Overdosed!




I

n
October 2003, Rep. Grace Napolitano (D-CA) introduced House Concurrent
Resolution 292, which expressed “the sense of Congress 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
wasn’t accepted, when the new Congress convenes it will likely
take up the issue once again. When it does, expect an unusually
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- 1970s. 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 July 2003 in a report
entitled “Achieving the Promise: Transforming Mental Health
Care in America.” 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 that 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 “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 (decision systems) 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. Launch- ed 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 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’s removal from the investigation is now under FBI examination. 


In
his report, posted on the website 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”
(www. psychrights.org). 


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 percent 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 Medi-
caid and Medicare markets that involve 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.” 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 recip-
ients 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 U.S. There is also mounting
evidence of the serious and even lethal health effects of the new
anti-psychotic 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
U.S., 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. 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.



 





Bill Berkowitz
is a freelance writer covering conservative politics. This article
was written with the assistance of Gale Bataille, director of Mental
Health for Northern California’s San Mateo County.