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Saving Congressman Murphy from Fraudulent Information

November 06, 2015

 Morning Zen Guest Blog Post ~ Dennis Embry

Shakespeare writes eloquently about the dangers of flattery and lies to great leaders. I’ve worked in Congress for Gerry Ford and Bob Dole, for Secretary Cheney during the Gulf War, various governors, and legislatures and at high levels for other national or provincial governments. Lies and fraud are often delivered in fat envelopes of flattery. I’ve come to realize that the very good intentions of Congressman Murphy to fix an obviously not-working mental health prevention, intervention, and treatment “system” has caused him to be swarmed by a flock of flatterers flogging fraudulent “facts.” Honest-to-God facts are the hardest thing for great leaders to get their hands on, for great decisions. This is why in all my counsel to leaders, as a scientist, is couched carefully and grounded in facts as best I know, even if I know the leader—of whatever party or persuasion—may or may not like it. Otherwise, a great leader cannot make a great decision.

Thus, I wrote a letter to Congressman Murphy, who is obviously a leader for issues of mental health, at the behest of my colleague. My letter was delivered to him personally, and I share much of it here. The more I thought about the pickle the Congressman is in—surrounded by people either flattering him or yelling at him—the more compassion I have for him as a human trying thread his way through the siren songs. So I ask that faithful readers of Children’s Mental Health Network hold their judgments lightly as you read this letter.

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Dear Congressman Murphy:

I am writing you at the urging of a colleague who is quite familiar with my work as child-psychologist and scientist bringing evidence-based practices and programs up from high-quality research studies to real use in the United States, Canada, and Europe. You may or may not know I am the person, behind the scenes, who helped Brian Stettin from the Treatment Advocacy Center get AOT on the NREPP list directly and indirectly, by contacting the people who do the work at NREPP.

Congressman, I wish to be blunt, based on verifiable facts that can be checked out. That is always my mode when I worked for Secretary Cheney as a GS-15 during the Gulf War, when I have done work for governors or their cabinets of different political parties, policy groups or foundations. Too often people slant “info” in such a way to obscure the truth for their own ends. I will give you the objective facts that you can verify, and you can be the judge of the veracity of the data.

I am specifically writing you about erroneous, false information you’ve been given about the National Registry of Evidence Base Programs and Practices. That erroneous information is likely to cause serious problems, which have been withheld from you.

You were led to believe that only four (4) evidence-based programs out of 300 were for seriously mentally ill persons. Seriously mentally ill (SMI) is not a DSM label; it’s a legal definition, such as found in state agencies found services (e.g., Oklahoma).[1] Now, what are the DSM disorders that meet the legal definition of SMI? Here are the actual DSM diagnoses that can meet the legal definition of SMI:

  • Schizophrenia
  • Paranoid and other psychotic disorders
  • Bipolar disorders (hypomanic, manic, depressive, and mixed)
  • Major depressive disorders (single episode or recurrent)
  • Schizoaffective disorders (bipolar or depressive)
  • Pervasive developmental disorders
  • Obsessive-compulsive disorders
  • Depression in childhood and adolescence
  • Panic disorder
  • Post-traumatic stress disorders (acute, chronic, or with delayed onset)
  • Bulimia Nervosa 307.51
  • Anorexia Nervosa 307.1

No one told you to look up some of these actual DSM definitions on NREPP. If they had, you would have found many more actual evidence-based practices on NREPP out of the 300 listed related to major mental illnesses. I have attached PDF’s for several such searches: bipolar (6), schizophrenia (18), and psychosis (4). These name searches are underestimates of actual powerful evidence-based practice that are absolutely proven to affect major mental illnesses. The reason is that some of the randomized trials or other high-quality studies have major results on the legal diagnoses for SMI, yet be missing from the search just because the web-search engine cannot reach into the actual scientific articles, only the limited number of descriptors provided by the authors or drafts of the NREPP posting. For example, the single most powerful evidence-based strategy (randomize control, longitudinal study) to reduce relapse/re-hospitalization from psychosis in the scientific literature to date is on NREPP [1, 2]. Could the search engine logic be improved? Probably, as such things are moving targets based on software and artificial intelligence.

It gets worse, how you were misled. As a clinical psychologist who has worked with military vets, I know that you know that substance abuse figures powerfully some of the most violent, fatal events related to persons with serious mental illnesses. In fact, multiple studies show that serious violence involving major mental illnesses that makes headlines rarely happens without significant substance abuse and early history of aggression. One of these cases is personally well known to me that of Jared Laughner, which I am happy to detail to you. The very, very best strategies in the world to prevent or treat substance abuse are NREPP; and the very, very best proven strategies in the world to prevent or treat aggressive behaviors are on NREPP.

Witnesses to Your Committee
Your witnesses were disingenuous for reasons I cannot fathom. For example, on May 29th, 2014, D.J. Jaffe provided both written and oral testimony on HR 3717 (the precursor to HR 2646), at a briefing by the Energy and Commerce Oversight and Investigations Subcommittee Majority Staff, that there was no evidence for the prevention of serious mental illness, as a criticism of SAMSHA. Oddly, he cited the 1994 Institute of Medicine Report [3], not the 2009 Institute of Medicine Report [4]. The 1994 IOM Report said there was only suggestive evidence that mental, emotional, and behavioral disorders might be prevented; the 2009 IOM report was clear on pages 1-2 that mental, emotional, and behavioral disorders ARE preventable including the most serious ones, but not in every case—just like cancer. Please note that DJ Jaffe is neither a scientist nor a licensed clinician, and Mr. Jaffe has never published a peer-reviewed scientific study on either the treatment or the prevention of mental illness. All this would have been quite different if you had called key members of the 2009 IOM members, such as acclaimed psychiatrist William R. Beardslee or the equally famous psychologist, Anthony Biglan. These are witnesses with powerful, randomized control studies that neither Mr. Jaffe, nor even Dr. Torrey has remotely achieved in terms of treatment of mental, emotional, or behavioral disorders who were witnesses who were so caustic in your hearings. In fact, Dr. Torrey has never been the first author of any randomized control trial or even quasi-experimental study of either the treatment or the prevention of serious mental illnesses. All of this is easily verified by a search of the National Library of Medicine at www.pubmed.gov. Dr. Torrey is most famous for his studies on the role of Toxoplasma Gondi in schizophrenia, a parasite carried by cats that can infect humans and cause schizophrenia.

Submissions To NREPP
The terrible misdirection has been perpetrated on you, Congress and American citizens in other ways. Two examples come to mind.

First, government agencies like SAMSHA and the FDA don’t pick which evidence-based programs or medical devices or drugs get submitted to NREPP or the FDA. The inventor/ company/ scientist(s) must initiate the submission. The reason AOT was not on NREPP was because nobody with authentic skin in the game had ever submitted it for review, until I agreed to help Brian Stettin at the Treatment Advocacy Center. There are probably hundreds of things in the scientific literature that a good and should be on the list, but they do require a proven dissemination and training mechanism to get a good grade and the scientist(s) or entity responsible for submitting it. Now, AOT is on the list, though its scientific evidence-base is not as robust as Dr. Torrey and others lead members of Congress to believe or their messaging to the general public would support; one only need to review the politically and scientifically neutral Cochrane review [5]. Successful AOT depends on the quality of T (treatments), and the NREPP list is chock-a-block full of exceedingly well-proven strategies to ramp up successful treatments. They could be indexed better arguably, but that is a software/conceptual user problem that the contractor for any such list has to work on.

In the second example, both Mr. Jaffe and Dr. Torrey either explicitly stated or implied that major mental illnesses cannot be prevented, as an indictment of the Congressionally mandated block-grant efforts of SAMSHA and its contractor, NREPP. Ironically, Dr. Torrey’s non-profit that he directs, the Stanley Medical Research Institute, funded the single most scientifically proven strategy to prevent first episode psychosis—with effects over the span of seven (7) years [6-8]. How powerful is this strategy? You be the judge from the Randomized Control Trials that I presented as a graph to the most recent national conference on mental health research in Tampa:

aminger

Theoretically, this ridiculously low-cost strategy with huge epidemiological underpinnings documented by the National Institutes of Health could avert tens of thousands of first episode psychosis each year. Now, I am very troubled by the fact that Dr. Torrey refuses to submit this to NREPP, and I have begged him to do so with the promise of the full cooperation of the National Institutes of Health researchers who have been doing deep research on this, including with military service members funded by DOD. I have begged Dr. Torrey to submit this to NREPP, as he is the only person who can since the actual investigator is not an American citizen. Only American researchers can submit to NREPP, and Dr. Amminger, who was funded by Dr. Torrey, is not a US citizen. The potential impact of this study is huge, based on the fact that Dr. Insel from NIMH notes that 500,000 cases of first episode psychosis happen each year in the U.S. In theory, this simple strategy that costs about $15 could avert about 100K to 150K cases of first episode psychosis per year. I am happy to provide you with the correspondence I have had with Dr. Torrey. If funders or investigators DON’T submit to NREPP, powerful strategies for major mental illness cannot be known to providers or policy makers in government or the private sector. Dr. Torrey cannot blame SAMSHA and NREPP for this powerful prevention strategy for major mental illness for not being on NREPP, because he refuses to submit it or allow others to do so. I am puzzled, therefore, why the committee relies on his expert testimony. Presently, I am in discussion with other scientists at the National Institute of Health who are doing powerful research on omega-3 that Dr. Insel is aware of, so that NIH scientists might do the deed that Dr. Torrey has not.

Mr. Jaffe has been critical of NREPP for not reviewing medication regimens, both in public and personal communications with me—which I am happy to share with you. This is most peculiar, as SAMSHA has no statutory authority from Congress to have oversight of drug treatments. As you know, FDA approves medications, but not necessarily off-label or drug-treatment cocktail regimens. Mr. Jaffe insisted that NREPP should do so in private communications with me, and it was their “fault” for not doing so. These regimen studies are often published in medical journals, indexed in www.pubmed.gov. These drug-cocktail regimens as best practices would have to have new authority, and would raise many, many questions—given that the Wall Street Journal documented that 40.4 million children out of 75 million received one script for psychotropic medications in 2009 [9].

Potential Policy and Practice Chaos by Undoing NREPP
It’s wise to remember that medicine is failed prevention. What you don’t know, nor does your committee, is that grantees and states are supposed to use powerful, evidence-base practices and programs from NREPP for both treatment and prevention with block grant dollars. The notion that few powerful treatment protocols for “serious mental illnesses” are on NREPP is easily proven false, that a journalist intern could discover—if he or she did the proper homework. Your committee was misled for reasons I cannot comprehend, and I can assure you that I have personally trained hundreds if not thousands of grantees, providers, and state administrators in practices on NREPP to treat, reduce or prevent serious mental illnesses, often paid to do so by SAMSHA. (And SAMSHA folks will tell you I can be a thorn in their sides about this and other scientific, dissemination and policy issues). That does not mean providers use these powerful, proven strategies to treat, reduce, or prevent serious mental illness. If they did so, I wouldn’t be writing this letter.

The real issue is that the proposed legislation and existing legislation by Congress has created perverse incentives for NOT adopting these evidence-based practices. Creating some new entity to review and promote scientifically proven prevention, intervention, and treatment strategies will just foster bureaucratic mania with no change. Believe me, as I was the co-author of the largest single per-capita ($25 million in Wyoming) legislation and appropriation for the use of evidence-based practices ever adopted in the United States [7, 8]. That number is ½ of the dollar proposed in the bill for the whole country for AOT.

I would love to converse with you about the research on getting providers to adopt evidence-based practices for mental-emotional and behavioral disorders. That is the real problem, not the lack of them on NREPP or for current or proposed legislative remedies. We don’t have a scientifically, experimentally driven policy for getting providers to adopt evidence-based practices. These are issues that my colleagues have written about in the prestigious Brain and Behavioral Sciences Journal [10] as well as in the American Psychologist [11]. My paper for the special issue of Psychiatric Clinics of North America on implementing the 2009 evidence-based strategies from the IOM Report [4] on mental illnesses details key proven principles for a large-scale, successful public health model [12], which is what is needed given the huge rise in prevalence rates of mental, emotional, behavioral disorders happening that is documented in the 2009 IOM report and other data by the Agency for Health Care Research and Quality [13, 14].

You may know that Brian Stettin recommended that people visit the star AOT site in the U.S., Hamilton, Butler County, OH. I did so at my own expense. As you know, AOT’s benefits really arise from the “T” (treatment) and less from the AO. By American standards, the operation of the AOT project in Hamilton, OH was a gem. I’ve written a detailed report about it. They naturally relied on a lot of drug-court training to do it, which the presiding judge confirmed. They were kind, gentle and helpful using excellent therapeutic language and processes.

That said, their AOT effort lacked a whole bunch of evidence-based procedures that would have made their outcomes more efficient and effective, which are in fact listed on NREPP that I’ve trained sites to do. Almost all of the patients in the system have significant addictions, yet they were not using NIDA’s most scientifically proven and cost-efficient way to treat addictions and to improve overall engagement (http://bit.ly/NIDA-DrPetry) in the multiple, needed therapeutic services and activities being “assisted” by the court. Folks with serious mental illnesses are notorious for haveing procedural errors (I know from first-hand experience working with even high-IQ folks with serious mental illnesses) at follow-through tasks, which is compounded if they are co-morbid for substance abuse. Dr. Petry’s studies cited in NREPP are helpful with that, especially when coupled with goal and behavior mapping found in Life Goals Collaborative Care (LGCC) also on NREPP, which is explicitly and successfully designed to treat serious affective and mania episodes.

No-Cost or Low-Cost Solution
Much of the problem you encountered in searching NREPP is simply a software problem of search terms, which could be fixed by the new NREPP contractors. That’s a management and software programming issue; it’s not a Congressional legislative issue. Looking up “serious mental illness” without a “Google Thesaurus” of terms is likely to have reduced returns, not because malice.

If the bill passes as is, there is a probability of huge chaos among the states, their rules and regulations for sub-awards. Almost all states require the use of NREPP strategies for treatment, intervention, and prevention—which are embedded in state and local laws, regulations and policies. Of course, some strategies are better than others. That can be addressed. If, however, the Congress requires a wholly new review of evidence-based practices, that will take at least three years to do. The states and providers will be left in chaos, and more patients and clients with all manner of problems that can lead to bad headline news.

How To Get More Treatment Strategies on NREPP
Testimony to your committee alleges that SAMSHA somehow blocks submissions of powerful programs to treat major mental illness. That might make a good TV; it is not true. SAMSHA cannot place things on NREPP. Investigators and developers like me must submit SAMSHA, just like a drug company must submit to FDA. It’s not just the research finding that is required; it is a powerful dissemination system that has to come with the request. Otherwise, people can simply search www.pubmed.gov for good ideas, which have research but are not commercially available. Dr. Torrey is the key to submitting to NREPP for his funded project for the prevention of first episode psychosis. I cannot, nor can the administrator of SAMSHA any more than the head of FDA or a member of Congress submit a drug to an FDA review panel.

What can Congress do? I suggest that the legislation be amended to require SAMSHA to have several “calls” in the federal register each year (say quarterly) for proven strategies to resolves important prevention, intervention, and treatment issues. Further, most academics have little or no skill in bringing proven strategies to market that might significantly avert or treat major mental illnesses. Dr. Torrey, himself, is an excellent example of failure to bring his practical treatment protocol to national use. Perhaps, NIH and other federal grantees might be required to have training and coaching for how to bring powerful mental, emotional, and behavioral prevention and treatment protocols to NREPP registration and market—which is beyond SAMSHA’s charter.

Congress might even require that grants have a better plan for product dissemination (not just scientific dissemination) that is presently embedded in grant announcements and rules across the departments of the federal government that fund research and practices related to the prevention of mental, emotional, behavioral and related physical disorders. Publishing a scientific article is good for tenure at universities, but it is not a potent product or service in the hands of providers and consumers. I know this very well, as an entrepreneurial scientist who has brought multiple well-proven strategies to population-level scale. This is why we’ve started the First Carbon Based Valley initiative (not the Next Silicon Valley) to develop proven, practical prevention, intervention and treatment strategies that can be scaled nationally (and internationally) as cost-effective products. The reason we call this the Carbon Based Valley Initiative is that our largest problems in society are other humans, which are all based on carbon atoms. Your bill is not about silicon transistor health; it’s about human mental health.

Congressman Murphy, I am happy to converse further about ways to improve the bill because of your noble intent. Scraping NREPP for a wholly new review won’t achieve your aims, as the rationale was based on completely misrepresented information to you and your committee. It is easy to fix your concern, without creating utter chaos in the states or providers with their allocations of funds based on reasonable long-term parameters, even though those parameters can be improved.

Note: Correction made clarifying DJ Jaffe testimony, adding CSPAN video and written remarks.

References

  1. Bach, P. and S.C. Hayes, The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting & Clinical Psychology, 2002. 70(5): p. 1129-1139.
  2. Bach, P., S.C. Hayes, and R. Gallop, Long-Term Effects of Brief Acceptance and Commitment Therapy for Psychosis. Behav Modif, 2011.
  3.  Mrazek PJ and H. RJ, Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. 1994, Institute of Medicine.
  4. O’Connell, M.E., T. Boat, and K.E. Warner, eds. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth and Young Adults: Research Advances and Promising Interventions. 2009, Institute of Medicine; National Research Council: Washington, DC. 576.
  5. Kisely, S.R. and L.A. Campbell, Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Schizophr Bull, 2015. 41(3): p. 542-3.
  6. Amminger, G.P., et al., Long-Chain {omega}-3 Fatty Acids for Indicated Prevention of Psychotic Disorders: A Randomized, Placebo-Controlled Trial. Arch Gen Psychiatry, 2010. 67(2): p. 146-154.
  7. Amminger, G.P., et al., Longer-term outcome in the prevention of psychotic disorders by the Vienna omega-3 study. Nat Commun, 2015. 6: p. 7934.
  8. Amminger, G.P., et al., Predictors of treatment response in young people at ultra-high risk for psychosis who received long-chain omega-3 fatty acids. Transl Psychiatry, 2015. 5: p. e495.
  9. Mathews, A.W., So Young and So Many Pills: More than 25% of Kids and Teens in the U.S. Take Prescriptions on a Regular Basis, in Wall Street Journal. 2010, The News Corporation: New York.
  10. Wilson, D.S., et al., Evolving the Future: Toward a Science of Intentional Change. Brain and Behavioral Sciences, 2014. 37(4): p. 395-416.
  11. Biglan, A., et al., The critical role of nurturing environments for promoting human well-being. American Psychologist, 2012. 67(4): p. 257-271.
  12. Embry, D.D., Behavioral Vaccines and Evidence-Based Kernels: Nonpharmaceutical Approaches for the Prevention of Mental, Emotional, and Behavioral Disorders. Psychiatric Clinics of North America, 2011. 34(March): p. 1-34.
  13. Soni, A., The Five Most Costly Children’s Conditions, 2006: Esitmates for the U.S. Civilian Non-nsitutionalized Children, Ages 0-17., A. Center for Financing, and Cost Trends, Editor. 2009, Agency for HealthCare Research and Quality: Rockville, MD. 20850. p. 5.
  14. Soni, A., The Five Most Costly Children’s Conditions, 2011: Estimates for U.S. Civilian Noninstitutionalized Children, Ages 0-17, A.f.H.R.a. Quality, Editor. 2014, Agency for Healthcare Research and Quality: Washington, DC.

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Dennis Embry, President/Senior Scientist at PAXIS Institute – Dennis D. Embry is a prominent prevention scientist in the United States and Canada, trained as clinician and developmental and child psychologist. He is president/senior scientist at PAXIS Institute in Tucson and co-investigator at Johns Hopkins University and the Manitoba Centre for Health Policy. His work and that of colleagues cited in 2009 the Institute of Medicine Report on The Prevention of Mental, Emotional, and Behavioral Disorders Among Young People. Clinically his work has focused on children and adults with serious mental illnesses. He was responsible for drafting of the letter signed by  23 scientists, who collectively represent scores of randomized prevention trials of mental illnesses published in leading scientific journals. In March 2014, his work and the work of several signatories was featured in a Prime-TV special on the Canadian Broadcast Corporation on the prevention of mental illnesses among children—which have become epidemic in North America. Dr. Embry serves on the Children’s Mental Health Network Advisory Council.


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