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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
psychiatric disorder, especially depression, antisocial
personality, and substance abuse disorders. (There has been
an increase in depression among young people since World
War II.)
A particularly lethal combination is psychiatric disorder,
alcohol or other drug abuse, and easy access to firearms.
The firearm suicide rate among young people more than
doubled from 1982-1987, while the non-firearm rate declined.
This increase parallels the increased availability of
firearms.
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 almed 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 Rental 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. We 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.

With that move, which occurred in February 1991, we also developed a plan of hosting a series of workshops to help formulate a research agenda to expand our program on rural mental health, and will advertise broadly to attract knowledgeable and capable candidates to direct this office.

FETAL ALCOHOL SYNDROME

Question. Doctor, I think that we are just beginning to understand the impact that alcohol has on unborn children. In fact, there are many mentally disabled adults in residential care today whose impairment is thought to be caused by Fetal Alcohol Syndrome.

The University of California at San Francisco conducted a study to get a handle on how Fetal Alcohol Syndrome affects American productivity and quality of life. They estimate that the total annual cost of this disease is approximately $1.6 billion. This includes the neonatal intensive care, costs of treating growth retardation, as well as care and support services for young people throughout their lives.

I don't see anything in your request that specifically addresses this problem, either in your research or treatment agenda. What is the Institute doing to research, prevent and treat Fetal Alcohol Syndrome?

Answer. A significant part of NIAAA's research addresses the issue of alcohol and pregnancy, including Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Ēffects (FAE). It is the research supported by NIAAA that first led to the identification and description of FAS in the 1970s, and found that heavy maternal drinking was a clear health risk to the infant. NIAAA distributed a health caution to every medical school in the country and informed the public of the research evidence.

Our research in this area has grown from $4.5 million in FY 1986 to over $10 million in FY 1990. In the FY 1992 request, FAS research would be funded at a level of $11.6 million. The goal of fetal alcohol research is the identification of women at risk and the development of therapeutic interventions leading to reduced incidence or even prevention of the effects. A wide range of research studies are supported through investigator-initiated research projects and an alcohol research center focused exclusively on this area. These studies include: possible mechanisms for fetal alcohol damage using animal models; alcohol's affect on placental function; genetic factors of parents and their infants that may contribute to the infants susceptibility to FAS; screening instruments to better identify women who are at high risk of a buse; and measures of development that predict later functional impairments in FAS/FAE children.

WOMEN AND SUBSTANCE ABUSE Question. Substance abuse is having a devastating impact on American children. Each year, thousands of drug-addicted women give birth to children who suffer physically at birth from drug-exposure and will go on to develop severe emotional and behavioral problems.

The GAO estimates that 100,000 to 375,000 babies are exposed to cocaine each year. It costs an average of $5,500 to treat each infant, compared to $1,400 to care for a health baby. And the GAO reports that this problem is as prevalent among privately insured patients as those on public assistance. But less then 11 percent of the 280,000 pregnant women who need substance abuse treatment are able to get it. How many States are currently receiving funds through OSAP's program for pregnant and post-partum women and infants?

Answer. Under the Pregnant women and Infants program, OSAP awards demonstration grant funds to organizations within states such as State and local government agencies, community-based organizations, universities, and educational institutions. Currently, organizations in 32 States and the District of Columbia are receiving funds under the Pregnant and Post-Partum Women and Infants program.

Question. How many treatment slots are supported through these OSAP grants, and how many additional slots would your budget allow in FY 19927

Answer. OSAP supports various activities devoted to the substance abuse problems of pregnant women and their infants. Principal among these is a demonstration grant program intended to coordinate services systems for linking health promotion and treatment services with substance abusing pregnant women and their small children. The Pregnant and Post-Partum Women and their Infants program is designed to provide a full continuum of care, from prevention to early, intervention to treatment and rehabilitation. Strategies include: biological/physical, such as substance abuse treatment, detoxification, and nutrition; obstetrical/psychological, such as prenatal care, treatment for anxiety, depression, and low selfesteem; instrumental child care and transportation to facilitate a woman's obtaining services; housing; and informational and educational.

Unlike the treatment programs of the Office for Treatment Improvement, OSAP does not target a given number of slots for support. However, it is estimated that approximately 10,200 women and their infants will receive services under the demonstration program by the end of FY 1991. Funding increases for FY 1992 will allow for an estimated 1,600 additional women and infants to receive these services.

Additional services are provided for pregnant women and their infants under the ADMS Block Grant to the states. A valid estimate of the number of pregnant women served through the Block Grant does not exist.

Question. How many applications for the OSAP women's program were approved but unfunded in FY 19917

Answer. Although only one of the two grant review cycles for FY 1991 has been completed to date, estimates based on grant approval and award rates for the first FY 1991 cycle as well as those during FY 1990 indicate that approximately 400 applications are expected to be received during FY 1991. Approximately 172 or 44 percent will be approved, 38 applications (22 percent) will be funded, and 134 (78 percent) will remain unfunded.

Question. I'm told that the most successful programs of all are those that combine residential treatment and prenatal care. In Iowa, for example, the Iowa Methodist Medical Center teaches mothers to care for their babies during a short-term treatment program followed by at-home care. Programs like these work, but they are scarce and often under-funded. Would increasing the ADMS Block Grant, with its 10 percent set-aside for women's treatment programs, expand every State's.capacity to treat pregnant women?

Answer. Increasing the Glock Grant would make additional funds available for women's treatment programs. However, additional funds alone will not add more capacity for treating pregnant women. We have found that many States need program development guidance including clinical protocols, model staffing patterns and appropriate facility types, and other program standards.

To meet these needs Oti is co-sponsoring with the Alcohol and Drug Problems Association a National Meeting on Women's Treatment Needs in Portland, Oregon May 5-8, 1991, and ensuring that every State drug authority sends at least one staff person.

Also, recent staff field work has made us aware that several States have not interpreted the set-aside requirement to require programs dedicated to women and their children with the appropriate mix of services. To address this problem, an expanded federal oversight role and significant revision to provisions of the DHHS Block Grant Regulation (45 CFR Part 96) that cover State's reporting requirements and State's interpretation of Block Grant statutes will be required. The regulations are currently under review within the Department and oversight is being expanded through the State Systems Development Program.

CAPACITY EXPANSION PROGRAM Question. With our Nation continuing to suffer the effects of substance abuse, it's disappointing to see that the budget proposes level funding--not even an increase to cover inflation--of the Alcohol, Drug Abuse, and Mental Health Services Block Grant. The only increase proposed for substance abuse treatment is the $99 million "capacity expansion" grant, targeted to drug abuse but not, it appears, to combat the Nation's number one substance abuse problem, alcohoi.

Dr. Goodwin, do you think it is the best policy to target funds to drugs only, or should we be taking into account the fact that many addicts use both drugs and alcohol?

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. If the Committee consents to provide these funds, how would the Department assure an equitable distribution of funds between urban and rural areas, where alcohol remains the primary drug of choice?

Answer. The Capacity Expansion Program will assist States and communities in expanding the capacity of their drug abuse treatment programs for specific population subgroups that are facing critical health and socio-economic difficulties as a result of their drug abuse. This new capacity expansion program will focus on adolescents, racial and ethnic minority populations, and residents of public housing projects. ADAMHA is particularly interested in funding projects that address the population subgroups of drug abusers who are homeless, have a co-occurrence of drug addiction and other health disorders, or are in a rural area.

The award criteria for grants under the announcement described above will be based, in part, on the application's technical merit and its focus on the program's target populations and subgroups. In making awards, consideration will also be given to the balance among target populations. In this way, OTI will ensure a reasonable distribution of funds to rural areas.

The CEP grants will target rural areas, particularly those where

demand for drug treatment services exceeds capacity, 2) there is a high prevalence of drug abuse, and 3) there is a high incidence of drug related criminal activities. The smaller towns and communities in rural States that face these problems will be served by this program when they are included as sub-recipients in the application from the State.

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