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May 03, 2005
Dr. Insel Substance Abuse Meeting
Read more... Government & Schizophrenia
Following is a short excerpt (from a very long transcript) of a US Representatives meeting on Substance Abuse and Mental Health Services that seems to have taken place on April 27th, 2005 in Washington, DC. The brief quotes immediately below are by Dr. Insel, head of the National Institue of Mental Health:
Dr. INSEL: Well, thank you, Mr. Chairman.
I'm happy to be here on behalf of the National Institute of Mental Health, and delighted that you and your leadership have asked for a hearing, specifically on this very important area of health care.
... Maybe just -- to speed things up, I just really want to make a few points and show you a few pictures to help you understand what we think is most important for the committee to know.
Initially -- and you can see from this slide on the screen here -- I think it 's going to be critical for you and other members of the committee to recognize the important burden -- public health burden -- that the disorders that you're going to hear about this morning convey for people in the United States -- and these data, which are from the World Health Organization, include United States and Canada.
The World Health Organization was making an attempt to try to understand what is the burden of illness for all of medical illnesses they could look at. And they have a particular metric for doing that. They were surprised, and I think many people here would be surprised to find out that when you do that, and when you look at the class that you call noncommunicable diseases, that the disorders that we're about this morning -- the group here -- represent the five largest sources of disabilities for people under 44 years of age -- in the 15 to 44 age group.
REGULA: Excuse me. Are these disabilities the type that are identified for Social Security purposes? Will these cause people to be put on Social Security disability?
INSEL: No, sir, these are defined by the World Health Organization by a set of metrics that they've used without reference to what the federal guidelines would be for disability.
What they're looking at are those -- these are nonfatal health outcomes that reduce employment, reduce function in a variety of ways, and have some very specific metrics that have been developed for that.
Our point here is that these represent, as a group, for people in this younger age bracket, more than 50 percent of the disability from all medical causes, suggesting that -- it's really two things.
That these are incredibly important, in terms of their public health burden, but also that if one is interested in trying to understand chronic diseases, it 's important to remember that substance abuse -- alcohol abuse, and depression, bipolar, schizophrenia -- these are the chronic disorders of the young. And in that way they're quite different from dementia, from cardiovascular disease and from many of the endocrine diseases that NIH has been involved with and other institutes.
It's also worth noting that the people who have these disorders don't often have them in an isolated way. And you can see from these numbers that if you look at people who have these very serious mental disorders, whether we're talking about major depression or bipolar illness or schizophrenia, the rate of having either alcohol or substance abuse is often in the range of almost 50 percent.
So these are not disorders that occur in an isolated fashion and that actually, co-morbidity may be as common as having any of these disorders alone; an important fact to remember as we think about the kinds of things that Mr. Curie was talking about in terms of how we provide services in the community and who we're providing those services for.
I just want to make a couple of other points, and one of them has to do with the work of this subcommittee around appropriations and costs.
We often don't recognize that many of the costs of these disorders are different than the cost of other medical illnesses in the sense that here, the indirect cost, that is the cost for social services may be greater than the direct cost -- the cost for treatment.
That's not true for hypertension, diabetes and cancer, but it's true across the board for these kinds of illnesses. And it's one of the facts here that we need to keep in mind when we think about how the nation supports people with these illnesses and what the actual public health burden would be in an economic sense.
People with serious mental illness represent the single largest group -- diagnostic group -- of those receiving SSI, the kind of disability that you asked about before.
It's also true that unlike the rest of medicine, that most of the costs here for both direct and indirect care are in the public sector. That means that more than 50 percent of all mental health expenditures are paid for by Medicaid/Medicare and state and local governments. Again, quite different from the rest of medicine, where we're often dealing with questions about third-party reimbursements and private insurance coverage.
Medicaid is the single largest payer of mental health services in the country. And just as one example, last year Medicaid wrote for more than half of the prescriptions for atypical antipsychotics, a group of medications that cost the nation over $12 billion. So this is a very large outlay of funds.
The other point that we want you to take away from this hearing is to -- and we say this every year, but it's one that I think we don't say enough -- is to remind you and others that these disorders are brain disorders. And our science has now taught us that without question.
What you see here on the screen is the evidence that we've had for some time that those people who are incapacitated by depression, whether it's bipolar depression or unipolar depression, have structural changes that we can now see with brain imaging.
But perhaps even more exciting -- what we've begun to realize in the last year with the advent of functional studies -- is that we can now begin to identify those areas in the brain where function has to change for someone to recover. And those are often areas that we hadn't recognized before as having a very important role in depression, whether we're talking about major depression, depressive disorder or bipolar depression. So we now really think about these as brain disorders.
The big difference between how we think about depression and schizophrenia and how we think about Parkinson's and perhaps Alzheimer's is in these disorders we're not talking about a specific lesion, in the sense that there are dead cells in one area, or there's a hole in the brain in the sense that you might look for some stroke victims; here what we're really interested in are changes in how the brain functions as a system and where the system is no longer functioning in a normal fashion. And we now have the tools to be able to identify that.
So for the first time, we can begin to think about these as brain disorders in a way that allows for different kinds of diagnosis and hopefully, different kinds of treatments.
My last point is just to say that as we have gotten this very new perspective on this group of illnesses, we've also had to change how we work. So one part of what we do...
Dr. Insel, I was wondering whether you couldn't just give an overall summary of how significant mental illnesses are in terms of the burden of disease here in our country and whether as a nation there's a commensurate, you know, effort and research capacity to deal with these illnesses, both for veterans and for, you know, those who are suffering from addiction disorders, in addition to those with severe mental illnesses?
Maybe you could, you know, give us some insight into the depth and burden of this disease.
INSEL: Well, thank you for that question.
Earlier in my opening remarks I spoke a little bit about this, because we do now have quantitative, as well as qualitative ways of measuring the burden of disease.
We have used the World Health Organization's approach, which has been a global effort. The data that I have up on the slide are the data for the United States and Canada.
This is an attempt to measure the burden of disease, measured in this case by disability of all medical illnesses, and the point here is that the five top disorders in people under the age of 44 -- 15 to 44 -- the top five disorders are the ones that we're concerned with this morning here.
It's -- depression, by far and away, is the largest source. It's just depression and alcohol use together represent 40 percent of all the burden from all -- or all the disability from all medical causes. So that's really quite extraordinary.
In terms of the question about what veterans face, and the issues in particular around those who are returning from Iraq, we don't have yet a good sense of how severe the burden will be.
We do know something about the experience from previous wars that we've been involved with and I thought, since you've asked, let me just share with you one very recent report on this which is a little bit worrisome.
These are data that are just out in the New England Journal in the last few weeks which suggest that as you look at the health complications of those returning from theater, that even though the rate of mental disorders was relatively low initially in some of the people who came back earliest -- and this may be difficult for you to read -- but the black bar is from February, the white bar from June and the gray bars from this past December. So this gives you some sense of the change over time.
And what you can see on the far right are cardiovascular disorders representing about 10 percent of the patients and that's, essentially, a flat line.
But what's worrisome is the mental disorders -- the far left there -- those three bars that look like a staircase, you're seeing the increase going from 15 percent to 25 percent in December, and from what we hear it's continuing to increase coming through the winter and the spring.
So we're expecting that we're going to be seeing a larger proportion of veterans coming back with mental disorders as time goes on.
The figure that we've been seeing are figures of around 15 percent to 17 percent having either depression or PTSD, or in some case another anxiety disorder.
And I think what's most of concern, given the question you asked about the burden, is that at least in the study that was published in the New England Journal, only about 23 to 40 percent, depending on the group you looked at, ever were willing to seek treatment.
So it's -- there's no question...
(UNKNOWN): Twenty-three percent of those who...
INSEL: ... who have the disorder -- or actually, while they are in service are willing to seek treatment.
So what this tells you is that when you look at the burden, as measured by treatment statistics, you're looking at a very small part of it.
(UNKNOWN): So essentially, people do not go because of the stigma. They don't want to go to mental health services, so less than, you know, around 23 percent go that are affected, and there's growing number of people who are affected.
Tell us about, like, Guard and Reserve. They're coming back, they're over half the force and yet they don't avail themselves of services for mental health within the veterans' organization, you know, because of the stigma issue.
And where do they get their health care, from the public sources or from the private sector?
You know, we're working on trying to get the private sector answer through mental health parity legislation.
But maybe you could talk about how deficient the public sector is in terms of treating that since most of our veterans -- I think there's 45 percent of our service members are Guard and Reserve, less than 10 of them take advantage of the mental health veteran system.
And of those, how many end up on our public assistance? Or could you explain just generally about that?
INSEL: We don't have those numbers.
The ones that I have actually fit exactly with what you've just said, it's about 40 percent or 45 percent of those who are serving are in the Reserve Corps. Only, in total, about 10 percent of those who return ever do receive V.A. care.
For PTSD, I think, which is the disorder that we talk the most about, but maybe isn't always the most important -- but it's certainly one of the occupational hazards of being in combat -- the numbers are probably going to end up to be in the 15 percent to 20 percent range based on what we know from other combat experiences.
Where those people will get care, if they're in the Reserve, partly depends on when they developed symptoms and where they seek out care.
Those who seek out care in the first two years after they return have access to the V.A. system should they choose it. The problem, as you know, with PTSD is it often doesn't emerge in the first two years. It may emerge sometimes years later, and can be most crippling even five, 10 years...
INSEL: ... after the fact.
At that point they no longer have the V.A. benefits. Where will they get care?
INSEL: That is a question that I don't have an answer for.
(UNKNOWN): Well, I don't think our country has answered that question and I think the country needs to answer that question.
We have -- twice as many veterans who served in Vietnam have killed themselves by suicide than were killed in action in Vietnam. And if we see that kind of phenomena happen with Iraq, we're going to be in for some real tragedies, as we've already seen in anecdotal evidence from people returning from Iraq.
And I think this is also an issue for our committee, not just the Veterans Committee.
So as we -- we're going to be -- how many in the Medicaid program, how much do they assign for psychotropic drugs as opposed to the private sector, would you say?
INSEL: We know that for atypical antipsychotics more than half of the prescriptions are written through Medicaid.
(UNKNOWN): Half of the prescriptions written through Medicaid -- I mean, that 's amazing.
And that's why if we get parity passed, we're going to begin to cover the private sector so it's not just on the taxpayer, you know, to have to pay for this.
CURIE: I might mention that our Center for Mental Health Services is working very closely with the V.A. currently to talk about community-based infrastructure on this particular issue in terms of addressing -- and we're working with associations like Therapeutic Communities of America right now that have stepped up to the plate to talk about what the provider-base needs to do.
So there have been -- we're putting some things in place to address this issue and would be more than happy to continue to apprise you of that.
VOLKOW: Good morning, Mr. Chairman, and members of the committee.
It is a privilege to be here to discuss NIDA's research priorities to reduce the burden of drug abuse in our nation.
However, we remain concerned about the persistently high levels of abuse of prescription medication such as the stimulants Ritalin and Adderall, and the painkillers Vicodin and OxyContin.
We're living in an era where being bigger and better are considered more important than how you get there. Thus, we're seeing a new pattern of drug abuse that is not triggered by the desire to get high, but by the pressure to improve performance. Yet use of anabolic steroids, which has garnered a great deal of attention, is just part of a much broader trend.
For example, stimulant medications are increasingly being abused by high school students to improve their scores on exams and by girls to achieve a body image that conforms to unrealistic standards.
Research and prevention is a major priority in our institute.
Addiction often begins in adolescence or even childhood. Therefore, we need to better understand how the normal brain develops and how it is influenced by drugs. Because drugs with abuse interact with the same chemical systems that are essential for brain development, drug exposure may be particularly harmful to the growing brain.
Equally important, key brain structures controlling motivation, emotion and judgment are still under construction well into the early adult years, which could explain the propensity of drunk people to act impulsively and to ignore the negative consequences of their act, which increases the risk for substance abuse.
Another major reason for drug abuse is the presence of a mental disorder. Indeed, children and adolescents suffering from depression, from the disorder ADHD or schizophrenia are at a major higher risk of abusing drugs than unaffected children.
Also, studies show that drug abuse can increase the risk or accelerate the onset of a mental disorder. Thus, research that can lead to an earlier recognition and treatment of mental illness will help prevent drug abuse. Similarly, more effective strategies to prevent drug abuse are likely to improve the prognosis of children suffering from a mental disorder.
Treatment is the second major priority for our institute.
Over the past five years we have identified many new targets for potential medications for addiction. Unfortunately, their clinical translation has been hampered by the incredibly high cost of bringing new medications into the clinic. These costs, for other diseases, are mostly carried by pharmaceutical effort, but industry's lack of interest in addiction forces NIDA to assume most of the research effort and associated expenses.
Though effective treatments for addiction are now available -- look at that slide, look at the effectual treatment -- notice the next one -- not just on the person stopping taking the drug, but actually on recovery.
Despite the fact that we have effective treatment, less than 10 percent of people that are addicted and need treatment receive it. And thus, NIDA has put this as a priority to develop treatments that are cost effective, but also acceptable to providers and patients.
In this respect, our close partnership with SAMHSA has been invaluable in the translation of research-based treatments into community settings.
SUBCOMMITTEE: HOUSE APPROPRIATIONS COMMITTEE
HEADLINE: U.S. REPRESENTATIVE RALPH REGULA (R-OH) HOLDS HEARING ON SUBSTANCE ABUSE/MENTAL HEALTH SERVICES
LOCATION: WASHINGTON, D.C.
APRIL 27, 2005
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More Information: Substance Abuse Mental Health Services Administration
Posted by szadmin at May 3, 2005 09:55 PM
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