The Clinton Administration unveiled nearly a dozen initiatives to improve treatment of mental illness, accelerate progress in research, and ensure parity of coverage for mental and substance use disorders at the first White House Conference on Mental Health, held June 7 at the Howard University campus in Washington, D.C.
Chaired by Tipper Gore, the President's mental health adviser, and attended by President and Mrs. Clinton and Vice-President Gore, the daylong conference was linked via satellite to more than 1,000 sites in communities throughout the nation, allowing participation in a town-hall format by consumers and their families and mental health professionals. At Mrs. Gore's invitation, more than 500 mental health advocates from across the country came to Howard University, as did several members of Congress and nine federal department and agency heads.
At the plenary session, Mrs. Gore called on participants to fight against the stigma that surrounds mental illness, which she called "the last great stigma of the 20th century." She stressed the importance of breaking the silence "by talking about mental illness in our homes, our workplaces, in the schools, with our colleagues, and everywhere we can." She described her own successful treatment for clinical depression, which she said developed as a delayed reaction after her son recovered from serious injuries sustained in a 1989 car crash.
Vice-President Gore pointed out that just as families provide support when a relative becomes mentally ill, the community must help families who need information and services. When families seek help, he said, "they must find a waiting ear, not a waiting list." He focused on the creation of school-based services to ensure that parents of emotionally ill children do not become isolated by stigma and hopelessness, and he called on business leaders to implement early-intervention programs for workers with mental health and substance abuse problems.
President's Executive Order Expands Federal Job Opportunities for Persons With Mental Disabilities
Three days before the White House Conference on Mental Health was convened on June 7, President Clinton issued an executive order giving persons with psychiatric disabilities the same hiring opportunities under Civil Service rules as persons with severe physical disabilities or mental retardation.
The executive order changes long-standing Civil Service policy that placed a two-year limit on appointments to government jobs for persons with psychiatric disabilities. At the end of that time they were required to leave government or to compete for the job against other applicants. The policy change now makes them subject to the same rules as persons with mental retardation or severe physical disabilities, who may be appointed to a position for more than two years and may convert to competitive status after two years of satisfactory service.
The order declared that "it is the policy of the United States to assure equality of opportunity, full participation, independent living, and economic self-sufficiency for persons with disabilities. The federal government as an employer should serve as a model for the employment of persons with disabilities and utilize the full potential of these talented citizens."
Mrs. Clinton drew attention to research in the past two decades that has greatly increased understanding of brain diseases and that has begun to break down myths about mental illness. She said that policymakers and clinicians have an obligation to ensure that new scientific knowledge is quickly disseminated to improve prevention, early intervention, and treatment.
President Clinton said his view of mental illness was deeply changed in 1990 when he read Darkness Visible, a personal account of recovery from clinical depression by his friend the novelist William Styron. Calling the loss of human potential from untreated mental illness "staggering," the President briefly described the mental health initiatives either under way or soon to be implemented by his Administration.
The centerpiece of the initiatives was the President's announcement that by next year the 285 health plans that provide care to all nine million federal government employees will be required to cover mental health and substance abuse treatments at full parity with medical treatments. The President said that as an employer the federal government must lead the parity challenge, and he called on other employers to examine the accumulating evidence showing that parity can be achieved with no significant cost increases. He also announced that the Department of Labor will launch a new outreach campaign to inform Americans of their rights to equal coverage under an existing law, the Mental Health Parity Act of 1996.
President Clinton also announced a national school safety training program being launched by the National Education Association. The public-private partnership, which will include the Departments of Education, Justice, and Health and Human Services (HHS), will link schools by satellite in a year-long instructional effort to train teachers and school personnel to identify and help troubled children and address other safety issues. EchoStar, a company based in Littleton, Colorado, is donating satellite dishes to more than 1,000 school districts, and Future View, EchoStar's partner, is donating free time for programming. The President called on other members of the business community, including cable companies, public television stations, and other media outlets, to donate resources so that every school district will have access to the instructional program.
Noting that 36 years ago President Kennedy called for returning mental health to the mainstream of American health care, President Clinton challenged Congress to hold hearings on the mental health parity law to review its strengths and weaknesses. He also challenged Congress to pass the Work Incentive Improvements Act enabling people with disabilities to return to work by ensuring access to affordable health insurance, to pass a strong and enforceable patients' bill of rights, to fund the historic $70 million increase in the mental health block grant to states requested in his fiscal year 2000 budget, and to pass comprehensive legislation eliminating discrimination based on genetic testing.
Other initiatives unveiled at the conference are summarized below.
Accelerating progress in research. Beginning in July, a $7.3 million nationwide study sponsored by the National Institute of Mental Health (NIMH) will explore the prevalence and duration of mental illness as well the types of treatment most commonly used. NIMH will invest about $61 million in two new five-year clinical trials—one to examine the relative effectiveness of available antipsychotic agents in community treatment settings, and the other to examine long-term effects of different sequences of drug therapy and psychotherapy for refractory depression.
Encouraging states to provide more coordinated care for Medicaid beneficiaries with mental illness. The Health Care Financing Administration (HCFA) will announce that Medicaid will reimburse for services provided in assertive community treatment programs. HCFA will also remind states that Medicaid beneficiaries are entitled to all medications approved by the Food and Drug Administration for the treatment of serious mental illness and will ask states to examine their formularies to ensure that these medications are available.
Helping SSDI beneficiaries return to work. Of the 4.7 millions Americans receiving Social Security Disability Insurance, it is estimated that one in nine—about 500,000 people—has an affective disorder. The Administration will launch a $10 million demonstration project to provide treatment for this group and examine whether it allows them to return to work.
Educating elderly Americans about their risk for depression. NIMH and the Administration on Aging will collaborate on an outreach program to educate the elderly and their health care professionals about mental illness. It is estimated that five million people over age 65 suffer from some form of depression, which is often undiagnosed and untreated. The Department of Veterans Affairs (VA) will launch a study at six new sites to test two modes of primary care for older Americans with mental and substance use disorders.
Reaching out to homeless Americans. The Department of Housing and Urban Development will implement an initiative to encourage communities to create safe havens where homeless people with mental illness can get treatment. HHS will launch a two-year, $4.8 million grant program to study the treatment, housing, education, training, and support services needed by homeless women and their children, many of whom have mental and substance use disorders. VA will double its number of outreach programs to homeless veterans with mental illness.
Meeting the mental health needs of crime victims. The Administration announced a new interagency partnership between the Department of Justice's Office for Victims of Crime and the Center for Mental Health Services (CMHS). This partnership will help ensure that the federal response to community crises such as terrorist acts or mass violence includes a strong mental health component.
Developing new strategies for addressing mental illness in the criminal justice system. Later this summer the Substance Abuse and Mental Health Services Administration and the Department of Justice (DOJ) will host a conference to focus on crime prevention among people with mental illness and to address the needs of offenders with mental and substance use disorders. After the conference DOJ will launch an outreach effort to educate the criminal justice community on how to better serve citizens with mental illness. Communities interested in pursuing these approaches can get technical assistance from the National GAINS Center for People With Co-Occurring Disorders in the Justice System. GAINS is a partnership between the Center for Substance Abuse Treatment, CMHS, and the National Institute of Corrections to collect and disseminate information about effective treatment in the justice system.
Implementing a new approach to combat stress in the military. The President announced that he will direct the Department of Defense (DOD) to report back within 180 days on implementation of a more comprehensive program for combat stress in all service branches. DOD will hold a fall conference to develop new strategies and educate military leaders and medical personnel about enhancing current prevention efforts.
Expanding the Caring for Every Child campaign. A new $5 million, five-year effort in targeted communities will highlight the needs of the estimated 10 percent of American children with behavioral problems and mental disorders.
Improving the mental health of Native American youth. A $5 million collaboration of the Departments of Interior, Justice, Education, and HHS in ten Native American communities will study effective strategies for improving mental health among Native Americans between the ages of five and 24. The suicide rate in this group is three times higher than in the general population.
Most Employers ReportNo Increased InsuranceCosts From Parity Law
The majority of employers who made changes in their health insurance programs to comply with the 1996 Mental Health Parity Act did not experience increased costs or have to change other benefit provisions, according to a study commissioned by the federal Substance Abuse and Mental Health Services Administration (SAMHSA).
The law, which became effective in January 1998, sought to establish the same level of benefits for mental health as for medical and surgical treatments and services. Group health plans are not required to provide mental heath benefits, but those that do may not impose a lifetime or annual dollar limit on mental health benefits that is less than that for medical and surgical benefits. The law applies to all employers with more than 50 employees.
The SAMHSA study was based on data obtained in a national survey of employer-sponsored health plans conducted in 1998 by Mercer/Foster Higgins. A total of 3,725 public and private employers responded to the survey, representing a 55 percent response rate. However, employers with no mental health coverage or fewer than 50 employees were eliminated, leaving a total of 1,946 respondents.
Forty-six percent of the 1,946 respondents reported that they were in compliance with the requirements of the law before it became effective in 1998. Another 17 percent now include mental health costs with medical-surgical costs in determining limits, while 11 percent have retained separate mental health limits but have raised them to equal those for medical-surgical benefits. One percent reported dropping mental health coverage, and 21 percent said they have taken no action.
Of the 882 respondents who had made mental health parity changes in their benefit plans, 86 percent reported they had made no compensatory changes in their benefits, 68 percent because they expected no increase in costs, 5 percent because they considered the possible increased costs affordable, and 13 percent because they lacked enough information. One percent reported an increase in employee cost-sharing, and another 1 percent had made changes in administration or utilization management.
Paroxetine approved for social anxiety disorder: The U.S. Food and Drug Administration has approved paroxetine hydrochloride for the treatment of social anxiety disorder, making it the first and only medication approved for treating the disorder in the United States. The drug is marketed by SmithKline Beecham under the trade name Paxil. Three 12-week multicenter controlled clinical trials showed that paroxetine was significantly more effective than placebo, resulting in reduced social anxiety, increased participation in social activities, and improvement in patients' overall clinical condition, as measured by scores on the Clinical Global Impression Scale and the Liebowitz Social Anxiety Scale.
New psychiatrist-administrators: Five psychiatrists were certified by the committee on psychiatric administration and management of the American Psychiatric Association as having met the requirements for certification in psychiatric administration and management. They are William T. Lewek, M.D., of Rochester, New York; Grace Marie Cobiella, M.D., of Idaho Falls, Idaho; Sreehari Patibandla, M.D., of Peoria, Illinois; Charles Smith, M.D., of New Hampton, New York; and Lawrence J. Nardozzi, M.D., of Newark, Delaware.
NARSAD 1999 grants: The National Alliance for Research on Schizophrenia and Depression (NARSAD) has announced that in 1999 it will fund 205 new psychiatric research grants and 167 continuing grants totaling $18.35 million. The awards will go to investigators at leading universities and medical research centers to support studies of the causes of schizophrenia, depression, and other mental illnesses. NARSAD is the largest publicly supported, nongov-ernmental funding organization in the nation. Over the last 13 years it has awarded a total of $82.13 million for 2,130 grants to 1,048 scientists in 146 universities in the United States, Isreal, the United Kingdom, Australia, and Canada.
Exemplary psychiatrists: The National Alliance for the Mentally Ill (NAMI) presented its 1999 Exemplary Psychiatrist Award to 39 psychiatrists from the U.S. and Canada during the annual meeting of the American Psychiatric Association in May in Washington, D.C. Recipients included Rodrigo A. Munoz, M.D., of San Diego, APA president; Francine Cournos, M.D., of New York City, author of City of One and a member of the Psychiatric Services editorial board; and frequent Psychiatric Services contributors Maurice Rappaport, M.D., Ph.D., of San Jose, California; Barbara Rohland, M.D., of Iowa City, Iowa; and Stephen M. Goldfinger, M.D., of Brooklyn, New York.
New COPE program: Zeneca Pharmaceuticals has launched a comprehensive resource program for people with psychosis-related disorders and their families called COPE, for caring, outreach, partnership, and education. COPE provides information for understanding and coping with serious mental illness through a series of four guides reviewed and supported by the National Alliance for the Mentally Ill. The guides, developed in consultation with psychiatrists, mental health consumers and their families, social workers, and other experts in the mental health community, focus on consumers, families, and housing and are supplemented by a resource directory. COPE materials are available from doctors and through NAMI state organizations. Phone numbers for NAMI's state offices can be obtained from NAMI's national headquarters at 800-950-6264.
Behavioral organizations merge: The Association of Behavioral Group Practices (ABGP) agreed to merge with the National Association of Psychiatric Health Systems (NAPHS) in mid-April. ABGP, formed in 1997 to advocate for behavioral group practices, has become a special-interest section within NAPHS. NAPHS represents more than 400 behavioral health care provider organizations, including specialty hospitals, general hospital psychiatric and addiction treatment units, and residential treatment centers.