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PSYCHOTHERAPY AND CHRONIC DISEASE In NIMH supported research, Dr. David Spiegel and colleagues at Stanford Uni. versity have shown that participation of metastic breast cancer patients in weekly group support treatment increases survival time to an average of thirty-six months. Women who participated in the one year intervention survived twice as long as women who received only medical treatment. The intervention was the only variable found to affect survival time. This effect was not apparent until 8 months after the intervention ended.

Dr. Spiegel is continuing to examine the effects of psychosocial treatment for pa. tients with metastatic carcinoma. One hypothesis to be tested is that as a result of decreased anxiety, depression, and pain, patients who are in the support group improve survival by added attention to exercise, diet, and medical treatment. Dr. Spiegel has proposed this group support intervention as a model system for other termi. nal illnesses that may be valuable not only to cancer patients but also to those with HIV/AIDS.

For cancer patients receiving repeated chemotherapy or other immune suppressive therapies, the suppression of the immune system may in some cases prove to be drastic enough to increase the risk of infectious disease. Psychological means may

be useful to block this immunosuppression. Conversely, when immunosuppression is necessary, such as in transplants or lupus erythematosus, physicians may use psychological means to decrease the number of treatments with immunosuppressive drugs, thus reducing both drug side effects and costs. An NIMH-funded project at the Memorial Sloan-Kettering Cancer Center, under the di. rection of Dr. William Redd, has as its long-term objective understanding how psychological factors influence immune functioning in humans. Researchers have been attempting to relate changes in immune function with physical and mental illnesses. Initial results with 20 breast cancer patients found that the repeated experience of the immune suppressing effects of chemotherapy in the distinctive hospital environment can affect patients so that merely returning to the clinic triggers immune suppression. These findings may help to elucidate the biological links between psychological factors and immune function; such changes in immune function may allow rigorous investigation of the mechanisms by which mind influences the body.

At UCLA, Professor Shelley Taylor is examining the psychosocial aspects of can. cer and other illnesses. NIMH is providing career support to Dr. Taylor who is studying social support needs and use of social support groups among cancer pa. tients with funding from the National Cancer Institute. The project seeks to gen. erate guidelines for social support groups in order to increase their appeal to target populations, such as male, working class, minority cancer patients.

ADMS BLOCK GRANT

Senator HARKIN. Interesting. I am prepared to yield to Senator Bumpers, if you would like at this time.

Senator BUMPERS. Mr. Chairman, thank you very much. I will be

very brief.

Dr. Goodwin, I am greatly concerned about the block grant-drug abuse block grant. Are you familiar with the GAO report that Senator Pryor and some of us had done last year?

Apparently, the report does indeed indicate that the drug problems of the larger metropolitan areas in the country are more acute than they are in rural areas, though I think the studies show they are much greater in rural areas than the ordinary layman might think, and while I might be willing to take some abuse for the rural areas, including Arkansas, in order to accommodate that slight disparity, according to the report, the fact is that here is what they say:

The studies we reviewed suggest that urban incidence rates are somewhat less than three times higher than nonurban rates. By comparison, the use of total urban population and current law produces a pattern of funding differences appropriate for an incidence-rate differential of over 15 to 1 between urban and nonurban residents.

Now, do you think a Senator from Arkansas ought to sit still for that?

Dr. GOODWIN. By no means. Actually, what we have seen, of course, is a shift from the older formula which was purely population based to this cruder way of getting at need through a new formula which is weighted toward the urban and the young. I emphasize crude because that was based on assumptions that you were just questioning, and I think we should be questioning the assumptions.

One of the reasons we are putting the new capacity expansion program in place, and it really represents our only expansion in the budget for drug treatment, is that this allows for more targeting of need. That is to say, we can look at areas that States submit evidence that they have, for example, a high rural problem that does not show up in the urban weighting in the existing block grant, and that will allow us to fill those gaps in the block grant.

Second, I would point out that one of the important efforts that Dr. Primm has launched in his Office for Treatment Improvement is a mainstreaming initiative which is particularly important in rural areas, because as you well know, health care delivery in rural areas is heavily dependent upon the primary care specialists.

Senator BUMPERS. That is right.

Dr. GOODWIN. They are the ones there for the mental illness services and for the substance abuse services, and until we can get substance abuse and mental illness treatment integrated into the general health stream, we are going to always have a problem about these illnesses in the rural areas.

Also, by the way, I have just been reminded that many of our prevention programs indirectly benefit rural areas. We estimate that about 23 percent of our OSAP programs in substance abuse prevention apply to rural areas, even though the percent of the population living in rural areas, of course, is substantially lower than that. Senator BUMPERS. How much money is in that program?

Dr. GOODWIN. In the total, $281 million, and it is 23 percent of that $281 million. We could also point out in our critical populations grants from the categorical part of OTI, 17 percent went to rural areas, which again is still above the population distribution.

Senator BUMPERS. Well, my State is a big loser in fiscal year 1992 under the current ADMS formula. We lose about 12 percent in 1992 over what we are going to get in 1991.

Dr. GOODWIN. I am sorry to say that it is, I think, the biggest loser, and that is because of the shift-although it was designed to be a gradual 4-year shift, the shift from that old formula that took into account only population and median income, so that the lower median income States got more.

The shift to the urban and young person weight, which was a crude attempt to target to drug addiction, has put States like Arkansas at a disadvantage, but we hope that the other programs that are targeted that is, the capacity expansion program and the other programs of OTI, as well as the prevention programs-can

Senator BUMPERS. Well, I must say this—I do not know whether somebody crafted it very carefully to make sure that there were going to be 51 votes against changing this formula in the Senate, but as I look it over, it looks that way. I do have Senator Dole on

fill that gap.

PERS

my side, because Kansas is a State that takes almost as big a hit as Arkansas does.

Dr. GOODWIN. Well, I am glad you reminded all of us that these formulas were in both cases were, of course, congressional formulas.

Senator BUMPERS. I know you did not do it, and I know who did. (Laughter.]

It was not in the Senate, I might also say. These things have a tendency to originate in the House.

HIGH SCHOOL DRINKING

Dr. Gordis, just one question—do you do the high school senior survey every year?

Dr. GOODWIN. Yes; now it is every year. Yes.

Senator BUMPERS. That is an extremely helpful and informative survey. I am pleased you do that. I get a chance to look that over, and I get a chance to make a lot of barn-burning speeches about some of the information in it.

Dr. Gordis, can you remind me of the percentage of high school seniors—it seemed to me like it was over one-third—who said they had had five successive drinks or more on one occasion in the preceding 2 weeks? What was that statistic? Was it 37 percent?

Dr. GORDIS. The 1990 numbers, Senator, are that episodes of heavy drinking-that is, five or more drinks at a time during the 2 weeks preceding the survey-were reported by 32 percent.

Senator BUMPERS. Thirty-two percent?

Dr. GORDIS. Down a little bit from the 34.7 percent in 1988, so there is a slight improvement in that, but it is still, obviously, a figure which we are all concerned about.

Senator BUMPERS. Well, it is encouraging that that figure has gone down ever so slightly, but that still is a shocking figure to me. I am still really appalled that that many seniors have and are willing to say on that survey that they have had five drinks or more in the preceding 2 weeks.

Dr. GOODWIN. It is a little more encouraging when you look at the long-term trends. The peak for binge drinking was back in 1979. It is down 22 percent, so one of the disadvantages of doing the survey every year is that looking at it year by year it may be hard to see some of these long-term trends, but as you said, we are much more encouraged about the drug trends in this mainstream population.

Dr. Primm just reminded me that an interesting aspect of that high school survey is that the reduction in drug use by our black population actually exceeded the reduction by the white population in that particular sample of kids, the 76 percent of kids who stay in school-that is, the mainstream population.

Senator BUMPERS. That is all very encouraging. What do you attribute that to, Dr. Goodwin?

Dr. GOODWIN. In terms of the overall trend downward, I think that the overall efforts of prevention, the efforts of the private sector, some of the highly publicized deaths of very important actors and athletes have caught the attention of kids, and most of the change is kids refusing to start using drugs. One thing we know about drugs is it is a lot easier not to start than it is to stop once you have started.

Senator BUMPERS. Is that the thrust of most of your educational programs?

Dr. GOODWIN. Yes; and I think we are catching them through OSAP programs, through the Advertising Council, through the media efforts, public and private. We are catching them young enough that they do not start, and that is why we predicted 5 years ago that the trend should continue down because we thought it was the beginning of a long-term change.

But I would emphasize that there are still significant portions of the population that are not going down that way. The school dropouts are not going down that rapidly. People in the highly impacted inner-city poverty zones are not going down that rapidly, although even there there are some encouraging early trends.

The DAWN data-that is, people who come to emergency rooms with cocaine overdoses—is down 22 percent in the last year. That is the beginning encouragement that perhaps even in this hardcore heavy user group there are some beginnings of some reductions there, but again, the hardcore group, particularly those who inject drugs, with the AIDS epidemic is still a major challenge and we cannot afford to let up.

Dr. SCHUSTER. Well, unfortunately, one of the things the high school senior survey has shown is that attitudes toward the dangerousness of smoking one or more packs of cigarettes has not changed as significantly as it has for marijuana and for cocaine use, and we believe that changes in attitude precede behavioral changes.

What we have seen is that for the past, actually 7 years, although overall there has been a downward trend in tobacco use in high school seniors, that for the past 7 years there has not been a continuing trend. In other words, it has flattened out.

I think this is an area that we need a great deal more intervention. As you may notice my button, here, which is an antismoking button, because NIDA, as well as OSAP and others are very much involved in prevention programs for tobacco use in adolescents as well as amongst children.

Let me just point out, I am very pleased that you used the high school senior survey, which we sponsor, and this next year we will be conducting the same survey in 8th graders and 10th graders, and this is an attempt to be able to get information about children who may never reach their senior year of high school, because they drop out of school earlier. That data will also be collected on a yearly basis from here on out.

Senator HARKIN. Thank you, Senator Bumpers.

I have one last question, Dr. Goodwin and Dr. Leshner. Once again the President's budget proposes to eliminate the protection and advocacy program. The program was created because States were not offering adequate protection to the institutionalized, mentally ill population. Is the number of protection and advocacy cases still increasing as it has for the past several years?

Dr. LESHNER. Yes; the number of cases has increased over the past few years, although the administration feels, as it has over the past few years, that this should become an increasing State responsibility to take over this program.

Senator HARKIN. Do you have evidence to show that States will continue to fund it if Federal support is eliminated as you propose?

Dr. LESHNER. We do believe that they will begin to take some responsibility for it.

Senator HARKIN. You said some responsibility, but I mean, if, for example, we do not fund it in our appropriations bill—how much is the total on that $16 million. Do you think the States will pick that all up?

Dr. LESHNER. I do not know whether they will initially pick up the entire balance, but I suspect over time that the systems have enough momentum that they will continue to develop.

PROTECTION AND ADVOCACY PROGRAM

Senator HARKIN. I want to know what evidence you have. The program was created because the States were not doing it, so we have been funding it. Now you are saying we can stop funding it because the States will do it. I do not understand what has happened all of a sudden.

Dr. LESHNER. They have become more incorporated into the normal operation of the States, and while I cannot prove to you that they will take over, we believe that it is the States' responsibility to pick this up.

Senator HARKIN. When did we start funding it, 1985?
Dr. LESHNER. In 1986.

Senator HARKIN. In 1986. Now that is a short timeframe. I wish I had some evidence that would show me that they would, in fact, pick it up, or something, because I believe that you say the cases are still going up? I read about them all the time. I get different letters or different indications from different parts of the country that we have a real problem here.

It is a small amount-well, it is not a small amount of money, but $16 million, it might be a big amount of money in some State budgets. I do not know, if I thought the States would pick it up, we might let them do it, but I am not certain that they would. And I do not see any evidence that they would.

QUESTIONS SUBMITTED BY THE SUBCOMMITTEE I have a number of other questions, but I will just have to submit those to you in writing. Is that all right, Dr. Leshner, to respond in writing?

Dr. GOODWIN. I would be happy to provide answers in writing.

Senator HARKIN. OK, thank you all very much. Again, thanks for your answers on your prevention activities. I will review the record on that, and I may get back to you, Dr. Goodwin, and in turn to all of you, about the prevention programs in different areas, and try to highlight this a little bit more as we go through the year. Dr. GOODWIN. OK. Thank you.

[The following questions were not asked at the hearing, but were submitted to the Department for response subsequent to the hearing:]

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