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The President's New Freedom Commission on Mental Health met on October
2-4, 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 October 2nd from
4:30 p.m. to 5:30 p.m., October 3rd from 8:30 a.m.- 5:00 p.m., and
October 4th from 8:30 a.m. to 12:30 p.m., when the meeting adjourned.
Commissioners present:
Michael F. Hogan, Chair
Jane Adams
Rodolfo Arredondo, Jr.
Patricia Carlile
Charles Curie
Daniel B. Fisher
Anil G. Godbole
Henry T. Harbin
Larke N. Huang
Mark Johnston
Ruben King-Shaw, Jr.
Norwood W. Knight-Richardson
Ginger Lerner-Wren
Stephen W. Mayberg
Joan Mele-McCarthy
Frances M. Murphy
Richard Nakamura
Robert Pasternack
Robert N. Postlethwait
Nancy C. Speck
Randolph J. Townsend
Deanna F. Yates
Staff members present:
Claire Heffernan, Executive Director
H. Stanley Eichenauer, Deputy Executive Director
James Finley, Senior Policy Analyst
Dawn Foti, Health Policy Analyst
Kevin Hennessy, Senior Policy Advisor
Elaine Viccora, Senior Policy Advisor
Patty DiToto, Administrative Assistant
Presenters who attended portions of the three-day meeting were:
Stephen Bartels, M.D., M.S., Associate Professor of Psychiatry, New
Hampshire-Dartmouth Psychiatric Research Center, Dartmouth Medical
School
Gary K. Kennedy, M.D., President, American Association for Geriatric
Psychiatry
Willard Mays, M.S., Immediate Past President, National Coalition for
Mental Health and Aging and Past Chair, Older Persons Division of
the National Association of State Mental Health Program Directors
Hikmah Gardiner, Older Adult Consumer Mental Health Alliance
Bryce Miller, Older Adult Consumer Mental Health Alliance
October 2, 2002
Presentation: Older Adults and Mental Health
Stephen Bartels, M.D., M.S., Associate Professor of Psychiatry,
New Hampshire-Dartmouth Psychiatric Research Center,
Dartmouth Medical School
Chair Michael Hogan convened the meeting at 4:30 p.m. and welcomed
Commissioners and members of the public to a presentation by Stephen
Bartels. Dr. Bartels described the anticipated growth in the number
of older Americans and the corresponding impact on the mental health
service delivery system. By the year 2040, 1 in 5 Americans will be
over the age of 65 with the fastest growing group being the "oldest
old," or those people over age 85. It is anticipated that 20
percent of these older individuals will have some sort of mental disorder,
including dementia, depression, psychosis, bipolar, schizophrenia
or an anxiety disorder.
Dr. Bartels also explained the significant impact that the mental
disorders of older adults has on health outcomes and health care costs.
For example, studies indicate that older adults with depression have
poorer rehabilitation outcomes after fracturing their hips while older
adults with cancer and clinical depression also experience worse health
outcomes. In addition, as older adults experienced more severe depression,
their aggregate health care costs increased. Research also has found
that older adults who have various medical disorders (e.g., diabetes)
and are depressed experience significant increases in hospitalizations,
emergency room visits and use of medication. Dr. Bartels pointed out
that the Medicare system is already paying for older adults with mental
health issues as a result of this increased use of the physical health
care system.
The cost to human lives also is striking as suicide is a major health
problem for the aging population. The suicide rate for those over
age 85 is twice the national average. One study of older men who committed
suicide indicated that one-third of them had seen their primary physician
in the week prior to their suicide, suggesting that the primary care
system is not identifying at-risk individuals and delivering preventive
mental health services.
Dr. Bartels noted the lack of a defined system to serve older people.
The "system" for older adults is loosely defined and encompasses
a wide range of providers, including primary care physicians, aging
network services (e.g., meals on wheels, senior centers), home care
settings, nursing homes, and assisted living facilities. Yet, despite
this wide-ranging system, mechanisms for providing mental health services
are primarily designed for nursing homes and hospitals.
As a result, there are significant unmet needs among older adults
with mental health problems. Less than 3 percent of older adults receive
outpatient mental health treatment from specialized mental health
providers. Only one-third of people with mental disorders living in
communities receive any mental health services. In nursing homes,
65-80 percent of residents have a diagnosable mental disorder (e.g.,
dementia, depression, anxiety, and psychotic disorders); yet one study
indicated that only 1 in 5 residents in need of mental health services
received care.
Dr. Bartels cited several barriers contributing to the problem of
extensive unmet needs, including systemic barriers (fragmented system
with little communication among providers), attitudinal barriers (ageism
and professionals' assumption that depression is a normal part of
aging), financing barriers (mechanisms that incentivize institutional-based
care), and the reluctance of older adults to seek mental health services
due to stigma.
Dr. Bartels mentioned several effective and evidence-based interventions
that address barriers, including conducting outreach in senior housing
projects to enhance access, providing specialized consultation services
in nursing homes to improve outcomes, providing psychotherapy and
medication to older adults, and providing family and caregiver education
and supports.
Dr. Bartels described several studies (PRISMe, PROSPECT and IMPACT)
which are examining different strategies for integrating primary and
mental health care to treat older adults with mental illnesses. Other
innovative programs include (1) the Gatekeeper model where community
members (e.g., meter readers, postal workers, bank tellers) are trained
to identify older adults at risk for mental health problems, (2) outreach
programs with multidisciplinary teams visiting urban housing developments
and providing evaluation and treatment in seniors' homes, (3) caregiver
support services which delay nursing home placements and have a positive
impact on caregivers' needs, and (4) peer support services where retired
people are trained to provide supportive psychosocial therapy to peers.
Dr. Bartels offered several recommendations to the Commission:
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Address financing mechanisms. Dr. Bartels noted the difficulty
faced by older adults seeking quality mental health health care
and medications when Medicare requires higher co-pays for mental
health services and does not cover psychotropic medications. Dr.
Bartels urged the Commission to recommend expansion of Medicaid
and Medicare waivers to reimburse for mental health services provided
to older adults in the community and facilitate integration of
mental health services into the primary and long-term care systems.
He also recommended (1) "unbundling" case management
services to allow those services to be delivered in homes and
(2) broadening a Medicare mechanism that covers care plans and
case management for people who are home-bound and /or eligible
for hospice care and extending similar coverage to individuals
with mental illnesses.
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Promote evidence-based practices. Dr. Bartels urged that professional
training around evidence-based practices for primary health care
providers go beyond traditional education approaches (e.g., conferences,
dissemination of guidelines). Innovative and effective training
approaches could include decision support technologies, tool kits,
and strategies that feature feedback/support mechanisms.
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Address workforce issues. Dr. Bartels stressed the huge shortfall
of clinicians trained in geriatric services across the health
disciplines, including mental health clinicians. The lack of a
trained work force compounds problems with access and quality
of mental health care for older adults. Examples of initiatives
to build a bigger and better trained workforce include nurse training
programs and loan repayment programs.
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Collaborate with caregivers and other supportive agencies. Dr.
Bartels recommended linking with Area Agencies on Aging (AAAs)
and their caregiver support services. Mental health providers
can collaborate with existing infrastructures (e.g., AAAs, senior
centers) and enhance those services to include mental health screening,
referral and treatment for seniors as well as caregivers.
During the question and answer period, Commissioners posed questions
about training legal guardians to recognize and refer their wards
with mental health issues, modifying funding streams to reimburse
for services that older adults value (e.g., life skills training and
activities and not simply talk therapy), and training primary physicians
and front-line professionals on the unique needs of aging adults.
After thanking Dr. Bartels for a comprehensive overview, Chair Hogan
concluded the session at 5:30 p.m.
A copy of Dr. Bartels' presentation will be available on the Commission's
web site, www.MentalHealthCommission.gov.
October 3, 2002
Panel Presentation: Older Adults and Mental Health
Gary K. Kennedy, M.D., President, American Association for Geriatric
Psychiatry
Willard Mays, M.S., Immediate Past Chair, National Coalition for Mental
Health and Aging and Past Chair, Older Persons Division of the National
Association of State Mental Health Program Directors
Hikmah Gardiner, Older Adult Consumer Mental Health Alliance
Bryce Miller, Older Adult Consumer Mental Health Alliance
Dr. Kennedy reminded Commissioners that older adults experience mental
health problems as a result of illness, not as an inevitable part
of aging. Among the 32 million older Americans, 5 million suffer from
some form of depression, leading to excess health care utilization,
premature mortality, unnecessary family burden, and complications
for other health problems (e.g., cancer, heart disease). He urged
giving top priority to the dissemination of science-based practices
into real world settings to treat older adults more effectively.
Dr. Kennedy requested that the Commission:
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Support pending legislation to enhance graduate training and
the Positive Aging Act. He maintained that, if enacted, both initiatives
would enhance service delivery by providing funding for training
and demonstration projects.
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Increase support for mental health and aging research. Dr. Kennedy
noted that, while funding for NIMH's bio-terrorism research agenda
has increased, funding for other mental health areas has been
reduced.
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Address the decreasing number of physicians trained in geriatric
care. The trend of fewer physicians and other health professionals
entering the geriatric field needs to be reversed through a multi-year
agenda.
Willard Mays shared that the National Coalition on Mental Health
and Aging includes 55 representatives from Federal agencies, consumer
and advocacy organizations, and professional organizations. In addition,
30 states have state-level mental health and aging coalitions, many
developed with support from the Center for Mental Health Services.
He urged continued support for these coalitions, particularly as they
begin incorporating the substance abuse and primary care systems.
In addition to promoting parity within Medicare, Mr. Mays proposed
the following changes:
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Maintain consistent national policies about Medicare coverage
of mental health services. Mr. Mays discussed the example of Medicare
coverage for people with dementia and the negative impact when
the Center for Medicare and Medicaid Services (CMS) published
regulations and the regional offices and state carriers subsequently
reinterpreted those rules.
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Address the reimbursement system with its disincentives for practitioners
to visit and treat seniors in nursing homes who have dual eligibility
(Medicaid and Medicare). For example, after spending two hours
on a visit to a nursing home (including travel, discussion with
staff, and intervention with patient), an Indiana psychologist
would receive a maximum of $26 dollars after billing both agencies.
Mr. Mays shared how Indiana uses its Area Agencies on Aging as a
single point of entry for seniors to apply for all services and utilizes
PASSAR's mental health assessment to identify persons with a mental
illness in nursing homes and ensures that they receive services. Finally,
Mr. Mays urged that the Commission's Final Report to President Bush
address mental health needs on a continuum of life basis and not refer
to older adults as a "problem" akin to transportation and
housing.
Representing the Older Adult Consumer Mental Health Alliance and
the Mental Health Association of Southeastern Pennsylvania, Hikmah
Gardiner shared her 63-year history with the mental health and substance
abuse systems. After detailing how the systems frequently broke down,
she urged that the two systems be tightly woven together and that
psychiatrists and substance abuse professionals interact. Referencing
Americans' biased attitude against elders, Ms. Gardiner pointed out
that, while America is the richest country in the world, older adults
are left with hard choices about paying for medication or food. She
requested that the Commission do something for seniors who are unable
to advocate for themselves.
Bryce Miller urged the Commission to remember "Nothing about
us without us" and include older adults in their deliberations.
Older adults with mental illnesses need education about how to deal
with stigma, particularly self-stigmatization, similar to the education
they would receive when diagnosed with diabetes. Given his 60-year
history of having a physical and mental illness, Mr. Miller was acutely
aware of the need for prescribing physicians to attend to side effects,
drug interactions, and aging effects. Mr. Miller also cited the importance
of peer support groups for older adults.
The question and answer period focused on housing opportunities for
senior adults. Dr. Kennedy described naturally occurring retirement
communities in New York where residents receive case management services.
Currently financed through state and city funds, this program originally
began as a Federal demonstration project. Mr. Mays suggested that
the Olmstead initiative was an opportunity for mental health consumers
to become involved with HUD planning. Commissioners and presenters
also discussed room and board facilities which now serve as de facto
housing programs for persons with mental illnesses, yet are not connected
to mental health services.
In addition, Commissioners discussed (1) older adults entering the
court system as a result of the process of criminalizing people with
a mental illness, (2) the diverse aging adults population and the
role of culture and ethnicity in designing culturally appropriate
interventions, and (3) SAMHSA's development of a strategic plan on
meeting the needs of older adults. Commissioner King-Shaw added that
CMS was aware of concerns about prescription drugs for the elderly
community and existing reimbursement schedules. The agency is trying
to respond and make adjustments, hopefully in conjunction with Congressional
action.
Work Session
Beginning at 3:10 p.m., Commissioner Robert Postlethwait facilitated
the Commission's work session to discuss the outline for the Interim
Report. The Interim Report, required within six months of the President's
April 29, 2002 Executive Order creating the Commission, will describe
the extent of unmet needs and barriers to care within the mental health
system. Commissioner Postlethwait reviewed sections of the detailed
outline, including the statement of overall findings, description
of unmet needs, description of barriers, profiles of promising community-based
models, and general recommendations. Each Commissioner was given the
opportunity to offer comments and suggestions about the Interim Report
outline during the work session. The following is a synopsis of those
comments:
Commissioner Anil Godbole approved of the outline's format, maintaining
it appropriately described the extent of unmet needs and fragmented
services for children, older adults and minority populations. He expressed
concern about the lack of focus on the mental health work force and
its inadequate numbers, training, and infrastructure. He recommended
that the field address the inertia, resistance, and/or lack of information
hindering implementation of evidence-based practices through regulations,
licensing, and reimbursement strategies.
Commissioner Nancy Speck supported the comprehensiveness, content,
and tone of the Interim Report outline. The Interim Report will lay
the foundation for the Final Report (due in April 2003), which will
contain specific recommendations aimed at policies and practices.
Commissioner Ginger Lerner-Wren agreed that the outline reflected
the themes the Commission had heard and discussed. She suggested that
the Interim Report expand its discussion about the criminalization
of persons with mental illnesses.
Commissioner Jane Adams commented that the outline did not capture
the compelling testimony heard by the Commissioners. The Interim Report
should have more of a human voice. Commissioner Adams also requested
that the Interim Report address the need for (1) meaningful outreach
to those people who are not even in the system yet, and (2) inclusion
of consumer and family voices across all ages.
Commissioner Ruben King-Shaw cited the section on unmet needs and
requested that "quality of care" be added to the mention
of "access to care" for both minority and rural populations.
He also recommended that environmental factors which affect mental
health (e.g., poverty) be mentioned. He suggested that Medicaid, Medicare
and SCHIP be viewed as positive vehicles for change and not just barriers
as currently depicted.
Commissioner Steve Mayberg stated that the Interim Report should
emphasize that treatment does work and that recovery can occur. Commissioner
Mayberg added that "race and place" do affect access to
and quality of care. Finally, system barriers include misinformation,
miseducation, and stigma.
Commissioner Fran Murphy urged that the Commission address the dichotomy
between the treatment of physical illness and mental illness. All
providers need to assess and evaluate for mental illness, as well
as physical pain.
Commissioner Henry Harbin recommended that the Interim Report adopt
a strengths-based perspective and emphasize the mental health system?s
strengths in addition to its challenges. Commissioner Harbin also
requested clarification about the term "coordination" (e.g.,
clinical coordination? policy coordination? funding coordination?).
Commissioner Larke Huang also urged that the Interim Report communicate
the passion of people who testified before the Commission. She recommended
that the Commission address the issue of prevention and define more
clearly which system is fragmented. She shared other Commissioners'
concerns about work force development, including work force for racial
and ethnic minority populations. Finally, Commissioner Huang suggested
that the Interim Report identify the criteria used to select profiled
community-based programs.
Commissioner Rudy Arredondo noted that the issue of co-occurring
disorders was not addressed adequately in the outline. The Co-occurring
Subcommittee expects to produce an issue paper in November, which
will have strong recommendations for the Commission's consideration.
Commissioner Arredondo also requested that the outline's current statement
on cultural competence be strengthened and framed as a crosscutting
issue.
Joan Mele-McCarthy (alternate for Commissioner Bob Pasternack) suggested
that the outline mention linguistic minorities in addition to ethnic/cultural
minority populations. She also urged more emphasis on school-based
systems and integrated efforts among the child welfare, juvenile justice,
and mental health systems.
Commissioner Dee Yates recommended that the outline address the private
mental health sector, particularly the disparity between how mental
illnesses and physical illnesses are treated.
Commissioner Dan Fisher requested that the Interim Report reflect
the value of hope. He recommended an emphasis on peer support and
collaboration among consumers, families and providers.
Commissioner Patricia Carlile urged that the Interim Report address
both housing and homelessness, stressing the importance of having
a place to live when seeking treatment.
Commissioner Charles Curie lauded the prominence of recovery in the
outline. To strengthen the Interim Report, he suggested that the outline
mention resiliency, place more emphasis on the criminal justice system,
use the phrase "treatment, services and supports" to reflect
the full range of interventions, and highlight practices that do not
facilitate recovery (e.g., seclusion and restraint) yet are still
practiced in various settings.
Commissioner Randolph Townsend urged that the Interim Report better
address the issue of stigma. He recommended that the Commission coordinate
the discussion about stigma with the need to educate the business
community about the benefits of employing people with mental illness.
Commissioner Richard Nakamura stressed the importance of highlighting
and bridging the gap between what is known and what is done in the
mental health system. Citing from a recent Institute of Medicine report
on suicide, Commissioner Nakamura relayed that 27,000 out of 30,000
suicide deaths were people who had mental illnesses.
Commissioner Robert Postlethwait echoed the desire to have the passion
and reality of consumers and families' stories reflected in the Interim
Report. He also shared concerns about the mental health work force's
capacity and questioned the assumption that there is sufficient work
force to translate evidence-based practices from science to practice.
After listening to the Commissioners, Chair Hogan summarized the
concepts and recommendations to be incorporated into the final draft
of the Interim Report:
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Address the urgency of these issues in a personal way. Speak
from the heart as well as the head. Include the need for outreach,
engagement, and involvement of consumers and families across the
spectrum of issues.
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Mention that "access and quality of care" are more
severe concerns for minority populations. Emphasize that cultural
competence is crucial; quality of care is not possible without
cultural competence.
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Cite the challenge of accessing care for rural and super-urban
populations. Determine whether the evidence base supports adding
"quality of care" to challenges for these populations,
too.
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Reflect a strengths-based theme. Clarify that those people providing
care and support should be seen as strengths rather than problems
of the system.
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Speak more compellingly about stigma, discrimination and criminalization.
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Clarify the concept of fragmentation.
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Include strategies for educating and incentivizing desired behaviors.
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More fully address co-occurring disorders.
- Mention the fundamental dichotomy in the system's approach to
mental illnesses and physical illnesses.
In addition, Chair Hogan indicated that several ideas offered by
the Commissioners warranted further study and discussion. In the coming
months, the Commission will give further attention to:
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strengths and opportunities within the current public and private
systems
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work force/service capacity (relevant for many populations, including
children and families, rural, and older adults)
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traumatic stress
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issue of fragmentation (including mental health and substance
abuse systems)
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prevention across the continuum, including early intervention/resilience/universal
prevention/targeted prevention
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current mental health practices that do not work or support recovery
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education of the private sector and business community.
Commissioner Mayberg moved that the President's New Freedom Commission
on Mental Health approve the outline of the Interim Report with the
comments, recommendations, and additions as discussed at the meeting
considered for inclusion in the Interim Report. He also moved that
the Chair of the Commission, Chair of the Interim Report Subcommittee,
and Subcommittee members be tasked with the implementation and clarification
of these issues for the Interim Report. After additional discussion,
Commissioner Speck called the vote and Commissioner Townsend seconded
the motion. The Commissioners unanimously approved the motion as stated.
After thanking Commissioner Postlethwait and members of the Interim
Report Subcommittee for their efforts, Chair Hogan recessed the public
session at 4:50 p.m.
A copy of the outline and the Interim Report (after October 29, 2002)
are available on the Commission's website, www.MentalHealthCommission.gov.
October 4, 2002
Public Comment
Dr. Hogan began the period for public comment at 11:45 a.m. Individuals
who spoke and submitted written testimony were:
Gordon Raley, National Mental Health Association
Solomon Jacobson, McMana Incorporated
Caroline Coause-Ehlers, Rutgers University Graduate School of Education
Deborah DeGilio, American Psychological Association
Trudy Persky, Older Adults Consumer Mental Health Association
Work Session
During the final work session, the following Subcommittees provided
brief updates on their activities: Children and Families, Criminal
Justice, Evidence based Practice, Consumers, Housing, Older Adults,
Interface with General Medicine, Employment, Medicaid, and Rights
and Engagement. After some discussion about how Subcommittees could
address the crosscutting issue of work force development, Chair Hogan
recommended further deliberation during the coming months before reaching
a decision.
Chair Hogan requested that the Commission approve the draft minutes
from the September 11-12, 2002 meeting. Commissioner Speck moved to
accept the minutes and Commissioner Huang seconded the motion. The
minutes were accepted unanimously with one spelling correction.
Adjournment and Next Meeting Announcement
Dr. Hogan thanked all presenters and adjourned the meeting at 12:20
p.m. The next Commission meeting will occur November 12-14, 2002 in
Los Angeles, California.
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.
Chair
President's New Freedom Commission on Mental Health
These minutes were considered and approved by the Commission at its
November 14, 2002 meeting and any corrections or notations incorporated
into the text.
Last Modified 11/17/02
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