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QUESTIONS SUBMITTED BY THE SUBCOMMITTEE
ADMS BLOCK GRANT APPLICATION
Question. I have received disturbing reports that your Agency's delay in determining the States' ADMS Block Grant allocations and in sending out Block Grant applications for several months into the fiscal year caused States to have serious cash-flow problems in their treatment programs. States couldn't even apply for funds. Some ran out of money to pay for substance abuse treatment. When did States learn their FY 1991 Block Grant allocations, and when were applications for the funds sent to States?
Answer. The States are free to apply for the ADMS Block Grant without waiting for us to formally invite their applications. Nevertheless, we do typically invite States to apply. When the FY 1991 letter of invitation was sent on January 22, 25 States and 2 Territories had already applied. That letter of invitation included a schedule showing the official State allotments; however, within two weeks of receiving our appropriation, we had shared tentative allotment information with state associations which, in turn, quickly provided the information to the States.
Question. What was the reason for the delay?
Answer. The application invitation letter is usually sent out shortly after our appropriation is enacted. However, this year the letter was delayed due to our desire to provide an alternative voluntary application format for the States to use. This optional format would have provided us and the Congress with additional information regarding State treatment services and would also have served as a "dry runs for development of State Substance Abuse Treatment Plans. We published the alternative format (and the existing format) in the Federal Register for State comment on November 29, and OMB granted approval on January 19. As a practical matter, ADAMHA staff had since September 1990 been reminding States of their right to apply using the older format without invitation. In fact as of March 25, we have awarded 43 grants, which is more than the 38 awarded by the same time last year.
PROTECTION AND ADVOCACY
Question. Once again, the President's budget proposes to eliminate the Protection and Advocacy program. This program was created because States were not offering adequate protection to the institutionalized mentally ill population. Is the number of P&A cases still increasing, as it has for the past several years?
The number of cases has increased over the past few
Question. What evidence do you have that States will continue to fund the P&As if federal support is eliminated as you propose?
Answer. P&As have become more incorporated into the normal operation of the States and while we have no direct evidence that the States will take over, we believe that it is the States' responsibility to pick this up.
ALCOHOL AND DRUG ABUSE TREATMENT
Question. Your Department released a report last November on the economic costs of alcohol and drug abuse, which estimates that alcohol abuse cost this nation $86 billion in 1988, and drug abuse cost $58 billion. In 1985, the most recent year for which we have data, alcohol abuse caused 94,768 deaths. Drug abuse caused 6,118 deaths. In terms of lost productivity, alcohol abuse cost $24 billion, drug abuse $2.6 billion.
Alcohol is our Nation's number one drug of abuse and a top public health problem, yet the budget proposes not a single penny more for the ADMS Block Grant than we provided in FY 1991. Would increasing excise taxes combat alcohol abuse?
Answer. Yes, research evidence indicates that increases in excise taxes on alcoholic beverages can reduce alcohol consumption and its adverse consequences. Specifically, increases in excise tax rates have been causally linked with decreased fatality rates for liver cirrhosis, reductions in traffic fatalities among young people, and reduced quantity, frequency, and prevalence of consumption among youth. The public health benefits of a specific tax increase will depend in part on the degree to which prices rise as a result. The recent increases in federal excise taxes are small in comparison to the prices charged for these beverages. It is not yet clear whether tax increases of this size will have a significant impact on alcoholrelated problems.
Question. Given that alcohol abuse is the most prevalent and costliest drug to society, should the National Drug Strategy address the issue?
Answer. The National Drug Strategy provides a cohesive strategy for attacking illegal drug usage including the use of alcohol for those under the age of 21. While the National Drug Strategy does not address alcohol, the Department is committed to tackling this public health problem. All of the prevention programs operated by the Office of Substance Abuse Prevention within ADAMHÀ incorporate alcohol as well as drug prevention. Most drug abusers are poly-drug abusers and in many cases alcohol is one of the many drugs they are abusing Through the Office of Treatment Improvement we are working toward providing comprehensive drug treatment which includes addressing alcohol abuse.
The Secretary, DHHS, and the Surgeon General are launching highly visible initiatives to increase public awareness on the dangers and costs of alcohol abuse and dependence; to reduce the number of associated deaths, injuries, and suffering; and to foster support for biomedical research on the causes and effects of alcohol abuse and alcoholism, and clinical research on the treatment and prevention of alcohol-related problems. The Secretary's initiative to reduce alcohol abuse is centered on a strong anti-drunk driving campaign, continuing communication with the Department of Treasury concerning the effectiveness of warning labels on alcoholic beverages, and the reduction of alcohol abuse among special populations such as high risk youth, pregnant and postpartum women, and Native Americans.
The Surgeon General is leading the PHS Five-Year Strategic Plan to Reduce Alcohol Abuse. The critical goals are to overcome public complacency about the toll of alcohol abuse and alcoholism; reduce the associated morbidity and mortality, especially the incidence of Fetal Alcohol Syndrome; and increase public and scientific knowledge about the adverse consequences of alcohol abuse through biomedical and behavioral research on alcohol-related problems.
Question. Is the $99 million proposed for "capacity expansion" to be directed to alcohol, drugs, or both?
Answer. Although the Capacity Expansion Program focuses on effective and comprehensive drug abuse treatment, the extensive overlap of alcohol and other drug abuse problems in the same individuals dictates that almost all service providers address the treatment of the dually diagnosed. The 1989 National Drug Abuse Treatment Utilization Survey reported that the percent of drug patients who have secondary alcohol problems ranged from 12 percent in Maine to 100 percent in Nebraska and Pennsylvania. Eighteen States reported in excess of 45 percent of drug patients with secondary alcohol problems.
Question. What would it cost to provide treatment on demand for alcohol and other drug problems?
Answer. Significant inroads to treatment of drug and alcohol abuse can only be achieved through a partnership between federal and State governments, communities and the private sector. Since 1989,, the Department's budget for drug treatment has nearly doubled, and I believe that the new $99 million Capacity Expansion Program in the FY 1992 budget is a significant effort in this direction.
The FY 1992 President's Budget would provide support for 106,474 ADAMHA drug treatment slots, which together with expected other federal and non-federal support would provide treatment services for 2.2 million persons. The Administration has not made similar projections for the number and cost of treating persons with alcohol problems.
ALCOHOL AND DRUG ABUSE PREVENTION
Question. Dr. Goodwin, I recently introduced a prevention package of seven bills designed to encourage wellness in both children and adults. It seems to me that, be using our dollars wisely today to provide prevention and screening programs to at-risk individuals, we will save billions of treatment dollars tomarrow.
ADAMHA recently released a study of the costs to society of alcohol, drug abuse, and mental illness. This report illustrates again the old adage the "an ounce of prevention is worth a pound of cure. The study estimates the total economic costs at over $273 billion in 1988, including $129 billion of mental illness, $86 billion for alcohol abuse, and $58 billion for drug abuse.
These really are alarming figures, especially when you take into account that mental and addictive disorders are chronically underreported; and this study doesn't even include costs associated with crack cocaine a buse or drug-exposed babies.
In light of this, Dr. Goodwin, how can you justify that your budget for research, treatment and prevention programs provides the smallest increase--a mere 3.7 percent, not enough to cover inflation-to prevention?
Answer. Since the Office of Substance Abuse Prevention was created, it has been the fastest growing component of ADAMHA.
OSAP has gone from a grant program of just over $20 million to nearly $300 million. In addition, there is a $20 million prevention setaside in the Block Grant; and also, prevention research is an extremely important component of the research inistitutes.
PREVENTION DEMONSTRATION AND YOUTH SUICIDE
Question. Dr. Leshner, we know that prevention is a major component of the NIMH mission. And the Institute supports research and programs that anticipate and intervene when an individual's behavior starts to deviate from the norm.
One of the Subcommittee's key concerns is the issue of preventing teenage suicide--a problem that has become increasingly significant in recent years.
In fact, the Centers for Disease Control reports that the suicide rate among 15-24-year-olds has almost tripled since 1950, Surely this steep increase in the teenage suicide rate is not simply due to increased rates of serious mental disorders such as schizophrenia. What is the Institute doing to identify other factors--what we often call "life stressors"--that place young people at risk of attempting suicide?
Answer. The NIMH is doing a great deal to identify risk factors for suicide and suicidal behavior. Research projects addressing this complex issue cut across a wide range of NIMH programs. One thing we have learned is that most adolescents who experience "life stressors" are not particularly at risk for suicide. It is important to emphasize that suicidal behavior is not a normal response to stress. Virtually all adolescents and young adults experience stressful life events such as difficulties in their relationships with peers, parents, or teachers. More than 99.9 percent of adolescents do not kill themselves because of stress. Almost all adolescents who are suicidal in response to acute stress have an underlying disorder. Studies supported by NIMH have found the following risk factors for teen suicide :
Almost all completed teen suicides involve a history of
A particularly lethal combination is psychiatric disorder,
Other risk factors for suicide and suicidal behavior include exposure to family violence, psychiatric and substance abuse disorders in the family, and a family history of suicide and
suicidal behavior, incarceration, and firearms in the home. Question. What research is underway on the most promising broadbased or targeted primary interventions?
Answer. The prevention of youth suicide and suicidal behavior ultimately rests with the prevention of mental disorders such as antisocial behavior/conduct disorder, depression, and substance abuse; and the early identification and treatment of disorders for which effective treatments are available, especially depression.
NIMH supports a wide range of preventive intervention research projects aimed at serious behavioral and emotional problems experienced by youth, problems that almost always precede suicide and suicidal behavior. NIMH Suicide Research Prevention Demonstrations are aimed at a broad variety of risk factors such as poor coping strategies, poor problem-solving abilities, poor peer relations, poor relations with teachers, depression, etc., especially among high risk youth. Leona Eggert, at the University of Washington, is studying a high school based, year-long personal growth class that integrates peer and teacher support, life skills training, and social network development. George Clum, at the Virginia Polytechnic Institute and State University, is using intensive group problem-solving, training for college students with persistent suicidal thoughts or behaviors. David Rudd, at Texas A & M, is examining intensive, short-term outpatient treatment, combining psychoeducation and problem solving components.
Because conduct disorder is implicated as a risk factor for suicide, prevention of conduct disorder can be effective in reducing the incidence of suicide. Conduct Disorder Research Prevention Demonstrations are aimed at a broad variety of serious behavioral problems.
The development of effective treatments for child and adolescent mental disorders offers the promise that effective treatment may prevent adverse outcomes such as suicide. Peter Lewinsohn, at the Oregon Research Institute, is examining behavioral group treatment of depressed adolescents and their parents, comparing two different treatments. Alan Kazdin, at Yale University, is comparing several interventions, alone and in combination, for children and adolescents with conduct and behavioral disorders.
RURAL MENTAL HEALTH RESEARCH
Question. This Committee has provided $25 million for research and demonstrations on rural and Native American mental health issues over the past two years: Could you highlight the portfolio of research and demonstrations now underway?
Answer. In FY 1990, NIMH supported research projects, demonstrations, and research centers on rural and Native American mental health issues. The research projects examined service needs and efficacy, epidemiology, and behavioral and psychological factors in mental illness in rural and Native American populations. The demonstrations examined case management, crisis assistance, and psychosocial rehabilitation, and supported housing, or services to dually diagnosed persons (those diagnosed with both a mental disorder and a substance abuse disorder).
Three research centers include two stimulated by a recent announcement. One, in Iowa, focuses on the role of families in rural society as providers of support for physical and mental health maintenance, to reduce the adverse behavioral and emotional consequences of economic stress. The other, in Arkansas, studies access to and effectiveness of services in rural areas. An established center in Wisconsin is studying the organization and financing of services for severely mentally ill persons.
The Adolescent Health Program of the University of Minnesota will study psychiatric disorders, substance abuse, and related services utilization in three widely separated, linguistically diverse, and largely rural Native American adolescent populations. Dr. Spero Manson, at the University of Colorado, will develop and evaluate an innovative program aimed at improving treatment of depressive disorders among American Indian primary care patients.
New NIMH-funded research at the University of Wisconsin is examining how burdens that rural families experience in caring for a severely mentally ill member are lessened or increased by family interactions with different types of county public mental health systems. This research is an outgrowth of a research center grant previously awarded to the University of Wisconsin for studies on the organization, financing, and delivery of mental health in nine rural Wisconsin counties.
OFFICE OF RURAL MENTAL HEALTH
Question. We also mandated the creation of an Office of Rural Mental Health within NIMH. But after two years, I'm concerned that no director has been appointed to the office. When do you expect that position to be filled?
Answer. We expect to reopen a national search for this position this year, with the initial advertisements appearing in June. hope to fill the position by late summer, depending on availability of the person selected. The search conducted in 1990 did not yield an individual with appropriate expertise for this position.
Initially, this office was located within the office of Dr. Delores Parron, the NIMH Associate Director for Special Populations, with Dr. Parron serving as Acting Director of the Office of Rural Mental Health Research. In the course of reviewing the structure of our programs, we felt that a more beneficial location for this coordinating and policy function would be within the Division of Applied and services Research, a new Division that consolidates all of our research, research demonstration, capacity development, technical assistance, and State planning efforts on mental health services delivery. Since these are areas where rural mental health research will focus most heavily, we believe it would be best to locate this office in closest proximity to these programs.