New SAMHSA Head Sees Promise in Public-Health Model

When Terry Cline, Ph.D., talks about “ripple effects” and“ human costs” in mental health and addiction policy he refers to specific people he has seen devastated by those conditions over the years.

During recent Senate testimony, Cline, the new administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), described his agency's most pressing public-policy issues through the prism of his personal experience.

Cline began his tenure as SAMHSA administrator on January 8, after serving as Oklahoma's secretary of health.

When discussing the need for community-based health care approaches with senators at the hearing, Cline first described the children he encountered during his college years while working in a childrens' psychiatric hospital, who were still there years later when he returned as a working psychologist.

Cline's push to apply a comprehensive health care approach to those with mental illness, including addiction, was fostered by his experience with a 50-year-old woman who finally managed to gain the upper hand over a mental illness shortly before she died of a heart attack.

Likewise, Cline discussed the need for more evidence-based suicide prevention efforts in the context of Americans dying annually in numbers that would have wiped out the Oklahoma town of 25,000 in which he grew up.

“I saw in the private and public-health sectors in Oklahoma what happens when we're not able to get the services to the people who need them,” Cline said.

Since becoming SAMHSA administrator Cline has sought to expand many programs he found helpful and effective as Oklahoma's secretary of health.

For example, his experience implementing Mental Health Transformation State Incentive Grants in Oklahoma—one of the first seven states to receive them—convinced him of the benefits of the program. The program helps states develop a comprehensive mental health plan and improve their service infrastructure and rewards them for concrete steps, such as expanded use of evidence-based practices and improved access to care through technology.

The latest evidence to support an increased federal role in mental health and addiction services, Cline said, is a recent Department of Health and Human Services survey that found a quarter of adult hospital stays involved a mental illness or substance-use problem.

Cline promoted a “public-health model” to Congress as a guide to future SAMHSA funding, which provides “a continuum of services that focus on an entire population rather than on individuals with individual illnesses.” The continuum starts with an assessment of the types and extent of mental health and substance use needs and continues through population-based research on addressing those needs and identifying policies and practices that promote recovery.

The public-health approach can help overcome the divisions between mental health and other types of health care, in which health professionals in each area fail to consider the areas of the patient's health outside their“ narrowly focused” responsibility, Cline said.

“If you have a relationship with a patient and are already providing care, it's a great opportunity to expand that care or to make sure they get the needed care elsewhere,” Cline said, about the comprehensive approach he advocates. “We've seen it work for other illness categories, and we know it works with mental illness.”

Such a quality-based approach aims to make sure those with substance abuse or mental health disorders not only get treatment but also become employed, connect with family members, and avoid incarceration.

Cline noted that SAMHSA's efforts to have all states collect and submit detailed information on the number and location of people who need either mental health or substance abuse assistance—information needed to make any national public-health model succeed—remains incomplete because some states “have struggled to collect the data.” However, he plans to push for completion of the data-collection effort.

Because data are the keys to comprehensive care, Cline said he will push the agency to continue development of an electronic health record that would be available to psychiatrists and mental health professionals, including those who treat substance abusers. Preliminary work on such records has begun but several issues, including ones regarding privacy of the records, remain unresolved.

SAMHSA under Cline also will expand its outreach to veterans. In recent months, the agency met separately with state mental health directors and officials from the Department of Defense and Department of Veterans Affairs to discuss ways SAMHSA can help returning combat veterans with posttraumatic stress disorder and other conditions. Their effort has so far resulted in development of an antistigma campaign that encourages former members of the military to seek help or get their friends and family members to health professionals when the warning signs of mental illness or substance abuse appear.

Although Cline came to SAMHSA well after its Hurricane Katrina response, he said the agency is still looking for ways to improve its response to future disasters. One lesson learned by SAMHSA officials was that disasters can ripple across many states, so they continue to coordinate interstate planning efforts. SAMHSA also is considering ways to compensate for the unanticipated flight of physicians and health care professionals from areas struck by disaster, he said. Leaders at SAMHSA sent every available health care worker they had to the Gulf region, but the need far exceeded the agency's personnel resources. ▪