Serious Mental Illness: A New Block Grant Priority
Mental health treatment practitioners have, over the years, observed that most individuals who have a serious mental illness (such as bipolar disorder, major depression, and schizophrenia) typically experience the first signs of illness during adolescence or early adulthood. Yet there are often long intervals between the onset of symptoms and diagnosis, referral, and treatment. In response, Congress has directed SAMHSA to require that states set aside 5 percent of their Community Mental Health Services Block Grant to address these needs.
The new set-aside is one of many new components included in Congressional budget appropriations for Fiscal Year 2014. The effort aims to support “evidence-based programs that address the needs of individuals with early serious mental illness, including psychotic disorders.”
Early intervention strategies are seen as increasingly important because they reduce the likelihood of long-term disability that people with severe mental illness often experience. The goal is to help these individuals lead fulfilling, independent, and productive lives, reduce the crises that may accompany more advanced mental illness, and ultimately reduce the financial burden on public systems.
For example, a first-break of serious mental illness in adolescence could cause disruptions in school, strained friendships and other relationships, and isolation. If this episode is left unaddressed, academic and professional careers could be delayed, independence could be hard to achieve, and recovery may remain elusive. With the implementation of early intervention strategies, mental health concerns can be identified earlier and supportive treatment can be made available. For a young adult, this not only helps them to keep their lives on track, but makes it possible to maintain supportive relationships while avoiding health risk behaviors like self-injury.
The Mental Health Services Block Grant is allocated to states and jurisdictions to support community-based mental health programs. SAMHSA also administers the Substance Abuse Prevention and Treatment Block Grant. Together, these block grants are used by states to provide prevention, treatment, and recovery support programs that supplement Medicaid, Medicare, and private insurance. Both block grants contain specific congressionally guided set-asides that target specific subpopulations or types of service. Those receiving block grants are required to expend and report on the portion of funds that meets or exceeds the amount of the set-aside.
Recognizing that similar first episode psychosis treatment programs have been effectively used in Australia, Canada, and the United Kingdom, Congress directed the National Institute of Mental Health (NIMH) to assist SAMHSA in in identifying evidence-based treatment models to present to states. The new five percent set-aside in the Mental Health Services Block Grant is designed to help states integrate these models so that early identification and support can take place.
Block grant recipients are required to use the set-aside funds to establish or expand evidence-based treatments. The evidence-based interventions focus on adolescents and young adults (ages 15 to 30) who have experienced an onset of psychotic symptoms during the past three years or less.
Results from the NIMH-funded research initiative, Recovery After an Initial Schizophrenia Episode (RAISE), suggest that mental health providers in a variety of disciplines can learn and adopt the components of coordinated specialty care to engage and treat persons in the early stages of psychotic illness. “Coordinated Specialty Care” (CSC) is a model treatment program designed primarily for adolescents and young adults, and it encompasses a team-based, multi-component approach to diagnosing and treating first episode psychosis. CSC consists of assertive case management, individual or group psychotherapy, supported employment and education services, family education and support, and possibly low doses of anti-psychotic medications. These services are also closely coordinated with primary health care.
In addition, CSC embraces a recovery-oriented approach that, when appropriate, engages the individual’s close friends, family members, or peer supports as active participants. The model program creates an effective therapeutic alliance that permits the individual to engage in day-to-day activities as quickly as possible.
OnTrackNY, one of several SAMHSA-funded state model programs, developed by the New York State Psychiatric Institute at Columbia University, is a program that works with individuals between the ages of 16 and 30 who recently reported experiencing psychotic symptoms. The program’s foundation is a shared decision-making approach in which individuals work actively with the treatment team to identify goals for employment, school, and inter-personal relationships. In keeping with the CSC model, OnTrackNY includes the components of cognitive-behavioral approaches, integrated treatment for mental health and substance use problems, and family education and support, among others.
Implications for States
Under the new set-aside, states and jurisdictions were required to revise their two-year block grant plans to include a proposed approach to addressing early serious mental illness(es) and a description of how funding will be used to support appropriate evidence-based services. States may have enhanced existing programs, or developed a new demonstration program if no CSC services currently exist. The state plan will required a needs assessment that documents why a particular target population has been chosen, what the planned activities are, and the proposed budget.
States may also use the new set-aside funds to build capacity for offering specialty care services. These services may include extending community outreach beyond emergency care services; expanding the number of specialty programs; establishing referral mechanisms with primary care physicians, schools, and child welfare agencies; including public education efforts, and instituting in-state trainings.
Webinars were held earlier this year and provide an overview of evidence-based approaches to treatment for individuals for first episode psychosis.