Terry L. Cline Ph.D.
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
A Systems of Care Approach to Substance Abuse and Mental Health Services
Committee on Health, Education, Labor, and Pensions
United States Senate
Tuesday May 8, 2007
Mr. Chairman and Members of the Committee, I am honored to present to you the vision, mission, and priorities of the Substance Abuse and Mental Health Services Administration (SAMHSA), an agency of the Department of Health and Human Services (HHS).
SAMHSA has established a clear vision for its work—a life in the community for everyone. To realize this vision, the Agency has sharply focused its mission on building resilience and facilitating recovery for people with or at risk for mental or substance use disorders. To achieve its vision and mission, SAMHSA directs a rich portfolio of grant programs and contracts that support State and community efforts to increase accountability, build capacity, and improve the effectiveness of substance abuse and mental health service delivery systems.
The need for SAMHSA’s strategic focus on strengthening service delivery systems is undeniable. There are economic costs of undiagnosed and untreated mental and substance use disorders. There are also human costs— measured in lost jobs, lost families and lost lives—that are incalculable and affect the well-being of millions of Americans. SAMHSA, through its offices and centers—the Center for Substance Abuse Prevention (CSAP), the Center for Substance Abuse Treatment (CSAT), and the Center for Mental Health Services (CMHS)—is working with state and local governments, tribal organizations, consumers, families, service providers, professional organizations, and the Administration to focus National attention and resources on prevention, treatment and recovery support services.
Without prevention, treatment and recovery support services, data confirm the enormous role that substance use and mental health disorders play in increasing our nation’s health care costs. For example, according to a new report by HHS' Agency for Healthcare Research and Quality, almost one-fourth of all stays in U.S. community hospitals for patients age 18 and older in 2004—7.6 million of nearly 32 million stays—involved depressive, bipolar, schizophrenia and other mental health disorders or substance use related disorders. This study presents the first documentation of the full impact of mental and substance use disorders on U.S. community hospitals.
The significant number of hospital stays related to mental and substance use disorders signals the need to identify and intervene early before the conditions require a hospital stay. Too often because of social stigma or lack of understanding, individuals and health care providers do not recognize the signs or treat mental or substance use disorders with the same urgency as other medical conditions. For example, the full spectrum of substance use disorders can be identified by screening tools which can result in an intervention. The Administration is working to meet this need through the Screening, Brief Intervention, Referral and Treatment (SBIRT) program funded by SAMHSA. This program uses cooperative agreements to expand and enhance a state or tribal organization’s continuum of prevention, intervention, and treatment by adding screening, brief intervention, referral, and treatment services within general medical settings.
Also to be considered is the component of mental and substance use disorders that patients themselves often do not recognize or understand. For example, in 2005 the number of persons 12 and older who needed treatment for an alcohol or drug use problem was 23.2 million, according to SAMHSA’s National Survey on Drug Use and Health. Of these, 2.3 million received treatment at a specialty facility. Specialty treatment is defined as treatment received at any of the following types of facilities: hospitals (inpatient only), drug or alcohol rehabilitation facilities (inpatient or outpatient), or mental health centers. The survey also points to a huge denial gap. Among individuals with drug or alcohol dependence or abuse who have not received treatment, more than 94 percent do not feel they need treatment.
Unlike an obvious broken bone, burn, laceration, or other physical wound, addiction and mental illnesses often do not have outward physical signs. Adding another layer to the complexity of seeking timely and appropriate treatment is the barrier of not knowing when or where to seek help and the lack of awareness that mental and substance use disorders often co-occur. Beyond these barriers, the issues of stigma, access, and availability of services also present roadblocks to early intervention, treatment, and recovery.
Yet SAMHSA – knowing the barriers, accepting the challenges, and fully understanding the importance of our role in the pubic health approach to creating a healthier America – continues to move forward working to improve and save lives that otherwise might be lost to devastating symptoms, isolation and even suicide. SAMHSA moves forward with the understanding that recovery is the expected outcome, by identifying areas of greatest need through data collection, filling those needs through evidence-based service delivery, and then measuring effectiveness and managing agency resources through an informed data strategy and recovery-based outcome measures.
Recovery is the Expected Outcome with the Public Health Approach
With appropriate help, individuals with mental illnesses, substance use disorders, and co-occurring disorders can and do recover. These conditions are chronic illnesses; relapses are possible; and the recovery process can be protracted. However, when these individuals take that brave step toward seeking help, and the right services and treatment take hold, the potential for recovery can unfold. Today, recovery is no longer the exception; it is the expectation. To advance the recovery paradigm the public health approach is required, working with people in the context of their environments. The public health model uses systems that provide a continuum of services that focus on an entire population rather than on individuals with individual illnesses. The continuum begins with an assessment of need and ends with a population-based, evaluated approach that extends into practice, research, policy, and the engagement of the public itself.
Data Collection to Define Needs
SAMHSA reports to the Nation on the prevalence of substance use and mental health problems in the United States. One of those measures is provided by our National Survey on Drug Use and Health. The survey provides national and comparable state-level estimates of substance use, abuse, and dependence. It also provides an ongoing source of nationally representative and state level information on mental health.
The analysis of trends over time from the survey, alone and in combination with other data sources, provides an invaluable tool to measure outcomes of the National Drug Control Strategy and to report our progress to Congress. Two other major national surveys conducted by SAMHSA include the Drug Abuse Warning Network (DAWN) and the Drug and Alcohol Services Information System (DASIS). The DAWN obtains information on drug-related admissions to emergency departments and drug-related deaths identified by medical examiners. DASIS consists of three data sets developed with State governments. These data collection efforts provide national and state information on the substance abuse treatment system.
Expanding Substance Abuse Treatment Capacity
The cornerstone of the Nation’s substance abuse prevention and treatment activities is the Substance Abuse Prevention and Treatment Block Grant funded by SAMHSA which is designed to support and expand substance abuse prevention and treatment services, while providing maximum flexibility to states. It provides support to 60 eligible states, territories, the District of Columbia and the Red Lake Indian Tribe. SAMHSA’s CSAT also funds an array of discretionary grants through the Programs of Regional and National Significance to build treatment capacity, including innovative financing (e.g. Access to Recovery Program) and increased use of screening, brief interventions, referral and treatment services.
SAMHSA has partnered with health care professionals to expand use of screening and brief interventions to identify the full spectrum of substance users as a routine part of standard health care and provide brief, cost-effective interventions to help them cease substance use once discovered. The modality, called Screening, Brief Intervention, Referral and Treatment (SBIRT), has been deployed to hospitals, health clinics, college campuses and school-based clinics across the country. Under SBIRT, medical professionals conduct brief screening in a general health care setting such as a hospital, a health clinic or a university-based clinic. Under SBIRT, once a problem is detected, a medical professional immediately performs a brief intervention, lasting less than 30 minutes. Brief interventions assist patients in recognizing the impact of unhealthy drinking or drug use and commit them to a plan of action to cease use. Studies show that this brief intervention can reduce substance abuse significantly, thus improving overall health. These interventions are very cost-effective as they reduce re-admission into emergency departments and re-hospitalizations. In many cases, the brief intervention is sufficient for the non-addicted user. Those with scores that fall into the range of dependence are referred to more intensive treatment.
To date the Federal SBIRT program has screened 504,334 people in healthcare settings in 10 states in the nation. A positive screen was obtained in 21.2 percent of people screened, and these were subsequently provided with brief intervention (15.1 percent), brief treatment (2.7 percent), or were referred to treatment (3.3 percent). Six-month follow ups on a sampling of those receiving an intervention show promising reductions in substance use, depression and improvements in other parameters.
For those referred to treatment because they have become addicted, SAMHSA has expanded options for treatment. The Access to Recovery Program (ATR) program, a Presidential initiative, is a key source of innovation in the field of addiction recovery. Through the use of vouchers, ATR provides clients with the opportunity to choose among a broad array of substance abuse clinical treatment and recovery support service providers. ATR is designed to: (1) allow recovery to be pursued through personal choice and many pathways; (2) require grantees to manage performance based outcomes that demonstrate client successes, (3) expand capacity by increasing the number the number and types of providers who deliver clinical treatment and/or recovery support services. The outcomes for clients served through the ATR program are very encouraging. As of December 31, 2006, the ATR program had served 137,579 clients, exceeding the initial target by 10 percent. After receiving services through ATR, 81 percent of clients are abstinent from substances and 51 percent are in stable housing.
Expanding substance abuse treatment capacity also has a direct link to shrinking rates of criminal recidivism. Upon discharge from the ATR program, 97 percent of clients have no involvement with the criminal justice system. This impressive rate reflects an 81 percent reduction among those who were involved with the criminal justice system at intake. Additionally, drug treatment courts provide a successful alternative to incarceration and help to break the cycle of addiction, crime, incarceration, release, relapse, and recidivism. These courts enable stakeholders to work together to give individual clients the opportunity to improve their lives, including recovering from substance use disorders and developing the capacity and skills to become full-functioning parents, employees, and citizens. Close supervision, drug testing, and the use of sanctions and incentives help to ensure that offenders stick with their treatment plans while public safety needs are met.
Other CSAT Programs of Regional and National Significance (PRNS) include: Targeted Capacity Expansion Grants (TCE-General) which have focused on treatment for methamphetamine use, minority populations, and rural areas, to name a few; Grants to Benefit Homeless Individuals; and the Minority HIV/AIDS and Substance Abuse Treatment Grant program. SAMHSA has focused its grant resources on activities that directly demonstrate improvements in substance abuse outcomes and increase capacity while eliminating less effective or redundant activities within the Substance Abuse Prevention and Treatment PRNS.
Strengthening and Streamlining Substance Abuse Prevention Efforts
While expanding substance abuse treatment capacity and recovery support services is critical, it is imperative not to lose sight of the importance of preventing addiction in the first place by stopping substance use before it starts. SAMHSA will continue the Strategic Prevention Framework grant program to accomplish the President’s goal to reduce youth drug use in America, thereby leading to a healthier populace. By focusing our attention, energy and resources we, as a nation, have made real progress toward reaching the President’s goal. The most recent data from the 2006 Monitoring the Future Survey confirms that we have reduced youth drug use by 23 percent by 2006. What this means is approximately 840,000 fewer youth used illicit drugs in 2006 than in 2001. Although our work is far from over, prevention remains key and SAMHSA’s Strategic Prevention Framework (SPF) will continue to play an important role in achieving the goals of the President’s Healthier US Initiative.
To more effectively and efficiently align and focus our prevention resources, SAMHSA launched the SPF State Incentive Grant Program in FY 2004. It is systematically implementing a risk and protective factor approach to prevention across the Nation. The success of the framework will continue to be determined by, in large part, on the tremendous work that comes from the Office of National Drug Control Policy's (ONDCP) grass-roots community anti-drug coalitions. Along those lines, SAMHSA expects to continue working with ONDCP to support the over 750 grantees funded through the Drug-Free Communities grant program. Moreover, with SAMHSA’s State Epidemiological Workgroups, we will target funding to areas of greatest need for various prevention interventions and services. Funding to states, communities and tribal organizations will be data driven.
Additionally, SAMHSA will continue to focus energy and take a leadership role in the prevention of underage drinking. According to the Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking, alcohol is used by more young people than tobacco or illicit drugs. An estimated 10.8 million young people between the ages of 12 and 20 (28.2 percent of this age group) are current drinkers. Nearly 7.2 million (18.8 percent) are binge drinkers, and 2.3 million (6.0 percent) are heavy drinkers. Each day, more than 10,000 young people under the age of 21 take their first drink. We know that we need to change how America thinks about underage drinking if we are to see a significant reduction in the problem. SAMHSA and HHS’ National Institute on Alcohol Abuse and Alcoholism (NIAAA) collaborated with the Office of the Surgeon General to produce the Call to Action, which was released on March 6, 2007. The Call to Action provides a public health approach to stimulate action in all sectors of society to prevent and reduce underage drinking.
SAMHSA’s Center for Substance Abuse Prevention supports a range of activities that address the substance abuse prevention needs of community-based populations. For example, CSAP supports over 148 grants that work to expand the capacity of community-level domestic public and private non-profit entities to prevent and reduce the onset of substance abuse and transmission of HIV and hepatitis among minority populations and minority reentry populations. In addition, CSAP supports a $9.8 million Fetal Alcohol Spectrum Disorders Center for Excellence that identifies best practices and builds on evidence-based prevention for pregnant and postpartum women, assistance for those with developmental disabilities, and support for other populations invested in serving those with, or affected by Fetal Alcohol Spectrum Disorders (FASD). Through subcontracts, the FASD program will implement system-wide prevention approaches through States, tribes, communities and territories that have high FASD incidence and prevalence rates. CSAP also has initiatives targeting Native American Populations and oversees the Federal Drug Free Workplace Program.
Implementing the Federal Mental Health Action Agenda
Today, there is unprecedented knowledge enabling people with mental illnesses to live, work, learn, and participate fully in their community. The President’s New Freedom Commission on Mental Health found in its 2003 report that the time has come for a fundamental transformation of the Nation’s approach to mental health care. It reported that the current system is unintentionally focused on managing the disabilities associated with mental illness rather than promoting recovery, and that this limited approach is due to fragmentation, gaps in care, and uneven quality. These systemic problems frustrate the work of many dedicated staff, and make it much harder for people with mental illness and their families to access needed care.
SAMHSA’s Center for Mental Health Services (CMHS) is leading the federal effort to achieve the vision of a transformed mental health system. Among the tasks are: helping Americans understand that mental health is essential to overall health; reorienting the system toward a consumer-and-family driven system; eliminating disparities; providing appropriate mental heath assessment and referral; delivering excellent mental health care and accelerating research; and utilizing technology to access mental health care and information through electronic health records.
Instead of focusing on a few grants that promote transformation, SAMHSA has worked to ensure that the principles of mental health transformation are present throughout all SAMHSA grant activities including the Community Mental Health Services Block Grant, which continues to support comprehensive, community-based systems of care for adults with serious mental illness and children with serious emotional disturbance. Within the CMHS Programs of Regional and National Significance (PRNS), the Mental Health Transformation State Incentive Grants are supporting states in developing a comprehensive mental health plan and improving their mental health services infrastructures. States receiving awards expand the use of evidence-based practices, use technology to improve access to care, and engage consumers in shaping the system to meet their needs.
A transformed mental health delivery system will have a direct impact on SAMHSA’s ability to improve services around suicide prevention, school violence prevention, children’s mental health, the transition from homelessness to stable housing, and protecting the rights of individuals with mental illnesses.
Starting with suicide prevention, suicide is a preventable tragedy and is a high-priority status within the agency. The reason for the priority is clear: in the past year, approximately 900,000 youth aged 12-17 during their worst or most recent episode of major depression made a plan to commit suicide, and 712,000 attempted suicide. Currently SAMHSA funds a total of $36 million for suicide prevention, including activities authorized by the Garrett Lee Smith Memorial Act, suicide prevention for the American Indian and Alaska Native youth populations, a Suicide Prevention Resource Center, and a 24-hour national hotline. The hotline is available to all those in suicidal crisis who are seeking help. Individuals seeking help through the hotline are routed to one of over 120 crisis centers across the country which creates a nationwide lifeline. Approximately 36,000 calls per month are answered by the hotline and responded to by trained counselors.
In regard to preventing school violence, SAMHSA collaborates with the Departments of Education and Justice through the Safe Schools/Healthy Students (SS/HS) program to support local partnerships that promote healthy childhood development and prevent substance abuse and violence. There is tremendous opportunity in the area of early identification of mental health problems as part of a comprehensive approach to prevention. For example, youths aged 12 to 17 who experienced depression in the past year were twice as likely to take their first drink or use drugs for the first time as those who did not experience depression. Among youths who had not used alcohol before, 29.2 percent of those who experienced depression took their first drink in the past year, compared with 14.5 percent of youths who took their first drink but did not have a major depressive episode. And 16.1 percent of youths who experienced depression and had not previously used illicit drugs began drug use; in contrast, 6.9 percent of youths who did not have a major depressive episode began drug use.
It is clear young people with serious emotional disturbances who receive help for their condition are far more likely to experience success in school and far less likely to enter the juvenile justice system or the institutional care system. The Agency’s Children’s Mental Health Services grant program develops comprehensive, community-based systems of care for children and adolescents with serious emotional disorders and their families. Of children receiving services under this program last year, nearly 70 percent did not require interaction with law enforcement and nearly 90 percent attended school regularly.
In addition to its system transformation activities, the CMHS PRNS also includes funding for National Child Traumatic Stress Initiative and the Minority HIV/AIDS and Mental Health Programs. Homelessness also continues to be a priority program area for SAMHSA. Approximately one-fifth of homeless individuals also have serious mental illnesses. Individuals with serious mental illnesses are homeless more often and have greater difficulty transitioning from homelessness to stable housing than other people. The Agency continues support for an array of individualized services to this vulnerable population through Projects for Assistance in Transition from Homelessness (PATH) and through SAMHSA's Mental Health and Substance Abuse Programs of Regional and National Significance.
Additionally, individuals with mental illnesses and serious emotional disturbances who reside in treatment facilities are particularly vulnerable to neglect and abuse. In response, SAMHSA provides support for State protection and advocacy systems to protect these individuals from abuse, neglect, and civil rights violations. Approximately 80 percent of substantiated allegations of abuse and neglect that are reported to protection and advocacy systems result in positive change for the client.
Meeting Needs Through Evidence-based Service Delivery
The success of SAMHSA’s programs and service delivery systems clearly hinges on collaboration. No single agency can do it all. Without exception, partnerships among private sector and federal, state and local public sector agencies are key to helping provide people with mental and substance use disorders the opportunity to achieve a fulfilling life in the community.
One of our public partners is the National Institutes of Health (NIH). In brief, the NIH Institutes and Centers, including the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism and the National Institute of Mental Health, develop evidence-based practices through research, and SAMHSA supports implementation of evidence-based practices through grants that support service delivery. This partnership forms the basis of our Federal efforts to ensure the best science is used in our service delivery systems. Working both independently and collaboratively, we are committed to establishing pathways to move research findings into community-based practice and to reducing the Institute of Medicine reported 15-20 year lag between the discovery of more efficacious forms of treatment and their incorporation into routine patient care.
To advance “Science and Service” and to ensure the public, and consumers and providers of mental health and substance abuse services are aware of the latest information, prevention interventions, treatments and recovery support services SAMHSA operates its Health Information Network. SAMHSA also created and funds the National Registry of Evidence-based Programs and Practices (NREPP). NREPP is a web-based decision support system designed to help States and community-based service providers make informed decisions about interventions they select to prevent and treat mental and substance use disorders. The NREPP system is the culmination of a multi-year process that included input from numerous scientific and health care service experts and the public. It currently provides information on 27 interventions. Two-thirds of these received NIH funds for development and testing.
Measuring Effectiveness and Managing Resources through a Data Strategy and Recovery-based Outcome Measures
Performance measurement and management is a challenging and complex issue. Our goal at SAMHSA is to achieve a performance environment with true accountability focused on a limited number of national outcomes and related national outcome measures. This goal is built on a history of extensive dialogue with our colleagues in state mental health and substance abuse service agencies and, most importantly, the people we serve.
The domains we have identified embody meaningful, real life outcomes for people who are striving to attain and sustain recovery, build resilience, work, learn, live, and participate fully in their communities. In collaboration with the States, we have identified ten domains as our National Outcome Measures, or NOMs.
The first and foremost domain is abstinence from drug use and alcohol abuse or decreased symptoms of mental illness with improved functioning. Four domains focus on resilience and sustaining recovery: getting and keeping a job or enrolling and staying in school; decreased involvement with the criminal justice system; securing a safe, decent, and stable place to live; and social connectedness to and support from others in the community such as family, friends, co-workers, and classmates. Two domains look directly at the treatment process itself in terms of available services and services provided: increased access to services for both mental and substance use disorders; and increased retention in services for substance abuse treatment or decreased inpatient hospitalizations for mental health treatment. The final three domains examine the quality of services provided: client perception of care, cost-effectiveness, and use of evidenced-based practices in treatment.
Data for reporting on these measures come from the States. States are supported in their efforts by SAMHSA with infrastructure, technical assistance, and financial support through the new State Outcome Measurement and Management System (SOMMS) Program, which is funded through the set-asides for the mental health and substance abuse block grants.
Among the states reporting data to SAMHSA in the Retention and Perception of Care domains for mental health, the NOMs data demonstrates a low percentage (8 percent) of patients returning to State hospitals 30 days after discharge and a high percentage (71 percent) of consumers of mental health services who reported they were doing better as a direct result of services received. With regard to substance abuse, the NOMs data reported to SAMHSA demonstrates significant success in the Abstinence domains for both alcohol and drug use with over 94 percent of reporting states indicating improvements in client abstinence. Similar successes were reported in improved client employment and reduction in arrests. Ultimately, SAMHSA will be able to report state-level, consistent, cross-year data which will allow us to examine the impact of programs and changes over time.
We have collected and reported to Congress the data that are available at this time. The NOMs are also available on the SAMHSA website, www.samhsa.gov. Each outcome measure is detailed in a table, and State profiles are available as well. The consensus that was needed to develop and implement the NOMs now needs to become widespread and used to guide the daily operations of provider organizations and individual providers to continue to improve service delivery systems.
As the Administrator of SAMHSA, I am steadfast in my commitment to lead SAMHSA and the people we serve toward achieving the best outcomes possible. Each of us lives and works in a time when behavioral health’s impact on everyday life and overall health can no longer be set aside with a clear conscience.
SAMHSA’s National Survey on Drug Use and Health indicates that nearly 21 million Americans who needed treatment for an illicit drug or alcohol use problem did not receive treatment. In addition, there were over 11 million adults who reported an unmet need for treatment or counseling for mental health problems in the past year, including 5.7 million adults who did not receive any mental health treatment at all. Helping more Americans achieve a healthy and rewarding life in the community in “the land of promise” is not a vague or lofty goal. It is an achievable milestone in our Nation’s story which is already underway through advancements in science and research, the introduction of promising and effective treatments, systems transformation, public outreach and education, and strong national leadership and commitment.
Thank you for the opportunity to appear today. I will be pleased to answer any questions you may have.
Last revised: April 19, 2011