Pamela S. Hyde, J.D.
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services (HHS)
Examining SAMHSA’s Role in Delivering Services to the Severely Mentally Ill
Energy and Commerce
Subcommittee on Oversight and Investigations
United States House of Representatives
Wednesday May 22, 2013
Good morning Chairman Murphy, Ranking Member DeGette and Members of the Subcommittee. Thank you for the opportunity to testify today about the mission and priorities of the Substance Abuse and Mental Health Services Administration (SAMHSA), including services for adults with serious mental illness and children with serious emotional disturbance. SAMHSA accomplishes its mission through partnerships, policies, products, and programs that build resilience, improve treatment, and facilitate recovery for people with or at risk for mental and substance use disorders.
SAMHSA was established in 1992 and is directed by Congress to effectively target substance abuse and mental health services to the people most in need of them and to translate research in these areas more effectively and more rapidly into the general health care system. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities. SAMHSA strives to create awareness that:
- Behavioral Health is essential for health;
- Prevention works;
- Treatment is effective; and
- People recover from mental and substance use disorders.
SAMHSA serves as a national voice on mental health and mental illness, substance abuse, and behavioral health systems of care. It coordinates behavioral health surveillance to better understand the impact of substance abuse and mental illness on children, individuals, and families as well as the costs associated with treatment. SAMHSA helps to ensure dollars are invested in evidence-based and data-driven programs and initiatives that result in improved health and resilience.
SAMHSA applies strategic, data-driven solutions to field-driven priorities. To this end, SAMHSA helps states, territories, and tribes build and improve basic and proven practices and system capacity by encouraging innovation, supporting more efficient approaches, and incorporating research-based programs and best practices into funded programs so they can produce measureable results. In addition, SAMHSA’s longstanding partnerships with other Federal agencies, systems, national stakeholders, and the public have uniquely positioned SAMHSA to collaborate and coordinate across multiple program areas, collect best practices and develop expertise around behavioral health services, and, understand and respond to the full breadth of the behavioral health needs of children, individuals and families across the country.
Substance abuse, addictions, poor emotional health, and mental illnesses take a toll on individuals, families, and communities. These conditions cost lives and productivity, and strain families and resources in the same way as untreated as physical illnesses. SAMHSA works to focus the Nation's attention on these preventable and treatable problems.
Mental Health and Substance Abuse Data
Health surveillance is critical to SAMHSA’s ability to develop new models of care to address substance abuse and mental illness. SAMHSA provides decision makers, researchers and the general public with enhanced information about the extent of substance abuse and mental illness, how systems of care are organized and financed, when and how to seek help, and about effective models of care, including the outcomes of treatment engagement and recovery.
It is estimated that almost half of all Americans will experience symptoms of a mental health condition – mental illness or addiction – at some point in their lives. Yet, today, less than one in five children and adolescents with diagnosable mental health problems receive the treatment they need.1 And according to data from SAMHSA’s National Survey on Drug Use and Health (NSDUH), only 38% of adults with diagnosable mental health problems – and only 11% of those with diagnosable substance use disorders - receive needed treatment.2
With respect to the onset of behavioral health conditions, half of all lifetime cases of mental and substance use disorders begin by age 14 and three-fourths by age 24.3
Currently, SAMHSA supports national surveys and surveillance, including the National Survey on Drug Use and Health, Drug Abuse Warning Network, and Drug and Alcohol Service Information System. SAMHSA also supports the behavioral health field by sharing information about evidence-based practices through tools such as the National Registry of Evidence-based Programs and Practices. SAMHSA also uses the Web, print, social media, public appearances, and the press to reach the public, providers and other stakeholders, including people in recovery and their families.
SAMHSA supports innovation and practice improvement by disseminating key evidence-based mental health and substance use practices, such as Treatment Improvement Protocols, Technical Assistance Publications, The National Registry of Evidence-based Programs and Practices, and evidenced-based toolkits, to the mental health and substance abuse delivery system and facilitates practice improvement by engaging in activities that support mental health system transformation and reform. One of SAMHSA’s roles is to provide grants and contracts consistent with congressionally-appropriated funding. SAMHSA uses this crucial funding to create, test, and disseminate models of services and programs to improve the Nation’s behavioral healthcare delivery systems as well as the promotion of mental health and the prevention of mental illness and addictions in children and adults. Additionally, SAMHSA holds policy academies for states, tribes and territories, provides technical assistance, training, and guidance for the behavioral health field, supports innovation in evaluation and research, moves innovations and evidence-based approaches to scale, identifies and disseminates new and emerging practices from the field, and cooperates with national and international partners to identify promising approaches to supporting behavioral health.
Public Education and Awareness
Today in the United States, opportunities to prevent or intervene early to reduce disability and death associated with mental illness and substance use disorders are often missed. The tragedy at Sandy Hook Elementary School in December 2012 underscores the importance of educating the American people about mental health and what we can do to connect people in need with services. By learning to recognize the signs and symptoms of mental illness and substance abuse, friends and family members can help their loved ones take action and seek care. Trained health professionals can also work with individuals and families to identify problems early.
To help with its public education effort, SAMHSA supports public awareness campaigns, produces and distributes public education materials, releases data from its surveillance and data collection efforts, and increasingly uses electronic and social media to help disseminate information to the public and the field. By confronting fear and misunderstanding with facts, raising awareness about the effectiveness of prevention and treatment, and improving knowledge about when and where to seek help, SAMHSA helps bring mental illness and addictions out of the shadows and helps the nation achieve the full potential of the science behind the prevention and treatment of mental illnesses and substance abuse.
Policy Development and Oversight
SAMHSA protects and promotes behavioral health through regulation and standard setting. For example, SAMHSA works to prevent tobacco sales to minors through the Synar Program, administers the Federal drug-free workplace and drug-testing programs, oversees opioid treatment programs and accreditation bodies, informs physicians’ office-based opioid treatment prescribing practices, and partners with other agencies at the U.S. Department of Health and Human Services in development and review of regulations and guidance documents affecting prevention, treatment and recovery support services that address mental health and substance abuse.
Overview of the Nation’s Mental Health Spending
According to SAMHSA’s National Expenditures for Mental Health Services & Substance Abuse Treatment 1986 – 2009, at $147 billion, mental health spending accounted for 6.3 percent of all health spending in calendar year 2009, while substance abuse spending accounted for approximately one percent. Mental health treatment spending depended more on public payers than spending for all-health care in calendar year 2009; public payers accounted for 60 percent of mental health spending compared to 49 percent of all-health care spending.
Medicaid and Medicare (40 percent) and private insurance (26 percent) accounted for approximately two-thirds of mental health spending in 2009, followed by state and local governments at 15 percent, out-of-pocket at 11 percent, other Federal spending at five percent (including SAMHSA funding), and other private sources at three percent.
In FY 2013, approximately 29 percent ($957.7 million) of SAMHSA’s funding was appropriated or designated for mental health programs and activities, with the remainder directed to substance abuse programs and activities. This distribution of funding between substance abuse and mental health has been consistent for the last five years. Of the SAMHSA mental health funding, most ($915.3 million) supports prevention, treatment and recovery support programs and activities within SAMHSA’s Center for Mental Health Services (CMHS). In addition to the CMHS funding, a portion ($42.4 million) of SAMHSA’s funding for the Health Surveillance and Program Support (HSPS) programs is used for the mental health activities.
Center for Mental Health Services (CMHS)
Approximately 48 percent ($436.81 million) of CMHS funding is directed toward the Community Mental Health Services Block Grant, which provides services and supports for adults with serious mental illness4 and children with serious emotional disturbance.5
The balance of the CMHS budget (52 percent) provides support for a range of mental health prevention, treatment and recovery support services as directed by Congress. In FY 2013, approximately 81 percent of the CMHS budget will support adults with and at risk for serious mental illness and/or children with serious emotional disturbance.
Within the CMHS budget over the last five years, 75-80 percent of appropriated funding has been used for mental health programs in support of adults with serious mental illness and children with serious emotional disturbance.
Examples of SAMHSA Programs with National Impact
To accomplish its work, SAMHSA administers a combination of competitive discretionary programs and block grant programs. This portfolio provides states and communities with support to establish or expand organized community-based systems of care for children with serious emotional disturbances and adults with serious mental illness through training, technical assistance, and provision of evidenced-based clinical and recovery support services.
Community Mental Health Services Block Grant
The Community Mental Health Services Block Grant is a key source of funding for community-based services for adults with serious mental illness and children with serious emotional disturbances. In Fiscal Year (FY) 2013, $408.9 million, was awarded to states through the Community Mental Health Services Block Grant. It is a flexible funding source used by states to provide a range of mental health services and system infrastructure and capacity supports. States use these limited but significant funds to support planning, administration, evaluation, educational activities, and direct service delivery. Services typically are for those not covered by Medicaid, insurance or other sources, and for services not otherwise covered, and include rehabilitation services, crisis stabilization and case management, peer specialist and consumer-directed services, wrap around services for children and families, supported employment and housing, jail diversion programs, and services for special populations. By law, states are not allowed to utilize these funds for inpatient services.
Each state’s Community Mental Health Services Block Grant application is based on a plan developed in collaboration with state mental health planning councils, which are required in order to receive block grant funding. Planning councils' membership is statutorily mandated to include consumers, family members of adult and child consumers, providers, and representatives of other principal state agencies delivering, paying for, or impacting mental health services.
The Community Mental Health Services Block Grant supports services and infrastructure for state mental health authorities that serve almost seven million adults with serious mental illness and children with serious emotional disturbance.
SAMHSA has placed a strong emphasis on ensuring that Block Grant funds are expended in a manner consistent with the statutory and regulatory framework, including providing states the flexibility to address service needs and approaches they believe are most critical for the populations of adults with serious mental illness and children with serious emotional disturbances. Currently, the primary goals of SAMHSA program integrity efforts are to: (1) promote the proper expenditure of Block Grant funds; (2) improve Block Grant program compliance nationally; and (3) demonstrate the effective use of Block Grant funds, including using National Outcomes Measures such as readmission to any state psychiatric hospital within 30 days and 180 days; proved functioning; and employment status.
Children’s Mental Health Initiative
The Children’s Mental Health Initiative (CMHI) provides $111.4 million in FY 2013 to states and communities to support the development of comprehensive, community-based systems of care for the estimated nine to 13 percent of children and youth with SED and their families. A system of care is a strategic approach to the delivery of services and supports that incorporate family-driven, youth-guided, strength-based, and culturally and linguistically competent care in order to meet the physical, intellectual, emotional, cultural, and social needs of children and youth.
CMHI has served over 120,000 children and youth with serious emotional disturbance since the inception of the program. Data from the CMHI National Evaluation demonstrates that the system-of-care approach is effective. For example, school attendance and performance improves, behavioral and emotional strengths are increased, and children and youth have more stable living conditions. Within six months of service in CMHI, the number of youth reporting suicide attempts or thoughts of suicide decreased. And, there were decreased contacts with law enforcement. Specifically, for youth involved in the juvenile justice system, arrests decreased by nearly 50 percent from intake into the program after 12 months of service in CMHI.
The National Child Traumatic Stress Network
Through the National Child Traumatic Stress Initiative (NCTSI), SAMHSA supports a national network of grantees—the National Child Traumatic Stress Network (NCTSN)—that works collaboratively to develop and promote effective trauma treatment, services and other resources for children and adolescents exposed to an array of traumatic events. The NCTSN Centers collaborate to develop, implement, and evaluate effective trauma screening, treatment and services, and partner with other community agencies to promote service delivery approaches so that trauma services are effectively implemented within local child-serving community service systems.
To date, NCTSI has developed and implemented 20 effective interventions to reduce immediate distress from exposure to traumatic events, developed and provided training in trauma-focused services for use in child mental health clinics, schools, child welfare and protective services, among other service areas; and developed widely used intervention protocols for disaster victims. In FY 2012, 2,367 children and adolescents received trauma-informed services through the NCTSI program, and over 121,310 people were trained in annual training education events. In the same year, 76.1 percent of children receiving trauma-informed services reported positive functioning at six-month follow-up.
Primary and Behavioral Health Integration
SAMHSA administers the Primary and Behavioral Health Care Integration (PBHCI) program. The purpose of the program is to improve the physical health status of adults with serious mental illness by supporting communities to coordinate and integrate primary care services into publicly funded community mental health and other community-based behavioral health settings. The program supports community-based behavioral health agencies’ efforts to build the partnerships and infrastructure needed to initiate or expand the provision of primary healthcare services for people in treatment for serious mental illness and co-occurring serious mental illness and substance use disorders.
Since September 2009, the program has awarded 94 grants, and 55 percent of awardees are partnering with at least one Federally Qualified Health Center (FQHC). The Health Resources and Services Administration (HRSA) and SAMHSA collaborate to fund a national technical assistance center to help these grantees and FQHCs integrate primary and behavioral health care in both types of settings. This integration of care and agency efforts has resulted in significant physical and behavioral health gains as well as reduced health care expenditures. Some results that are based on grantee-reported outcome measures from February 2010 through January 7, 2013, include:
- Health: The percentage of consumers who rated their overall health as positive increased by 20 percent from baseline to most recent reassessment (N=3737).
- Tobacco Use: The percentage of consumers who reported they were not using tobacco during the past 30 days increased by 6 percent from baseline to most recent reassessment (N=3787).
- Illegal Substance Use: The percentage of consumers who reported that they were not using an illegal substance during the past 30 days increased by 12 percent from baseline to most recent reassessment (N=3568).
Projects for Assistance in Transition from Homelessness
The Projects for Assistance in Transition from Homelessness (PATH) is a unique program that is specifically authorized to address the needs of individuals with serious mental illness and/or serious mental illness with a co-occurring substance use disorder who are experiencing homelessness or are at risk of homelessness. PATH funds community-based outreach, mental health, substance abuse, case management and other support services, as well as a limited set of housing services to connect homeless individuals to housing services and support them in community housing settings. In the past 5 years, the PATH program has reached approximately 170,000 individuals each year, with an average of about 68,000 of those individuals becoming enrolled in the PATH program each year.
Youth Violence Prevention
The Safe Schools/Healthy Students program is a unique Federal grant program designed to prevent violence and substance abuse among our nation's youth in schools and communities. Since 1999, this program has been jointly administered and supported by SAMHSA and the Departments of Education and Justice. The Safe Schools/Healthy Students initiative implements an enhanced, coordinated, and comprehensive plan of activities, programs, and services that promote healthy childhood development, prevent violence, and prevent alcohol and drug abuse. A key element of Safe Schools/Healthy Students activities is the expansion of school-based mental health services, as well as referral to treatment to community health providers. SAMHSA is in the process of completing a national cross-site evaluation of Safe Schools/Healthy Students. Preliminary findings include:
- The program has seen significant increases in the number of students who received school-based mental health services, and community-based services.
- Nearly 90 percent of school staff stated that they were better able to detect mental health problems in their students and more than 80 percent of school staff reported that they observed reductions in alcohol and other drug use among their students.
- Over 90 percent of school staff saw reduced violence on school grounds and nearly 80 percent reported that Safe Schools/Healthy Students had reduced violence in their communities.
President’s Now is the Time Initiatives
In addition to the programs discussed above, I would like to share some of the initiatives related to mental health included in the President’s proposed plan, Now is the Time, which emphasizes early intervention and treatment for young people struggling with mental health problems.
On January 16, 2013, the President announced his plan to ensure that students and young adults receive treatment for mental health issues. These proposals are included in the President’s FY 2014 Budget. Specifically, SAMHSA will take a leadership role in initiatives that would:
- Reach 750,000 young people through programs to identify mental illness early and refer them to treatment: To support training for teachers and other adults who regularly interact with students to recognize young people who need help and ensure they are referred to mental health services, the Administration has proposed a new initiative, Project AWARE (Advancing Wellness and Resilience in Education), to provide this training and set up school-community partnerships to promote mental health, and facilitate referrals when needed. This initiative, which will be coordinated with related proposals at the Departments of Justice and Education, has two parts:
- Provide “Mental Health First Aid” training for teachers: Project AWARE proposes $15 million for training for teachers and other adults who interact with youth to detect and respond to mental illness, including how to encourage adolescents and families experiencing these problems to seek treatment.
- Ensure students with signs of mental illness get referred to treatment: Project AWARE also proposes $40 million to help states and school districts work with community leaders, law enforcement, mental health agencies, families and youth, and other local organizations to assure students with mental health issues or other behavioral issues are referred to and receive the services they need. This initiative builds on strategies that, for over a decade, have proven to decrease violence in schools and increase the number of students receiving mental health services.
- Support individuals ages 16 to 25 at high risk for mental illness: The Administration is proposing $25 million for a new initiative, Healthy Transitions, to support innovative state-based strategies to support young people ages 16 to 25 with mental health or substance abuse issues. Efforts to help youth and young adults cannot end when a student leaves high school. Individuals ages 16 to 25 are at high risk for mental illness, substance abuse, and suicide, but they are among the least likely to seek help. Even those who received services as a child may fall through the cracks when they leave school or turn 18.
- Train more than 5,000 additional mental health professionals to serve students and young adults: Experts often cite the shortage of skilled mental health service providers as one reason it can be hard to access treatment. To help fill this gap, the Administration is proposing $50 million to train social workers, counselors, psychologists, behavioral health paraprofessionals, marriage and family therapists, nurses, and other mental health professionals. This would allow SAMHSA and HRSA to provide financial support to train more than 5,000 mental health professionals to serve children, adolescents, young adults (including individuals aged 16-25 years old), and their families, in our schools and communities.
As part of his plan to reduce gun violence, President Obama directed Secretaries Sebelius and Duncan to launch a national conversation to increase understanding and awareness about mental health. As part of that effort, on June 3rd, the President and Vice President will host a National Conference on Mental Health. The conference will bring together people from across the country, including mental health advocates, educators, health care providers, faith leaders, and individuals who have struggled with mental health problems, to discuss how we can all work together to reduce negative attitudes, and help the millions of Americans struggling with mental health problems recognize the importance of reaching out for assistance.
In addition to these initiatives where SAMHSA is taking a leadership role, other offices in the Department of Health and Human Services have been taking steps – as outlined in the President’s Now Is the Time plan, to expand coverage of mental health services. Additionally, the Department of Education has proposals to help 8,000 schools create safer and more nurturing school climates and address pervasive violence.
Ensuring Efficiencies and Effectiveness
Evaluation, Outcomes and Quality
SAMHSA has a long history of conducting evaluations designed to ascertain information about programs funded with Federal dollars. More recently, SAMHSA has embarked upon a course to enhance the rigor of its evaluations in order to use data to examine the effectiveness of programs, the quality of program implementation, and to better understand how certain interventions or activities influence behavioral health outcomes in communities across the nation. To this end, SAMHSA evaluations are examined to ensure that the methods are appropriate to the evaluation questions and that the right data is collected to inform our understanding of the results of programs.
Recently SAMHSA completed an inventory of all evaluations currently ongoing in the agency. These evaluations will be closely monitored by evaluation staff and will be strengthened where indicated and possible. These evaluation experts are collaborating with program staff to develop reporting mechanisms to ensure that the data collected in an evaluation are used to inform policies and practices for the future.
SAMHSA has also undertaken to develop a National Behavioral Health Quality Framework (NBHQF), modeled after the National Quality Strategy, to guide behavioral health services and programs throughout the country and to provide a consistent set of validated measures at the payer, practitioner/program and population levels. The six goals articulated by the NBHQF are: (1) effective services; (2) person-centered care; (3) effective care coordination; (4) use of best practices; (5) safe care; and (6) accessible and high-value care. The draft NBHQF will soon be in its third round of public input with expected release later this year.
SAMHSA takes its role as a steward of taxpayer dollars seriously. SAMHSA has closely examined its portfolio to find efficiencies and as a result has reduced redundancy or duplication of programs. For example, in 2012, SAMHSA evaluated its contracting process to achieve purchasing efficiencies and leverage similar contracting vehicles. As a result, SAMHSA consolidated three state technical assistance contracts into a single contract resulting in both programmatic as well as administrative efficiencies. In 2011, several similar consolidations took place. SAMHSA constantly evaluates its programs via review of grantee performance and data collection. Program adjustments, in scope or focus, are directly affected by that data.
Technical assistance is a key activity provided by SAMHSA in order to ensure that systems, services, and programs are delivered in the most effective and efficient way possible, and to lead the field toward the use of processes and practices that obtain the best outcomes. SAMHSA provides technical assistance not only to its grantees for the implementation of specific grant programs but also to the field at large for system-wide change and enhancement. SAMHSA’s technical assistance is provided through staff subject matter experts as well as through a combination of grants and contracts for technical assistance centers and independent organizations that are managed by SAMHSA staff. The provision of technical assistance encompasses a series of strategies, processes, techniques, and activities (e.g., training, consultation, expert guidance, etc.) designed to maximize overall performance and result in improved outcomes. SAMHSA has developed principles to guide its technical assistance efforts. This approach ensures that SAMHSA’s technical assistance activities are delivered in the most effective and efficient way possible, leading the behavioral health field toward the use of processes and practices that obtain the highest level of outcomes.
We have made important strides in the prevention, treatment, and recovery supports for mental and addictive disorders. However, much work remains to be done. The Administration continues to advance our work on this important issue and we look forward to continuing to work with the Congress on these efforts.
1 Unmet Need for Mental Health Care Among U.S. Children: Variation by Ethnicity and Insurance Status Sheryl H. Kataoka, M.D., M.S.H.S.; Lily Zhang, M.S.; Kenneth B. Wells, M.D., M.P.H., Am J Psychiatry 2002;159:1548-1555. 10.1176/appi.ajp.159.9.1548
2 Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-45, HHS Publication No. (SMA) 12-4725. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.
3 Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–602.
4 Pursuant to Section 1912(c) of the Public Health Service Act, SAMHSA’s definition of SMI can be found at: http://www.samhsa.gov/healthreform/healthhomes/Definitions_SIM_SUD_508.pdf.
5 Pursuant to Section 1911(c) of the Public Health Service Act, SAMHSA’s definition of SED can be found at: http://www.samhsa.gov/healthreform/healthhomes/Definitions_SIM_SUD_508.pdf.
Last revised: November 7, 2013