SAMHSA National Policy Lab Rethinking NREPP- Advocates Pay Attention!

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Last Thursday, at 2:05 pm, a research scientist colleague of mine received an email from the contractor who manages the SAMHSA National Registry of Evidence-based Programs and Practices (NREPP). The email was direct and to the point. It read:

nrepp

NREPP, as described on the SAMHSA website, “is an evidence-based repository and review system designed to provide the public with reliable information on mental health and substance use interventions. All interventions in the registry have met NREPP's minimum requirements for review. The programs' effects on individual outcomes have been independently rated by certified NREPP reviewers.”

Getting a program or therapeutic approach to be recognized as an evidence-based practice on NREPP means that, in effect, you have SAMHSA’s approval that this is a recognized evidence-based practice. Mental health evaluators and program developers across the nation have come to rely on NREPP as a “go to source” when making decisions about which treatment strategies to use in their work.

So you can imagine the shock and surprise to program developers across the nation when getting a notice such as this, effectively telling them that the program or therapeutic approach they had been working so hard to get NREPP approval for would now no longer be reviewed.

After the notice went out, I began receiving calls and emails asking what the heck was going on. Was this the end of NREPP? Was SAMHSA moving away from evidence-based practice? Recent articles in the news about HHS encouraging the non-use of words such as evidence-based practice, diversity, transgender, etc., have had many in the mental health community on edge. Was this another step in that direction? And most important for program developers in the midst of NREPP review – What would happen to them? Would the reviews of their work continue or would they just stop?

Is NREPP Being Canceled? The Short Answer
The short answer is no, NREPP is not being canceled, per se. (There is a longer, more complicated answer. But let’s address the short answer first. It is so much easier!)

I spoke with a representative from SAMHSA about the email from the NREPP contractor that went out to program developers involved with NREPP notifying them of the termination of the contract. The representative was most helpful in clarifying that SAMHSA’s commitment to evidence-based practice had not changed, but that SAMHSA was re-evaluating the program, and that the overall program would now fall under the domain of the newly created National Mental Health and Substance Use Policy Lab (Policy Lab). At this point, the Policy Lab team is not yet in place, though a Director, Christopher M. Jones, PharmD., M.P.H., has been hired. As well, SAMHSA is working on an answer to the question of what happens to those programs currently in the review process. So a lot of "wait and see" while SAMHSA gets the Policy Lab set up. The representative from SAMHSA wrote:

"Although the current NREPP contract has been discontinued, SAMHSA is very focused on the development and implementation of evidence-based programs in communities across the nation.  SAMHSA’s Policy Lab will lead the effort to reconfigure its approach to identifying and disseminating evidence-based practice and programs."

What we can glean from this response is that SAMHSA is not moving away from evidence-based practice and programs, but they are most definitely going to reevaluate what that should look like. The SAMHSA representative assured me that the website is not going away anytime soon. However, decisions about the website (what it looks like, what is included, etc.) will be decided by the Policy Lab. At this point, there are no defined timelines for how or when these changes will roll out.

Sources informed me (after my conversation with SAMHSA representatives) that the NREPP website has been “frozen” since September 2017. Between then and now, close to ninety programs that have been reviewed and rated are not being allowed to be posted. I have not been able to independently verify this, but if it is accurate, it is chilling. Why would the website be frozen? What does that mean for the programs that have been reviewed and rated and are awaiting inclusion in the registry since September 2017?

Is NREPP Being Canceled? The Long Answer - Still No, but with a Twist
First, let’s revisit history. Way back in 2013, when then-Representative Tim Murphy was leading the charge to get the Helping Families in Mental Health Crisis Act through the House, he led a sustained campaign railing against SAMHSA, and specifically then Administrator, Pamela Hyde, for what he perceived as SAMHSA’s focus on soft science. The horrible massacre at Sandy Hook had sparked justified outrage and many questions about the state of the mental health system in America. Murphy seized on this, and suddenly the conversation about mental health was centered around a fuzzy, and oft ill-informed notion, of young adult mentally ill individuals who were a danger to society. The mantra became one that was continually drilled into the psyche of America, through a barrage of news editorials, that SAMHSA, as the lead mental health agency in Federal government, was overly focused on peer recovery programs and not nearly focused enough on “evidence-based” programs for addressing the treatment needs of the seriously mentally ill. At various congressional briefings, members of Murphy’s committee would openly disparage “feel good” programs, and were constantly berating Administrator Hyde for squandering money on various expenditures, often using out-of-context examples.

Did some of Murphy’s ire about perceived lack of focus on the seriously mentally ill merit attention? Of course. But the wholesale lumping of SAMHSA efforts to promote peer to peer support into a category of “wasteful” and “non-scientific” was the kind of us “good versus bad” debate that short-changed both sides and led to an “us against them” atmosphere among mental health advocates. And as we know, a divided community is a weakened community.

Murphy Inserts Proposed Structural Changes to SAMHSA in the Mental Health Bill
In a shrewd maneuver, amidst all of the public flame-throwing about guns, violence, mental illness and the need for more psychiatric beds, Murphy and his colleagues inserted three proposed structural changes to SAMHSA that would have an important impact on how SAMHSA would approach defining the criteria for evidence-based practice that would be used to award grants.

The Addition of the Assistant Secretary to the Mental Health Bill
As the openly public feud between Representative Murphy and Administrator Hyde continued, and it was clear that Administrator Hyde could give as good as she could take, the Murphy camp came up with a novel idea. Instead of spending energy on forcing Administrator Hyde to give the information they wanted or to force her out of her position, why not just create a position above her which would effectively subsume her role, making her position obsolete? Promoting the idea of an Assistant Secretary position that could coordinate efforts across federal agencies, while at the same time making the current Administrator position obsolete was a controversial stroke of pure genius. And who could argue with the expressed desire to better coordinate a federal approach to mental health and substance use across agencies? In August 2017, as a result of the passage of the CURES Act, Dr. Elinore McCantz-Katz was appointed Assistant Secretary for Mental Health and Substance Use.

The Addition of the ISMIC and Policy Lab to the Mental Health Bill 
But Murphy and his colleagues did not stop there. In addition to the proposal of the Assistant Secretary position, they added the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) and the National Mental Health and Substance Use Policy Lab (Policy Lab), further cementing significant structural changes to the way SAMHSA did its work, infusing congressional oversight into the management of SAMHSA work (in the case of the ISMICC), in ways that had not been done before. Both the ISMICC and the Policy Lab were adopted as part of the CURES Act.

All three of these structural changes to SAMHSA were conceived during a time of vitriol and polarization about what defined evidence-based practice, pitting advocates against advocates, and a congressional committee against SAMHSA. The big loser in all of the fighting was peer support, prevention services, and viewing evidence-based practice through a cultural lens. Peer support was routinely dragged through the mud, often with derogatory terms used to describe the practice, and prevention was a mere afterthought in discussions. Cultural context discussions about what worked best for different populations (i.e., practice-based evidence) was rarely, if at all, even discussed. And all three entities, in various ways, will have an important say in what defines evidence-based practice for SAMHSA.

Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC)
The Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) was created to “report to Congress and federal agencies on issues related to serious mental illness (SMI) and serious emotional disturbance (SED).” A key component of their work is the charge to make “specific recommendations for actions that agencies can take to better coordinate the administration of mental health services for adults with SMI and children with SED.” The committee was formed several months ago and has provided a preliminary report outlining their work plan for the near future.

National Mental Health and Substance Use Policy Lab
The purpose of the Policy Lab is to, among other things, “provide leadership in identifying and coordinating policies and programs, including evidence-based programs, related to mental and substance use disorders.” (42 U.S. Code § 290aa–0)

A primary focus of the Policy Lab is to “periodically review programs and activities operated by the Administration relating to the diagnosis or prevention of, treatment for, and recovery from, mental illness and substance use disorders, including identifying any such programs or activities that are duplicative and are not evidence-based, effective, or efficient.” (McCantz-Katz testimony before Congress) In addition, the Policy Lab plays the important role of working in coordination with the Assistant Secretary to “award grants to States, local governments, Indian tribes or tribal organizations (as such terms are defined in section 5304 of title 25), educational institutions, and nonprofit organizations to develop evidence-based interventions, including culturally and linguistically appropriate services, as appropriate.” 42 U.S. Code § 290aa–0 - National Mental Health and Substance Use Policy Laboratory

So let’s put it all together. The three prominent structural changes given to us via the CURES Act were the Assistant Secretary position, the ISMICC, which reports to Congress, and the Policy Lab. And the Policy Lab is a gateway to awarding grants, which makes its role as overseer of the government understanding of what defines evidence-based practice immensely important to researchers, practitioners and advocates alike.

Given that the Policy Lab, with its oversight of what will become SAMHSA’s guidance around evidence-based practice, will help drive grant award decisions, it should be one of the most important components of SAMHSA for us to pay attention to. We need to ensure that SAMHSA frames a comprehensive and culturally inclusive view of what encompasses an evidence-based practice and practice-based evidence approach. But let's not forget the ISMICC and the Assistant Secretary, who are also critically important to shaping the SAMHSA worldview about evidence-based practice. We must share our thoughts and ideas with them as well.

Here are some specific things you can do:

To those program developers and researchers who have written to me and shared your shock and dismay about the sudden announcement of the termination of the NREPP contract, I wish I could give you definitive answers to all of your questions, but the reality appears to be that SAMHSA is still working out the details. Hopefully, the context I have provided will light a fire under your advocacy core and get you involved in sharing your voice!

Please continue to send me your questions and concerns about the changes with the NREPP contract. We are in a fluid situation given that SAMHSA is just beginning to provide shape and structure to the Policy Lab. Despite my many concerns about the myriad of ways the focus of the Policy Lab could be steered in a narrow, non-inclusive way, I am hopeful that the coming weeks present an important opportunity for advocates to get involved with SAMHSA, ask a lot of questions (no question is a bad question) and stay vigilant on the importance of a culturally responsive approach to identifying, promoting and cultivating evidence-based practices that are available to all.

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scott

 Scott Bryant-Comstock
President & CEO
Children's Mental Health Network

 

Comments

  1. DJ's avatar
    DJ
    | Permalink
    Im a Dem, but this is a very pro-science move as I wrote in The Hill yesterday (It is also a subject I examined in my book, Insane Consequences: How the Mental Health Industry Fails the Mentally Ill) http://thehill.com/opinion/healthcare/368653-lets-take-step-to-improve-the-science-of-treating-serious-mental-illness
  2. William Geary's avatar
    William Geary
    | Permalink
    Thank you so much for putting this up and thank you Dennis for bringing this to our attention and your added comments.
  3. Evelyn Frankford's avatar
    Evelyn Frankford
    | Permalink
    Thanks so much, Scott, for this comprehensive overview. Very helpful. The incoming head of the Policy Lab is getting his doctorate from GWU's Milken Institute School of Public Health, certainly a very reputable place. I hope many people can engage with him around evidence-based practice and what we are doing in the field.
  4. Dennis Embry's avatar
    Dennis Embry
    | Permalink
    This is an excellent summary of the history and events. A few items are missing:

    1) The testimony that led to the creation of the Policy Lab was choreographed by critics who falsely claimed that NREPP had no evidence-based programs for seriously mentally ill (e.g. schizophrenia, bipolar, psychosis, etc.) At the time there were more than 40 strategies with good science that addressed those issues, including the single best non-pharma strategy so far to reduce hospital re-admission for psychosis. These studies are largely very well done science (e.g., randomized control studies with longitudinal follow up).

    2) There were other falsehoods perpetrated such as SAMHSA administrators dictated what was on the list. As someone who has multiple evidence based strategies on NREPP, I can tell you that it's up to the scientists and developers to submit.

    3) The reviews have become more and more rigorous—you've got to have really good science to get high scores and good dissemination to get a good score for that.

    4) There is another purpose of NREPP to grow prevention science and prevention innovation. Some things submitted early in their evolution get useful feedback to become better. Not everybody has multiple randomized control, comparative effectiveness studies with 20 year longitudinal follow up like our work at Johns Hopkins. The good ideas need light and feedback to grow bigger and better. It's important to note that the Good Behavior Game (now one the most robust, replicated prevention strategies in the world) started out as a single classroom study using a multiple baseline study.

    We must grow better and better prevention, intervention, and treatment science. Why because the prevalence rates are worsening every year in America. The Wall Street Journal (Dec 28, 2010) reported that more than half of American kids received at least one script for psychotropic medication in 2009. And, the Agency for Health Care Research and Quality has documented that psychiatric disorders among children is the largest single expense for Children's Medicaid/S-CHIP and rising $1 billion per year.
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