At the Missouri's state mental health Transformation Implementation Kick-off in Jefferson City Joel Slack President of Respect International described his own psychotic break during college and his life history following that event. It is a remarkable story. Through his experiences he realized that respect for yourself, which is realized by treating others with respect and being treated with respect by others, is the basis of mental health.

Joel now leads "Respect" seminars world wide and the respect seminar will be available to the citizens of Missouri as part of our new transformation.

As I listened to his stories I reflected on some of those in the past who have made exactly this same point.

"We are all much more simply human than otherwise."
Harry Stack Sullivan

"Act to bring out the best in others so that you can bring out the best in yourself."
Felix Adler

---- update ----

Joel will be presenting a free workshop in Jefferson City 1-5 p.m. Tuesday, May 13 at First Assembly of God Church, 1900 Highway C, Jefferson City, MO 65109. Located at the intersection of Southwest Blvd and Hwy C, approximately one block west of the Hwy 54/Ellis Blvd Exit. "Advanced registration is suggested. To register, please provide your name, agency or affiliation (if any), e-mail (for confirmation) and if you are interested in obtaining CEUs. Phone: 573.526.3702, Toll Free: 800.364.9687, transformation@dmh.mo.gov"

As I was using Gmail this morning I noticed the new feature notification for "Custom Time." Opening the link I found that Gmail had added the ability to alter the sent time header on an email message.

-

This seemed a bit strange (e.g., using an e-flux capacitor - but geeks are fond of borrowing terms from SI-FI for their new inventions). Besides, the Google folks are always ones for creating things outside of the box. Finally, after reading and closing the page I realized what this was all about - 1-Apr! Perhaps I would have been faster if they had not used the calendar image for 31-Mar.

Great job guys. You brought a smile to my lips this morning.

According to this NY Times article bad guys can get encrypted data out your computer by reading keys from the DRAM chips. This original report demonstrated that decryption data does remain in these dynamic chips for some time after the computer has been turned off and that chilling those chips will extend that period of time.

So what does this mean practically? Perhaps there are other ways, but off hand what I can envision is:

You are rushed by bad guys (take for example Jack Bauer) while you are using the computer and reading your encrypted data. You quickly unplug it but your assailants are able to open the computer and chill the chips before they loose their stored information.

It seems to me that in this case you are in trouble no matter what. So, unless there is some other way this might work I am not going to worry about it.

I am back from attending the National Association of State Mental Health Program Directors NASMHPD Research Institute's18th annual conference of State Mental Health Agency Services Research, Program Evaluation and Policy in Arlington VA. I posted notes on all of the presentations that I attended so you can read about those as you like. They also promised to have slides available on their web site so you can get more detail as well (the abstracts are already available from the link above).

NRI was interested in getting more participation from research institutes like MIMH and offered us an all expenses paid trip to the meeting (as well as individuals from two other Institutes). As the newest Division Director at the Institute I got asked to attend. While NRI paid my way they did not ask me to write about the experience and they may have never even considered that someone would blog their conference. So the comments (and errors in those comments) in this and the other posts from the meeting are my own.

It was interesting that while NRI paid for our attendance, they made no efforts during the meetings to meet me (or I presume the other research institute attendees) or to have us meet together to explore their goals for our participation. While I was exhausted from the rounds of presentations this seems like a missed opportunity that I suggest they address if they do this again.

When I first looked at the two and a half day program there was lots of stuff that seemed of interest. After all, I have been working in public mental health for over 25 years so how could presentations for the NRI be uninteresting. The night before I read the abstracts and plotted out my selections. However, I was beginning to get cool feet and felt that I might be in for the usual sort of conference "fluff" that was long on flash and short on substance. One of the reasons for this is that a couple of the presentations were reporting anew the same sort of work I had read 25 years ago.

Well I was wrong. The presentations were anything but fluff. They were solid, data supported, presentations that showed states effectively using information to make changes to improve the lives of their citizens. Outstanding!

I have always been an "L" and believe that government could (and should) be a source of help for those in need. As a single individual I cannot have much impact of the mental health needs of my fellows. But as a member of a community, which is what a state represents, our united efforts and dollars can have a positive impact. Those attitudes have taken a beating in recent years, but the programs presented at this conference and the states hosting them have shown this can be true. They have helped excite me and restore my belief in the power of the community, as represented  by our governments, to be a positive force in the lives of those in need.

To me, this is great outcome and well worth my time and effort. Thanks for the invitation, I'll be back!

To make it easier to find them, here are the available posts:

• NRI - Better but not well
• NRI - Learning Collaboratives in New York
• NRI - Chronic Medial Disorders with SMI
• NRI - Behavioral health assessment system
• NRI - Collaborative Research
• NRI - Improving data
• NRI - PTSD
• NRI - NOMs and TRAC data systems
• NRI - Enhancing mental health treatment effectiveness
• NRI - Grading the states
• NRI - Describing state mental health agencies
• NRI - Evidence based practice in practice

From NRI's State Mental Health Agency Services Research, Program Evaluation and Policy in DC, PTSD Then and Now, There and Here, Robert J. Ursano, MD, Director, Center for the Study of Traumatic Stress www.usuhs.mil/csts.

Robert Glover (Ex Dir., NASMHPD) introduction. NASMHPD has been focusing on this at a high level and considers it a serious problem. Concerned about suicide prevention particularly with returning National Guard and reservists. 1-800-273-talk (www.shicidepreventionlifeline.org) suicide prevention lifeline which has access to military. On last Saturday 238 vets called the line for help!

"Trauma is bad for your health" and "War is a trauma."

Hospitalizations in the DoD for trauma are second only to those for pregnancy.

Trauma associated with death is important for some individuals but trauma associated with separation and return is the common event for all service personnel.

War is an intentional and human made traumatic event the combination of which create the most trauma. 1.5 million Americans have returned from Iraq or Afghanistan (300,000/state; 1,500-6,000 cases of PTSD/Depression per state). Because combat is an ongoing traumatic event it is harder to treat and does not respond as readily to medications.

Of the vets who have problems only 20% actually get specialized MH treatment. If you have PTSD you are likely to fear admitting the problem or getting service because it would negatively impact your career. This is no different from the risks people in the general population feel.

PTSD treatment (for all individuals) often does not begin for 12 years after the events. Even then only 65% actually get treatment. PTSD seems to increase over the course of time with injured solders having 12% PTSD and 9% depression after 7 months.

From NRI's State Mental Health Agency Services Research, Program Evaluation and Policy in DC two presentations on the implementation of evidence based practices.

Linking Outcomes to Services: Using Montana's Recovery Markers for Program Development and System Change, Alison Hwong & Bobbi Renner.

Fourth largest state but a rural frontier population with 12 Native American tribes and seven reservations. They have developed a web based system to measure their outcomes.

Four recovery markers are used

1. Employment status,
2. housing,
3. level of symptom interference, and
4. substance use.

which are collected every 3 months. The Information system also links to pharmacy data, demographic, diagnosis, functioning, living status, and service provides. Will be able to link to the medicare/medicaid data.

[The nice thing about the markers is that they are typically single items with a few categories. This will be simple for users to enter and conceptualize, though psychometrically weak. Their simplicity may also lead to system gaming.]

Problems with implementation

• Lack of computer experienced (one user called reporting a strange moving line on their screen. After a bit of description it turned out to be the cursor.)
• Communication problems between users and computer professionals
• Art vs. science [practitioners think about treatment as a holistic interpersonal enterprise while computer folks are interested in the change in recovery markers]
• providers say they were required to enter to much information without additional compensation (advocacy groups wanted more information)
• maintenance level
• providers felt that the information collected "will never be useful to us"

[The implementation issues discussed in this presentation are exactly the same as those addressed during the early days of computer applications in mental health. Why is it we keep rediscovering the same facts over and over? Why have the folks who develop these systems not been taught the lessons we have learned?]

Ohio's Wellness Management and Recovery Program: Working Collaboratively to Develop, Implement and Evaluate a Statewide Recovery Initiative, Marion Becker, Airia Sasser, Timothy Boaz, Amber Gum, Wesley Bullock, Kelly Wesp, Deborah Wilcox, & Stephanie Rich. www.wmrohio,org 

Participants develop a wellness plan using a psycho educational (social learning model) curriculum with role plays, video, lots of interactive content. Trainers are pairs one consumer and one staff. Doing a rigorous evaluation because they want it to be an evidence based practice.

Session topics (10 2-hour sessions)

1. Mental Health recovery
2. Wellness
3. Understanding of Mental health
4. role of Medication in recovery and wellness
5. Learning to manage symptoms and side effects
6. Effective communication
7. communicating with your providers
8. Coordinating your care
9. Building social supports and involving others
10. Planning for wellness.

Lots of focus on learning new skills.

Have moved from systems data to individualized data. Asking each consumer what they want to achieve. Steve will provide these on request.

[This is a really nice idea and one that I have been advocating for a number of years. If an individual's services are being directed to areas A, D, and E why would we bother assessing changes in areas B, and F? While this makes sense to evaluators this does not seem to be clinically reasonable. With our advanced statistical and data management techniques we should be able to define specific outcomes for specific individuals rather than assuming everyone is the same.]

From NRI's State Mental Health Agency Services Research, Program Evaluation and Policy in DC, Understanding State Mental Health Agencies, Ted Lutterman & Bernadette Phelan  (NRI).

State mental health agencies

Agencies provide services, public health, and public safety.

There has been a shifts in organization with reductions in the number of states with a separate department (19-13 1981-2007) and fewer linked directly to the governor. This is important because the closer to the governor the more resources are available.

Most states (26) have MH and ADA in the same agency. This has increased since the 80s. Most directly fund agencies (28) but many fund counties/cities (16) which adds another level of government to the provision of services.

In 1954 there wee 354 state hospitals with 550,000 residents. In 2007, 228 hospitals with 50,000 residents. The size of hospitals dropped in the 60s and 70s but hospitals themselves did not start closing in large numbers until the 90s.

In 1979 1 our of 3 hospital beds were psychiatric. In 2007 1 out of 7 is psychiatric. These decreases have lead to shortages of acute psychiatric inpatient capacity with increase ED treatment, long treatment waits, overcrowding, etc. States have been addressing this by trying to increase programs to keep folks in the community.

Many states are working to decrease service fragmentation by working with various other state agencies (housing, employment, juvenile and criminal justice, etc.

Most states have mental health courts or diversion programs (43).

Public mental health agencies treat 2% of the population with 96% of those being treated in the community. Almost half of these are not in the workforce and most live in private residence (76%). Most of those (75%) treated are seriously mentally ill.

Over time there has been no improvement in terms other the number who return to the hospital within 30 days (9%) or after 189 days (20%). [Interesting that with the increases in treatment effectiveness that this has not changes. Though it may be related to the fact the the number of individual served has decreased so that those in the hospital will likely have more difficulties.]

There has been a shift in funding from state funds to medicaid. with 45% currently coming from the latter.

Other state agencies

MH services are also provided by other state agencies. NRI is looking to see if they can get information from these other agencies so that they can better understand what states are doing for mental health. Sending letters from the state MH agencies and identifying where they can find the answers to the questions.

NRI has no data to report because they need to get the appropriate clearances (will report at the next year's conference).

While the states and agencies are interested in this there are challenges in getting the data. Agencies may not record data in an obvious way. For example states working with education counted all of the $s spent on special education as mental health services.

Note that all of the data they report is publicly available.

From NRI's State Mental Health Agency Services Research, Program Evaluation and Policy in DC, Grading the States: Assessing State Mental Health Systems, Michael Fitzpatrick & Laudan Aron (NAMI) www.nami.ogg/grades

NAMHI ad ranked states previously but decided grades would be fairer to the states. They also offered suggestions of ways to move from a lower to a higher grade in each area. The report is aligned it with the President's New Freedom Commission recommendations and the transformational language it embodies. Will be doing this biannually with hopes of doing it annually.

In the 2006 report the national average D

Positive trends

• Increase focus on evidence based services
• more consumer/family involvement
• increased linkages to other departments and partners
• 'pockets of innovation in virtually every state, even those receiving an "F"'

Negative trends

• Budget cuts or flat funding
• Medicaid changes (e.g., eligibility, cost-sharing)
• Shortage of inpatient beds
• Cost shifting to other systems
• Long waiting lists for community services

They are now working on the 2008 survey trying to refine the methodology and gather information from additional systematic databases. The presenters took a lot of feedback and welcomed more. So if you have suggestions about how to improve their methodology shoot them an email.

From NRI's State Mental Health Agency Services Research, Program Evaluation and Policy in DC, Enhancing the Clinical Effectiveness of Mental Health Treatments: Research to Improve Practice & Inform Policy, Philip Wang, (NIMH).

What are the unmet needs

• Mental health treatment seeking is very slow 10-30 years
• About 41% needing care receive it.
• The sorts of treatments being received are sub optimal
• For people with SMI only 20% re receiving minimally acceptable care

How to improve effectiveness (innovation and enhancement)

• Because the cost of genetic typing costs have dropped so much we can use that information to identify diseases with specific genetic locations
• Increase potential for more personalized treatments
• If the Quality adjusted year costs are$50k or less it would be appropriate to do these procedures. This is because dialysis costs this much and the government is willing to pay for that treatment.
• There is an increasing use in new medications (even before comparative studies) which has resulted in rapidly increasing costs.
• States are spending a large percentage of their mediation budgets on atypical antipsychotics event thought do not know if this is appropriate or not.
• While there is a lot of money being spent on healthcare there is no evidence that this improves health outcomes. [Suggested that this means we need more effective treatments. What it really means is that we are leaking money in our systems which are not as efficient other nations.]
• Use real use data
• use quasi-experimental studies
• Use simulations to create studies

From NRI's State Mental Health Agency Services Research, Program Evaluation and Policy in DC two presentations about new data systems NOMs and TRAC.

Are We Ready for the NOMS?, Mark Reynolds and Tracy Leeper (OK). http://www.odmhsas.org/nri

Spent a lot of effort collecting data and using it but never sent it back to the providers. National Outcomes Measures. Web based fee for service model which requires good admission data to stat billing.

Their admission-discharge data did not show much improvement. This is because the discharge data is never updated providers simply carry data over from the admission.

Changes to address this problem

• 6 month updates
• after 6 months of no service unplanned discharge (this will attract the agency's attention as they get dinged for this difficulty).
• clinician of record for each client and their performance will be tracked
• required very few data elements (6) for an update

They provide a very nice set of reports for the agencies. Go to agencies and talk with clinicians about the data that they are providing. They also train their own staff how to understand the data and reports. 

TRansformation ACcountability (TRAC): A Coordinated Approach to Performance Measurement by the Center for Mental Health Services, Diane Abbate and Jessica Taylor. https://www.samhsa-gpra.samhsa.gov/home/index.htm

Performance management and outcomes systems for all CMHS programs (PRNS, CMHI, PATH, PAIMI). Needed to meet SAMHSA data reporting requirements with standardized measures and accountable. TRAC is basically reporting the NOMs (service) data. Data is collected at baseline, reassessment (6 or 3 months), and discharge. They are collecting client level data though it is deidentified. There is no mechanism for uploading data require the individual data to be entered one at a time.