News and Notes

Final IOM report on DoD and VA programs for PTSD: In 2010, Congress directed the Department of Defense (DoD) and the Department of Veterans Affairs (VA) to assess prevention and treatment programs for posttraumatic stress disorder (PTSD) offered to military and veteran populations. Recently released by the Institute of Medicine (IOM), the 284-page assessment notes that both DoD and VA “have made a sustained commitment to PTSD management and invested substantial financial and programmatic resources to provide care to service members and veterans. However, a lack of standards, reporting, and evaluation significantly compromises these efforts. The departments often do not know what treatments patients receive or whether treatments are evidence based, delivered by trained providers, cost-effective, or successful in improving PTSD symptoms.” The need for centralized oversight is a critical issue described in the report. Although some programs are under the authority of the DoD central office, others are dispersed across service branches and installation and medical commands. In VA, policy and oversight are managed by the central office, but regional and local authorities have responsibility for operations and service innovations. Neither DoD nor VA has a mechanism for the systematic collection, analysis, and dissemination of outcome and cost data for assessing the quality of PTSD care. As the report notes, both DoD and VA have expanded their mental health workforce to broaden access, often by use of “purchased care providers.” However, the report raised questions about these providers’ adherence to VA/DoD PTSD practice guidelines. The report ends with eight recommendations, including mandating use of best and evidence-based practices, implementing a measurement-based PTSD management system, and establishing a central database of programs and services. The report is available on the IOM Web site at www.iom.edu/reports.

SAMHSA's Treatment Improvement Protocol on FASD: Fetal alcohol spectrum disorders (FASD) is an umbrella term for a range of potentially lifelong behavioral, physical, and psychological effects that can occur when a fetus is exposed to alcohol. Some researchers suggest that there may be as many as 200,000 new cases of FASD in the United States each year. FASD is the subject of the latest addition to the Treatment Improvement Protocol (TIP) series published since 1993 by the Substance Abuse and Mental Health Services Administration (SAMHSA). Part 1 of the 198-page TIP focuses on screening women of childbearing age for at-risk alcohol consumption and outlines basic interventions that can help women reduce or eliminate alcohol consumption. Part 2 outlines a process for recognizing individuals in treatment who have or may have a FASD and modifying treatment to improve outcomes and meet their unique needs. A section for administrators examines cost and implementation factors of adding or expanding FASD-related services in a treatment setting. The 58th TIP, Addressing Fetal Alcohol Spectrum Disorders (FASD), was developed through a collaborative effort with key federal agencies and FASD-related organizations, including the Centers for Disease Control and Prevention, the Indian Health Service, the National Institute on Alcohol Abuse and Alcoholism, the National Organization on Fetal Alcohol Syndrome, and the Washington State FAS Diagnostic and Prevention Network. SAMHSA established the FASD Center for Excellence in 2001 to help increase the quality of services available to at-risk women and to individuals who have an FASD. The TIP is available at no cost from the SAMHSA Store at store.samhsa.gov/home.

ACLU and Bazelon Center's road map for diversion programs: In June 2014, the U.S. Department of Justice (DOJ) found that Los Angeles County violates the constitutional rights of inmates by failing to provide adequate mental health care and appropriate suicide prevention policies. DOJ encouraged efforts to expand diversion programs for these inmates. In July, the American Civil Liberties Union (ACLU) of Southern California and the Bazelon Center for Mental Health Law jointly released a report that makes recommendations for diversion programs for inmates with mental illness charged with nonviolent offenses in LA County jails. The report describes LA County’s jail system as “the nation’s largest psychiatric institution,” housing an estimated 3,200 inmates with severe mental illnesses on any given day. Ninety-five percent of the inmates with mental illness have offended before, and many cycle in and out of LA County jails. The 20-page report, A Way Forward, emphasizes that the county “does not have to reinvent the wheel” to create effective programs, pointing to an array of community-based programs that already provide services to this population and describing how diversion would save the county money by reducing capital expenses on jail construction, shifting some costs to the federal government, and taking advantage of “realignment money” available from the state. The report presents “diversion success stories,” including descriptions of programs in Miami–Dade County and San Francisco County. The proposed programs for LA County would direct nonviolent offenders with mental illness to community-based programs that combine treatment with supportive housing, medication management, and employment assistance. The report and related materials are available on the ACLU Web site at www.aclusocal.org/awayforward/main.

NRRC highlights eight states’ efforts to reduce recidivism: For many years, keeping people who committed crimes behind bars was seen as the best way to ensure public safety. But this mindset has shifted as research has shown that certain programs and approaches to supervision can change some people’s criminal behaviors. Encouraged by these positive outcomes, Congress passed the Second Chance Act in 2008, which established grant programs to stimulate further innovation at the state and local levels. A new report from the National Reentry Resource Center (NRRC), In Reducing Recidivism: States Deliver Results, highlights eight states that have achieved reductions in statewide recidivism in recent years: Colorado, Connecticut, Georgia, North Carolina, Pennsylvania, Rhode Island, South Carolina, and Wisconsin. The report focuses on statewide recidivism data for adults released in 2007 and 2010, with a three-year follow-up period, and offers a snapshot of current criminal justice outcomes. Reductions in recidivism rates ranged from 5.8% in Colorado to 19.3% in North Carolina. The report also highlights successful strategies cited by officials in the eight states, such as the Ten Step Framework developed by the Georgia Department of Corrections for revamping community supervision through the use of risk assessments; targeted, evidence-based interventions and community impact programs; and swift and proportionate sanctions and incentives. The 24-page report is available on the Council of State Governments Justice Center Web site at csgjusticecenter.org/reentry/publications/reducing-recidivism-states-deliver-results.

OECD publication on the high cost of untreated mental illness: A new publication from the Organization for Economic Co-operation and Development (OECD), Making Mental Health Count: The Social and Economic Costs of Neglecting Mental Health Care, examines mental disorders and mental health systems across its 34 member countries, pointing out that despite growing evidence of the enormous burden of mental illness, particularly in terms of workforce productivity, mental health care is still not a priority in these countries’ health systems. Although most OECD member countries have made great strides in deinstitutionalizing care, few can reliably measure the resources that they devote to mental health care and therefore cannot quantify costs. Also, a lack of outcome data prevents full assessment of quality and performance, according to the report. A separate chapter devoted to advancing the organization, payment, and integration of care for people with severe mental illness describes the need to move toward a payment system that spans care settings and provides greater incentives for care coordination, with examples of innovative approaches in Australia and the Netherlands. The final chapter of the 243-page report, “Good Governance for Better Mental Health,” identifies the roles that mental health stakeholders are playing in OECD countries, describes how countries are using mental health legal frameworks and strategies to address challenges, and offers a wide range of positive examples that can serve as starting points for efforts in other countries. The report is available on the OECD Web site at www.oecd-ilibrary.org.

KFF issue brief highlights continued reach of Olmstead decision: June 2014 marked the 15th anniversary of the Supreme Court’s Olmstead decision, which found that the unjustified institutionalization of people with disabilities constitutes illegal discrimination under the Americans with Disabilities Act (ADA). A 16-page issue brief from the Kaiser Family Foundation (KFF) examines the Olmstead case and its legacy, with an emphasis on legal case developments and policy trends in the past five years and related contributions of the Medicaid program. Several themes emerging from recent Olmstead cases highlight Medicaid’s role, such as in providing community-based services to prevent institutionalization, providing services in the most integrated setting to enable people with disabilities to interact with nondisabled peers to the fullest extent possible, replacing sheltered workshops with supported employment, and eliminating disability-based discrimination in the Medicaid program. Examples of court cases in several states illustrate how the lower courts and the U.S. Department of Justice have used the power of Olmstead and the ADA to improve care for people with psychiatric disabilities. The brief also identifies “issues to watch” as Olmstead implementation proceeds. Olmstead’s Role in Community Integration for People With Disabilities Under Medicaid: 15 Years After the Supreme Court’s Olmstead Decision is available on the KFF Web site at www.kff.medicaid.

KFF survey on health exchanges and the uninsured: A Kaiser Family Foundation (KFF) survey found that nearly six of every ten people (57%) who purchased health insurance through the Affordable Care Act's (ACA’s) new exchanges had been uninsured just prior to obtaining coverage. Survey responses indicated that most had been without coverage for at least two years. Seven in ten (72%) respondents said that they decided to buy their own health insurance because of the ACA. Most gave positive ratings to their new insurance plans, but four in ten found it difficult to afford their monthly premium. Half got help with enrollment, and most said the shopping process was easy. However, 35% of enrollees in states using Healthcare.gov and 30% of those in states with their own exchange Web sites said that it was at least somewhat difficult to set up an account. The survey was conducted by telephone from April 3 through May 11, 2014, with a nationally representative random sample of 742 adults who purchased their own insurance. Computer-assisted telephone interviews were conducted by landline (N=333) and cell phone (N=409, including 219 who had no landline) in English and Spanish. Exchanges, along with expanded eligibility in Medicaid, are the primary mechanism for reducing the number of uninsured Americans under the ACA. Other results of the survey are on the Kaiser Web site at kff.org/health-reform.