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March 09, 2007
National Institute of Mental Health, 2008 Research and Budget Cuts
Read more... Government & Schizophrenia
The following is an excerpt from a capital hill House Appropriations Committee hearing on the funding of major US mental health initiatives in the president's proposed 2008 budget. The discussion covers important funding issues (what programs are being cut), new trends in schizophrenia research into causes and treatments, as well as prevention efforts and community support programs. If you are interested in any of these topics - we recommend you read the entire discussion below. We found it extremely interesting - and we think you will too. Under discussion is the NIMH's $1.4 Billion budget - which sounds like a lot of money until you compare it to the $72 Billion a year we're spending on the Iraq war-- spending which is driving the budget cuts in US health care and mental illness prevention programs (see below). While we've focused on Dr. Insel's presentation - we've also included occasional comments from other participants in the meeting. The hearing took place on March 1st, 2007. The chair of the meeting was Representative Dave Obey (D-WI). Presenters in the meeting include:
I have already submitted testimony that you've seen which talks about some of the excitement in the science that we're doing and why I think that this is a particularly extraordinary time for those who study mental illness and those who have family members with mental illness. We think that there's never been a more promising time in terms of the research and a better time to, as Congressman Walsh said, think about research that will inform practice.
I'd like to just summarize what I think may be the most important message for you to get from what I can tell you today and to do that in just a minute.
And that message is that you're going to be looking over the next few weeks at a number the agencies that deal with health care. You know, as all of us know, that health care is a growing part of the economic challenge in this country. It's now 16 percent of the GDP. It's predicted by CMS, from research that was just published in the last few weeks, to go to perhaps 20 percent over the next decade. So this is a growing part of the economy for the United States. Everyone in this room can attest to that from their own personal finances.
Mental health care represents about 7.5 percent of that overall figure. Parts of the mental health budget are increasing at a much faster rate. Medications are increasing at a rate of about 15 percent per year. But what I think you need to understand is that as we talk about the costs of health care and of mental health care, we're not capturing where much of the economic burden is for those of us here at this end of the table.
What we struggle with in the world of mental illness and substance abuse are what we often talk about as the indirect costs, the costs of social services. Just to give you a very quick idea of what that means, the president's New Freedom Commission provided a series of numbers which you should hear about at some point.
SSI, Supplementary Security Income, 1.6 million people: 35 percent of the people who receive SSI are people with mental disorders at a cost of about $8.2 billion in the most recent year for which we have numbers, 2002.
SSDI, the Social Security Disability Income: 1.7 million people, 26 percent of all the people receiving SSDI are people with mental disorders, cost of $18 billion in 2002.
A recent report from the Department of Justice estimates that 61 percent of the people incarcerated in this country have mental disorders. A report out earlier this week on homelessness, figures of about three-quarters of a million according to the president's New Freedom Commission. Forty-six percent of those who are homeless have a serious mental illness.
So we're talking about just enormous costs in terms of social services, as well as the explicit health care costs that tend to be on the ledger, as you look at what we're dealing with over the next few years.
The only other point I want to make for you before we move on is that the real costs here are not just in dollars. They're in lives lost.
One of the things you heard a little bit about from Dr. Volkow, and you'll hear more about this, I think, as we go on this morning, is that across medicine, we think about the 21st century as being the century for chronic illnesses. And that's true. Diabetes, hypertension, heart disease, dementia, stroke: These are the illnesses that will be very much in focus for the next few years.
The mental disorders, including substance abuse, are also chronic illnesses, but what makes them different is that these are the chronic diseases of young people in this country. Epidemiological studies published in the last year or so show that 50 percent of adults with mental illness describe onset by age 14, 75 percent by age 24. It's a very different picture from the rest of medicine. And it's part of the reason why when the World Health Organization looked at what are the disorders that caused the greatest disability, these go right to the top, because they're chronic, they're disabling, they're often fatal, but they start young, and that's what sets them apart from all the other disorders that you'll be hearing about over the next few weeks when you talk to institutes, directors from the NIH, as well as other sectors of health care in the government.
I mentioned that they are also deadly. And I think it's important for you to know, particularly those of you who are new to the committee, because I say this every year, but I'll say it again for those of you who haven't heard it before: There are 30,000 suicides in the United States every year, 90 percent with a mental disorder. That's almost twice the number of homicides. So this is a problem that not only causes disability but death as well.
The costs are huge. They're largely unrecognized. Along with my colleagues on this panel, I want to say how much we appreciate having the opportunity to have a theme hearing where we can lay some of this out for you and talk about what we think are some of the exciting opportunities to make a real difference here.
And to go back to your point, Mr. Walsh, the idea of finding a way to make research inform practice, to reduce both the economic and emotional and personal losses here -- there's never been a better time for this, but there's also never been a more urgent time for us to face that.
I look forward to your questions.
REP. OBEY: what's the number one thing that you would like to be able to do that you won't be able to do under this budget?
DR. CLINE: I think the important thing at this point is to stay the course, make sure that we have the data, that we have the strategy, that we use the dollars that we have effectively as part of this comprehensive approach. Again, those dollars I think have not been used as efficiently as they may have been used in the past, and that's not through any fault; that's more about developing management and operation and performance measures, utilization of those, and moving the dollars into practice in the field.
DR. VOLKOW: I've thought about it a lot, so if I have to chose the one thing that I think would make the greatest impact in the way that we deal with the treatment of drug abuse and addiction, five to 10 years, I'll say right now for me one of the most frustrating areas is a inability to bring very exciting findings in terms of potential medications to the clinic. It takes approximately half a billion to a billion to take one [new medication] compound into clinical practice. Our budget for 2008 is $1 billion.
This means that because -- and that's why I highlighted the notion that the lack of involvement of the pharmaceutical industry makes this a tremendous burden but also limits our capacity to move rapidly.
So, because it's such an extraordinary important priority to bring treatments -- and there are medication compounds now that look incredibly promising, but I have to delay the initiation of the clinical trials because I don't have funding -- I mean I have to balance a budget.
So if I were to say, I will bring forward that concept that medication development is very much slowed because it's so extraordinary expensive, and we don't have the engagement of the pharmaceutical industry for the most part.
DR. INSEL: This is the kind of question that we think about all the time. It's an important one. And it's not just to us a dollars questions; it's a question of finding the sweet spot of where you have something that you can actually do. So it's both the scientific opportunity, having the traction, and then also having, as sometimes people say, the gas in the car to get to where you want to go.
The last four or five years, we've been involved with some very large-scale practical clinical trials: 10,000 patients, 200 sites. That's been a very big effort, and it's now mostly over. And what we've learned from that, which was an attempt to look at the medications we now have for depression, schizophrenia and bipolar illness, including depression in adolescents and in college kids, we've learned that they're not very good. I mean, they are good enough for some people, but for many, many people they're not enough.
This year, we had two projects that reached maturity that showed medications for depression that instead of taking six to 10 to 12 weeks to work worked within four to five hours. And I think for us a high priority is going to be jumping on that and trying to understand how to leverage those findings to be able to move very quickly to really move the bar on what we expect of antidepressant treatment, so that kids at Wisconsin or wherever else they might be don't have to wait six to eight weeks to find out whether the treatment's going to work or not.
The second piece, if I could have a second wish, would be something in the realm of biomarkers. We have so much happening now; there's so much opportunity to be able to define the biology of these disorders in the way that T. K. was talking about and Nora's been talking about, to be able to now identify who's at risk before they become alcohol-dependent or before they have the psychotic experience of schizophrenia.
So there's probably nothing more important for us than getting there early, preventing the worst parts of these disorders by intervening very early, and reducing much of the disability that might occur because you've had a psychotic break.
DR. VOLKOW: One of the most important environmental factor in terms of increasing the vulnerability, actually not just for substance abuse but also for some of the mental disorders, is stress, if you do have that genetic component.
Now stress is a very complex issue, but I'm going to focus on one of that aspects of complexity that's probably the most important, and that's social stressors.
And indeed, when you mention about kids at school the social stressors of performance is one of them. But there are other social stressors that are as devastating, such as, for example, parental neglect. And that's why I made a point of putting it forward.
Why? Because the lack of that interaction has been shown from studies to actually significantly change the expression of genes and the way that the brain functions. So, one of the things that we're actually starting to do is we've recognized for many years that social stressors are contributing to drug abuse, parental neglect, poverty. Why is it that poverty increases the likelihood of taking drugs? Because of you are much more likely to be encountering stressors.
So what we are doing is trying to understand why these social stressors -- what are they doing to our brains, such that they make us more vulnerable to take drugs? Why do we want to do that? Because if we can identify, for example, what proteins are affected, then we can develop medications, number one. If we understand how the environments affect the function of your brain, then we can do behavioral interventions that can compensate.
So, for example, in a kid that doesn't have the social skills, could we implement a tutorial to teach them [social skills]? But instead, we don't care about them. They have to do very well in mathematics, but if they have no social skills, guess what? Nobody's speaking up. And yet that could be one of the most important factors in enabling to navigate through a social, stressful environment. So we're emphasizing the basic knowledge so that we can tailor better prevention strategies.
And in parallel, there are many prevention studies that have shown which interventions work. For example, one of the things that has become evident is prevention interventions that are universal are more effective. So you don't just target the kid and say, "Don't smoke marijuana." You target the kid on terms of healthy lifestyles. Those are the ones that have the best outcomes.
And we are partnering with SAMHSA in order to maximize the likelihood that those preventions are applied in communities and that they are sustainable.
DR. INSEL: just to add -- if I can step back from what Dr. Volkow just said, I think there are two messages which she's giving you that may be different from what you might have expected. One is that most people when they think about stress think about the psychology of stress. It's a behavior; it's an emotion; it's an environmental contingency.
What she's telling you about is that we can now study and understand stress as a biological phenomenon, as a phenomenon that changes the brain in some very critical ways. And stress during development may have long-term consequences that we have the ability to study at very great precision now. So the biology is really critical.
The second piece, as she talks about interventions and how you reduce stress -- it's very important, what she said, which is that one size isn't going to fit all. You know, what may be stressful for one child actually is a challenge and is somehow reinforcing for the next. One of the pieces of this that we need to bring our science to in a much more refined way is to understand these individual differences, to understand who is going to be susceptible to long-term adverse consequences of being stressed in development, or even in adulthood, and who may find that actually immunizing and might be steeled or strengthened and may actually grow from the experience.
We don't know enough about that, but once again, we've got the tools now to be able to lay that out in a very precise way. Within a relatively short time, we'll have a lot more information about these individual differences that -- even at the genetic level, that help us to understand that.
REP. REHBERG: So I've got about a million people in the district, and my concern is on the seven reservations, the Native American population. I'd like to hear specifically about especially suicide -- oh, okay, I'm sorry -- suicide prevention as far as Montana being ranked fourth in the nation for adjusted population of suicide. And what specifically are you all trying to do towards both the alcoholism, but more importantly the suicide rate on the Native American population?
DR. INSEL: I'm going to let my colleague speak to alcohol and maybe to methamphetamine or drug abuse, as well. But let me say something about suicide.
It's, again, not well known that if one looks at the pattern of suicide in the United States, the areas with the highest rates of suicide are not where we often might assume it, which would be in urban centers. It's actually in rural America. The states with the two highest rates are Nevada and Alaska.
And that tells us something about the need to provide far better services, as you're suggesting, and to be there well ahead of time. The thought is that because suicide is most common particularly in older Americans and particularly in white males over 65, who have the highest rate of suicide in the country, that in rural areas that may be a population that's particularly susceptible.
One of the interests that we've had is recognizing the challenge of rural mental health and that often the evidence-based practices that Dr. Cline mentioned before just aren't available to people in those places as being able to use what they do have available, which is the Internet. And we have projects currently under way that are developing very powerful Internet-based techniques that can help people to link.
Again, it's a bit paradoxical. Turns out that many people are far more comfortable telling their problems to their computer than they are telling them to someone face to face. We wouldn't have perhaps expected that, but as soon as you start looking at these social networking sites, you realize that must be the case.
And it does say that there's an opportunity for us there, to be able to intervene and to be very helpful to people, even people who we don't have immediate access to face to face.
REP. : let me first of all just echo, I guess, what many others have said in terms of the cuts in prevention.
And Administrator Cline, all of you have talked a lot about prevention, but you look at these numbers, the $159 million cut below the FY '07 CR numbers, and in the Center for Substance Abuse Prevention we've got close to a $40 million dollar cut.
I don't know how that can't have just a huge, huge impact on the ability to make a difference on these problems. But one of the things that you don't mention and I was wondering about in terms of these issues of alcohol abuse and drug addiction and drug abuse, what -- how do the U.S. rates compare with other industrialized countries, countries around the world?
I mean, what -- is there -- are there things that we can learn there? What does it say about societal patterns here compared to there, the pressures of modern society? I mean, have there been studies that look at the -- look at tribal societies which have, I think, availability to things like drugs and things that could be abused, but maybe it doesn't happen? I mean, what's going on there? What tells you when you look around the world what we learn here and what maybe we can -- what we can gather from that wealth of experience and that wisdom out there?
DR. VOLKOW: Well, unfortunately, it's one of those indicators where -- I mean, I'm never proud to say because in illicit substance abuse United States probably has one of the highest rates In the world.
DR. INSEL: I'm -- I can answer as well. I think it's a great question; we often don't focus on the global picture as much as we should. The NIMH is part of a project with the World Health Organization, with 300,000 people being surveyed in I believe now it's up to something like 80 countries to compare the prevalence of mental disorders.
But we've already been able to look rather quickly at some comparisons, and it does look like rates in the United States are higher, particularly for disorders that could be related to stress, such as depression. But they're changing in the emerging economies, as well, where stress is becoming a greater factor.
I'd add to this that one of the interesting pieces of looking at global mental health -- there's a special issue of Lancet, the medical journal Lancet, that will be out in April, in which much of this will be described, and we'll be happy to provide that to you. But in that special issue, there's a focus not only on doing the counts -- how many people have these disorders, including substance abuse -- but it's also looking at services.
What are the services available; what works where?
And I think for us, that's a bit of a heads-up, because it turns out that there are ways of addressing some of the problems that we face that are being done in other countries that are just so much more effective. It's clear that as you look at even some of the -- not the usual suspects: mental health care in Chile; the way that schizophrenia is treated in India. There are important clues to us about how we might be able to do things better.
India's an interesting example because much less of an emphasis on medications, much greater emphasis on family support, social support. Outcomes look pretty good. So I think we have a lot to learn.
REP. MICHAEL HONDA (D-CA): Thank you. And I'll be brief, given the time.
To Administrator Cline, in your written testimony you identify improvement services -- service quality through data collection as a focus of the administration and your agency. The White House has had a -- the White House Commission on Asian-Pacific Americans (sic/White House Commission on Asian-Americans and Pacific Islanders), and they've conducted a series of town hall meetings since 2001. And from the -- and they changed their focus from health to small businesses, but they continued to look at health and health disparities and gaps in mental health, also.
In terms of data collection and in terms of Asian-American populations, how is it that you collect data, and do you disaggregate the data by ethnic groups so that you can disaggregate that large group of folks, and look at specific issues?
DR. CLINE: Thanks for the question, and there are two parts to the answer to that.
One is that our data collection strategy has really been done in collaboration with the states and the states that are providing that mental health and substance abuse services. So what we have is a very accurate read from the information that's reported through those state authorities.
If you think about the overall population, obviously that data is skewed. It's skewed to those people who are being served by the system. What has been more of a challenge for our system is -- and those systems do reflect different ethnic groups; that's data that is available. But again, we're talking about one part of the population: those people who are being served through those systems.
What has been more of a challenge because of the costs associated are those population-based studies that actually look at the broader population, not just those individuals who are being served through the system. And SAMHSA just recently completed the -- a national study of drug use that looked at respondents across the country and then extrapolates from that.
REP. HONDA: Okay, so what you're telling me is you push it to the states, and the states do what they do, and then in terms of the aggregate information -- the disaggregation of information on the Asian-American population relative to mental health is too costly.
My question is: Are you disaggregating the information to see the different issues in the different communities, yes or no?
DR. CLINE: Yes. The answer is yes, we are. But I want to be clear: That information is limited, because the most detailed information is from systems that are only serving a small number of people, and they're for those people who need mental health service or those people who need substance abuse services. What it doesn't tell us, there might be a huge segment of the population that may actually need services but they're not yet connected with our system. And that would be across all --
REP. HONDA: So you're saying that data collection are only those who are in the system.
DR. CLINE: That is correct. Or for that particular data segment.
REP. HONDA: So are you looking at doing data collection and asking states to do data collection using a formula or using a process that will extract accurate information of the total population so that you'll know how to design and plan for prevention and for intervention?
DR. INSEL: Can I -- if I can interrupt for a moment, we are funding a very large effort called the National Survey of American Life, which is looking specifically at Asian populations, African- American populations and Latino populations. At a population-based level, not -- we're looking carefully at what services people receive, but the question is being asked as a household survey, not of people who have already come into treatment.
The first part of that is quite striking, and it's not surprising, perhaps, that prevalence of these problems is high, the number of people who actually seek treatment is quite low. And it depends, of course, on what the problem is and on its severity.
But within, I would say, another six months, we will have much of the data from what's been a very long season of collecting it. We'll be able to harvest it to be able to provide much of that to you.
REP. HONDA: One of the reasons I ask is that a lot of the newcomers come from war-torn countries. And we know today our veterans that are coming back are going to be experiencing a heavy dose of the PTSD. And I suspect that the populations that we're looking at today who are new arrivals are probably coping with that and it may be expressing itself soon or already expressing itself without us knowing it.
So I think that it's incumbent upon us to look at that data and not aggregate Asian-Americans as one monolithic group, but disaggregate it by communities.
DR. INSEL: If I can -- again, that's an extremely important point. One particular study that was published in 2006 -- early in the year, I believe -- was of a Cambodian refugee population in which the rate of social phobia and PTSD approached 90 percent.
REP. HONDA: That's right.
DR. INSEL: Almost none of these people had sought treatment, because they wouldn't leave their homes.
So this is a very significant and under-recognized problem, particularly for some of the refugee populations where there's a language problem, cultural problem, and you graph on top of that a very severe trauma. You've got a group that's really hurting and not getting the care.
REP. HONDA: It'll be Cambodians and Hmongs among --
REP. KENNEDY: And enormous distrust of government.
REP. KENNEDY: Welcome everybody back to the hearing.
The presenters of the administration budget aside, they are -- my personal feelings for them aside, I too want to take exception along with my colleagues to the administration's budget that they are forced to represent up here, because I think that it shows the enormous departure from reality that this administration has in terms of what our country's priorities should be in the face of the facts.
And the facts are: 54 million Americans suffer from a diagnosable mental illness; 26 million Americans suffer from chemical dependency and alcoholism; 300,000 Americans were denied -- over 300,000 Americans who were denied treatment last year, and over 178,000 died as a direct result; 34,000 Americans have killed themselves as a result of suicide -- twice the rate of homicide. We'll see over 1,400 Americans in college this year kill themselves. It's the third leading killer for young people 15 to 24, second leading killer among certain other young people's age groups.
And then you ask yourself, well, what's the leading killer? Well, accidents. Well then, you might add, probably -- those accidents are probably largely attributed to behavioral disorders as well.
So mental health, behavioral health, has everything to do with the health and well-being of our people. And yet, what are we doing in these budgets? But the substance abuse and mental health services -- we're seeing a 13 percent cut since 2005, a 17 percent cut in the mental health block grant, 12 percent cut in substance abuse block grant. We're seeing the children's mental health block grant - we're seeing that cut by 8 percent. We're seeing cuts all the way along the line. NIMH in real dollars is cut since 2005 $165 million.
yesterday in our science subcommittee all the leading scientists talking about how we're falling behind in the world in terms of research, in terms of science and technology. There's no more important computer in the world than the one that sits between our shoulders. It is what's going to keep us on the cutting edge in the world. And all the most important findings are going to be discoveries that are going to be in that area. And what are we doing? We're falling behind in the importance of those discoveries.
To think that we are falling behind in that area and underfunding is just absolutely inexplicable in my mind -- absolutely inexplicable.
I would say that for a consumer society like ours that is so really, I think, consumed with its own well-being and satisfaction, it's quite ironic to me that we wouldn't spend more money on ourselves and our own sense of feeling of well-being.
And if we were truly interested in our own sense of well-being, why wouldn't we invest in the one area that would provide a better sense of well-being? And that's our emotional and mental health. I just don't understand it.
We could -- for every American of every socio- and economic group in this country -- have a better understanding of our emotional and mental health by investing in the national institutes of mental health, alcoholism and drug abuse and, in doing so, learn more and provide more relief to a lot of suffering that is needless in this country due to all of these disorders and illnesses that afflict the mind of every American -- one in five Americans who are suffering from a mental illness and their families who are suffering as a result of their suffering. And we could do so with this investment.
And yet, what do we do as Americans? We medicate. We self- medicate. We go out as consumers and buy things to try to solve our insatiable appetite, to try to find relief in our consumerism. And we try to find answers in every other part of our lives, in spite of the fact that the answer is right there between our own eyes. And yet, we fail to acknowledge that. And as a result, we're missing what's most obvious in front of us. And that is our own brain and the fact that it's there to be explored and the mysteries solved.
And I just can't explain why we're not -- this administration is failing to answer that call. I think it's so shortsighted. The NIAAA [National Institute on Alcohol Abuse and Alcoholism] budget has been cut by $50 million in real terms since 2005. NIDA, which studies drug abuse, was cut by $118 million in real terms since 2005. And in just this one year, in substance abuse prevention -- which is what we're heard here -- the best way avert both the onset of many mental illnesses is to -- which are -- and co-occurring disorders -- is prevention. And what do we do? We have an 18.89 percent cut in substance abuse prevention.
We have -- the main Community Mental Health Services Block Grant is frozen. The mental health seniors services is eliminated. You know, we have a baby boom generation that's about to retire. We have exploding alcoholism rates amongst elderly. We don't have a system in place to reach out and identify mental illnesses properly amongst our aging Americans.
And what are we doing? Instead of putting in place a system where we can identify depression and mental illnesses amongst our aging population, we fall backwards.
Children's mental health, where we could do more to avert disability and mitigate the biggest cost of mental illness -- which is the disability caused by mental illness -- that comes from early identification of mental illness in children. That is going to be compromised from freezing these dollars in children's mental health.
Formula grants for homeless people is frozen, and another part of it is cut. And of course, jail diversion, which is just an example of what's going to happen when we cut all these other programs, which are in essence jail diversion programs themselves, because we know when we cut all these other mental health programs what ends up happening: many of these people end up in our corrections system.
Chief Bacca, from the Los Angeles County jails told me three weeks ago he runs the largest mental health institution in the country. He runs the Los Angeles County jails. And that's a sorry indictment on our country that we have left our corrections system to be the mental health system of last resort.
And what are we doing? We're not saving any money by these cuts. All we're doing is shifting the cost. This is nothing but cost displacement. We're displacing the -- whatever savings the administration thinks they're making by making these cuts here, and we're shifting those costs to another committee. And that's another committee I happen to serve on, that's the justice committee (sic/Subcommittee on Commerce, Justice, Science, and Related Agencies).
So I'm going to have to go over to my other committee hearing tomorrow at the justice committee, and we'll see what the administration's budget is for that. And last year, the administration proposed a $685 million increase in prison construction. That's what they proposed.
So we'll build more jails; we'll put more pressure on the states to put more bonds out so that they can build more state jails and detention facilities, and we'll incarcerate more people. And most of those people -- because we know statistically 67 percent of the people at the time of arrest test positive for drugs and alcohol; that's no mystery that those are people that are there because of drugs and alcohol. If they'd only gotten the treatment, they'd only gotten the prevention, they may not end up in the criminal justice system at the cost of $35,000 to $40,000 a year at your dime -- as taxpayers, on our dime.
And over 85 percent of those in the California state penitentiary are going to go back into the California state penitentiary within two years because there's no access to mental health services once they come out. Fortunately, California's now starting to do their own -- take up their own initiatives with Prop 63 to try to address that, but most states in the country have well over 50 percent recidivism rate.
Bottom line is we are just "pay me now or pay me later." And what this budget that we have here today for NIMH, NIDA, SAMHSA, NIAAA is saying to us is, "Pay me later, and pay me through the corrections system." That's what this budget says. But I'd like to get into some specifics.
In the SAMHSA budget, Dr. Cline, if you could address the whole issue of the -- what you feel the administration can do better in terms of treating those with co-occurring disorders, so that we're not wasting money in the "siloing" of dollars between mental illness and substance abuse. If a patient shows up, how do you think you can better administer treatment so that there isn't that, you know, waste of bureaucratic dollars?
DR. CLINE: Great. Thank you for the question, Mr. Chair.
Co-occurring disorders is an area where we have seen significant changes in the last several years. Then-Secretary Tommy Thompson had released a report to Congress on co-occurring disorders which really highlighted the importance of co-occurring and made it clear that co- occurring disorders should be the expectation rather than the exception.
That has really created much change in the field. SAMHSA has worked very closely with both the National Association of State Alcohol and Drug (Abuse) Directors, as well as the National Association of State Mental Health Program Directors, in making certain that we have best practices that are getting out into the states and into the communities that are providing services.
REP. KENNEDY: So do you think that you can work with us to better use the two sets of block grants and integrate them better under SAMHSA reauthorization this year? I know there's politics behind the two different block grants for mental health and substance abuse, but it's your feeling that we don't have to bother with the fact that we have to justify it under one or the other in order for people to get treatment, but we can integrate those dollars better?
DR. CLINE: What I think we can do is work with the states about flexibility within those existing block grants, flexibility within programs. Congressman, I'm from the state of Oklahoma, where I was the commissioner for the state. So -- and we had both of those block grants and in consultation with SAMHSA at the time learned to utilize the flexibility that currently exists in those block grants.
REP. KENNEDY: I noticed in the SAMHSA budget you eliminated the minority fellows -- fellowship programs. Obviously, this contradicts the surgeon general's "Mental Health: Culture, Race and Ethnicity" New Freedom Commission report that says there needs to be more cultural and, you know, competency in the delivery of mental health services.
So can you justify why this has been eliminated in the proposal?
DR. CLINE: Sure. The SAMHSA is in the process of developing -- and should be finished in April -- a work force development strategy that will undoubtedly address the issue of both disparities and the low number of individuals who are available to actually provide services that represent the communities that they serve. This is an issue of grave concern to us.
Another area of focus for SAMHSA has been around cultural confidence. We know that when we look at psychiatrists, social workers, psychiatric nurses, that no one of those groups has over 5 percent representation in the work force from the four major ethnic groups in our country, even though those four groups combined represent about 30 percent of the population.
So there's much work to do. We want to have our resources as part of that strategic plan and we have been behind the curve in terms of pulling together that strategy. That will be within two months -- that strategy will be developed; the work force development strategy.
REP. KENNEDY: I outlined, obviously, the enormous cuts in the budget for NIDA, NIAAA and NIMH. Could you just talk about what this means in terms of the scientists who are going into research in your institutes and how they're unable to stay in the field now, and what that means in terms of the future for -- from your experience, when you started out as researchers, and what that means now in terms of the prospects long term for that kind of breakthrough work that we need to keep going in the future?
DR. INSEL: We talk a lot about this at NIH, and it's one of the places where we've been very grateful to have a little bit of flexibility from the continuing resolution budget in 2007 this year. Much of the additional funds that came in this year are going into protecting new investigators and trying to ensure that we have the same number of new investigators this year as we've had on average for the last five years, because this is a time when there's a vulnerability. And the vulnerability is that we could lose people who would have gone into science and who we may really have needed, but don't see that there's a pathway there because in fact there is a imbalance between supply and demand.
For all three of us who are on the research end of this, this comes at a particularly critical moment. We have the sense that whether you're talking about substance abuse, alcohol, depression, schizophrenia, we now recognize that these are brain disorders, and so we need a new cohort of very gifted neuroscientists to help us make the breakthroughs.
So it isn't simply a matter of capturing the new bright minds, but it's also a very select group that we need. We need, actually, a different group than many of the people that we have been funding in the past. So to be able to expand that we want to maintain many of the people who've been in the population but also bring in this new cohort.
There is this supply-and-demand disconnect, which is going to be tough.
REP. KENNEDY: Before I turn it over, just the bigger issue here is how do we convey to business in America so that politically we get more support for research and more saliency on the Hill politically for this kind of work that you're doing? The vital importance of this to our economic security -- the work that you do -- how do we buy in the business community and the rest of America to -- how critical this is to them?
I mean, it's over $80 billion in lost productivity due to, you know, lost work days, the burden of illnesses, so forth -- $400 billion when you factor in the costs of correction system. The taxpayers' dollars are being wasted. The -- in terms of the health care, it's 100 percent higher premium for an untreated mental illness. All of these businesses are paying higher premiums for their workers. Eighty percent of those with substance abuse are workers who are all working at these places of business, these employers of corporate America.
Why aren't they, like, endowing chairs? I go to all of these universities all over America and meet with your investigators who are doing your peer review. None of them are getting endowed. All these cancer endowments, all of these diabetes endowments, all of these great endowments for every other disease, but brains -- then no one touches it.
So why -- what are we not doing to get people more bought into this brain science?
DR. INSEL: I think it's a great question.
What we need to do, I believe, is to build a better business case for the importance of -- particularly one that we're focused on is depression in the workplace.
Now we've been doing this recently. A paper that was out in December in the Archives of General Psychiatry showed very clearly what the business case is for treating depression in the workplace. Yes, it does require an upfront investment, but by the second year, you make all of that back in absenteeism and what we now call "presentee-ism" and in terms of quality of the work on the job. People who are depressed are more likely to have accidents. So there are all these other costs that hadn't been factored in.
So I would argue that this is a place where you can bring the best science, and that's the science that involves economics as well as the kinds of things we've been talking about before about the public health issues. You can bring that to just these kinds of questions and you can make a very strong case for how critical it is to provide these -- this kind of treatment.
DR. CLINE: Just to add to that, I think part of that comprehensive approach again is making sure that we increase awareness on these issues at the business level. But also, the individuals who are struggling with these issues I think would give you a different answer to this. And I think what they might say is that the terrible stigma that's associated with these issues is pervasive. We see this not only the business community. We see it everywhere. And we see that level of discrimination that is based on that stigma and lack of understanding about the severity of the illnesses, the productivity, but also the very nature of these illnesses as illnesses.
And I think that that gets into the -- some of the prevention work that we need to do, some of the increasing awareness -- anti- stigma work that has been a struggle for so many communities.
REP. WALSH: Are they -- the programs that you've proposed reductions in -- Center for Mental Health Services is a $76 million reduction. Center for Substance Abuse Prevention is a $36 million reduction. Center for Substance Abuse Treatment is a $46 million reduction. Are these programs not effective?
DR. CLINE: Those are -- again those are broad centers. Just like we had three centers here represented within the institutes, each of those centers that you're talking about are broad centers that have a number of programs within them.
So what we did is within those programs looked at those that may not have had good performance measures or performance measures where we're not getting positive outcomes from those.
You know, one of the things that I had mentioned earlier is that SAMHSA has been in the process of developing these performance outcomes measures. And I think in some ways we have been our own worst enemy by not having those outcomes measures in place earlier, being able to demonstrate to you and to others the importance and the effectiveness of those programs.
REP. WALSH: It certainly is a mixed message about the effectiveness of those centers.
REP. KENNEDY: Does CMS do that same cost effectiveness with mental health and substance abuse deliveries -- programs?
DR. CLINE: I'm not sure if CMS does or not.
REP. KENNEDY: I mean, do you consult with them and help them decide whether they're --
DR. CLINE: No.
REP. KENNEDY: Don't you think you should, though?
DR. CLINE: Well, what we have done is we have a federal executive steering committee, which is comprised of several agencies and departments who are looking specifically at mental health services and behavioral health services. So that is --
REP. KENNEDY: Remember that they spent all that money on that anti-psychotropic drugs and CMS -- what is it, $44 billion for schizophrenic drugs? Forty-four billion dollars at CMS a year.
DR. INSEL: No, I don't think so. The anti-psychotic budget nationally is about 12 billion (dollars).
REP. KENNEDY: Twelve billion (dollars).
DR. INSEL: And about 80 percent of that is through public dollars. And a fraction of that is through CMS, so it'll be down somewhere below.
REP. WALSH: Dr. Cline, I, for the last 10 years, had responsibility for the Veterans -- actually the last eight years -- the Veterans Affairs Health Administration appropriations responsibility in the House.
Many of our veterans suffer from mental illness, some of which is a direct result of their combat experience and some of which is not. What level of involvement does SAMHSA have with the VA in general and with particular VA hospitals across the country? And do you work with the VA to help ensure that veterans receive mental health care that they may require?
REP. UDALL: Okay, thank you.
Two of you, I think, have mentioned the great progress that's made in genomics and imaging in your testimony and talked about how it's transformed medicine and it's now being applied to schizophrenia and depression and bipolar and ADHD and autism.
Could you talk a little about what's happening there, what the transformation is, and then what we could do to support the further growth in these two areas?
DR. VOLKOW: Yeah, and those are two areas, neuroimaging and genetic, where there's been an enormous amount of advances and how are we using them.
In terms of genetics, of course, the idea is to be able to identify the genes such that when you go to the doctor you can get an idea of your level of vulnerability. So I'm a doctor, I want to give you a painkiller. I'd like to know, what are your genes in terms of vulnerability?
With imaging, the applications are actually multiple.
To start with, imaging has allowed us to try to understand what are the areas of the brain and the neurotransmitters that are affected in a given disease? Of course, that allows you then to develop interventions.
Imaging technologies have also allowed us to directly measure how a drug -- a medication will impact on the effects of the brain and thus it optimizes their development and their dosing.
And finally, the areas where we are using these technologies in more innovative ways like the one of being able to learn how to activate or deactivate a given area of the brain, which is absolutely extraordinary. It's like science fiction for the behavioral treatment. So they apply it, for example, for pain. You have pain; let me show you how you can control that pain by teaching you how to activate your brain. We're applying them now to other conditions.
But we are also interested in another application that's very innovative which is the notion of prevention. So when you approach a kid, for example, and you say to him or her, "Do not take drugs," what are the messages and how to deliver them that are more likely to change the behavior of that child?
So it's being used in advertisement to sell you better a product like Coca-Cola. So the notion is how can we apply these technologies to maximize our messages of prevention but also as a therapist, our messages that may likely lead to changing your behavior when you go to therapy. So these are examples of how we are applying them.
REP. UDALL: how close are we in terms of the day-to-day practice with doctors at applying just what you started out with? The idea that you come in and you present to a doctor and being able to analyze the genetics of an individual and then what course you're going to put them on and being able to steer that course in terms of genetics?
DR. VOLKOW: Unfortunately, that's now not right in a clinical practice. It's at the research level. So this whole work is research and the integration of this research is also important because when you deal with genetics and you say, "Okay this gene is going to make you more vulnerable for taking drugs," why is that so?
So through imaging, you can inquire the brain and say, how does the difference in this gene affect, for example, the development of the brain, the function of the brain? But all of that work is at this point still on the research arena.
DR. INSEL: You have to realize with Dr. Volkow here you've got one of the world's experts on imaging, so you can take whatever she says to the bank.
On the genetics side, let me just add a couple of things that you should understand. This field, which has been in the works for at least 20 years where we've been trying to find the genetic underpinnings of these disorders, has really taken off in a completely different way in the last six months. And that's because of two huge breakthroughs.
One was being able for the first time to do what we call whole genome studies, to look at the whole 3 billion complex of DNA instead of doing one gene at a time; we can do the survey of the whole thing and we can do it quickly. And that's the second big breakthrough.
We now have high-throughput sequencing methods that allow us to do what would have taken a year, two years just two years ago to now do within a week. So the cost overall and the speed of this has been transformed by about a factor of a thousand in terms of cost.
In the last two months, we've already launched through a public- private partnership very large-scale studies on ADHD, autism, depression, bipolar disorder, schizophrenia. And these kinds of studies, which years ago, or even when all of us arrived four years ago, would have taken maybe a decade will now take about 10 to 12 weeks. We can actually do this in very real time. We should have the results of all of this by this summer.
That will not be the final answer, but it will give us the new set of candidates. And just as Nora was saying, those will help us along this pathway of being able to individualize the way we take care of people.
REP. KENNEDY: They're going to be able to tell from your genes, just from a swab of your mouth, whether you have the genetic makeup to take a certain enzyme that will -- to have a certain pill that you can take will metabolize in your system or not and will work on schizophrenia or on another bipolar or other medication, so that you won't have to wait two months if you're suffering from a mental illness to see whether that medication works or not.
REP. HONDA: On imaging and the ability to construct, if you will, the different kinds of genes and the -- that will give us some idea of the disposition of an individual. What kind of institutional changes will that have in terms of impacting the kinds of -- the way we treat populations? Because in the past, we got rid of state mental hospitals and state hospitals and we said it goes to the community, and all of a sudden we lost the seamless service floor for people who need these services. And now they're impacting our prisons and other arenas which seem to be more costly and less effective.
What kind of implications does this research have on shaping the kind of prevention intervention institutions that we could be looking at, say, a few years from now?
DR. INSEL: I think the vision, if you want to know what it might look like, all you need to do is go to your private cardiologist and know how you would get taken care of if you had a bout of chest pain.
So they would look at your plasma lipids, including cholesterol and a number of other factors that are high-risk proteins. They would look -- they would do an imaging task, probably even a stress test -- a thallium stress test in his private office and he'd be able to tell you whether you've got -- or she would be able to tell you whether you've got an area of ischemia.
And then there would be a very extensive family history and he or she could tell you what that could mean in terms of your risk factors.
Putting all that together, your cardiologist would say, "Well, you haven't had a heart attack, but this is what you need to do to prevent it."
That's exactly where we ought to be in the treatment of schizophrenia, which is a preemptive treatment. We ought to be able to get someone at age 16 before they've had a psychotic break and by putting together the genes and the family history and the proteins and the imaging, say this is a young person who's at a 95 percent risk and let's do something to preempt the worst outcome here.
See, our field now really mostly is focused on people who've already had the heart attack. We're always seeing people after the fact. And then we worry and beat up on ourselves that we can't fix it completely. Well, you can't also fix a broken heart if you're a cardiologist seeing someone only after the MI.
What we need to do is to get there much, much earlier. This is what you heard about from each of us in terms these strategic preventions and understanding who's at risk and then preempting these outcomes by getting their very early.
DR. VOLKOW: And there's another point because in terms of treatment, it's likely to revolutionize us, as Tom was mentioning. There's another aspect that is extraordinarily important for our diseases and that you may have a gene that predisposes you for a disease. That doesn't necessarily mean predetermination.
So a better understanding what factors when you have those genetic-vulnerable genes are contributing to expression of that gene such that it leads to behavior. That knowledge will allow us to do intervention to prevent them.
Let me just give you an example. As more and more it is becoming evident that the fetal developmental theory is extraordinarily important for a wide variety of medical and also, very likely, psychiatric disorders.
So certain environmental exposures during that period, such as alcohol or nicotine, which we speak much less, are likely to have a very different impact in that developing brain than in an older one and are likely to contribute to why these kids are more likely to have conduct disorders, more likely to have ADHD, more likely to be prematurely born, more likely to become addicted to drugs. We don't understand why, but that notion and how your own genes may make you resilient and how your genes may make you more vulnerable.
So that understanding of the interaction with the environment and genetics is likely what will allow us to do much more tailored prevention interventions.
REP. KENNEDY: Just to conclude: Since so much of this is about adhering to the evidence base and knowledge and so forth, and since we've come back to that point that you made at the beginning, Dr. Cline, about the data strategy and the science-to-service effectiveness, could each of you just conclude by kind of commenting on, first, Dr. Insel -- you know, you're talking about these enormous multisite clinical trial networks that serve a large number of subjects in real-world settings and you were referring to these trials, and if the best of evidence-based treatments are failing, where do you go next and how do you retool these trials, networks with infrastructure, and change gears? Or do you change gears altogether? And how do we put in place this translational medicine infrastructure going forward?
DR. INSEL: Well, very quickly, I would say that the trials have been successful in providing some evidence base.
And I wouldn't -- I don't think it would be fair to say the medications are failing, but they perhaps aren't as good as we thought they were. They're clearly very good for a segment of the population, but they're not getting us where we really want to be which is to make, as Terry said in the very beginning, a life in the community for everybody.
So to get to that point, we're going to need a new generation of interventions, some of which will be medications and some of which will be psychosocial. The hope is to keep these networks together, at least to keep the best parts of these networks together as a platform that will allow us to do a new generation of trials. And we're right in the middle of that. We hope to have some decisions about which trials will run on which networks over the next three months and then move very quickly because everything's ready to go. And we certainly have the urgency of the problems and move the kinds of questions that have great translational importance, great practical importance, out into the networks certainly in the 2008 period.
REP. KENNEDY: Because you might with the Business Group on Health get insurance companies to start reimbursing for behavioral health interventions rather than just paying for pills. That would be huge.
DR. INSEL: It's a great goal and it's one that we've worked on together. And I think you know (ARC ?) is now very involved with this as well.
It's tricky, so just beware. A lot of people talk about doing cognitive behavior therapy and do very different things. When you're giving medication, everybody's writing a prescription for the same medication. The medication's all coming from the same source and there's a level of consistency there that is more difficult to demonstrate with psychosocial treatments, particularly with psychotherapies. It's not a reason not to do it, but it means it can't be done as simply as what we do for medications.
REP. KENNEDY: Right.
DR. LI: I think that's a very important point. When we do clinical trials, we always do behavioral therapy as part of that because that's what's necessary.
And I think in order for the trial to be successful, because of the factor that Tom just mentioned, we have big manuals on what kind of behavior therapy to do. And we've done some of the research on this in terms of alcohol use. It probably doesn't matter what kind you use.
We can't identify which ones will respond to one form versus a second or versus a third. And this is where in terms of personalized medicine we can do this and test people to see whether they might be responsive to an opioid antagonist because of the new opioid receptor polymorphism.
But we can't do this yet with behavior therapies and that's what we need to do to be able to see which ones -- forms of therapy will work best for what kinds of patients.
REP. KENNEDY: I'd like to ask you, because I want to see your budgets increase and I want to provide the political case for it, to identify the various disorders that are in your -- within your institutes, and you to take some of the investigators that do research within those disorders and identify how additional dollars in peer review research grants and various case trials that are being conducted in your institutes could help break away kind of -- either break basic or kind of practical research in the advancement of those -- the understanding of those disorders so that I can then turn it over to those advocacy groups for families whose loved ones suffer from those disorders so they can see in a very real way that if we implement additional dollars in those ways, here is the practical effect.
We're going to be able to do these additional -- grants are going to be able to let so we can do additional peer review research in bipolar, peer review research in schizophrenia. We're going to be able to fund -- and if you could, like, for example, with the UCLA early schizophrenia diagnosis and treatment center, I was just there. If you could talk about these developments and provide some testimony that if we are able to -- if we are going to be able to fund more research in identification early on of these -- some of these psychiatric disorders, then we're going to be able to intervene earlier. And if we're able to intervene earlier, then we can mitigate the disability earlier. And if we're able to mitigate the disability earlier, we can offset the costs by X percent, and then you can make honest assessments about what those costs are.
I know in terms of autism, the MIND Institute out in Sacramento has made some very accurate assessments in terms of what those cost savings can be through early detection of children; now they can really identify those children really early -- or very earlier on than they were able to do just a year or two ago. And that's truer now with schizophrenia as well.
And if they're able to do that, now we have some evidence-based interventions for autism spectrum disorders and with schizophrenia. And a percentage of those cases, that intervention can delay and mitigate enormous disability. And the costs of that disability to our society is fantastic in terms of our cost to Medicaid and Medicare.
So what I'm -- what I want to make the presentation is is that there's some real easy comparisons to make in terms of our dollars that we're investing here. I don't think it's going to be very hard for us to queue that comparison of dollars invested versus dollars saved.
But if you could just lay out some of what those early dollars and investment in identification have brought us and what those interventions have proven to us in terms of savings in those cases as I mentioned, in autism and schizophren
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