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President's New Freedom
Commission on Mental Health


Meeting Minutes
December 4-6, 2002

Crystal Gateway Marriott
Arlington, Virginia

The President's New Freedom Commission on Mental Health met on December 4-6, 2002 at the Crystal Gateway Marriott, 1700 Jefferson Davis Highway in Arlington, Virginia. In accordance with the provisions of Public Law 92-463, the meeting was open to the public on December 4th from 3:00 p.m. to 5:30 p.m., December 5th from 8:30 a.m. to 10:15 a.m. and 3:15 p.m. - 5:15 p.m., and December 6th from 8:30 to noon, when the meeting adjourned.

Commissioners present:
Michael F. Hogan, Chair
Laurent S. Lehmann
Jane Adams
Mark Johnston
Rodolfo Arredondo, Jr.
Norwood W. Knight-Richardson
Patricia Carlile
Ginger Lerner-Wren
Charles G. Curie
Stephen W. Mayberg
Wayne Fenton
Joan Mele-McCarthy
Daniel B. Fisher
Frances M. Murphy
Anil G. Godbole
Robert Pasternack
Henry T. Harbin
Robert N. Postlethwait
Larke N. Huang
Waltraud E. Prechter
Gail P. Hutchings
Nancy C. Speck
Thomas R. Insel
G lenn Stanton
Ruben King-Shaw, Jr.
Randolph J. Townsend
Deanna F. Yates

Staff members present:

Claire Heffernan, Executive Director
James Finley
H. Stanley Eichenauer, Deputy Executive Director
Dawn Foti Levinson
Patty DiToto
Ann Jacob Smith
Elaine Viccora

Consultants who attended portions of the meeting were:
Eric Caine, M.D., University of Rochester Medical Center
Henry Steadman, Ph.D., Policy Research Associates
Howard Goldman, M.D., Ph.D.

December 4, 2002

Panel Presentation: Dealing with Fragmentation in the Service Delivery System

Steve Sharfstein, President and CEO, Sheppard Pratt Health System, and Clinical Professor of Psychiatry, University of Maryland, Baltimore, Maryland
Timothy A. Kelly, Ph.D., Associate Professor of Psychology and Director of Clinical Training, Fuller Graduate School of Psychology, Pasadena, California
Laurie Flynn, Director, Carmel Hill Center for Early Diagnosis and Treatment, Division of Child and Adolescent Psychiatry, Columbia University, New York, New York

Chair Michael Hogan convened the meeting at 3:05 p.m. and introduced members of the expert panel addressing the issue of service delivery fragmentation.

Dr. Steve Sharfstein, President and CEO of Sheppard Pratt Health System in Maryland and a former staffer for the Presidential Commission on Mental Health during the Carter Administration focused on system fragmentation. He maintained that fragmentation of funding leads to fragmented care. Few financial incentives (e.g., reimbursement) exist to promote coordinated care. In addition, providers have been overwhelmed by the administrative paperwork required by reimbursement processes.

Dr. Sharfstein suggested that the Commission's final report to the President include a strong statement that, at a time when treatment for mental illness has never been more effective, access to care is fragmented, discontinuous, sporadic, dysfunctional, and often totally unavailable. He encouraged the Commission to emphasize both the recovery model and the medical/scientific service delivery model.

He offered several principles for the Commission's consideration, including

  • Care should be based on "continuous healing relationships" as described in the Institute of Medicine report, Crossing the Quality Chasm.
  • The costs of mental illness should be interpreted broadly to include budgets of criminal justice, general health care, and welfare and disability systems so that adequate resources can be redirected to these systems.
  • Integration of care must include integration of substance abuse and mental illness treatment, developmental disabilities with mental illness treatment, primary care with specialty in mental health, and medication management with psychotherapy and psychosocial supports.
  • Payment for care should be nondiscriminatory. Cost containment principles should apply identically to health and mental health.

Given the importance of the Commission's work, Dr. Sharfstein urged a focus on the next steps once the Commission issues its report to the President. A critical, yet subsequent, outcome of the Carter Commission was the development of the National Plan for the Chronically Mentally Ill, a series of reforms that improved access to rehabilitation and housing.

Dr. Kelly, a former Commissioner of the Virginia Department of Mental Health, also provided his perspective on fragmentation. According to Dr. Kelly, the problem is that the mental health service system is stuck on a status quo approach to care that accepts tradition and mediocrity rather than demanding innovation and excellence. He highlighted three areas for the Commission to focus upon:
· Quality of care. The measurement of standardized and reliable clinical outcomes is too rare in both the public and private sector. Even when such data is collected, there is resistance to feeding back that information into the system due to concern that the data might be misused or impose an administrative burden.
· Cost effectiveness. Dr. Kelly cited the problem of funding expensive facilities that served fewer patients, resulting in a drain of resources that could go toward innovative community-based services. States should establish priorities and conduct comprehensive program reviews that do not spare traditional "sacred cows." He also urged reduction in regulations through block-granting state and Federal funds to providers, but with the critical provision that results-oriented outcome data be generated for funding to continue.
· Agency accountability. Dr. Kelly suggested that the Commission recommend strategies for coordinating and restructuring Federal agencies around evidence-based reforms, while recognizing the principle of federalism, encourage states to ensure the quality of their state's mental health care by requiring state mental health agencies to institute outcome measurements for all providers, publish the findings regularly, and allow policy makers and consumers to evaluate quality of care.

Laurie Flynn, former Executive Director of NAMI, and current Director, Carmel Hill Center for Early Diagnosis and Treatment, Division of Child and Adolescent Psychiatry at Columbia University, urged Commissioners to remember that engaged and energetic parents and consumers are the most effective tools for securing needed change.

She attributed the current system fragmentation to lack of knowledge by some providers and/or implementing interventions poorly. For example, preventive interventions aimed at adolescents often include phone numbers for contact; yet, adolescents do not reach out by calling phone numbers. Or, she suggested, periodic media campaigns to educate people about depression do not have an impact, as they are too general or not sustained. These types of programs represent good intentions and large investments of money; yet do not have sufficient outcomes.

Ms. Flynn described a promising strategy utilized by Columbia University, which provides a diagnostically based screening for youth, which can identify youth who are at risk for serious mental disorders. This computerized diagnostic tool can be self-administered in less than an hour. Yet, Ms. Flynn described the challenges of implementing the screening in communities. Implementation in just one school district often requires piecing together over a dozen funding streams from the education and mental health fields. She cited the need for blended funding to help engage partners in education. She also recommended that children obtain routine mental health check-ups.

During the question and answer period between Commissioners and panelists, comments included:

  • While there are a multitude of programs for people with mental illness, the availability of specialty care exacerbates fragmentation given the lack of coordination.

  • Instead of letting one group buy services for another, the system should create a market dynamic by allowing consumers and families to make their own choices and equip them with clinical outcome data to guide those choices.

  • It is important to involve PTA's when forming school-based partnerships and interventions.

A copy of Dr. Sharfstein's and Dr. Kelly's presentations is available on the Commission's web site,

Panel Presentation: Business Executives Share Personal Experiences with Depression

Larry Gellerstedt, III, President and COO, The Integral Group, Atlanta, Georgia
J.B. Fuqua, Chairman, The Fuqua Companies, Atlanta, Georgia
Tom Johnson, Retired Chair and CEO, CNN News Group, Atlanta, Georgia

Mr. Gellerstedt, Mr. Fuqua, and Mr. Johnson shared their personal experience of dealing with depression while maintaining high-level executive positions. Panelists agreed that far too many people who suffer from mental illness do so in secret due to stigma. Until the stigma is diminished, too many people will not seek treatment and some will take their own lives. Stigma exists around acknowledging one has a mental disorder, but also when seeking treatment and facing public perceptions. Acknowledging that one has a mental disorder may result in discrimination including financial, (e.g., when seeking health or life insurance), which creates a strong disincentive to seeking treatment.

The business leaders pointed out that those employed in the Federal government also experience fear and stigma which prevents them from acknowledging their mental illness. The Federal government could exhibit leadership by reviewing its forms and applications for stigmatizing questions. Currently, employees are fearful of seeking psychiatric care or taking antidepressant medication. It will take both political and corporate leaders to ensure their policies do not discriminate against people with mental disorders.

Commissioners were interested in how they might encourage corporate leaders to create environment that encourage people to come forward. Mr. Gellerstedt responded that corporations should provide information about how common mental illnesses are and suggested that companies can gain a competitive advantage and increase productivity by adopting favorable policies.

Mr. Johnson agreed that the Commission "cannot legislate" the end of stigma. It will require leadership and education of colleagues in all available forums. He is involved with trying to mobilize other CEO's to engage in a proposed national depression campaign. Other Commissioners suggested that the media and insurance parity would help foster acceptance and minimize stigma.

Mr. Johnson urged the Commission to endorse two activities: (1) creation of a national awareness campaign about the treatment of depression aimed at defeating the stigma of depression and (2) creation of a national information center about depression to make information about depression as easy to obtain as information on cancer, perhaps in partnership with Emory University and Stanford University.

After thanking the business leaders for their willingness to speak publicly about their experiences and help penetrate that veil of stigma, Chair Hogan closed the meeting at 5:30 p.m.

December 5, 2002

Expert Presentation: A Model to Reduce Fragmentation

Ron Diamond, M.D., Professor, Department of Psychiatry, University of Wisconsin, and Medical Director, Mental Health Center of Dane County, Madison, Wisconsin

Upon opening the day's session at 8:40 p.m., Chair Hogan introduced the presenter, Dr. Diamond, who added his perspective on system fragmentation.

Dr. Diamond explained how perceptions of effective treatment of persons with mental illnesses have evolved from (1) simply decreasing the number of hospital patients (2) decreasing the number of rehospitalizations by either decreasing hospital bed availability and/or increasing community supports so that rehospitalization is not required to (3) focusing on persons' rehabilitation to ensure they have more to life than their illnesses to (4) achieving community integration for persons with mental illnesses. In Dr. Diamond's opinion, Dane County was currently in the third stage of treatment development.

He also distinguished the difference between a system and a set of programs, maintaining that having a number of good programs does not constitute a system. While a program is responsible for a defined set of clients, a system is responsible for all high priority clients in its locality (e.g., including those in jails and people not yet connected to services). An effective system provides ongoing services to a priority population (e.g., persons with serious and persistent mental illness) and individual program components support one another as part of a larger, integrated system.

In contrast, traditional systems have clinical programs that decide what services they want to offer and the person is expected to fit into the available services. If the person needs a service not offered by a program, it the person's problem, not the system's problem. In contrast, an effective mental health system does whatever is required to meet the needs of its high priority clients.

Dr. Diamond also emphasized how clinical systems and funding streams are inevitably intertwined: financial incentives and disincentives drive the system. With traditional funding streams, community programs and hospitals are often at odds, competing for dollars from the state budget and debating over responsibility for clients. In Dane County, the local authority controls the pot of money and is able to purchase services from hospitals (including state and private hospitals), as well as a range of community-based programs services (including outpatient clinics, rehabilitation programs, crisis resolution programs and residential programs). Under this arrangement, the locality may allocate resources creatively based on clinical needs (e.g., for a client who needs a brief, supported placement, the system can pay for a person to stay in a hotel accompanied by a crisis aide in lieu of a hospital stay). While flexible funding enables this system to work, leadership and available clinical programs are essential.

He laid out several principles for designing a system of care:

  • One central authority. This central authority controls all of the resources, is responsible for all high priority clients, and can be organized in many different ways.

  • Case manager system. Core service teams are responsible for ensuring that all needed services are provided by through coordination of a complex array of services and sustained relationship with the client.

  • Continuity of care. Case managers strive for cross-sectional continuity (i.e., the various systems involved in a persons' life are communicating) and longitudinal continuity (i.e., a person's history is recorded and remembered as they go through system).

  • Ongoing rather than time limited services. People are able to move through the system at their own rate. While some may require life-long services, the intensity of those services likely will change over time.

  • Need for different service options. To meet individuals' needs, there must be an array of available services (e.g., ACT teams, clubhouse, medication, clinics, supportive therapy, self help, skill training, etc.). Funding decisions are based upon clinical needs rather than clinical decisions based on funding.
    Dane County's system embodies many of these principles. Treatment is individualized and starts with the client's goals. The treatment team provides ongoing and integrated services by focusing on the client's strengths and working with the support system, including family, landlords, church, police, etc. Over time, a person may require differing amounts of structure and support in the following elements of a community support system: housing, money and other basic necessities, work and other ways to structure time, socialization, medical services, mental health services, crisis intervention, support to the community, and case management.

Dr. Diamond also offered some "system truisms" based upon his experience in Dane County:

  • The fewer hospital beds you use, the more important it is to always have one immediately available.

  • Client choice requires open slots. True choice means service options are available.

  • Systems that are effective in supporting people over long periods of time will tend to "silt up." As more people avail themselves of services, the system will begin to clog. Systems then face choices of diluting the services (forcing more people into the program) or creating waiting lists.

To prevent the system from filling up, administrators may obtain additional resources, choose to extrude people from the system, establish barriers to prevent entry into the system (e.g., cumbersome intake process), increase case load size, or sacrifice one program to protect the rest of the system. As Dane County has experienced system clog, it has determined to "sacrifice" its mobile crisis by expanding its role to provide case management services to individuals who are waiting to get into other services. Dr. Diamond also stressed that it is important to have consumers and families participate in the discussion about how to handle system clogging.

During the question and answer period, Commissioners posed questions about how such systems works for people in rural areas, how the community responds to discussions about establishing priority clients, and how to integrate Medicaid financing into this type of system. Dr. Diamond underscored the premise that financial incentives drive clinical programs and the need to look at unintended consequences of funding decisions. In response to questioning, he suggested that the Commission might recommend wrapping Federal and nonfederal monies together and placing it under local control. If localities had access to all resources, as well as all of the responsibility of ensuring care, the system would be more efficient and, in some localities, promote creative experimentation. Such local control also could be combined with accountability mechanisms (e.g., outcomes). Another recommendation was to integrate the budgets of hospitals and community-based programs so that localities are able purchase beds, which may spur the creation of additional service options.

Work Session

Chair Hogan opened the public work session at 3:25 p.m. and provided an overview of the Commission's Subcommittees structure and activities, including preparation of background Issue Papers on a range of topics. He stated that while the Commission will submit a report to the President, the final Issue Papers would provide a good foundation for the Commission's final recommendations and be useful resources for the field.

As of the December meeting, several Subcommittees were prepared to engage the full Commission in a discussion about their respective topics. Subcommittee Chairs were asked to frame issues and offer policy options for eventual consideration by the full Commission. As Chair Hogan explained, these preliminary
discussions about policy options would be followed in the coming months by more detailed deliberations about specific recommendations.

The opening report was offered by Commissioner Lerner-Wren, Chair of the Subcommittee on Criminal Justice, accompanied by Dr. Henry Steadman, consultant to the Subcommittee.

Report of the Subcommittee on Criminal Justice

Commissioner Lerner-Wren outlined the significant problem of the criminalization of people with mental illnesses. In its discussions, the Subcommittee suggested that three major responses were needed: (1) keep people with serious mental illness who do not need to be there out of the criminal justice system through diversion programs; (2) provide constitutionally adequate services in correctional facilities for people with serious mental illnesses; and (3) link people with serious mental illnesses to community-based services when they are discharged through reentry transition programs. Commissioner Lerner-Wren described several policy options discussed by the Subcommittee, including:

  • The Centers for Medicare and Medicaid Services (CMS) and the Social Security Administration (SSA) should work with representatives of state agencies to offer technical assistance regarding provisions of Federal Medicaid and Disability Program rules as they apply to inmates to: (1) promulgate a clear statement of the limited requirements for disenrollment from Medicaid for jail detainees and how state rules often result in a narrower interpretation than is required by the Department of Health and Human Services, (2) facilitate the process of application for SSI or SSDI benefits while incarcerated. Incentives for disenrolling recipients should be matched with incentives for enrolling eligible inmates prior to release and (3) ensure released inmates are returned immediately to Medicaid rolls if previously eligible.

  • The Department Housing and Urban Development (HUD) should provide guidance in its Continuum of Care application and to HUD McKinney grantees that explicitly recognizes the people who meet McKinney definitions for homelessness upon entry to the criminal justice system are eligible for targeted homeless housing and service programs upon discharge from the criminal justice system.

  • HUD should provide explicit guidance to all its programs, including Public and Indian Housing, Section 8, and others, that people with mental illness exiting the criminal justice system are eligible applicants for HUD programs.

  • The Bureau of Justice Assistance Edward Byrne Memorial State and Local Law Enforcement Assistance Program guidelines should clearly state that funds could be used for community-based mental health services for inmates released from correctional facilities.

  • The Department of Justice, when investigating institutions under the Civil Rights of Institutionalized Persons Act (CRIPA), should review the extent to which institutional services (per Ruiz v. Estelle requirement that treatment is more than mere seclusion or close supervision) are consistent with evidence-based practices.

  • The Department of Labor should use its national evaluation and technical assistance contractors to assist program grantees in the implementation of supported employment practices for inmates with serious mental illness released from jail or prison.

  • HHS through SAMHSA should provide technical assistance to ADMS Block Grantees to improve access to comprehensive and integrated treatment programs for inmates with mental illness and co-occurring disorders.

  • CMS should work with representatives of state Medicaid agencies to offer guidance and technical assistance regarding revising state Medicaid plans to cover services provided by Assertive Community Treatment teams for persons in contract with the criminal justice system. CMS should provide assistance to state Medicaid directors on developing financial constructs to cover ACT services, including specialized ACT teams for criminal justice system clients.

  • HHS should prioritize the training of judges for all of its existing and prospective technical assistance centers within SAMHSA. The Subcommittee recommended the adoption of multidisciplinary legal education for judges and lawyers on offenders with mental illness and co-occurring substance use disorders.

Once Commissioner Lerner-Wren completed her overview of the policy options, a number of Commissioners engaged her and Dr. Steadman in questions.

Commissioner Godbole inquired whether the Subcommittee discussed strategies for developing community awareness and acceptance of this population, citing prevalent Not In My Back Yard (NIMBY) attitudes among community members and even mental health professionals. Dr. Steadman responded that while the Issue Paper will address the public's fear of violence among this population, ultimately this population represents the same poor and homeless people who currently cycle through the mental health, substance abuse and criminal justice systems. Through the policy options, the Subcommittee aimed to underscore the importance of good public health and good public safety by ensuring there are appropriate and comprehensive services for individuals with mental illnesses, and often co-occurring substance abuse disorders.

Commissioner Postlethwait asked about the application of the policy options to adolescent and school-aged populations. Although there are many overlapping issues between adult and juvenile justice systems, the juvenile justice system also has many unique needs. Thus, the Subcommittee on Criminal Justice did not deal with the juvenile justice system believing the Children's Subcommittee should address the issue. Commissioner Adams and Commissioner Huang agreed that the Subcommittee on Children and Families should focus on the juvenile justice population.

Commissioner Mayberg expressed concern about the framing of CRIPA issues and the emphasis on the constitutional right of persons in institutions to treatment. After some discussion about rights and responsibilities, Commissioners agreed that the emphasis should be on the need for Federal leadership to decriminalize this population, promote public health/public safety, and divert individuals into community programs that can assist them.

Commissioner Fisher requested that the theme of recovery be woven into the report. He also suggested that treatment in jails should include more than medication. Dr. Steadman indicated that the Issue Paper would distinguish between treatment available in jails (average length of stay is two days) and prison facilities (average length of stay is 18 months).

In response to Commissioner Townsend's question about suggested mechanisms for implementing several policy options, Chair Hogan suggested that many of the proposals required clarification from Federal agencies (e.g., clarification from CMS to state Medicaid agencies) rather than changing regulations. Dr. Steadman underscored the need for Federal guidance (e.g., technical assistance or program guidance), as communities have more opportunities to provide services than then they recognize currently.

Commissioner Huang requested that the Subcommittee consider providing more specific programmatic or policy options related to persons with mental illnesses who are minorities and involved with the criminal justice system.

Once the discussion was complete, Commissioner Godbole moved to accept the Subcommittee on Criminal Justice's report and Commissioner Yates seconded the motion. Commissioners voted unanimously to accept the report. The full outline for the Draft Report of the Subcommittee on Criminal Justice is available on the web site,

Report by the Subcommittee on Evidence-based Practices

Commissioner Godbole, Chair of the Subcommittee on Evidence-based Practices, accompanied by Dr. Howard Goldman, consultant, gave the following Subcommittee report:

During its discussions, Subcommittee members agreed that there is a need to expand efforts at developing and testing new treatments and practices, at promoting awareness of and improving training in evidence-based practices, and in better financing those practices. Commissioner Godbole stressed the need for national leadership to overcome fragmentation and diffusion of responsibility around promoting evidence-based practices.

The Subcommittees offered three primary policy options:

1. Partnership for National Leadership. The subcommittee recommended a "national consortium" to create a partnership for leadership, initiated and sustained by the Federal government and involving relevant agencies along with other organizations in the public and private sectors. The partnership should include all stakeholders, including consumers and families, to advance knowledge, disseminate findings and implement evidence-based practices.

To establish this national leadership, the Subcommittee further suggested:

  • Expanding mental health outreach partnerships and mental health awareness activities

  • Developing and strengthening quality improvement programs using evidence-based practices in the public and private sectors, linking to organizations involved with licensure, credentialing, accreditation, treatment guidelines, and algorithms

  • Creating a national infrastructure for leadership training in evidence-based practices, such as through a renewed staff college operated jointly by the partnership involving NIMH and SAMHSA

  • Building infrastructure for a national multidisciplinary mental health professional training program to focus on disseminating and implementing evidence-based practices, and

  • Advancing knowledge including rigorously evaluated service demonstration programs.

For each of these policy options, the Subcommittee favors a partnership approach that is initiated by the Federal government and has significant Federal participation and support but is "national" rather than Federal. Federal resources should serve as a "match" to contributions from state and local governments, as well as from private sources, such as foundations and advocacy organizations.

2. Advance knowledge including rigorously evaluated service demonstration programs. Service demonstrations are intended to provide knowledge to assist in disseminating and implementing new service models. Under the direction of the national partnership, CMHS (SAMHSA) and NIMH (NIMH) should strengthen their collaboration in planning, fielding, and evaluating mental health service programs in evidence-based practices in collaboration with other Federal agencies, state and local governments, as well as private organizations, including foundations, and involve all stakeholders, including consumers and families.
3. Assure existing funding mechanisms encourage the use of evidence-based practices. The failure of most mental health service financing mechanisms to pay adequately for evidence-based practices is one of the most important reasons for problems with implementation. It is essential to reduce financial barriers to providing evidence-based practices. Subcommittee recommends a range of strategies and tactics to assure financing, including:

  • Modify Medicaid. There is a need to cover evidence-based practices in Medicaid benefits. It is also critical that the rates paid to providers create an incentive for them to deliver evidence-based practices.

  • Modify Medicare. It is essential to cover evidence-based practices in Medicare benefits, particularly the disease management interventions that cannot be paid for in their "bundled" form. These practices should be brought to the attention of the Medicare National Coverage Process to add them to the list of covered services.

  • Use the Mental Health Services Block Grant to initiate evidence-based practices. Even though it represents a small portion of state mental health resources the block grant is a flexible source of financing for initiating and supporting evidence-based practices. The Subcommittee recommends that state mental health directors are encouraged to continue to use these Federal resources to implement evidence-based practices but that they are required to use the block grant to create an infrastructure, such as a center for implementing evidence-based practices in each state.

Upon completion of the Subcommittee report, Commissioner Curie stated his appreciation of the Subcommittee's focus on the sciences to services cycle, a priority area for SAMHSA and NIH. For the suggestions to modify Medicaid and Medicare, he suggested that more appropriate terms might be "clarify" or "address" as the goal is to create an environment where financing mechanisms (including Medicaid and Medicare) begin purchasing evidence-based practices. Commissioner Curie also noted the Subcommittee's mention of research, dissemination, demonstration, and evaluation and the difference in meanings of those respective terms and the implications.

Alternate Commissioner Stanton commented that the Subcommittee's report was philosophically consistent with CMS' goal of "getting into the business of paying for what works." He also suggested that the Subcommittee clarify its use of terms, specifically around the difference in coverage and payment issues. For example, rates are set by states, not the Federal government. In addition, there are services that CMS cannot completely support given existing laws (e.g., supported employment). However, technical assistance may be helpful to clarify what supports for employment can be funded and which cannot.

Commissioner Fenton was pleased with the Subcommittee's mention of continued research to develop new evidence-based practices in addition to disseminating current knowledge.

Commissioner Fisher echoed approval of a focus on new research, indicating this issue is particularly relevant for consumer research. He requested that the Subcommittee address research on emerging services so that the emphasis on evidence-based practices does not preclude the advances in consumer research and services. He suggested that a statement be added about consumer involvement with research design and
research analysis and that positive outcome be defined as integration into the community versus simply a reduction in symptoms.
At the conclusion, Commissioner Postlethwait made a motion to accept the Subcommittee on Evidence-based Practice's report, which Commissioner Townsend seconded. The full Commission voted unanimously to accept the report. A copy of the full Outline for the Draft Report of the Subcommittee on Evidence-based Practices can be found on the web site, Chair Hogan closed the meeting at 5:15 p.m.

December 6, 2002

Work Session

Chair Hogan began the work session at 8:40 a.m. and explained the Commission's task to listen to, discuss and accept the reports from the Subcommittees on Suicide Prevention and Co-occurring Disorders.

Report of the Subcommittee on Suicide Prevention

As Chair of the Subcommittee on Suicide Prevention, Commissioner Prechter provided the report to the full Commission. After describing the pressing public health crisis of suicide, she highlighted the Subcommittee's policy options, including:

  • · Develop leadership with in the Department of Health and Human Services - with authority stemming from the Office of the Secretary - to coordinate all Federal suicide research and prevention efforts over a sustained period of time. This leadership should provide sufficient authority to coalesce and shape multiple Federal institutional forces in a common direction.

  • · Design, implement and rigorously evaluate Court Integrated Mental Health Services to deal with persons seen in family court (associated with domestic disputes and threats) and criminal court associated with domestic violence, substance abuse, and crises among those with persisting mental disorders). These services should be supported with Medicare and Medicaid waivers - along with analogous mechanisms through the criminal justice systems.

  • · Create public health oriented national centers of excellence through the National Institute of Mental Health (NIMH) to support research focused on developing and testing novel interventions to prevent suicide and attempted suicide. The research agenda should include both high-risk group and population-oriented methods.

  • · Establish Federal and state surveillance systems for reporting suicide and attempted suicide, with reliable and valid reporting standards and strict confidentiality safeguards. Tightly monitored evaluation programs at the local level that use standard outcome measures should be supported which can expand the evidence base on suicide prevention program effectiveness.

  • · Assert the central coordinating role of state mental health authorities as links between Federal and local suicide prevention efforts. This requires a reaffirmation of historic state commitments to caring for people with serious mental illness, and reflects states' unique ability to implement program initiatives in collaboration with local agencies, and to assure linkage among community agencies and clinical providers.

  • · Develop broad-based Community Suicide Prevention Coalitions. "Community Coalitions" are defined, for the purposes of this report, as the engines for local collaborative action, reflecting the efforts of mixed nongovernmental and local governmental agencies, established on a foundation of rigorously evaluated community prevention initiatives. The Subcommittee recognizes that each community may have distinctive collations that may differ in many respects while sharing a common commitment to suicide prevention (e.g., efforts to prevent suicide among youth or among older adults).

Following the report, Commissioner Prechter and Dr. Eric Cain, who served as a consultant to the Subcommittee on Suicide Prevention, fielded questions and comments from the full Commission.

Commissioner Lerner-Wren expressed support for incorporating suicide screening into the criminal justice settings, as well as a range of settings, such as the schools.

Commissioner Yates questioned if current surveillance systems can indicate whether people who commit suicide were in mental health treatment at the time and, if so, were they in the public or private mental health system. Dr. Cain responded that the data is uneven, but some research has shown that (1) among elderly suicide victims, only 20 percent had a mental health contact during their life times while 70 percent had a primary health care visit within the last month and 40 percent had a visit in the week prior to their suicide, (2) for persons with serious mental illnesses, virtually all were in treatment, but it is difficult to ascertain where they fall between the cracks, (3) during the age span 25-55 when most suicides occur, those who commit suicide often have chronic substance abuse histories, particularly alcohol abuse, and may be seen in chemical dependency settings, the court system, or exhibit at-risk signs in the workplace.

Commissioner Insel suggested that the Subcommittee might want to incorporate World Health Organization data on global risk of violent deaths, which indicated 49 percent of deaths were self-inflicted. He suggested that the Subcommittee may not want to compare the number of deaths resulting from AIDS and suicide, as such data may appear to pit one population against another. In response to a question from Dr. Insel, Dr. Cain discussed the quality of systems to track people who are at high risk of suicide, suggesting that it may be more helpful to examine substance abuse, family turmoil, incidence of depression, and work-place problems. The goal should be to seek out and treat populations that demonstrate such risk factors.

Commissioner Harbin inquired whether establishing parallel or additional systems outside of the mental health or medical system is desirable. Dr. Cain commented that it would be preferable to better utilize existing systems and cited the cost savings achieved when New York's Monroe County was able to integrate more than a dozen funding streams to provide suicide prevention activities.

Commissioner Godbole inquired about how and whether suicide prevention is incorporated into professional training. Dr. Cain indicated that the biggest need is to educate professionals outside of the mental health
disciplines about suicide risk factors, including primary care providers, EAP providers, and school professionals.

Commissioner Adams expressed concerns about the need to educate consumers and families about suicide prevention, the need for culturally sensitive and alternative methods for suicide prevention (e.g., Native American models), the need for sufficient attention to the suicide rates among youth in juvenile justice and in foster care, and the issue of tracking/surveillance.

Commissioner Huang addressed the challenging of determining effectiveness of suicide prevention efforts and even defining what constitutes a suicide (e.g., accidents or homicides which may really be passive suicides).

Alternate Commissioner Hutchings spoke of the tremendous mental health needs of the surviving family members after a suicide and questioned how the Subcommittee's policy options might address that need. Dr. Cain suggested that the trauma field might offer better interventions for this group to address the significant ripple effects of the 30,000 suicides each year.

At the conclusion of the discussion, Commissioner Townsend moved to accept the report offered by the Subcommittee on Suicide Prevention and Commissioner Lerner-Wren seconded the motion. Commissioners voted unanimously to accept the Subcommittee's report. The Outline for the Draft Report of the Subcommittee on Suicide Prevention is available on the web site,

Approval of November Meeting Minutes

Chair Hogan requested that Commissioners approve the draft minutes from the November 12-14, 2002 meeting. After Commissioner Townsend moved to accept the minutes and Commissioner Lerner-Wren seconded the motion, the minutes were adopted by a unanimous vote.

Report of the Subcommittee on Co-occurring Disorders

As Subcommittee Chair, Commissioner Arredondo acknowledged the contributions of consultants Dr. Ken Minkoff and Dr. Doug Ziedonis, as well as the Subcommittee members. He gave an overview of the report, including integrated treatment focus. Commissioner Arredondo outlined the issue of appropriately serving people with co-occurring disorders and put forth several policy options for discussion, including:

  • All Federally funded health, human services, and criminal justice programs should include co-occurring disorders as an expectation in program design, development of program standards, and monitoring of clinical outcomes and quality indicators.

  • The SAMHSA Administrator should issue a directive establishing a visible focus of authority and responsibility for co-occurring disorder-related issues with direct reporting to the Administrator. This entity would coordinate existing activities in this area by SAMHSA agencies and coordinate linkages with other Federal agencies regarding co-occurring disorders. In addition, it would promote new functions and activities, including implementing a collaborative process with states and the private sector to reach consensus definitions of "co-occurring disorders" and "integrated co-occurring disorder treatment," and develop accompanying specific, measurable performance standards.

  • The Secretary of Health and Human Services (DHHS) should issue a directive that all health training programs receiving DHHS funding should include co-occurring disorders as an expectation in curriculum design.

  • The SAMHSA Administrator should issue a directive to launch a major Federal/state initiative to foster system change initiatives at the state and local (regional, county) levels. Such effort would aim to improve utilization of existing resources through integration of system planning, elimination of regulatory barriers, creation of regulatory and funding incentives, and dissemination/implementation of best practice programs, interventions, and services for individuals with co-occurring disorders. The SAMSHA Office of Co-occurring Disorders could coordinate with the regional Technology Transfer Centers to disseminate information to state and local systems regarding evidence-base practices, and provide technical assistance and consultation to support state system change initiatives.

  • The Secretary of DHHS should issue a directive to require collaboration between SAMHSA and the Center for Medicare and Medicaid Services (CMS) to develop and implement policy guidance to
    promote access and utilization of appropriate services by Medicaid and Medicare beneficiaries with co-occurring disorders.

  • The NIH Administrator should issue a directive to launch a major Federal research initiative on co-occurring disorders through the development of an Office of Co-occurring Disorders Research with a mandate to increase interagency collaboration in the development of co-occurring disorder research proposals.

  • The SAMHSA Administrator should issue a directive to encourage investment of existing Mental Health Block Grant and Substance Abuse Prevention and Treatment Block Grant funding in prevention efforts directed specifically at co-occurring disorders, under the coordination of the Office of Co-occurring Disorders.

  • The Secretaries of DHHS, the Department of Justice, and the Department of Education should issue a joint directive to mandate that co-occurring disorders are routinely addressed and integrated into every initiative relating to either mental health or substance abuse in every human service setting. The new requirements would include comprehensive screening and identification for both disorders in all Federally funded correctional, criminal, or juvenile justice programs. The Federally-funded behavioral health programs in criminal justice or correctional programs would also be required to provide treatment services that meet dual diagnosis capability standards.

Commissioner Curie reported to the Commission about SAMHSA's recently submitted report to Congress on co-occurring disorders and the matrix of SAMHSA's priorities, which includes a focus on co-occurring disorders. Both of these efforts should dovetail well with the Commission's eventual recommendations around treatment of co-occurring disorders.

Commissioner Harbin questioned how many states have departments that combine mental health and substance abuse and how many have separate departments. While it is likely that comparable numbers of states operate under both structures, there is still tremendous variation within states, including at the local levels. Commissioner Curie commented that, while some level of structural merging may need to occur to facilitate better integration, a focus on function rather than structure is more helpful. Chair Hogan added that the Commission should focus on the need for integrated treatment rather than how the integration occurs.

Commissioner Yates suggested that the Commission include the private sector in its policy options about integrating care. Perhaps dialogues and education efforts could be initiated with the national leadership of organizations like Alcoholics Anonymous and Narcotics Anonymous.

Commissioner Fisher expressed interest in an Office of Co-occurring Disorders, citing the roles of consumers in recovery within both the mental health and substance abuse fields. It also would be helpful to have
dialogues among the consumer leadership within both those fields and move toward complementary perspectives of self-help.

Commissioner Godbole expressed concern that the subcommittee's report may be too proscriptive by recommending a specific model, the integrated treatment model, particularly given the evolving field and the diversity of systems. Commissioner Curie responded that Subcommittee's intention was not to promote one model but to encourage integrated care, particularly as multiple systems are already spending resources upon individuals with co-occurring disorders.

Alternate Commissioner Mele-McCarthy suggested expanding the policy options about health training programs to include collaboration with professional organizations, which educate practitioners, as well as families and consumers.

Commissioner King-Shaw Ruben encouraged the Subcommittee to include community and faith-based organizations in the policy options and suggest ways to partner with and leverage the capacities of those organizations.

Commissioner Huang requested that the Subcommittee address the needs of adolescents with or at-risk of co-occurring disorders, given the important window of opportunity to intervene with these youth.

At the end of the discussion, Commissioner Lerner-Wren moved that the Commission accept the report of the Subcommittee on Co-occurring Disorders, which Commissioner Townsend seconded. The Commissioners voted unanimously to accept the subcommittee's report. The Outline for the Draft Report of the Subcommittee on Co-occurring Disorders is available on the web site,

Public Comment

During its public comment period, the Commission heard from the following individuals:
Linda Boone, National Coalition for Homeless Veterans
Bob Reeg, National Network for Youth
Mary May, National Coalition for the Homeless
Jeremy Rosen, National Law Center on Homelessness and Poverty
Eric Lowder, Missouri Statewide Parent Advisory Network for Children with Serious Emotional Disturbances
Joan Esnayra and Craig Love, Psychiatric Service Dog Society
Megan Linz, National Health Care for the Homeless Council
Diane Engster, Northern Virginia Mental Health Consumers Association
Valerie Porr, National Association for personality Disorders

Work Session

During the final work session, the following Subcommittees provided brief updates on their activities: Cultural Competence, Children and Families, Housing and Homelessness, Consumer Issues, Medicaid, and General Medicine Interface. Several Subcommittees indicated they might be prepared to report out at the Commission's January Meeting.

Chair Hogan highlighted a matrix of Federal government programs prepared by Commission staff for Commissioners. Given the more than thirty Federal programs spanning multiple Departments that impact persons with mental illnesses, he indicated that many of the issues before the Commission must be examined more broadly than the narrow confines of the mental health system, particularly for children.

Chair Hogan also mentioned recent correspondence received by the Commission, including a piece submitted by the father of young man who testified before the Commission in September, which encouraged reducing fragmentation by giving consumers and families a more central role in directing their care. In addition, a California mother who lost her son to suicide wrote Mrs. Bush to encourage the replication of programs like The Village. Commissioner Godbole requested that Commissioners receive more qualitative analysis about public comments received by the Commission's web site, in addition to the quantitative report.

Chair Hogan mentioned that many Commissioners are reaching out in their respective communities and region to solicit input and engage in dialogue. Commissioner Lerner-Wren sponsored a forum in south Florida, while Commissioner Knight-Richardson hosted a forum for western states in Oregon.

Finally, Chair Hogan noted that the Commission's web site,, has sections that have been translated into Spanish. Also, in process, and soon to be active are web sections that have been translated into Chinese, Korean, and Vietnamese. Chair Hogan expressed appreciation to members of those communities who were able to contribute to the translation effort.

Adjournment and Next Meeting Announcement

Chair Hogan adjourned the meeting at 12:05 p.m. The next Commission meeting will occur January 7-9, 2003 in Arlington, Virginia.

I hereby certify that, to the best of my knowledge, the foregoing minutes are accurate and complete.

Claire Heffernan
Executive Director
President's New Freedom Commission on Mental Health

Michael Hogan, Ph.D.
President's New Freedom Commission on Mental Health

These minutes were considered and approved by the Commission at its January 8, 2003 meeting and any corrections or notations incorporated into the text.

Last Modified 1/17/03


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