieces of legislation. 
Senator Cornyn has a bill that he is working on in the 
Judiciary Committee.
    I expect to see the HELP Committee report additional 
legislation in the coming months that better supports States in 
addressing mental health and substance use disorder in their 
communities. We will see what the Judiciary Committee might be 
doing, what the Finance Committee might be doing on Medicaid 
and Medicare and see about putting all those together to better 
coordinate our response toward mental health.
    Today's hearing, though, is really to better understand the 
Federal Government's role in mental health treatment and how it 
can help States like Tennessee meet such high need and deliver 
such critical care.
    I am looking forward to hearing from today's witnesses. Are 
there administrative things we can do, programmatic things? Are 
we putting up roadblocks? How are our Federal programs working?
    I am particularly interested in your thoughts on mental 
health research. One of the most important things the Federal 
Government does is research that enables individuals to move 
forward in this big, complex society of ours. We are not such 
good managers. Sometimes, we are not even good regulators. The 
research that we have funded and encouraged has enabled 
enormous breakthroughs in our country, so I would like your 
thoughts on the state of mental health research as well.
    Senator Murray.

                  Opening Statement of Senator Murray

    Senator Murray. Mr. Chairman, thank you so much. Thank you 
to all of our colleagues who are joining us today, and I 
especially want to thank the witnesses who are taking time to 
join us today. Dr. Insel, I especially want to welcome you as 
you prepare to move on, and thank you for your tremendous 
amount of work. We all appreciate what you have been able to do 
and will continue to do, I am sure.
    Over the last few years, we have made real progress toward 
building a health care system that works for our families and 
communities, and puts their needs first. As I have often said, 
there is a lot more we can and must do, and this is especially 
true when it comes to addressing mental health and substance 
abuse.
    Today, nearly 1 in 5 people in our country experience 
mental illness in a given year. Far too many of them do not 
receive treatment when they need it. In fact, there is on 
average nearly a decade between someone showing signs of mental 
illness and getting treatment. Suicide is the second-highest 
cause of death for those ages 15 through 34, and nearly a 
quarter of the State prison population has struggled with 
mental illness.
    These statistics are deeply disturbing, but the stories 
behind them are even more tragic: a stigma that keeps too many 
of them from seeking help even though it could make all the 
difference; treatable illnesses dealt with by a judge rather 
than a clinician; millions of lives, especially young lives, 
that are cut short. All of us have heard these stories far too 
often and they demand action.
    Members of this committee on both sides of the aisle have 
made clear that improving our mental health system is a 
priority. In particular, I do appreciate the bipartisan work 
that Senators Murphy and Cassidy are doing to push for 
progress. I am looking forward to hearing from my colleagues 
and our witnesses about the ideas they have to strengthen our 
mental health system and prevent more of our parents and our 
friends and our neighbors, students, and children from falling 
through the cracks.
    There are a few challenges I am focused on in particular. 
Our mental health workforce should serve as the foundation on 
which a strong, supportive system is built, but today, far too 
many communities have inadequate access to mental health 
professionals. In fact, half of all U.S. counties today do not 
have a single psychiatrist, psychologist, or social worker. 
That means that for far too many patients and their families, 
it is unclear to them where they should turn for help.
    We need to make sure communities have access to trained 
professionals who can intervene and treat and support those 
struggling with mental illness. This is critical to ensuring 
that mental health is seen as just as much a priority as 
physical health. Is integrating primary care with mental health 
care.
    Too often, patients' mental and physical health are 
considered separately, and that silo means that, on the one 
hand, patients with serious mental health illness who need 
primary care may not get it when they need it, and on the other 
hand, that any signs of mental illness may go undetected. That 
presents a real threat to patients with mental illness, 
especially those with chronic physical health problems or 
substance abuse disorders that can make mental illness worse.
    I am very interested in a collaborative model being 
practiced in my home State of Washington where mental health 
professionals provide telehealth consulting to primary care 
physicians in communities that lack access to mental health 
care. That model helps patients receive treatment that is 
mindful of both their mental and physical health.
    As we work to improve detection and treatment of mental 
illness, we need to prioritize crisis response. I have heard 
too many stories in my State and across the country of patients 
with mental illness held for days and weeks in emergency rooms 
or even solitary confinement waiting for treatment. That is 
unacceptable. Communities need the resources to respond quickly 
and appropriately when someone is clearly in or approaching a 
crisis because without those resources, intervention often 
comes too late or not at all.
    Suicide prevention must be a priority. Each year, suicide 
takes tens of thousands of lives in our country and shatters 
countless others. Like many here today, I have been deeply 
concerned about the high rate of suicide among our veterans.
    We also need to take a close look at what is driving those 
tragic decisions among other populations. I was very concerned 
to learn, for example, recent studies show young adults from 
tribal communities are at especially high risk. I know the 
Administration is very focused on suicide prevention, and our 
committee recently passed the Mental Health Awareness and 
Improvement Act, which reauthorized the critical Garrett Lee 
Smith Suicide Prevention Act. I look forward to continuing our 
working together to put an end to this crisis in every one of 
our communities.
    Finally, it is critical to acknowledge that in order to 
confront the challenges we have talked about 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 that helps enhance 
our understanding of and ability to effectively treat mental 
illness. It also means raising awareness so those struggling do 
not feel they have to struggle alone.
    I saw the stigma early on when I interned in a VA 
psychiatric ward when I was a college student. There were 
veterans returning from the Vietnam War at the time with severe 
psychological trauma, and they were told they were simply 
shell-shocked.
    Over the course of my career, I have heard time and again 
from veterans and constituents from all walks of life that 
stigma and stereotypes are a crushing burden to bear on top of 
illness. Those struggling with mental illness should be treated 
with compassion and respect and dignity, and they should have 
the resources they need to live and work in their communities. 
That is something that I will continue to be very focused on.
    Mr. Chairman, I am very pleased that we are having this 
discussion today, and I look forward to working with you on a 
bipartisan basis to strengthen our mental health system and 
give more patients and families the opportunity to lead 
healthy, fulfilling lives.
    I am confident that everyone in this room has a story about 
a friend or a loved one or a classmate or a coworker who faced 
mental illness. The harsh reality is these challenges impact 
all of us, and I hope our efforts here today are a step on the 
way to overcoming them.
    Thank you again for everyone participating in this.
    Mr. Chairman, thank you for holding this hearing, and I 
look forward to this conversation.
    The Chairman. Thank you, Senator Murray.
    This is a subject that has broad interest among members of 
the committee, as is indicated by the number of Senators here 
today, and I would say to our committee members, this is yet 
another bipartisan hearing, which means that Senator Murray and 
I have agreed on the subject and we have agreed on the 
witnesses, and we have agreed that this is the best way to get 
a result. We have had very few partisan hearings during this 
year, and that has been good for our committee.
    I am pleased to welcome three witnesses to our hearing 
today. First, thanks to each of you for taking the time to be 
here. You have busy jobs overseeing important agencies.
    First, we will hear from Kana Enomoto. Ms. Enomoto is 
acting administrator of the Substance Abuse and Mental Health 
Services Administration. That means she oversees four centers, 
the one for mental health, one for substance abuse prevention, 
substance abuse treatment, and behavioral health statistics and 
quality. She has been serving at SAMHSA since 1998 in several 
positions.
    Our second witness is Mr. Jim Macrae. He is acting 
administrator of the Health Resources and Services 
Administration, often called HRSA. He joined HRSA in 1992 and 
has since held several positions. He has received several 
awards for his service and leadership as a HRSA administrator.
    Next, we will hear from Dr. Tom Insel. He is director of 
the National Institute of Mental Health, which is part of the 
National Institutes of Health, and leads research related to 
mental health. He has held that position since 2002. He is 
focused on genetics and biology of mental disorders. Before 
that, he was professor of psychiatry at Emory University. He 
will be leaving his position soon to pursue research outside of 
NIH, but we appreciate his service, and we especially 
appreciate his willingness to come here before his departure to 
tell us, bluntly and in plain English, exactly what we ought to 
be doing.
    [Laughter.]
    It is safe to do it now.
    [Laughter.]
    Senator Collins. I think it will be safe to do it in 2 
days.
    [Laughter.]
    The Chairman. We will begin, Mrs. Enomoto.

    STATEMENT OF KANA ENOMOTO, M.A., ACTING ADMINISTRATOR, 
  SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION, 
                         ROCKVILLE, MD

    Ms. Enomoto. Chairman Alexander, Ranking Member Murray, and 
members of the committee, thank you so much for holding this 
hearing on a topic that is critical to the physical, emotional, 
and economic health of the Nation. Thank you for inviting me to 
testify today.
    It is a great honor to talk to you about the State of 
America's mental health system, a topic that is very near and 
dear to my heart, and I would like to discuss with you some of 
the initiatives of SAMHSA, delivering impact for American 
people every day.
    As my colleague Dr. Insel will also tell you, 
neuropsychiatric disorders are the leading cause of disability 
burden in the United States. More than one in four Social 
Security Disability Insurance recipients are enrolled due to a 
mental illness, and individuals with serious mental illness, or 
SMI, make up over 40 percent of those people who are dually 
eligible for Medicare and Medicaid.
    Yet at $147 billion per year in 2009, mental health 
spending accounted for only 6 percent of health care spending, 
and substance use spending accounted for only 1 percent. The 
burden of untreated or undertreated behavioral health 
conditions on the labor market, criminal justice system, 
families, schools, communities, and others, is tremendous.
    In this context, SAMHSA's mental health budget, 
approximately $1 billion in 2015, is a small, as noted, but 
important influencer of the Nation's mental health system. To 
accomplish our mission, SAMHSA cannot work alone. Therefore, 
another one of our--a key role is to lead by coordinating 
mental health services and programs across HHS and with other 
Federal departments.
    One main example of this is that SAMHSA co-chairs the HHS 
Behavioral Health Coordinating Council, which was established 
in 2010. The chief goal of that group is to provide a platform 
for knowledge exchange and then to ensure that behavioral 
health issues are handled collaboratively and without 
duplication of effort across the department.
    Across Federal Government, SAMHSA works closely with 
Department of Defense, Education, HUD, Justice, Veterans 
Affairs, and the Social Security Administration. We work on a 
wide range of issues spanning prevention, treatment, and 
recovery support for people with or at risk of mental illness.
    To achieve our mission, we administer a combination of 
competitive and formula grant programs. I will share a few 
examples. First, the Community Mental Health Services Block 
Grant is a flexible spending source for State mental health 
authorities. States use these limited but significant funds, 
about $500 million, to support planning, administration 
evaluation, educational activities, and direct service delivery 
for adults with serious mental illness and children with 
serious emotional disturbance.
    Starting in fiscal year 2014, Congress required States to 
set aside 5 percent of those funds for evidence-based programs 
that addressed the needs of individuals with early serious 
mental illness, including psychotic disorders. These programs 
are informed by the NIMH RAISE project and similar research, 
and an initial evaluation tells us that this set-aside funding 
is helping States increase access to early intervention 
programs and reduce the duration of untreated psychosis and 
other psychiatric conditions.
    This news is so exciting. The ability to pre-empt long-term 
disability for hundreds of thousands of young Americans is at 
our fingertips.
    At SAMHSA we also recognize that financing is a central 
piece of the puzzle. We work closely with our colleagues at CMS 
and across HHS to align payment systems to encourage high-
quality care for adults and children with both mental illnesses 
and substance use disorders.
    Just last week, thanks to Congress's passage of legislation 
in 2014, SAMHSA was pleased to award section 223 planning 
grants to 24 States to certify community behavioral health 
clinics, establish a prospective payment system, and prepare to 
participate in a 2-year Medicaid demonstration program. The 
ability to transform the way community services are reimbursed 
could help us turn the corner on key provider quality and 
capacity issues.
    Youth suicide prevention is also a critical area of focus, 
and evaluation of the Garrett Lee Smith tribal, State grant 
program demonstrated that counties with GLS suicide-prevention 
activities saw lower rates of suicide and suicide attempts.
    Unfortunately, too many communities and too many people are 
unaware of the major public health crisis that we are facing 
around suicide. While we are making progress in the area of 
youth suicide, middle-age and older adult suicide continues to 
climb, and SAMHSA's suicide prevention grants, as currently 
funded, limit their focus to youth and adolescents. Yet the 
data show that almost 9 out of 10 people who die by suicide are 
over age 24. To move the needle, we must expand the scope of 
our prevention efforts.
    As my fellow acting administrator Jim Macrae well knows, no 
conversation about any aspect of health care can be complete 
without talking about workforce needs. Together, the Affordable 
Care Act and the Mental Health Parity and Addiction Equity Act 
are expected to expand parity protections and coverage of 
behavioral health services to over 60 million Americans.
    Thus, the current infrastructure and workforce will need 
additional capacity in order to help have space for the people 
who need treatment who will now begin to seek it. The expanded 
workforce includes prescribing and non-prescribing professions, 
including psychiatrists, social workers, counselors, 
therapists, and peers.
    We are grateful to HRSA for its collaboration in the area 
of behavioral health workforce, we are grateful to the NIMH for 
its outstanding work in mental health research, and we are 
thankful to the committee for allowing me to share highlights 
of SAMHSA's portfolio.
    If I may take liberty for just a few more seconds, I would 
like to dedicate a couple of moments to express appreciation to 
my colleague Dr. Tom Insel. Tom, you are a powerful leader for 
our field. You have been steadfast in your vision that mental 
health research, whether at the level of the genome or the 
globe, should be of no less rigor or quality than any other 
field of research. Your commitment to bringing the best science 
to bear on any policy or program question has been invaluable 
to SAMHSA.
    Thank you for your service. We at SAMHSA stand ready to 
help you achieve the tenfold impact of your next innovation. 
Thank you.
    [The prepared statement of Ms. Enomoto follows:]
                Prepared Statement of Kana Enomoto, M.A.
    Chairman Alexander, Ranking Member Murray, and members of the 
Senate Health, Education, Labor, and Pensions Committee, thank you for 
inviting me to testify at this important hearing. I am pleased to 
testify along with Dr. Insel from the National Institute of Mental 
Health (NIMH) and Acting Health Resources and Services Administration 
(HRSA) Administrator Macrae on the state of America's mental health 
system and, specifically, to discuss some of the Substance Abuse and 
Mental Health Services Administration's (SAMHSA) initiatives related to 
mental health. I understand that the committee will be holding a series 
of hearings on behavioral health issues, including potentially one on 
the opioid public health crisis; however, this testimony will focus on 
SAMHSA's roles as it relates to reducing the impact of mental illness 
on America's communities.
                                 samhsa
    As you are aware, SAMHSA's mission is to reduce the impact of 
substance abuse and mental illness on America's communities. SAMHSA 
envisions a Nation that acts on the knowledge that:

     Behavioral health is essential to health;
     Prevention works;
     Treatment is effective; and
     People recover.

          leadership in coordinating mental health activities
    In partnership with the Assistant Secretary for Health, SAMHSA co-
chairs the Department of Health and Human Services (HHS) Behavioral 
Health Coordinating Council (BHCC), which was established in 2010. The 
Council coordinates behavioral health policy activities within HHS, by 
facilitating information sharing and collaboration across the 
Department. Its chief goals are to share information and ensure that 
all behavioral health issues are handled collaboratively and without 
duplication of effort across the department. BHCC subcommittees 
include, but are not limited to Serious Mental Illness, Primary Care/
Behavioral Health Integration, and Trauma and Early Interventions.
    SAMHSA and NIMH co-chair the Subcommittee on Serious Mental Illness 
(SMI) charged with improving research, treatment, and supports for 
Americans with serious mental illness. The subcommittee has established 
several goals for the near term to engage people with SMI in treatment 
especially through early intervention approaches and prevention of 
mental illness; promoting higher quality of mental health care and 
medical care to reduce morbidity and mortality with incentives for 
evidence-based practices and performance measurement; and improving 
availability of community-based supports and prospects for long-term 
recovery.
    SAMHSA works with a number of other Departments--including the 
Departments of Defense, Education, Housing and Urban Development, 
Justice, and Veterans Affairs, as well as the Social Security 
Administration (SSA)--both directly and through Federal workgroups to 
promote mental health. For example, SAMHSA leads the Federal Working 
Group on Suicide Prevention as well as the Federal Partners Committee 
on Women and Trauma.
        prevalence of behavioral health conditions and treatment
    It is estimated that almost half of all Americans will experience 
symptoms of a behavioral health condition--mental illness or substance-
use disorder--at some point in their lives. Yet, today, less than one 
in five children and adolescents with diagnosable mental health 
problems receive the treatment they need.\1\ And according to data from 
SAMHSA's 2014 National Survey on Drug Use and Health (NSDUH), an 
estimated 45 percent of the almost 44 million adults with any mental 
illness and 69 percent of the almost 10 million adults with serious 
mental illness received mental health services in the past year. Only 
11 percent of those with diagnosable substance use disorders receive 
needed treatment.\2\
---------------------------------------------------------------------------
    \1\ Unmet Need for Mental Health Care Among U.S. Children: 
Variation by Ethnicity and Insurance Status Sheryl H. Kataoka, M.D., 
M.S.H.S.; Lily Zhang, M.S.; Kenneth B. Wells, M.D., M.P.H., Am J 
Psychiatry 2002;159:1548-55. 10.1176/appi.ajp.159.9.1548
    \2\ Substance Abuse and Mental Health Services Administration, 
Results from the 2011 National Survey on Drug Use and Health: Mental 
Health Findings, NSDUH Series H-45, HHS Publication No. (SMA) 12-4725. 
Rockville, MD: Substance Abuse and Mental Health Services 
Administration, 2012.
---------------------------------------------------------------------------
    When persons with mental health conditions or substance use 
disorders do not receive the proper treatment and supportive services 
they need, crisis situations can arise affecting individuals, families, 
schools, and communities. We need to do more in regard to early 
identification by helping communities understand and implement 
prevention approaches we know can be effective in stopping issues from 
developing in the first place.
            overview of the nation's mental health spending
    According to SAMHSA's National Expenditures for Mental Health 
Services & Substance Abuse Treatment 1986-2009, at $147 billion, mental 
health spending accounted for 6.3 percent of all health spending in 
calendar year 2009, while substance use spending at $24 billion 
accounted for approximately 1 percent.
    Although most of the funding for services for people with mental 
illnesses comes through Federal insurance programs, especially 
Medicaid, in addition to funding a portion of the Nation's mental 
health treatment, SAMHSA's programs are also critical in supporting the 
coordination of services for people with mental illnesses and improving 
the quality and accessibility of these services and supports.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                            samhsa's budget
    In fiscal year 2015, approximately 30 percent of SAMHSA's total 
funding was appropriated or designated for mental health programs and 
activities, with the remainder directed to substance use programs and 
activities. This distribution of funding between substance use and 
mental health has been consistent for the last 5 years. Of the SAMHSA 
fiscal year 2015 mental health funding, $1.079 billion supports 
prevention, treatment and recovery support programs and activities 
within SAMHSA's Center for Mental Health Services (CMHS). In addition 
to funding within the CMHS appropriation, approximately $67 million of 
SAMHSA's Health Surveillance and Program Support (HSPS) appropriation 
is used for mental health activities.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                      examples of samhsa programs
    To inform mental and substance use disorder policy, SAMHSA conducts 
national surveys and analyses. For example, the National Survey on Drug 
Use and Health (NSDUH), which SAMHSA administers, serves as the 
Nation's primary source for information on the incidence and prevalence 
of substance use and mental disorders and related health conditions. 
NSDUH provides key data such as the fact that 1 in 10 adolescents (11.4 
percent) had a major depressive episode in the past year.\3\
---------------------------------------------------------------------------
    \3\ Substance Abuse and Mental Health Services Administration, 
Results from the 2014 National Survey on Drug Use and Health: Mental 
Health Findings, NSDUH Series H-45, HHS Publication No. (SMA) 12-4725. 
Rockville, MD: Substance Abuse and Mental Health Services 
Administration, 2015.
---------------------------------------------------------------------------
    To accomplish its work, SAMHSA administers a combination of 
competitive programs and formula-based programs, including the two 
block grant programs. SAMHSA also collects performance and evaluation 
data to measure impact and mitigate risk. Below are a few examples of 
SAMHSA mental health programs.
Community Mental Health Services Block Grant (MHBG)
    Approximately 45 percent ($482.57 million) of CMHS funding is 
directed toward the MHBG, which provides services and supports for 
adults with serious mental illness and children with serious emotional 
disturbance, an analogous definition of serious mental illness for 
children. The MHBG is a flexible spending source that supports a range 
of services, infrastructure, and capacity efforts for State mental 
health authorities that serve the over seven million individuals 
affected by these conditions. States use these limited but significant 
funds to support planning, administration, evaluation, educational 
activities, and direct service delivery. Services typically include 
those not covered by Medicaid or other funding sources, such as 
rehabilitation services, crisis stabilization, case management, 
supported employment and housing, jail-diversion programs, and services 
for special populations. By law, States are not allowed to use these 
funds for inpatient services.
    Starting in fiscal year 2014, the Congress--through annual 
appropriations legislation--required States to set aside 5 percent of 
their MHBG funds to support evidence-based programs that address the 
needs of individuals with early serious mental illness, including 
psychotic disorders. These programs are informed by the NIMH-supported 
Recovery After an Initial Schizophrenia Episode (RAISE) project and 
similar research. The majority of individuals with serious mental 
illness experience their first symptoms during adolescence or early 
adulthood, and there are often long delays between the initial onset of 
symptoms and a person receiving treatment. The consequences of delayed 
treatment can include loss of family and social supports, reduced 
educational achievement, disruption of employment, substance use, 
increased hospitalizations, and reduced prospects for long-term 
recovery.
    The 5-percent set-aside equals $24.2 million and is allocated to 
States consistent with the block grant formula. It supports 
implementation of promising models that seek to address treatment of 
serious mental illness at an early stage through reducing symptoms and 
relapse rates, and preventing deterioration of cognitive function in 
individuals suffering from psychotic illness. SAMHSA has collaborated 
closely with NIMH in providing guidance and technical assistance to 
States regarding effective programs funded by this set-aside. SAMHSA 
and NIMH are also working with the Office of the Assistant Secretary 
for Planning and Evaluation (ASPE) within HHS on an initial examination 
of how States are utilizing the set-aside funding.
Certified Community Behavioral Health Clinics
    SAMHSA has also been working closely with Centers for Medicare & 
Medicaid Services (CMS) and ASPE to improve the quality and 
coordination of care for adults with serious mental illness, children 
with serious emotional disturbance, and those with long-term and 
serious substance use disorders, through implementation of the 
demonstration program for Certified Community Behavioral Health Clinics 
established by the Protecting Access to Medicare Act (also known as 
section 223). Last week, SAMHSA awarded planning grants to 24 States to 
certify community behavioral health clinics, establish a prospective 
payment system to reimburse clinics for services to Medicaid 
recipients, and to prepare to participate in a 2-year demonstration 
program. States will certify agencies meet certain criteria developed 
by SAMHSA, such as staffing requirements, standards for availability 
and accessibility of services, including prompt evaluation and crisis 
management services, and that provide a comprehensive scope of services 
including extensive requirements for enhanced care coordination. In 
addition, community behavioral health clinics will be required to 
report on quality measures that will include care coordination. An 
evaluation of the demonstration program will be conducted by ASPE in 
close collaboration with SAMHSA and CMS.
Transforming Lives through Supported Employment
    For people with serious mental illness, employment contributes to 
stability and independence. Unfortunately, many of these individuals 
are unemployed. In fiscal year 2014, SAMHSA initiated a new $5.6 
million program, Transforming Lives through Supported Employment, to 
promote the employment of people with serious mental illness, and this 
initiative includes collaboration with the Department of Education, the 
Department of Labor, and States, among others. Transforming Lives 
through Supported Employment grants help people with serious mental 
illnesses discover paths of self-sufficiency and recovery rather than 
disability and dependence. These grants support States that establish a 
supported-employment program in two communities within the State, 
secure sustainable funding for on-going community supportive employment 
services, establish a permanent training program using in-person and 
virtual platforms, and collect and analyze program data. The goal of 
the program is to increase the number of individuals with serious 
mental health obtain gainful employment.
Suicide Prevention
    Suicide is a serious public health crisis--approximately 41,000 
Americans die by suicide each year.\4\
---------------------------------------------------------------------------
    \4\ American Association of Suicidology. (2015). USA Suicide 2013 
Official Final Data.
---------------------------------------------------------------------------
    SAMHSA has many initiatives that help prevent suicide and suicide 
attempts. For example, the National Suicide Prevention Lifeline (1-800-
273-TALK), which works with the Department of Veterans' Affairs, has 
helped more than six million people since its inception in January 
2005. SAMHSA also received funding for the first time in fiscal year 
2014 for Tribal Behavioral Health Grants that aim to reduce suicide and 
substance misuse and abuse among American Indian/Alaska Native youth.
    The Garrett Lee Smith Memorial Act State and Tribal grant program 
is SAMHSA's largest suicide prevention program and is focused on 
reducing suicide and suicide attempts among youth and young adults 10 
to 24 years old. Evaluation of the impact of these grants has shown 
that counties that have implemented grant-supported suicide prevention 
activities have lower rates of youth suicide and non-fatal suicide 
attempts than matched counties without such activities in the year 
following the suicide prevention activities.
    At the same time, SAMHSA's suicide prevention grant programs, as 
currently funded, almost exclusively focus on reducing suicide among 
youth and adolescents. However, data shows that in 2013, the latest 
year for which suicide completion data is available, 87 percent of 
individuals who died by suicide were over age 24.\5\ As the country 
moves forward in addressing this public health crisis, more attention 
must be paid to addressing suicide among adults. One particular 
promising model for doing so is Zero Suicide, an initiative to 
eliminate suicides among individuals under care within health and 
behavioral health systems. This initiative has seen promising results 
such as at Centerstone, a non-profit community-based behavioral-health-
care provider based in Tennessee.
---------------------------------------------------------------------------
    \5\ CDC's WISQARS website ``Fatal Injury Reports,'' http://
www.cdc.gov/wisqars/index.html.
---------------------------------------------------------------------------
                 improving the behavioral health system
Workforce
    The Affordable Care Act builds on the Mental Health Parity and 
Addiction Equity Act of 2008 to extend Federal parity protections to 62 
million Americans.\6\ The current behavioral healthcare infrastructure 
and workforce, however, will need additional capacity to absorb the 
influx of patients with behavioral health needs who now have the 
coverage to seek treatment. Research has identified the need for 
additional prescribing and non-prescribing behavioral health 
professionals, including psychiatrists, social workers, counselors, and 
therapists.\7\
---------------------------------------------------------------------------
    \6\ http://aspe.hhs.gov/health/reports/2013/mental/rb_mental.cfm.
    \7\ KC Thomas, et al. County-Level Estimates of Mental Health 
Professional Shortage in the United States, Psychiatric Services, 
60:1323-28, 2009.
---------------------------------------------------------------------------
    The President's fiscal year 2016 Budget includes $77.7 million for 
SAMHSA for behavioral health workforce programs. This includes $10.0 
million for a new program entitled Peer Professional Workforce 
Development. These grants would provide tuition support and further the 
capacity of community colleges to develop and sustain behavioral health 
paraprofessional training and education programs. Overall, this new 
program would result in adding approximately 1,200 peer professionals 
to the current behavioral health workforce. The Budget also includes 
$56 million for the SAMHSA-HRSA Behavioral Health Workforce Education 
and Training (BHWET) Grant Program to expand the behavioral health 
workforce.
    This additional funding would add approximately 5,600 health 
professionals to the workforce. SAMHSA's collective workforce efforts 
will help add several thousand new professionals to the workforce each 
year. In addition, SAMHSA, HRSA, and CMS engaging in ongoing work to 
promote integration of behavioral health and primary care services 
which will also help improve access to care.
Crisis Systems
    In addition to building the behavioral health workforce, there is 
also a pressing need for more accessible and appropriate community 
crisis systems. In 2010, 2.2 million hospitalizations and 5.3 million 
emergency department visits involved a diagnosis related to a mental 
illness.\8\
---------------------------------------------------------------------------
    \8\ Agency for Healthcare Research and Quality. (2010). Healthcare 
Cost and Utilization Project (HCUP). Custom data query. Retrieved from 
http://www.hcup-us.ahrq.gov/.
---------------------------------------------------------------------------
    Such services as 24-hour crisis stabilization, warm lines that 
provide peer support for people living with mental illness to help 
prevent a crisis, peer crisis services, mobile crisis services, short-
term crisis residential services, and community-based crisis followup 
services can help avoid unnecessary and expensive hospitalization and 
emergency department visits and provide improved outcomes for adults 
and children with behavioral health conditions. However, many 
communities encounter challenges in funding and coordinating these 
systems.
    People with serious mental illnesses and their families often find 
themselves facing crisis situations in which the only available care is 
overworked emergency departments often ill-equipped to address the 
needs of such individuals. That is why the President's fiscal year 2016 
Budget includes $10 million in new funding for a demonstration program 
designed to help States and communities test the best way to structure, 
fund, and deliver services to prevent, de-escalate, and followup after 
behavioral health-related crises to assure the individual, family, 
community, and delivery systems are adequately supported. These grants 
can help in coordinating effective crisis response with ongoing 
outpatient services and supports.
                               conclusion
    SAMHSA has made important strides in the prevention, treatment, and 
recovery supports for mental and substance use disorders. However, we 
know that more work remains. We look forward to continuing to work with 
the Congress on these efforts. I would be pleased to answer any 
questions that you may have.

    The Chairman. Thank you, Ms. Enomoto.
    Mr. Macrae.

 STATEMENT OF JIM MACRAE, M.A., M.P.P., ACTING ADMINISTRATOR, 
  HEALTH RESOURCES AND SERVICES ADMINISTRATION, ROCKVILLE, MD

    Mr. Macrae. Thank you, Chairman. Thank you, Chairman 
Alexander, Ranking Member Murray, and all members of the 
committee.
    I am pleased to join my colleagues today to share with you 
what we are doing at the Health Resources and Services 
Administration to address the mental health needs in our 
Nation.
    As my written testimony conveys, HRSA is the primary 
Federal agency within the Department of Health and Human 
Services charged with improving access to health care services 
for people who are medically underserved, including those who 
are low-
income, live in rural communities, and vulnerable populations.
    We carry out our work in partnership with community-based 
organizations, State and local governments, and academic 
institutions, among others.
    HRSA's programs and its over 3,000 grantees provide 
affordable health care to tens of millions of Americans across 
the country, and we train thousands of health care 
professionals.
    One key area of our work has been on expanding behavioral 
health within primary care settings, as Ranking Member Murray 
mentioned. HRSA recognizes that primary care can often serve as 
a critical access point for those suffering from mental health 
issues, as some individuals often feel less stigma and feel 
more comfortable discussing and sharing their mental health 
concerns with their primary care providers.
    For example, in our Community Health Center program, 
depression and anxiety are ranked third and fifth as the most 
important reasons why people come to the health center, to a 
primary care setting. Health centers have also shared with us 
that by having a mental health provider actually on staff and 
co-located in that primary care setting, that their other 
primary care providers actually feel more comfortable and are 
better able to address the mental health care needs of their 
patients and better able to coordinate their care.
    To support this type of integration that we have heard from 
our health centers that they need, HRSA has invested more than 
160 million in the past year to expand the mental health 
capacity at health centers nationwide. We have done this 
through either establishing new mental health services or 
expanding existing services. Through those investments, we hope 
to provide care to an additional 1 million people suffering 
from mental illness.
    In addition, HRSA, with SAMHSA, jointly supports the Center 
for Integrated Health Solutions. This is a national technical 
assistance resource that helps health centers and other HRSA 
safety-net providers on the mechanics of actually integrating 
primary care and mental health and substance abuse services, 
how best to actually do it.
    One of the other keys, though, to addressing access to 
mental health care services is of course building a strong 
mental health workforce so that individuals can see a provider 
when they need one. The National Service Corps, which is one of 
our key programs, provides scholarships and repays the loans 
for those who are practicing in underserved communities either 
in primary care, dental, or behavioral health. In return, they 
agree to provide service for 2 to 4 years in designated areas 
of the country that need them most.
    In particular, the National Health Service Corps places a 
number of mental health and behavioral health providers, 
including psychiatrists at facilities in high-need mental 
health profession shortage areas. Since 2008, the number of 
mental health providers in the National Health Service Corps 
has increased from about 800 to well over 3,300 in 2015.
    In addition, our agency also supports a number of health 
workforce training programs that help increase the mental 
health training of our providers nationwide. For example, since 
2014, in collaboration with SAMHSA, HRSA has administered the 
Behavioral Health Workforce Education and Training grant 
program as part of the Administration's Now Is the Time 
initiative. These grants have enabled more than 1,100 master's-
level social workers, psychologists, and marriage and family 
therapists, as well as more than 950 mental health 
paraprofessionals to receive clinical training in academic 
years 2014 and 2015.
    We also, though, recognize that mental health is in 
particular a need in our rural communities. In particular, 
despite the need per capita, there are fewer mental health 
providers in rural communities compared to urban ones, and 
through the use of telehealth, telemedicine, as well as health 
information technology, HRSA has expanded support for providers 
in rural and isolated areas of the country to improve patient 
care.
    Last, we also recognize that mental health and substance 
use disorders are also common in persons living with HIV and 
AIDS and are critical barriers to both retention in care, as 
well as adherence to treatment. Through our Ryan White 
programs, we support training for our providers to screen, 
identify, and treat those with substance abuse or mental health 
needs.
    In conclusion, HRSA shares the goal of ensuring a strong 
primary care health system that supports quality mental health 
and substance abuse services in particular by integrating an 
expanded capacity of behavioral health into primary care, 
training more behavioral health providers, and utilizing new 
methods and technologies such as telemental health to reach 
underserved populations.
    We look forward to continuing our work with your committee, 
as well as others in Congress, to address the Nation's mental 
health and substance abuse needs.
    Thank you.
    [The prepared statement of Mr. Macrae follows:]
            Prepared Statement of James Macrae, M.A., M.P.P.
    Good morning Chairman Alexander, Ranking Member Murray, and members 
of the committee. I am Jim Macrae, Acting Administrator at the Health 
Resources and Services Administration (HRSA). I appreciate the 
opportunity to join my colleagues today and share with you some of the 
activities underway at HRSA to address the mental health needs of our 
Nation. In appearing before you, I bring the perspective from my 
vantage point as the Acting Administrator at HRSA as well as the former 
head of HRSA's Bureau of Primary Health Care. In both of these 
capacities, I have had the privilege of leading important primary 
health care activities to improve the health of individuals and 
families throughout the United States.
    HRSA is the primary Federal agency within the Department of Health 
and Human Services (HHS) and across the Federal Government charged with 
improving access to health care services for people who are medically 
underserved because of their economic circumstances, geographic 
isolation, or serious chronic disease, among other factors. To address 
these issues, HRSA works through partnerships with States, community-
based organizations, academic institutions, health care providers, and 
others to improve our primary care infrastructure, strengthen the 
health care workforce, and achieve health equity. HRSA works closely 
with the Substance Abuse and Mental Health Services Administration 
(SAMHSA), the National Institutes of Health and other HHS divisions 
through the Department's Behavioral Health Coordinating Council (BHCC) 
and other mechanisms to collaborate on initiatives related to mental 
health.
    This committee has a long history of leadership on and engagement 
in a number of HRSA programs and activities including the Community 
Health Centers, the National Health Service Corps, the Federal Office 
of Rural Health Policy, and the Ryan White HIV/AIDS Program. To begin, 
I want to thank members of this committee and your colleagues in the 
Senate and the House of Representatives for the bipartisan, bicameral 
efforts that you undertook earlier this year in passing the Medicare 
Access and CHIP Reauthorization Act of 2015. That legislation extended 
funding for, among other things, the Health Center Program and National 
Health Service Corps. The President's Budget for these and other HRSA 
programs also provide important health resources focused on primary 
health care, including the integration of mental health services.
    Since 2008, HRSA's efforts to increase access to mental health 
services have included the following:

     With the support of the Affordable Care Act and other 
investments, health centers have added more than 3,000 mental health 
providers to expand access to mental health services in primary care 
settings. As a result of these efforts, today, health centers employ 
nearly 6,400 mental health providers.
     With the support of the Affordable Care Act and other 
investments, the number of mental health providers in the National 
Health Service Corps (who receive scholarships and loan repayment for 
practicing in underserved areas) has quadrupled, increasing from 
approximately 800 in 2008 to more than 3,300 in 2015.
     In response to the President and Vice President's Now is 
the Time Initiative, since fiscal year 2014, HRSA has worked with 
SAMHSA to help expand the mental health workforce by supporting 
clinical training of approximately 1,156 additional masters level 
social workers, psychologists and marriage and family therapists and 
960 mental health paraprofessionals.
           supporting primary care mental health integration
    Across HRSA, there are a range of programs and resources that 
support primary and mental health care integration.
Health Center Program
    One particular area of focus of our primary and mental health care 
integration has been within our Health Center Program. Health centers 
provide an accessible, affordable, and dependable source of primary 
care for uninsured and medically underserved patients. HRSA supports 
nearly 1,300 health centers operating approximately 9,000 health center 
service sites across the country, and approximately 50 percent of them 
serve rural communities. Today, 1 in 14 people receive care at a HRSA-
supported health center, including 1 in 7 people living at or below the 
Federal poverty level. For the 23 million patients served annually, 
health centers provide comprehensive, high-quality, cost-effective 
primary health care regardless of patients' ability to pay.
    Increasingly, as recognized providers of primary health care 
services, health centers are also experiencing a greater demand for 
mental health services. Some health center patients have shared with 
their providers that they often feel more comfortable discussing and 
sharing their mental health concerns within a primary care setting 
rather than a traditional mental health facility. For example, in 2014, 
according to health center program data, depression and anxiety 
disorders, including post-traumatic stress disorder (PTSD), ranked 
third and fifth, respectively, among the top 10 reasons that a patient 
visited a health center. In 2014, we invested $166 million in 
Affordable Care Act funding to expand mental health capacity at health 
centers, which is expected to establish or expand services to more than 
one million people nationwide. As a result, even though the statute 
does not require health centers to have a mental health specialist on 
staff to be eligible for health-center funding, health centers 
increasingly have opted to integrate mental health providers into their 
primary care operations, or have built strong relationships with other 
community mental health providers. In addition, health centers have 
shared with us that by having a mental health provider on staff and co-
located in the primary care setting, their other primary care providers 
are better able to address the mental health needs of their patients 
and coordinate their care.
    Integrating mental health care into primary care presents a unique 
opportunity for patients and providers. Approximately 84 percent of 
health centers nationwide currently provide mental health treatment and 
counseling onsite or under contracts with other providers, resulting in 
more than 6.2 million mental health visits in 2014.
    In addition, HRSA and SAMHSA jointly support the Center for 
Integrated Health Solutions (CIHS), which offers direct technical 
assistance and a wide-range of resources to health centers and other 
HRSA-funded safety-net providers regarding integrating mental health 
and substance use services within primary care settings. For example, 
CIHS has developed a rural-specific, interactive, 8-hour training 
course that presents an overview of mental illnesses and substance use 
disorders in the United States. The course introduces participants to 
risk factors and warning signs of mental health or addiction problems, 
builds understanding of their impact, and reviews treatments.
               building a strong mental health workforce
    While the Health Center Program focuses on delivering patient care, 
HRSA's health workforce programs target the education, training, and 
distribution of a highly skilled primary care workforce through health 
professions training, curriculum development, and scholarship and loan 
repayment programs. HRSA's efforts support a diverse and culturally 
competent primary care workforce that delivers high quality, efficient 
health care. A key program focus at HRSA is to increase access for 
Americans to a mental health care provider through its health 
professional training programs.
    HRSA supports several grant programs that work to expand access to 
mental health services by increasing the number of mental health 
providers. HRSA has made important investments with workforce program 
funding supporting the training of mental health disciplines, including 
physicians, nurses, and physician assistants with psychiatric 
specialties.
    HRSA's National Health Service Corps (NHSC) programs provide 
scholarships and repay educational loans for primary care, dental, and 
mental and behavioral health clinicians who agree to 2, 3 or 4 years of 
service in designated areas of the country that need them most. 
Overall, NHSC clinicians provide preventive and primary care to 
approximately 9.7 million people.
    Over one in three NHSC clinicians--3,371 out of 9,683--provided 
mental and behavioral health services. This includes psychiatrists, 
psychiatric physician assistants, psychiatric nurse practitioners, 
health service psychologists, licensed clinical social workers, 
licensed professional counselors, marriage and family therapists, and 
psychiatric nurse specialists. Of these 3,371 mental health providers 
in the NHSC field, 1,231 (37 percent) are in rural communities, and 116 
(3 percent) are practicing in Indian Health Service facilities.
    In addition to NHSC programs, HRSA supports a wide range of other 
workforce training programs to increase the number of mental health 
providers. The Mental and Behavioral Health Education and Training 
Programs support increased access to services by training providers. 
Between academic year 2012-13 and 2014-15, the number of students 
supported by stipends increased from 86 to 214. The Scholarships for 
Disadvantaged Students (SDS) program increases diversity in the health 
workforce by providing grants to eligible health professions schools to 
award scholarships to students from disadvantaged backgrounds, 
including those pursuing degrees in mental health. In academic year 
2014-15, there were 411 students pursuing mental health disciplines who 
received SDS scholarships The Geriatrics Workforce Enhancement Program 
also supports various mental health disciplines, including 
psychiatrists, psychologists, social workers, psychiatric nurses, 
professional counselors, marriage and family therapists and substance 
abuse counselors.
    Additionally, since fiscal year 2014, HRSA has worked with SAMHSA 
to administer the Behavioral Health Workforce Education and Training 
grant program (BHWET) as part of the Administration's Now is the Time 
Initiative. As I noted in my testimony earlier, these grants help 
expand the mental health workforce by supporting clinical training of 
approximately 1,156 additional masters level social workers, 
psychologists and marriage and family therapists and 960 mental health 
paraprofessionals in academic year 2014-15. Through this initiative, 
HRSA and SAMHSA have partnered to address critical needs for mental 
health professionals and paraprofessionals trained to address the needs 
of transition-age youth (ages 16-25). The President's fiscal year 2016 
Budget proposes $56 million for the BHWET program, an increase of $21 
million over fiscal year 2015.
         strengthening mental health activities in rural areas
    Per capita, there are fewer mental health providers (ranging from 
counselors to psychologists) in rural as compared to urban communities. 
To support access to mental health services in rural communities and to 
better reach populations in rural settings, HRSA has expanded support 
for providers in rural and isolated areas to improve patient care 
through the use of telehealth, telemedicine and health information 
technology. These emerging health tools utilize electronic information 
and telecommunications technologies to support long-distance clinical 
health care, patient and professional health-related education, public 
health, and health administration.
    HRSA's Telehealth Network Grant Program supports efforts to 
demonstrate how telehealth technologies can be used through telehealth 
networks to increase the number of communities that have access to 
pediatric, adolescent, and adult mental health services. As a result of 
$5.4 million in funding from this program in fiscal year 2015, more 
than 300 communities now have access to telehealth services. In 
addition, the Flex Rural Veterans Health Access Program provides grants 
to States to support telehealth and health information exchange 
projects to enhance care for veterans in rural areas.
    HRSA also funds a number of community-based grant programs designed 
to improve access to and coordination of care in rural communities, 
with roughly one quarter of the fiscal year 2015 projects focusing on 
mental health care.
         meeting mental health needs in other hrsa initiatives
    The Ryan White HIV/AIDS Program (RWHAP) is an example of where we 
see contributions to addressing the mental-health needs of the Nation 
in other programs as well.
    Mental illness occurs in persons living with HIV/AIDS at almost 
twice the rate as in the general population. Mental health and 
substance-use disorders are common in persons living with HIV/AIDS and 
are critical barriers to retention in care and adherence to treatment. 
In fact, for the RWHAP, mental health represents the third-highest 
category of visits and approximately 14 percent of clients received 
mental health services. In Parts A and B, where we have available 
expenditure data, approximately $32 million was spent on mental health 
services in fiscal year 2013. Of those who received mental-health 
services, 78 percent were virally suppressed and 88 percent were 
retained in care; overall, 79 percent of clients served by the RWHAP 
are virally suppressed and 81 percent are retained in care.
                               conclusion
    Mr. Chairman, we share the goal of ensuring a strong Federal 
primary health care system that supports quality mental health care. As 
I have outlined today, with our multifaceted strategy, we are employing 
many effective tools to maximize our reach and provide quality and 
accessible mental health services and mental health care professionals. 
HRSA will continue to seek ways to enhance these services and related 
resources in partnership with our colleagues across the Department and 
with communities across the country. I appreciate the opportunity to 
testify today.

    The Chairman. Thank you, Mr. Macrae.
    Dr. Insel.

 STATEMENT OF THOMAS INSEL, M.D., DIRECTOR, NATIONAL INSTITUTE 
                 OF MENTAL HEALTH, BETHESDA, MD

    Dr. Insel. Thank you, first, for holding this hearing. It 
is really, for me, important to see the priority that both of 
you have put on this issue and how several members of the 
committee have expressed their passion. Some of this I know, 
Senator Murray, as you said, comes from every one of us having 
a personal experience, so this is something that we care about.
    Mr. Chairman, you nicely laid out that this is very much a 
partnership between Federal, State, and private sector, and how 
we do that going forward has got to be better than what we have 
done up until now.
    I am not going to read my testimony. You have that. I want 
to simply add to the comments from my colleagues here that 
there is a lot going on that is worth talking about. Senator 
Murray, as you kind of clicked through your list of the issues 
around the workforce, the opportunity of collaborative care, 
what we are doing for crisis response, certainly suicide and 
the stigma, as you have heard, we are already, as a partnership 
here across these agencies, very engaged on those issues.
    It is incredibly important to have HRSA here because we 
have to always remember that the brain is part of the body, and 
that mental health issues need to be thought of as health 
issues. Many people with serious mental illness also have 
issues around diabetes and metabolic syndrome and tremendous 
number of problems with the fact that about two-thirds of them 
are smokers and so they develop chronic pulmonary disease. One 
of the reasons why people with a serious mental illness die 10 
years early, as you mentioned, is not because of suicide so 
much as of all the chronic and often very expensive medical 
complications that they develop for a variety of reasons.
    These are huge health issues that need all of our 
attention, and we need to be thinking about how to address them 
in the most impactful way.
    As you have all mentioned and understand, we at NIMH, as 
part of NIH, we are the research part of this. We do the 
science and the science is changing as well, partly because of 
the BRAIN initiative, partly because of our understanding that 
we can now address mental disorders as brain disorders. We have 
the tools to be able to change the way we do diagnosis to be 
able to develop new kinds of treatments. Most of all, the 
understanding that we have here very much coming out of our 
experience with heart disease and cancer, that if we are going 
to bend the curve, we have to detect early, intervene early. We 
have to really move upstream.
    So much of our past focus in this area has been on people 
with chronic disability. That is obviously very important for 
us to do. The future has to be much better detection and much 
earlier intervention, and then developing, as Kana mentioned, 
these comprehensive treatments for early psychosis to ensure 
that someone who does actually develop psychosis, if we fail to 
preempt it, gets the best chance for recovery.
    The focus on reducing suicide, as you mentioned, Senator 
Murray--this is just an area that has not budged. In the same 
time when homicide has come down 50 percent, we are still 
looking at about the same suicide rate we had in 1990. We have 
got to understand how to address that in a better way.
    My last comment, as many of you have noted, this is my swan 
song, and I am in some ways wistful about leaving the position. 
I am leaving a lot of people I care about so much and certainly 
want to continue to focus on these issues now from the private 
sector.
    I did want to share with you what I mentioned in my 
testimony, which is--in leaving, as I look back on what have I 
learned--what are the sort of abiding truths that I would carry 
with me and want to convey, there are really two factors that 
come back to me over and over again.
    One is that we can do much, much better than we are doing 
currently with the diagnostics and the treatments we have. 
There is just in this field, more than in many areas of 
medicine, just this unconscionable gap between what we know and 
what we do. Both of you spoke to that a little bit in your 
opening statements. We are all aware of that from our own 
communities or from our own personal experience. This is a huge 
gap that we have got to figure out how to bridge.
    At the same time I want to stress that, as with heart 
disease and cancer and maybe even more so in this area, we do 
not know enough. We just do not know enough to ensure that 
everyone will recover, to have a cure for every one of the 
problems that people with schizophrenia, depression, bipolar 
disorder, or autism develop. These are really difficult, 
complicated problems, and we have got to invest not only in 
better services but also in more science. It is going to be 
essential that we understand these disorders at a deeper level 
if we are going to come up with the treatments that are going 
to be most effective.
    I think we can do it. In my career I have seen this happen 
for childhood cancer. I have seen it happen for heart disease 
where the mortality has come down 63 percent. I have seen it 
happen recently for AIDS with the mortality coming down 50 
percent. We have not seen those numbers budge for morbidity and 
mortality in this area, and that is something we have got to 
tackle in a new way, fresh ideas, better science, and closing 
this gap to take the things we know today and make sure that is 
what we are actually doing in practice.
    Thank you very much. I look forward to your questions.
    [The prepared statement of Dr. Insel follows:]
                Prepared Statement of Thomas Insel, M.D.
    Mr. Chairman and members of the committee: I am Thomas R. Insel, 
M.D., Director of the National Institute of Mental Health (NIMH) at the 
National Institutes of Health, an agency in the Department of Health 
and Human Services (HHS). Thank you for this opportunity to provide an 
update on the state of mental health research at NIMH, with a 
particular focus on our efforts to address serious mental illness, and 
our efforts to discover, develop, and disseminate new treatments for 
these brain disorders. I will review the scope of mental disorders in 
the United States and their impact on public health, and I will outline 
examples of NIMH's research efforts designed to address this challenge.
                 public health burden of mental illness
    NIMH is the lead Federal agency for research on mental health, with 
a mission to transform the understanding and treatment of mental 
illnesses through basic and clinical research. The burden of mental 
illness is enormous. In the United States, an estimated 10 million 
American adults (approximately 4.1 percent of all adults) suffer from a 
serious mental illness (SMI) each year,\1\ including conditions such as 
schizophrenia, bipolar disorder, and major depression. According to a 
recent Global Burden of Disease study, neuropsychiatric disorders are 
the leading cause of disability in the United States in 2010, 
accounting for 18.7 percent of all years of life lost to illness, 
disability, or premature death (Disability-adjusted Life Years, or 
DALYs).\2\ The personal, social, and economic costs associated with 
these disorders are tremendous. Suicide is the second leading cause of 
death among American youth and young adults aged 15-34, and accounts 
for the loss of more than 41,000 American lives across all age groups 
each year, more than triple the number of lives lost to homicide and 
more than the deaths from breast cancer.\3\ \4\ A cautious estimate 
places the direct and indirect financial costs associated with mental 
illness in the United States at well over $300 billion annually, and it 
ranks as the third most costly medical condition in terms of overall 
health care expenditure, behind only heart conditions and traumatic 
injury.\5\ \6\ Even more concerning, the burden of illness for mental 
illnesses is projected to sharply increase, not decrease, over the next 
20 years.\7\
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    \1\ Substance Abuse and Mental Health Services Administration. 
Results from the 2014 National Survey on Drug Use and Health: Mental 
Health Detailed Tables: http://www.samhsa.gov/data/sites/default/files/
NSDUH-MHDetTabs2014/NSDUH-MHDetTabs2014
.htm (accessed October 2015).
    \2\ US Burden of Disease Collaborators. The state of US health, 
1990-2010: burden of diseases, injuries, and risk factors. JAMA, 
310(6): 591-608, 2013.
    \3\ Centers for Disease Control and Prevention (CDC), National 
Center for Injury Prevention and Control. Web-based Injury Statistics 
Query and Reporting System (WISQARS): www.cdc.gov/ncipc/wisqars 
(accessed October 2015).
    \4\ CDC, National Violent Death Reporting System, 2012. WISQARS: 
www.cdc.gov/ncipc/wisqars (accessed October 2015).
    \5\ Insel TR. Assessing the economic cost of serious mental 
illness. Am J Psychiatry. 2008 Jun;165(6):663-5.
    \6\ Soni A. The Five Most Costly Conditions, 1996 and 2006: 
Estimates for the U.S. Civilian Noninstitutionalized Population. 
Statistical Brief #248. July 2009. Agency for Healthcare Research and 
Quality, Rockville, MD.
    \7\ Bloom DE, Cafiero ET, Jane-Llopis E, Abrahams-Gessel S, Bloom 
LR, Fathima S, Feigl AB, Gaziano T, Mowafi M, Pandya A, Prettner K, 
Rosenberg L, Seligman B, Stein A, Weinstein C. The Global Economic 
Burden of Non-communicable Diseases. Geneva, Switzerland: World 
Economic Forum, 2011.
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    NIMH-supported research has found that Americans with SMI die up to 
10 years earlier than the general population.\8\ The low rates of 
prevention, detection, and intervention for chronic medical conditions 
and their risk factors among people with SMI contribute to significant 
illness and earlier death. Two-thirds or more of adults with SMI 
smoke;\9\ over 40 percent are obese (60 percent for women);\10\ \11\ 
and metabolic syndrome is highly prevalent, especially in women.\12\ In 
addition, people with SMI frequently have co-occurring substance use 
disorders, and practitioners are often called upon to address mental 
illness and substance use problems simultaneously. Approximately 5 
percent of individuals with schizophrenia will die by suicide during 
their lifetime, a rate 50-fold greater than the general population.\13\
---------------------------------------------------------------------------
    \8\ Walker ER, McGee RE, & Druss BG. (2015). Mortality in mental 
disorders and global disease burden implications: a systematic review 
and meta-analysis. JAMA Psychiatry, 72(4), 334-41.
    \9\ Goff DC, Sullivan LM, McEvoy JP, et al. A comparison of 10-year 
cardiac risk estimates in schizophrenia patients from the CATIE study 
and matched controls. Schizophrenia Res. 2005;80(1):45-53.
    \10\ Allison DB, Fontaine KR, Heo M, et al. The distribution of 
body mass index among individuals with and without schizophrenia. J 
Clin Psych. 1999;60(4):215-20.
    \11\ McElroy SL. Correlates of overweight and obesity in 644 
patients with bipolar disorder. J Clin Psych. 2002;63:207-13.
    \12\ McEvoy JP, Meyer JM, Goff DC, et al. Prevalence of the 
metabolic syndrome in patients with schizophrenia: Baseline results 
from the (CATIE) schizophrenia trial and comparison with national 
estimates from NHANES III. Schizophrenia Res. 2005;80(1):19-32.
    \13\ Hor K. & Taylor M. Suicide and schizophrenia: a systematic 
review of rates and risk factors. J Psychopharmacol. 2010;24(4S): 81-
90.
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          delays in receiving treatment--and the consequences
    While most people with SMI eventually make contact with a health 
care professional, delays in seeking care can be extensive.\14\ In a 
recent NIMH-funded study of first episode psychosis (FEP) in 22 States, 
the average duration of untreated psychosis was approximately 74 
weeks--six times the World Health Organization's (WHO's) standard for 
initiating early psychosis services (i.e., 12 weeks). The period 
immediately after the onset of psychosis when young people lose touch 
with reality and experience hallucinations and delusions is a critical 
timeframe for intervention.
---------------------------------------------------------------------------
    \14\ Wang PS, Berglund PA, Olfson M, Kessler RC. Delays in initial 
treatment contact after first onset of a mental disorder. Health Serv 
Res. 2004 Apr;39(2):393-415.
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          how nimh is addressing this public health challenge
    In the past, we viewed mental illnesses as behavioral conditions 
defined by their symptoms. Increasingly, research reveals that mental 
illnesses are brain disorders, with specific symptoms rooted in 
abnormal patterns of brain activity. In brain disorders, as a general 
rule, symptoms represent a late stage of a process that began years 
earlier. To achieve the greatest impact, our interventions should be 
focused on earlier, pre-symptomatic phases of illness, with a goal of 
preempting the disability of a chronic behavioral syndrome. Moving 
forward, NIMH aims to support research on earlier detection and earlier 
treatment. NIMH has a three-pronged research approach to achieve this 
aim: (1) optimize treatment to improve the trajectory of illness in 
people who are already experiencing the symptoms of SMI; (2) preempt 
the transition from the pre-syndromal (prodromal) phase to the acute 
phase of illness; and (3) define the risk architecture of SMI in order 
to move from preemption to prevention. As examples of the approach, 
here are four NIMH efforts on these fronts in psychosis:

    (1) NIMH is continuing to support the Recovery After an Initial 
Schizophrenia Episode (RAISE) initiative, a large-scale research 
project to explore whether using early and aggressive treatment will 
reduce the symptoms and prevent the gradual deterioration of 
functioning that is characteristic of chronic schizophrenia. RAISE 
began with two studies examining different aspects of coordinated 
specialty care (CSC) treatments for people who are experiencing FEP in 
a range of clinics, so that the results are relevant to community 
treatment settings throughout the country. RAISE investigators have 
recently shown that CSC for FEP improves psychopathology, work and 
school functioning, and quality of life compared to usual community 
care. Importantly, improvements are greatest among individuals with a 
shorter duration of untreated psychosis, suggesting that both the 
timing and content of treatment are critical.\15\ Moreover, in 2014, 
the Congress allocated a 5-percent set-aside to the Substance Abuse and 
Mental Health Services Administration (SAMHSA) for the Mental Health 
Block Grant program to develop early psychosis treatment programs, and 
further directed SAMHSA to collaborate with NIMH in developing input 
for States regarding evidence-based FEP treatment models such as CSC. 
An initial evaluation of the set-aside program has shown increased 
access to services. An upcoming, more comprehensive evaluation will 
measure key symptomatic and functional outcomes from the set-aside 
evaluation. Building on the lessons learned from studying CSC, NIMH 
plans to link a series of clinics to launch the Early Psychosis 
Intervention Network (EPINET), an effort that will create a learning 
health care system within early psychosis treatment settings, in order 
to improve the effectiveness of early psychosis treatment.
---------------------------------------------------------------------------
    \15\ Addington J, et al., Duration of untreated psychosis in 
community treatment settings in the United States. Psych Serv. 2015 
October (in press).
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    (2) NIMH is continuing to fund research directed at the prodromal 
phase of schizophrenia, the stage just prior to full psychosis. A 
consortium of eight clinical research centers (North American Prodrome 
Longitudinal Study, or NAPLS) are using neuroimaging, 
electrophysiology, neurocognitive testing, hormonal assays, and 
genomics, to improve our ability to predict who will convert to 
psychosis, and to develop new approaches to pre-emptive intervention. 
NAPLS investigators recently reported that clinical factors such as 
disorganized communication, suspiciousness, compromised verbal memory, 
and declining social function indicate an increased risk for conversion 
to psychosis among adolescents.\16\
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    \16\ Cornblatt BA, Carrion RE, Auther A, McLaughlin D, Olsen RH, 
John M, Corell CU. Psychosis prevention: a modified clinical high-risk 
perspective from the recognition and prevention (RAP) program. Am J 
Psychiatry. 2015 Oct;172(10):986-94.
---------------------------------------------------------------------------
    (3) NIMH's initiative, Research to Improve the Care of Persons at 
Clinical High Risk for Psychotic Disorders,\17\ has funded seven 
clinical trials to expand knowledge regarding effective interventions 
during the prodromal phase, to build an evidence base to support high-
quality community care focused on preempting psychosis and improving 
long-term outcomes.
---------------------------------------------------------------------------
    \17\ http://grants.nih.gov/grants/guide/rfa-files/RFA-MH-14-
211.html.
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    (4) The NIMH-funded Psychiatric Genomics Consortium (PGC), the 
largest ever genomic dragnet of any psychiatric disorder--involving 
over 200,000 samples from 80 institutions across 25 countries--has 
identified overlapping genetic risk among schizophrenia, bipolar 
disorder, and depression for pathways affecting the immune system and 
brain cell communication.\18\ These findings may help lead the way 
toward the development of treatments for such SMIs.
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    \18\ The Network and Pathway Analysis Subgroup of the PGC. 
Psychiatric genome-wide association study analyses implicate neuronal, 
immune and histone pathways. Nat Neurosci. 2015 Feb;18(2):199-209.

    In addition to these and other similar efforts, NIMH collaborates 
with other HHS agencies and other public and private partners to 
evaluate and promote SMI programs and to improve access to early 
intervention treatment for psychosis. For example, together with 
SAMHSA, NIMH co-chairs the HHS Behavioral Health Coordinating Council's 
Subcommittee on SMI. The subcommittee is charged with coordinating 
research, treatment, and supports for Americans with SMI, through 
collaborative, action-oriented approaches across HHS, and by 
contributing to the development of the Secretary's action plan to 
address the needs of Americans living with SMI. Another important 
example of trans-HHS--and, in fact, trans-Departmental--collaboration 
is the Brain Research through Advancing Innovative Neuro-
technologies (BRAIN) Initiative.\19\ NIMH and the National Institute of 
Neurological Disorders and Stroke (NINDS) are co-leading the BRAIN 
Initiative, with participation from 10 NIH Institutes and Centers, the 
Defense Advanced Research Projects Agency (DARPA), the National Science 
Foundation (NSF), the U.S. Food and Drug Administration (FDA), and the 
Intelligence Advanced Research Projects Activity (IARPA). The BRAIN 
Initiative is accelerating the development and application of 
innovative technologies to the creation of new tools for decoding the 
language of the brain.
---------------------------------------------------------------------------
    \19\ http://www.nih.gov/science/brain/index.htm.
---------------------------------------------------------------------------
    In addition to our work on psychosis, NIMH also supports a range of 
mental health research on autism spectrum disorder, attention deficit-
hyperactivity disorder, eating disorders, mood disorders, and post-
traumatic stress disorder (PTSD). NIMH is partnering with other NIH 
Institutes and other Federal agencies as part of the National Research 
Action Plan to develop biomarkers, define the pathophysiology, and 
create new treatments for PTSD. NIMH-funded researchers recently 
reported that a computerized attention-control training program 
significantly reduced combat veterans' preoccupation with--or avoidance 
of--threat and attendant PTSD symptoms.\20\
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    \20\ Badura-Brack AS, Naim R, Ryan TJ, Levy O, Abend R, Khanna MM, 
McDermott TJ, Pine WSD, Bar-Haim Y. Effect of attention training on 
attention bias variability and PTSD symptoms: randomized controlled 
trials in Israeli and US combat veterans. Am J Psychiatry, 2015 July.
---------------------------------------------------------------------------
    Moreover, NIMH has played a key role in developing a prioritized 
research agenda for suicide prevention.\21\ The Institute funded a 
series of ongoing grants that address the six key questions that 
organize the research agenda, and developed a $12 million initiative to 
solicit research to improve screening and risk stratification for 
suicidal youth who present for care in emergency departments. NIMH has 
also recently announced a partnership with the NIH Office of Behavioral 
and Social Sciences Research and the National Institute of Justice to 
support the Suicide Prevention for at-Risk Individuals in Transition 
(SPIRIT) study.\22\ This study will evaluate the effectiveness of an 
evidence-based Safety Planning Intervention for reducing suicide events 
in the year following incarceration among persons recently released 
from jail. NIMH is working with SAMHSA and other Federal partners, 
including the Departments of Veterans Affairs and Defense, to address 
the issue of suicide among middle-aged adults, a demographic at high 
risk for suicide.
---------------------------------------------------------------------------
    \21\ http://actionallianceforsuicideprevention.org/sites/
actionallianceforsuicideprevention.org/files/Agenda.pdf.
    \22\ See: http://www.nimh.nih.gov/news/science-news/2015/embracing-
the-spirit-of-reducing-suicide.shtml.
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            preemption: the future of mental health research
    Research has taught us to detect diseases early and to intervene 
quickly to preempt later stages of illness. This year we will avert 1.1 
million deaths from heart disease because we have not waited for a 
heart attack to diagnose and treat coronary artery disease.\23\ The 
100,000 young Americans who will experience FEP this year will join 
over two million with schizophrenia.\24\ Our best hope of reducing 
mortality from schizophrenia, other SMIs, and other brain disorders 
will come from realizing that just like other medical disorders, we 
need to diagnose and intervene before the symptoms become manifest. 
This is our call to action.
---------------------------------------------------------------------------
    \23\ Vital Statistics of the United States, CDC/National Center for 
Health Statistics. (2011, August). Age-adjusted Death Rates for 
Coronary Heart Disease (CHD). Retrieved January 23, 2013, from http://
www.nhlbi.nih.gov/news/spotlight/success/conquering-cardiovascular-
disease.html.
    \24\ Calculated from McGrath J., Saha S., Chant D., & Welham J. 
Schizophrenia: a concise overview of incidence, prevalence, and 
mortality. Epidem Rev, 2008; 30, 67-76.
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    Mr. Chairman, as you know, this is my final hearing in front of 
your committee as the Director of NIMH. After 13 years of public 
service at NIMH, I have lost count of the number of times I have 
testified in front of this committee. It has been an honor to serve at 
NIMH and to work with members of this committee. I leave with great 
pride in what we have accomplished and with great anticipation for the 
potential of research to improve the lives of people with mental 
illnesses. My tenure at NIMH has convinced me of two abiding truths 
about the state of mental health care in our Nation. First, we can do 
much better delivering the treatments we have today. Second, today's 
treatments are not good enough. Too many people are untreated, and too 
many who are treated get better, but do not get well. Going forward, I 
hope the committee understands that families challenged by mental 
illness need both the immediate benefit of high-quality services, as 
well as a future of better services from high-quality science.

    The Chairman. Thank you, Dr. Insel.
    We will now have a round of 5-minute questions.
    Dr. Insel, did you say that two-thirds of those with mental 
health were smokers?
    Dr. Insel. With serious mental illness----
    The Chairman. With serious----
    Dr. Insel [continuing]. Particularly with schizophrenia. 
The numbers even climb higher than two-thirds.
    The Chairman. Is that a lot higher than for people with 
diseases other than mental health?
    Dr. Insel. Yes, absolutely. It is not higher than when you 
look at males with lung cancer. They have very high rates of 
smoking as well. As a group, I do not think there is any 
medical demographic group that high rate of smoking that you 
see in people with serious mental illness.
    And I might add that it is not just that they are smokers 
but the way in which people with chronic schizophrenia smoke is 
actually quite different than the way other people smoke. They 
consume more cigarettes, they inhale further, and they are 
much, much more likely to develop chronic respiratory disease 
as a result. It is a huge comorbidity, a huge medical public 
health problem.
    We have launched, and SAMHSA has worked with us on many of 
these efforts, these new programs to get people with 
schizophrenia who are chronically ill to stop smoking. It is 
doable but it is a tough slog. It is hard for them to stop, and 
there have always been questions about whether nicotine in some 
ways is a way of self-medicating. We are not really quite--the 
science there is not quite baked.
    The Chairman. Dr. Frieden says that smoking still is the 
No. 1 killer in the United States.
    Let us talk about research just a little bit. Last time you 
were here you talked about findings from your RAISE study, 
Recovery After an Initial Schizophrenia Episode. You have done 
some work since then. What have you found out? What have we 
done to translate those findings into practice?
    Dr. Insel. Right. RAISE, Recovery After Initial 
Schizophrenia Episode, was a program in 36 sites across 22 
States, community sites to try to understand whether we can do 
better.
    With what we know today, so taking a whole range of 
interventions from medication, family pscyhoeducation, 
providing what is called resilience training, looking at both 
ACT teams and supported housing, supported employment, all of 
these things that we have known about for years, putting them 
together in a package and then delivering them, the results for 
the primary outcomes were just published about 2 weeks ago, and 
they are very positive. It looks great.
    The most disheartening part of that story was that amongst 
the nearly 400 subjects that were part of this study, the mean 
duration of untreated psychosis was 74 weeks, which is just 
stunning. It is hard to believe.
    What we are doing now is moving this forward into 
communities, working very closely with SAMHSA. Kana mentioned 
the importance of putting this, what is now called coordinated 
specialty care, into the State system. It is part of this 
mental health block grant add-on. There are nearly 32 States 
that have programs based on this.
    We are looking to even expand it further through something 
called the Early Psychosis Intervention Network, which will 
create a learning health care system that will actually allow 
us to have a single electronic health system and a coordinated 
care effort that can incrementally improve as we go.
    It is a high priority for the Institute, a high priority 
for SAMHSA. It is a great story of teamwork across the agencies 
as well.
    The Chairman. You referred to your BRAIN initiative. What 
are the most significant findings so far there? Is this part of 
the overall BRAIN initiative that Dr. Collins has talked to us 
about at NIH that he hopes to be able to do?
    Dr. Insel. It is. Dr. Collins has--we sometimes joke he has 
become a born-again neuroscientist. Though he was trained in 
another area, he has discovered how spectacular neuroscience is 
today, and that of almost any area in science, this is a place 
where we have so much traction and so much excitement.
    The BRAIN initiative launched by the President in April 
2013 has moved forward. We now have funded our second year, 
about $84 million that we have invested for over 100 projects 
across the country. What we are----
    The Chairman. Just within your agency or the entire----
    Dr. Insel. The $84 million is NIH alone.
    The Chairman. NIH.
    Dr. Insel. There are 10 institutes within NIH that are 
engaged in this. Dr. Walter Koroschetz and I lead it, Dr. 
Koroschetz at the Neurology Institute, myself from NIMH. It is 
a partnership, though, with DARPA, with FDA, with IARPA, and 
with NSF as well. There are many different Federal agencies 
involved, lots of private partners.
    The important thing to understand here is it is really----
    The Chairman. Is $84 million the total funding or just the 
NIH funding?
    Dr. Insel. NIH funding----
    The Chairman. Yes.
    Dr. Insel [continuing]. In 2014. That is what we are up to. 
The President has asked that that would go to 150, and that 
both in the House and Senate there is an ambition to go way 
beyond that as well for next year, for 2016.
    This is not about the specific diseases or brain disorders. 
It is about developing the technologies to be able to 
understand how the brain works. We are seeing already fantastic 
tools being developed across the country.
    Without wanting to say too much about it at this time, 
there is a group in Seattle at the Allen brain institute that 
has really opened up this whole field for all of us in a way 
that gives us the excitement that over the next few years we 
will transform the way we study the brain.
    The Chairman. Thank you.
    Senator Murray.
    Senator Murray. I will just followup with that.
    In my home State we have the BrainSpan Atlas, Paul Allen's 
brain institute, which is in downtown Seattle. Tell us what you 
can about that and some of the other applied research projects. 
We have got the Mental Health Research Network there as well 
that are making amazing strides. We have great hopes for them. 
Talk a little bit about that.
    Dr. Insel. Yes, I could spend all morning bragging about my 
colleagues in Seattle.
    Let me just quickly tell you what those two projects are. 
BrainSpan was funded through the Recovery Act, so that was a 
great opportunity with some additional funding for us to build 
something that did not exist. It essentially was a way of 
saying could we create a map for the human brain of where and 
when genes are expressed. It was an atlas, a reference atlas 
for all of us to use.
    When we find a gene that is associated with autism or with 
schizophrenia, the first question you ask is, well, is that 
gene even found in the brain? It is expressed there, and if so, 
when?
    The most significant piece of information that has come out 
of this work by the Allen Institute is that there are enormous 
differences in both space and time for how the genome gets read 
out in the brain, in the human brain, and that the developing 
brain looks almost like a different organ than the adult brain.
    To our amazement, even though we think about schizophrenia 
and autism and bipolar disorder as neurodevelopmental 
disorders, it was not until we had this atlas that we began to 
realize that the genes that we are finding, which may not be 
that significant in the adult brain, are remarkably important 
in the developing brain. Often, though they do not get 
expressed together in adulthood, they sit in the very same cell 
in the same part of the brain at the same time in development. 
That is fantastic. We would never know that without this 
reference atlas. It has been transformative.
    The Mental Health Research Network--which was developed 
through Group Health, Greg Simon in Seattle--is a fantastic 
opportunity, 10 million patients across actually 12 different 
States with 11 different health care systems to create a single 
data framework.
    All of these people getting mental health care are now 
using the same electronic health records, and it has given us a 
platform to move very quickly to ask questions about what is 
the best followup after a suicide attempt? If someone shows up 
in the emergency room, we know that 2 percent of those people 
after an attempt will be dead in a year from suicide. That 
represents about one in five suicides are people who have been 
in an ER within 12 months.
    Can we figure out who those people are? With Greg's help 
and with the MHRN, which is a vast scale, you can begin to look 
at how to deploy services for those people to make sure that we 
bring down the suicide rate in that population.
    The MHRN has turned out to be for us an ideal platform to 
ask very practical questions about how to provide better care. 
Instead of the classic how do we move research into practice, 
what they are saying is how do we take practice and move that 
into research and make sure that every patient becomes a 
partner.
    Senator Murray. It is really interesting, exciting, and 
will really open up this field. Thank you for that.
    Ms. Enomoto, let me go back to you in the short time I have 
left. You talked about suicide in America as a public health 
crisis. When I was chair of the Veterans' Affairs Committee, I 
was very focused on improving mental health services and 
suicide prevention for our veterans.
    It is not just veterans that are at risk here. We know 
suicide is the second-leading cause of death among American 
Indians and Alaska Natives who are between the ages of 10 and 
34. CDC reports that lesbian, gay, and bisexual youth are more 
than twice as likely to die by suicide as their peers.
    Going back, based on some of our experience working with 
veterans, what lessons have we learned about reducing stigma or 
encouraging individuals to seek out care and peer counseling, 
those kinds of things?
    Ms. Enomoto. Through the work of the Veterans 
Administration, they have developed a systematic process for 
suicide screening assessment and risk assessment, and we have 
learned that it is important to specifically screen for 
suicidality from that work.
    We have also learned the importance of connecting, as Tom 
has mentioned, connecting after a hospital visit, as well as 
the need to connect people who do express further desire for 
services with suicide-specific services. It is not enough just 
to connect them with the general mental health services but 
services that are going to address the suicidality itself.
    We have seen great progress with these ``zero suicide'' 
models. We have also seen them deployed outside of a VA system 
into other community and health hospital systems, into tribal 
communities, and it is something that SAMHSA is building its 
suicide initiative around.
    Senator Murray. Is it fair to say that in the past we have 
said do not talk about suicide because you might make it happen 
and rather gone to a ``let us talk about it so it is open and 
we can prevent it'' conversation?
    Ms. Enomoto. Absolutely. That is a very insightful comment.
    Senator Murray. Thank you.
    The Chairman. Thank you, Senator Murray.
    We have 11 Senators who are here in addition to Senator 
Murray and me. I am going to ask the Senators and the witnesses 
if we can try to keep each Q&A session to about 5 minutes. We 
want everybody to have a chance to join the conversation.
    I will call on Senators in seniority if they arrived before 
the gavel, and first arrival after the gavel. The next Senators 
will be Senator Collins, Franken, Cassidy, and then Murphy.
    Senator Collins.

                      Statement of Senator Collins

    Senator Collins. Thank you, Mr. Chairman.
    Ms. Enomoto, one of the issues in our current mental health 
system is that it is often far too difficult for parents to get 
help for their adult children who are suffering from serious 
mental illness. Over the past few months, I have gotten to know 
Joe Bruce from Caratunk, ME, who has told me of what happened 
to his family.
    I would like to share his story with you and with my 
colleagues on the committee in the hope that we can work 
together to come up with some kind of solution as we look to 
revise our mental health laws.
    Joe's son Will was 24 years old at the time of this 
tragedy. He had schizophrenia, and yet he was discharged from a 
psychiatric hospital and returned home without the benefits of 
any medication. He had a history of serious and persistent 
mental illness, but he had been advised by federally funded 
advocates that his parents had no right to participate in his 
treatment or to have access to his medical records.
    According to his father and an extensive Wall Street 
Journal piece, eventually his medical records were released, 
and they showed that the doctors were all opposed to his being 
discharged but the advocates had coached him in a way that he 
was able to secure his release. He was convinced that he was 
fine and that he could refuse medication and not involve his 
parents in his treatment.
    This ended in a terrible tragedy because Will butchered his 
mother and killed her. He was in a deep psychotic state at the 
time, and ultimately he was found innocent by reason of 
insanity, or not responsible for his actions, and he was 
recommitted to the same mental hospital from which he had been 
prematurely discharged.
    He is now doing well because he is getting the treatment he 
so desperately needed, but his father put it this way to me: 
``Ironically and horribly, Will was only able to get the 
treatment he needed by killing his mother.''
    NI want to make two important points.
    First, I understand that only a tiny number of Americans 
with serious mental illness engage in unspeakable acts of 
violence either toward themselves or others.
    Second, I understand that these federally funded advocates 
can do some enormously valuable work in preventing the abuse of 
patients who are institutionalized.
    I cannot help but wonder how many tragedies that we have 
witnessed in recent years might have been prevented if those 
suffering from mental illness had had access to treatment and 
if the parents of these adult children had more of a role in 
their treatment. How do we address what admittedly is a very 
difficult challenge?
    Ms. Enomoto. Thank you for that question, Senator Collins.
    I agree that the circumstances of the Bruce case are 
extremely tragic, and the loss of anyone in such a horrible act 
of violence is too much. Our thoughts go out to the Bruce 
family.
    In the case of the Protection and Advocacy program, we 
believe that it is important to have a program that protects 
the rights of people with serious mental illness. At the same 
time, we have worked with the Office of Civil Rights, and they 
have provided guidance to families to understand and to 
physicians to understand that, under HIPAA, physicians are able 
to listen to parents, and when it is in the interest of the 
patient, that they are able to share information with family 
members.
    There is more to be understood about the circumstances of 
the Bruce case in particular, but I could not agree with you 
more that our country needs to better understand how to get 
people with the greatest need connected with the care that 
would most benefit them, keep them safe, keep their families 
safe, and ensure the greatest chance of recovery, as we have 
seen in this particular situation.
    Senator Collins. Thank you.
    The Chairman. Thank you, Senator Collins.
    Senator Franken.

                      Statement of Senator Franken

    Senator Franken. First of all, I thank the Senator from 
Maine for raising that. That is a very, very important area, 
and I know that in the Cassidy-Murphy bill we are addressing 
that.
    Thank you, Mr. Chairman, for this important hearing. This 
is obviously of enormous importance.
    There is so much talk about it. I would like to talk about 
mental health in schools. Ms. Enomoto, I read that you started 
in dealing with minority mental health and trauma, which I find 
very interesting. Treating trauma, is very important in terms 
of learning in school as a matter of fact, something that we 
all care about here.
    I am proud that some of my work got into the new Every 
Child Achieves Act in terms of mental health in schools. These 
provisions will support programs in schools to train staff, 
everybody from the bus driver to the principal to the 
custodians to the lunch ladies to the teachers to spot when it 
looks like a kid might have a mental health issue, and then get 
that adult to talk to a professional in the school, a 
counselor, maybe a psychologist to see the kid and refer them 
if they have a mental health--a serious one to get the 
appropriate services. We have seen that work.
    My understanding is that Project AWARE, which is a grant 
program created by President Obama in 2013 and administered by 
your agency, supports exactly this type of mental health 
training for youth-serving adults, and I am proud that a number 
of these recipients are in Minnesota.
    Can you talk about how the collaboration between schools, 
mental health providers, and other community-based 
organizations helps students and families and how this program 
is helping connect young people to the services that they need?
    Ms. Enomoto. Absolutely, and thank you for the question.
    The program such as the one that you have proposed and the 
one that we have implemented under Project AWARE do connect 
schools, communities, and families with shared information 
about mental health, about mental illnesses, and about 
substance use disorders, about what they appear like and what 
you can do about them. They are not meant to replace treatment 
or care, but they are meant to raise awareness.
    As Senator Murray noted, negative attitudes, lack of 
understanding, these things are what create barriers for people 
accessing services. First and foremost, we are educating 
people, we are helping them understand that these are diseases. 
These are brain diseases that are treatable, preventable, and 
recoverable, and so people are more willing to talk to people 
about what they are experiencing, and offer some solutions. 
Then because people understand it better, it is less 
frightening, it is more accessible, and we can move to 
intervene earlier and get people connected to care more 
quickly.
    Senator Franken. Early intervention, early diagnosis, early 
treatment is something----
    Ms. Enomoto. Absolutely.
    Senator Franken [continuing]. That we as witnesses----
    Ms. Enomoto. Right.
    Senator Franken [continuing]. Know is so important.
    I just want to ask you a little bit about your background 
in minority health and trauma. We know that trauma reduces a 
child's ability to succeed in school. What can we do in school 
to build resilience in kids who have experienced these adverse 
childhood experiences so that they can overcome them? Because I 
know it changes the brain chemistry to go through this kind of 
trauma. Trauma could be witnessing violence, seeing chemical 
abuse, mental illness, child abuse, all of those subjects, 
extreme poverty.
    What can schools do to build resilience in kids to overcome 
those early adverse experiences?
    Ms. Enomoto. There are many evidence-based interventions 
that are school-based that schools can employ. Through our 
National Child Traumatic Stress Network and the initiative 
there, there are many, many resources available online and 
through technical assistance for schools to learn about those 
programs that can be done in classroom, those programs that can 
be done in partnership with families, with communities to help 
children cope with the experiences that they have had, how to 
learn positive coping and social development skills, and then 
for teachers as well how to understand how to modulate 
classroom environments and climates so that we can create a 
place where all children can learn well and have healthy and 
productive lives.
    Senator Franken. OK. Thank you. I am out of time.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Franken.
    Senator Cassidy.

                      Statement of Senator Cassidy

    Senator Cassidy. Hello, you all. Thank you for being here.
    By the way, let me just thank many in the audience who have 
sent a letter in support of the bill that Senator Murphy and I 
have put up.
    I thank you all for your concern and for being here.
    I am going to ask two questions. I only have 5 minutes, now 
4 minutes and 45 seconds, and so please keep your answers 
brief, and if I interrupt, it is not to be rude or pre-emptory. 
It is just because I have got limited time.
    Ms. Enomoto, GAO has released two reports this year 
critical of how HHS has managed mental health issues and 
singling out SAMHSA for some of that. My first questions will 
center upon that.
    The Department of Health and Human Services is charged with 
leading the Federal Government's public health efforts related 
to mental health and substance abuse, and the Substance Abuse 
and Mental Health Services Administration is specifically told 
to promote coordination of programs related to mental illness 
through the Federal Government.
    The Federal Executive Steering Committee for Mental Health 
with members across the Federal Government is designated to 
work on these issues, but the Government Accountability Office 
reports that you have not met since 2009.
    HHS officials have stated that the Behavioral Health 
Coordinating Council, the BHCC, performs some functions 
previously carried about by the steering committee, yet that is 
limited to HHS and is not interagency.
    While that sort of coordination is important, it does not 
take the place of or achieve the level of leadership GAO has 
previously found key to successful coordination and that which 
is essential to identifying whether there are gaps in services.
    By the way, I will also point out that the Cassidy-Murphy 
bill creates an assistant secretary for mental health 
specifically charged to do this job, the interagency 
coordination, which has not been done since 2009.
    That being the case, would you agree that HHS should 
raise--what are your thoughts about the Cassidy-Murphy bill? Do 
you think HHS should raise that profile to get that interagency 
coordination, which, despite being mandated, has not occurred 
since 2009? Thoughts?
    Ms. Enomoto. Any effort to raise the profile of mental 
health issues and to increase collaboration across Federal 
Government is a good one. I am happy to engage in further 
conversation and work with you on creating a positive 
opportunity for that collaboration.
    You noted that the FESC, the Federal Executive Steering 
Committee, has not met since 2009. The BHCC started meeting in 
2010. Many subcomponents of the original Federal Executive 
Steering Committee, which had 25 components participating, do 
still meet, so does the Federal Executive Steering Committee on 
trauma, on disaster. There are also groups related to 
employment that have----
    Senator Cassidy. I really want to hear about mental health, 
and that is what appears to be what was lacking per GAO.
    Let me move on, again.
    Ms. Enomoto. OK.
    Senator Cassidy [continuing]. I have limited time.
    The second report talked about the problems of a lack of 
evaluation for programs for the seriously mentally ill at 
SAMHSA. For example, of 30 programs specifically targeting 
individuals with SMI, 9 had a completed program evaluation, 4 
had evaluation underway, 17 had no evaluation completed and 
none planned. I can go through but it is more like that, dismal 
statistics regarding those getting evaluated.
    Again, I will say that the Cassidy-Murphy bill focuses on 
the need for evidence-based practices.
    That said, recognizing that there are serious gaps and that 
there is need for consistency and review into monitoring 
programs, what is SAMHSA doing to create a better culture of 
evaluation at the agency?
    Ms. Enomoto. I agree that evaluation is a really important 
issue. SAMHSA takes its responsibility regarding program 
oversight very seriously. We are continually working to improve 
our----
    Senator Cassidy. Can you give me a specific because I have 
got limited time?
    Ms. Enomoto. SAMHSA has established a SAMHSA evaluation 
committee, so we are overlooking all of our programs to 
identify what is the right level----
    Senator Cassidy. The 17 which were not evaluated and none 
were planned, how do we avoid that? Why did that ever occur?
    Ms. Enomoto. There were some challenges in terms of how 
those were measured, so I do not know that that is exactly the 
same way that we see it. However, we are committed to 
evaluating our programs and will continue to do so.
    Senator Cassidy. Dr. Insel, again, thank you for your 
service.
    I have been told that the reason more National Institute of 
Health research funds have not been put toward mental health is 
that the scientific promise is not there as it might be 
elsewhere. You have previously noted in written documents that 
you have published that if you look at DALYs, disability-
adjusted life years, the amount that SMI gets is below that 
which would normally be the main. Others like AIDS is way up 
here but serious mental illness is there.
    I have also seen a statistics that we spend at NIH $987 for 
every death from suicide and $420,000 for every death from HIV, 
$420,000/$987. It may be too difficult. Is it worthwhile to put 
more dollars specifically toward the issue of suicide, knowing 
it is so heterogeneous? If we put more research dollars there, 
can we expect to see some benefit from that? Is there academic 
promise?
    Dr. Insel. That is a good point and a good question. How do 
you balance both scientific traction and burden of disease? We 
look at both of those in making decisions about investments. We 
have the traction here. It is a place where greater investment 
will get us greater return. We see that already when we got the 
Recovery Act dollars in as additional money. The results of 
that are spectacular. We have lots of projects that would not 
have happened that we can point to from Recovery Act dollars, 
which I think are some of the best things that this institute 
has done over the last decade. No question that we could use 
more funding in great ways.
    The last issue here, just take a moment, in comparing 
suicide to AIDS, I want to stress the fact that that investment 
in AIDS could be attributed to the fact that we have reduced 
mortality 50 percent.
    Senator Cassidy. Totally accept that.
    Dr. Insel. It may be that we are not spending too much on 
AIDS but we are not spending enough on other areas like suicide 
prevention.
    Senator Cassidy. We will talk to the appropriators and try 
and get you all more.
    Dr. Insel. Thank you very much.
    [Laughter.]
    Senator Cassidy. I have gone over. I yield back. Thank you.
    The Chairman. Thank you, Senator Cassidy.
    Senator Murphy.

                      Statement of Senator Murphy

    Senator Murphy. Thank you very much, Mr. Chairman. Thank 
you to Senator Alexander and Senator Murray for taking this 
issue so seriously, convening us here today. Senator 
Alexander's comments were useful in understanding why Congress 
really has not taken on this issue of comprehensive mental 
health reform in the past because it does cut across so many 
agencies both latitudinally and longitudinally. It does cut 
across so many different committees. I really appreciate the 
focus on trying to get to a product that can eventually get to 
the floor.
    A few of us were at a really interesting bipartisan 
briefing this morning from the Commonwealth Fund, which they 
were talking about the need to integrate our behavioral health 
systems with our physical health systems, and there were some 
really interesting facts that they brought out. One of them was 
that if you study the incidence of diabetes alone as a cost-
driver and you study the incidence of mental health diagnoses 
alone as a cost-driver in Medicare, they are actually not that 
extraordinary by themselves. What makes them extraordinary 
cost-drivers is when they are linked together. When you have a 
physical health diagnosis and a mental health diagnosis 
together, all of a sudden you are now in that small percentage 
of patients that are driving cost.
    Mr. Macrae, is this issue of workforce a question of not 
having enough providers or simply not being as coordinated as 
we should be between the mental health side and the physical 
health side? Our bill certainly is focused on this question of 
coordination. Where should our attack be, more providers or 
better-integrated providers?
    Mr. Macrae. Thank you, Senator. It is actually a 
combination of the two. I would say that in terms of the 
primary care piece, we have seen an incredible interest from 
our primary care providers to increase their capacity to have 
behavioral health providers onsite because a lot of the primary 
care providers have shared with us that they sometimes feel 
uncomfortable in terms of dealing with mental health issues. By 
our investments that we have made over the last several years, 
we have doubled the number of mental health providers that are 
at our health centers.
    By having those providers onsite, it has actually helped 
our screening in terms of what we do. It has really afforded 
the primary care system to expand its capacity to do more. We 
really see it as we need to build out the primary care capacity 
to do more screening integrated with behavioral health.
    The second part of your question about whether we have 
enough providers, I would say we see an incredible demand for 
mental health providers from our different programs. Right now, 
we are only able to fund about half of our applications through 
the National Service Corps for mental health providers. Our 
community health centers, 65 percent of the demand has been for 
behavioral health in terms of what they are requesting. We 
definitely see the need of both support for coordination and 
also providers.
    Senator Murphy. Ms. Enomoto, I want to followup on this 
question of HIPAA that is certainly an aspect of our bill as 
well. Is this a question of providers not interpreting the 
existing statute correctly or do we need clarification of what 
allows a provider to share information with a family member? 
Senator Collins has identified a particularly acute problem, 
the lack of information that goes to parents and caregivers, 
especially when you are talking about a young adult who may be 
psychotic who needs that help and assistance and that 
coordination. Is this a matter of needing to clarify the 
standard?
    Ms. Enomoto. We believe that there are more flexibilities 
than many physicians and many people understand, and that 
clarifying the rules of the flexibilities that they have to 
disclose information to family members, when it is in the best 
interest of the patient, would be very helpful to a lot of 
people. We are happy to work with our colleagues at OCR and 
across the department to do that.
    Senator Murphy. Dr. Insel, the time in which you have been 
at the Institute has roughly corresponded with the period of 
time in which we have reduced the number of inpatient beds 
across the country by about 4,000, and mostly that has occurred 
during the recession and afterwards. There was about a 15 
percent reduction.
    I appreciate what you are saying in terms of the focus on 
trying to identify early, but can we sustain this level of 
continued reduction of inpatient beds over time? Is this 
something, as you leave, that worries you, the lack of capacity 
that we have to provide short-term acute-care stays for people 
that need a period of stabilization?
    Dr. Insel. Oh, absolutely. It is a big issue. There is no 
room at the end. There is no place to send patients. Often, 
that is why we see people being boarded in emergency rooms, 
which is a ridiculous situation that we find ourselves in here.
    We need to look at how you extend capacity. It is not the 
answer to all questions, but that at least needs to be 
developed. I should just note that the last 13 years there has 
been a reduction, but the big reduction came long before that. 
There is over 90 percent reduction in public beds for people 
with mental illness since the 1970s, so a huge, huge change in 
what the capacity is to help people when they really need full-
time support.
    Senator Murphy. This all changed in the 1960s. We did 
something great. We took people out of the institutions and we 
put them in the community, but we did two things wrong. We did 
not fund the support in the community, and we set up a 
community mental health system that was wholly separate and 
apart from the rest of the health care system. Hopefully, our 
discussion will be around those two fixes, making that promise 
real and bringing those two systems back to----
    Dr. Insel. That would be great. I just want to take another 
moment to say that we do have a system out there. It is called 
the criminal justice system, which has become the de facto 
mental health care system in this country. As you look at 
legislation, you cannot ignore that. You need to really ask, in 
a bipartisan way, is this the country we want to be? Is this 
the way that we want to treat people with a brain disorder?
    Senator Murphy. Hallelujah. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Murphy. Thanks for the 
time you and Senator Cassidy are spending on this issue.
    The next four Senators are Isakson, Warren, Scott, and 
Baldwin.
    Senator Isakson.

                      Statement of Senator Isakson

    Senator Isakson. Thank you, Mr. Chairman.
    Thank you for your testimony today.
    Senator Murray, myself and Senator Cassidy are 
participating in a number of hearings in the VA Committee on 
the issue of suicide. There are approximately 22 suicides a 
day, 8,000 a year in our Veterans Administration for veterans 
of the United States. It is a crisis we are trying to deal 
with.
    I am not a physician, nor am I a technical person, but it 
appears to me that in emergency room practices there is a 
golden hour. It is that hour from the time the accident takes 
place until the time the person is treated where you could save 
a life if somebody is in a traumatic accident.
    It seems like being in terms of suicide, it is a golden 
minute. It is that minute when they realize they are at risk 
and are willing to make a call, that there is an accessible 
person they can get to talk to. If there is not one, then we 
lose people sometimes because of a lack of access to someone to 
talk to, to get them to an appointment, to get them to an 
intervention, to get them to a place where they can at least 
talk to a professional.
    Am I right about that or am I wrong about that? Mr. Macrae?
    Mr. Macrae. I would defer to my colleague Kana, but I would 
say absolutely. The other piece is that early intervention is 
also important when you are even talking about suicide. We have 
had much success in terms of doing screening again in that 
primary care setting where you are actually able to identify 
children, in particular adolescents, but also veterans and 
other vulnerable patients where if they just had some of that 
intervention early on, it could make a big difference.
    I know Kana can talk specifically about that golden minute.
    Ms. Enomoto. Because of that, there is that moment that 
someone is reaching out for help. That is why SAMHSA has 
established the National Suicide Prevention Lifeline and that 
we have partnered with the Department of Veterans Affairs for 
the ``press 1 if you are a veteran or a service member'' so 
that people can access that military culturally informed type 
of support and then get connected with services that are in a 
local area to them through the telephone that is available 
through that phone number network.
    Senator Isakson. Out of curiosity, has HRSA had any 
interaction with the VA in terms of peer review and peer 
process in terms of mental health?
    Mr. Macrae. Yes, we have. We have worked with them both in 
terms of workforce, in terms of working together to see if we 
can expand the mental health workforce both for the VA, as well 
as for a lot of the underserved programs that we work in.
    In addition, we have been working very closely with them 
around the Veterans Choice Act in terms of that connection 
between the VA and some of our community health centers, for 
example. We are working right now on some model contract 
language to make that process easier so that veterans can have 
greater access.
    Senator Isakson. Talking about Veterans Choice, I realize 
it is important for us to improve that Veterans Choice program 
so that golden minute can actually take place, because right 
now, by calling the 800-number to get the appointment and prove 
you are more than 40 miles away from a center takes a long 
time. In mental health issues, particularly suicide prevention, 
a long time is not a very long time and you do not need to 
delay that as much as possible.
    It occurred to me, that our Veterans Administration's 
biggest problem in terms of service delivery is rural America 
where there are a lot of veterans and there is not a lot of 
health care. I know our health centers, community health 
centers, serve a lot of rural America. Does the VA depend on 
you or do you work with the VA in terms of rural environments 
to try and make available the professionals to help them?
    Mr. Macrae. We do. We actually right now, through the 
community health center, serve about 300,000 veterans across 
the country, and a significant number of those are actually in 
rural communities.
    In addition, we have been partnering with the VA around 
telehealth in particular where we cannot actually get providers 
necessarily out into the rural communities but make sure that 
they have access through telehealth resources. That is 
something we have been working with, particularly in rural 
communities to expand the capacity for health centers to do 
more but also through the VA in partnership.
    Senator Isakson. Thank you for your testimony.
    Mr. Chairman, thank you for calling this hearing.
    The Chairman. Thank you, Senator Isakson.
    Senator Warren.

                      Statement of Senator Warren

    Senator Warren. Thank you, Mr. Chairman.
    Thank you all for being here.
    With every mass shooting in this country, the American 
people call for action and the U.S. Congress does nothing. 
Instead, the deaths continue to add up with more than 30,000 
people lost to gun violence during 2013 alone.
    There is a lot that we could do, but according to those who 
object to more thorough background checks or to improved gun 
safety, the problem of mass shootings is a mental health 
problem and should be dealt with that way. When it comes time 
to fund mental health research, the same people turn their 
backs on studying mental health problems.
    Over the past 5 years, the National Institute of Mental 
Health's inflation-adjusted research budget has been cut by 
about 12 percent, and SAMHSA's inflation-adjusted budget is 
down about 8 percent. No one knows where this year's health 
budget will land.
    Worse yet, even if they had adequate funding, the NIH and 
CDC are effectively banned from conducting research on gun-
related violence. Every Appropriations bill since 1996 has 
included language that bans the CDC from conducting any 
meaningful research related to reducing gun violence.
    Former Republican Congressman Jay Dickey, who is the author 
of that rider, wrote an op-ed 3 years ago calling for that ban 
to be lifted, but it remains in place year after year.
    In fact, just months after the shooting in Arizona that 
nearly took the life of Congresswoman Gabby Giffords, Congress 
expanded the research ban to include NIH research as well.
    Dr. Insel, let me ask you, what meaningful research that 
might help us better understand the connections between mental 
health and gun deaths and ultimately that might help us reduce 
gun violence are we not conducting because of Congress's ban on 
gun-related science?
    Dr. Insel. Thank you, Senator Warren. It is obviously a 
very topical and in some ways difficult issue.
    The President has talked about this almost from the day 
after the Sandy Hook massacre when he announced the Now Is the 
Time initiative, which included a focus on just this issue.
    I understand and appreciate your concern about the CDC, and 
of course Congressman Dickey's language has been talked about a 
lot in the press, and it is something that we have heard quite 
a bit about as well.
    I should say that at NIH we have taken a somewhat different 
tack. Our interpretation of that language was that, well, it 
put a prohibition against advocating for or promoting any sort 
of gun control. It did not actually prohibit us from doing 
research on firearms and violence as a public health issue. We 
have continued to do that.
    Last year, we announced a Request for Applications on the 
research on the health determinants and consequences of 
violence and its prevention, particularly firearm violence. 
That was an RFA put out by the National Institute of Alcohol 
Abuse and Addiction that was then joined by many, many other 
institutes at NIH, including NIMH. We have funded grants under 
that that look at issues around means restriction.
    What does the science tell us about how to assess risk for 
someone when they have made a suicide attempt, particularly for 
young people who are seen in an ER? One of the grants is to 
understand the best way to assess their access and the best way 
to deal with that.
    There are projects on developmental pathways of violence 
and substance use in a high-risk sample looking at people who 
we are particularly concerned about having access to weapons 
and whether there is a way, again, to put some sort of a 
scientific understanding on the question of who is most likely 
to get into trouble here and what are the best interventions we 
can do to prevent that?
    I guess in a word for us it has become--it is entirely a 
public health issue and is something that we feel is very much 
in the sweet spot of what we do at NIH in terms of trying to 
understand how science can save lives.
    Senator Warren. I appreciate that, and I just want to make 
sure I understand. You are telling me that CDC has been caught 
by this ban but that, in effect, NIH has found ways to work 
around it so that you are still conducting some research about 
the link between mental health issues and guns and gun 
violence?
    Dr. Insel. I am not going to speak to CDC because I do not 
know enough about what their portfolio does, but certainly, at 
NIH we are doing the work, and we are trying to get the science 
that will serve the public that is related to this issue.
    Senator Warren. I am grateful for the direction that you 
are trying to go.
    The idea that Congress would witness children, bystanders, 
spouses, people watching movies, people going to church die by 
gun violence and refuse to take any action is irresponsible in 
the extreme and clearly a sellout to a powerful gun lobby.
    To follow that up, with congressional inaction, by 
underfunding mental health research and then by refusing to 
support researchers who could produce fact-based nonpartisan 
scientific research that could help us reduce gun violence and 
improve our mental health system moves this Congress from 
irresponsible to culpable. Gun violence is tearing apart our 
families and our communities, and we cannot turn away from 
that.
    Thank you.
    The Chairman. Thank you, Senator Warren.
    Senator Scott.

                       Statement of Senator Scott

    Senator Scott. Thank you, Mr. Chairman, and thank you to 
the panelists for being here this morning and discussing a very 
important issue. Certainly, without question coming from South 
Carolina, I have an appreciation of the impact of mental 
illness and violence, mass violence in South Carolina, in 
Washington, and around the country as well. Certainly, we are 
looking forward to ways to help to reduce the impact.
    Thank you for your comments on the progress that is being 
made at NIH on such an important issue.
    You also highlighted a little earlier the de facto location 
of too many folks that are suffering from mental illness are 
local and county jails. Frankly, in South Carolina there are 
about 20,000 folks that are incarcerated and at least 3,000 
have been diagnosed with some mental illness. I have heard that 
some studies suggest that the number could be two or three 
times even higher.
    By default, we are finding folks incarcerated not because 
they necessarily committed a crime but because of their mental 
illness as a primary reason for their incarceration. That is 
something that we must address, we need to address, and 
frankly, from a financial perspective, one of the most 
expensive ways of addressing it is to have folks incarcerated, 
losing their freedom at the expense of taxpayers.
    Dr. Insel, you probably know that chronic mental illness 
cases begins for so many folks--I have heard studies suggest 
that at least by age 14, half of the mental illness cases have 
begun, and by the age of 24, three-fourths of those cases have 
begun. There has been a lot of conversation around 
intervention, early intervention, and to me it seems like the 
first folks that might be in the best position, if they 
understand what signs to look for, are the family members in 
the household.
    Can you comment on how we remove the stigma associated with 
mental illness? As you have said, that we have had great 
success in dealing with physical illnesses from cancer and 
other issues because we have had the ability to put a major 
spotlight to reduce those challenges. How do we do the same 
thing in the area of mental illness?
    I appreciate your service to the NIH as well.
    Dr. Insel. Thank you, Senator Scott, for that question.
    I wish it was an easy one to answer. In these other medical 
areas, we do not have the legacy we have here of really a long 
era in which we either considered these not illnesses but some 
moral failings for individuals or, even worse, for a long time 
blamed families. The explanation for every mental illness was 
that your mother or your father did this to you, so not 
surprising that families have not been at the forefront of 
being able to turn the tide here.
    The future will be largely around better education, as well 
as better science. We need to help people to understand that 
these are disorders that are like any other disorders.
    As you say, the one thing that sets them apart is, unlike 
cancer and heart disease and most endocrine diseases like 
diabetes, they start in young people. These are the disorders 
of young people, and it makes it therefore even more touching 
that we do not do enough to help people grapple with them 
early, to give people the supports they need, to help people 
understand that these are real disorders and there are real 
treatments that we have available. Yet those treatments are not 
getting to the people who need them.
    Senator Scott. Yes, sir. Thank you, sir.
    Mr. Macrae, Let me just say thank you for your work with 
the VA in helping so many of our veterans, especially in the 
rural areas of our States. My brother served 32 years in the 
Army and worked with the Warrior Transition Unit. We have spent 
a lot of time focusing on the suicide-a-day issue that the 
military has faced. It is very heartwarming to hear someone 
talk about the importance and having a sense of urgency in 
dealing with the issues.
    South Carolina is a rural State, and according to your 
reports, I believe we have 70 or so areas that are underserved. 
We looked at telemedicine as the panacea that is going to fix 
all the problems, but we both know that it is probably not 
going to fix all the problems.
    Have you seen any other innovations coming our way that 
might give us reasons to be hopeful for challenging some of the 
rural areas in States like South Carolina? When I say 
challenging, Sometimes we have to challenge the challenges that 
we face in these rural areas, and frankly, with 46 counties in 
South Carolina, 70 underserved areas, it would be helpful to 
understand and appreciate any new opportunities beyond 
telemedicine for us to impact those areas.
    Mr. Macrae. Sure. Thank you, Senator.
    Definitely, telemedicine is one of the initiatives that we 
are promoting quite a bit, especially in those rural 
communities where it can be a challenge to get those providers 
in. We are also looking beyond that to see if we can provide 
support where there are other types of providers in the 
community that need some assistance.
    One of the projects that we have been working on recently 
is something called Project ECHO where we bring together 
academia, and basically, we bring together different 
communities--and we have done a lot in rural communities--to 
basically be able to bring cases forward and talk to someone 
who has more expertise in terms of that knowledge or 
information, and they can then use that information to then go 
back to their practice and provide more care.
    We are definitely looking at every way we can use any other 
types of technologies and terms of improving health care in 
rural, but a lot of it, honestly, is also meeting the needs 
through some of our programs. The Community Health Center 
program has reached out into rural communities. The National 
Health Service Corps. is close to 50 percent. The Community 
Health Center program is out in rural, almost 40 percent out in 
the National Health Service Corps.
    It is a combination of getting physical presence, 
telehealth where we can, and then providing support to those 
current providers that might need it, just that extra support. 
We have been doing that through this Project ECHO model.
    Senator Scott. Thank you. I know I am out of time but one 
quick question, sir.
    With the number of PTSD cases coming back from the 
military, have you found that the level of awareness and 
interest in mental health issues has risen substantially in the 
last few years?
    Mr. Macrae. Absolutely. In fact, we had been working very 
closely with the VA in terms of--in particular, we have been 
working on the Veterans Choice Act to increase the capacity, in 
particular in our community health centers to first identify 
and then also treat people with PTSD, in particular veterans. 
We have actually worked with them on a whole curriculum and 
providing guidelines to our providers to provide them that 
support.
    Senator Scott. Thank you, sir.
    The Chairman. Thank you, Senator Scott.
    Senator Baldwin.

                      Statement of Senator Baldwin

    Senator Baldwin. Thank you, Mr. Chairman and Ranking Member 
Murrray.
    We know that in recent years we have made great strides in 
improving access to insurance coverage in this space with the 
Mental Health Parity and Addiction Equity Act and also the 
Affordable Care Act.
    However, still, too many Americans face barriers to getting 
access to high-quality treatment options for mental health 
issues. I wanted to specifically hone in on eating disorders.
    I hear from countless people who share their stories 
relating to seeking treatment for eating disorders, and they 
describe insurance that will not cover the care that they need. 
In some cases, if the plan covers this type of treatment at 
all, it is usually in another State and often will only cover a 
couple of days of residential care.
    Alternatively, a plan may send them to a general 
psychiatric hospital or facility where the treating 
professionals lack the education and background about treating 
eating disorders.
    I have teamed up with a number of my colleagues in 
introducing the Anna Westin Act, which aims to improve care for 
those with eating disorders by clarifying that mental health 
parity includes coverage for residential treatment services.
    Ms. Enomoto and Mr. Macrae, I wonder if you can speak a 
little bit about the consequences when insurance companies fail 
to treat individuals with eating disorders and certainly other 
serious mental health issues in appropriate care settings by 
professionals who are fully qualified to address their specific 
disorder.
    If you could tell me a little bit about what your 
respective agencies are doing to help improve comprehensive 
treatment and access for those suffering from eating disorders 
in their own communities, obviously, if possible.
    Then, I hope to turn to a little bit more about the state 
of the science in this arena.
    Ms. Enomoto, would you mind starting?
    Ms. Enomoto. Thank you very much for this question because 
so many people do not understand that eating disorders have 
some of the highest mortality rates of any mental disorders and 
also strike very early in life from children as young as 8 
years old. Access to services is critical. Denial of coverage 
can result in tragic outcomes for the affected patient, as well 
as their families.
    SAMHSA is working very hard with our Federal partners at 
the Department of Labor and Treasury, as well as inside of HHS 
with Assistant Secretary for Planning and Evaluation in the 
Centers for Medicare and Medicaid Services to improve insurance 
compliance with MHPAEA, as well as to ensure parity of 
insurance coverage for mental disorders, including eating 
disorders.
    We are developing informational materials for the public as 
well as for insurers, and we are partnering with HRSA and CMS 
on integrated care models such as the Primary Behavioral Health 
Care Integration so that we can bring the treatment for mental 
illness and health care together, as well as ensure that health 
care organizations are caring for the whole person, as you have 
noted is so vitally important.
    Senator Baldwin. Mr. Macrae.
    Mr. Macrae. We have two programs that are, in particular, 
focused on a workforce training around the whole issue of 
eating disorders to really increase the capacity of primary 
care providers to first identify and then to provide additional 
treatment and support and we can share that information with 
you if that would be helpful.
    Senator Baldwin. Great.
    Mr. Macrae. It definitely is a concern.
    Senator Baldwin. I appreciate that. Let me just continue in 
this vein.
    The Anna Westin Act directs SAMHSA to award grants to train 
primary care physicians, mental health providers, and other 
public health professionals on early identification and 
intervention of eating disorders and how properly to refer 
patients.
    Sadly, as noted, individuals suffering from an eating 
disorder are facing very, very high risks, and they are sort of 
duel, the risks of a person with an eating disorder being more 
likely to attempt suicide or engage in self-injury, in addition 
to all the physical impacts of living with and struggling with 
an eating disorder.
    What more can SAMHSA do to increase awareness about these 
co-occurring mental illnesses and suicidal behavior among 
individuals suffering from eating disorders? Again, I would 
certainly invite a conversation about the current state of the 
science on this issue.
    Ms. Enomoto. Yes, people with eating disorders have higher 
rates of co-occurring health conditions, as well as substance 
use and suicidality and self-injury. They are very complicated 
conditions to treat and manage. SAMHSA does have some specific 
guidance for clinicians to improve their skills and knowledge 
in this area for those who are interested. Unfortunately, we do 
not currently have any funding dedicated to improving or 
raising the clinical floor around eating disorders, and it is 
an area for potential growth.
    Mr. Macrae. I will take just a moment if I can.
    The science is going great guns. The good news is that 
there is a new treatment called family-focused therapy, which 
does the opposite of what we have traditionally done. The old 
treatment was to take parents out of the scene. We called it a 
parent-ectomy. Today, we train parents and make them the focus 
of the treatment. The remission rates are 50 percent sustained 
at 2 years. This is with adolescents with anorexia nervosa--
saves lives. This is a really good story.
    The bad news is that very few people are at this point 
trained to provide that therapy with fidelity with the features 
of it that seem to be most effective. There is more work to do 
to get a workforce that actually is able to help the kids who 
need it.
    The Chairman. I want to thank our three witnesses for your 
testimony.
    Senator Murray, do you have any concluding remarks?
    Senator Murray. Mr. Chairman, I just really appreciate this 
hearing and the participation of so many people. We are all 
learning as we go every day. Moving forward to make sure that 
we are making our health care system work for everyone has to 
include the issue of mental health care. I really appreciate 
the focus of this hearing, look forward to working with 
everyone.
    The Chairman. Thank you.
    I appreciate the attendance and involvement of so many 
members of the committee today. We may very well try to have 
another hearing on mental health before the end of the year. I 
will talk with Senator Murray about that and I will talk with 
other members of the committee about exactly how to do that.
    The hearing record will remain open for 10 days. Members 
may submit additional information for the record within that 
time if they would like. The next hearing exploring issues of 
mental health and substance abuse disorders will be an opioid 
abuse hearing on Thursday, November 19th.
    Thank you for being here today. The committee will stand 
adjourned.
    [Additional Material follows.]

                          ADDITIONAL MATERIAL

Response by Kana Enomoto to Questions of Senator Enzi, Senator Isakson, 
Senator Hatch, Senator Roberts, Senator Murray, Senator Casey, Senator 
             Franken, Senator Whitehouse and Senator Warren
                              senator enzi
    Question 1. An October 5 article in the Washington Post described a 
Substance Abuse and Mental Health Services Administration (SAMHSA) 
contract with the public relations firm Edelman, Inc. under which 
Edelman sought to interview journalists--even offering to make 
charitable donations of $175 on their behalf--in order to learn how to 
refine SAMHSA's ``messaging'' efforts. It appears that this contract 
may not have been in the best interest of taxpayers.
    I wrote the director of the Office of Management and Budget on 
October 7, requesting more information about this contract and other 
public relations spending by SAMHSA and other executive branch 
entities.
    Please provide a full and complete description of the 
aforementioned contract with Edelman, including its purpose and terms, 
how much has been spent on the contract to date, and how much more is 
anticipated to be spent. Also provide a detailed narrative description 
of all spending by SAMHSA during Fiscal Year 2015 on public relations, 
media relations and advertising activities--both contract and in-house 
expenditures--including total spending and category subtotals.
    Answer 1. SAMHSA takes very seriously its obligation to use 
taxpayer funds responsibly, especially those appropriated by Congress. 
This activity was in no way intended to influence reporters' coverage 
of SAMHSA. Given that the issues around mental health and substance 
abuse are complex and evolving, SAMHSA wants to ensure that our 
information resources were perceived as clearly, concisely and 
accurately as possible. Therefore, SAMHSA conducted a brief task on or 
about Sept 18-24, 2015, at a cost of $7,579.87. The objective was to 
obtain quick feedback from a handful of stakeholders and trade 
reporters who routinely cover behavioral health topics. The contract 
has expired.
    The vast majority of SAMHSA's Public Awareness and Support budget 
is used to deliver critical resources through our Treatment Locator, 
crisis hotlines, website, and the publications development and 
dissemination. These resources inform the public and behavioral health 
and other health care professionals about behavioral health issues, 
share the latest evidence-based programs and practices, and promote 
prevention, treatment and recovery.
                            senator isakson
    Question 1. The Secretary's announcement of plans to focus on a 
single medication might ignore non-opioid alternatives such as 
detoxification, relapse prevention followed by recovery supports. Do 
you agree that opioid-addicted individuals admitted should receive 
treatment based on their individualized clinical needs, and be provided 
with the option that is most appropriate for them?
    Answer 1. Opioid-use disorder is a chronic disease, like heart 
disease or diabetes. A person with opioid-use disorder can regain a 
healthy, productive life. Medication-assisted treatment (MAT) is the 
most effective treatment option for individuals with opioid-use 
disorder. There are three equally important parts to this form of 
treatment: medication, counseling, and recovery support. These three 
parts work together to provide a whole-person approach to treatment. 
All three medications approved by the Food and Drug Administration for 
treating opioid-use disorder (methadone, naltrexone, buprenorphine and 
buprenorphine/naloxone) have been shown to be effective, safe, and 
cost-effective treatments when used and monitored properly by a 
physician and substance-use disorder professional. Research has shown 
that patients receiving MAT are significantly more likely to stay in 
treatment and significantly less likely to use illicit opioid drugs 
than patients who receive detoxification and psychosocial services 
alone. In addition, these medications lead to greater improvement in 
patients' social functioning, risks for overdose, risk of contracting 
HIV or hepatitis C, and lessen risk of criminal justice involvement. 
All of these medications have the same positive effect: they reduce 
problem addiction behavior.
    When a person seeks treatment for an opioid use disorder, the first 
step is to meet with a doctor or other medical staff member for an 
individualized assessment. It is during the assessment that a doctor or 
substance use disorder professional discusses treatment choices with 
the person. This discussion empowers the person to develop an 
individualized treatment plan that addresses their specific needs 
including which medication is available and appropriate for the 
patient. A key component of MAT is counseling. It is through counseling 
that people learn about the disease of addiction--why the addiction 
occurred, the problems it has caused, and what they need to change to 
overcome those problems. Counseling can also provide encouragement and 
motivation to stay in treatment. It can teach coping skills and how to 
prevent relapse. It can help people learn how to make healthy 
decisions, handle setbacks and stress, and move forward with their 
lives. The third part of MAT is recovery support. Recovery support is 
provided through treatment, services, and community-based programs by 
peer providers, family members, friends and social networks, the faith 
community, and people with experience in recovery. Recovery support 
services help people enter into and navigate systems of care, remove 
barriers to recovery, stay engaged in the recovery process, and live 
full lives in communities of their choice. Examples of recovery support 
services include supported employment, education, and housing; 
assertive community treatment; illness management; and peer-operated 
services.
    Ultimately, MAT can help people move into healthy, addiction-free 
lifestyles--into a way of living referred to as recovery in which a 
person improves their health and wellness, live self-directed lives, 
and strive to reach their full potential.

    Question 2. Can you discuss SAMHSA's recruitment efforts to attract 
and retain senior staff with medical, clinical, and direct patient care 
backgrounds such as psychiatric physicians or other mental health 
providers?
    Answer 2. As a public health agency, SAMHSA employs individuals 
with a broad range of skills and training in order to achieve its 
mission and appropriately conduct activities under each of its key 
roles. Although SAMHSA does not provide direct clinical services, it 
employs numerous behavioral health professionals. Among these 
outstanding professionals are medical doctors and other individuals 
with masters and doctorates in psychology, social work, professional 
counseling, nursing, accounting, communications, statistics, pharmacy, 
and forensic toxicology, as well as individuals with bachelor's level 
degrees in key behavioral health fields and peer professionals.
    SAMHSA is currently recruiting for a Chief Medical Officer, a 
position that was vacated earlier this year.

    Question 3. How does SAMHSA interact with other HHS agencies and 
Federal departments concerning the development and implementation of 
mental health and substance abuse policies? What improvements--if any--
could be made in this area?
    Answer 3. SAMHSA works with other HHS agencies and Federal 
departments on the development and implementation of mental health and 
substance abuse policies every day.
    The primary mechanism for intra-agency coordination is the 
Behavioral Health Coordinating Council (BHCC) which is co-chaired by 
the Acting SAMHSA Administrator and the Acting Assistant Secretary of 
Health. The BHCC coordinates behavioral health policy activities within 
HHS, by facilitating information sharing and collaboration across the 
Department. The BHCC's goal is to share information and ensure that all 
behavioral health issues are being handled collaboratively and without 
duplication of effort across the department. It has several 
subcommittees on topics such as serious mental illness, behavioral 
health quality measures, prescription drug abuse, and primary and 
behavioral health integration among others.
    A recent example of cross-HHS work relates to the implementation of 
Section 223 of the Protecting Access to Medicare Act which created a 
demonstration project to establish certified community behavioral 
health clinics to deliver high-quality behavioral health care. In May, 
SAMHSA, in conjunction with CMS and the Assistant Secretary for 
Planning and Evaluation (ASPE), released a funding announcement 
inviting States to apply for a planning grant related to the 
demonstration program. The funding announcement included the criteria 
for States to certify Community Behavioral Health Clinics which was 
developed by SAMHSA and guidance on the development of a Prospective 
Payment System for testing during the demonstration program by CMS. 
ASPE has been highly engaged in both sets of guidance and will be 
conducting an evaluation of the program. In October, SAMHSA awarded 
planning grants to 24 States and 8 States will begin a Medicaid 
demonstration program in 2017.
    At the interdepartmental level, there are also a number of 
coordinating bodies that focus on the needs of individuals with mental 
illness and substance use disorders. For example:

     SAMHSA leads the Federal Working Group on Suicide 
Prevention and co-manages the National Suicide Prevention Lifeline with 
the U.S. Department of Veterans Affairs (VA);
     SAMHSA serves as the HHS lead for the Interagency Task 
Force on Military and Veterans Mental Health, which is tasked with 
implementing the President's Executive order related to military, 
veterans and their families' mental health;
     SAMHSA provides leadership for the Federal Partners 
Committee on Women and Trauma;
     SAMHSA also recently co-chaired two committees of the 
National Heroin Task Force which was convened by DOJ and ONDCP and 
produced a Final Report on December 31, 2015.
                             senator hatch
    Question. As you know, the United States is in the midst of a 
severe opioid abuse epidemic. In 2013 alone, approximately 1.9 million 
Americans met the diagnostic criteria for abuse or dependence on 
prescription pain relievers.
    Given the severity of the opioid addiction epidemic, what role do 
you think Medication Assisted Therapy should have in combating the 
problem?
    Answer. Research has shown that a comprehensive approach to 
treatment yields the best results. By combining the different 
components of treatment, such as withdrawal management, use of FDA-
approved addiction pharmacotherapies--otherwise referred to as 
Medication-Assisted Treatment (MAT)--counseling, and recovery support 
in a manner that is individualized to meet the needs of the individual, 
the best possible outcomes can be promoted. These outcomes include 
reduced death from overdose, reduced infection with HIV and Hepatitis 
C, improved social functioning, and reduced criminal activity. To 
accomplish this MAT needs to be available in all its forms wherever 
people seek treatment. Persons with opioid use disorder need access to 
all forms of effective therapy in the same way that someone with 
diabetes needs to be treated with the medication that will work best 
for him or her.
                            senator roberts
    Question 1. Access to substance abuse and mental health services 
and treatment in rural States like Kansas continues to be a problem. 
What is being done to address this within your respective agencies?
             samhsa's community mental health block grant.
    Answer 1. A regional model is being used for allocation of SAMHSA's 
Community Mental Health Block Grant (MHBG) funds for Kansas. The 
Regional Model brings specialized and evidenced-based services to every 
region including rural areas. This approach equips the mental health 
system to serve a wider variety of challenges through collaboration, 
capacity building and resource sharing among the individual Community 
Mental Health Centers (CMHCs) that comprise the region. This also will 
expand the mental health system's funding by leveraging MHBG funds with 
other resources to accomplish long-term goals. Last, this approach 
encourages a systemic perspective, which creates potential for more 
efficiency and more cost savings.
    Kansas has contracted with three Managed Care Organizations (MCO) 
to provide children and families greater choice of care. This also 
ensures a child and their family's timely access to services and a 
provider within a specified timeframe in rural, semi-urban and urban 
communities across the State. With the MCO's in place this will also 
increase the accountability of our system. The MCO's will be capable of 
identifying gaps and barriers within our system.
    On July 1, 2014 Health Homes for people with serious mental illness 
were implemented as Kansas believes that they are a critical core 
component of the positive health outcomes expected from KanCare. The 
comprehensive and intensive coordination of care provided by Health 
Homes will result in positive outcomes for KanCare members who 
experience chronic conditions such as serious mental illness (SMI) or 
diabetes.
    Health Homes will ensure that:

     Critical information is shared among providers and with 
Health Home consumers;
     Members have the tools they need to manage their chronic 
conditions;
     Critical screenings and tests are performed regularly and 
on time;
     Unnecessary emergency room visits and hospital stays are 
avoided; and
     Community and social supports are in place to help Health 
Home consumers stay healthy.

    There are 26 licensed Community Mental Health Centers (CMHCs) that 
currently operate in the State. These Centers have a combined staff of 
over 4,000 providing mental health services in all 105 counties of the 
State. Together they form an integral part of the total mental health 
system in Kansas. Each of the 26 licensed CMHCs operating in Kansas has 
a separate duly elected and/or appointed board of directors. Each of 
these boards is accountable to the citizens served, its county 
officials, the State legislature, and the Governor; and all have 
reporting responsibilities to the national level of government. The 
primary goal of CMHCs is to provide quality care, treatment and 
rehabilitation to individuals with mental health problems in the least 
restrictive environment.
    The Centers provide services to all those needing it, regardless of 
their ability to pay, age or type of illness. The Centers strongly 
endorse treatment at the community level, to allow individuals to 
experience recovery and live safe, healthy lives in their homes and 
communities. Staff are assigned to assist and support the development 
of funding programs for children and families which includes the Youth 
Leaders in Kansas Program (YLinK). This program is for youth ages 12 to 
18; with the support and guidance of their parents/guardians; to 
support them with information, education and development of individual 
and group leadership skills in their community, statewide and 
nationally. They also oversee the Family Care Treatment (FCT) which was 
replicated from the Oregon Model of Intervention with Antisocial Youth 
and their Families. This program trains therapists in providing 
interventions to youth who are experiencing severe challenging 
behaviors which threaten their continued success in a family setting 
and their families who reside in Kansas to increase their pro-social 
behaviors and their families' ability to positively support them. The 
target population of this effort is children who have had or are at 
serious risk of having multiple foster care placements and/or children 
referred to State hospitals or other in-patient treatment or Juvenile 
Justice Programs due to severe challenging behaviors.
    In 2015, the needs assessment focused on transitional care 
services. The housing options assessed include the following:

     Emergency Shelter--Any facility whose primary purpose is 
to provide temporary shelter for the homeless in general or for 
specific populations of the homeless.
     Interim Housing--Short-term (up to 6 months) project-based 
housing that provides immediate community-based housing for persons who 
are homeless or who are homeless and being discharged from inpatient or 
residential mental health or substance use treatment facility (e.g., a 
State psychiatric hospital (SPH), nursing facility for mental health 
(NFMH), substance use disorder (SUD) treatment facility or community 
hospital inpatient psychiatric program.
     Structured Care Living Environment--Short-term residential 
facility providing a safe, structured environment for individuals with 
high psychiatric needs. Services are available 24 hours per day and are 
offered according to clinical need. The facility can be owned or leased 
by the CMHC or owned by a community organization. Length of stay in the 
facility is short term and is no more than 6 months.
     Housing Vouchers--Short-term financial assistance used to 
temporarily place an individual or family in a hotel following 
discharge from an institution.
     Transitional Housing Beds--Short-term housing beds coupled 
with supportive services. Short term stays can be defined as residing 
in the beds for up to 6 months; 6 months--1 year, or 1-2 years.
     Rapid-Rehousing--Programs to assist individuals and 
families who are homeless move as quickly as possible into permanent 
housing and achieve stability in that housing through a combination of 
short-term rental assistance and supportive services.
     Housing Placement Services--Services to help people find 
permanent housing after discharge from the transitional housing option.
            evidence-based practices for early intervention
    Kansas utilized the Mental Health Block Grant 5 percent set aside 
to develop and issue a Request for Proposal (RFP) that was for eligible 
applicants from one of the 26 Community Mental Health Centers (CMHC) 
within the State for competitive bid. The RFP would create a pilot for 
establishing a Coordinated Specialty Care (CSC) program designed to 
provide early interventions services for persons experiencing first 
episode psychosis (FEP). The proposals provided for early episode 
Serious Mental Illness (SMI) interventions; including early psychotic 
disorders which incorporate the Recovery After an Initial Schizophrenia 
Episode (RAISE) model of intervention and supports by NIMH.
    Funds are used to serve individuals with a serious mental illness 
who within 1 week to 2 years have experienced their first episode of 
psychosis. The age range of the target population is 15-25-year-olds. 
The diagnosis that is used for inclusion in the program, following the 
recommendations of the RA1SE model, include: schizophrenia, 
schizoaffective disorder, schizophreniform disorder, brief psychotic 
disorder, psychosis not otherwise specified and delusional disorder. 
Funds were awarded to Wyandot Center for Community Behavioral 
Healthcare, Inc. in 2015. Wyandot has established an Early Intervention 
Team (EIT) and has completed all required trainings. They began 
accepting participants in the program in April 2015. From April 1st to 
May 31st there were 19 referrals; 6 were accepted into the program and 
13 were pending at the time of the last report.
                     samhsa's discretionary grants
    SAMHSA currently has 13 discretionary grants in Kansas that include 
programs to promote statewide family networks, statewide consumer 
networks, data infrastructure, suicide prevention, early childhood 
education and referrals, jail diversion, Tribal behavioral health, and 
Mental Health First Aid. These grants ensure a wide range of support 
for mental health treatment and services in Kansas.
                   medicated assisted treatment (mat)
    SAMHSA conducts a number of activities to address barriers to MAT 
in rural States. These include technical assistance to opioid treatment 
programs and support in opening and operating medication units to 
reduce the burden of travel for persons receiving care in programs 
serving large geographic areas. The Provider Clinical Support System 
for MAT provides training and mentors to health professionals in rural 
States to working in isolation or new to the area of addiction 
treatment in order to increase adoption of evidence-based practices and 
delivery of high-quality care. SAMHSA is piloting a collaborative 
learning community for providers using the Extension for Community 
Healthcare Outcomes (ECHO) model designed for improving access in rural 
States so busy providers without access to academic or specialty 
consultation can acquire the skills they need to manage challenging 
patients in their communities. In addition, in 2015 SAMHSA awarded 11 
grants for the Targeted Capacity Expansion: Medication Assisted 
Treatment-Prescription Drug and Opioid Addiction (MAT-PDOA) to States 
partnering with hard hit communities to develop MAT and the counseling 
and ancillary services necessary for MAT to be most successful. Two of 
the grants were awarded to rural States, Iowa and Wyoming.

    Question 2. I have heard about the VA utilizing people called Peer 
Support Specialists to help and support individuals with mental health 
and substance use conditions. How are SAMHSA and HRSA utilizing peer 
support specialists and what more can be done to expand their use in 
the private sector?
    Answer 2. SAMHSA and HRSA have been working closely together to 
explore the increased use of peer support specialists in a wide variety 
of integrated behavioral and physical health care settings. We have 
collaborated to explore the documentation of promising practices 
including such issues as scope of practice, certification standards, 
reimbursement strategies, and ongoing training. In addition, through 
the Behavioral Health Workforce Education and Training Grants offered 
in academic year 2014-15, SAMHSA and HRSA have supported the training 
of 960 students in a variety of paraprofessional certificate programs, 
including peer professional programs. The utilization of peer support 
specialists in States across the country is a fast expanding area of 
employment.
    SAMHSA's Bringing Recovery Supports to Scale Technical Assistance 
Center Strategy (BRSS TACS) aims to build resilience and facilitate 
recovery by developing, promoting and disseminating effective policies 
and practices to support the development and expansion of addiction and 
mental health recovery support initiatives and strategies. Through BRSS 
TACS, SAMHSA provides policy/data analysis, training, technical 
assistance, and needed information tailored to the perspectives of 
States, counties, behavioral health systems officials and providers, 
including consumer/peer providers, family members, and other 
stakeholders in recovery-oriented services and systems.
    SAMHSA in conjunction with diverse stakeholders and subject matter 
experts from the mental health consumer and substance use disorder 
recovery movements developed the first integrated guidance on core 
competencies for peer workers with mental health and substance-use 
lived experience. These competencies provide guidance for the 
development of initial and on-going training designed to support peer 
workers' entry into the peer workforce and continued skill development.
    SAMHSA has also offered funding and planning assistance to States, 
territories and tribes or tribal organizations to develop and implement 
actions plans that engage peers; funded two subcontracts to peer-run 
and recovery community organizations. One subcontract supports 
education, planning, and implementation of recovery supports. A second 
aims to build the capacity to implement statewide outreach and 
dissemination efforts that increase knowledge of health care policies 
and activities; and provided training and technical assistance to 
promote further adoption and implementation of recovery supports and 
services nationwide.
    BRSS TACS has:

     Disseminated training and technical assistance products 
about the benefit of peer services to approximately 4,799 people 
nation-wide who have opted in to receive messages from SAMHSA BRSS TACS 
about the benefit of peer services and recovery coaching.
     Funded 26 peer subcontracts in amounts up to $40,000 for 
an estimated total amount of $1 million to peer-run/recovery community 
organizations to promote the adoption of peer-delivered, recovery-
oriented services for people in recovery.
     Funded 43 peer subcontracts in amounts up to $40,000 for 
an estimated total amount of $1.7 million to peer-run/recovery 
community organizations to build the capacity to implement statewide 
outreach and dissemination efforts that increase knowledge of health 
care policies and activities, and changes in health care systems and 
services for people in recovery from mental health and/or substance use 
disorders.
     Funded 30 State planning subcontracts to behavioral health 
authorities in designated State, territories and tribes in the amount 
of $50,000 for an estimated total amount of $1.5 million for the 
development of peer specialist/recovery coach programs, the expansion 
of peer-operated services, establishment of shared-decisionmaking 
approaches and the initiation of supported employment programs.
     Funded four annual State policy academies to 25 State 
teams participating in amounts up to $75,000 for an estimated total 
amount of $1.8 million to assist States, territories and tribes or 
tribal organizations to develop and implement actions plans that engage 
peers, address development of system, service provision, and treatment 
approaches for more effective utilization of all Federal, State and 
local funding sources and resources in addressing the goals and 
objectives of SAMHSA's Recovery Support Initiative. One additional 
State Policy academy will include five jurisdictions in 2016.

    Although SAMHSA's current activities contribute the expansion of 
recovery supports and services by peer-run/recovery community 
organizations, and more effective utilization of funding sources in 
systems, service provision and treatment approaches within the States, 
some of these practices can be shared collaboratively with the private 
sector. One natural place to begin is with organizations or entities in 
the private sector that exist in the communities served by SAMSHA and 
Federal partners.
    Examples of milestones to consider include an increase access to 
care, integrate delivery of recovery-oriented services and supports, 
and increase coordination of effective eservices across systems. 
Recipients of the subcontracts to peer-run/recovery community 
organizations to receive or provide technical assistance may also work 
in public and private sectors. For example, Project Return Peer Support 
Network in California led an initiative to reduce negative perceptions 
about mental health by training peers to effectively share experiences 
in recovery using a stigma and discrimination model in Latino 
communities.
    BRSS TACS has also hosted training and provided technical 
assistance for efforts and innovations that support and promote peer 
services and inclusion of peers in the behavioral health workforce. 
Examples include SAMHSA's establishment of a new strategic initiative 
focused on workforce issues; the development of a set of core 
competencies for peer providers; and the development of national 
practice guidelines for peer providers. Skills acquired can be applied 
to both sectors.
    In June 2015, SAMHSA/CMHS held a 2-day dialog meeting to discuss 
the financing of recovery support services, including peer services, in 
the public and private sectors. A variety of stakeholders from both 
sectors participated in this dialog discussing/exploring ways to (1) 
expand access to treatment for serious mental illness (SMI) and co-
occurring disorders and access to recovery support services with 
evidence-based practices (EBP) to improve outcomes and (2) further 
engage the private sector in financing. This dialog not only forwarded 
the discourse on recovery support services between public and private 
stakeholders, but also yielded several short- and long-term 
recommendations. A summary of the meeting will be published in the next 
few months.
    SAMHSA/CSAT promotes the utilization of peer support specialists/
peer recovery coaches through several grant funding initiatives that 
build the capacity of community-based, faith-based organizations and 
State substance abuse treatment systems and other allied health systems 
to employ peer support specialists/peer/recovery coaches , as well as 
to train and certify peer support specialists/peer/recovery coaches 
that expand the behavioral health workforce and reach beyond clinical 
treatment into the individuals every day environment. Since 1998, 
SAMHSA/CSAT has funded over 104 programs across the Nation and in 
tribal communities to train and employ peer support specialists/peer/
recovery coaches , and to provide peer recovery support services in 
local communities and in behavioral health treatment systems. SAMHSA/
CSAT also supports the use of peer specialists in discretionary grant 
programs of adolescent treatment, criminal justice re-entry, including 
drug courts, and in supportive housing grants. Peer support 
specialists/recovery coaches could be expanded and enhanced through a 
comprehensive training and certification network that is supported and 
monitored through a Peer Specialist guild that provides oversight to 
training, supervision ethical codes of conduct, practice standards, and 
competencies for the work of peer specialists/recovery coaches. Unlike 
other professions, peer practice through certification and other 
standards vary among States and forms of reciprocity across States and 
health care systems do not exist. The private sector can benefit the 
work of the peer specialist/recovery coaches through the promotion of a 
career ladder that may have varying specializations for work in 
specialty areas as forensics, healthcare, children and youth, etc.
    Use in the private sector could also be expanded by support from 
standardization of funding mechanisms. For example, some States support 
Medicaid reimbursement of peer specialists/recovery coaches in certain 
settings, whereas other States do not reimburse for the same ``peer 
specialist'' service. Likewise, there is discrepancy across 
disciplines. Often the mental health discipline is able to reimburse 
for peer support specialists when equally trained peer support 
specialists or recovery coaches in the substance use disorder field are 
not considered ``reimbursable.''

    Question 3. The number of individuals dying by suicide continues to 
increase. Please tell me what the agency is doing to help individuals 
in crisis and connect them with care so we can save lives?
    Answer 3. SAMHSA is very concerned about the increasing number of 
suicides in the United States. Much of this increase is in suicides 
among adults: from 1999 to 2010, the suicide rate among middle-aged 
Americans (35-64) rose significantly, by 28.4 percent (Centers for 
Control and Prevention. MMWR 2013;62:321-3). The largest number of 
suicides is also among adults: CDC's recently released 2014 mortality 
data show that 87 percent of the suicides in this country are among 
adults (aged 25+).
    In contrast, the majority of community-based federally funded 
suicide prevention programs focus on young people. Currently the United 
States supports a major effort in youth suicide prevention at SAMHSA 
through the Garrett Lee Smith Memorial Act, as well as the Tribal 
Behavioral Health Program, both of which focus on young people through 
age 24, which have demonstrated effectiveness in reducing youth suicide 
attempts and fatalities. The Departments of Veterans Affairs and 
Defense implement significant efforts for their specific populations, 
veterans and active duty military. Our sister agencies NIH (NIMH) and 
CDC conduct research and surveillance, both of which are vital for 
effective suicide prevention work. However, there is no major national 
suicide prevention program aimed at adults, with the exception of 
SAMHSA's small National Strategy for Suicide Prevention grants 
(currently funded at $2M, proposed at $4M in the President's fiscal 
year 2015 and fiscal year 2016 budgets).
    The National Suicide Prevention Lifeline (Lifeline), which serves 
all ages, is a major life saving crisis intervention resource that can 
be accessed anywhere in the country at any time of the day or night. 
Over 160 crisis centers across the country receive calls from the 
Lifeline and in the past year the Lifeline answered over 1.5 million 
calls. SAMHSA evaluation studies have shown that approximately 25 
percent of these calls are from individuals who are actively suicidal 
at the time of the call. The Lifeline, which can be reached at 1-800-
273-TALK (8255), also provides access to the Veterans Crisis Line 
through an agreement with the Veterans Health Administration.
    SAMHSA places major emphasis on improving the care of both youth 
and adults in crisis by working to improve followup services after 
someone who has attempted suicide is discharged from inpatient units 
and emergency rooms. These are times of very high risk where studies 
have shown that intervention, especially assisting people transition to 
the next level of care, can save lives. Improving such care transitions 
is a requirement of SAMHSA's Garrett Lee Smith and National Strategy 
grants, and SAMHSA has provided small grants to a cadre of Lifeline 
crisis centers to assist them in providing these services. In addition, 
SAMHSA is working with the National Action Alliance for Suicide 
Prevention on promoting and implementing comprehensive crisis 
intervention services, as well as on improving care transitions.
                             senator murray
    Question 1. Integrating mental health care with primary care is 
critical to Washington State's effort to reform the health care system. 
One project in particular is making a big difference in the lives of 
patients with mental illness. The Washington Mental Health Integration 
Program is a partnership between the University of Washington AIMS 
Center has partnered with Community Health Plan of Washington 
throughout the State and expanded to additional sites in King County by 
working with Seattle and King County Public Health. It has promoted an 
evidence-based model for collaboration between primary care and mental 
health providers to hundreds of community health centers across the 
State serving more than 50,000 patients with mental health and 
substance use disorders. I know that there are many similar projects 
underway across the country.
    How are SAMHSA and HRSA supporting the integration of mental health 
and primary care? How are community health centers helping to support 
this work?
    Answer 1. SAMHSA's Center for Mental Health Services recently 
awarded an additional 60 grants for Primary and Behavioral Health Care 
Integration (PBHCI) bringing the total number of active grantees to 
121. The purpose of the program is to improve the physical health 
status of people with serious mental illnesses (SMI) by supporting 
communities to coordinate and integrate primary care services into 
publicly funded community mental health and other community-based 
behavioral health settings. An estimated 75 percent of the active PBHCI 
grantees partner with a federally Qualified Health Center to provide 
onsite primary care services. Grantees are working toward integrating 
primary and behavioral health care services in their facilities.
    The SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) 
promotes the development of integrated primary and behavioral health 
services to better address the needs of individuals with mental health 
and substance use conditions, whether seen in specialty behavioral 
health or primary care provider settings. CIHS is funded jointly by 
SAMHSA and HRSA.
    CIHS provides training and technical assistance to community 
behavioral health organizations, community health centers, and other 
primary care and behavioral health organizations.
    The Primary and Behavioral Health Care Integration (PBHCI) grant 
program helps prevent and reduce chronic disease and promote wellness 
by treating behavioral health needs on an equal footing with other 
health conditions.
    CIHS support increases the number of:

     Individuals trained in specific behavioral health-related 
practices;
     Organizations using integrated health care service 
delivery approaches;
     Consumers credentialed to provide behavioral health-
related practices;
     Model curriculums developed for bidirectional primary and 
behavioral health integrated practice; and,
     Health providers trained in the concepts of wellness and 
behavioral health recovery.

    CIHS has a number of resources available that outline the need for 
integrated health services and the barriers to achieving these models. 
A selection of key resources is included below:

     Evolving Models of Behavioral Health Integration in 
Primary Care: Summarizes the available evidence and States' experiences 
around integration as a means for delivering quality, effective 
physical and mental health care.
     Behavioral Health Homes for People with Mental Health & 
Substance Use Conditions: Core Clinical Features: Proposes a set of 
core clinical features of a behavioral health home (i.e., a behavioral 
health agency that serves as a health home for people with mental 
health and substance use disorders). The report provides context to the 
development of the health home option and its relationship to the 
person-centered medical home; outlines established principles of 
effective care and the chronic care model for serving people with 
chronic illnesses; applies the chronic care model as the framework for 
the behavioral health home's clinical features; and describes multiple 
organizational models for structuring the behavioral health home.
     Reimbursement of Mental Health Services in Primary Care 
Settings: Identifies the barriers to successful provision and 
reimbursement of mental health services by practitioners in primary 
care settings.
     Strategies for Integrating and Coordinating Care for 
Behavioral Health Populations: Case Studies of Four States: Provides 
case studies of four State programs that harnessed different funding 
streams and used a variety of strategies to organize and deliver care.

    Integration of Mental Health Substance Use and Primary Care: 
Addresses the evidence for integration of mental health services into 
primary care settings and primary services into specialty outpatient 
settings through a comprehensive systematic review.

    Question 2. Behavioral health crises are a critical time for 
individuals with mental illness or substance use disorders. Individuals 
in crisis and their loved ones don't always know where to turn. Local 
governments, States, and community organizations work hard to 
coordinate responses but our fragmented health care system complicates 
this work.
    What resources do communities need to improve care coordination 
when someone experiences a behavioral health crisis? What additional 
support do individuals and families need so that they know where to 
turn in a crisis situation?
    Answer 2. In 2014, SAMHSA examined the effectiveness and costs of a 
number of psychiatric emergency services to stabilize and improve 
psychological symptoms of distress and to engage individuals in the 
most appropriate course of treatment. In contrast to the traditional 
hospital inpatient-based care settings available to individuals in need 
of immediate attention for psychiatric or substance abuse symptoms, 
crisis services include an array of services that are designed to reach 
individuals in their communities through telephone hotlines or warm 
lines, and mobile outreach; and to provide alternatives to costly 
hospitalizations--such as short-term crisis stabilization units and 23-
hour observation beds.
    Over the past year, input from consumers and their families, crisis 
responders, and system administrators through webinars, interviews, 
focus groups, and expert panel meetings, has elaborated the elements of 
a comprehensive response system and how components of the system should 
work together. A continuum of services has emerged that follows a 
public health model (prevention, early intervention, intervention/
stabilization and post-vention), beginning with the individuals' and/or 
their families' initial experiences of crisis and extending to more 
intrusive and costly interventions.

     Prevention: access to quality behavioral health care 
treatment; housing education, social supports, peer and family 
supports, wellness recovery action plans (WRAP), psychiatric advanced 
directives (PAD), and family psycho-education.
     Early Intervention: warm lines, hotlines, mobile crisis 
outreach, Open Dialogue model interventions, and respite services.
     Intervention and Stabilization: recovery centers; 23 hour 
crisis stabilization; mobile crisis teams; Crisis Intervention Teams 
(Police CIT); detox centers; short-term crisis residential; Emergency 
room and inpatient settings.
     Post-vention: assessment/reassessment of services and 
supports; WRAP post crisis planning, transitional support including 
case management, family support, and peer bridgers.

    Effective crisis response systems are dependent upon the adequacy 
of the community behavioral health system in which they are embedded. 
Individuals with access to an adequate array of behavioral health 
services are less likely to require more intensive, expensive and 
potential traumatizing emergency room visits and hospitalizations. The 
better the community behavioral health system, the more likely that it 
can prevent a crisis from occurring in the first place or provide low 
cost and less intrusive practices to address the crisis. Similarly, 
after the emergency room or hospitalization occurs, post-crisis or 
bridging services and supports are needed to prevent recurrence. The 
most effective crisis response systems are understood as vital 
components of the larger community behavioral health services and not 
separate or parallel systems accessed only to execute detentions and 
hospitalizations.
    While most States have some components of the continuum, the entire 
continuum of services, is not universal across the country or even 
across a state. Prevention activities, particularly wellness recovery 
action plans (WRAP), psychiatric advanced directives (PAD), and family 
psycho-education can enable consumers and their families to respond to 
crises with greater self-efficacy.

    Question 3. As the author of the Children's Recovery from Trauma 
Act, I am a strong supporter of the National Child Traumatic Stress 
Network. This program--administered by your agency--supports a 
nationwide network of centers that provides evidence-based treatment, 
services, and training related to child trauma. One of the strengths of 
this program is its broad emphasis on evidence-based care for children 
recovering from trauma. The bipartisan Mental Health Awareness and 
Improvement Act, seeks to strengthen this work.
    How does SAMHSA intend to continue to support the Network and 
emphasize evidence-based care? What are some examples of how SAMHSA 
will strengthen the network's work?
    Answer 3. SAMHSA's National Child Traumatic Stress Initiative 
(NCTSI) grant program is a leader in developing and disseminating 
evidence-based trauma treatment, consultation, training and other 
information to address child traumatic stress. SAMHSA continues to 
actively work to support the National Child Traumatic Stress Network 
(NCTSN) as the Nation's key resource for evidence-based child trauma 
information for families, providers and other stakeholders. SAMHSA is 
in the process of issuing Funding Opportunity Announcements (FOAs) for 
up to 78 fiscal year 2016 grant awards that will continue and expand 
the work and impact of the NCTSN. SAMHSA staff is engaged in ongoing 
linkage with NCTSN leadership, through participation in the NCTSN 
Steering Committee, the NCTSN Advisory Board, and regular calls with 
leadership of the National Center for Child Traumatic Stress. As a 
result, new opportunities and ongoing commitments to improve or expand 
NCTSN impact are discussed, developed and implemented.
    A unique role SAMHSA plays in strengthening the work of the Network 
is that of bringing the essential work and benefits of the NCTSN to the 
awareness of Federal partners who are helping to disseminate Network 
information and resources broadly. Through linkages with the Agencies 
such as the: Administration for Children and Families (ACF), Centers 
for Medicare and Medicaid Services (CMS), Federal Emergency Management 
Agency (FEMA), and the Department of Justice (DOJ), SAMHSA's child 
trauma knowledge, experience and resources are routinely benefiting 
children, adolescents and families in the child welfare, Medicare and 
Medicaid, Disaster Response, and Juvenile Justice systems respectively, 
throughout the country. SAMHSA will be working to sustain established 
connections, such as those with ACF, FEMA and the DOJ, and build 
additional Federal linkages.
    An example of a newer collaboration is the provision of NCTSN-
developed information on the assessment and treatment of complex trauma 
to support the CMS Health Homes program. SAMHSA staff has been an 
active intermediary, from clarifying options that could support CMS to 
reviewing technical assistance materials that will support States that 
may wish to prioritize child trauma in their Health Homes services.
    SAMHSA has developed and increased the public awareness emphasis 
around the serious impact of child traumatic stress. In May 2015, the 
campaign, ``National Child Traumatic Stress Initiative (NCTSI): Helping 
Children Recover and Thrive'' launched a new website full of resources 
at www.samhsa.gov/child-trauma. This campaign included the creation of 
a new infographic titled, 'Understanding Child Trauma.'' SAMHSA also 
released two NCTSI child trauma educational public service 
announcements (PSA's) at this year's National Children's Mental Health 
Awareness Day event in May 2015. These PSA's entitled, Bounce and 
Notice, are available in both English and Spanish. To date, the NCTSI's 
Helping Children to Recover and Thrive Campaign PSA's have reached over 
96 million viewers online and radio airings have reached over 157 
million. Network Members have been instrumental in helping to create 
campaign products and in distributing the materials of the campaign.

    Question 4. ``Conversion'' therapy, or so-called ``reparative'' 
therapy, is a practice that falsely claims to change a person's sexual 
orientation or gender identity. This practice has been widely 
discredited by nearly all major American medical, psychiatric, 
psychological, professional counseling, educational, and social work 
professional organizations. Most concerning are the effects on children 
and youth, which can include guilt, anxiety, and societal rejection 
that negatively impacts healthy development. State legislatures across 
the country have also banned the practice including California, New 
Jersey, Oregon, Washington, and the District of Columbia.
    What steps has SAMHSA taken to address conversion therapy and 
protect young people?
    Answer 4. In October 2015, SAMHSA published a report on positive 
and appropriate ways to address distress related to sexual orientation, 
gender identity, and gender expression with children, adolescents, and 
their families. This report, which was developed in collaboration with 
the American Psychological Association and a panel of behavioral health 
experts, is the first Federal in-depth review of conversion therapy. As 
SAMHSA reported, variations in sexual orientation, gender identity, and 
gender expression are normal. Conversion therapy is not effective, 
reinforces harmful gender stereotypes, and is not an appropriate mental 
health treatment.
    SAMHSA is working with partners to broadly disseminate this 
information to providers and other stakeholders. As part of the initial 
dissemination efforts, SAMHSA staff partnered with the White House on 
the release of the report and joined White House officials such as 
Senior Advisor Valerie Jarrett and Office of Public Engagement LGBT 
Lead Aditi Hardikar for a press call, Tumblr chat and Rural Summit.

    Question 5. Improving the quality, affordability, and accessibility 
of health care remain top priorities, especially in the treatment of 
individuals with mental illness or substance use disorders. Experts are 
evaluating the impact of access to mental health facilities that 
integrate: (1) crisis stabilization services, (2) inpatient beds, (3) 
peer-to-peer counseling, and (4) onsite partnership with community 
health organizations.
    Experts are looking for nationally replicable models that 
incorporate these elements and seek to integrate their services with 
housing assistance, professional development, community health centers, 
and support groups.
    How many facilities currently exist nationwide that include: (1) 
crisis stabilization services, (2) inpatient beds, (3) peer-to-peer 
counseling, and (4) onsite partnerships with community health 
organizations?
    At the Federal level, what barriers exist for the replication and 
expansion of this model? How does the supply of health care 
professionals and associated training costs affect expansion of the 
model? How do Federal payment systems encourage the expansion of this 
type of model of care?
    Answer 5. To answer these questions, data was pulled from several 
tables drawn from the 2010 National Mental Health Services Survey 
(NMHSS) report--the most recent year for which these data are 
available. More information about the survey can be found online at: 
http://www.samhsa.gov/data/mental-health-facilities-data-nmhss/reports.
    It is important to note that the survey does not report on the 
number of facilities that offer all four types of services in 
combination. Further, the survey does not collect data on onsite 
partnerships with community health organizations.
    Table 2.15 shows the number and percent of facilities in the United 
States that employ a crisis intervention team, by facility type, for 
2010. A total of 5,295 (57.9 percent) facilities reported having a 
crisis intervention team. 2,157 (23.6 percent) facilities had a crisis 
intervention team only within the facility; 951 (10.4 percent) had a 
team only offsite; and 185 (23.9 percent) had a team both within the 
facility and offsite.
    Table 2.2 shows the number of inpatient mental health treatment 
beds in facilities providing 24-hour hospital inpatient care, by 
facility type, for 2010. A total of 1,975 (19 percent) facilities 
reported having inpatient mental health treatment beds, representing a 
total of 99,493 clients and 113,569 beds as of April 30, 2010.
    Tables 2.11a and 2.11b show the number of facilities offering 
consumer-run services (i.e., peer-to-peer counseling) as part of their 
supportive services and practices. A total of 1,849 (18.5 percent) 
facilities reported that they offer consumer-run services.
    Also in response to this question, SAMHSA also did an outreach to 
behavioral health organizations to identify case examples of facilities 
that provide all of the following services addressing both substance 
use disorders and mental illness: (1) crisis stabilization services; 
(2) inpatient beds; (3) peer-to-peer counseling; and, (4) onsite 
partnerships with community health organizations.
    The following is a list of some barriers that may impact the 
replication and expansion of integrated models of care.

     Regulatory siloes that discourage integration of substance 
use and mental health services;
     Reimbursement rates for services provided, including those 
provided by peer specialists;
     Compliance with behavioral health insurance parity;
     Workforce shortages in specialty care, in particular with 
psychiatry;
     Long term sustainability;
     IT infrastructure that allows for seamless integration of 
substance use, mental health and physical health information;
     Tools to measure consumer experiences and outcomes;
     Access to mobile applications to concurrently support 
recovery;
     Prejudice and discrimination toward individuals with 
mental illnesses and addictions; and
     System fragmentation.

    Serious workforce shortages exist for health professionals and 
paraprofessionals across the United States. For example:

     In 2011, there were only 2.1 child and adolescent 
psychiatrists per 100,000 people and 62 clinical social workers per 
100,000 people across the United States.
     Sixty-two million people (20-23 percent) of the U.S. 
population live in rural or frontier counties; 75 percent of these 
counties have no advanced behavioral health practitioners.
     In 2012, the turnover rates in the addiction services 
workforce ranged from 18.5 percent to more than 50 percent. (SAMHSA 
Website)

    The shortage of health care professionals and the associated costs 
with training and educating a competent and qualified workforce impact 
the ability to develop new models of care.
    The Medicaid Health Home model supports integration of behavioral 
health in alignment with the Triple Aim of improving healthcare, 
containing costs, and improving health outcomes. The four principles 
which are highlighted in the SAMHSA-HRSA report, Behavioral Health 
Homes for People with Mental Health & Substance Use Conditions: Core 
Clinical Features include: person-centered care; population-based care; 
data-driven care and evidence-based care.
                             senator casey
    Question 1. As a member of the Senate Finance Committee as well as 
the HELP Committee, I frequently hear about mental health and the child 
welfare system.
    Given the importance of screening for mental illness early, do any 
of the efforts funded by SAMHSA work to ensure that children who enter 
the foster care and adoption system are screened for mental illness and 
referred to appropriate treatment?
    Answer 1. SAMHSA has had, and continues to have, partnerships with 
the Administration for Children and Families (ACF) to address the 
mental, emotional, and behavioral issues for youth in the foster care 
and adoption systems.
    In 2012, SAMHSA was instrumental in hosting a 2-day meeting, 
``Domestic and International Adoption: Strategies to Improve Behavioral 
Health Outcomes for Youth and Their Families,'' to discuss science, 
policy, and practice related to behavioral health challenges of 
children who have been adopted and their families. The interagency 
planning committee for the meeting included representatives from the 
Administration for Children and Families, Centers for Disease Control 
and Prevention, National Institute on Alcohol Abuse and Alcoholism, 
National Institute on Drug Abuse, National Institute of Mental Health 
and the National Institute of Child Health and Human Development. The 
meeting provided an interdisciplinary opportunity for participants to 
share knowledge and discuss implications for future research, practice, 
and policy.
    Based on the meeting, and subsequent work, on January 28, 2015, 
SAMHSA published the document, ``Domestic and International Adoption: 
Strategies to Improve Behavioral Health Outcomes for Youth and Their 
Families.'' This document provided a summary of the expert panel 
meeting, along with suggestions for future action in the areas of 
research, practice and policy (see https://www.samhsa.gov/sites/
default/files/children-2015-domestic-international-adoption-
strategies.pdf).
    In February 2015, SAMHSA also produced a webisode (Internet 
television show) on the behavioral health needs of children, youth, and 
young adults who have been adopted. (The Adoption Webisode is available 
at www.samhsa.gov/children). The archived webisode was promoted to 
behavioral health and adoption organizations throughout the country.
    In addition to this work, SAMHSA also continues to provide direct 
services in the form of assessment and treatment to youth in the foster 
care system as part of the Comprehensive Community Mental Health 
Services for Children with Serious Emotional Disturbances program (also 
known as the Children's Mental Health Initiative or CMHI). In fact, 
youth in foster care is one of the priority populations for this 
program, which has resulted in specialized approaches from grantees 
across the country. Data from the national evaluation indicate that 
over 15 percent of referrals for this program come directly from the 
child welfare system, and outcome data demonstrate that significant 
improvements occur in the areas of mental, emotional and behavioral 
functioning. Because of the importance of this population, SAMHSA has 
had an Interagency Agreement with ACF to provide technical assistance 
specifically designed to address the needs of youth in foster care. The 
importance of this activity is further demonstrated by having a 
specific task for child welfare technical assistance in the recently 
awarded contract for a National Training and Technical Assistance 
Center (NTTAC).
                            senator franken
    Question 1. The Mental Health Parity and Addiction Equity Act 
passed in 2008. Seven years later we are still waiting for the law to 
be fully implemented. The consequences are dire. A recent report by the 
National Association of Mental Illness (NAMI) reported that:

    1. Even with insurance many people continue to struggle finding 
therapists within their network;
    2. The claims for mental health treatment are more often denied 
than those for a physical disease; and
    3, Medications for mental illness carry higher copayments. There 
have been numerous letters sent to HHS--the most recent in October--
requesting greater clarity regarding compliance and enforcement and to 
release final regulations regarding Medicaid parity.

    Please describe how the Wellstone mental health parity legislation 
and the improvements added to the Affordable Care Act have improved 
access to mental health services.
    Answer 1. The Affordable Care Act (ACA) and the regulations 
implementing the ACA included numerous provisions relevant to 
behavioral health, including increases in health coverage through the 
Health Insurance Marketplaces and Medicaid expansion; application of 
mental health parity to qualified health plans issued by the 
Marketplaces and other individual and small group health plans; and a 
requirement that young adults (under age 26) be allowed to remain on 
their parent or guardian's health plan.
    Under the Affordable Care Act, most individual and small-group 
health plans (including Qualified Health Plans), must provide essential 
health benefits, including mental health and substance use disorder 
treatment. The final rule implementing these provisions requires mental 
health and substance use disorder services, including behavioral health 
treatment, required to be covered as essential health benefits are 
subject to parity requirements laid out in the Mental Health Parity and 
Addiction Equity Act (MHPAEA).
    As a result of the ACA and MHPAEA, HHS projected in a 2013 report 
that 32 million Americans will gain new health coverage that includes 
coverage of mental and substance use disorders and an additional 30 
million people who already had insurance will benefit from parity 
protections that prevent restrictions on behavioral health benefits 
that are not also applied to physical health benefits.

    Question 2. My colleagues and I have sent a letter to HHS asking 
that the agency investigate the findings reported in the recent NAMI 
study.
    Has this investigation begun? If the investigation has not yet 
begun, what has caused the delay? If the investigation has begun, are 
you uncovering similar discrepancies between mental health and physical 
health coverage when it comes to access?
    Answer 2. SAMHSA remains committed to working with HHS to provide 
consumers access to mental health and substance-use disorder benefits. 
In the May 8, 2015 letter sent to Secretary Burwell by 17 Senators, HHS 
was asked to proactively take steps to ensure that qualified health 
plan issuers on the Federal Marketplace make public an accurate, up-to-
date list of mental health providers participating in-network; ensure 
that mental health and substance use disorder benefits are clearly 
enumerated in the summary of benefits; and require an explanation of 
benefits that includes the criteria for making medical necessity 
determinations on such coverage.
    In the HHS Notice of Benefit and Payment Parameters for 2016 final 
rule, HHS required qualified health plan issuers to publish an up-to-
date, searchable, and complete provider directory, including the 
requested information on which providers are accepting new patients. In 
addition, the rule requires issuers to make available online, and 
accessible to those shopping but not enrolled for coverage, detailed 
information about specific benefits contained the mandatory Summary of 
Benefits and Coverage (SBC) and any limitations or exclusions that 
apply. This will allow shoppers to see a comprehensive, detailed list 
of mental health and substance use disorder benefits before making a 
coverage purchase.
    Finally, the November 13, 2013 final rule implementing the Paul 
Wellstone and Pete Domenici Mental Health Parity and Addiction Equity 
Act of 2008, plan administrators must make available the criteria for 
medical necessity determinations to any current or potential plan 
participant or contracting provider on request. Further, the reason for 
any such coverage denial must also be made available to the beneficiary 
under the 2013 final rule.
    HHS is working with other Federal departments to fully implement 
parity and access to mental health and substance use disorder benefits 
as provided under the Affordable Care Act and the Mental Health Parity 
and Equity Act, and SAMHSA will continue to help identify and overcome 
barriers to doing so.

    Question 3. What additional steps can HHS and/or Congress take in 
order to alleviate disparities in access to care?
    Answer 3. In order to alleviate disparities in access to behavioral 
health care, it is important to support early intervention to address 
serious mental illness and psychosis, develop better systems to respond 
to people in crisis and continue to build the behavioral health 
workforce.
    supporting early intervention to address serious mental illness 
                             and psychosis
    Research has shown that treatment is most effective for people if 
they receive it as soon as possible after psychotic symptoms begin.
    The RAISE (Recovery After an Initial Schizophrenia Episode) Project 
funded by the National Institute of Mental Health has demonstrated 
improved outcomes compared with typical care in quality of life, 
symptoms and occupational and social functioning. Recent publications 
by RAISE investigators have shown that CSC is also cost-effective and 
can be implemented in community treatment settings nationwide (PMIDs: 
26834024 and 26481174). The use of coordinated specialty care offers 
clients personalized treatment planning, recovery-oriented therapy, low 
doses of antipsychotic medications, family education and support, case 
management, and employment or education support soon after experiencing 
first episode psychosis.
    This type of approach is being advanced across the country through 
a set-aside from SAMHSA's Mental Health Block Grant. SAMHSA is working 
with our Federal partners and States to advance this exciting approach 
across the country. Congress increased funds for this program in the 
fiscal year 2016 appropriations bill and SAMHSA appreciates continued 
engagement on this important approach.
        developing better systems to respond to people in crisis
    People having a psychiatric emergency may seek help in hospitals, 
they may be taken to the emergency rooms by first responders, or they 
may become involved in the criminal justice system. These settings 
often lack the time and staff with specialized training needed to 
address patients' needs.
    SAMHSA supports intervening earlier through crisis support services 
designed to stabilize individuals in psychological distress and engage 
them in the most appropriate course of treatment. In contrast to 
inpatient or hospital-based care, these services are designed to reach 
people in their own communities. The continuum of services includes 
telephone hotlines, peer crisis services, crisis intervention teams, 
mobile crisis services, crisis stabilization beds, short-term 
residential services, and more. In communities with robust crisis 
services, individuals experiencing mental health crises will be less 
likely to have unnecessary law enforcement contact. When they do, 
criminal justice entities will be better positioned to divert 
individuals in crisis from the criminal justice system to community-
based providers.
    To support these types of services, SAMHSA proposed a crisis 
systems demonstration program in the fiscal year 2016 budget. Support 
for this program would help mitigate the demand for inpatient beds for 
those with serious mental illnesses and substance use disorders by 
coordinating effective crisis response with ongoing outpatient services 
and supports. These new funds would provide demonstration grants to 
States and communities to build, fund and sustain crisis systems 
capable of preventing and de-escalating behavioral health crises as 
well as connecting individuals and families with needed post-crisis 
services.
           continue to build the behavioral health workforce
    In order to take advantage of coverage expansions resulting from 
the ACA and MHPAEA and connect additional people in need to treatment, 
there must be available system capacity. Strengthening the behavioral 
health workforce is central to building this capacity.
    There are a number of ways that the behavioral health workforce 
could evolve in the coming years to meet the behavioral health needs of 
Americans. By drawing on the experience of peer providers, we can 
engage individuals in treatment and ensure that they receive care that 
responds to their needs. In addition, as we move to a more integrated 
health system, it will be important to build behavioral health capacity 
into primary care settings and to develop team-based care which 
includes behavioral health expertise, so that health care systems can 
meet the range of physical and behavioral health care needs experienced 
by individuals in their care in a coordinated fashion.
    SAMHSA works closely with CMS and HRSA to expand the utilization of 
services by behavioral health professionals, including peer support 
specialists, through training grants, innovation grants, and work with 
States. Through the Behavioral Health Workforce Education and Training 
grants, professionals and paraprofessionals are being trained and 
introduced to the behavioral and physical health fields. As part of the 
President's ``Now is the Time'' initiative, funding for the SAMHSA 
Minority Fellowship program doubled and was expanded to reach addiction 
counselors.

    Question 4a. The United States has 5 percent of the world's 
population, but has 25 percent of the world's prison population. This 
is in part because mental illness has been criminalized and the 
criminal justice system has become a substitute for a fully functioning 
mental health system.
    Please specify how the Substance Abuse and Mental Health Services 
Administration and the Department of Justice working together to 
address this problem?
    Answer 4a. In fiscal year 2002, SAMHSA and the U.S. Department of 
Justice Bureau of Justice Assistance (USDOJ/BJA) began working together 
to address the problem with people with mental illness who come into 
contact with the justice system. In that year, SAMHSA issued SM-02-010 
(``Targeted Capacity Expansion Grants for Jail Diversion''), authorized 
by the Public Health Service Act, section 520G. SAMHSA funded 34 TCE 
grants that operated between 2002 and 2011.
    The initiative was coordinated with BJA's ``Mental Health Court 
Grant Program,'' authorized under PL 106-515, Part V, Section 2201. 
Congress appropriated, over a 4-year period approximately $7.5 million 
to the Department of Justice to administer the Mental Health Courts 
Program. Through this work, the two agencies established a strong and 
extensive foundation. For example, the agencies jointly coordinated and 
convened four national training and technical assistance events, 
sponsored jointly by BJA and SAMHSA, over the course of which thousands 
of criminal justice and mental health professionals learned about 
promising practices and emerging trends across the field.
    The collaboration between SAMHSA and USDOJ/BJA was described as 
follows:

          ``It is the intention of both agencies to collaborate on both 
        the implementation and analysis of these two programs. The 
        overall goal of this collaboration is to improve policy and 
        practice for addressing the needs of persons with a mental 
        illness or co-occurring disorder who become involved with the 
        criminal justice system.
          ``To this end, each agency will fund programs that do not 
        overlap by type of diversion model implemented. SAMHSA will 
        fund diversion programs for pre- and post-booking diversion 
        that do not involve continuous judicial supervision for 
        treatment and case disposition. In contrast, the Department of 
        Justice will fund Mental Health Courts that will be limited to 
        models where continuous judicial supervision is a key design 
        component.'' (quoted in SM-02-010, p.3)

    Beginning in 2002, as a result of the partnership between SAMHSA 
and BJA, the technical assistance providers for the TCE grants and the 
Mental Health Court grants launched joint quarterly meetings to ensure 
collaboration across initiatives in order to improve community-based 
responses to people with mental illness in the justice system. SAMHSA's 
GAINS Center and the Council of State Governments Justice Center have 
met quarterly since 2002. The quarterly meetings have continued for 13 
years.
    In fiscal year 2006, as a result of the initial appropriations for 
the Mentally Ill Offender Treatment and Crime Reduction Act of 2004 
(MIOTCRA) (PL 108-414), a memorandum of understanding was signed by 
SAMHSA, BJA, the National Institute of Corrections (NIC), and the 
Office of Juvenile Justice and Delinquency Prevention (OJJDP). The 
Federal Partners meetings have met two to three times per year since 
2006, with attendance by SAMHSA's GAINS Center and the Council of State 
Governments Justice Center. Since the passage of the Affordable Care 
Act, the membership of the Federal Partners has expanded to include the 
U.S. Department of Health and Human Services and the Centers for 
Medicare and Medicaid Services.
    SAMHSA participates in the BJA Justice and Mental Health 
Collaboration Program (JMHCP) and Second Chance Act (SCA) sponsored 
conferences. In addition to providing grant funding directly to States, 
tribes and units of local government the Justice and Mental Health 
Collaboration Program provides for delivery of training and technical 
assistance to grant recipients, calls for fostering collaboration 
between State and local governments, and provides that the U.S. 
Attorney General establish an interagency taskforce to facilitate local 
collaborative initiatives for people with mental illness in the justice 
system.
    The Judges' Criminal Justice/Mental Health Leadership Initiative 
was a joint initiative of SAMHSA and BJA from 2004-12. The Judges' 
Leadership Initiative was formed to help judges expand their role in 
community and State responses to the involvement of people with serious 
mental illnesses in the justice system. The JLI facilitated information 
sharing and networking opportunities among judges. The JLI was chaired 
by Judge Stephen Leifman of the 11th Judicial Circuit in Miami (FL) and 
Justice Evelyn Lundberg Stratton of the Ohio Supreme Court. Justice 
Kathryn Zenoff of the Appellate Court for the Second District of 
Illinois served as co-chair following Justice Stratton's departure. The 
JLI convened four national meetings (2004, 2006, 2008, and 2010) and 
developed three judges' guides: Judges' Guide to Mental Health Jargon; 
Judges' Guide to Mental Health Diversion; and the Judges' Guide to 
Juvenile Mental Jargon.
    Since 2010 SAMHSA and BJA have issued joint adult drug court 
solicitations. Eligible drug court models include adult drug courts, 
Tribal Healing to Wellness Courts, DWI/DUI courts, and co-occurring 
courts. 89 grants have been awarded through the initiative.

    a. 2015 (BJA-2015-4179): https://www.bja.gov/Funding/
15BJASAMHSADrug
CourtSol.pdf.
    b. 2014 (BJA-2014-3842): https://www.bja.gov/Funding/
14BJASAMHSADrug
CourtSol.pdf.
    c. 2013 (BJA-2013-3606): https://www.bja.gov/Funding/
13BJASAMHSADrug
CourtSol.pdf.
    d. 2012 (BJA-2012-3261): https://www.bja.gov/Funding/
12BJASAMHSADrug
CourtSol.pdf.
    e. 2011 (TI-11-001): Solicitation not available.
    f. 2010 (TI-10-013): Solicitation not available.

    Question 4b. What has the administration learned from these 
collaborations regarding how to best help individuals with mental 
illness when they encounter the criminal justice system?
    Answer 4b. SAMHSA recommends reducing involvement with the justice 
system for individuals with mental illness through front-end strategies 
along the Sequential Intercept Model.

     Law enforcement officers are often the first responders to 
behavioral health crises because they are the only resource available 
in many communities. Over the past two decades, law enforcement 
agencies have sought specialized interventions, such as Crisis 
Intervention Teams, to improve their responses to people experiencing 
behavioral health crises and to reduce officer injury and use of force. 
CIT was developed by the Memphis Police Department (TN). The first jail 
diversion funding, the SAMHSA KDA initiative in the 1990s, included 
Memphis CIT as a grantee. SAMHSA continued to fund CIT programs in 
Dubuque (IA), Jackson County (MO), Bexar County (TX), and Miami (FL), 
among others, through the Targeted Capacity Expansion initiative.
     However, the primary mandate of law enforcement is to 
protect public safety. Yet specialized behavioral health responses to 
people in crisis (e.g., mobile crisis teams) are often under-resourced 
and lack 24/7 coverage. Given that law enforcement officers will 
continue to be called upon, even in communities with treatment options 
available for behavioral health crises, several communities have 
launched early diversion initiatives where behavioral health 
practitioners take over for law enforcement officers during the 
encounter. SAMHSA has funded the Law Enforcement and Behavioral Health 
Partnerships for Early Diversion in three communities since 2013.

    Jail diversion programs should address public health and public 
safety goals.

     People with mental disorders in the justice system often 
have multiple and complex needs, including substance use disorders, 
chronic physical health conditions, chronic homelessness, histories of 
physical and sexual trauma, and unemployment. SAMHSA has emphasized the 
need for people with mental and substance use disorders in the justice 
system to have access to evidence-based practices, wraparound support 
services, and access to health coverage.
     The evaluation of the TCE programs found that the risk 
factors for new arrests (male participants, younger age, and prior 
arrests) among participants were consistent with risk factors for 
offender populations in general (e.g., Andrew, Bonta, & Wormith, 2006). 
Subsequent SAMHSA-funded initiatives, such as the Adult Treatment Court 
Collaboratives and the Behavioral Health Treatment Court 
Collaboratives, have emphasized the need for cognitive-behavioral 
therapies and other services that directly address risk factors for 
criminal behavior.

    Given the prevalence of co-occurring disorders, jail diversion 
programs should focus on addressing mental and substance use disorders 
rather than mental disorders alone.

     A significant number of people in the justice system have 
co-occurring mental and substance use disorders. For example, over 70 
percent of people in the justice system have substance use disorders 
and approximately 17-34 percent have serious mental illnesses--rates 
that greatly exceed those found in the general population (Baillargeon, 
et al., 2010; Ditton, 1999; Lurigio, 2011; Abram & Teplin, 1991; Abram, 
Teplin, & McClelland, 2003; Peters, Kremling, Bekman, & Caudy, 2012; 
Steadman, Osher, Robbins, Case, & Samuels, 2009; Steadman, et al., 
2013). Three-quarters of people with mental disorders in jails have a 
co-occurring substance use disorder (Teplin, Abram, & McClelland, 
1996). These individuals often require specialized interventions to 
address their CODs and supervision that is structured based on their 
needs.

    Treatment courts can be effective in addressing co-occurring 
disorders by adopting an integrative, collaborative approach.

     In the United States, there are approximately 1,500 adult 
drug courts (National Institute of Justice, 2015) and 350 adult mental 
health courts (Goodale, Callahan, & Steadman, 2013). In 2011, SAMHSA 
launched the Adult Treatment Court Collaborative, which focused on 
bridging the treatment court cultures of drug courts and mental health 
courts given the prevalence of co-occurring disorders among people in 
the justice system. The cross-site evaluation of the first cohort of 11 
grantees found that collaborative courts expanded access to services, 
expanded target populations, implemented infrastructure change, and 
consolidated activities across courts (e.g., standardized screening and 
assessment)..
     The Adult Treatment Court Collaborative experience 
resulted in guidance from the National Drug Court Institute and 
SAMHSA's GAINS Center (2013) on the adaptation of drug courts to better 
address people with co-occurring disorders. The suggested adaptations 
were as follows:

     Know who your participants are and what they need;
     Adapt your court structure;
     Expand your treatment options;
     Target your case management and community supervision;
     Expand mechanisms for collaboration; and,
     Educate your team.

    Question 5. SAMHSA's 2011 publication--``Current Statistics on the 
Prevalence and Characteristics of People Experiencing Homelessness in 
the United States,'' reports that up to 26 percent of all sheltered 
persons who were homeless had a severe mental illness and 35 percent of 
all sheltered adults who were homeless had chronic substance use 
issues. The emotional stress and physical impact from living without 
shelter predisposes these individuals to physical disease.
    This is a vicious cycle--mental illness contributes to homelessness 
and homelessness contributes to physical disease. Failing to address 
housing insecurity is limiting our ability to effectively treat mental 
illness and substance abuse. It is important to ensure that housing 
services and mental health treatment are provided concurrently in order 
to break this cycle. Permanent supportive housing is an evidence-based 
practice that facilitates recovery and housing security for individuals 
with serious mental illness.
    How is SAMHSA coordinating with HUD to examine the link between 
housing insecurity and mental illness? What best practices have been 
identified? What more is needed from the public and private sectors to 
ensure that individuals with mental illness have access to secure 
housing?
    Answer 5. According to the most recent Continuum of Care data 
published by HUD, approximately 15 percent of people who were sheltered 
had serious mental illnesses, and approximately 15 percent had chronic 
substance use disorders.\1\ (These figures include an undetermined 
number who have both conditions.)
---------------------------------------------------------------------------
    \1\ U.S. Department of Housing and Urban Development. (Oct. 17, 
2015). HUD 2015 Continuum of Care Homeless Assistance Programs Homeless 
Populations and Subpopulations. Retrieved from: https://
www.hudexchange.info/resource/reportmanagement/published/CoC_PopSub_
NatlTerrDC_2015.pdf.
---------------------------------------------------------------------------
    Overall, the number of unsheltered people declined by over 82,000 
(nearly 32 percent) between 2007 and 2014, according to HUD's most 
recent Annual Homeless Assessment Report to Congress (AHAR),\2\ but the 
number of sheltered people rose 2.5 percent in the same timeframe.
---------------------------------------------------------------------------
    \2\ Solari, C. D., Althoff, S., Bishop, K., Epstein, Z., Morris, 
S., & Shivji, A. (Nov. 2015). The 2014 Annual Homeless Assessment 
Report to Congress, Part 2: Estimates of Homelessness in the United 
States.
---------------------------------------------------------------------------
    Furthermore, significant numbers of people with behavioral health 
conditions who might otherwise remain in shelters, in transitional 
housing, or on the street are living in permanent supportive housing 
(PSH), which is not time-limited and which offers voluntary supportive 
services. The number of PSH beds in the United States increased by 59 
percent between 2007 and 2014, from 188,636 to 300,282. Approximately 
34 percent of adults living in PSH have mental illnesses, and 10 
percent have substance use disorders.
                         coordination with hud
    SAMHSA and HUD collaborate on numerous projects, and both agencies 
participate in the activities of the U.S. Interagency Council on 
Homelessness (USICH). Together, SAMHSA and USICH promote a PSH for 
people with mental and substance use disorders.\3\ Rather than 
requiring people demonstrate ``readiness'' for housing, providers are 
encouraged to place the most vulnerable people, including those with 
chronic physical and behavioral health conditions, into permanent 
housing as quickly as possible and provide flexible wrap around 
services in order to promote recovery and stability in housing.
---------------------------------------------------------------------------
    \3\ USICH and SAMHSA. (June 2014). Implementing Housing First in 
Permanent Supportive Housing. Retrieved from: https://www.usich.gov/
resources/uploads/asset_library/Implement
ing_Housing_First_in_Permanent_Supportive_Housing.pdf.
---------------------------------------------------------------------------
    HUD is an essential partner in SAMHSA's homelessness activities, 
and local Continuums of Care (which administer HUD homelessness 
funding) and Public Housing Agencies (PHAs, which administer HUD public 
housing and housing choice voucher funds) are involved in the 
implementation of SAMHSA grants. For example:
     HUD staff routinely provide technical assistance to SAMHSA 
grantees through SAMHSA's Homeless and Housing Resource Network (HHRN). 
HUD staff are involved in online learning communities for SAMHSA 
grantees; they are involved in planning virtual workshops; and they 
present at workshops and webinars. Further, SAMHSA makes its HHRN 
technical assistance available to HUD grantees, promoting events 
through HUD's email lists.
     HUD staff participated in SAMHSA's Policy Academies to 
Reduce the Prevalence of Chronic Homelessness, which operate at the 
State level to coordinate housing and services for people who have 
disabilities and who have experienced prolonged or repeated periods of 
homelessness.
     By the end of fiscal year 2016, all of SAMHSA's Projects 
for Assistance in Transition from Homelessness (PATH) grantees are 
expected to report data using the Homeless Management Information 
System (HMIS) designated by the local Continuum of Care. This 
expectation helps to streamline data gathering and analysis and ensure 
that a Continuum's plan to prevent and end homelessness provides 
appropriate services for individuals who have a serious mental illness. 
In addition, the PATH program's participation in HMIS allows for 
enhanced service coordination between SAMHSA-funded homeless outreach 
services and the housing and services provided by HUD-funded Continuum 
of Care programs.
     SAMHSA is committed to coordinated entry and actively 
supports HUD's policies and goals for developing these processes. 
Coordinated entry systems ensure that services and housing are 
prioritized for those who are most vulnerable, including those with 
behavioral health conditions. SAMHSA encourages its grantees to 
participate in their local coordinated entry systems in order to better 
integrate SAMHSA- and HUD-funded programs and to improve coordination 
of care. Joint technical assistance opportunities have highlighted the 
importance of SAMHSA grantee participation in coordinated entry 
systems, and additional technical assistance in this area is expected 
as these systems are developed and improved.
     SAMHSA's Cooperative Agreements to Benefit Homeless 
Individuals for States (CABHI-States) program requires grantee States 
to form or enhance interagency councils on homelessness that include 
PHAs.
                    identification of best practices
    SAMHSA strongly promotes PSH, which is an evidence-based practice. 
SAMHSA grants enable recipients to provide voluntary, flexible services 
to people residing in HUD-funded permanent housing. Grant applicants 
are required to describe the housing in which people reside, in order 
to ensure that best practices are followed.
    In order to promote best practices in PSH, SAMHSA offers a 
comprehensive toolkit\4\ for implementing PSH. In addition to practical 
advice for mental health agencies, housing providers, and service 
staff, the toolkit contains research on the effectiveness of the 
practice for ending homelessness, as well as a tool for programs to 
evaluate how well they are adhering to best practice standards. The 
toolkit contains extensive advice for collaboration among mental health 
agencies, PHAs, Continuums of Care, and housing providers. A revised 
and expanded version of the toolkit, containing recent research, is 
forthcoming.
---------------------------------------------------------------------------
    \4\ SAMHSA. (July 2010). Permanent Supportive Housing Evidence-
Based Practices (EBP) KIT. Publication no. SMA10-4510. Retrieved from: 
http://store.samhsa.gov/product/Permanent-Supportive-Housing-Evidence-
Based-Practices-EBP-KIT/SMA10-4510.
---------------------------------------------------------------------------
                   public and private sector support
    Opening Doors: Federal Strategic Plan to Prevent and End 
Homelessness provides a roadmap for the efforts that are needed in the 
public and private sector to ensure that people with behavioral health 
conditions have access to appropriate housing. SAMHSA, HUD, and 
numerous other Federal agencies have supported USICH in developing and 
implementing this plan. Among the key recommendations, which SAMHSA 
fully supports, are:

     Get States and localities to update and implement plans to 
end homelessness, which SAMHSA is promoting through its CABHI-States 
and PATH grants.
     Coordinate Federal technical assistance resources related 
to preventing and ending homelessness, which SAMHSA is doing by 
collaborating with HUD and other Federal agencies in its HHRN technical 
assistance.
     Make information more readily available on working 
effectively with special populations, which SAMHSA is doing by 
expanding technical assistance regarding homelessness among veterans, 
LGBT youth, older adults, and other vulnerable populations.
     Continue to increase use of HMIS by local communities and 
encourage its use by additional programs targeted at homelessness, 
which SAMHSA is doing by setting an expectation that PATH grantees 
report data through HMIS by the end of fiscal year 2016.
     Improve access to federally funded housing assistance by 
eliminating administrative barriers and encouraging prioritization of 
people experiencing or most at risk of homelessness. Although SAMHSA 
does not fund housing, its grantees work with local PHAs and Continuums 
of Care to prioritize the use of HUD resources for people with 
behavioral health conditions who are experiencing homelessness.
     Increase service-enriched housing by co-locating or 
connecting services with affordable housing. SAMHSA's PSH toolkit 
provides practical advice for achieving this aim.
     Increase use of mainstream resources to cover and finance 
services in permanent supportive housing. SAMHSA's SSI/SSDI Outreach, 
Access, and Recovery Technical Assistance (SOAR TA) Center helps 
connect people experiencing homelessness to Social Security benefits, 
with much higher success rates and in a quicker timeframe, compared to 
typical Social Security applications.
     Coordinate employment services with housing and 
homelessness assistance. Homelessness is the result of the inability to 
afford housing, and employment provides a path out of poverty. SAMHSA's 
Supported Employment evidence-based practice toolkit\5\ provides 
detailed guidance on improving employment outcomes among people with 
behavioral health conditions, including those who are experiencing 
homelessness.
---------------------------------------------------------------------------
    \5\ SAMHSA. (February 2010). Supported Employment Evidence-Based 
Practices (EBP) KIT. Publication no. SMA08-4365. Retrieved from: http:/
/store.samhsa.gov/product/Supported-Employment-Evidence-Based-
Practices-EBP-KIT/SMA08-4365.
---------------------------------------------------------------------------
     Increase the number of problem solving courts, which 
SAMHSA is doing by providing grants that divert people with behavioral 
health conditions out of jail and into treatment programs.

    Finally, a key recommendation contained in Opening Doors that 
requires concerted Federal and stakeholder action is: Bring the supply 
of permanent supportive housing to scale, in partnership with State and 
local governments and the private sector. Although communities have 
made tremendous strides in reducing homelessness, particularly among 
veterans and people experiencing chronic homelessness, hundreds of 
thousands of people continue to experience homelessness due to the lack 
of affordable housing. Currently, SAMHSA is partnering with USICH, HUD, 
CMS and several national organizations to provide up to eight States 
with targeted program support aimed at strengthening State-level 
collaboration between health and housing agencies to bring to scale 
permanent supportive housing by coordinating housing resources with 
Medicaid-covered housing-related services. The partnership is committed 
to bringing to scale the cost-effective, evidence-based solution known 
as permanent supportive housing to end chronic homelessness in 2017, as 
well as to support community integration for people with long-term 
services and supports needs. USICH, HHS, and HUD recognize that access 
to affordable, stable housing and access to coordinated and 
comprehensive health care services will improve health outcomes for 
Medicaid beneficiaries and lower health care and other public services 
costs for States and communities.
                           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.
    Does your organization support the objectives set forth in S. 524?
    Answer 1. SAMHSA envisions a Nation that acts on the knowledge 
that:

     Behavioral health is essential to health;
     Prevention works;
     Treatment is effective; and
     People recover.

    In line with this vision, SAMHSA's strategic plan, Leading Change 
2.0, includes six strategic initiatives:

     Prevention of Substance Abuse and Mental Illness;
     Health Care and Health Systems Integration;
     Trauma and Justice;
     Recovery Support;
     Health Information Technology; and
     Workforce Development.

    As a result, SAMHSA works every day to expand prevention and 
educational efforts; identify and treat justice involved individuals 
with or at risk for substance use disorders by collaborating with 
criminal justice stakeholders and by ensuring access to evidence-based 
treatment; provide training and technical assistance related to 
evidence-based substance use disorder treatment and interventions; and 
work with States, communities and partners to strengthen prescription 
drug monitoring programs and help at-risk individuals access services.
    In particular, as a public health agency, SAMHSA has a key role in 
advancing the Secretary's Opioid Initiative. Beyond, HHS, SAMHSA works 
with the Department of Justice and the Office of National Drug Control 
Policy (ONDCP) to implement ONDCP's four-part Prescription Drug Abuse 
Prevention Plan and participates in ONDCP's Interagency Workgroup on 
Prescription Drug Abuse to ensure coordination across the Federal 
Government.
    A number of SAMHSA's programs support the Secretary's initiative to 
expand the use of medication-assisted treatment (MAT). In 2015, SAMHSA 
provided approximately $1 million per year for 3 years to 11 States 
through the ``Medication-Assisted Treatment for Prescription Drug and 
Opioid Addiction'' (MAT-PDOA) grant program which allows States to 
expand or enhance MAT and other clinically appropriate services for 
persons with opioid use disorders. In fiscal year 2016, SAMHSA proposes 
to increase the program by $13 million.
    Additionally, the fiscal year 2016 Budget for SAMHSA includes $12 
million for a new program entitled Grants to Prevent Prescription Drug/
Opioid Overdose-Related Deaths which will provide grants to States to 
purchase naloxone, equip first responders in high-risk communities, and 
provide education and the necessary materials to assemble overdose 
kits, as well as cover expenses incurred from dissemination efforts.
    The fiscal year 2016 Budget for SAMHSA also includes $10 million 
for a new program Strategic Prevention Framework Rx. In fiscal year 
2016, SAMHSA is implementing this prevention program, targeted 
specifically at prescription drug misuse, to raise awareness about the 
dangers of sharing medications and to work with pharmaceutical and 
medical communities on the risks of overprescribing to young adults. 
SAMHSA's program will also focus on raising community awareness and 
bringing prescription drug use prevention activities and education to 
schools, communities, parents, prescribers, and their patients. SAMHSA 
will also track reductions in opioid overdoses and the incorporation of 
Prescription Drug Monitoring Program (PDMP) data into needs assessments 
and strategic plans as indicators of program success. SAMHSA plans to 
award up to 29 grants.
    Thus, across the spectrum SAMHSA strongly supports, and is highly 
engaged in programs related to substance use prevention, treatment, and 
recovery support.

    Question 2. Can you tell me what your agencies are doing to address 
the overlap between substance abuse and mental health issues and what 
additional tools you might like to see at your disposal?
    Answer 2. Several current SAMHSA programs promote the integration 
of substance abuse and mental health in prevention programs, treatment, 
and recovery supports.
    Addressing co-occurring mental and substance use disorders involved 
in, and at risk for involvement in, the criminal justice system is 
crucial. Current SAMHSA criminal and juvenile justice programs require 
grantees to address substance use and co-occurring mental health 
condition in their initiatives. Additionally, comprehensive, community-
based crisis systems prevent justice involvement by diverting 
individuals in a mental health or substance use crisis to treatment 
rather than jail. SAMHSA has proposed a demonstration program, Crisis 
Systems: Increasing Crisis Access Response, which would require 
participating States and communities to develop crisis systems to 
address both the mental health and addiction needs of community 
members.
    Tribal Behavioral Health Grants also promote integration for AI/AN 
communities that are at an elevated risk of both mental and substance 
use disorders.
    SAMHSA also funds the Primary Behavioral Health Care Integration 
grant program and co-funds with HRSA the Center for Integrated Health 
Solutions (CIHS). CIHS promotes the development of integrated primary 
and behavioral health services to better address the needs of 
individuals with mental health and substance use conditions, whether 
seen in specialty behavioral health or primary care provider settings.
    Other SAMHSA programs that require an integrated approach to mental 
and substance use disorder treatment and recovery include the Certified 
Community Behavioral Health Centers planning grants, and the Minority 
AIDS initiative. SAMHSA's prevention programs address the shared risk 
factors for mental and substance use disorders, including Project AWARE 
(Advancing Wellness and Resilience Education) and Project LAUNCH 
(Linking Actions for Unmet Needs in Children's Health).
    Unfortunately, significant barriers to the integration of mental 
and substance use disorder prevention, treatment, and recovery exist. 
For example, most behavioral health providers are not eligible for the 
Medicare and Medicaid EHR Incentive Programs, so they have not received 
incentives to adopt electronic health records. Adoption of electronic 
health records helps behavioral health providers furnish appropriate, 
comprehensive care that links mental health treatment, substance use 
treatment, primary care, and treatment for other chronic conditions.
                             senator warren
    Question 1. According to the Health Resources and Services 
Administration, one in eight women suffer from postpartum depression. 
In Massachusetts, the Department of Mental Health has funded the 
Massachusetts Child Psychiatry Access Project (MCPAP) for Moms--the 
first statewide program dedicated to helping medical providers 
recognize the signs of and address the symptoms of postpartum 
depression in the country. The Commonwealth's Medicaid program, 
MassHealth, recently announced that, starting next year, it would cover 
the cost of post-partum depression screening for all women who give 
birth.
    What steps has each of your agencies taken to expand programs, like 
the one in Massachusetts, to women across the country or otherwise 
address postpartum conditions?
    Answer 1. SAMHSA understands how critical it is to screen, assess, 
refer, treat, and support mothers with or at risk for post-partum 
depression. It is not only beneficial to the mother, but to the child 
and the entire family structure. SAMHSA has a long history of providing 
States, tribal nations, and communities with funds and supports to not 
only implement parental depression screenings and referral mechanisms, 
but to also support the integration of behavioral health into primary 
care, and mental health consultation into early care and education 
(ECE) settings. Both the integration efforts as well as availability of 
mental health consultation in ECE settings allow for additional 
opportunities to address the mental health and social/emotional health 
of parents and children that are being served. Since 2008, 55 5-year 
Project LAUNCH (Linking Actions for Unmet Needs in Children's Health) 
grants have been awarded, including one to Massachusetts in 2009. Over 
the 5-year grant cycle, Project LAUNCH States, tribes, and communities 
increase the quality and availability of evidence-based programs for 
children and families, improve collaboration among child-serving 
organizations, and integrate physical and behavioral health services 
and supports. Lessons learned from communities guide systems changes 
and policy improvements at the State, territorial and tribal levels, 
such as implementing universal screening efforts and integrated data 
systems. Strong partnerships lead to the sustainability and replication 
of successful practices on a large scale and to systems improvements 
lasting beyond the life of the grant.
    Project LAUNCH grantees are guided by Young Child Wellness 
Councils, which bring families and public and private partners together 
to improve policies, programs, and approaches to using data and funds 
effectively. Each Project LAUNCH community implements a core set of 
five prevention and promotion strategies drawn from current research:

     Screening and assessment in a range of child-serving 
settings (including screening, referral, and followup for parental 
depression);
     Integration of behavioral health into primary care 
(including screening, referral, and brief intervention, and followup 
for parental depression);
     Mental health consultation in early care and education;
     Enhanced home visiting with a focus on social and 
emotional well-being (including screening, referral, and followup for 
parental depression); and
     Family strengthening and parent skills training.

    Moreover, maternal mental health is a key focus of Project LAUNCH 
that is interwoven in each core strategy. For example, enhanced home 
visits include mental health services and support in a mother's home 
delivered by a trained Home Visitor or a Home Visitor and Mental Health 
Consultant. This service helps pregnant women and new mothers to see 
themselves as a nurturing mother and attach to her baby. Specifically, 
mothers are assisted to explore not only the experiences she has had 
with her own mother or caregiver(s), but also her past trauma, 
substance/alcohol use and how these past experiences impact her 
relationship with her baby now and in the future. Screening for 
depression on a regular basis through the baby's first year of life 
helps mothers understand her own emotional and mental health, improve 
the mother and child relationship, as well as promote healthy 
development of the baby and the mother's self-care. Several Project 
LAUNCH States, such as Colorado, Iowa, Missouri, and New York use this 
promising practice to address maternal mental health, and the issue of 
maternal depression.
    In addition to providing direct services, Project LAUNCH 
communities increase knowledge about healthy child development through 
public education campaigns and cross-disciplinary workforce 
development. Project LAUNCH grantees also work to address health 
disparities and this component is integrated into their work both at 
the service and system levels. A cornerstone of Project LAUNCH is the 
Federal-level partnership between SAMHSA, the Administration for 
Children and Families, the Health Resources and Services 
Administration, and the Centers for Disease Control and Prevention.
    To provide successful alumni grantees with the supports to expand 
the LAUNCH model in their States and tribes, in fiscal year 2015, 
SAMHSA awarded five Project LAUNCH Expansion grants. These 5-year 
grants provide States and tribes the opportunity for broader 
dissemination of these innovative practices and policies that will lead 
to better outcomes for young children and families. This program builds 
on previous LAUNCH efforts and aims to expand best practices in early 
childhood wellness promotion and prevention of mental, emotional and 
behavioral disorders--including screening for parental depression--into 
new communities, thereby furthering implementation of the effective 
practices.
    Massachusetts is one of the recipients of these grant funds. The 
Massachusetts LAUNCH Expansion will replicate the Mass LAUNCH model of 
integrating infant and early childhood mental health (IECMH) into 
primary care in three high-need communities. The Expansion will work 
with State agencies and other stakeholders on policy and fiscal reforms 
to develop a sustainable funding strategy for its ``power team'' model 
of a Clinician and Family Partner with lived experience.
    The Expansion will build on the original Massachusetts LAUNCH State 
and local partnership between the lead applicant, the Massachusetts 
Department of Public Health (MDPH), and the Boston Public Health 
Commission. MDPH will lead the State policy component, while the 
Commission will use the model's replication toolkit to support practice 
transformation at three new community health center sites through 
training and technical assistance, a Learning Collaborative, and onsite 
coaching.
    The goals of the Mass LAUNCH Expansion are to continue to 
demonstrate efficacy of the Mass LAUNCH model, further disseminate it, 
and sustain it, while continuing to support the development of the 
overall IECMH system of care in the State. The model replication will 
focus on two of the most successful components of Mass LAUNCH, 
integration of behavioral health into primary care and family 
strengthening and parent support. Family and community outcomes will 
include reducing parental stress (and parent depression, as well as 
reducing child social emotional risks and challenging behaviors) and 
increasing the number of primary care practices focusing on integrating 
IECMH into primary care. The Mass LAUNCH will embed a bi-lingual 
clinician and Family Partner ``power team'' in each site, paired with a 
pediatric champion and a site administrator. This team supports the 
development of a family-centered medical home with a strong IECMH 
focus, including provision of a menu of family strengthening and parent 
support services.
    The State systems outcome is financing reforms/policy change to 
support IECMH primary care integration, which will be supported by the 
State agency, community and family representatives on the Mass LAUNCH 
Young Children's Council. The Mass LAUNCH Expansion intends to serve at 
least 1,410 children, birth to 8, and their families across the three 
community health centers (240 in year one, and 390 each year in years 
2-4). The sites serve a combined number of 19,294 children. The focus 
will be on young children and families facing adverse childhood 
experiences, such as exposure to violence, substance abuse, or 
homelessness. The three communities were selected due to high needs and 
their high percentages of immigrants/refugees and Latino children and 
their families who are likely to experience behavioral health 
disparities, with Chelsea serving 62 percent, Springfield 39 percent, 
and Worcester 21 percent Latino children and families.
    In 2015, SAMHSA announced the launch of the Center of Excellence 
for Infant and Early Childhood Mental Health Consultation (IECMHC). 
Infant and Early Childhood Mental Health Consultation (IECMHC) is a 
preventive intervention that partners mental health professionals with 
children's caregivers. IECMHC builds the capacities of families and 
other providers, such as Home Visiting staff who frequently interact 
with parents, to understand and manage behaviors and build healthy 
relationships, resulting in improved social, emotional, and behavioral 
outcomes for young children.
    In one study of a Healthy Families America home visiting program, 
almost 30 percent of mothers enrolled screened positive for depression, 
and about 70 percent reported experiencing at least one violent trauma 
in their lives. Furthermore, although estimated rates of depression 
among pregnant, postpartum, and parenting mothers range from 5 percent 
to 25 percent, a review of studies revealed that between 28 percent and 
61 percent of mothers enrolled in home visiting programs were 
identified with depression (Pediatrics, 2013).
    Home visiting programs have been successful in engaging and 
enrolling families who are at high risk for stress, depression, and 
substance abuse. However, many of these mothers may not be receiving 
mental health services because home visitors lack the knowledge and 
skills to identify mental health or determine how to appropriately 
address these problems. IECMHC involves a partnership between a 
professional consultant with early childhood mental health expertise 
and home visiting or family support programs, staff, and families. This 
integrated model holds the promise of promoting parent and child 
behavioral health by enhancing the capacity of home visitors to 
identify and appropriately address the unmet mental health needs of 
children and families. SAMHSA, in partnership with ACF and HRSA, 
launched this Center of Excellence to bring together best practices and 
innovations in this area to develop a comprehensive IECMHC toolkit that 
can be used in States, tribes, and communities across the Nation.

    Question 2. What additional steps could your agencies take, within 
your existing statutory and budgetary authority, to expand screening 
programs or otherwise address postpartum conditions?
    Answer 2. At this point, SAMHSA has taken every opportunity to 
maximize our existing statutory and budgetary authority--building on 
evaluation findings, lessons learned, and the latest research to build 
capacity within States, tribal nations, and communities for screening 
for postpartum depression.

    [Whereupon, at 11:37 a.m., the hearing was adjourned.]

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