News & Notes
Rural Mental Health Work Group Calls for Better Training, More Flexibility in Provision of Services
Addressing the inadequacies of mental health services in rural areas requires innovative training strategies for rural providers and removal of constraints on who can deliver and be paid for services, according to a recent report of a work group sponsored by the Center for Mental Health Services (CMHS). The 18-member Ad Hoc Rural Mental Health Provider Work Group also emphasized that in rural areas mental health and substance abuse services should be fully integrated into primary health care.
The report cites data showing that almost 21 percent of Americans live in nonmetropolitan areas with serious shortages of appropriately trained professionals, and that 55 percent of the 3,075 U.S. counties are rural counties with no practicing psychiatrists, psychologists, or social workers. Compared with their urban counterparts, rural residents have fewer service delivery alternatives, a more limited array of support services, and limited opportunities to obtain affordable health insurance that includes mental health and substance abuse benefits.
CMHS convened the work group at the request of the Secretary of the Department of Health and Human Services to examine the delivery of rural mental health services by nonphysician providers. The group was asked to make recommendations about how to increase the pool of qualified rural mental health professionals through educational programs, changes in current standards for the delivery and reimbursement of mental health services, and changes in credentialing of mental health professionals. The work group was also asked to consider strategies that promote the acceptance of nonphysician mental health providers in rural communities and improved interdisciplinary collaboration. Its final report, Mental Health Providers in Rural and Isolated Areas, was released in October.
The work group said that innovative training strategies for rural mental health providers are needed and that federal and state funding for such programs is critically important given the financial constraints on academic institutions. Existing professional training programs and credentialing bodies are not well suited for rural mental health providers because they emphasize specialization, while the delivery of mental heath services in rural areas requires providers to be generalists. In addition, most training programs are geared to the needs of urban settings. Training programs should stress recruitment of qualified applicants from rural areas who are more likely to practice in rural locations after graduation, the work group recommended. In addition, training and service delivery models should respect and include natural helpers and traditional healers found in rural cultures so as to maximize available resources.
Because providing effective health care increasingly requires interdisciplinary collaboration, training programs should try to enhance opportunities for interdisciplinary training and service delivery. Interdisciplinary teamwork is increasingly important in all health care, the work group noted, but even more so in rural areas, where health and mental health services are often provided at a single site and providers routinely consult with one another.
The work group identified statutory barriers and practices related to professional training and credentialing that restrict the supply of rural mental health providers. The practice of vesting legal responsibility and accountability solely in physicians, who are in short supply in rural areas, creates difficulties in obtaining approval or supervision for care under Medicaid. To increase access to care in rural areas, at least two studies have recommended the use of mid-level pro viders, such as nurse practitioners and master's-level psychologists.
Decisions about which tasks can be performed by which providers have generated much controversy among the various professions, the work group noted. Nevertheless, it concluded that the core professions as currently defined--psychiatry, psychiatric nursing, psychology, and social work--are unlikely to produce sufficient numbers of clinicians for rural practice. It recommended developing statutory and regulatory mechanisms for approving mental health providers to deliver the full range of services for which they have the appropriate skills and competencies.
Related to training and credentialing but a more ambitious undertaking, the work group said, is the need to identify ways to enhance the sharing of resources, collaborative decision making, and joint risk taking among providers. Strategies that would allow more flexibility in assigning responsibility for treatment planning and other decisions would greatly improve the match between client problems and needed services.
In urging full integration of mental health and substance abuse services into primary health care, the work group said that federally funded health programs targeted at rural areas should be required to include mental health and substance abuse services as part of their mission. Many federal grant programs do not currently have such a requirement.
The report is available from the National Mental Health Services Knowledge Exchange Network (phone, 800-789-2647) or from the Internet at http:/www.mentalhealth.org.
Employers Must Comply With Parity Act Before Seeking Exemption, Clinton Administration Rules
Despite intense lobbying by powerful business groups, the Clinton Administration has decided that employers must first comply with the 1996 Mental Health Parity Act before seeking an exemption because of higher health care costs.
The 1996 law, which became effective on January 1 of this year, requires employers with 50 or more workers and all group health insurance plans to provide the same level of annual and lifetime benefits for mental health care as for physical health care. However, employers may seek an exemption if their health insurance costs rise more than 1 percent as a result of complying with the law.
Publication of interim regulations governing the new law was delayed while some business groups, including the U.S. Chamber of Commerce and the Association of Private Pension and Welfare Plans, argued with mental health advocates over whether they should be allowed to use the exemption based on advance estimates of higher costs, rather than actual experience with them. The interim regulations were finally published in the December 22 Federal Register.
Leading the opposition to advance exemptions were the National Alliance for the Mentally Ill, the National Mental Health Association, the American Psychiatric Association, and the American Psychological Association. Tipper Gore, a presidential adviser on mental health issues, and Secretary of Health and Human Services Donna Shalala supported the advocates' position, as did Senators Pete Domenici (R.-N.Mex.) and Paul Wellstone (D.-Minn.), sponsors of the parity legislation.
The business groups had argued for exemptions based on 1997 estimates that health care costs would increase by more than 1 percent in 1998. But the new regulations permit only employers who already provide mental health parity to use 1997 data to request an exemption. Others can seek an exemption after complying with the law for at least six months. The regulations also permit disclosure of the names of companies seeking exemptions.
New Guide Helps Primary Care Clinicians Identify and Treat Patients With Substance Abuse Problems
The Center for Substance Abuse Treatment (CSAT) has released a 168-page guide explaining how primary care physicians and other clinical medical practitioners can screen and assess their patients for substance abuse problems, provide office-based interventions for some patients, and refer others for in-depth assessment and treatment.
Because of their long-term contacts with patients, primary care clinicians represent an important untapped resource in solving the serious problem of substance abuse in America, Nelba Chavez, Ph.D., said when the guide was released in mid-December. Dr. Chavez is administrator of the Substance Abuse and Mental Health Services Administration, of which CSAT is a part. She noted that studies show that primary care providers can have a dramatic impact on their patients' substance use through brief intervention and follow-up at regular office visits.
CSAT's director, David J. Mactas, pointed out that although substance misuse is the single largest cause of morbidity and mortality in the United States, less than ten hours of the medical school curriculum is devoted to training physicians to recognize and treat substance use disorders. In the primary care setting, as few as one in 30 cases is identified. Physicians do not typically treat people for addictive disorders until severe complications have made medical care necessary, he noted. Such patients are the least responsive to behavioral interventions, which has led many physicians to develop the incorrect and harmful attitude that addiction treatment is ineffective.
The purpose of CSAT's new publication--A Guide to Substance Abuse Services for Primary Care Clinicians--is to provide clinicians with a set of tools to intervene up to ten or 15 years before severe complications develop, at a point when patients' drinking patterns have begun to put them at risk of medical and psychosocial consequences. The guide was developed by a consensus panel of 18 experts in the field of substance abuse treatment--physicians, nurses, social workers, researchers, certified alcohol counselors, program directors, and pharmacologists--many of whom work in the primary care setting.
Recognizing the time constraints on clinicians in that setting, the panel focused on identifying brief screening instruments. Seven such questionnaires, with specific instruments for adolescent and geriatric populations, are included in an appendix. The chapter on screening provides practical tips for raising the topic of substance use in a nonjudgmental way during routine medical history taking.
For patients found to have problem drinking patterns, the guide includes a chapter tapping a decade of new research on the critical components of a brief intervention, which can be conducted by a clinician in ten to 15 minutes. Sample comments with neutral nonstigmatizing language are included for clinicians to use to communicate their concerns about a patient's drinking or drug use, educate the patient, and assess the patient's awareness of the problem and readiness for change. The importance of follow-up and monitoring is emphasized.
A chapter describing the spectrum of specialized treatment programs was included in response to complaints by primary care clinicians that their lack of a clear overview of the substance abuse treatment system hampers their making effective referrals. To help clinics, health maintenance organizations, and other primary care facilities implement substance abuse screening programs and train clinicians, another chapter addresses system change and summarizes the panel's recommendations; it is designed to be especially useful to administrators and planners.
A detailed overview of the pharmacotherapy of addictive disorders is provided in an appendix, as is a discussion of the legal and ethical issues raised when substance abuse diagnosis and treatment are conducted in a primary care setting. Practical suggestions for maintaining patient privacy and confidentiality are provided.
A Guide to Substance Abuse Services for Primary Care Clinicians is number 24 in CSAT's Treatment Improvement Protocol (TIP) series. All TIPs are available on the CSAT Web page at www.samhsa.gov, or they can be ordered free of charge by contacting the National Clearinghouse for Alcohol and Drug Information at 800-729-6686.
NEWS BRIEFS
Surgeon General's report on mental health: A Surgeon General's report on mental health is being developed under the direction of the Substance Abuse and Mental Health Services Administration (SAMHSA) in partnership with the National Institute of Mental Health. The first such report to focus on mental health, it will be a comprehensive public health document directed to the general public. The report will summarize the latest scientific and clinical information about the causes, treatment, and prevention of mental illness and will also cover public policy issues that affect the mental health field, including parity in insurance coverage, the changing service environment, and confidentiality of medical information. The report is expected to be completed within 24 months of the date it was commissioned, September 30, 1997. Information about the report will be available through SAMHSA's Knowledge Exchange Network on the Internet (http.//www.mentalhealth.org) after March 1.
Cost-effective philanthropy: The American Institute of Philanthropy (AIP) has awarded the National Alliance for the Mentally Ill (NAMI) an A+ rating for its cost-effective charitable spending and fund-raising practices. NAMI was one of ten nonprofit organizations throughout the country to receive an A+ rating. AIP helps consumers judge the fund-raising efficiency of a charity by evaluating the amount of money spent on the charity's intended purpose versus administrative costs and by comparing its fund-raising expenses with contributions. AIP found that NAMI spends $93 of every $100 raised on charitable activities and spends only $3 on administrative and fund-raising costs.
Guttmacher Award: Submissions are invited for the 1999 Manfred S. Guttmacher Award, presented by the American Psychiatric Association (APA) and the American Academy of Psychiatry and the Law (AAPL) to recognize outstanding contributions to the literature of forensic psychiatry. The contribution may be in the form of a book, monograph, paper, or any other work presented at a professional meeting or published between May 1, 1997, and April 30, 1998. The award will be formally presented in May 1999 at the AAPL meeting held in conjunction with the APA annual meeting in Washington, D.C. The award includes an honorarium of $500, and the recipient is expected to present an award lecture. Applicants should submit six copies of the work and six copies of an abstract to Robert L. Sadoff, M.D., Chairman, Guttmacher Award Board, APA, 1400 K Street, N.W., Suite 327, Washington, D.C. 20005. The deadline for submissions is May 25.
Research on autism: The Autism Research Project at the University of Pittsburgh and the Center for Cognitive Brain Imaging of Carnegie Mellon University in Pittsburgh have received a five-year, $7 million grant from the National Institutes of Health to conduct research on the specific cognitive processes that are impaired in autism and the underlying abnormalities in the activity and "wiring" of the brain. The grant is part of a larger $27 million effort involving an international collaborative network of researchers established to accelerate progress in defining the causes of autism. The network is funded by the National Institute of Child Health and Development and the National Institute of Deafness and Communication Disorders. The Pittsburgh researchers will use functional magnetic resonance imaging, eye movement studies, computerized cognitive tests, and neuropsychological testing to define the deficits in cognitive processes, their location in the brain, and their impact on behavior. Subjects of the study will be 300 verbal individuals with autism who are between the ages of seven and 50 and have IQ scores of 80 or above.
PEOPLE & PLACES
Appointment: James Thompson, M.D., has been appointed deputy medical director for education at the American Psychiatric Association in Washington, D.C. He assumed his new post in January. Dr. Thompson formerly was associate director of residency training and professor of psychiatry at the University of Maryland School of Medicine in Baltimore.
