In October 2003, Rep. Grace Napolitano (D-CA) introduced House Concurrent Resolution 292. Her resolution expressed “that Congress should adopt and implement the goals and recommendations provided by the President's New Freedom Commission on Mental Health through legislation or other appropriate action to help ensure affordable, accessible, and high quality mental health care for all Americans.” Although Rep. Napolitano's resolution is yet to be accepted, the new Congress will likely take up the issue. When it does, expect a passionate debate over the role the federal government should play in promoting a broad array of mental health services.
When the Bush Administration set up the New Freedom Commission on Mental Health in April 2002, it was the first such national focus on mental health since the Carter Commission of the mid 1970's. Charged with conducting a “comprehensive study of the United States mental health service delivery system" the New Freedom Commission unveiled a set of sweeping recommendations in a report entitled "Achieving the Promise: Transforming Mental Health Care in America” in July 2003. To its credit the report promotes a vision that individuals with mental illness can recover if they are provided access to effective treatment and community assistance including health care, housing and job supports.
While there is widespread support by mental health consumers, advocates and professionals for the Commission's goals, the report is not without controversy:
* Consumer/client and ethnic organizations/providers are concerned that the Commission's goal of promoting "evidence-based" or science-based services may squeeze out support for emerging treatments that are not yet mainstream;
* Privacy watchdog groups and conservative organizations are troubled by the report's Recommendation 4.2 which states: "The key to improving academic achievement is to identify mental health problems early and, when needed, provide appropriate services or links to services. The extent, severity, and far-reaching consequences make it imperative that our Nation adopt a comprehensive, systematic approach to improving the mental health status of children"; and Recommendation 4.3 which backs the "systematic screening procedures to identify mental health and substance use problems and treatment needs in all settings in which children [and] youth... are at high risk for mental illnesses or in settings in which a high occurrence of co-occurring mental and substance use disorders exists. In addition to specialty mental health and substance abuse treatment settings, screening for co-occurring disorders should be implemented when an individual enters the juvenile or criminal justice systems, child welfare system, homeless shelters, hospitals..."
* Others are concerned that the lack of new funding for goals and priorities will result in a federal shell game as existing dollars are either reshuffled or actually reduced. For example, Medicaid, which provides essential funding for state mental health services to the poor, is being held flat or is actually declining as a result of new federal requirements. States such as Mississippi, Utah and Washington are cutting the scope of mental health services as well as who is eligible. Other funding priorities, most notably the wars in Iraq and Afghanistan, leave little to no room for the expansion of mental health services.
One of the biggest potential problems with the Commission's recommendations, however, is the unacknowledged influence of the pharmaceutical industry in the Commission's support for the adoption of medication algorithms that promote use of new generations of expensive antidepressants and antipsychotic drugs; the biggest customers for these drugs are cash-strapped state Medicaid programs.
According to a January 2003 report from the Center on Budget and Policy Priorities, “prescription drug costs [are] the fastest-rising component of Medicaid costs” and they “are rising sharply because of increases in the number of prescriptions used, increases in the prices of prescription drugs, and the tendency for prescriptions to shift from older, less-expensive drugs to newer, more-expensive ones. In the past year, the great majority of states have adopted initiatives to limit the cost of, or access to, prescription drugs to slow Medicaid spending growth.”
The New Freedom Commission cites a Texas-based project called the Texas Medication Algorithm Project (TMAP) as an evidence-based practice that leads to better consumer outcomes. Launched in 1995, while George W. Bush was still Governor, TMAP was developed through an “expert consensus” process that included the University of Texas, the mental health and corrections systems of Texas, and representatives from -- or with strong financial ties to -- the pharmaceutical industry. TMAP was funded through a grant by the Robert Wood Johnson Foundation as well as money from ten drug companies.
The new generation psychiatric drugs -- both antidepressants and anti-psychotics -- represent a growth market for drug companies. “National sales of antipsychotics reached $6.4 billion in 2002, making them the fourth-highest-selling class of drugs, behind cholesterol-lowering drugs, ulcer drugs and antidepressants, said IMS Health, a company that tracks drug sales,” the New York Times’ Erica Goode reported in May 2003. In 2002, according to NDCHealth, another company monitoring the industry, “more than 7.4 million prescriptions were written for Zyprexa and more than 7.6 million for Risperdal.” Antidepressants and antipsychotics thus constitute two of the four top classes of drug sales.
The Texas program -- which tends to support the first line use of these newer, more expensive antidepressants and antipsychotic drugs -- became the subject of a national debate when Allen Jones, an employee of the Pennsylvania Office of the Inspector General, turned whistle-blower and revealed that key officials with influence over the adoption of TMAP in Pennsylvania had received money and perks from drug companies involved in promoting the medication algorithm. Jones' removal from the investigation is now under FBI examination.
In his report, posted on the Web site of The Law Project for Psychiatric Rights, Jones documented that the “pharmaceutical industry has methodically compromised our political system at all levels and has systematically infiltrated the mental health delivery system of this nation. They are poised to consolidate their grip via the New Freedom Commission and the Texas Medication Algorithm Project.”
The influence of the pharmaceutical industry has become so controversial that the National Institutes of Health recently proposed new restrictions on its employees’ financial relations with drug companies. According to a mid-July report in Mental Health Weekly, NIH employees would be limited to no more than 400 hours of outside work with payments equal to no more than 25% of base pay. Much of this outside employment and consulting has been on the payroll of the pharmaceutical industry. If this is a new NIH limit, imagine the extent of prior drug company direct financial influence.
Allen Jones not only investigated the conflict of interest of Pennsylvania officials but also pointed out that the companies that funded the start up of the Texas project were big contributors to Bush's reelection campaign. In addition, some members of the New Freedom Commission have served on advisory boards for these same companies, while others have direct ties to the Texas Medication Algorithm Project.
According to a May 2004 New York Times report, drug companies are using new strategies to capture the government's lucrative Medicaid and Medicare markets that involved a “focus on a much smaller group of customers: state officials who oversee treatment for many people with serious mental illness. Those patients -- in mental hospitals, at mental health clinics and on Medicaid -- make states among the largest buyers of antipsychotic drugs. For Big Pharma, success in the halls of Congress has required a different set of marketing tactics.” And for the states, increased spending on psychiatric medications is one of the biggest drivers for the current fiscal crisis that is resulting in the denial of care to Medicaid recipients and the uninsured.
Psychiatric medications are essential to the recovery of many people with mental illness, but they are not without risk. The dramatic increase in the use of medications in the treatment of children has given rise to questions about safety, effectiveness, and the “off-label” use of drugs without adequate age-specific scientific research. The role that antidepressants might play in adolescent suicide has recently made headlines in Britain and the US. There is also mounting evidence of the serious and even lethal health effects of the new antipsychotic medications -- including diabetes, serious weight gain, and heart arrhythmias.
While these medications may help people with mental illness live meaningful lives, the scientific verdict is not in on some of the newer drugs. What we do know is that these new psychiatric drugs consume a huge share of the public health care dollar -- often at the expense of other services. Political influence and big money make scary bedfellows when questions of health are in the balance.
During the past year a number of federal agencies have been developing policy initiatives and restructuring funding incentives to promote the Commission's recommendations. In January, the new Congress is expected to consider related funding increases. Although mental illnesses remain four of the top ten causes of disability in the US according to the World Health Organization, it is unclear whether Congress will move beyond lip service and address our national crisis in mental health.
According to a recent Bazelon Center Mental Health Policy Report, President Bush, rather than actively supporting his Commission's recommendations, had actually “proposed cuts in his... 2004 budget to the jail diversion grants program ($7 million) and the seniors mental health program ($5 million)” -- two areas of critical need according to the New Freedom Commission.
Mental illness is not a Republican or Democratic issue. And while there are specific grant initiatives that will be dealt with by Congress, no comprehensive legislative package is “being proposed at this time,” Leah Young, Director of Media Services at SAMHSA (Substance Abuse and Mental Health Services Administration), told me in a telephone interview earlier this fall. “There will be a report, a roadmap” that will be issued later this year that will discuss “where we are going from here,” she said.
This article was written with the assistance of my wife, Gale Bataille, the Director of Mental Health for Northern California's San Mateo County.
Bill Berkowitz is a longtime observer of the conservative movement. His WorkingForChange.com column Conservative Watch documents the strategies, players, institutions, victories and defeats of the American Right.
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