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OMH - Office of Mental Health - New York State

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2005‒2009<br />

<strong>State</strong>wide Comprehensive Plan<br />

for <strong>Mental</strong> <strong>Health</strong> Services<br />

January 2005<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong><br />

George E. Pataki, Governor<br />

<strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

Sharon E. Carpinello, RN, PhD, Commissioner


Message from the Commissioner<br />

O<br />

ver the past year, the hallmark 2004-2008<br />

<strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong><br />

<strong>Health</strong> Services has created strong momentum<br />

toward advancing <strong>OMH</strong>'s quality agenda. The<br />

intent <strong>of</strong> <strong>OMH</strong> to provide energetic, innovative<br />

and transparent approaches to quality and stakeholder<br />

collaboration has taken on new meaning.<br />

Participants in the planning process have<br />

applauded the data-rich content <strong>of</strong> the Plan. This<br />

new depth <strong>of</strong> information and the key questions<br />

posed in the Plan have created a platform for<br />

discussing actions necessary to address some <strong>of</strong><br />

the more difficult challenges we face. For example,<br />

we participated with a NYC-based group <strong>of</strong><br />

general hospitals to streamline the longstanding<br />

referral processes that impeded easy access to<br />

our <strong>State</strong> psychiatric hospital beds, we commissioned<br />

a broadly representative coalition <strong>of</strong> people<br />

who use mental health services to craft a<br />

first-<strong>of</strong>-its kind white paper, "Infusing Recovery-<br />

Based Principles into <strong>Mental</strong> <strong>Health</strong> Service," and<br />

we partnered with the Conference <strong>of</strong> Local <strong>Mental</strong><br />

Hygiene Directors in their efforts to reach<br />

consensus about priorities for planning, target<br />

populations, and service needs.<br />

I have several new insights to share as a<br />

result <strong>of</strong> my personal efforts this year to reach<br />

out and engage the large community <strong>of</strong> those<br />

interested in the <strong>State</strong>'s public mental health<br />

system. First, people are "hungry" for information<br />

and for their voices to be heard. Second,<br />

building a new, comprehensive, inclusive planning<br />

process in the <strong>State</strong> is not something that<br />

emerges quickly. It is a developmental process<br />

that we have made a strong beginning towards<br />

since the publication <strong>of</strong> last year's plan. Our<br />

challenge in this year's plan is to continue to<br />

fuel the positive energy and momentum we<br />

have built. The 2005-2009 <strong>State</strong>wide Comprehensive<br />

Plan is meant to do just this. It is not<br />

intended as a stand-alone document, but as a<br />

complement to last year's work. While we have<br />

intentionally not resurfaced content that is readily<br />

available to you, I know that you will be<br />

pleased with this year's Plan.<br />

In this 2005-2009 Plan, <strong>OMH</strong> has operationalized<br />

the agency's strategic planning framework by<br />

creating a set <strong>of</strong> priorities that will guide its operations<br />

over this planning horizon and well into<br />

the future. This set <strong>of</strong> measurable goals is the<br />

agency's "strategic plan," which is presented for<br />

the first time in this year's Plan. <strong>OMH</strong> will seek<br />

public input for this initiative through our planning<br />

process and will regularly report on progress<br />

related to achieving its goals. Having a strategic<br />

plan does not preclude <strong>OMH</strong> from continuing all<br />

ongoing efforts at advancing key initiatives, but it<br />

does serve to focus attention on a concise set <strong>of</strong><br />

pivotal activities to address our priorities.<br />

Our strategic plan serves as a guidepost for<br />

agency executives to develop and oversee a targeted<br />

set <strong>of</strong> management activities, several <strong>of</strong><br />

which become the basis for resource allocation<br />

and initiation <strong>of</strong> new planning activities. By<br />

concluding our 2005-2009 <strong>State</strong>wide Comprehensive<br />

Plan with our strategic plan and next<br />

steps for performance improvement, we intend<br />

to conclude with a new beginning-an informed,<br />

interactive planning process based on performance<br />

measurement.<br />

In each <strong>of</strong> its nine chapters, this document<br />

provides further evidence <strong>of</strong> <strong>OMH</strong>'s commitment<br />

to quality and pursuit <strong>of</strong> excellence. The 2005-<br />

2009 Plan begins with restatements <strong>of</strong> the<br />

agency's commitment to quality. We then provide<br />

an overview <strong>of</strong> the public mental health<br />

system and describe 2004 planning outreach<br />

efforts and stakeholder input. We continue<br />

describing our commitment to quality by highlighting<br />

recent work done by <strong>OMH</strong> in basic,<br />

clinical and services research, and provide indepth<br />

explanations <strong>of</strong> growing policy interest in<br />

childhood anxiety and depression, in people<br />

who are in prison and require mental health<br />

services, and in preventing suicide. The Plan<br />

concludes with our approach to performance<br />

improvement through use <strong>of</strong> a strategic plan and<br />

an ongoing performance measurement process.<br />

As you read through this Plan, you may consult<br />

the 2004--2008 Plan which complements<br />

this document and serves as a valuable reference<br />

guide. We have released this 2005--2009<br />

Plan in conjunction with our agency's 2005--<br />

2006 Executive Budget and legislative agenda.<br />

We anticipate your interest and encourage public<br />

participation in the important discussions that<br />

will surround this statewide planning initiative<br />

in the upcoming legislative session.<br />

Sharon E. Carpinello, RN, PhD<br />

Commissioner<br />

NYS <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


I<br />

Table <strong>of</strong> Contents<br />

Chapter 1<br />

Mission and Vision ....................................................................................................1<br />

Chapter 2<br />

Who is Served ..........................................................................................................13<br />

Chapter 3<br />

Collaborations to Strengthen Planning....................................................................21<br />

Chapter 4<br />

Basic and Clinical Research ....................................................................................35<br />

Chapter 5<br />

Services Research ....................................................................................................51<br />

Chapter 6<br />

Children and Depression ..........................................................................................81<br />

Chapter 7<br />

Forensic Services ......................................................................................................89<br />

Chapter 8<br />

Preventing Suicide ..................................................................................................105<br />

Chapter 9<br />

Implementing <strong>OMH</strong>’s Strategic Plan......................................................................113<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


II<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 1: Mission and Vision 1<br />

Mission and Vision Chapter 1<br />

Introduction<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

he <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong><br />

T<strong>Mental</strong> <strong>Health</strong> (<strong>OMH</strong>) is committed<br />

to enhancing the quality <strong>of</strong> our<br />

<strong>State</strong>’s public mental health system.<br />

During 2005-2009, the agency’s fundamental<br />

goals are to continue<br />

maximizing access to quality mental<br />

health services for adults with serious<br />

mental illness and children with<br />

serious emotional disturbance, and<br />

to continue promoting the mental<br />

health <strong>of</strong> all <strong>New</strong> <strong>York</strong>ers through<br />

public education and advocacy.<br />

Maximizing access to appropriate<br />

and effective mental health services<br />

is central to promoting recovery for<br />

individuals with mental illness so<br />

they can live full and productive<br />

lives in their communities. Recent<br />

research shows high rates <strong>of</strong> recovery<br />

for people with even the most<br />

serious diagnoses, and new studies<br />

document the effectiveness <strong>of</strong> selfhelp<br />

and rehabilitation. Collectively,<br />

these studies demonstrate that<br />

people with psychiatric disabilities<br />

can and do recover and services<br />

can be designed to enhance this<br />

process. This emphasis on recovery<br />

oriented services is central to<br />

achieving quality outcomes and to<br />

advancing <strong>OMH</strong>’s mission, vision,<br />

and values.<br />

Leaders in health and mental<br />

health care including the World<br />

<strong>Health</strong> Organization (WHO), the<br />

U.S. Surgeon General, and the<br />

President’s <strong>New</strong> Freedom Commission<br />

on <strong>Mental</strong> <strong>Health</strong> have identified<br />

a need for a public mental<br />

health approach to mental illness<br />

that expands efforts beyond treatment<br />

for the most severely affected<br />

individuals. <strong>OMH</strong> also recognizes<br />

this need and will continue to pursue<br />

initiatives to educate people<br />

about using health promotion and<br />

disease prevention interventions<br />

designed to improve and enhance<br />

quality <strong>of</strong> life.<br />

This 2005-2009 <strong>State</strong>wide Comprehensive<br />

Plan for <strong>Mental</strong> <strong>Health</strong><br />

Services is intended to be read and<br />

utilized in conjunction with the<br />

2004-2008 Plan. In the 2004-2008<br />

Plan, <strong>OMH</strong> provided an extensive<br />

discussion <strong>of</strong> how we are applying<br />

our strategic planning framework<br />

to promote the agency’s commitment<br />

to quality. This continues to<br />

be the basis for addressing trends<br />

and challenges during the 2005-<br />

2009 planning period, and <strong>OMH</strong><br />

will continue its commitments in<br />

these areas. Although the planning<br />

framework is not rearticulated in its<br />

entirety in this 2005-2009 <strong>State</strong>wide<br />

Comprehensive Plan, last year’s<br />

presentation <strong>of</strong> agency initiatives in<br />

the context <strong>of</strong> the strategic planning<br />

framework can be found in<br />

Chapter 10 <strong>of</strong> the 2004-2008 Plan<br />

on the <strong>OMH</strong> Web site at http://<br />

www.omh.state.ny.us/omhweb/<br />

statewideplan/.<br />

This 2005-2009 <strong>State</strong>wide Comprehensive<br />

Plan complements last<br />

year’s plan by expanding the<br />

strategic planning framework into a<br />

2005 agency strategic plan. It pres-<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


2 Chapter 1: Mission and Vision<br />

ents new and expanded information<br />

on emerging topics central to<br />

moving the quality agenda forward<br />

based on input from our 2004 public<br />

forums. It also provides comprehensive<br />

overviews <strong>of</strong> selected segments<br />

<strong>of</strong> the public mental health<br />

system which have not been fully<br />

addressed in earlier plans.<br />

The Strategic<br />

Planning Framework<br />

I<br />

n the 2004-2008 <strong>State</strong>wide Comprehensive<br />

Plan, <strong>OMH</strong> described a<br />

strategic planning framework to<br />

guide agency operations and to support<br />

its commitment to quality. This<br />

framework consists <strong>of</strong> two components.<br />

The first includes the agency’s<br />

mission and vision statement, its values<br />

and the “ABC’s” <strong>of</strong> mental health<br />

care, which are core operating principles<br />

governing the conduct <strong>of</strong> agency<br />

business. The second is <strong>OMH</strong>’s commitment<br />

to recovery as a guiding<br />

principle for agency operations.<br />

These two components comprise the<br />

framework for developing specific<br />

long and short term goals and for<br />

implementing solid action plans to<br />

achieve them – a process which is<br />

referred to as strategic planning.<br />

<strong>OMH</strong> has a strong commitment to<br />

strategic planning requiring that<br />

managers act “strategically,” meaning<br />

that they develop and use a targeted<br />

approach to achieving measurable<br />

goals and that they<br />

continually “check and correct”<br />

progress toward goal attainment.<br />

The <strong>OMH</strong> Strategic Plan appears in<br />

Chapter 9, however, it is not possible<br />

to have a strategic plan without<br />

first having a strong framework to<br />

direct agency initiatives toward “true<br />

North” – a compass point intended<br />

to guide managers at all levels <strong>of</strong><br />

the system as they integrate strategic<br />

planning into daily management<br />

operations. Having a “true North”<br />

helps <strong>OMH</strong> to consistently reflect<br />

on the degree to which operations<br />

are aligned with our organization’s<br />

cultural norms and expectations.<br />

<strong>OMH</strong>’s Mission, Vision,<br />

and Values<br />

n emphasis on recovery-orient-<br />

services is central to advanc-<br />

Aed<br />

ing <strong>OMH</strong>’s mission, vision, and values,<br />

and achieving quality<br />

outcomes.<br />

Figure 1.1<br />

Mission and Vision and Values<br />

Mission<br />

The mission <strong>of</strong> the <strong>New</strong> <strong>York</strong> <strong>State</strong><br />

<strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong> is to promote<br />

the mental health <strong>of</strong> all <strong>New</strong> <strong>York</strong>ers<br />

with a particular focus on providing hope<br />

and recovery for adults with serious<br />

mental illness and children with serious<br />

emotional disturbances.<br />

Vision<br />

The <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong><br />

<strong>Health</strong> will work toward a more effective<br />

public mental health system, which values<br />

recovery, hope, excellence, respect,<br />

and safety.<br />

Values<br />

◆ Recovery is the process <strong>of</strong> gaining<br />

control over one’s life in the context<br />

<strong>of</strong> the personal, social and economic<br />

losses that may result from the experience<br />

<strong>of</strong> psychiatric disability. It is a<br />

continuing, non-linear, highly individual<br />

process that is based on hope<br />

and leads to healing and growth.<br />

◆ Hope is the belief that one has both<br />

the ability and the opportunity to<br />

engage in the recovery process.<br />

◆ Excellence is the state <strong>of</strong> possessing<br />

superior merit in the design, delivery and<br />

evaluation <strong>of</strong> mental health services.<br />

◆ Respect is esteem for the worth <strong>of</strong> a<br />

person including recognition <strong>of</strong> dignity,<br />

diversity and cultural differences.<br />

◆ Safety is an environment free from<br />

hurt, injury or danger.<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 1: Mission and Vision 3<br />

<strong>OMH</strong> is pursuing its mission and<br />

vision by focusing on accountability,<br />

best practices, and coordination<br />

<strong>of</strong> care to plan and manage performance<br />

in its day-to-day operations.<br />

Known as the “ABC’s <strong>of</strong><br />

mental health care,” they are:<br />

◆ Accountability for Results,<br />

whereby a clearly defined entity<br />

or individual is responsible for<br />

the effectiveness <strong>of</strong> services<br />

delivered. Services are designed<br />

and delivered to achieve specific<br />

outcomes, which are measured<br />

by performance indicators.<br />

◆ Best Practices, whereby service<br />

design and delivery is based on<br />

the best research and evidence<br />

available and best practice guidelines<br />

are incorporated into treatment<br />

practices. Adherence to<br />

these guidelines is measured as<br />

part <strong>of</strong> the accountability process.<br />

◆ Coordination <strong>of</strong> Care, whereby<br />

coordinated, comprehensive networks<br />

<strong>of</strong> providers deliver a balanced<br />

array <strong>of</strong> medical, self-help,<br />

social, supportive and rehabilitative<br />

services and programs.<br />

These services are focused on<br />

rehabilitation and recovery, and<br />

individualized service plans are<br />

designed around the needs and<br />

desires <strong>of</strong> the individual.<br />

Commitment to Recovery<br />

Oriented Services<br />

MH’s commitment to expanding<br />

Othe recovery-oriented approach<br />

to service design and delivery is<br />

grounded in empirical data demonstrating<br />

that people can and do<br />

recover from diagnoses <strong>of</strong> serious<br />

mental illnesses. 1 Recovery-oriented<br />

services are characterized by a<br />

commitment to promoting and preserving<br />

wellness, to expanding<br />

choice and eliminating coercion,<br />

and to providing the least intrusive<br />

services in the most integrated environments.<br />

This approach promotes<br />

maximum flexibility and choice to<br />

meet individually defined goals and<br />

to permit person-centered rather<br />

than program-centered services.<br />

The recovery-oriented approach<br />

is influenced and informed by people<br />

who have been diagnosed with<br />

mental illness, recognizing that<br />

they have valuable knowledge and<br />

insights about healing, coping, and<br />

recovery that can help shape service<br />

delivery systems. The agency’s<br />

commitment to a quality improvement<br />

agenda is only meaningful<br />

when viewed against a recovery<br />

“lens.” Recovery provides the perspective<br />

for hope and meaning in<br />

each person’s life, and also for a<br />

system <strong>of</strong> care which sees itself as<br />

instrumental to improving the quality<br />

<strong>of</strong> life for individuals and their<br />

families. While quality improvement<br />

activities exist in all business<br />

domains, the role <strong>of</strong> <strong>OMH</strong> as the<br />

<strong>State</strong> mental health authority is to<br />

promote the recovery “lens” within<br />

its own constituencies and elsewhere<br />

in <strong>State</strong> government.<br />

The recovery “lens” and <strong>OMH</strong>’s<br />

mission, vision, and values are<br />

yardsticks for leaders to use in<br />

developing and prioritizing goals<br />

and management strategies to<br />

guide the public mental health system<br />

toward enhanced quality and<br />

improved outcomes. The strategic<br />

planning initiatives which emanate<br />

from this framework serve two purposes.<br />

First, they help managers<br />

improve the quality <strong>of</strong> their work<br />

in day-to-day operations, and second,<br />

they provide a structure<br />

where management and planning<br />

activities can merge to effectively<br />

respond to changing needs inside<br />

and outside <strong>of</strong> our organization. To<br />

fulfill the <strong>OMH</strong> mission, it is essential<br />

that there is organizational<br />

capacity to chart a course <strong>of</strong> strategic<br />

direction which is responsive to<br />

changing conditions and needs.<br />

Blending the management <strong>of</strong> daily<br />

operations with strategic direction<br />

Notes<br />

1 Harding CM, Brooks GW, Ashikaga T, Strauss<br />

JS, Breier A. (1987).The Vermont longitudinal<br />

study <strong>of</strong> persons with severe mental illness,<br />

I: Methodology, study sample, and overall<br />

status 32 years later. Am J Psychiatry,<br />

144(6):718-26.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


4 Chapter 1: Mission and Vision<br />

Notes<br />

2 <strong>OMH</strong>’s <strong>New</strong> <strong>York</strong> <strong>State</strong> Psychiatric Institute<br />

also provides a small number <strong>of</strong> inpatient<br />

services in its Washington Heights Community<br />

Service division.<br />

is generally referred to as a strategic<br />

management approach.<br />

<strong>OMH</strong>’s intent to move toward a<br />

strategic management approach<br />

begins by describing who we are<br />

as an organization, in terms <strong>of</strong> the<br />

agency’s strengths, and challenges.<br />

As one <strong>of</strong> the nation’s largest mental<br />

health authorities, <strong>OMH</strong> can best<br />

be understood within the following<br />

discussion <strong>of</strong> roles and functions.<br />

The <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>’s<br />

Role as <strong>State</strong> <strong>Mental</strong> <strong>Health</strong><br />

Authority<br />

MH has two primary functions<br />

Oas <strong>State</strong> mental health authority:<br />

to ensure access to high quality<br />

services for adults with severe<br />

mental illness and children with<br />

serious emotional disturbance and<br />

to promote overall public mental<br />

health through education and<br />

advocacy for all <strong>New</strong> <strong>York</strong>ers.<br />

These dual functions are carried<br />

out as <strong>OMH</strong> conducts integrated,<br />

results-oriented oversight <strong>of</strong> <strong>State</strong><br />

and Local resources. Management<br />

decisions are guided by accurate<br />

and timely performance measurement<br />

focused on the key areas <strong>of</strong><br />

access to services, service quality<br />

and appropriateness, outcomes,<br />

and cost. To effectively meet<br />

agency responsibilities, day-to-day<br />

operations are organized in four<br />

lines <strong>of</strong> business:<br />

1. Regulation, Certification, and<br />

Oversight <strong>of</strong> <strong>New</strong> <strong>York</strong>’s Public<br />

<strong>Mental</strong> <strong>Health</strong> System<br />

MH is responsible for the regu-<br />

and licensing <strong>of</strong> all mental<br />

Olation<br />

health facilities and programs in the<br />

<strong>State</strong> other than private practices<br />

and Federal facilities. In this role,<br />

the agency provides oversight to<br />

the <strong>State</strong>’s 62 counties and more<br />

than 2,500 mental health programs<br />

operated by Local governments and<br />

private agencies that provide mental<br />

health services to the people <strong>of</strong><br />

<strong>New</strong> <strong>York</strong> <strong>State</strong>. The services provided<br />

by locally operated programs<br />

include inpatient, outpatient, emergency,<br />

residential, and community<br />

support. While certain policy, funding,<br />

regulatory, and management<br />

functions are centrally administered,<br />

actual program administration takes<br />

place on the Local government<br />

level. Each year approximately<br />

588,000 individuals receive services<br />

in County operated or not-for-pr<strong>of</strong>it<br />

mental health programs.<br />

<strong>OMH</strong> oversight includes administrating<br />

a Prior Approval Review<br />

(PAR) process for the establishment<br />

<strong>of</strong> new programs, establishing rates<br />

<strong>of</strong> reimbursement for licensed programs,<br />

and administering a <strong>State</strong><br />

aid to Local governments funding<br />

program. The agency uses certification<br />

standards to improve clinical<br />

service and quality. <strong>OMH</strong> ensures<br />

that public mental health services<br />

are responsive to local needs by<br />

collaborating actively with the <strong>New</strong><br />

<strong>York</strong> City and county departments<br />

<strong>of</strong> mental health, and evaluating<br />

performance <strong>of</strong> the public mental<br />

health system on an ongoing basis.<br />

2. Direct Provision <strong>of</strong> <strong>State</strong>-operated<br />

Inpatient and Outpatient<br />

<strong>Mental</strong> <strong>Health</strong> Services<br />

MH is a major provider <strong>of</strong> inpa-<br />

and outpatient treatment<br />

Otient<br />

with a broad array <strong>of</strong> services.<br />

Intermediate and long-term inpatient<br />

services are provided in a network<br />

<strong>of</strong> 26 psychiatric centers that<br />

include 20 psychiatric centers serving<br />

adults with severe mental illness,<br />

three <strong>of</strong> which serve adult<br />

with mental illness involved with<br />

the criminal justice system, and an<br />

additional six serving children with<br />

severe emotional disturbances. 2<br />

Appendix 1 contains maps which<br />

describe the locations <strong>of</strong> all <strong>New</strong><br />

<strong>York</strong> <strong>State</strong> adult, children, and<br />

forensic psychiatric centers and<br />

research institutes, as well as the<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 1: Mission and Vision 5<br />

locations <strong>of</strong> children’s inpatient<br />

programs throughout the <strong>State</strong>.<br />

<strong>State</strong>-operated inpatient services<br />

are typically utilized by individuals<br />

who require longer lengths <strong>of</strong> stay<br />

than what is <strong>of</strong>fered in locally<br />

operated community hospitals.<br />

<strong>State</strong>-operated outpatient services<br />

are similar to those provided by<br />

locally operated agencies, and are<br />

primarily used by individuals who<br />

also use <strong>State</strong>-operated inpatient<br />

services. This includes an active<br />

caseload <strong>of</strong> prison inmates who<br />

receive mental health services<br />

while incarcerated in Department<br />

<strong>of</strong> Correctional Services’ facilities in<br />

over 33 sites statewide.<br />

3. <strong>Mental</strong> <strong>Health</strong> Research to<br />

Advance Prevention, Treatment,<br />

and Recovery<br />

MH research is an important<br />

Opart <strong>of</strong> agency efforts to identify<br />

scientifically based, effective interventions<br />

and incorporate them into<br />

mainstream practice throughout the<br />

public mental health system.<br />

Research in basic science to better<br />

understand the biochemical and<br />

genetic mechanisms underlying<br />

mental illness is conducted primarily<br />

at the Nathan S. Kline Institute<br />

(NKI) in Orangeburg <strong>New</strong> <strong>York</strong>,<br />

and the <strong>New</strong> <strong>York</strong> <strong>State</strong> Psychiatric<br />

Institute (NYSPI) in <strong>New</strong> <strong>York</strong> City.<br />

Researchers at the institutes conduct<br />

clinical trials to develop and<br />

evaluate new treatments and services<br />

as well, and have been participants<br />

in numerous collaborative,<br />

multi-site clinical trials that have<br />

led to U.S. Food and Drug Administration<br />

(FDA) approval <strong>of</strong> new<br />

medications for schizophrenia,<br />

bipolar disorder, depression, and<br />

anxiety disorder. <strong>OMH</strong> researchers<br />

also focus on outcome studies to<br />

determine better methods <strong>of</strong> service<br />

delivery, and recognize the<br />

importance <strong>of</strong> involving consumers<br />

from diverse cultural communities<br />

at every stage <strong>of</strong> the process <strong>of</strong><br />

recovery. <strong>OMH</strong> research is<br />

described in greater detail in Chapters<br />

4 and 5.<br />

4. Promoting <strong>Mental</strong> <strong>Health</strong><br />

through Public Education<br />

s part <strong>of</strong> our commitment to<br />

Aenhancing quality throughout<br />

our public mental health system,<br />

<strong>OMH</strong> promotes mental health<br />

through education and advocacy<br />

for all <strong>New</strong> <strong>York</strong>ers. <strong>OMH</strong> is<br />

increasing the general public’s<br />

awareness and understanding <strong>of</strong><br />

mental health by developing and<br />

distributing information about the<br />

nature and impact <strong>of</strong> mental illness,<br />

effective treatments and services,<br />

useful preventive and coping strategies,<br />

and how to get help when it<br />

is needed. The agency’s information<br />

dissemination strategies are<br />

designed to reach as many <strong>New</strong><br />

<strong>York</strong>ers as possible, with a particular<br />

focus on high-risk groups. As<br />

public awareness <strong>of</strong> the scale and<br />

scope <strong>of</strong> the impact <strong>of</strong> mental illness<br />

has increased, a corresponding<br />

increase in societal desire and<br />

expectations for an effective mental<br />

health system is emerging. More<br />

information on specific public mental<br />

health promotion strategies<br />

regarding suicide prevention is presented<br />

in Chapter 8.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


6 Chapter 1: Mission and Vision<br />

Notes<br />

3 The Winds <strong>of</strong> Change campaign is now in its<br />

fourth year and is described in more detail<br />

on the <strong>OMH</strong> Web site at<br />

http://www.omh.state.ny.us/omhweb/ebp/w<br />

inds_<strong>of</strong>_change.htm.<br />

4 Carpinello SE, Rosenberg L, Stone J, Schwager<br />

M, Felton CJ. (2002). Best Practices:<br />

<strong>New</strong> <strong>York</strong> state’s campaign to implement<br />

evidence-based practices for people with<br />

serious mental disorders. Psychiatr Serv.,<br />

53(2):153-5.<br />

Enhancing Quality<br />

in Our Public <strong>Mental</strong><br />

<strong>Health</strong> System<br />

efore an organization can devel-<br />

a set <strong>of</strong> goals and manage-<br />

Bop<br />

ment strategies it needs to assess<br />

its strengths. <strong>OMH</strong> has made four<br />

major structural inroads in the past<br />

year which can provide significant<br />

support to its management initiatives<br />

and attainment <strong>of</strong> goals. First,<br />

<strong>OMH</strong> has a continuing commitment<br />

to quality as well as the<br />

nationally recognized “Winds <strong>of</strong><br />

Change,” a campaign dedicated to<br />

providing access to mental health<br />

services that are based on the best<br />

available evidence. 3 Second, <strong>OMH</strong><br />

has adopted a population-based<br />

planning approach to the design<br />

and delivery <strong>of</strong> public mental<br />

health services. Third, <strong>OMH</strong> is<br />

increasing stakeholder input to the<br />

<strong>State</strong> and Local mental health planning<br />

process. Fourth, <strong>OMH</strong> has initiated<br />

a performance measurement<br />

system as a critical component <strong>of</strong> a<br />

quality and strategic planning<br />

framework. These efforts are all<br />

enhanced by <strong>OMH</strong>’s extensive,<br />

multi-year commitment to the<br />

development <strong>of</strong> a decision support<br />

infrastructure that is accessible to<br />

both <strong>State</strong> and county mental<br />

health planners.<br />

Continuing Commitment<br />

to Quality<br />

MH is a leader in the national<br />

Omental health quality improvement<br />

agenda and our commitment<br />

to quality is the cornerstone <strong>of</strong> all<br />

agency planning initiatives. In last<br />

year’s 2004-2008 <strong>State</strong>wide Comprehensive<br />

Plan, <strong>OMH</strong> affirmed its focus<br />

on quality and articulated the<br />

agency’s strategy for advancing the<br />

quality agenda. In this 2005-2009<br />

<strong>State</strong>wide Comprehensive Plan,<br />

<strong>OMH</strong> reaffirms our commitment to<br />

this multi-year quality agenda, which<br />

includes the “Winds <strong>of</strong> Change” campaign<br />

to integrate evidence-based<br />

practices into routine care. 4 Much <strong>of</strong><br />

this 2005-2009 Plan chronicles steps<br />

in this quality agenda to improve<br />

access to and quality <strong>of</strong> mental<br />

health services in <strong>New</strong> <strong>York</strong> <strong>State</strong>.<br />

<strong>OMH</strong>’s quality agenda is consistent<br />

with a sweeping national<br />

agenda for improving quality in<br />

health care which envisions a<br />

health care system with a renewed<br />

focus on innovation and quality,<br />

based on scientifically proven ‘evidence-based’<br />

treatments and practices<br />

as the foundation <strong>of</strong> routine<br />

health care. This agenda is also<br />

integral to the promotion <strong>of</strong> recovery<br />

and community integration for<br />

individuals with mental illness,<br />

because without quality services<br />

and appropriate access to care, it is<br />

unlikely that the full potential for<br />

recovery can be realized. This<br />

national mental health quality<br />

agenda has been developed with<br />

contributions from nationally<br />

respected institutions and individuals<br />

including the Institute <strong>of</strong> Medicine<br />

<strong>of</strong> the National Academies, the<br />

President’s <strong>New</strong> Freedom Commission<br />

on <strong>Mental</strong> <strong>Health</strong>, the federal<br />

Substance Abuse and <strong>Mental</strong><br />

<strong>Health</strong> Services Administration<br />

(SAMHSA), the U.S. Surgeon General,<br />

the Joint Commission on<br />

Accreditation <strong>of</strong> <strong>Health</strong>care Organizations<br />

(JCAHO), and the Schizophrenia<br />

Patient Outcomes Research<br />

Team (PORT).<br />

The national quality improvement<br />

agenda recognizes that although<br />

medical leaders and research scientists<br />

make discoveries every day to<br />

improve the quality <strong>of</strong> health care,<br />

routine medical practice does not<br />

rapidly assimilate these advances.<br />

As a result, gaps <strong>of</strong>ten exist<br />

between what research has identified<br />

as state-<strong>of</strong>-the-art health care<br />

and the care that is actually delivered<br />

in day-to-day medical practice.<br />

In the mental health care system,<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 1: Mission and Vision 7<br />

there is a need for substantial<br />

reform to fully implement a science<br />

to practice quality agenda. Through<br />

our ‘Winds <strong>of</strong> Change’ campaign,<br />

<strong>OMH</strong> is collaborating with the<br />

research, academic and clinical<br />

communities to effectively bring<br />

proven evidence-based practices<br />

into day-to-day clinical settings.<br />

Over time, these interventions, if<br />

available and utilized, could<br />

improve the opportunity for individuals<br />

with serious mental illness and<br />

serious emotional disturbance to<br />

lead more productive, satisfying<br />

lives in their communities. Examples<br />

<strong>of</strong> <strong>OMH</strong> achievements in this area<br />

are presented throughout this Plan.<br />

Population-based Planning<br />

s part <strong>of</strong> our commitment to<br />

Aquality improvement in mental<br />

health care, <strong>OMH</strong> is utilizing a<br />

population-based planning<br />

approach in the design and delivery<br />

<strong>of</strong> public mental health services.<br />

<strong>OMH</strong>’s population-based planning<br />

goals include determining:<br />

◆ The current and future mental<br />

health care needs <strong>of</strong> priority<br />

populations.<br />

◆ The types <strong>of</strong> mental health care<br />

services across the continuum<br />

that will be required to meet<br />

these needs.<br />

◆ Where mental health care services<br />

should be located throughout<br />

our communities and mental<br />

health care system.<br />

◆ What types <strong>of</strong> facilities and<br />

providers are needed to accommodate<br />

these services.<br />

◆ What quality <strong>of</strong> life outcomes<br />

are experienced by service recipients<br />

within these populations.<br />

Today, population-based planning<br />

provides the most productive<br />

method <strong>of</strong> looking at the public<br />

mental health system. It begins<br />

with geographically-based analysis<br />

<strong>of</strong> population characteristics such<br />

as demographics (e.g., age, gender,<br />

race, ethnicity), in conjunction with<br />

data related to mental health such<br />

as estimates <strong>of</strong> the prevalence <strong>of</strong><br />

mental disorders, inpatient and outpatient<br />

service utilization patterns,<br />

and service outcomes data. Stakeholder<br />

input to the populationbased<br />

planning process is critical<br />

for providing important information<br />

on how individuals access mental<br />

health care services, their perception<br />

<strong>of</strong> service gaps and unmet<br />

needs within their communities,<br />

and comments on improvements<br />

that are needed in mental health<br />

care delivery.<br />

Continued movement toward a<br />

population-based planning system<br />

is necessary to fulfill both the <strong>State</strong><br />

and national commitments to<br />

improving the quality <strong>of</strong> mental<br />

health services by focusing on the<br />

needs <strong>of</strong> each individual. <strong>OMH</strong> is<br />

using population-based planning<br />

methods that promote focused<br />

attention on care coordination<br />

across diverse groups as the foundation<br />

for customized, culturally<br />

competent care. More information<br />

about population-based planning is<br />

included in Chapter 3.<br />

Increased Public Input<br />

into the <strong>State</strong> and Local<br />

Planning Process<br />

strong collaboration between<br />

Athe <strong>State</strong>, Local governments<br />

and stakeholders is integral to<br />

implementing quality mental health<br />

initiatives. <strong>OMH</strong>’s review <strong>of</strong> feedback<br />

received during the 2004-2008<br />

mental health planning process<br />

identified a call from multiple<br />

stakeholders to revitalize the planning<br />

process by emphasizing a<br />

commitment to Local planning<br />

input and data driven approaches.<br />

The 2004-2008 Comprehensive<br />

<strong>State</strong>wide Plan was developed<br />

using these approaches and has<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


8 Chapter 1: Mission and Vision<br />

CHIEVING RESULTS-<br />

“A Integral to effective<br />

government management is<br />

the continuous need for<br />

agencies to justify the<br />

investment choices made to<br />

fund programs and services.<br />

Governor Pataki has<br />

challenged agency leaders<br />

to establish an outcomefocused<br />

management culture<br />

that examines the basic<br />

operating assumptions, allocation<br />

decisions and<br />

accepted business practices.<br />

Limited resources are a<br />

reality and agency managers<br />

are expected to meet<br />

the challenge <strong>of</strong> operating<br />

in ways most beneficial to<br />

the <strong>State</strong> and citizens.”<br />

Excerpt from the 2004-2005<br />

Executive Budget Overview<br />

received broad stakeholder<br />

endorsement. In 2004, <strong>OMH</strong> conducted<br />

an expanded series <strong>of</strong><br />

events and opportunities for stakeholder<br />

input on how to build on<br />

the progress made in the 2004-2008<br />

Comprehensive Plan. Chapter 3<br />

describes the stakeholder involvement<br />

that occurred during 2004.<br />

Performance Measurement<br />

he 2004-2008 Comprehensive<br />

TPlan also described <strong>OMH</strong>’s commitment<br />

to creating a performance<br />

measurement system, the extensive<br />

accomplishments already achieved,<br />

and the strategic direction for the<br />

future. Efforts made in 2004 to<br />

advance the performance measurement<br />

approach are consistent with<br />

the leadership provided by Governor<br />

Pataki which was reiterated in<br />

the 2004-2005 Executive Budget.<br />

Throughout 2004, <strong>OMH</strong> has continued<br />

to develop its information technology<br />

and data infrastructures and<br />

core components <strong>of</strong> performance<br />

measurement.<br />

<strong>OMH</strong> believes that a next important<br />

step in advancing the quality<br />

agenda is to enhance and integrate<br />

the performance management<br />

framework. Relying on the continued<br />

leadership from Governor<br />

Pataki regarding an outcomesfocused<br />

management culture, <strong>OMH</strong><br />

has consolidated our achievements<br />

to date with extensive stakeholder<br />

input to create the conceptual<br />

framework for the next iteration <strong>of</strong><br />

the agency’s performance management<br />

system, which is articulated<br />

in Chapter 9 <strong>of</strong> this document. A<br />

major goal <strong>of</strong> the 2005 planning<br />

cycle will be receiving and reviewing<br />

stakeholder input in response<br />

to the performance measurement<br />

framework presented.<br />

Addressing Challenges -<br />

Continuing to Advance<br />

the Quality Agenda<br />

he fundamental challenge that<br />

Tconfronts <strong>New</strong> <strong>York</strong> <strong>State</strong> and<br />

the rest <strong>of</strong> the nation is reshaping<br />

the public mental health system<br />

from an institutional to a community-based<br />

system <strong>of</strong> care that utilizes<br />

evidence-based services and supports,<br />

and financing that transition<br />

in a challenging financial environment.<br />

Advances in psychopharmacology<br />

and mental health treatment<br />

interventions have made living in<br />

integrated community settings a<br />

realistic possibility for most individuals<br />

with serious mental illness or<br />

emotional disturbance. <strong>New</strong> <strong>York</strong><br />

<strong>State</strong>, under Governor Pataki’s<br />

leadership, has engaged in a sustained<br />

effort to achieve that goal.<br />

In <strong>New</strong> <strong>York</strong> <strong>State</strong>, the transition<br />

away from institutionally-based care<br />

has been made possible by<br />

increased investments to strengthen<br />

and expand community-based services.<br />

These increased investments<br />

were made possible by reinvesting<br />

resources associated with unneeded<br />

<strong>State</strong> psychiatric center inpatient<br />

capacity, fully utilizing non-<strong>State</strong><br />

resources, and achieving administrative<br />

consolidations and efficiencies.<br />

These investments were further<br />

advanced by Governor Pataki’s<br />

Enhanced Community Services<br />

package, which provided more than<br />

$125 million in new funding for key<br />

community support services.<br />

<strong>New</strong> <strong>York</strong> is recognized not only<br />

as a national leader in mental<br />

health quality improvement, but<br />

also as a leader in investing in<br />

mental health care. A recent<br />

national survey conducted by the<br />

National Association <strong>of</strong> <strong>State</strong> <strong>Mental</strong><br />

<strong>Health</strong> Program Directors showed<br />

that <strong>New</strong> <strong>York</strong> <strong>State</strong> leads all other<br />

states in its financial investments in<br />

major sectors <strong>of</strong> mental health service<br />

delivery, including inpatient<br />

care, mental health residential serv-<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 1: Mission and Vision 9<br />

ices, and psychiatric research, and<br />

ranks second among states in total<br />

investments in community-based<br />

mental health care. 5<br />

While <strong>OMH</strong>'s strategic direction<br />

is well defined and substantial<br />

progress has been made, fundamental<br />

challenges must continue to<br />

be addressed to move forward and<br />

achieve an even more comprehensive<br />

system <strong>of</strong> care. <strong>OMH</strong> recognizes<br />

the realities <strong>of</strong> <strong>New</strong> <strong>York</strong><br />

<strong>State</strong>'s structural budget imbalance<br />

and the need to evaluate strategic<br />

objectives against fiscal realities.<br />

The challenge is how to align these<br />

realities and the <strong>OMH</strong> mission to<br />

achieve the very best outcomes.<br />

<strong>OMH</strong> will retain its commitment to<br />

the following two fundamental<br />

goals as these efforts continue:<br />

1. Maintaining the Structural<br />

Integrity <strong>of</strong> Existing Service System<br />

Capacity, and<br />

2. Providing Targeted Service System<br />

Expansion Where Needed and<br />

Supported by the Evidence Base.<br />

The agency recommends proceeding<br />

on a course in which continued<br />

redirection <strong>of</strong> savings and new<br />

investment in these planning priorities<br />

take place as fiscal realities<br />

allow. Generally, initiatives to<br />

reestablish or maintain the structural<br />

and financial integrity <strong>of</strong> existing<br />

service providers and capacity take<br />

precedence over program expansion.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong><br />

Adult Psychiatric<br />

Center Trends and<br />

Opportunities<br />

oday, the <strong>New</strong> <strong>York</strong> <strong>State</strong> psy-<br />

center system, by far the<br />

Tchiatric<br />

largest in the nation, continues to<br />

support unneeded infrastructure.<br />

Table 1.1 describes how <strong>New</strong> <strong>York</strong><br />

<strong>State</strong>'s adult psychiatric centers<br />

have decreased in size as the locus<br />

<strong>of</strong> care shifted to the community.<br />

During the 1950s, <strong>New</strong> <strong>York</strong> <strong>State</strong><br />

operated 20 psychiatric centers<br />

with a total inpatient census <strong>of</strong><br />

approximately 93,000.<br />

The public mental health system<br />

has changed dramatically since that<br />

time. Since advances in psychopharmacology<br />

and mental<br />

health treatment interventions have<br />

made living in integrated community<br />

settings a realistic possibility for<br />

most individuals with serious mental<br />

illness or emotional disturbance,<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> and the rest <strong>of</strong> the<br />

nation have engaged in a sustained<br />

effort to transition the public mental<br />

health service delivery system<br />

from institutional to communitybased<br />

settings.<br />

In <strong>New</strong> <strong>York</strong> <strong>State</strong> this transition<br />

has included a substantial expansion<br />

<strong>of</strong> community-based services,<br />

including housing, case management<br />

and other supports, which<br />

have made the decrease in inpatient<br />

census possible. The existing<br />

community-based residential system<br />

currently supports almost 27,000<br />

operating beds and another 4,100<br />

beds are in various stages <strong>of</strong> planning<br />

and development. Including<br />

the beds authorized in this year's<br />

Executive Budget, the total number<br />

<strong>of</strong> community beds will be 31,100.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> continues to<br />

operate more psychiatric centers<br />

than any other state in the nation,<br />

and inpatient bed utilization also<br />

Notes<br />

5 Additional information regarding this national<br />

comparative information is contained on<br />

the NASMHPD web site.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


10 Chapter 1: Mission and Vision<br />

Table 1.1<br />

The Shrinking Size <strong>of</strong> <strong>New</strong> <strong>York</strong>’s <strong>State</strong> Adult Psychiatric Centers<br />

1955 (Peak) Dec. 31, 1993 Dec. 31, 1998 Oct. 1, 2003<br />

Total Census 93,197 10,162 5,309 4,223<br />

Number <strong>of</strong> Psychiatric Centers 20 21 17 17<br />

Average Census <strong>of</strong> Psychiatric Centers 5,178 484 312 248<br />

Largest Psychiatric Center Census 14,325 1,167 1,077 703<br />

Smallest Psychiatric Center Census 2,164 107 95 71<br />

Workforce 24,500 20,900 13,600 11,225<br />

continues to exceed that <strong>of</strong> other<br />

mid-Atlantic states. Today, <strong>New</strong><br />

<strong>York</strong> operates 20 <strong>State</strong> adult psychiatric<br />

centers, three <strong>of</strong> which serve<br />

forensic inmate-patients. The 17<br />

non-forensic adult psychiatric centers<br />

currently have a total inpatient<br />

census <strong>of</strong> less than 4,200. With the<br />

number <strong>of</strong> people requiring inpatient<br />

psychiatric treatment only a<br />

fraction <strong>of</strong> the size it once was,<br />

there is no longer a need to continue<br />

operating this many facilities.<br />

With an estimated adult inpatient<br />

census <strong>of</strong> less than 4,100 by the<br />

end <strong>of</strong> the 2006 <strong>State</strong> fiscal year,<br />

<strong>New</strong> <strong>York</strong> must continue to examine<br />

the role <strong>of</strong> <strong>State</strong>-operated inpatient<br />

care within the broader context<br />

<strong>of</strong> community-based treatment,<br />

rehabilitation and support services<br />

available in each area <strong>of</strong> the <strong>State</strong>.<br />

The benefits <strong>of</strong> maintaining the<br />

<strong>State</strong> adult psychiatric center infrastructure<br />

at the present level for<br />

the number <strong>of</strong> individuals being<br />

served does not justify current<br />

associated costs or anticipated<br />

future costs.<br />

To continue the transition to evidence-based<br />

adult and children's<br />

services that are delivered in the<br />

community, maintain community<br />

access to inpatient services, and<br />

avoid investing in unneeded adult<br />

psychiatric center administrative<br />

and infrastructure costs, <strong>OMH</strong> has<br />

identified the following criteria for<br />

the consolidation <strong>of</strong> adult inpatient<br />

capacity:<br />

◆ Substantial administrative savings<br />

could be realized and reinvested<br />

in community-based services;<br />

◆ Large capital expenditures could<br />

be avoided that would support<br />

unneeded inpatient infrastructure;<br />

and<br />

◆ Inpatient beds could be transferred<br />

to a nearby psychiatric<br />

center where adequate unused<br />

physical space exists.<br />

<strong>OMH</strong> has concluded that Middletown<br />

Psychiatric Center meets<br />

these criteria and has recommended<br />

its closure; transferring Middletown's<br />

inpatient beds to the Rockland<br />

Psychiatric Center; maintaining<br />

existing <strong>State</strong> outpatient services in<br />

their current communities; and<br />

reinvesting 100% <strong>of</strong> the associated<br />

savings to expand <strong>State</strong>-operated<br />

community services in Orange and<br />

Sullivan Counties. These actions<br />

will be taken without eliminating<br />

any inpatient capacity.<br />

Several key factors were considered<br />

in reaching these recommendations.<br />

Middletown Psychiatric<br />

Center is serving a small number <strong>of</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 1: Mission and Vision 11<br />

individuals and this number continues<br />

to decline: although Middletown<br />

once had over 3,000 inpatient<br />

beds, it now has only 115. It is difficult<br />

to justify the $28 million capital<br />

investment that would be<br />

required to maintain certification<br />

compliance for a psychiatric center<br />

<strong>of</strong> this size. There is sufficient<br />

unused physical space at nearby<br />

Rockland Psychiatric Center to relocate<br />

Middletown's inpatient services.<br />

Finally, adults and children in<br />

the current Middletown catchment<br />

area will be better served by the<br />

expanded new <strong>State</strong>-operated community-based<br />

services.<br />

2005-2006 Executive<br />

Budget Actions<br />

T<br />

he 2005-2006 Executive Budget<br />

for the <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

advances the Governor’s transformation<br />

<strong>of</strong> <strong>New</strong> <strong>York</strong>’s public mental<br />

health system by continuing to<br />

redirect resources to community<br />

settings, provide funding for targeted<br />

service expansion in sciencebased<br />

treatments, and provide<br />

funding to preserve and reinforce<br />

the existing service system. The FY<br />

2005-2006 budget continues the<br />

advancement <strong>of</strong> an agenda that is<br />

integral to the promotion <strong>of</strong> recovery<br />

and community integration for<br />

individuals with mental illness. The<br />

Executive Budget strengthens key<br />

community programs and maximizes<br />

access to quality mental<br />

health care, while still achieving<br />

the necessary efficiencies to ensure<br />

the most cost-effective use <strong>of</strong> all<br />

resources.<br />

Additional information regarding<br />

the 2005-2006 Executive Budget is<br />

included in Appendix 11.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


12 Chapter 1: Mission and Vision<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 2: Who is Served 13<br />

Who is Served Chapter 2<br />

Introduction<br />

n 2004 <strong>OMH</strong> made a major com-<br />

to increasing opportunities<br />

Imitment<br />

for public input into the planning<br />

process. 2004 stakeholder input<br />

identified planning priorities for the<br />

continued provision and refinement<br />

<strong>of</strong> planning data. These priorities<br />

include using a population-based<br />

approach to organize data regarding<br />

adults served in the public mental<br />

health system to focus on priority<br />

sub-populations including young<br />

adults and older adults.<br />

This Chapter provides the latest<br />

data available from the 2003 Patient<br />

Characteristics Survey (PCS). 1 This<br />

system-wide data is two years more<br />

current than the 2001 data provided<br />

in the 2004 Comprehensive<br />

Plan, and can be compared to that<br />

data to look for emerging trends.<br />

As one might expect, changes over<br />

a two-year period may not be striking,<br />

but can provide an indication<br />

<strong>of</strong> potential trends that may require<br />

continued monitoring. Chapter 2<br />

presents PCS data using a population-based<br />

approach to describe<br />

sub-populations <strong>of</strong> interest by<br />

demographics and diagnosis.<br />

The <strong>State</strong>wide<br />

Perspective<br />

E<br />

ach year, more than 600,000 persons<br />

receive services in <strong>New</strong><br />

<strong>York</strong>’s public mental health<br />

system. 2 Of this total, approximately<br />

22% are children aged 17 years<br />

or younger. At least two-thirds <strong>of</strong><br />

all individuals served have both a<br />

mental disorder and severe functional<br />

impairment resulting from<br />

their disorder. This combination <strong>of</strong><br />

a mental disorder and severe functional<br />

impairment is referred to as<br />

serious mental illness. In the U.S.,<br />

mental illnesses rank first among<br />

illnesses that cause disability. The<br />

disabling effects <strong>of</strong> mental illness in<br />

adults can result in homelessness,<br />

joblessness, health problems, and<br />

social isolation. In children, the<br />

effects are <strong>of</strong>ten serious and long<br />

lasting, leading to poor academic<br />

achievement, failure to complete<br />

high school, substance abuse,<br />

involvement with the correctional<br />

system, lack <strong>of</strong> vocational success,<br />

inability to live independently, and<br />

health problems. Additional information<br />

about the disease burden<br />

and costs <strong>of</strong> mental illness is<br />

included in Chapter 4.<br />

Specifically, in <strong>New</strong> <strong>York</strong> <strong>State</strong><br />

66% <strong>of</strong> adults served have serious<br />

mental illness and 72% <strong>of</strong> children<br />

and adolescents served have serious<br />

emotional disturbance. These<br />

proportions are consistent with<br />

Notes<br />

1 <strong>OMH</strong> derives its estimates <strong>of</strong> the number <strong>of</strong><br />

people served annually by the public mental<br />

health system from its Patient Characteristics<br />

Survey (PCS). The PCS, which is administered<br />

every other year, gathers information<br />

about the demographic and clinical characteristics<br />

<strong>of</strong> persons receiving mental health<br />

services in programs operated, funded, or<br />

certified by <strong>OMH</strong> during a one-week period.<br />

The one-week data are then used to estimate<br />

the total number <strong>of</strong> people served<br />

annually and their characteristics. <strong>OMH</strong> uses<br />

estimates rather than actual counts because<br />

the variety <strong>of</strong> administrative data systems<br />

used today in the public mental health system<br />

does not allow a complete enumeration<br />

across all service sectors <strong>of</strong> the number <strong>of</strong><br />

persons served. For simplicity, point estimates<br />

are reported in this document. The<br />

range for estimates will vary by size <strong>of</strong> the<br />

population, but is typically less than ±5%.<br />

The data presented in this chapter are<br />

derived from the 2003 PCS, which is the<br />

most recent available.<br />

2 Services provided in <strong>New</strong> <strong>York</strong>’s public mental<br />

health system include those delivered by<br />

programs funded, certified or operated by<br />

<strong>OMH</strong>. They do not include mental health<br />

services provided by private practitioners or<br />

physicians or mental health services provided<br />

by programs operated by other <strong>State</strong><br />

agencies, for example, the <strong>Office</strong> <strong>of</strong> Children<br />

and Family Services.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


14 Chapter 2: Who is Served<br />

reported U.S. averages <strong>of</strong> 65% and<br />

62% respectively.<br />

The diversity <strong>of</strong> the population<br />

served in <strong>New</strong> <strong>York</strong>’s public mental<br />

health system emphasizes the need<br />

for population-based planning.<br />

Twenty two percent <strong>of</strong> this population<br />

is under 18 years <strong>of</strong> age, 9%<br />

are young adults aged 18-24, 13%<br />

are adults aged 25-34, 29% are<br />

aged 35-49, 17% are aged 50-64,<br />

9% are over 65 years <strong>of</strong> age, and<br />

for 1%, the age is unknown. Across<br />

age groups, approximately 50% are<br />

male and 50% female. This racially<br />

diverse population is 55% White,<br />

24% Black, 17% unknown race, 2%<br />

Asian, and 2% another race or<br />

multi-racial. Hispanic ethnicity is<br />

reported separately from race.<br />

Twenty-one percent (21%) are ethnically<br />

Hispanic, including many <strong>of</strong><br />

those whose reported race was<br />

unknown.<br />

How do the demographic characteristics<br />

<strong>of</strong> individuals served in the<br />

public mental health system compare<br />

with those <strong>of</strong> <strong>New</strong> <strong>York</strong>’s general<br />

population? Figure 2.1<br />

describes persons served annually<br />

in the public mental health system<br />

with a population-based approach<br />

Figure 2.1<br />

Number <strong>of</strong> Persons Served Annually,<br />

Rate per 1,000 Persons in the General Population<br />

60<br />

that utilizes 2003 U.S. Census data. 3<br />

On an annual basis, 31.63 females<br />

per 1,000 females in the general<br />

population and 33.15 males per<br />

1,000 males in the general population<br />

receive services in our public<br />

mental health system. By age<br />

group, the rates are highest among<br />

13-17 year olds (51.71) and 35-49<br />

year olds (40.82), and lowest<br />

among children aged 12 years or<br />

younger (21.59) and those 65 years<br />

and older (21.48). By race, the rates<br />

are highest among individuals who<br />

are Multi-racial (43.05) and Black<br />

(42.23), and lowest among Asians<br />

(7.36) and American Indian or<br />

Alaskan Natives (9.44). Rates for<br />

persons with Hispanic ethnicity<br />

were nearly as high as the Black<br />

and Multi-racial groups (41.55).<br />

These data show that although individuals<br />

who are 35-49 years old<br />

comprise the largest group <strong>of</strong> service<br />

recipients and that the majority<br />

<strong>of</strong> service recipients are White,<br />

services are delivered at the highest<br />

rate to individuals who are 13-17<br />

years <strong>of</strong> age and to members <strong>of</strong> the<br />

Black and Hispanic populations.<br />

50<br />

51.71<br />

40<br />

33.15<br />

31.63<br />

30<br />

20<br />

21.59<br />

28.73 31.15 40.82<br />

33.42<br />

21.48<br />

43.05 42.23 41.55<br />

25.21<br />

23.72<br />

10<br />

9.44 7.36<br />

Notes<br />

3 The rate is the number <strong>of</strong> persons served per<br />

1,000 persons in the general population having<br />

the same demographic,<br />

0<br />

MaleFemale<br />

0-12 13-17 18-24 25-34 35-49 50-64 65 & Multracial<br />

White<br />

Pacific<br />

Black Hispanic<br />

older<br />

Gender Age in Years Ethnicity Islander<br />

Am Asian<br />

Ind./<br />

AL Nat.<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 2: Who is Served 15<br />

Age Groups Served<br />

Children Aged 17 and Under<br />

y diagnosis among children<br />

Bserved, the largest proportions<br />

have attention deficit disorder (24%)<br />

or adjustment disorder (19%). Smaller<br />

numbers have conduct disorder<br />

or bipolar/major depressive disorder<br />

(16% each), 12% have some other<br />

disorder, 8% have anxiety disorder,<br />

and 3% each have either schizophrenia/<br />

psychotic or personality or<br />

impulse control disorder.<br />

Young Adults, Aged 18-24<br />

mong individuals served who<br />

Aare aged 18-24, 36% are diagnosed<br />

with bipolar disorder or<br />

major depression, 22% with some<br />

other disorder, 13% each with<br />

schizophrenia and related disorders<br />

or an adjustment disorder, 8% with<br />

an anxiety disorder, 5% with a<br />

delusional or psychotic disorder,<br />

and 3% with a personality or<br />

impulse control disorder.<br />

Schizophrenia/<br />

Psychotic (3%)<br />

Adults Aged 25-64<br />

mong adults served who are<br />

Aaged 25-64, 40% have either<br />

bipolar disorder or major depression,<br />

24% have schizophrenia and<br />

related disorders, 15% have some<br />

other disorder, 9% have anxiety<br />

disorder, 6% have adjustment disorder,<br />

4% have delusional and<br />

other psychotic disorder, and 2%<br />

personality or impulse control<br />

disorder.<br />

Older Adults<br />

mong adults served who are<br />

Aaged 65 and over, 40% are<br />

diagnosed with either bipolar disorder<br />

or major depression, 18% with<br />

schizophrenia and related disorders,<br />

13% with organic brain disorder,<br />

10% with some other disorder,<br />

7% each with an adjustment or<br />

anxiety disorder, and 5% with a<br />

delusional or psychotic disorder.<br />

These data show that bipolar disorder<br />

is the most common diagnosis<br />

among adults served regardless<br />

<strong>of</strong> age group. In each adult popu-<br />

Figure 2.2<br />

Primary <strong>Mental</strong> Disorders Among People Served in the Public <strong>Mental</strong> <strong>Health</strong> System<br />

Personality/<br />

Impulse (3%)<br />

Attention<br />

Deficit (24%)<br />

Adjustment<br />

(19%)<br />

Conduct<br />

(16%)<br />

Anxiety<br />

(8%)<br />

Other (12%)<br />

Bipolar/Major<br />

Depressive<br />

(16%)<br />

Personality &<br />

Impulse Control<br />

(3%)<br />

Delusional &<br />

Other Psychotic<br />

(5%)<br />

Other (22%)<br />

Adjustment<br />

(13%)<br />

Anxiety<br />

(8%)<br />

Bipolar/Major<br />

Depressive (36%)<br />

Schizophrenia<br />

and Related<br />

(13%)<br />

Personality &<br />

Impulse Control (2%)<br />

Delusional & Other<br />

Psychotic (4%)<br />

Adjustment<br />

(6%)<br />

Children, Aged 17 and Under<br />

Anxiety<br />

(9%)<br />

Other (15%)<br />

Schizophrenia<br />

and Related<br />

(24%)<br />

Adults, Aged 25-64<br />

Bipolar/Major<br />

Depressive (40%)<br />

Organic Brain<br />

Disorder (13%)<br />

Delusional & Other<br />

Psychotic (5%)<br />

Adjustment<br />

(7%)<br />

Young Adults, Aged 18-24<br />

Anxiety<br />

(7%)<br />

Other<br />

(10%)<br />

Schizophrenia<br />

and Related<br />

(18%)<br />

Bipolar/Major<br />

Depressive<br />

(40%)<br />

Older Adults, Aged 65 and over<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


16 Chapter 2: Who is Served<br />

lation, diagnoses <strong>of</strong> bipolar disorder<br />

and schizophrenia together<br />

comprise nearly half or more <strong>of</strong> all<br />

diagnoses: 49% <strong>of</strong> all diagnoses<br />

among adults aged 18-24; 64%<br />

among adults aged 25-64; and 58%<br />

among adults aged 65 and over.<br />

Where are People Served?<br />

Figure 2.3<br />

Persons Served Annually<br />

by Program<br />

70%<br />

60%<br />

50%<br />

40%<br />

30%<br />

65%<br />

20% 22%<br />

10%<br />

15% 14%<br />

0%<br />

6%<br />

Outpatient Inpatient Residential<br />

Community Emergency<br />

Support<br />

o live successfully in our com-<br />

most individuals with<br />

Tmunities,<br />

serious mental illness need both<br />

treatments that control or eliminate<br />

their psychiatric symptoms and a<br />

range <strong>of</strong> support services that meet<br />

the complex needs caused by the<br />

disabling effects <strong>of</strong> their illness.<br />

Public mental health services are<br />

grouped in four major categories<br />

across the health care continuum:<br />

community support, outpatient,<br />

inpatient, and emergency services.<br />

◆ Community support helps<br />

individuals diagnosed with serious<br />

mental illness live as independently<br />

as possible in the<br />

community, and helps children<br />

with serious emotional disturbance<br />

to remain with their families.<br />

These programs provide<br />

case management, vocational,<br />

self-help, residential and other<br />

support services. Although the<br />

specific array <strong>of</strong> community support<br />

services differs for adults<br />

and children, the goal is always<br />

to support successful and full<br />

community living.<br />

◆ Outpatient services provide<br />

treatment and rehabilitation in an<br />

ambulatory setting, including clinics,<br />

partial hospitalization treatment<br />

for children, continuing day<br />

treatment for adults, Assertive<br />

Community Treatment (ACT),<br />

Prepaid <strong>Mental</strong> <strong>Health</strong> Plan<br />

(PMHP) and the soon to be<br />

implemented Personalized Recovery-Oriented<br />

Services (PROS).<br />

◆ Inpatient services provide<br />

acute stabilization and intensive<br />

treatment and rehabilitation with<br />

24-hour care in a controlled<br />

environment. They are the programs<br />

<strong>of</strong> choice only when the<br />

required services and supports<br />

cannot be delivered in community<br />

settings.<br />

◆ Emergency services provide<br />

rapid psychiatric and/or medical<br />

stabilization and ensure the safety<br />

<strong>of</strong> individuals who present a<br />

risk to themselves or others.<br />

These programs include a range<br />

<strong>of</strong> crisis counseling and residential<br />

services, as well as comprehensive<br />

psychiatric emergency<br />

programs.<br />

In <strong>New</strong> <strong>York</strong> <strong>State</strong>, both <strong>State</strong><br />

and locally operated programs provide<br />

services in each <strong>of</strong> these categories.<br />

The overall goal is to promote<br />

recovery and full community<br />

living for individuals with serious<br />

mental illness, while preserving<br />

public safety, and ensuring that<br />

respect, empowerment, and quality<br />

<strong>of</strong> life are incorporated into every<br />

aspect <strong>of</strong> care.<br />

On an annual basis, among persons<br />

receiving services in <strong>New</strong><br />

<strong>York</strong> <strong>State</strong>’s public mental health<br />

system, 65% are served in outpatient<br />

programs, 22% in community<br />

support programs, 14% in emergency<br />

programs, and 15% in inpatient<br />

programs. Six percent are also<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 2: Who is Served 17<br />

Figure 2.4<br />

Program Participation by Age<br />

70% 69% 60%<br />

66%<br />

60%<br />

58%<br />

Ages 0-17<br />

Ages 25-64<br />

Ages 18-24<br />

Ages 65 +<br />

50%<br />

40%<br />

30%<br />

20%<br />

17% 17%<br />

23% 23%<br />

19%<br />

16% 15%<br />

16%<br />

22%<br />

13% 12%<br />

1%<br />

10%<br />

11%<br />

8%<br />

4%<br />

3%<br />

0%<br />

Outpatient Community Support Inpatient Emergency Residential<br />

served in residential programs, a<br />

community support service. The<br />

total exceeds 100% because individuals<br />

may receive services from<br />

more than one category depending<br />

upon need (Figure 2.3).<br />

Figure 2.4 describes program participation<br />

by age group. Among<br />

children 17 or younger, 69% participate<br />

in outpatient, 17% in community<br />

support programs, 11% in<br />

inpatient, 16% in emergency, and<br />

1% in residential programs. Among<br />

young adults aged 18-24, 60% participate<br />

in outpatient, 17% in community<br />

support programs, 19% in<br />

inpatient, 22% in emergency, and<br />

4% in residential programs. Among<br />

adults aged 25-64, 66% participate<br />

in outpatient, 23% in community<br />

support programs, 16% in inpatient,<br />

13% in emergency, and 8% in residential<br />

programs. Among adults 65<br />

and over, 58% participate in outpatient,<br />

23% in community support<br />

programs, 15% in inpatient, 12% in<br />

emergency, and 3% in residential<br />

programs. As depicted in Figure<br />

2.4, the totals exceed 100%<br />

because individuals may receive<br />

services from more than one category<br />

depending upon need.<br />

Across age groups, the largest<br />

proportion <strong>of</strong> individuals (approximately<br />

60% or more) participate in<br />

outpatient services.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


18 Chapter 2: Who is Served<br />

Infrastructure<br />

Development<br />

to Support<br />

Local Planning<br />

I<br />

n 2000, <strong>OMH</strong>, <strong>New</strong> <strong>York</strong> City and<br />

Local mental hygiene directors<br />

formed a multi-year partnership to<br />

improve access to information systems<br />

and enhance data-driven decision<br />

making. The group targeted<br />

data systems that, given improved<br />

local access, could assist Local<br />

directors in managing service delivery<br />

and provider performance. In<br />

response, <strong>OMH</strong> initiated a Webbased<br />

information portal containing<br />

Medicaid services and expenditures,<br />

patient characteristics, and<br />

adult housing admissions. In addition,<br />

a <strong>State</strong>/Local workgroup collaborated<br />

to define the systems’<br />

specifications for the Child and<br />

Adult Integrated Reporting System<br />

(CAIRS), a local management information<br />

system designed to track<br />

specialty, housing and case management<br />

services to high-need,<br />

high-risk populations.<br />

CAIRS is a dynamically generated,<br />

Web-based application that<br />

enhances the ability <strong>of</strong> Local<br />

providers to access information,<br />

generate performance management<br />

reports, and carry out care coordination<br />

activities. By the end <strong>of</strong><br />

2004, more than 3,000 individuals<br />

from over 1,100 program units<br />

statewide were authorized to use<br />

CAIRS. Furthermore, nearly 140,000<br />

records exist in the CAIRS system<br />

as <strong>of</strong> December 31, 2004. Children’s<br />

programs that are required<br />

to report on CAIRS information<br />

include residential treatment facilities,<br />

family-based treatment, teaching<br />

family homes, community and<br />

crisis residences, the Home and<br />

Community Based Services Waiver,<br />

Home-based Crisis Intervention,<br />

intensive, supportive, and blended<br />

case management, mobile mental<br />

health teams, and school-based<br />

mental health. Adult programs<br />

reporting include Assertive Community<br />

Treatment, Assisted Outpatient<br />

Treatment, adult housing, and<br />

family care providers.<br />

<strong>OMH</strong>’s Enterprise Data Warehouse<br />

is a repository <strong>of</strong> data from<br />

a wide variety <strong>of</strong> sources and a<br />

cornerstone <strong>of</strong> the agency’s<br />

increasing capacities for data-driven<br />

Figure 2.5<br />

People Receiving Services During Patient Characteristics Survey Week<br />

per 1,000 General Population. 1999 vs. 2003<br />

14<br />

12<br />

1999 2003<br />

12.5 12.4<br />

10.9 10.7<br />

Per 1,000 General Population<br />

10<br />

8<br />

6<br />

4<br />

5.8 5.8<br />

9.5<br />

8.9<br />

5.6<br />

5.1<br />

8.4<br />

7.8<br />

5.8<br />

5.2<br />

2<br />

0<br />

Under 12<br />

13 to 17 18 to 24 25 to 34 35 to 49 50 to 64 65 and older<br />

Age in Years<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 2: Who is Served 19<br />

performance-based management.<br />

Data marts in the Warehouse<br />

organize all relevant and available<br />

recipient level information to provide<br />

a comprehensive and integrated<br />

view <strong>of</strong> the needs and treatment<br />

<strong>of</strong> users <strong>of</strong> mental health services<br />

in <strong>New</strong> <strong>York</strong> <strong>State</strong>. Financial data<br />

marts provide reporting and analysis<br />

capability in the areas <strong>of</strong> payroll,<br />

personnel, and financial transactions.<br />

The Data Warehouse<br />

organizes and integrates these data<br />

to facilitate rapid ad-hoc analysis<br />

and reporting.<br />

Due to successful data infrastructure<br />

development, <strong>OMH</strong> is able to<br />

track services across time and<br />

providers, enabling the agency to<br />

measure performance in such critical<br />

areas as inpatient readmissions<br />

and time to first outpatient service<br />

following discharge from hospital<br />

settings. By integrating data from a<br />

variety <strong>of</strong> sources, <strong>OMH</strong> is able to<br />

detect trends in services delivery.<br />

For example, Figure 2.5 shows<br />

the increase in the number <strong>of</strong> persons<br />

served from the 1999 to 2003<br />

surveys by age group. To control<br />

for differences in the general population<br />

by age, the figure shows<br />

rates <strong>of</strong> persons served per 1,000<br />

persons <strong>of</strong> the same age group in<br />

the population. Increases were<br />

observed in the adolescent and<br />

young adult groups. These trends<br />

are notable and are one reason<br />

why adolescents and young adults<br />

are receiving focused attention.<br />

Further discussion <strong>of</strong> agency priorities<br />

regarding this population<br />

group is found in Chapter 3.<br />

Using Geographical<br />

Information Systems<br />

(GIS) to Support<br />

Population-based<br />

Planning<br />

MH population-based planning<br />

Oefforts are supported by a Geographic<br />

Information Systems (GIS)<br />

initiative, products <strong>of</strong> which<br />

include:<br />

◆ A repository <strong>of</strong> geo-coded data<br />

(providers, location <strong>of</strong> services,<br />

recipients, prevalence estimates,<br />

census information).<br />

◆ Easily reproducible “geomaps”<br />

that are used to describe and<br />

compare information across and<br />

between geographic areas (e.g.,<br />

counties) including service use<br />

and expenditures and prevalence<br />

<strong>of</strong> mental illness versus treated<br />

prevalence. Geomaps are excellent<br />

tools for population-based<br />

planning and are also used to<br />

support analysis <strong>of</strong> “what-if” scenarios<br />

in addition to actual public<br />

mental health system characteristics<br />

and modeling.<br />

An example <strong>of</strong> how populationbased<br />

planning efforts can be supported<br />

by geo-mapping technology<br />

is presented in Figure 2.6, which<br />

uses 2004 U.S. Census estimates<br />

and prevalence rates <strong>of</strong> serious and<br />

persistent mental illness (SPMI) to<br />

describe the estimated number and<br />

locations <strong>of</strong> adults aged 18-54 with<br />

SPMI in <strong>New</strong> <strong>York</strong> <strong>State</strong>. <strong>State</strong>wide<br />

the estimated prevalence <strong>of</strong> SPMI<br />

among adults ages 18-54 is 2.6%.<br />

The population’s density is plotted<br />

on the map by zip code. Using<br />

geomaps <strong>of</strong> this type, <strong>OMH</strong> is able<br />

to determine correlations between<br />

estimated SPMI prevalence and<br />

mental health program locations.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


20 Chapter 2: Who is Served<br />

Figure 2.6<br />

Geomap: Estimated Number <strong>of</strong> Adults with SPMI Ages 18-54 (Prevalence rate 2.6%)<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 3: Collaborations to Strengthen Planning 21<br />

Collaborations<br />

to Strengthen Planning<br />

Chapter 3<br />

MH believes that a high quality<br />

Opublic mental health system can<br />

only be sustained with a strong,<br />

ongoing collaboration between the<br />

<strong>State</strong>, Local governments and<br />

numerous stakeholder groups in<br />

the planning and delivery <strong>of</strong> quality<br />

mental health services. To this<br />

end, <strong>OMH</strong> continues to create new<br />

opportunities for ongoing dialogues,<br />

stakeholder input, and<br />

planning collaborations.<br />

Chapter 3 provides a brief<br />

overview <strong>of</strong> planning activities and<br />

collaborations carried out since the<br />

release <strong>of</strong> the 2004-2008 <strong>State</strong>wide<br />

Comprehensive Plan for <strong>Mental</strong><br />

<strong>Health</strong> Services. Included are references<br />

and links to related documents<br />

describing planning activities<br />

carried out during 2004. The Chapter<br />

also describes progress made in<br />

a number <strong>of</strong> specific, important<br />

planning collaborations during the<br />

past year.<br />

2004 Planning<br />

Activities<br />

O<br />

MH has made a major commitment<br />

to improve and strengthen<br />

the statewide mental health planning<br />

process. In 2004, the agency<br />

continued this commitment by substantially<br />

expanding opportunities<br />

for stakeholder input in response<br />

to the 2004-2008 Comprehensive<br />

Plan. For the first time, interactive,<br />

informational briefing sessions<br />

were held in all five <strong>OMH</strong> regions.<br />

Briefings were attended by stakeholders<br />

including recipients, families,<br />

providers, advocates, and<br />

county mental health directors and<br />

their staff. During these briefings,<br />

participants were encouraged to<br />

identify and discuss issues <strong>of</strong> local,<br />

regional and statewide importance<br />

regarding the adult and children’s<br />

mental health systems. Topics<br />

included the planning process, and<br />

areas <strong>of</strong> the public mental health<br />

system requiring ongoing attention.<br />

Public hearings to obtain formal<br />

public response to the 2004-2008<br />

Plan were also held in all five<br />

regions. Individual testimony given<br />

at the five hearings varied widely<br />

in content and focus, but<br />

addressed virtually all aspects <strong>of</strong><br />

the public mental health system.<br />

This year, for the first time ever,<br />

<strong>OMH</strong> is providing the full text <strong>of</strong><br />

this testimony on our Web site at<br />

http://www.omh.state.ny.us/<br />

omhweb/<strong>State</strong>wideplan/testimony/<br />

index.htm.<br />

<strong>OMH</strong> has long considered input<br />

from its advisory committees (Multicultural<br />

Advisory Committee, Recipient<br />

Advisory Committee, Commissioner’s<br />

Committee on Families, <strong>Mental</strong><br />

<strong>Health</strong> Planning Advisory Council,<br />

and <strong>Mental</strong> <strong>Health</strong> Services Council)<br />

to be critical elements that are vital to<br />

the planning process. Building upon<br />

the positive results from advisory<br />

committee input, <strong>OMH</strong> has put into<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


22 Chapter 3: Collaborations to Strengthen Planning<br />

place a number <strong>of</strong> formal and informal<br />

methods to cultivate ongoing dialogue,<br />

obtain public comment and<br />

suggestions, promote the cooperative<br />

sharing <strong>of</strong> information, and ultimately,<br />

promote recovery.<br />

Figure 3.1<br />

Statutory, Oversight and Administrative Functions which Contribute to the Planning Process<br />

Judicial branch<br />

Executive branch<br />

Legislative branch<br />

Commission on<br />

Quality <strong>of</strong> Care<br />

for the <strong>Mental</strong>ly<br />

Disabled (MHL-<br />

Section 45.07)<br />

<strong>Office</strong> <strong>of</strong><br />

Alcoholism and<br />

Substance Abuse<br />

Services<br />

NYS<br />

Department<br />

<strong>of</strong> <strong>Mental</strong><br />

Hygiene<br />

Inter-<strong>Office</strong><br />

Coordinating<br />

Council<br />

(MHL-<br />

Section<br />

5.05 (b))<br />

<strong>Office</strong> <strong>of</strong> <strong>Mental</strong><br />

Retardation and<br />

Developmental<br />

Disabilities<br />

Policy Advisory<br />

Boards for:<br />

• Families<br />

• Recipients<br />

• Multicultural Issues<br />

• Boards <strong>of</strong> Visitors<br />

• (MHL-Section 7.37)<br />

Local<br />

Comprehensive<br />

Plans from<br />

Each County<br />

(MHL-Section<br />

5.07 (b) (1))<br />

<strong>Office</strong> <strong>of</strong><br />

<strong>Mental</strong> <strong>Health</strong><br />

<strong>State</strong>wide<br />

Comprehensive<br />

Plan<br />

Policy Advice from:<br />

• Oversight Bodies<br />

• Courts<br />

• Legislators<br />

• The Public<br />

• Stakeholder<br />

• Groups<br />

• Pr<strong>of</strong>essional<br />

• and Trade<br />

• Associations<br />

<strong>Mental</strong> <strong>Health</strong><br />

Planning Advisory<br />

Council (PL-99-660)<br />

<strong>Mental</strong> <strong>Health</strong><br />

Services Council<br />

(MHL-Section 7.05)<br />

Statutory<br />

Planning Process<br />

(MHL Section 5.07)<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 3: Collaborations to Strengthen Planning 23<br />

Highlights <strong>of</strong> 2004 Efforts<br />

to Promote Dialogue and<br />

Planning Collaboration<br />

MH has productive partnerships<br />

Owith stakeholder groups including<br />

the Conference <strong>of</strong> Local <strong>Mental</strong><br />

Hygiene Directors (CLMHD), general<br />

hospitals that operate psychiatric<br />

units (known as Article 28<br />

hospitals), current and former<br />

recipients <strong>of</strong> mental health services,<br />

families and loved ones <strong>of</strong> those<br />

with a mental illness, culturally<br />

diverse communities and constituents,<br />

and advocates for special<br />

populations including children,<br />

older adults and adult home residents.<br />

These partnerships provide<br />

valuable insight and information<br />

for the planning process as <strong>OMH</strong><br />

continues working toward a system<br />

<strong>of</strong> care that supports an individual’s<br />

personal path to recovery. Highlights<br />

are provided below.<br />

The Conference <strong>of</strong> Local <strong>Mental</strong><br />

Hygiene Directors<br />

n ongoing collaboration<br />

Abetween <strong>OMH</strong> and CLMHD is a<br />

critical element <strong>of</strong> the revitalized<br />

planning process, and the two<br />

organizations continue to work<br />

together to develop and implement<br />

principles that will guide the planning<br />

process. A collaborative planning<br />

agenda was formally renewed<br />

in 2004 and an initial meeting was<br />

held in January. The two organizations<br />

are also working together to<br />

refine and strengthen the specific<br />

planning roles for the counties and<br />

for <strong>OMH</strong>.<br />

During the 2004-2005 planning<br />

cycle, a top planning priority for<br />

the Conference was a survey <strong>of</strong> its<br />

membership regarding issues<br />

impacting persons with mental illness<br />

and services in their localities.<br />

Findings from the survey have<br />

been shared with <strong>OMH</strong> and were<br />

considered in the formulation <strong>of</strong><br />

this 2005-2009 Comprehensive<br />

Plan. A summary <strong>of</strong> the survey<br />

findings is included as Appendix 2<br />

<strong>of</strong> this document and can be found<br />

on the Web at http://www.clmhd.<br />

org/itemfiles/survey_0508_<br />

planningpriorities.pdf.<br />

In the longer term, <strong>OMH</strong> and the<br />

Conference continue to collaborate<br />

to identify and develop ways to<br />

strengthen the planning process.<br />

Key areas to be addressed in 2005<br />

include the design and production<br />

<strong>of</strong> county planning templates, and<br />

the development <strong>of</strong> county strategic<br />

data sets. An agenda and “next<br />

steps” have been developed, and<br />

<strong>OMH</strong> has agreed to provide training<br />

and technical assistance to counties<br />

to facilitate the planning process. A<br />

draft County Planning Template is<br />

provided in Appendix 3.<br />

<strong>OMH</strong> is also beginning to work<br />

with some counties to identify high<br />

users <strong>of</strong> inpatient care, formulate<br />

service plans to help these people<br />

live successfully in the community,<br />

and develop approaches to link<br />

these individuals with intensive<br />

community mental health resources.<br />

As the utilization <strong>of</strong> inpatient beds<br />

by this group declines, inpatient<br />

bed days will be freed up and used<br />

to increase access to both Article 28<br />

and <strong>State</strong> hospital beds.<br />

Recipient Community Input<br />

MH's partnership with current<br />

Oand former recipients <strong>of</strong> mental<br />

health services is another example<br />

<strong>of</strong> expanded opportunity for collaboration.<br />

In addition to the ongoing<br />

communication and dialogue<br />

that flows through the <strong>Office</strong> <strong>of</strong><br />

Consumer Affairs, the agency commissioned<br />

Infusing Recovery-Based<br />

Principles into <strong>Mental</strong> <strong>Health</strong> Service:<br />

A White Paper by <strong>New</strong> <strong>York</strong><br />

<strong>State</strong> Consumers, which was presented<br />

to Commissioner Carpinello<br />

in August 2004. Over 10,000 recipients<br />

<strong>of</strong> mental health services from<br />

across <strong>New</strong> <strong>York</strong> <strong>State</strong> participated<br />

in the white paper, which presents<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


24 Chapter 3: Collaborations to Strengthen Planning<br />

a picture <strong>of</strong> what quality, recoverybased<br />

services would look like<br />

from a recipient's perspective.<br />

This white paper was an outgrowth<br />

<strong>of</strong> <strong>OMH</strong>'s Winds <strong>of</strong> Change<br />

quality initiative, and agency efforts<br />

to incorporate the perspectives <strong>of</strong><br />

recipients into the implementation<br />

<strong>of</strong> evidence-based practices (EBPs).<br />

As part <strong>of</strong> that process, an EBP and<br />

recovery consumer/survivor steering<br />

committee was convened, and its<br />

members have participated in many<br />

<strong>of</strong> <strong>OMH</strong>'s internal workgroups.<br />

The recipient community decided<br />

that rather than focusing solely on<br />

EBPs, they would take advantage<br />

<strong>of</strong> the opportunity to make recommendations<br />

to improve mental<br />

health services as a whole. The<br />

steering committee discussed the<br />

Institute <strong>of</strong> Medicine's Crossing the<br />

Quality Chasm: A <strong>New</strong> <strong>Health</strong> System<br />

for the 21st Century, and, using<br />

that document as a starting point,<br />

held a number <strong>of</strong> inclusive meetings<br />

with recipients to draft and<br />

explain ten rules for quality mental<br />

health services in <strong>New</strong> <strong>York</strong> <strong>State</strong><br />

(Table 3.1).<br />

Table 3.1<br />

Recipients’ Ten Rules for<br />

Quality <strong>Mental</strong> <strong>Health</strong> Services<br />

in <strong>New</strong> <strong>York</strong> <strong>State</strong><br />

1 There must be informed<br />

choice.<br />

2 It must be recovery focused.<br />

3 It must be person centered<br />

4 Do no harm.<br />

5 There must be free access to<br />

records.<br />

6 It must be a system based on<br />

trust.<br />

7 It must have a focus on cultural<br />

values.<br />

8 It must be knowledge based.<br />

9 It must be based on a partnership<br />

between consumer and<br />

provider.<br />

10 There must be access to services<br />

regardless <strong>of</strong> ability to pay.<br />

In its introduction, the white<br />

paper is described as “the first step<br />

to bring attention and gain support<br />

to infuse clear and measurable indicators<br />

<strong>of</strong> quality into all aspects <strong>of</strong><br />

the mental health system that will<br />

guide individuals toward self-help,<br />

empowerment and self-determination.<br />

The idea [is] that no matter<br />

what kind <strong>of</strong> mental health services<br />

are delivered, if the new rules were<br />

applied, the recovery outcomes for<br />

people who use mental health services<br />

would increase....”<br />

After the paper’s formal presentation<br />

to Commissioner Carpinello,<br />

and the request that <strong>OMH</strong> partner<br />

with people who use mental health<br />

services to bring the white paper<br />

values into the mental health system,<br />

the Commissioner publicly<br />

supported the document and<br />

charged the <strong>Office</strong> <strong>of</strong> Consumer<br />

Affairs with implementing the white<br />

paper into all areas <strong>of</strong> service delivery.<br />

Additionally, Commissioner<br />

Carpinello requested that the group<br />

make recommendations for infusing<br />

the white paper rules into <strong>OMH</strong>’s<br />

policies, regulations, and licensing.<br />

The first meeting <strong>of</strong> the white<br />

paper implementation committee<br />

was held in November 2004 to<br />

examine how to accomplish this<br />

task. Sixty people who use mental<br />

health services met and reached<br />

consensus on concepts that will<br />

lead to the implementation <strong>of</strong> quality<br />

indicators. The meeting set forth<br />

an ambitious time line for a variety<br />

<strong>of</strong> implementation strategies that<br />

include multiple presentations,<br />

technical assistance <strong>of</strong>ferings, and<br />

refinement strategies. Specific,<br />

actionable steps are currently being<br />

refined for each <strong>of</strong> the service<br />

components within the public<br />

mental health system.<br />

Already a valuable resource to<br />

<strong>OMH</strong>, the white paper has been<br />

heralded as one <strong>of</strong> the most important<br />

documents <strong>of</strong> recent years. Its<br />

full text is included in Appendix 4.<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 3: Collaborations to Strengthen Planning 25<br />

Planning for Service Needs<br />

<strong>of</strong> Special Populations<br />

takeholders' feedback on the 2004-<br />

S2008 Comprehensive Plan has<br />

helped to identify the following set <strong>of</strong><br />

emerging community mental health<br />

needs that <strong>New</strong> <strong>York</strong> will begin facing<br />

during the next five years.<br />

Populations with Emerging<br />

Special Needs<br />

opulation groups with emerging<br />

Pspecial needs were identified<br />

during the planning process to<br />

include young adults, older adults,<br />

and adults in adult homes and in<br />

prisons. Information about adult<br />

homes is included in Chapter 5.<br />

Young Adults<br />

s an <strong>OMH</strong> special population,<br />

Ayoung adults are persons ranging<br />

in age from 18 to 24 years. Each year<br />

<strong>New</strong> <strong>York</strong>'s public mental health system<br />

serves approximately 52,434<br />

young adults. Of these individuals,<br />

the greatest number, 36%, is diagnosed<br />

with bipolar disorder or major<br />

depression, and a sizeable minority<br />

(13%) suffer from schizophrenia and<br />

related disorders. The Diagnostic and<br />

Statistical Manual <strong>of</strong> <strong>Mental</strong> Disorders<br />

– Fourth Edition (DSM-IV) also indicates<br />

that the average age <strong>of</strong> onset<br />

for anorexia nervosa is 17 years old<br />

and the onset rarely occurs in<br />

females over age 40. Among young<br />

adults, four potential areas <strong>of</strong> need<br />

have been identified and initial goals<br />

to address them include:<br />

◆ The smooth transition to adult<br />

services for young adults "aging<br />

out" <strong>of</strong> the children's mental health<br />

system who will require ongoing<br />

services in the adult system.<br />

Goal: Assess issues <strong>of</strong> access, linkage<br />

and coordination, and new<br />

service models.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

◆ Effective intervention for young<br />

adults <strong>of</strong> college age who present<br />

with serious diagnoses, such<br />

as schizophrenia or bipolar disorder,<br />

who have not been<br />

served in the children's mental<br />

health system.<br />

Goal: Identify the at-risk population<br />

in preparation for the development<br />

<strong>of</strong> prevention and early<br />

intervention strategies.<br />

◆ Suicide prevention among young<br />

persons between 18-24 years,<br />

recognizing that suicide is the<br />

third leading cause <strong>of</strong> deaths<br />

among this group in our nation.<br />

Goal: As part <strong>of</strong> <strong>OMH</strong>'s SPEAK<br />

public education campaign,<br />

identify depression and suicidal<br />

ideation among young persons<br />

in need <strong>of</strong> intervention.<br />

◆ Care for young adults suffering<br />

from eating disorders.<br />

Goal: Collaborate with the Department<br />

<strong>of</strong> <strong>Health</strong> in planning and<br />

implementing Comprehensive<br />

Care Centers for Eating Disorders,<br />

which were signed into legislation<br />

by Governor Pataki in June 2004.<br />

Older Adults<br />

uring the public input process to<br />

Dthe 2004-2008 Comprehensive<br />

Plan, stakeholders identified the mental<br />

health needs <strong>of</strong> older adults as a<br />

priority area. This subject was the<br />

most prominent theme addressed in<br />

the <strong>New</strong> <strong>York</strong> City public hearing,<br />

and the newly formed Geriatric <strong>Mental</strong><br />

<strong>Health</strong> Alliance <strong>of</strong> <strong>New</strong> <strong>York</strong><br />

(GMHANY) presented <strong>OMH</strong> with the<br />

report Issues in Geriatric <strong>Mental</strong><br />

<strong>Health</strong> Policy: A Report <strong>of</strong> the Observations<br />

<strong>of</strong> Advocates, Providers,<br />

Researchers, Academics, Government<br />

Officials and Older Adults. As stated<br />

in the report, the Alliance was<br />

formed “to advocate for changes in<br />

mental health policy that will result in<br />

improvements <strong>of</strong> current mental<br />

health services for older adults, and<br />

for changes that will lay the ground-<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


26 Chapter 3: Collaborations to Strengthen Planning<br />

work for the development <strong>of</strong> an adequate<br />

response to the mental health<br />

needs <strong>of</strong> the elder boom generation.”<br />

The GMHANY report provides an<br />

overview <strong>of</strong> themes that emerged<br />

from a series <strong>of</strong> discussion groups<br />

that included representatives <strong>of</strong><br />

mental health agencies, psychiatric<br />

hospitals, settlement houses and<br />

senior centers, nursing homes,<br />

home health care agencies, governmental<br />

leaders from both aging and<br />

mental health, researchers, academics,<br />

and advocates. The representation<br />

in these groups illustrates that<br />

mental health problems <strong>of</strong> older<br />

adults are a shared concern across<br />

the public and private sectors.<br />

There was widespread agreement<br />

among discussion group participants<br />

that the fundamental job <strong>of</strong> a<br />

system <strong>of</strong> services for older adults<br />

with mental health problems is to<br />

provide support for them to lead<br />

satisfying lives in their communities.<br />

separate analysis <strong>of</strong> population projections for<br />

Aolder residents <strong>of</strong> <strong>New</strong> <strong>York</strong> <strong>State</strong> identifies<br />

four major trends that will have a significant impact<br />

on agency policies, programs and services:*<br />

◆ Increased racial and ethnic diversity:<br />

Between 2000 and 2015, the number <strong>of</strong> older<br />

<strong>New</strong> <strong>York</strong>ers will increase by approximately<br />

19%, and will be more diverse than any preceding<br />

old age group in terms <strong>of</strong> ethnicity, income<br />

level, education, family configurations, living<br />

arrangements and health. Minority elderly populations<br />

will increase the fastest: Black, non-Hispanic<br />

by 27%, Hispanic by 76%, and<br />

Asian/Pacific by over 110%.<br />

◆ Weakened family support structures: Baby<br />

boomers moving into the older population will<br />

be more likely than the preceding cohort to<br />

enter old age without spouses, and more will<br />

be childless or parents <strong>of</strong> only children. More<br />

grandparents will be involved in raising their<br />

grandchildren, and the most significant mental<br />

health problem for this group will be depression,<br />

with one in four grandparent caregivers<br />

(nationally) now experiencing a significant level<br />

<strong>of</strong> depression.<br />

There was also widespread confidence<br />

that effective treatments are<br />

now available and they can help<br />

people sustain satisfying lives in<br />

their communities. At the same<br />

time, the report acknowledges that<br />

access to effective treatments is limited,<br />

and many older adults and<br />

their families do not seek treatment<br />

even when it is accessible.<br />

Since receiving the report, <strong>OMH</strong><br />

has been collaborating with stakeholders,<br />

including GMHANY, concerning<br />

these issues. These collaborations<br />

have resulted in the<br />

identification <strong>of</strong> two sub-population<br />

for consideration: individuals<br />

with a mental illness who are getting<br />

older and developing comorbid<br />

conditions related to aging, and<br />

older <strong>New</strong> <strong>York</strong>ers who are at risk<br />

for developing mental illness. A<br />

series <strong>of</strong> roundtable discussions is<br />

planned for Spring 2005, at which<br />

experts, stakeholders and providers<br />

will further discuss the mental<br />

Figure 3.2<br />

Expected Increase<br />

in Ethnic and Racial<br />

Diversity by 2015<br />

120%<br />

100%<br />

80%<br />

60%<br />

40%<br />

20%<br />

0%<br />

110%<br />

Asian/<br />

Pacific<br />

76%<br />

27%<br />

Hispanic Black,<br />

Non-Hispanic<br />

◆ Major growth in<br />

two groups: Rapid<br />

population growth<br />

<strong>of</strong> younger and<br />

older minority<br />

populations is<br />

expected; also<br />

anticipated is major<br />

growth in the older<br />

worker and preretirement<br />

populations<br />

as baby<br />

boomers age out.<br />

◆ More demand<br />

for care, fewer<br />

caregivers: <strong>New</strong><br />

<strong>York</strong>’s dependency<br />

ratio is changing, and there are fewer caregivers<br />

for a larger number <strong>of</strong> older persons<br />

needing care. As a result, the family, which currently<br />

provides 80% <strong>of</strong> long-term care services,<br />

will be providing less care and the “systems <strong>of</strong><br />

care” providing more.<br />

*In Project 2015, <strong>OMH</strong> and 35 other <strong>State</strong> agencies were directed by Governor Pataki<br />

to consider what <strong>New</strong> <strong>York</strong> <strong>State</strong>'s demographic makeup will be by 2015, and identify<br />

strategies for assuring that the <strong>State</strong> is prepared to recognize the opportunities<br />

and meet the challenges presented by its changing population.<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 3: Collaborations to Strengthen Planning 27<br />

health needs <strong>of</strong> aging <strong>New</strong> <strong>York</strong>ers.<br />

The GMHANY report and additional<br />

information can also be<br />

found on the Web at http://www.<br />

mhawestchester.org/advocates/<br />

issuesd1004.pdf.<br />

Adults in Prison<br />

ndividuals with mental health dis-<br />

in prisons require mental<br />

Iorders<br />

health services to reduce psychiatric<br />

symptoms and promote functioning.<br />

As <strong>of</strong> December 2003, there were<br />

approximately 65,000 prisoners<br />

incarcerated in Department <strong>of</strong> Correctional<br />

Services' facilities. Of<br />

those, approximately 11% or 7,500<br />

inmates were assigned to the <strong>OMH</strong><br />

corrections-based caseload. The<br />

2005-2006 Executive Budget continues<br />

$7 million for a multi-year<br />

effort to expand mental health<br />

treatment, clinical staffing, and bed<br />

capacity. More detailed information<br />

about adults in prison is included in<br />

Chapter 7.<br />

Planning for Children’s<br />

Inpatient Services<br />

oundtable discussions have also<br />

Rplayed a prominent role in planning<br />

the mental health needs <strong>of</strong><br />

children and adolescents. When<br />

developing the structural design <strong>of</strong><br />

a children’s unit currently under<br />

construction at the Greater Binghamton<br />

<strong>Health</strong> Center, <strong>OMH</strong> administrators<br />

and the project’s architect<br />

sat down with children who have<br />

been hospitalized and their families,<br />

facility staff, and other area mental<br />

health providers. Together, they discussed<br />

various design elements that<br />

would enhance the recovery<br />

process, as well as those that may<br />

inhibit it. They fine tuned the<br />

details, and the end result will be<br />

an inpatient unit truly designed to<br />

support recovery. It will balance<br />

individual privacy and appropriate<br />

supervision, provide a safe and<br />

therapeutic environment, and will<br />

be family friendly, especially in the<br />

visiting areas.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

In November 2004, <strong>OMH</strong> hosted a<br />

roundtable discussion among leading<br />

providers <strong>of</strong> inpatient care for children<br />

and adolescents in the metropolitan<br />

<strong>New</strong> <strong>York</strong> City area. The discussion<br />

also included <strong>State</strong> and City<br />

government representatives, family<br />

advocates, and parents whose children<br />

have been hospitalized. The<br />

purpose <strong>of</strong> the gathering was to<br />

examine the clinical pr<strong>of</strong>iles <strong>of</strong> the<br />

youngsters currently receiving inpatient<br />

care, explore what treatments<br />

are currently being used, and discuss<br />

clinical, administrative and structural<br />

opportunities that might improve the<br />

quality <strong>of</strong> care provided.<br />

Participant discussion led to consensus<br />

around a number <strong>of</strong> themes<br />

including the following examples:<br />

1. Develop more extensive crisis<br />

services for children. Many<br />

children in emergency rooms<br />

were described as needing immediate<br />

mental health services, but<br />

not necessarily inpatient hospitalization.<br />

In the absence <strong>of</strong> a more<br />

systematic, completely reliable<br />

alternative, many emergency<br />

room physicians opt for the safety<br />

and immediacy <strong>of</strong> inpatient care.<br />

2. Increase family involvement<br />

in the course <strong>of</strong> inpatient hospitalizations.<br />

Family involvement<br />

was seen as an important<br />

yet <strong>of</strong>ten missing component,<br />

especially in acute settings.<br />

3. Develop core clinical competencies<br />

where there is strong<br />

research support for particular<br />

interventions.<br />

4. Explore the use <strong>of</strong> common<br />

assessment and outcome<br />

measurement systems.<br />

Discussions and follow-up are<br />

continuing. A second follow-up<br />

roundtable is planned.<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


28 Chapter 3: Collaborations to Strengthen Planning<br />

Population-based Planning Efforts<br />

MH is committed to providing<br />

Oquality mental health services to<br />

all <strong>New</strong> <strong>York</strong>ers in need. Many different<br />

communities and constituents<br />

are continually engaged to assist<br />

the agency in the development and<br />

evaluation <strong>of</strong> services that are culturally<br />

appropriate and linguistically<br />

suited for <strong>New</strong> <strong>York</strong>’s diverse populations.<br />

Examples include:<br />

◆ The Multicultural Advisory Committee<br />

(MAC) is composed <strong>of</strong><br />

diverse consumers, family members<br />

and providers. During 2004,<br />

the group met directly with the<br />

<strong>OMH</strong> cabinet to address population-based<br />

planning efforts as<br />

well as disparities that may be<br />

present in mental health services.<br />

There was an opportunity to<br />

exchange information regarding<br />

language assistance needs and<br />

service adaptations based upon<br />

culture, ethnicity, age and gender.<br />

Members also made recommendations<br />

for development <strong>of</strong> a<br />

standardized cultural competence<br />

curriculum for use in training<br />

community-based licensed programs.<br />

The first draft <strong>of</strong> the training<br />

content has been outlined,<br />

and its development continues.<br />

◆ In addition to the statewide<br />

MAC, several counties have local<br />

multicultural advisories that are<br />

working in collaboration with<br />

<strong>OMH</strong> to improve service quality:<br />

The Nassau County MAC has<br />

developed a series <strong>of</strong> culturespecific<br />

training opportunities;<br />

Suffolk County held an annual<br />

cultural competence symposium;<br />

Orange County has expanded its<br />

training activities to include technical<br />

assistance for the development<br />

<strong>of</strong> cultural competence<br />

plans for all county human service<br />

agencies; Broome County<br />

has continued its language interpreter<br />

program; and Monroe<br />

County continues an extensive<br />

cultural competence evaluation,<br />

training and plan development<br />

process for county agencies.<br />

◆ Throughout the <strong>State</strong>, grassroots<br />

networks are also partnering<br />

with <strong>OMH</strong> to enhance mental<br />

health services. Consumer and<br />

family groups such as National<br />

Alliance for the <strong>Mental</strong>ly Ill<br />

(NAMI) Harlem and Harlem<br />

Hospital have hosted events to<br />

provide a public education<br />

forum about mental illness and<br />

mental health. The training, “Cultural<br />

Competence: Maintaining<br />

an Asking Stance,” has been presented<br />

to provider agencies,<br />

trade associations, social work<br />

education programs, and community<br />

groups throughout the<br />

<strong>State</strong>. Agencies have adapted the<br />

material to directly address specific<br />

community issues and to<br />

enhance service planning.<br />

◆ <strong>OMH</strong> is also working to increase<br />

its outreach efforts by partnering<br />

with groups including the Association<br />

<strong>of</strong> Hispanic <strong>Mental</strong><br />

<strong>Health</strong> Pr<strong>of</strong>essionals, Black Psychiatrists<br />

<strong>of</strong> Greater <strong>New</strong> <strong>York</strong>,<br />

and the Coalition for Asian<br />

American <strong>Mental</strong> <strong>Health</strong>. Recognizing<br />

that many <strong>New</strong> <strong>York</strong>ers<br />

seek assistance outside <strong>of</strong> formal<br />

mental health settings, <strong>OMH</strong> has<br />

also formed alliances with other<br />

systems and programs, including<br />

the Peri-natal Network and the<br />

Caribbean Cultural Center.<br />

The 2004 Interim Report <strong>of</strong> the<br />

<strong>State</strong>wide Comprehensive Plan for<br />

<strong>Mental</strong> <strong>Health</strong> Services contains a<br />

more complete description <strong>of</strong><br />

increased opportunities for public<br />

input. It is available on the <strong>OMH</strong> Web<br />

site at http://www.omh.state.ny.us.<br />

Partnerships in the Development<br />

and Implementation <strong>of</strong> <strong>New</strong><br />

Service Models<br />

ersonalized Recovery-Oriented<br />

PServices (PROS) is a comprehensive<br />

program for individuals<br />

with severe and persistent mental<br />

illness that is designed to facilitate<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 3: Collaborations to Strengthen Planning 29<br />

individual recovery by integrating<br />

treatment, support, and rehabilitation<br />

services. Goals for individuals<br />

in the program are to improve<br />

functioning, increase employment,<br />

attain higher levels <strong>of</strong> education,<br />

secure preferred housing, reduce<br />

contact with the criminal justice<br />

system, and decrease utilization <strong>of</strong><br />

inpatient and emergency services.<br />

Throughout the PROS development<br />

process, <strong>OMH</strong> actively sought<br />

input from a broad array <strong>of</strong> stakeholders,<br />

and frequently modified<br />

the program’s design in response<br />

to their questions and concerns.<br />

The agency conducted more than<br />

150 briefings and meetings on<br />

PROS with other <strong>State</strong> agencies,<br />

county government <strong>of</strong>ficials, mental<br />

health service providers, and service<br />

recipients who are attending<br />

programs that might convert to the<br />

new PROS license.<br />

<strong>OMH</strong> has made concerted efforts<br />

to involve county governments as<br />

partners in the planning, implementation,<br />

and oversight <strong>of</strong> PROS programs.<br />

An extensive county planning<br />

process was initiated to ensure<br />

that county mental hygiene directors<br />

had an opportunity to manage<br />

the impact <strong>of</strong> PROS on their Local<br />

service systems. Since PROS programs<br />

are funded by Medicaid,<br />

<strong>OMH</strong> has worked with county representatives<br />

to fashion regulatory<br />

requirements for a county/provider<br />

agreement that will replace Local<br />

contracting for <strong>State</strong> Aid funding as<br />

the vehicle for supporting the county<br />

role in program monitoring and<br />

quality improvement.<br />

The <strong>OMH</strong> Web site contains a<br />

PROS section that includes a program<br />

description, announcements<br />

on the status <strong>of</strong> implementation<br />

efforts, responses to frequently<br />

asked questions, and sections <strong>of</strong> a<br />

draft handbook for PROS providers<br />

(http://www.omh.state.ny.us/omhweb/pros/).<br />

Draft PROS regulations<br />

have been posted on the site, and<br />

stakeholders have been invited to<br />

submit comments in advance <strong>of</strong><br />

the mandatory comment period<br />

that is initiated once the regulations<br />

are formally filed as proposed.<br />

The PROS <strong>State</strong>/county collaborative<br />

relationship is continuing as<br />

program implementation begins. As<br />

announced in October 2004, an initial<br />

implementation phase will<br />

involve seven counties representing<br />

a mix <strong>of</strong> urban, suburban, and rural<br />

settings. The scope <strong>of</strong> this phase<br />

takes into consideration <strong>OMH</strong>’s<br />

ability to provide the intensive technical<br />

assistance necessary to support<br />

successful program transitions<br />

to the new PROS license.<br />

Strengthening the Capacity for<br />

Data-Driven Decision Making<br />

MH remains committed to pop-<br />

based planning, fore-<br />

Oulation<br />

casting, and management that uses<br />

relevant data from agency performance<br />

measures to enable data-driven<br />

decision-making. Populationbased<br />

planning in the public<br />

mental health system requires that<br />

localities identify the specific services<br />

needed in their communities<br />

based on the specific groups that<br />

need service, taking into account<br />

age, ethnicity, sex, and growth projections<br />

within the population.<br />

Beginning in April 2004, <strong>OMH</strong><br />

launched an initiative to strengthen<br />

its capacity to use modern geographic<br />

information systems (GIS)<br />

technology to support datainformed<br />

<strong>State</strong> and Local mental<br />

health planning. Local planning is<br />

by definition geographically based,<br />

and an increasing number <strong>of</strong> the<br />

data sources needed for datainformed<br />

planning include geographic<br />

information such as county,<br />

zip code, and street address. In<br />

recent years, the capabilities <strong>of</strong> GIS<br />

technology have expanded rapidly,<br />

making it feasible to look with<br />

fine-grained geographic precision<br />

at important public mental health<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


30 Chapter 3: Collaborations to Strengthen Planning<br />

system issues such as prevalence <strong>of</strong><br />

serious mental illness and access to<br />

evidence-based services. <strong>OMH</strong>’s<br />

GIS initiative has two tracks:<br />

◆ Improving staff skills so that<br />

increasingly sophisticated and<br />

useful geomaps <strong>of</strong> mental health<br />

phenomena can be produced.<br />

◆ Incorporating geographic data<br />

into the <strong>OMH</strong> enterprise data<br />

warehouse so that geomaps and<br />

spatial analysis can be carried<br />

out more efficiently and with<br />

greater frequency.<br />

A major target audience for <strong>OMH</strong><br />

GIS efforts is Local mental health<br />

directors and their staff. In a May<br />

2004 regional planning meeting<br />

with county mental health directors<br />

and <strong>State</strong> psychiatric center directors,<br />

<strong>OMH</strong> staff presented and discussed<br />

an initial set <strong>of</strong> geomaps<br />

that displayed local variation in the<br />

prevalence <strong>of</strong> serious and persistent<br />

mental illness and access to<br />

Assertive Community Treatment<br />

and Intensive Case Management<br />

services at the zip code level. At<br />

this and subsequent presentations,<br />

counties have expressed strong<br />

interest in the GIS initiative and<br />

have requested additional<br />

geomaps, including maps <strong>of</strong> the<br />

prevalence <strong>of</strong> serious emotional<br />

disturbance and access to specialized<br />

children’s services. Joint <strong>State</strong><br />

and Local planning discussions<br />

stimulated by the geomaps have<br />

begun to produce a common<br />

understanding <strong>of</strong> mental illness<br />

prevalence estimates and the relationships<br />

between prevalence and<br />

service access and use.<br />

Disaster Response<br />

and Preparedness<br />

A<br />

s described in the 2004-2008<br />

Comprehensive Plan, <strong>OMH</strong> is<br />

responsible for coordinating <strong>New</strong><br />

<strong>York</strong> <strong>State</strong>’s emergency mental<br />

health response and ensuring that<br />

mental health services are available<br />

for those in need. <strong>OMH</strong> is continuing<br />

the emphasis on disaster preparedness<br />

and response, which<br />

includes reviewing emergency mental<br />

health response systems through<br />

a comprehensive disaster preparedness<br />

planning process conducted in<br />

collaboration with other <strong>State</strong> and<br />

Local agencies. <strong>OMH</strong> also continues<br />

to provide leadership in disaster<br />

mental health planning with other<br />

<strong>State</strong> agencies, Federal agencies,<br />

CLMHD, and the American Red<br />

Cross in <strong>New</strong> <strong>York</strong> <strong>State</strong> (ARCNYS).<br />

Through these processes, <strong>OMH</strong> recognizes<br />

the complementary roles,<br />

shared commitment, and the mutual<br />

advantage <strong>of</strong> an integrated<br />

approach to improving emergency<br />

mental health services for all <strong>New</strong><br />

<strong>York</strong>ers.<br />

The 2004-2008 Comprehensive Plan<br />

reported on two initiatives to strengthen<br />

<strong>State</strong> and local disaster response<br />

and preparedness capabilities.<br />

◆ <strong>OMH</strong>, CLMHD, and ARCNYS<br />

have been collaborating to<br />

establish procedures and protocols<br />

to strengthen county and<br />

<strong>State</strong> ability to respond to disasters<br />

by providing critical mental<br />

health supports to victims. The<br />

first step in this effort was signing<br />

a <strong>State</strong>ment <strong>of</strong> Understanding<br />

outlining the roles, responsibilities,<br />

and expectations <strong>of</strong> each<br />

organization when responding to<br />

a moderate or severe disaster.<br />

This document also outlined<br />

steps to provide for a more<br />

coordinated and cooperative<br />

effort in the areas <strong>of</strong> communication,<br />

training, and mobilization<br />

<strong>of</strong> mental health responders, as<br />

well as a commitment to pursue<br />

an evidence-based approach.<br />

◆ An additional collaboration with<br />

the <strong>State</strong> Department <strong>of</strong> <strong>Health</strong><br />

(DOH) was initiated to develop<br />

public mental health education<br />

materials that will be included in<br />

a Bio-Terrorism Toolkit designed<br />

to facilitate Local disaster plan-<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 3: Collaborations to Strengthen Planning 31<br />

ning with a focus on preparing<br />

families and communities for the<br />

potential effects <strong>of</strong> a biological<br />

weapons attack. The kit will<br />

include fact sheets about smallpox<br />

and anthrax, vaccination<br />

information, and how to cope<br />

during these uncertain times.<br />

These two initiatives were merged<br />

into a single, coordinated project<br />

during 2004 and substantial progress<br />

was achieved. The next major goal<br />

<strong>of</strong> the partners in this collaboration<br />

is to operationalize these agreements<br />

at the county level. In Spring<br />

2004, <strong>OMH</strong> initiated site visits, with<br />

its CLMHD and ARCNYS partners,<br />

to several counties with a reputation<br />

for having established best practices<br />

in the area <strong>of</strong> disaster mental health<br />

response. The purpose was to<br />

review current practices, identify<br />

potential best practices, and create<br />

models that can be shared with<br />

other counties. During July visits<br />

were completed to five county<br />

mental health departments selected<br />

to be pilots.<br />

<strong>OMH</strong>, CLMHD and ARCNYS are<br />

also seeking to develop a disaster<br />

response curriculum for mental<br />

health responders based on evidence-based<br />

practice. The goal <strong>of</strong><br />

this effort is to undertake statewide<br />

training <strong>of</strong> <strong>State</strong> and county disaster<br />

mental health pr<strong>of</strong>essionals to<br />

expand their capabilities for providing<br />

effective disaster mental health<br />

interventions. The<br />

development team<br />

has included staff<br />

from the University<br />

<strong>of</strong> Rochester Medical<br />

Center (URMC) for<br />

Disaster Medicine<br />

and Emergency<br />

Preparedness.<br />

URMC was tasked<br />

to research<br />

national “best<br />

practices” and<br />

develop the appropriate<br />

curriculum upon which the<br />

statewide training is to be based.<br />

The county mental health directors<br />

invited their Local disaster services<br />

partners to the full-day training<br />

development meetings. Information<br />

gathered at these sessions, together<br />

with best practices research, was<br />

used to complete an eight-module<br />

training curriculum. In August 2004<br />

the full curriculum was successfully<br />

pilot tested with two county mental<br />

health departments. Phase II <strong>of</strong> this<br />

project, scheduled to begin soon,<br />

will advance the training to <strong>OMH</strong><br />

and county mental health <strong>of</strong>fices<br />

through the use <strong>of</strong> “train-the trainer”<br />

(TTT) techniques. This work is to<br />

be undertaken during the first half<br />

<strong>of</strong> the 2005 calendar year.<br />

It is <strong>OMH</strong>’s intent to facilitate the<br />

use <strong>of</strong> this TTT cadre to undertake<br />

the training <strong>of</strong> disaster mental<br />

health pr<strong>of</strong>essional responders<br />

across <strong>New</strong> <strong>York</strong> <strong>State</strong>. These<br />

resources can than be made available<br />

for individual counties to customize<br />

the mix <strong>of</strong> <strong>State</strong>, Local, and<br />

voluntary disaster mental health<br />

providers together with the application<br />

<strong>of</strong> the EBP methodologies in<br />

which they have been trained.<br />

Project Liberty<br />

he September 11 terrorist attacks<br />

T on the World Trade<br />

Center have no<br />

precedent in<br />

the history <strong>of</strong><br />

the U.S. The<br />

disaster had a<br />

dramatic<br />

impact on<br />

Americans,<br />

especially<br />

those who<br />

were living and<br />

working in <strong>New</strong><br />

<strong>York</strong> City, in terms<br />

<strong>of</strong> the devastating<br />

loss <strong>of</strong> life,<br />

enormity <strong>of</strong><br />

physical<br />

To All Project Liberty<br />

provider agencies and staff:<br />

n the behalf <strong>of</strong> <strong>OMH</strong> and<br />

Opersonally, I wish to<br />

thank all <strong>of</strong> you who have<br />

participated in Project Liberty.<br />

Faced with a humancaused<br />

disaster <strong>of</strong> unprecedented<br />

scope, <strong>New</strong> <strong>York</strong>’s<br />

mental health providers<br />

responded with alacrity, creativity<br />

and commitment.<br />

Through your steadfast<br />

efforts, hundreds <strong>of</strong> thousands<br />

<strong>of</strong> <strong>New</strong> <strong>York</strong>ers have<br />

been reached and their individual<br />

needs met. You have<br />

been instrumental in helping<br />

your community recover and<br />

become more resilient in the<br />

aftermath <strong>of</strong> the tragedy <strong>of</strong><br />

9/11. <strong>New</strong> <strong>York</strong> is proud <strong>of</strong><br />

what you have accomplished<br />

and grateful for the dedication<br />

each <strong>of</strong> you brought to<br />

your work in Project Liberty.<br />

Sharon E. Carpinello, RN, PhD<br />

Commissioner<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong><br />

<strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


32 Chapter 3: Collaborations to Strengthen Planning<br />

Notes<br />

1 Felton, C.J., Donahue, S., Lanzara, C.B.,<br />

Pease, E.A., & Marshall R. (in press). Project<br />

Liberty: Responding to mental health needs<br />

after the World Trade Center terrorist<br />

attacks. Cambridge: Cambridge University<br />

Press.<br />

2 Norris, F.H., Friedman, M.J., Watson, P.J.,<br />

Byrne, C.M., Diaz, E., & Kaniasty, K. (2002).<br />

60,000 disaster victims speak: An empirical<br />

review <strong>of</strong> the empirical literature, 1981-2001.<br />

Psychiatry, 65, 207-239.<br />

3 Schuster, M.A., Stein, B.D., Jaycox, L.,<br />

Collins, R.L., Marshall, G.N., Elliott, M.N.,<br />

Zhou, A.J., Kanouse, D.E., Morrison, J.L., &<br />

Berry, S.H. (2001). A national survey <strong>of</strong> stress<br />

reactions after the September 11, 2001, terrorist<br />

attacks. <strong>New</strong> England Journal <strong>of</strong> Medicine,<br />

345, 1507-1512<br />

destruction, adverse economic consequences,<br />

and serious mental distress<br />

and psychological disorder.<br />

With support from the Federal government<br />

and <strong>State</strong> and Local mental<br />

health authorities, <strong>OMH</strong> responded<br />

rapidly with the development and<br />

implementation <strong>of</strong> a large-scale<br />

Federally funded public health program<br />

called Project Liberty, which<br />

was aimed at addressing a range <strong>of</strong><br />

psychological reactions and lessening<br />

the traumatic consequences<br />

experienced by individuals in close<br />

proximity to the disaster site and its<br />

surrounding areas. 1<br />

With incidents <strong>of</strong> intentional mass<br />

violence that result in a significant<br />

loss <strong>of</strong> life and property, as well as<br />

extensive unemployment, previous<br />

research shows that the resulting<br />

trauma may be associated with<br />

severe, long lasting, and widespread<br />

psychological effects. 2 In<br />

the immediate aftermath <strong>of</strong> the<br />

World Trade Center disaster, widespread<br />

mental distress was found<br />

in the general population. One<br />

national study found that 44% <strong>of</strong><br />

adults and 35% <strong>of</strong> children reported<br />

one or more reactions consistent<br />

with traumatic stress. For<br />

adults living in the City and within<br />

100 miles <strong>of</strong> the disaster site, 61%<br />

reported considerable traumatic<br />

stress symptoms. One year after the<br />

disaster, <strong>New</strong> <strong>York</strong> Academy <strong>of</strong><br />

Medicine uncovered new-onset<br />

post-traumatic stress disorder<br />

(PTSD) among World Trade Center<br />

disaster victims, where 5% <strong>of</strong> survey<br />

respondents without PTSD in<br />

March 2002 met criteria for PTSD<br />

in September 2002. 3<br />

The terrorist attacks produced an<br />

unprecedented and chaotic postdisaster<br />

environment that required<br />

the most complex emergency management<br />

response ever mounted in<br />

national history. Project Liberty,<br />

which was <strong>of</strong>ficially launched in<br />

September 2001, was jointly operated<br />

by the Federal Emergency Management<br />

Agency (FEMA) and the<br />

Center for <strong>Mental</strong> <strong>Health</strong> Services<br />

(CMHS) <strong>of</strong> the Substance Abuse<br />

and <strong>Mental</strong> <strong>Health</strong> Services Administration<br />

(SAMHSA). It provided<br />

funding for short-term public education,<br />

outreach, crisis counseling<br />

and referral services. The role <strong>of</strong><br />

<strong>OMH</strong> was to develop an infrastructure<br />

for Project Liberty that enabled<br />

the City and county departments <strong>of</strong><br />

mental health to ensure the effective<br />

delivery <strong>of</strong> a continuum <strong>of</strong> supportive<br />

counseling interventions<br />

designed to meet disaster-related<br />

mental health needs in their communities.<br />

Program services were<br />

ended December 31, 2004. In all,<br />

Project Liberty was a successful collaboration<br />

between the <strong>State</strong>, local<br />

governments, and more than 130<br />

local service providers. It was and<br />

continues to be the single largest<br />

public mental health program put<br />

into operation in the U.S.<br />

While Project Liberty services have<br />

ended, Governor Pataki has continued<br />

to support the ongoing needs <strong>of</strong><br />

<strong>New</strong> <strong>York</strong> City firefighters and their<br />

families. <strong>New</strong> <strong>York</strong> <strong>State</strong> has provided<br />

$2 million in <strong>State</strong> funds, which<br />

will be utilized with <strong>New</strong> <strong>York</strong> City<br />

funds to provide additional mental<br />

health and crisis counseling services<br />

to the <strong>New</strong> <strong>York</strong> City firefighter community.<br />

An important Project Liberty innovation<br />

was its evaluation <strong>of</strong> various<br />

components <strong>of</strong> the crisis counseling<br />

model. Prior to Project Liberty, Federal<br />

funds were prohibited from<br />

being used to evaluate disaster<br />

response programs. In partnership<br />

with <strong>New</strong> <strong>York</strong> City, the disasterdeclared<br />

counties and its academic<br />

partners, Project Liberty, however,<br />

began to remedy gaps in knowledge<br />

through its evaluation <strong>of</strong> programs<br />

and services. In addition to collecting<br />

service encounter data, the Project<br />

gathered feedback from stakeholders<br />

who provided counseling, shedding<br />

light on program implementation<br />

and operational issues and the needs<br />

<strong>of</strong> the communities served. Addition-<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 3: Collaborations to Strengthen Planning 33<br />

ally, service recipients were surveyed<br />

about their experiences, needs, and<br />

opinions and their views on the<br />

helpfulness <strong>of</strong> and satisfaction with<br />

counseling services. 4<br />

The evaluation provided important<br />

information that proved valuable<br />

to Project Liberty senior leadership<br />

in administering and<br />

monitoring program operations,<br />

such as reaching populations that<br />

are difficult to serve, and enhancing<br />

project decision making. 5 An<br />

essential by-product <strong>of</strong> the evaluation<br />

was the ability <strong>of</strong> <strong>OMH</strong> to use<br />

data to inform disaster preparedness<br />

efforts, by providing a clear<br />

picture <strong>of</strong> the process <strong>of</strong> implementing<br />

a large-scale disaster mental<br />

health program; gaining a fuller<br />

appreciation <strong>of</strong> best practices and<br />

obstacles encountered; and articulating<br />

lessons learned.<br />

During 2005, Project Liberty will<br />

complete final reporting to FEMA<br />

and CMHS. The final report is<br />

expected to yield new insights into<br />

the assessment, organization,<br />

implementation and evaluation <strong>of</strong><br />

future disaster mental health<br />

response initiatives. <strong>OMH</strong> will<br />

employ reports, presentations, publications,<br />

and the dissemination <strong>of</strong><br />

tools to aid disaster mental health<br />

response efforts nationwide.<br />

Through its public, private, and<br />

academic partnerships, <strong>OMH</strong> will<br />

continue to build on the strengths<br />

<strong>of</strong> Project Liberty’s World Trade<br />

Center disaster mental health<br />

response efforts and contribute<br />

new and vital information to the<br />

growing body <strong>of</strong> disaster mental<br />

health knowledge.<br />

National Collaborations for<br />

Disaster Preparedness<br />

ince September 11, <strong>OMH</strong> has<br />

Sbeen participating in national<br />

efforts sponsored by the Federal<br />

government to advance our country’s<br />

evidence base concerning the<br />

mental health impact <strong>of</strong> terrorism<br />

and effective response strategies.<br />

Several Federally sponsored scientific<br />

meetings have brought together<br />

disaster mental health researchers,<br />

trauma experts and mental health<br />

policymakers over the past three<br />

years. These efforts have been an<br />

effective forum for synthesizing<br />

existing information on the mental<br />

health impact <strong>of</strong> terrorism and<br />

appropriate responses and for initial<br />

reactions by these experts to new<br />

data collected post-9/11, including<br />

Project Liberty evaluation findings.<br />

Participants at the first <strong>of</strong> these<br />

meetings developed consensus<br />

guidelines for appropriate mental<br />

health response during the first four<br />

weeks following an event. These<br />

guidelines were subsequently published<br />

by the National Institute <strong>of</strong><br />

<strong>Mental</strong> <strong>Health</strong> (NIMH).<br />

A second forum was held by the<br />

National Institute <strong>of</strong> Medicine<br />

(IOM) for the purpose <strong>of</strong> soliciting<br />

expert testimony as a first step in<br />

the creation <strong>of</strong> an IOM report on<br />

the mental health impact <strong>of</strong> terrorism.<br />

<strong>OMH</strong> staff were invited to participate<br />

and provided testimony<br />

that reviewed the lessons learned<br />

from the first year <strong>of</strong> Project Liberty’s<br />

operation. The final IOM<br />

report, titled Preparing for the Psychological<br />

Impact <strong>of</strong> Terrorism contains<br />

a series <strong>of</strong> recommendations<br />

aimed at strengthening the nation’s<br />

disaster mental health preparedness<br />

and further increasing scientific<br />

knowledge concerning the mental<br />

health impact <strong>of</strong> terrorism and the<br />

necessity and effectiveness <strong>of</strong> interventions<br />

to counter that impact.<br />

Together, the recommendations<br />

represent an overall “call to action”<br />

for the creation <strong>of</strong> a nationwide<br />

surveillance and response infrastructure.<br />

A third national meeting in which<br />

<strong>OMH</strong> participated focused on<br />

screening procedures and interventions.<br />

Discussion at that meeting<br />

was informed both by the guide-<br />

Notes<br />

4 Felton, C.J. (2004). Lessons learned since<br />

September 11th 2001 concerning the mental<br />

health impact <strong>of</strong> terrorism, appropriate<br />

response strategies and future preparedness.<br />

Psychiatry 67(2), 147-152.<br />

5 Appendix 5 contains the latest Project Liberty<br />

service delivery data.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


34 Chapter 3: Collaborations to Strengthen Planning<br />

lines produced at the October 2001<br />

meeting and the IOM report but<br />

also the intervening two years <strong>of</strong><br />

real-world experience in responding<br />

to September 11. The meeting<br />

yielded a high degree <strong>of</strong> consensus<br />

amongst participants concerning<br />

the necessary components <strong>of</strong> an<br />

overall mental health response<br />

model, and workgroups are now<br />

finalizing these recommendations.<br />

As part <strong>of</strong> our efforts to preserve<br />

the mental health response infrastructure<br />

created after September<br />

11 and disseminate lessons learned,<br />

<strong>OMH</strong> has developed a toolkit consisting<br />

<strong>of</strong> public educational materials,<br />

training curricula, data collection<br />

tools and protocols, and<br />

screening instruments developed<br />

for Project Liberty. This toolkit,<br />

which will continue to be revised,<br />

is available for free on CD-ROM<br />

from <strong>OMH</strong>. 6 We are currently<br />

working with our Federal partners<br />

at SAMHSA to further refine these<br />

toolkit materials into national technical<br />

assistance resources available<br />

to other jurisdictions in the future.<br />

Notes<br />

6 The CD-ROM can be ordered from the<br />

Project Liberty Web page at: http://www.<br />

projectliberty.state.ny.us/educational.htm<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 4: Basic and Clinical Research 35<br />

Basic and Clinical Research Chapter 4<br />

umerous reports document<br />

Nextraordinary gains recently<br />

made in mental health care, some<br />

<strong>of</strong> them based on advances in our<br />

understanding <strong>of</strong> the human brain<br />

and some based on a better understanding<br />

<strong>of</strong> how to deliver care to<br />

those who suffer from mental disorders.<br />

Since 1999, the U.S. Surgeon<br />

General has released two<br />

broad-ranging reports on mental<br />

health, one general, 1 and one<br />

focused on ethnic, cultural, and<br />

Table 4.1.<br />

Disease Burden by Selected<br />

Illness Categories in Established<br />

Market Economies,<br />

1990<br />

Illness<br />

Category<br />

Percent <strong>of</strong> Total<br />

Years Lost<br />

All cardiovascular<br />

conditions ..............................18.6<br />

All mental illness 5 ..................15.4<br />

All malignant<br />

diseases (cancer)....................15.0<br />

All respiratory conditions ........4.8<br />

All alcohol use ........................4.7<br />

All infectious<br />

and parasitic diseases ..............2.8<br />

All drug use..............................1.5<br />

Source: DHHS, 1999<br />

racial issues. 2 In 2001, the World<br />

<strong>Health</strong> Organization (WHO)<br />

released a comprehensive report<br />

on the state <strong>of</strong> global mental<br />

health. 3 In 2003, a White House<br />

Commission released its final report<br />

on the U.S. mental health care<br />

delivery system. 4<br />

Collectively, these reports<br />

demonstrate an increasing societal<br />

awareness <strong>of</strong> mental illness, and<br />

reflect the unambiguous emergence<br />

<strong>of</strong> mental health research as a key<br />

priority in the U.S. and internationally.<br />

However, the reports also<br />

point to substantial gaps in basic<br />

and clinical scientific knowledge<br />

related to the treatment and prevention<br />

<strong>of</strong> mental diseases, as well<br />

as gaps in mental health services<br />

research to translate state-<strong>of</strong>-the-art<br />

treatments and incorporate them<br />

into mainstream practice. As a<br />

result, the disease burden <strong>of</strong> mental<br />

illness remains very high, perhaps<br />

higher than that <strong>of</strong> any other<br />

single category <strong>of</strong> disease, and the<br />

costs for treating mental illness are<br />

higher than those <strong>of</strong> other chronic<br />

diseases. 5<br />

Disease Burden<br />

<strong>of</strong> <strong>Mental</strong> Illness<br />

ecent WHO estimates suggest<br />

Rthat at any one time, 450 million<br />

persons worldwide suffer from<br />

neuropsychiatric disorders, including<br />

depression and/or mania,<br />

Notes<br />

1 United <strong>State</strong>s Department <strong>of</strong> <strong>Health</strong> and<br />

Human Services. (1999). <strong>Mental</strong> health: A<br />

report <strong>of</strong> the surgeon general. Rockville, MD:<br />

U.S. Department <strong>of</strong> <strong>Health</strong> and Human Services,<br />

Substance Abuse and <strong>Mental</strong> <strong>Health</strong><br />

Services Administration, Center for <strong>Mental</strong><br />

<strong>Health</strong> Services, National Institutes <strong>of</strong><br />

<strong>Health</strong>, National Institute <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>.<br />

2 United <strong>State</strong>s Department <strong>of</strong> <strong>Health</strong> and<br />

Human Services. (2001). <strong>Mental</strong> health: Culture,<br />

race and ethnicity. A supplement to<br />

<strong>Mental</strong> health: A report <strong>of</strong> the surgeon general.<br />

Rockville, MD: U.S. Department <strong>of</strong><br />

<strong>Health</strong> and Human Services, Substance<br />

Abuse and <strong>Mental</strong> <strong>Health</strong> Services Administration,<br />

Center for <strong>Mental</strong> <strong>Health</strong> Services,<br />

National Institutes <strong>of</strong> <strong>Health</strong>, National Institute<br />

<strong>of</strong> <strong>Mental</strong> <strong>Health</strong>.<br />

3 World <strong>Health</strong> Organization. (2001). The World<br />

<strong>Health</strong> Report 2001. <strong>Mental</strong> health: <strong>New</strong><br />

understanding, new hope. Geneva: WHO.<br />

4 <strong>New</strong> Freedom Commission on <strong>Mental</strong><br />

<strong>Health</strong>, Achieving the Promise: Transforming<br />

<strong>Mental</strong> <strong>Health</strong> Care in America. Final Report.<br />

DHHS Pub. No. SMA-03-3832. Rockville, MD:<br />

2003. Retrieved November 1, 2004 from<br />

http://www.mentalhealthcommission.gov/<br />

reports/FinalReport/toc.html<br />

5 Disease burden associated with “mental<br />

illness” includes suicide. In these rankings,<br />

mental illness ranks first if one includes<br />

the burden <strong>of</strong> substance abuse in addition<br />

to suicide.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


36 Chapter 4: Basic and Clinical Research<br />

Figure 4.1<br />

Prevalence <strong>of</strong> major depression in patients with physical illnesses<br />

Hypertension<br />

Myocardial Infarction<br />

Epilepsy<br />

Stroke<br />

Diabetes<br />

Cancer<br />

HIV/AIDS<br />

Tuberculosis<br />

General<br />

Population<br />

Up to 10%<br />

Up to 29%<br />

Up to 22%<br />

Up to 30%<br />

Up to 31%<br />

Up to 27%<br />

Up to 33%<br />

Up to 44%<br />

Up to 46%<br />

0 10 20 30 40 50<br />

Source: WHO, 2003<br />

Notes<br />

6 World <strong>Health</strong> Organization. (2003). Investing<br />

in mental health. Geneva: WHO.<br />

7 <strong>Mental</strong> disorders include unipolar major<br />

depression, schizophrenia, bipolar disorder,<br />

obsessive-compulsive disorder, panic disorder,<br />

post-traumatic stress disorder, and selfinflicted<br />

injuries (e.g., suicide). Excluded are<br />

substance-abuse disorders that include alcohol<br />

addiction.<br />

8 Murray, C. J., & Lopez, A. D. (1996). Evidence-based<br />

health policy—lessons from<br />

the global burden <strong>of</strong> disease study. Science,<br />

274(5288), 740-743.<br />

schizophrenia, dementias, and anxiety<br />

disorders. 6 In <strong>New</strong> <strong>York</strong> <strong>State</strong>,<br />

a majority <strong>of</strong> the more than 600,000<br />

adults and children who receive<br />

services in the public mental health<br />

system each year are diagnosed<br />

with serious mental illness–a mental<br />

disorder where symptoms have<br />

led to serious impairment <strong>of</strong> dayto-day<br />

functioning.<br />

The WHO uses disability-adjusted<br />

life years (DALYs), a measure that<br />

combines estimates <strong>of</strong> disease morbidity<br />

(relative incidence) and mortality<br />

to estimate how many productive<br />

years <strong>of</strong> life are lost due to<br />

the impact <strong>of</strong> disease. <strong>Mental</strong> disease<br />

ranks second only to cardiovascular<br />

disorders in the number <strong>of</strong><br />

years lost (Table 4.1). Specifically,<br />

1991 data collected by WHO, Harvard<br />

University, and others indicate<br />

that 15.4% <strong>of</strong> the total disease burden<br />

in industrialized countries can<br />

be directly attributed to mental disorders.<br />

7 By comparison, only cardiovascular<br />

diseases rank higher, at<br />

18.6%. Cancer is a close third, at<br />

15%, while respiratory diseases<br />

(6.2%) and alcohol-related morbidity<br />

(4.7%) are fourth and fifth,<br />

respectively. 1, 8<br />

Comorbidity, which signifies the<br />

simultaneous occurrence <strong>of</strong> two or<br />

more disorders in a person is also<br />

important to understanding the disease<br />

burden <strong>of</strong> mental illness.<br />

Comorbid mental disorders are<br />

<strong>of</strong>ten under-recognized and not<br />

always effectively treated; they<br />

result in lower adherence to medical<br />

treatment, an increase in disability<br />

and mortality, and higher health<br />

costs. According to WHO (2003),<br />

research shows that a number <strong>of</strong><br />

mental disorders (e.g., depression,<br />

anxiety, and substance abuse) occur<br />

in people suffering from other diseases<br />

more <strong>of</strong>ten than would be<br />

expected by chance. In addition,<br />

people suffering from chronic physical<br />

conditions have a greater probability<br />

<strong>of</strong> developing mental disorders<br />

such as depression (Figure<br />

4.1), and rates <strong>of</strong> suicide are higher<br />

among people with physical disorders<br />

than among other people.<br />

These relationships between mental<br />

and medical illnesses further<br />

emphasize the need for continued<br />

mental health research.<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 4: Basic and Clinical Research 37<br />

Figure 4.2<br />

Yearly Cost per Patient <strong>of</strong> Selected Medical Conditions:<br />

United <strong>State</strong>s US$/Patient/Year<br />

Alzheimer<br />

Schizophrenia<br />

Cancer<br />

Stroke<br />

Coronary Heart Disease<br />

Diabetes<br />

Congestive Heart Failure<br />

Depression<br />

Osteoporosis<br />

Arthritis<br />

Hypertension<br />

Asthma<br />

0 5,000 10,000 15,000 20,000 25,000<br />

High costs <strong>of</strong> mental<br />

disorders compared to other<br />

major chronic conditions<br />

I<br />

Source: WHO, 2003<br />

n addition to the severe disease<br />

burden <strong>of</strong> mental disorders,<br />

research shows that the costs for<br />

treating these disorders are high<br />

compared to the costs for treating<br />

other major chronic conditions. A<br />

recent study 9 considers different<br />

diseases in terms <strong>of</strong> the average<br />

cost per patient, and as shown in<br />

Figure 4.2, Alzheimer’s disease and<br />

schizophrenia are the two most<br />

costly, their average cost per<br />

patient being higher than that for<br />

cancer and stroke.<br />

Given the high disease burden<br />

and treatment costs for mental illness,<br />

the WHO, U.S. Surgeon General,<br />

and President’s <strong>New</strong> Freedom<br />

Commission on <strong>Mental</strong> <strong>Health</strong> have<br />

concluded that we must continue<br />

to invest in research at all levels to<br />

gain needed advances in treatment,<br />

and ultimately to prevent mental<br />

illness. Just as research <strong>of</strong>fers great<br />

hope for cancer, heart disease, and<br />

diabetes, research is essential to<br />

reducing the burden <strong>of</strong> mental illness<br />

by improving access to effective<br />

care and achieving urgently<br />

needed knowledge about the<br />

brain, mind, and behavior.<br />

<strong>OMH</strong> Research<br />

s a national and international<br />

Aleader in mental health research,<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> is committed to<br />

reducing the burden <strong>of</strong> mental illness<br />

and improving access to effective<br />

care. <strong>OMH</strong> research is conducted<br />

by the Research Division and<br />

also by Evaluation Research (ER)<br />

staff from the Center for Information<br />

Technology and Evaluation Research<br />

(CITER). The Research Division performs<br />

basic, clinical and services<br />

research primarily at two locations:<br />

the Nathan S. Kline Institute for Psychiatric<br />

Research (NKI) in Orangeburg<br />

<strong>New</strong> <strong>York</strong>, and the <strong>New</strong> <strong>York</strong><br />

<strong>State</strong> Psychiatric Institute (NYSPI) in<br />

<strong>New</strong> <strong>York</strong> City. 10 Evaluation research<br />

focusing on service system improve-<br />

Notes<br />

9 Berto, P., D’Ilario, D., Ruffo, P., Di Virgilio, R.,<br />

& Rizzo, F. (2000). Depression: Cost-<strong>of</strong>-illness<br />

studies in the international literature: A<br />

review. The Journal <strong>of</strong> <strong>Mental</strong> <strong>Health</strong> Policy<br />

and Economics, 3(1), 3-10.<br />

10 More information about the institutes can<br />

be found at their respective Web sites:<br />

http://nyspi.org/Kolb/index.htm<br />

and http://www.rfmh.org/nki/.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


38 Chapter 4: Basic and Clinical Research<br />

Table 4.2<br />

Mission and Goals<br />

<strong>of</strong> <strong>OMH</strong> Research<br />

Mission<br />

The mission <strong>of</strong> <strong>OMH</strong><br />

Research is to develop<br />

better methods <strong>of</strong> prevention<br />

and treatment <strong>of</strong><br />

mental illness.<br />

Goals<br />

◆ Learn more about the<br />

causes <strong>of</strong> mental disabilities.<br />

◆ Contribute to the development<br />

<strong>of</strong> new treatments.<br />

◆ Evaluate the effectiveness<br />

<strong>of</strong> existing and emerging<br />

treatment methods.<br />

◆ Determine new and better<br />

models <strong>of</strong> service<br />

delivery which are<br />

planned with input from<br />

consumers and are culturally<br />

relevant.<br />

◆ Quickly and effectively<br />

disseminate the results <strong>of</strong><br />

research findings to <strong>State</strong><br />

and local clinicians,<br />

providers, recipients,<br />

families, and other stakeholders.<br />

◆ Make the expertise <strong>of</strong><br />

research scientists available<br />

to practitioners in<br />

the <strong>OMH</strong> system through<br />

continuous education<br />

and consultation.<br />

◆ Delineate the magnitude<br />

<strong>of</strong> social cost and burden<br />

<strong>of</strong> mental disorders in<br />

order to prioritize utilization<br />

<strong>of</strong> resources.<br />

ment is conducted by staff from<br />

CITER-ER at <strong>OMH</strong> Central <strong>Office</strong> in<br />

Albany, and some research activities<br />

are also carried out at other <strong>OMH</strong><br />

facilities, including Bronx Psychiatric,<br />

Bronx Children's, Buffalo, Creedmoor,<br />

Hutchings, Manhattan, Pilgrim,<br />

Rochester, Rockland, and Sagamore<br />

Children's Psychiatric Centers.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong>’s investment in<br />

research is augmented by many<br />

grants from Federal and other<br />

sources through the Research Foundation<br />

for <strong>Mental</strong> Hygiene (RFMH),<br />

Inc. This Chapter provides highlights<br />

<strong>of</strong> the exemplary basic and clinical<br />

research that is taking place in the<br />

Research Division. Chapter 5 provides<br />

an overview <strong>of</strong> <strong>OMH</strong> evaluation<br />

activities that focus on service<br />

system improvement.<br />

<strong>OMH</strong>’s interdisciplinary teams <strong>of</strong><br />

clinical and services researchers<br />

include physicians, epidemiologists,<br />

psychologists, neuroscientists, and<br />

sociologists who perform a broad<br />

range <strong>of</strong> basic, clinical and services<br />

research (Table 4.3). All institute<br />

clinical research must first receive<br />

approval from the facility Institutional<br />

Review Board (IRB), which is in<br />

turn overseen by the Director <strong>of</strong> the<br />

Research Division with the assistance<br />

<strong>of</strong> staff from RFMH. All <strong>OMH</strong><br />

Table 4.3<br />

<strong>OMH</strong> Research Areas <strong>of</strong> Study<br />

◆ Alzheimer’s Disease and<br />

Other Memory Disorders<br />

◆ Personality Disorders<br />

◆ Assessment and Prevention<br />

<strong>of</strong> Violence<br />

◆ Post-traumatic Stress and<br />

Other Anxiety Disorders<br />

◆ Child and Adolescent<br />

Psychiatry<br />

◆ Psychiatric Epidemiology<br />

◆ Genetics<br />

◆ Psychoanalytic Research<br />

◆ Geriatrics and Gerontology<br />

◆ Psychopharmacology and<br />

Other Therapeutics<br />

Central <strong>Office</strong>’s research must first<br />

receive approval from either the<br />

Central <strong>Office</strong> or Forensic IRB<br />

(depending on the population under<br />

study), which is in turn overseen by<br />

the Senior Deputy Commissioner<br />

and Chief Information <strong>Office</strong>r <strong>of</strong><br />

CITER, with the assistance <strong>of</strong> RFMH.<br />

As they contribute to the science<br />

knowledge base for mental illness<br />

prevention, treatment, and service<br />

delivery, <strong>OMH</strong> researchers are<br />

actively involved in national and<br />

international research communities.<br />

Each research institute has a strong<br />

collaboration with an academic<br />

partner–NKI with <strong>New</strong> <strong>York</strong> University,<br />

and NYSPI with Columbia<br />

University. Research is also performed<br />

collaboratively with institutions<br />

including Alzheimer’s Disease<br />

International, the Institute <strong>of</strong> Psychiatry<br />

in London, the Louis de la<br />

Parte Florida <strong>Mental</strong> <strong>Health</strong> Institute,<br />

the National Association <strong>of</strong><br />

<strong>State</strong> <strong>Mental</strong> <strong>Health</strong> Program Directors<br />

Research Institute, and the<br />

World <strong>Health</strong> Organization. Additional<br />

academic collaborations take<br />

place with universities including<br />

the <strong>State</strong> University <strong>of</strong> <strong>New</strong> <strong>York</strong><br />

(SUNY) at Albany, SUNY Buffalo,<br />

SUNY Upstate, SUNY Downstate,<br />

Brown, Harvard, the University <strong>of</strong><br />

◆ Homelessness and<br />

<strong>Mental</strong> Illness<br />

◆ Schizophrenia and Bipolar<br />

Disorder Research<br />

◆ Social and Community<br />

Psychiatry<br />

◆ Neurochemistry<br />

◆ Statistical Sciences and<br />

Research Methods<br />

◆ Neuroimaging<br />

◆ Substance Abuse<br />

and <strong>Mental</strong> Illness<br />

◆ Neurophysiology<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 4: Basic and Clinical Research 39<br />

Pennsylvania, the University <strong>of</strong><br />

Rochester, Texas A&M, and Yale.<br />

Research in public mental health<br />

is also supported through public<br />

psychiatry fellowships designed to<br />

train psychiatrists who plan to<br />

devote their careers to working<br />

with high-risk populations in the<br />

public sector and conducting<br />

research. Fellows are trained to use<br />

evaluation strategies, clinical techniques,<br />

and management skills<br />

within established institutions serving<br />

these populations.<br />

◆ A Public Psychiatry Fellowship at<br />

NYSPI and the Columbia University<br />

College <strong>of</strong> Physicians and<br />

Surgeons was initiated in 1981<br />

with funds from <strong>OMH</strong> to facilitate<br />

recruitment and retention <strong>of</strong><br />

high-caliber psychiatrists in the<br />

public sector. Each year, ten<br />

one-year Fellowships are awarded<br />

to psychiatrists desiring a<br />

career in public psychiatry, with<br />

funding support from <strong>OMH</strong> and<br />

placement sites.<br />

◆ <strong>OMH</strong> is also affiliated with the<br />

Albert Einstein College <strong>of</strong> Medicine<br />

Forensic Psychiatry Fellowship,<br />

which is a one-year training<br />

program in Law and<br />

Psychiatry <strong>of</strong>fered by the College’s<br />

Division <strong>of</strong> Law and Psychiatry.<br />

Forensic psychiatry is a<br />

subspecialty <strong>of</strong> psychiatry in<br />

which scientific and clinical<br />

expertise is applied to legal<br />

issues in legal context embracing<br />

civil, criminal, and correctional<br />

or legislative matters.<br />

◆ The Forensic Psychiatric Residency<br />

Program <strong>of</strong> the SUNY Upstate<br />

Medical University in Syracuse<br />

was developed in 1986 in collaboration<br />

with Central <strong>New</strong> <strong>York</strong><br />

Psychiatric Center and the Syracuse<br />

University College <strong>of</strong> Law.<br />

The program was awarded<br />

ACGME (Accreditation Council<br />

for Graduate Medical Education)<br />

Accreditation in August 2000.<br />

This one-year program incorporates<br />

didactic experiences at the<br />

College <strong>of</strong> Law and Upstate Medical<br />

University, clinical experience<br />

at Central <strong>New</strong> <strong>York</strong> Psychiatric<br />

Center and several local<br />

correctional institutions, and<br />

courtroom experiences.<br />

Improving Care<br />

through Basic and<br />

Clinical Research<br />

MH’s Research Division makes<br />

Oimportant contributions toward<br />

improving care through basic and<br />

clinical research. Described here<br />

are contributions in two critical<br />

areas: schizophrenia and dementia.<br />

Schizophrenia Research<br />

Burden <strong>of</strong> Care<br />

chizophrenia is among the<br />

Scostliest <strong>of</strong> diseases. It affects<br />

about two million people in the<br />

United <strong>State</strong>s and is more prevalent<br />

than epilepsy or multiple sclerosis.<br />

11 Nationwide, individuals with<br />

schizophrenia account for approximately<br />

20% <strong>of</strong> all social security<br />

disability days and 25% <strong>of</strong> hospital<br />

bed days are devoted to individuals<br />

with schizophrenia. 12 In <strong>New</strong> <strong>York</strong>,<br />

approximately 23% (96,000) <strong>of</strong><br />

adults aged 18-64 who receive care<br />

in the public mental health system<br />

have a primary diagnosis <strong>of</strong> schizophrenia<br />

or a related disorder. Ten<br />

percent <strong>of</strong> individuals with schizophrenia<br />

take their own lives. 13<br />

According to 1996 figures, schizophrenia<br />

costs the U.S. health care<br />

system $17.3 billion per year with<br />

an additional $15.2 billion per year<br />

in indirect costs. 14 Much <strong>of</strong> the burden<br />

<strong>of</strong> caring for individuals with<br />

schizophrenia is borne at state,<br />

county and local levels as the first<br />

Notes<br />

11 Hafner, H., & an der Heiden, W. (1997). Epidemiology<br />

<strong>of</strong> schizophrenia. Canadian Journal<br />

<strong>of</strong> Psychiatry, 42, 139-51.<br />

12 Management Decision and Research Center.<br />

(October, 2002). Effective treatment for<br />

schizophrenia. Practice Matters, 7(1): 1-6.<br />

13 National Institute <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>. (2000,<br />

May). Schizophrenia research fact sheet.<br />

Bethesda, MD: NIMH <strong>Office</strong> <strong>of</strong> Communications<br />

and Public Liaison. Retrieved December<br />

15, 2004, at http://www.nimh.nih.gov/publicat/NIMHschizresfact.pdf<br />

14 Knapp, M., Mangalore, R., & Simon, J.<br />

(2004). The global costs <strong>of</strong> schizophrenia.<br />

Schizophrenia Bulletin, 30(2):279-293.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


40 Chapter 4: Basic and Clinical Research<br />

Notes<br />

15 White, L., Harvey, P.D., Opler, L.A., & Lindenmayer,<br />

J.P. (1997). Empirical assessment <strong>of</strong><br />

the factorial structure <strong>of</strong> clinical symptoms<br />

in schizophrenia. A multisite, multimodel<br />

evaluation <strong>of</strong> the factorial structure <strong>of</strong> the<br />

Positive and Negative Syndrome Scale. The<br />

PANSS Study Group. Psychopathology,<br />

30(5):263-274.<br />

16 Robinson, D.G., Woerner, M.G., McMeniman,<br />

M., Mendelowitz, A., & Bilder, M. (2004).<br />

Symptomatic and functional recovery from a<br />

first episode <strong>of</strong> schizophrenia or schizoaffective<br />

disorder. Am J Psychiatry, 161(3):473-479.<br />

onset <strong>of</strong> schizophrenia, which can<br />

be longstanding, is usually in the<br />

teens and twenties.<br />

<strong>OMH</strong> researchers were the first to<br />

show that symptoms can be<br />

grouped into five categories: positive<br />

symptoms including delusions<br />

and hallucinations; negative symptoms<br />

such as loss <strong>of</strong> interest in the<br />

environment and emotional withdrawal;<br />

autistic preoccupation<br />

symptoms such as preoccupation,<br />

poor attention and cognitive deficits;<br />

activation symptoms such as hostility,<br />

excitement, and poor impulse<br />

control; and dysphoric mood symptoms,<br />

such as anxiety, guilt, and<br />

depression. 15 Prior to the introduction<br />

<strong>of</strong> the second generation<br />

antipsychotics in the 1990s, positive<br />

symptoms were considered the only<br />

symptoms <strong>of</strong> schizophrenia<br />

amenable to medication treatment.<br />

Now, thanks to research initiated in<br />

<strong>OMH</strong> facilities, new medications are<br />

becoming available that target not<br />

only positive but also negative, activation,<br />

dysphoric mood, and autistic<br />

preoccupation symptoms.<br />

The precise causes <strong>of</strong> schizophrenia,<br />

at present, are unknown. We<br />

do, however, know that schizophrenia<br />

is associated with both<br />

genetic and environmental factors.<br />

Children <strong>of</strong> individuals with schizophrenia<br />

have about a 15% chance<br />

<strong>of</strong> developing the illness, and if<br />

one member <strong>of</strong> an identical twin<br />

pair has schizophrenia, then there<br />

is a 50% likelihood that the other<br />

twin will have schizophrenia, too.<br />

These rates are similar to other<br />

complex conditions such as diabetes<br />

or obesity, but much lower<br />

than those that are single gene.<br />

Current Treatments<br />

for Schizophrenia<br />

ll current medications for schiz-<br />

including both typical<br />

Aophrenia,<br />

and newer atypical antipsychotics,<br />

function by blocking the actions <strong>of</strong><br />

dopamine, a neurotransmitter that<br />

carries signals between nerve cells<br />

in the brain. Because <strong>of</strong> various<br />

improvements, the newer atypical<br />

antipsychotics produce fewer neurological<br />

side effects, such as motor<br />

disturbances, than did older medications,<br />

and are also better tolerated<br />

by many individuals. Nevertheless,<br />

many <strong>of</strong> the newer atypical<br />

medications have turned out to<br />

have unexpected side effects, such<br />

as propensity to cause weight gain<br />

and precipitate diabetes, complicating<br />

clinical care.<br />

Most importantly, only about 20%<br />

<strong>of</strong> individuals with schizophrenia<br />

show full resolution <strong>of</strong> symptoms<br />

despite treatment with the best<br />

available agents. 16 Although persistent<br />

positive symptoms contribute<br />

to poor outcomes, many individuals<br />

can learn to function despite<br />

hallucinations or even delusions.<br />

More debilitating are negative<br />

symptoms such as severe apathy,<br />

loss <strong>of</strong> drive, social withdrawal,<br />

and cognitive deficits, such as<br />

impaired memory and problem<br />

solving ability. These core symptoms<br />

<strong>of</strong> schizophrenia remain<br />

largely unaffected by current medications,<br />

suggesting that new treatment<br />

approaches are required.<br />

Research Programs<br />

<strong>OMH</strong> conducts schizophrenia<br />

research with the overarching goal<br />

<strong>of</strong> developing new treatment<br />

approaches for this disease. Over<br />

the past five years, <strong>OMH</strong><br />

researchers have been awarded<br />

numerous grants from both the<br />

Federal government and independent<br />

research foundations to support<br />

their research, and have also published<br />

hundreds <strong>of</strong> articles and<br />

chapters on topics relevant to<br />

schizophrenia. This section highlights<br />

how <strong>OMH</strong> is facilitating the<br />

translation <strong>of</strong> new research<br />

approaches into practical new<br />

treatments for schizophrenia in<br />

three key areas: basic research,<br />

studies <strong>of</strong> neurocognition, and<br />

medication treatment studies.<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 4: Basic and Clinical Research 41<br />

Basic research studies<br />

o develop better treatments,<br />

Tinvestigators need to understand<br />

how schizophrenia arises. Many<br />

brain regions and systems operate<br />

abnormally in schizophrenia.<br />

Although imbalances in the neurotransmitter<br />

dopamine were once<br />

thought to be the prime cause <strong>of</strong><br />

schizophrenia, new findings suggest<br />

that impoverished signaling by<br />

the more pervasive neurotransmitter<br />

glutamate–or, more specifically,<br />

by one <strong>of</strong> glutamate’s key targets<br />

on neurons (the NMDA receptor)–<br />

better explains the wide range <strong>of</strong><br />

symptoms in this disorder.<br />

These new findings are guided by<br />

the “phencyclidine model <strong>of</strong> schizophrenia.”<br />

The model is based on<br />

the observation that phencyclidine<br />

causes symptoms similar to those<br />

seen in schizophrenia by blocking<br />

the NMDA receptors, which are<br />

widely distributed in the brain and<br />

participate in processes such as<br />

learning, memory, attention, and<br />

“signal amplification.” The ability <strong>of</strong><br />

phencyclidine and related drugs to<br />

induce symptoms <strong>of</strong> schizophrenia<br />

by blocking NMDA receptors has<br />

led to the theory that dysfunction<br />

<strong>of</strong> NMDA receptors may cause<br />

symptoms <strong>of</strong> schizophrenia. This<br />

model was first proposed by <strong>OMH</strong><br />

research scientists in a 1991 journal<br />

article, 17 which has since been cited<br />

over 700 times, and was the second<br />

most widely cited schizophrenia<br />

paper during the 1990s.<br />

Studies conducted over the past<br />

several years have investigated<br />

effects <strong>of</strong> phencyclidine, with the<br />

goal <strong>of</strong> developing new targets for<br />

treatment. One issue addressed by<br />

these studies is the relationship<br />

between NMDA disturbances and<br />

dopamine functioning in individuals<br />

with schizophrenia. With a goal<br />

<strong>of</strong> better understanding the possible<br />

causes <strong>of</strong> schizophrenia and<br />

developing more effective treatments,<br />

these studies investigated<br />

first, the ability <strong>of</strong> phencyclidine to<br />

induce abnormalities <strong>of</strong> the<br />

dopamine system similar to those<br />

seen in schizophrenia, and second,<br />

the ability <strong>of</strong> amino acids, such as<br />

glycine, to reverse the effects.<br />

Study results suggest that glycine<br />

counteracts the effects <strong>of</strong> phencyclidine.<br />

This pattern is similar to<br />

what has been observed symptomatically<br />

in individuals with schizophrenia<br />

receiving glycine. A limitation<br />

<strong>of</strong> glycine treatment is that<br />

high doses must be given to obtain<br />

significant therapeutic effect.<br />

This analysis, and others like it that<br />

have been developed by <strong>OMH</strong><br />

research scientists, permit testing <strong>of</strong><br />

newer medications that may be<br />

shown to treat schizophrenia more<br />

effectively. To date, several novel<br />

medications, including a class <strong>of</strong><br />

drugs termed “glycine transport<br />

inhibitors,” have been shown to produce<br />

effects quite similar to those<br />

produced by glycine. Several such<br />

compounds are currently under clinical<br />

development and are expected to<br />

begin clinical testing within the next<br />

few years. Other newer approaches<br />

are currently under development in<br />

the Research Division, providing a<br />

multifaceted attack on the problem.<br />

These studies were funded from<br />

grants received from both the<br />

National Institutes <strong>of</strong> <strong>Health</strong> (NIH)<br />

and the Stanley Medical Research<br />

Institute. Study results have been<br />

published in several high pr<strong>of</strong>ile<br />

journals, including Biological Psychiatry<br />

and Neuropsychopharmacology.<br />

Studies <strong>of</strong> neurocognition<br />

MH studies <strong>of</strong> neurocognition are<br />

Oproviding a better understanding<br />

<strong>of</strong> the cognitive deficits associated<br />

with schizophrenia. Average IQ in<br />

the normal adult population is set at<br />

100, and a value <strong>of</strong> 70 is considered<br />

the cut<strong>of</strong>f for “borderline” intellectual<br />

function. Approximately 80% <strong>of</strong><br />

individuals with schizophrenia are<br />

below their expected IQ, based on<br />

Notes<br />

17 Javitt, D. C., & Zukin, S. R. (1991). Recent<br />

Advances in the Phencyclidine Model <strong>of</strong><br />

Schizophrenia. American Journal <strong>of</strong> Psychiatry,<br />

148(10), 1301-1308.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


42 Chapter 4: Basic and Clinical Research<br />

Notes<br />

18 Goldberg, T.E., Torrey, E.F., Gold, J.M.,<br />

Bigelow, L.B., Ragland, R.D., Taylor, E., Weinberger<br />

DR. (1995). Genetic risk <strong>of</strong> neuropsychological<br />

impairment in schizophrenia: a<br />

study <strong>of</strong> monozygotic twins discordant and<br />

concordant for the disorder. Schizophrenia<br />

Research, 17(1):77-84.<br />

19 Hollis, C. (2002). Adolescent schizophrenia.<br />

Advances in Psychiatric Treatment, 6, 83-92.<br />

those <strong>of</strong> their parents and siblings. 18<br />

On average, adolescents with schizophrenia<br />

have a mean IQ <strong>of</strong> 85 and<br />

30% <strong>of</strong> these adolescents have IQs<br />

<strong>of</strong> 70 or below. 19 This is because<br />

their mean IQ is reduced by about<br />

five points during childhood, and<br />

they then experience another ten to<br />

15 point drop in the six-month to<br />

two-year period prior to the onset <strong>of</strong><br />

the illness. This drop in IQ is illustrative<br />

<strong>of</strong> the “dementia” aspect <strong>of</strong><br />

schizophrenia that robs individuals<br />

<strong>of</strong> the coping skills they need to<br />

deal effectively with their symptoms.<br />

The pattern <strong>of</strong> cognitive deficit in<br />

schizophrenia, however, is different<br />

from the pattern observed in other<br />

dementing illnesses such as<br />

Alzheimer’s disease. Further, the<br />

degree <strong>of</strong> brain degeneration is<br />

much less, suggesting that the<br />

deficits might be reversible (or at<br />

least preventable) if underlying<br />

causes are known. Thus, <strong>OMH</strong><br />

studies <strong>of</strong> neurocognition have the<br />

overall goals <strong>of</strong> providing information<br />

to allow early identification <strong>of</strong><br />

individuals predisposed to schizophrenia,<br />

and early intervention to<br />

prevent cognitive decline, as<br />

important next steps in the management<br />

<strong>of</strong> the disease.<br />

In recent years, significant strides<br />

have been made in developing<br />

tests that distinguish individuals<br />

with schizophrenia from those<br />

without the disease. A goal over<br />

the next several years is application<br />

<strong>of</strong> these tests to individuals showing<br />

what may be early signs <strong>of</strong><br />

schizophrenia to identify those<br />

who require early intervention.<br />

<strong>OMH</strong> researchers use a combination<br />

<strong>of</strong> high-density electrophysiology,<br />

which analyzes the minute<br />

electrical waves given <strong>of</strong>f by the<br />

brain during cognitive activity using<br />

electrodes placed on the scalp, and<br />

functional brain imaging, which<br />

analyzes blood flow in key brain<br />

regions using magnetic resonance<br />

imaging. Together these techniques<br />

can trace the flow <strong>of</strong> information in<br />

the brain, and determine the locations<br />

and hopefully, the causes <strong>of</strong><br />

abnormal brain functions.<br />

One area <strong>of</strong> particular interest is<br />

in the early stages <strong>of</strong> information<br />

processing. Most schizophrenia<br />

studies focus on dysfunction <strong>of</strong><br />

complex brain regions, and while<br />

there are deficits associated with<br />

those regions in schizophrenia,<br />

even much simpler processes<br />

appear to be impaired which<br />

involve how individuals “decode”<br />

the world around them. For example,<br />

it has <strong>of</strong>ten been assumed that<br />

individuals with schizophrenia hear<br />

and see information normally, but<br />

just interpret it incorrectly. <strong>OMH</strong><br />

research has shown that this is not<br />

the case. For example, individuals<br />

with schizophrenia have much<br />

more difficulty than others in<br />

detecting simple changes in musical<br />

pitch. As a result, they are less sensitive<br />

than other individuals to<br />

detecting emotion based upon<br />

other people’s vocal intonations.<br />

Individuals with schizophrenia also<br />

have difficulty in decoding complex<br />

images, such as partially obscured<br />

pictures, or even facial expressions.<br />

This also leads to difficulty in<br />

understanding other people’s emotions.<br />

These same deficits also give<br />

rise to difficulty in reading books or<br />

magazines, another overlooked<br />

deficit in schizophrenia.<br />

These deficits in basic sensory<br />

processes contribute to the difficulty<br />

that individuals with schizophrenia<br />

may have in what for most<br />

people are simple day-to-day interactions-decoding<br />

a person’s emotions<br />

by looking at their face or listening<br />

to the tone <strong>of</strong> their voice,<br />

expressing their own emotions, or<br />

distinguishing frightening from<br />

non-frightening objects. These<br />

basic deficits are not affected by<br />

the types <strong>of</strong> medication available to<br />

date, and whether or not they<br />

respond to newer medications<br />

remains to be established. Recent<br />

<strong>OMH</strong> studies <strong>of</strong> cognitive dysfunc-<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 4: Basic and Clinical Research 43<br />

tion point up new avenues for cognitive<br />

remediation. For example,<br />

when individuals with schizophrenia<br />

are helped to read, their comprehension<br />

is <strong>of</strong>ten relatively normal.<br />

These findings provide new<br />

avenues for designing remediation<br />

programs to address the core disturbances<br />

in schizophrenia, and<br />

hope for ultimate rehabilitation.<br />

Medication treatment studies<br />

MH research scientists conduct<br />

Omedication trials in order to<br />

hasten the use <strong>of</strong> behavioral science<br />

and neuroscience advances in<br />

clinical care. The research institutes<br />

have been test sites for several<br />

promising compounds, including<br />

glycine and other compounds that<br />

stimulate NMDA receptors.<br />

Clinical trials are conducted collaboratively<br />

across several centers. For<br />

example, an <strong>OMH</strong> research institute<br />

participated recently in the National<br />

Institute for <strong>Mental</strong> <strong>Health</strong> (NIMH)<br />

CONSIST trial for treatment <strong>of</strong> cognitive<br />

and negative symptoms, and<br />

will be one <strong>of</strong> only six sites nationwide<br />

that will be evaluating new<br />

medications to treat neurocognition<br />

as part <strong>of</strong> the newly awarded,<br />

NIMH-funded TURNS consortium.<br />

Some <strong>of</strong> the compounds entering<br />

clinical trials, such as D-serine, are<br />

compounds conceived or developed<br />

within <strong>OMH</strong> research institute laboratories.<br />

Others have been developed<br />

based upon complementary<br />

theories elsewhere.<br />

Dementia Research<br />

Burden <strong>of</strong> Care<br />

ementia describes a syndrome<br />

Dassociated with a range <strong>of</strong> diseases<br />

that progressively impair<br />

brain functions and rob the afflicted<br />

<strong>of</strong> their ability to learn, reason,<br />

make judgments, communicate and<br />

carry out daily activities. Dementia<br />

knows no social, economic, ethnic<br />

or geographical boundaries, and<br />

the full extent <strong>of</strong> its impact has only<br />

begun to be appreciated.<br />

Alzheimer’s disease, the leading<br />

cause <strong>of</strong> dementia, accounts for 50-<br />

60% <strong>of</strong> all cases. Other common<br />

causes <strong>of</strong> dementia include vascular<br />

dementia, Parkinson’s disease, and<br />

Lewy Body disease. 20 Alzheimer’s<br />

disease or other forms <strong>of</strong> dementia<br />

frequently coexist with psychiatric<br />

conditions. In older psychiatric<br />

patients with even mild dementia,<br />

disruptive behaviors are more common<br />

and persistent, and increase<br />

the utilization <strong>of</strong> psychiatric services,<br />

including hospitalization. Studies<br />

<strong>of</strong> psychiatric inpatient populations<br />

show that the presence <strong>of</strong> dementia<br />

is under-recognized by clinicians,<br />

which may complicate the treatment<br />

outcomes <strong>of</strong> these individuals.<br />

Increasing age is the greatest risk<br />

factor for Alzheimer’s disease. The<br />

likelihood <strong>of</strong> developing<br />

Alzheimer’s approximately doubles<br />

every five years after age 65. 21, 22 By<br />

age 85, the risk reaches nearly<br />

50%. 23, 24 An estimated 4.5 million<br />

Americans have Alzheimer’s disease<br />

25, 26<br />

and, based on a 1992 Gallup<br />

survey that indicated 1 in 10 persons<br />

had a family member with<br />

Alzheimer’s disease, in 2000 an estimated<br />

19 million Americans 21<br />

years <strong>of</strong> age or older had a family<br />

member with the disease. 27, 28 These<br />

numbers have more than doubled<br />

since 1980 as the percentage <strong>of</strong> elderly<br />

in the population has risen. In<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong>, the number <strong>of</strong><br />

people with dementia, currently<br />

estimated to be 300,000, will grow<br />

to approximately 500,000 in just<br />

five years. 29 Without a preventative<br />

therapy, the burden <strong>of</strong> care for this<br />

growing population will fall to a<br />

smaller, younger generation.<br />

The impact <strong>of</strong> Alzheimer’s and<br />

related disorders on individuals,<br />

families, and our health care system<br />

makes dementia one <strong>of</strong> soci-<br />

Notes<br />

20 Lewy Body disease, the second most frequent<br />

cause <strong>of</strong> dementia in elderly adults, is<br />

a neurodegenerative disorder associated<br />

with abnormal structures (Lewy bodies)<br />

found in certain areas <strong>of</strong> the brain. Because<br />

these structures and many <strong>of</strong> the symptoms<br />

<strong>of</strong> dementia with Lewy bodies are associated<br />

with Parkinson’s and Alzheimer’s diseases,<br />

researchers do not yet understand<br />

whether dementia with Lewy bodies is a distinct<br />

clinical entity or perhaps a variant <strong>of</strong><br />

Alzheimer’s or Parkinson’s disease.<br />

21 Brookmeyer, R., Gray, S., & Kawas, C. (1998).<br />

Projections <strong>of</strong> Alzheimer's Disease in the<br />

United <strong>State</strong>s and the public health impact<br />

<strong>of</strong> delaying disease onset. American Journal<br />

<strong>of</strong> Public <strong>Health</strong>, 88(9): 1337-1342.<br />

22 National Institute <strong>of</strong> Aging. (2004). 2003<br />

Progress report on Alzheimer’s disease:<br />

Research advances at NIH. U.S. Department<br />

<strong>of</strong> <strong>Health</strong> and Human Services, National<br />

Institutes <strong>of</strong> <strong>Health</strong>, Publication No. 04-5570.<br />

23 Evans, D.A., Funkenstein, H.H., Albert, M.S.,<br />

et al. (1989). Prevalence <strong>of</strong> Alzheimer’s Disease<br />

in a community population <strong>of</strong> older persons:<br />

higher than previously reported. JAMA,<br />

262(18): 2551-2556.<br />

24 National Institute <strong>of</strong> Aging. (2000). 2000<br />

Progress report on Alzheimer’s disease: Taking<br />

the next steps. U.S. Department <strong>of</strong><br />

<strong>Health</strong> and Human Services, National Institutes<br />

<strong>of</strong> <strong>Health</strong>, Publication No. 00-4859.<br />

25 Hebert, L.E., Scherr, P.A., Bienias, J.L., Bennett,<br />

D.A., & Evans, D.A. (2003). Alzheimer<br />

disease in the U.S. population: Prevalence<br />

estimates using the 2000 Census. Archives<br />

<strong>of</strong> Neurology, 60(8): 1119-1122.<br />

26 National Institute <strong>of</strong> Aging. (2004). 2003<br />

Progress report on Alzheimer’s disease:<br />

Research advances at NIH. U.S. Department<br />

<strong>of</strong> <strong>Health</strong> and Human Services, National<br />

Institutes <strong>of</strong> <strong>Health</strong>, Publication No. 04-5570.<br />

27 Alzheimer’s Association. (1993). Gallup survey<br />

commissioned by the Alzheimer’s Association.<br />

Chicago: Alzheimer’s Association<br />

Green-Field Library.<br />

28 U.S. Census Bureau. (2000). QT-01. Pr<strong>of</strong>ile <strong>of</strong><br />

general demographic characteristics: 2000.<br />

Data Set: Census 2000 supplementary survey<br />

summary. Tables. Accessed online December<br />

15, 2004, at http://factfinder.census.gov/<br />

servlet/QTTable?_bm=y&-geo_id=D&-<br />

qr_name=ACS_C2SS_EST_G00_QT01&-<br />

ds_name=D&-_lang=en&-redoLog=false.<br />

29 <strong>New</strong> <strong>York</strong> <strong>State</strong> Department <strong>of</strong> <strong>Health</strong>.<br />

(2004). Chronic disease teaching tools - <strong>New</strong><br />

<strong>York</strong> <strong>State</strong> dementia registry: Quick facts<br />

about the registry and dementia in <strong>New</strong> <strong>York</strong><br />

<strong>State</strong>. Albany, NY: Author. Retrieved December<br />

15, 2004, at http://www.health.state.ny.<br />

us/nysdoh/chronic/nysdr.htm.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


44 Chapter 4: Basic and Clinical Research<br />

Notes<br />

30 The bulk <strong>of</strong> this care is custodial care/supervision<br />

(e.g., help with activities <strong>of</strong> daily living,<br />

preventing wandering, etc.) and may<br />

include skilled or unskilled nursing care.<br />

31 Medicare and Medicaid Costs for People with<br />

Alzheimer’s Disease. Washington, D.C.; April<br />

2001: The Lewin Group; p.1. Retrieved<br />

December 16, 2004 at http://www.alz.org/<br />

Media/newsreleases/alzreport.pdf<br />

32 Koppel, R. (2002). Alzheimer’s disease: The<br />

costs to U.S. businesses in 2002. Chicago:<br />

Alzheimer’s Association. Retrieved December<br />

15, 2004, at: http://www.alz.org/Media/<br />

newsreleases/2002/062602ADCosts.pdf<br />

ety’s greatest medical, social and<br />

fiscal challenges. Alzheimer’s disease<br />

advances at widely different<br />

rates, and consequently, the duration<br />

<strong>of</strong> the illness can vary from<br />

three to 20 years. Because <strong>of</strong> its<br />

disabling rather than fatal nature,<br />

dementia not only deprives individuals<br />

<strong>of</strong> many years <strong>of</strong> healthy life,<br />

but also consigns family members<br />

to long years <strong>of</strong> care giving associated<br />

with substantial psychological<br />

and financial strain.<br />

More than 70% <strong>of</strong> people with<br />

Alzheimer’s disease live at home,<br />

where nearly 75% <strong>of</strong> their care is<br />

provided by family and friends. The<br />

remaining care 30 is provided by pr<strong>of</strong>essional<br />

caregivers at an average<br />

cost <strong>of</strong> $12,500 per year, which is<br />

paid mostly out-<strong>of</strong>-pocket by families.<br />

Dementia is the greatest single<br />

contributor to the cost <strong>of</strong> residential<br />

aged care, which <strong>of</strong>ten exceeds<br />

$60,000 per year per consumer.<br />

Nationally, direct and indirect annual<br />

costs <strong>of</strong> caring for individuals with<br />

Alzheimer’s disease alone are at least<br />

$100 billion a year. 31 These include<br />

$61 billion in costs to American businesses<br />

for Alzheimer health care and<br />

expenses related to caregivers <strong>of</strong><br />

individuals with Alzheimer’s, which<br />

include lost productivity, absenteeism,<br />

and worker replacement. 32<br />

The promise<br />

<strong>of</strong> Dementia Prevention<br />

n the absence <strong>of</strong> a cure for<br />

IAlzheimer’s, interventions that produce<br />

even a modest delay in the<br />

onset <strong>of</strong> dementia will have a major<br />

positive public health impact. It has<br />

been estimated that a preventative<br />

treatment in 2005 that delays the<br />

onset <strong>of</strong> Alzheimer’s by just five<br />

months could reduce new cases by<br />

5% each year. A preventative treatment<br />

that delayed onset by five<br />

years could reduce new cases annually<br />

by 50%, and halve the burden<br />

<strong>of</strong> total cases by 2040. The savings<br />

in terms <strong>of</strong> human suffering are<br />

immeasurable. Given the impending<br />

epidemic <strong>of</strong> dementia, there is an<br />

urgent need to maintain the commitment<br />

to research to reduce the<br />

human toll <strong>of</strong> dementia and its<br />

expanding economic burdens.<br />

Research Programs<br />

wealth <strong>of</strong> accumulating evi-<br />

indicates that with a sus-<br />

Adence<br />

tained research effort, the goal <strong>of</strong><br />

delaying dementia is within reach.<br />

Over the last 15 years, remarkable<br />

progress has been made toward<br />

understanding dementia and<br />

improving its management as a<br />

result <strong>of</strong> advances in neuroscience,<br />

genetics, medical technology, and<br />

clinical care. <strong>OMH</strong> researchers<br />

have been on the forefront <strong>of</strong> these<br />

developments, contributing to both<br />

the understanding <strong>of</strong> the causes <strong>of</strong><br />

dementia and the use <strong>of</strong> this<br />

knowledge to develop the newest<br />

generation <strong>of</strong> therapies aimed at<br />

preventing or delaying its onset.<br />

Complementary clinical programs<br />

have continued to make advances<br />

in the treatment and management<br />

<strong>of</strong> individuals who already have<br />

dementia and are in the community,<br />

residential homes, and <strong>State</strong><br />

hospitals.<br />

For their work in dementia, <strong>OMH</strong><br />

researchers have received the highest<br />

awards bestowed by the National<br />

Institute <strong>of</strong> <strong>Health</strong> (NIH), the<br />

national Alzheimer’s Association<br />

and other organizations. Their<br />

research has been published in<br />

highly regarded scientific journals,<br />

including Nature, Science, and Neuron.<br />

More importantly, as illustrated<br />

below, <strong>OMH</strong> research in dementia<br />

and affiliated clinical programs has<br />

made tangible progress toward<br />

translating research findings into<br />

practical clinical treatments for the<br />

prevention, treatment and management<br />

<strong>of</strong> dementia, and disseminating<br />

this knowledge to individuals<br />

with dementia and their caregivers.<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 4: Basic and Clinical Research 45<br />

Progress toward dementia<br />

prevention is accelerating<br />

lzheimer’s disease is a devastat-<br />

disorder <strong>of</strong> the brain’s nerve<br />

Aing<br />

cells and not a normal part <strong>of</strong><br />

aging. By the time symptoms<br />

emerge, nerve cells that process,<br />

store and retrieve information have<br />

already begun to degenerate and<br />

die. The areas <strong>of</strong> the brain that<br />

control memory and thinking skills<br />

are affected first, but as the disease<br />

progresses, cells die in other<br />

regions <strong>of</strong> the brain. Alzheimer’s<br />

disease has no known single cause,<br />

but in less than two decades, scientists<br />

have learned a great deal<br />

about factors that play a role. Two<br />

abnormal microscopic structures<br />

that appear in the brain, called<br />

“plaques” and “tangles,” are considered<br />

Alzheimer hallmarks. Plaques<br />

contain clumps <strong>of</strong> amyloid protein<br />

that accumulate outside the brain’s<br />

nerve cells. Tangles are twisted<br />

strands <strong>of</strong> another protein that<br />

form inside cells. Although it has<br />

not been fully resolved whether or<br />

not plaques or tangles cause<br />

Alzheimer’s, therapies that lower<br />

amounts <strong>of</strong> these abnormal proteins<br />

have been a key objective <strong>of</strong><br />

many researchers trying to develop<br />

new therapies to prevent or treat<br />

the disorder.<br />

<strong>OMH</strong> researchers have advanced<br />

this goal by identifying novel<br />

processes that can cause nerve<br />

cells to overproduce amyloid,<br />

thereby revealing new possibilities<br />

for blocking amyloid accumulation.<br />

In international collaborative studies,<br />

<strong>OMH</strong> research scientists recently<br />

discovered that amyloid in the<br />

blood outside the brain may contribute<br />

to its accumulation in the<br />

brain. This research is being<br />

viewed as a scientific basis for<br />

novel medications that act outside<br />

the brain to prevent amyloid accumulation,<br />

including the Alzheimer’s<br />

vaccine currently in clinical trials.<br />

<strong>OMH</strong> research scientists were also<br />

instrumental in a milestone study<br />

that first demonstrated memoryenhancing<br />

effects <strong>of</strong> an amyloid<br />

vaccine, and are well recognized<br />

for their models <strong>of</strong> Alzheimer’s<br />

which are being used worldwide<br />

by pharmaceutical companies and<br />

scientists to screen potential therapeutic<br />

agents for both Alzheimer’s<br />

and Parkinson’s disease. In addition,<br />

new models <strong>of</strong> Alzheimer tangle<br />

pathology recently patented by<br />

<strong>OMH</strong> researchers are already being<br />

used in drug discovery programs.<br />

It has become clear that whatever<br />

triggers Alzheimer’s disease<br />

begins to damage the brain years<br />

before symptoms appear. <strong>OMH</strong><br />

research scientists have shown that,<br />

even before this damage or amyloid<br />

appears, critical changes in<br />

nerve cell function are detectable<br />

up to a decade or more before the<br />

person develops symptoms <strong>of</strong><br />

Alzheimer’s. These Alzheimer’s-specific<br />

changes, the earliest known<br />

sentinels <strong>of</strong> the disease detected so<br />

far, involve defects in the way<br />

brain cells bring in and metabolize<br />

nutrients, and provide insights into<br />

why and how brain cells eventually<br />

die in the disease. These findings,<br />

which were the principal basis for<br />

a 1999 $7 million NIH grant award<br />

for <strong>OMH</strong> Alzheimer’s research, are<br />

revealing novel strategies for early<br />

diagnosis and a rationale for new<br />

prevention approaches, some <strong>of</strong><br />

which have already reached the<br />

stage <strong>of</strong> clinical testing. That disease-specific<br />

changes precede the<br />

symptoms <strong>of</strong> Alzheimer’s by many<br />

years, or even its earliest nerve cell<br />

damage, has enormous implications.<br />

The time that exists between<br />

the first tell-tale biochemical sign <strong>of</strong><br />

disease and the first memory symptoms<br />

provides a valuable opportunity<br />

to intervene before brain cells<br />

are ever lost.<br />

Achieving earlier diagnoses and<br />

preventative treatments by capitalizing<br />

on this knowledge is a major<br />

I<br />

t has been estimated that<br />

a preventative treatment<br />

in 2005 that delays the<br />

onset <strong>of</strong> Alzheimer’s by just<br />

five months could reduce<br />

new cases by 5% each<br />

year. A preventative treatment<br />

that delayed onset by<br />

five years could reduce<br />

new cases annually by<br />

50%, and halve the burden<br />

<strong>of</strong> total cases by 2040.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


46 Chapter 4: Basic and Clinical Research<br />

thrust <strong>of</strong> current <strong>OMH</strong> dementia<br />

research. For example, <strong>OMH</strong><br />

researchers have utilized advanced<br />

brain imaging to detect abnormal<br />

brain function, possibly heralding<br />

the future onset <strong>of</strong> Alzheimer’s, in<br />

symptom-free elderly individuals<br />

who are at higher genetic risk to<br />

develop the disease. Other new<br />

imaging techniques are now being<br />

applied with the goal <strong>of</strong> widening<br />

the window <strong>of</strong> prevention opportunity<br />

even further.<br />

Promising recent advances<br />

in the treatment and<br />

prevention <strong>of</strong> Alzheimer’s<br />

mong the most promising recent<br />

Aadvances in the treatment and<br />

prevention <strong>of</strong> Alzheimer’s are new<br />

studies revealing factors, beyond<br />

age and rare genetic causes, that<br />

increase the risk <strong>of</strong> dementia. These<br />

studies have raised hopes that<br />

dementia onset may be delayed or<br />

prevented by modifying these factors.<br />

Of particular importance is the<br />

discovery that vascular disease<br />

plays a large role not only in vascular<br />

dementia, but also in<br />

Alzheimer’s disease, most likely by<br />

decreasing blood flow to the brain.<br />

The benefits from this research in<br />

terms <strong>of</strong> Alzheimer’s prevention<br />

may be coming soon since moderately<br />

effective measures that can<br />

prevent stroke and disease <strong>of</strong> the<br />

blood vessels in the brain already<br />

show promise.<br />

People with heart disease are at<br />

higher risk <strong>of</strong> developing dementia<br />

while those with Alzheimer’s<br />

disease pathology decline faster if<br />

they also have vascular-related<br />

brain damage. Research in this area<br />

was catalyzed by the findings <strong>of</strong> an<br />

<strong>OMH</strong> research scientist, who identified<br />

the first gene causing a form <strong>of</strong><br />

dementia that is related to<br />

Alzheimer’s but affects primarily the<br />

blood vessels. Subsequently, these<br />

scientists have developed unique<br />

laboratory models <strong>of</strong> the disease for<br />

drug screening and understanding<br />

further this important interaction <strong>of</strong><br />

blood vessel disease with<br />

Alzheimer’s disease. In current clinical<br />

trials <strong>of</strong> the amyloid vaccine<br />

and other amyloid-lowering therapies,<br />

the impact on blood vessels<br />

has assumed critical importance<br />

and research by <strong>OMH</strong> scientists is<br />

having a crucial influence on the<br />

design <strong>of</strong> these promising therapeutic<br />

strategies.<br />

Strengthening the link between<br />

heart and brain in Alzheimer’s disease<br />

even further are new observations<br />

that a host <strong>of</strong> risk factors for<br />

vascular disease (including high<br />

blood pressure, cholesterol and<br />

homocysteine, diabetes, smoking,<br />

and obesity) increase risk for<br />

dementia and hasten memory<br />

decline. Emerging evidence suggests<br />

that controlling these risk factors<br />

and promoting general healthy<br />

aging reduce Alzheimer risk.<br />

Observations that dementia may<br />

develop at different rates in individuals<br />

from the same ethnic population<br />

living in different parts <strong>of</strong> the<br />

world has suggested that lifestyle<br />

factors, many <strong>of</strong> which are modifiable,<br />

may potentially forestall the<br />

onset <strong>of</strong> dementia. Diet is one <strong>of</strong><br />

these lifestyle factors. Foods or<br />

supplements containing antioxidants<br />

or omega-3 fatty acids have<br />

been found to be protective whereas<br />

foods high in total and saturated<br />

fat and cholesterol increase risk.<br />

Seminal work by several <strong>OMH</strong><br />

researchers showing that dietary<br />

reductions <strong>of</strong> cholesterol lowered<br />

amyloid accumulation in the brain<br />

led to the first demonstration that<br />

cholesterol-lowering drugs, called<br />

statins, have similar but even more<br />

potent effects. These and other<br />

findings have provided the impetus<br />

for current clinical trials <strong>of</strong> statins<br />

nationwide in people with<br />

Alzheimer’s disease, the first <strong>of</strong><br />

which has recently reported very<br />

encouraging results.<br />

Based on these rapidly emerging<br />

findings and the precedent that<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 4: Basic and Clinical Research 47<br />

population-based strategies to<br />

reduce heart disease (general<br />

screening, dietary interventions,<br />

education, and pharmacotherapy)<br />

reduce mortality and cardiovascular<br />

risk, and are cost effective, the<br />

Alzheimer community and the<br />

national Alzheimer’s Association<br />

urge the adoption <strong>of</strong> healthy<br />

lifestyles such as regular exercise to<br />

delay the onset <strong>of</strong> dementia, which<br />

would have enormous benefits to<br />

citizens around the nation and in<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong>. 33<br />

Even after neurodegenerative<br />

processes have begun, the symptoms<br />

<strong>of</strong> dementia are treatable. Of<br />

the four medications available to<br />

treat Alzheimer’s, three act by raising<br />

levels <strong>of</strong> a chemical messenger<br />

(acetylcholine) that is depleted<br />

when cells die, while the fourth<br />

(memantine) belongs to a new<br />

generation <strong>of</strong> drugs aimed at preventing<br />

brain cells from dying.<br />

In addition to its history <strong>of</strong> conducting<br />

trials on acetylcholineenhancing<br />

drugs as they were<br />

developed, <strong>OMH</strong> research institutes<br />

served as a clinical site in the first<br />

U.S. study showing the efficacy <strong>of</strong><br />

memantine in moderate<br />

Alzheimer’s. The study found that<br />

memantine showed beneficial<br />

effects on thinking, behavior, and<br />

overall functioning (as compared to<br />

a placebo). Moreover, the medication<br />

was found to be quite safe<br />

and not significantly different from<br />

placebo in terms <strong>of</strong> reported side<br />

effects. As a result, memantine<br />

received FDA approval and was<br />

made available in 2004 for the<br />

treatment <strong>of</strong> “moderately to severely<br />

impaired” individuals with<br />

Alzheimer’s. Individuals who were<br />

in the group receiving the study<br />

medication were able to receive<br />

this medication when they were in<br />

the earlier, rather than later stages<br />

<strong>of</strong> the disorder, and three or four<br />

years prior to the time it became<br />

available to others commercially.<br />

Managing Dementia:<br />

Raising Standards <strong>of</strong> Care<br />

n important mission <strong>of</strong> <strong>OMH</strong><br />

AAlzheimer’s research has been<br />

to optimize the management <strong>of</strong><br />

both memory and behavioral<br />

symptoms <strong>of</strong> people with dementia.<br />

Besides trials <strong>of</strong> new memoryenhancing<br />

medications, these<br />

efforts have included research<br />

into effective treatments for agitation,<br />

the most common symptom<br />

leading to hospitalization and residential<br />

nursing care <strong>of</strong> demented<br />

individuals, as well as investigations<br />

on the adverse effects <strong>of</strong><br />

commonly used medicines for<br />

dementia. Such studies are crucial<br />

to the development <strong>of</strong> best practice<br />

standards for dementia care.<br />

<strong>OMH</strong> clinicians and scientists are<br />

also working in concert with residential<br />

care groups, local clinicians,<br />

and Alzheimer’s Association chapters<br />

to inform them about the latest<br />

advances in dementia therapy and<br />

management. The need is great. A<br />

recent <strong>OMH</strong> public information<br />

event for Alzheimer’s disease<br />

attracted an audience <strong>of</strong> more than<br />

400. Although there is now greater<br />

awareness <strong>of</strong> dementia, there is<br />

much less understanding <strong>of</strong> the<br />

nature <strong>of</strong> these disorders, their progression,<br />

and the potential for prevention.<br />

Increasing public awareness<br />

and understanding on an<br />

ongoing basis sends a strong public<br />

health message that individuals<br />

may be able to reduce their risk <strong>of</strong><br />

dementia and that support for caregivers,<br />

evidence-based care interventions,<br />

and medications can<br />

reduce the impact <strong>of</strong> the condition.<br />

Future Directions for Schizophrenia<br />

and Dementia Research<br />

hile <strong>OMH</strong> research programs<br />

Wcontinue to be highly effective<br />

in determining causes and new<br />

treatment approaches for schizophrenia<br />

and dementia, much work<br />

still remains. In schizophrenia<br />

Notes<br />

33 Alzheimer’s Association. (2004, July 20).<br />

Alzheimer’s, cardiovascular disease share<br />

risk factors: Cholesterol levels, diabetes and<br />

hypertension - known risk factors for strokes<br />

and heart attacks - can contribute to risk <strong>of</strong><br />

cognitive decline and dementia later in life<br />

[news release]. Chicago: Author. Retrieved<br />

December 15, 2004, at http://www.alz.org/<br />

internationalconference/pressreleases/<br />

072004_head_heart.asp<br />

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48 Chapter 4: Basic and Clinical Research<br />

research, new imaging approaches<br />

have been developed over recent<br />

years that permit detailed assessment<br />

<strong>of</strong> structural brain abnormalities<br />

in schizophrenia, to complement<br />

functional neuroimaging<br />

studies. Highly significant relationships<br />

have been observed between<br />

these brain structural deficits and<br />

both symptoms and neurocognitive<br />

dysfunction that need further study.<br />

There is also a clear need to start<br />

translating current treatment<br />

approaches into younger populations<br />

to prevent the deterioration<br />

that <strong>of</strong>ten occurs in the early years<br />

<strong>of</strong> the illness, and to determine<br />

whether schizophrenia can be prevented<br />

rather than just treated.<br />

In dementia research, more<br />

needs to be done to establish safe<br />

therapies that prevent or delay the<br />

onset <strong>of</strong> the many forms <strong>of</strong> dementia.<br />

We are beginning to identify<br />

some <strong>of</strong> the factors that increase or<br />

reduce the risk for Alzheimer’s disease,<br />

but it is also critical to know<br />

how these factors influence specific<br />

aspects <strong>of</strong> the disease process in<br />

the brain in order to maximize the<br />

effectiveness and safety <strong>of</strong> potential<br />

therapies. The most successful preventative<br />

and treatment approaches<br />

will require that interventions begin<br />

during the period between the first<br />

brain changes and the appearance<br />

<strong>of</strong> the first memory symptoms <strong>of</strong><br />

Alzheimer’s. Such interventions can<br />

happen only if this crucial window<br />

<strong>of</strong> time can be recognized reliably<br />

in a diverse and aged population.<br />

No such early diagnostic test currently<br />

exists but momentum toward<br />

this goal is building. Biomarkers,<br />

which are factors measurable in<br />

blood or other fluids that provide<br />

information about the presence <strong>of</strong><br />

disease, are being investigated in<br />

people with Alzheimer’s disease.<br />

More research in this area is needed<br />

if caregivers are to begin treatments<br />

early enough in the disease<br />

to make the greatest difference.<br />

<strong>OMH</strong> Research Benefits<br />

Many <strong>New</strong> <strong>York</strong>ers<br />

s has been also described<br />

Aabove, research conducted at<br />

<strong>OMH</strong>'s research institutes benefits<br />

an increasingly large proportion <strong>of</strong><br />

<strong>New</strong> <strong>York</strong> <strong>State</strong>’s population and<br />

many millions <strong>of</strong> people nationally<br />

and internationally. Table 4.4 presents<br />

examples <strong>of</strong> how a broader<br />

population benefits from <strong>OMH</strong><br />

research. In addition to the examples<br />

provided below, Chapter 8<br />

presents an extensive review <strong>of</strong><br />

<strong>OMH</strong>'s suicide prevention initiative,<br />

which represents a significant<br />

research effort applicable to a<br />

broader audience.<br />

Conclusion<br />

ew <strong>York</strong> <strong>State</strong> has a tradition <strong>of</strong><br />

Ncommitment to engaging in<br />

basic and clinical mental health<br />

research that has brought hope to<br />

many thousands <strong>of</strong> individuals with<br />

mental illness and their families.<br />

Individuals with mental illness<br />

and their care providers are entitled<br />

to the same high quality <strong>of</strong><br />

research-based information upon<br />

which to make treatment and service<br />

decisions as persons with heart<br />

disease, cancer, or other general<br />

medical conditions. Today,<br />

researchers, mental health care<br />

providers, general health care personnel,<br />

service systems administrators,<br />

policymakers, and most critically,<br />

individuals with mental<br />

illnesses and their families recognize<br />

that research is essential to<br />

generate information that, properly<br />

used, will better enable people with<br />

mental illnesses to receive optimal<br />

care. <strong>Mental</strong> health research must<br />

be sustained to guarantee improving<br />

the health and quality <strong>of</strong> life <strong>of</strong><br />

individuals with mental illness, their<br />

families and our communities<br />

across <strong>New</strong> <strong>York</strong> <strong>State</strong>.<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 4: Basic and Clinical Research 49<br />

Table 4.4.<br />

Examples <strong>of</strong> <strong>OMH</strong> Research Benefiting a Broader Population<br />

Psychological Risk Factors<br />

for Heart Disease<br />

This research explores a psychophysiological<br />

model <strong>of</strong> coronary disease that identifies<br />

the autonomic nervous system as the link<br />

between psychological factors and atherosclerosis.<br />

Specifically, the model suggests that by<br />

enhancing parasympathetic control <strong>of</strong> the<br />

heart, already known by cardiologists to promote<br />

survival following myocardial infarction,<br />

potentially pathogenic oscillations in blood<br />

pressure can be buffered. This model is the<br />

basis <strong>of</strong> several ongoing investigations funded<br />

by NIMH and the National Heart, Lung, and<br />

Blood Institute to explore factors that alter cardiac<br />

autonomic control: aerobic conditioning,<br />

cognitive-behavioral reduction <strong>of</strong> hostility, and<br />

surgical denervation. Additional research studies<br />

the relationship <strong>of</strong> depression to the development<br />

<strong>of</strong> cardiac disease and to mortality<br />

and morbidity in heart attack, unstable angina,<br />

and coronary artery bypass patients.<br />

Seasonal Affective Disorder<br />

Within the past two decades, seasonal affective<br />

disorder (SAD) has been increasingly diagnosed<br />

and treated. <strong>OMH</strong> researchers are comparing<br />

three distinct treatments for seasonal<br />

affective disorder: post-awakening bright light<br />

therapy, dawn simulation, and high-intensity<br />

negative air ionization (the latter two administered<br />

during sleep). Interim results demonstrate<br />

superiority <strong>of</strong> all three active treatments<br />

relative to a low-density negative ion placebo<br />

control. <strong>OMH</strong> researchers have also published a<br />

novel on-line instrument (http://www.cet.<br />

org/AutoMEQ.htm) by which people can estimate<br />

their circadian rhythm phase and determine<br />

the optimum time for antidepressant<br />

light exposure. The instrument is being used in<br />

a new research study to chart chronotype (e.g.,<br />

the set <strong>of</strong> circadian factors that determine<br />

whether someone is a morning or an evening<br />

person) globally and across the seasons.<br />

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50 Chapter 4: Basic and Clinical Research<br />

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Chapter 5: Services Research 51<br />

Services Research Chapter 5<br />

ental health services research<br />

Mintegrates research, practice,<br />

and policy directions into mainstream<br />

practice. It takes place in<br />

“real-world” settings and examines<br />

characteristics <strong>of</strong> individuals, families,<br />

providers and the service system;<br />

aspects <strong>of</strong> social, psychological<br />

and cultural environments and<br />

their influence on how people<br />

seek care; the nature and type <strong>of</strong><br />

care selected or provided; and<br />

what occurs during service delivery<br />

and the outcomes <strong>of</strong> care. The<br />

overall goal is to improve treatment<br />

and services for people with mental<br />

illness by helping them get the<br />

best possible care. While evaluation<br />

and services research conducted<br />

by <strong>OMH</strong> is the focus <strong>of</strong> Chapter<br />

5, information about <strong>OMH</strong> basic<br />

and clinical research related to the<br />

treatment and prevention <strong>of</strong> mental<br />

diseases is found in Chapter 4.<br />

A 1999 National Institute <strong>of</strong> <strong>Mental</strong><br />

<strong>Health</strong> (NIMH) report, Bridging<br />

Science and Service, focuses attention<br />

on the need for mental health<br />

services research that is useful and<br />

practical for people with mental illnesses,<br />

clinicians, purchasers, and<br />

policy makers. 1 <strong>OMH</strong> conducts rigorous<br />

services research that is<br />

strongly influenced by the demands<br />

<strong>of</strong> the public mental health system<br />

and, in turn, influences the development<br />

<strong>of</strong> policy and practice on a<br />

wide range <strong>of</strong> pertinent issues. A<br />

significant portion <strong>of</strong> <strong>OMH</strong> services<br />

research is conducted in the Evaluation<br />

Research (ER) branch <strong>of</strong> the<br />

<strong>OMH</strong> Center for Information Technology<br />

and Evaluation Research<br />

(CITER), with additional services<br />

research being conducted at the<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> Psychiatric Institute<br />

and the Nathan S. Kline Institute for<br />

Psychiatric Research. Evaluation<br />

research and statistical analysis on<br />

agency operations provide information<br />

that improves the effectiveness<br />

and facilitates the management <strong>of</strong><br />

mental health services in <strong>New</strong> <strong>York</strong><br />

<strong>State</strong>. <strong>New</strong> knowledge gained<br />

through these activities leads to<br />

improved public mental health outcomes<br />

in meaningful and measurable<br />

ways. This information affects<br />

the organization, financing, management,<br />

delivery, and access to services,<br />

as well as the course, cost, and<br />

consumer level outcomes <strong>of</strong> care.<br />

This chapter reviews 2004 <strong>OMH</strong><br />

services research regarding a number<br />

<strong>of</strong> evidence-based practice initiatives<br />

designed to improve the<br />

quality <strong>of</strong> care <strong>of</strong>fered to adults<br />

with serious mental illness and<br />

children with serious emotional<br />

disturbance. It also highlights care<br />

coordination initiatives, which are<br />

designed to support important<br />

<strong>OMH</strong> program initiatives. Together,<br />

<strong>OMH</strong> program and care coordination<br />

initiatives are contributing to<br />

the base <strong>of</strong> knowledge in <strong>New</strong><br />

<strong>York</strong> <strong>State</strong> and nationally on effective<br />

clinical strategies that support<br />

individuals with serious mental illness<br />

as they strive toward recovery.<br />

Notes<br />

1 National Advisory <strong>Mental</strong> <strong>Health</strong> Council.<br />

(1999). Bridging science and service: A<br />

report by the National Advisory <strong>Mental</strong><br />

<strong>Health</strong> Council’s Clinical Treatment and Services<br />

Research Workgroup. NIH Publication<br />

No. 99-4353.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

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52 Chapter 5: Services Research<br />

Science Informing<br />

Practice: Evidence-<br />

Based Initiatives<br />

ental health services research<br />

Mhas demonstrated that some<br />

specific treatment approaches are<br />

effective in improving outcomes for<br />

individuals diagnosed with serious<br />

mental illness. Called evidencebased<br />

practices (EBPs), these interventions<br />

are rooted in reliable scientific<br />

inquiry, and supported by a<br />

body <strong>of</strong> evidence; they have demonstrated<br />

effectiveness in improving<br />

outcomes in areas relating to wellness<br />

(e.g., physical health, selfesteem,<br />

symptom management, and<br />

behavior management) and community<br />

integration (e.g., housing,<br />

employment, and education). Adherence<br />

to specific population, outcome,<br />

and implementation standards<br />

is key to producing outcomes consistent<br />

with recovery.<br />

<strong>OMH</strong>’s Winds <strong>of</strong> Change campaign<br />

continues the drive to promote<br />

recovery from serious mental<br />

illness through the implementation<br />

<strong>of</strong> EBPs in routine mental health settings.<br />

The implementation <strong>of</strong> EBPs<br />

in <strong>New</strong> <strong>York</strong> <strong>State</strong> has been guided<br />

by a model that builds on strategies<br />

for change through three phases:<br />

consensus building, enacting, and<br />

sustaining. As described in Table 5.1,<br />

the process is dynamic and involves<br />

Table 5.1<br />

<strong>OMH</strong> Planning Matrix For Evidence-Based Practice Implementation<br />

Change<br />

Strategies<br />

PHASE I:<br />

Consensus<br />

Building<br />

PHASE II:<br />

Enacting<br />

PHASE III:<br />

Sustaining<br />

AWARENESS:<br />

Encouragement and<br />

collaboration with<br />

stakeholders<br />

Identify and use a<br />

network <strong>of</strong> champions<br />

from local government,<br />

stakeholders,<br />

and advising<br />

groups<br />

Using formal consensus-building<br />

projects to<br />

create a set <strong>of</strong> evidence<br />

based demonstrations<br />

throughout the state<br />

(including Drake pilot sites)<br />

Evaluate for widespread<br />

replication<br />

EDUCATION:<br />

Introduction and<br />

development <strong>of</strong> new<br />

quality initiatives<br />

Produce introductory<br />

materials, include<br />

national EBP toolkits<br />

and quality outcome<br />

measures<br />

Develop several 'Centers<br />

for Excellence'<br />

for ongoing research<br />

and education<br />

Secure permanent<br />

funding for 'Centers<br />

for Excellence'<br />

statewide<br />

STRUCTURAL<br />

& CLINICAL<br />

IMPROVE-<br />

MENT:<br />

Incorporation <strong>of</strong> quality<br />

measures into both<br />

individual practitioner<br />

and provider performance<br />

Develop and test<br />

quality outcome<br />

measures using network<br />

<strong>of</strong> champions<br />

and demonstration<br />

sites<br />

Develop fiscal and<br />

regulatory changes<br />

indicated during<br />

development and<br />

testing<br />

Create a local level<br />

evaluative capacity to<br />

monitor performance<br />

against outcomes<br />

CONTINUAL<br />

IMPROVEMENT<br />

& SUPPORT:<br />

Monitoring <strong>of</strong> the<br />

quality measures and<br />

means for continuous<br />

upgrading<br />

Use existing progress<br />

report structure to<br />

'test' an initial series<br />

<strong>of</strong> performance<br />

reviews in selected<br />

EBP areas<br />

Use performance<br />

data in selected EBP<br />

areas to make regulatory<br />

and funding<br />

decisions<br />

Periodically revisit<br />

consensus building<br />

stages to identify and<br />

promote innovations<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 5: Services Research 53<br />

careful coordination, monitoring,<br />

and ongoing evaluation <strong>of</strong> the<br />

implementation <strong>of</strong> EBPs.<br />

A cornerstone <strong>of</strong> the Winds <strong>of</strong><br />

Change campaign is involvement<br />

<strong>of</strong> stakeholders at all levels <strong>of</strong> the<br />

system in continual quality<br />

improvement efforts. During 2003-<br />

2004, approximately 6,000 individuals<br />

who used mental health services<br />

participated in public forums to<br />

provide input on the EBP campaign.<br />

Additionally, ongoing support<br />

for the seamless integration <strong>of</strong><br />

EBPs into the <strong>OMH</strong> quality agenda<br />

occurred when more than 400 people<br />

from <strong>New</strong> <strong>York</strong> <strong>State</strong> and<br />

around the nation attended a July<br />

2001 symposium on EBPs and trauma<br />

treatment.<br />

<strong>OMH</strong> evaluations <strong>of</strong> specific EBPs<br />

share common components and<br />

target areas specific to the practice<br />

under study. Common elements<br />

include tracking the number <strong>of</strong> programs,<br />

staff trained in the delivery<br />

<strong>of</strong> the intervention and individuals<br />

served; measuring clinician satisfaction<br />

with training; examining program<br />

adherence to EBP standards<br />

(better known as fidelity to implementation);<br />

and assessing the quality<br />

<strong>of</strong> programs being implemented<br />

and clinical outcomes.<br />

Adult Services<br />

he implementation <strong>of</strong> EBPs<br />

Tamong the adult population<br />

with serious mental illnesses is<br />

being studied across service settings:<br />

inpatient, outpatient, and in<br />

jails and prisons. Principal areas <strong>of</strong><br />

study currently under way include<br />

medication management, Assertive<br />

Community Treatment, family psychoeducation,<br />

and consumer<br />

assessments <strong>of</strong> service quality.<br />

Improving the Quality<br />

<strong>of</strong> Medication Practices<br />

edications are a critical compo-<br />

<strong>of</strong> the treatment <strong>of</strong> serious<br />

Mnent<br />

mental illness. Two important studies<br />

<strong>of</strong> medication management have<br />

been designed to better understand<br />

their impact on the quality <strong>of</strong> medication<br />

practices in the public mental<br />

health system. The first study is<br />

aimed at investigating the effect <strong>of</strong><br />

an innovative s<strong>of</strong>tware application<br />

called PSYCKES, which has been<br />

developed by <strong>OMH</strong> for use in <strong>State</strong><br />

hospitals to improve the quality and<br />

safety <strong>of</strong> medication prescribing<br />

practices. The second involves collaboration<br />

with the <strong>State</strong> Department<br />

<strong>of</strong> <strong>Health</strong> (DOH) to extend<br />

the reach <strong>of</strong> the PSYCKES concept<br />

to physicians throughout the <strong>State</strong>,<br />

who prescribe antipsychotic medications<br />

for Medicaid clients with<br />

schizophrenia.<br />

Implementation <strong>of</strong> PSYCKES, an<br />

Automated Clinical Decision<br />

Support Tool.<br />

MH researchers have developed<br />

Othe Pharmacy Service and Clinical<br />

Knowledge Enhancement System<br />

(PSYCKES), a novel Webbased,<br />

clinical and management<br />

decision support system, to support<br />

evidence-based decision making in<br />

the <strong>State</strong> mental health system<br />

(Sidebar, page 54). PSYCKES is<br />

designed to increase the quality <strong>of</strong><br />

care and enhance consumer safety<br />

by improving clinician access to<br />

medical record information, relevant<br />

clinical practice guidelines,<br />

and medical reference information.<br />

It is contributing toward standardizing<br />

practice patterns and error<br />

pro<strong>of</strong>ing through automated,<br />

guideline-driven performance<br />

measures that pr<strong>of</strong>ile quality, safety,<br />

and conformance to EBPs at the<br />

hospital and physician levels. In<br />

making data available to the clinician<br />

at the point <strong>of</strong> practice, PSY-<br />

CKES addresses a key barrier to<br />

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54 Chapter 5: Services Research<br />

Special Recognition Goes to the <strong>OMH</strong> PSYCKES Team<br />

he <strong>New</strong> <strong>York</strong> <strong>State</strong> Governor’s <strong>Office</strong> <strong>of</strong> Employee Relations pre-<br />

the 2004 Workforce Champions Award to the <strong>OMH</strong> PSYCKES<br />

Tsented<br />

Team for its extraordinary contribution <strong>of</strong> a system that provides better<br />

service to the public and advances the mission <strong>of</strong> <strong>OMH</strong>. At the October<br />

5, 2004, ceremony, the PSYCKES Team was honored for its innovation<br />

and dedication in creating and implementing the PSYCKES decision<br />

support system, one <strong>of</strong> the first <strong>of</strong> its kind in the nation. The<br />

Team was praised for improving the quality and safety <strong>of</strong> medication<br />

prescribing practices in the <strong>New</strong> <strong>York</strong> <strong>State</strong> mental health system and<br />

incorporating this EBP into day-to-day patient care. “The excellence <strong>of</strong><br />

<strong>New</strong> <strong>York</strong> Government depends on the hard work, creativity and innovation<br />

<strong>of</strong> its workforce,” George Madison, Director <strong>of</strong> the Governor’s<br />

<strong>Office</strong> <strong>of</strong> Employee Relations said in presenting the award. “It gives me<br />

great pleasure to honor those who exemplify that ideal.”<br />

Left, GOER Director<br />

George Madison presents<br />

the Workforce Champions<br />

Award to <strong>OMH</strong> Commissioner<br />

Carpinello (first row<br />

center), Senior Deputy<br />

Commissioner Felton, and<br />

the PSYCKES Team.<br />

implementing evidence-based<br />

guidelines-the lack <strong>of</strong> knowledge<br />

<strong>of</strong> which medications were tried in<br />

the past. When deciding which<br />

medication to try next, the clinician<br />

is able to obtain from PSYCKES<br />

critical decision making information,<br />

for example, which medications<br />

have been previously tried,<br />

for how long, at what dose, and in<br />

what sequence.<br />

PSYCKES is currently available at<br />

18 <strong>OMH</strong> inpatient facilities and<br />

training sessions have been held at<br />

ten facilities. Full statewide implementation<br />

at the remaining facilities<br />

is anticipated by April 2005. Currently,<br />

more than 400 clinicians<br />

have access to the system and data<br />

collected during PSYCKES training<br />

sessions show that PSYCKES is<br />

user-friendly and a practical clinical<br />

tool. Clinicians gave the system<br />

high average usability scores (6 or<br />

more on a 7-point scale), rated<br />

PSYCKES as the single most useful<br />

source <strong>of</strong> information about medication<br />

histories (8.8 on a 10-point<br />

scale), and gave it high average<br />

usefulness scores (6 or more on a<br />

7-point scale). Preliminary findings<br />

also show that PSYCKES meets<br />

clinical information needs in a<br />

time-efficient way. Due to the fact<br />

that many individuals who have<br />

serious mental illness have lengthy<br />

treatment histories spanning multiple<br />

years and are <strong>of</strong>ten served during<br />

the course <strong>of</strong> their treatment by<br />

multiple providers, physicians <strong>of</strong>ten<br />

lack access to full and complete<br />

information documenting an indi-<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 5: Services Research 55<br />

vidual’s complete history <strong>of</strong> medication<br />

trials. Physicians without<br />

access to PSYCKES correctly identified<br />

only 24.6% <strong>of</strong> medication trials;<br />

with PSYCKES, the physicians<br />

improved to 76.9% and also<br />

recorded a 59.8% decrease in the<br />

time needed to assemble a medication<br />

history. Further analysis will<br />

explore factors associated with use<br />

and the impact <strong>of</strong> PSYCKES on<br />

clinical prescribing practices.<br />

Incorporating Quality<br />

Indicators into Antipsychotic<br />

Drug Utilization and Review<br />

Processes.<br />

O<br />

MH researchers are also working<br />

with NYS Department <strong>of</strong> <strong>Health</strong><br />

(DOH) staff to review the prescribing<br />

practices <strong>of</strong> physicians outside <strong>of</strong><br />

the <strong>State</strong> mental health system who<br />

prescribe antipsychotic medications<br />

for clients who have schizophrenia.<br />

The two agencies are working to<br />

incorporate quality indicators adapted<br />

from PSYCKES into the DOH<br />

Drug Utilization and Review<br />

processes. The overall goal is to<br />

educate physicians outside <strong>of</strong> the<br />

public mental health system on best<br />

practice guidelines, with the potential<br />

over the long term <strong>of</strong> using a<br />

PSYCKES-type information system to<br />

improve the quality <strong>of</strong> care.<br />

Assertive Community<br />

Treatment (ACT): A Measure<br />

<strong>of</strong> the Quality <strong>of</strong> Care<br />

CT is a model <strong>of</strong> care that<br />

Aincludes outpatient treatment,<br />

rehabilitation, case management,<br />

and support services. It is aimed at<br />

adults with serious mental illness<br />

who have not fared well in traditional<br />

treatment settings. Research<br />

has consistently found that ACT,<br />

when compared to other case management<br />

approaches, is more effective<br />

at decreasing psychiatric hospitalizations<br />

and improving housing<br />

stability among individuals with<br />

mental illness. 2<br />

ACT services are delivered by a<br />

mobile, multidisciplinary mental<br />

health treatment team that shares<br />

caseloads and includes specialists<br />

from the fields <strong>of</strong> psychiatry, nursing,<br />

psychology, social work, substance<br />

abuse, and vocational rehabilitation.<br />

Team members<br />

collaborate, plan and deliver a set<br />

<strong>of</strong> integrated services that are<br />

responsive to clients’ individual<br />

choices and preferences and tailored<br />

to meet their specific needs.<br />

Services are delivered primarily in<br />

the community and include medication<br />

management, counseling<br />

and psychotherapy, housing support,<br />

job search and retention assistance,<br />

life skills development, integrated<br />

mental health and substance<br />

abuse treatment, and family support<br />

and education. The staff-toclient<br />

ratio is small and services are<br />

provided 24-hours a day, seven<br />

days a week, for as long as they<br />

are needed.<br />

ACT is documented to be effective<br />

by the National Institute <strong>of</strong><br />

<strong>Mental</strong> <strong>Health</strong>’s Schizophrenia<br />

Patient Outcomes Research Team<br />

(PORT) study, 3 and is endorsed in<br />

the Surgeon General’s 1999 report<br />

on mental health as an essential<br />

treatment for many individuals who<br />

have serious mental illness. Additionally,<br />

families and clients have<br />

generally indicated high levels <strong>of</strong><br />

satisfaction with ACT. The federal<br />

Centers for Medicare and Medicaid<br />

Services has authorized ACT as a<br />

reimbursable treatment service, and<br />

the Substance Abuse and <strong>Mental</strong><br />

<strong>Health</strong> Services Administration<br />

(SAMHSA) has designated access to<br />

ACT as a measure <strong>of</strong> the quality <strong>of</strong><br />

a state’s mental health system.<br />

<strong>OMH</strong> has fostered growth <strong>of</strong> the<br />

ACT treatment model through the<br />

development <strong>of</strong> a new licensed<br />

Notes<br />

2 Phillips, S.D., Burns, B.J., Edgar, E.R.,<br />

Mueser, K.T., Linkins, K.W., Rosenheck, R.A.,<br />

et al. (2001). Moving assertive community<br />

treatment into standard practice. Psychiatric<br />

Services, 52(6), 771-779.<br />

3 Lehman, A.F., & Steinwachs D.M. (1998).<br />

Patterns <strong>of</strong> usual care for schizophrenia: Initial<br />

results from the Schizophrenia Patient<br />

Outcomes Research Team (PORT) client survey.<br />

Schizophrenia Bulletin, 24(1), 11_20.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


56 Chapter 5: Services Research<br />

program category in Medicaid<br />

billing. As <strong>of</strong> December 2004, 61<br />

ACT programs were licensed, serving<br />

3,037 individuals. An additional<br />

11 ACT teams are in the licensing<br />

process, bringing the capacity <strong>of</strong><br />

individuals served to 4,656.<br />

The ACT evaluation is also examining<br />

the impact <strong>of</strong> introducing<br />

ACT model fidelity requirements<br />

into the licensing and certification<br />

process.<br />

Using feedback from the provider<br />

community, <strong>OMH</strong> recently enriched<br />

funding <strong>of</strong> the ACT model,<br />

enabling more effective recruitment<br />

and retention <strong>of</strong> qualified staff and<br />

providing additional funding for<br />

training. These enhancements<br />

underscore <strong>OMH</strong>’s commitment to<br />

this form <strong>of</strong> care coordination.<br />

ACT Evaluation<br />

MH continues to support an<br />

Oongoing evaluation <strong>of</strong> ACT in<br />

the <strong>State</strong>, with a focus on contributing<br />

to the base <strong>of</strong> knowledge<br />

that will improve care in <strong>New</strong> <strong>York</strong><br />

<strong>State</strong> and nationally. The evaluation<br />

<strong>of</strong> ACT covers seven specific areas,<br />

from better understanding <strong>of</strong> who<br />

is served by ACT and clinical outcomes<br />

<strong>of</strong> ACT in relation to other<br />

forms <strong>of</strong> case management, to an<br />

examination <strong>of</strong> factors related to<br />

successful implementation <strong>of</strong> the<br />

ACT model. The evaluation is also<br />

examining the role <strong>of</strong> licensing in<br />

ACT implementation and is helping<br />

to determine how effectively a<br />

nationally developed toolkit facilitates<br />

program implementation.<br />

The <strong>OMH</strong> Child and Adult Integrated<br />

Reporting System (CAIRS) is<br />

an important tool in meeting a<br />

number <strong>of</strong> ACT evaluation aims,<br />

including the capacity to aid clinicians<br />

in monitoring individual<br />

client outcomes. Data from CAIRS<br />

provide a picture <strong>of</strong> the characteristics<br />

<strong>of</strong> individuals from around the<br />

<strong>State</strong> who are being served by<br />

ACT. Based on eligibility criteria for<br />

admission to ACT, <strong>of</strong> the 1,039<br />

clients on new ACT teams, 60% are<br />

considered high risk, including 17%<br />

with involvement in the criminal<br />

justice system/jail in the past six<br />

months, 32% with two psychiatric<br />

hospitalizations in the past year,<br />

24% homeless, and 11% assigned<br />

to ACT through Assisted Outpatient<br />

Treatment (AOT) court orders.<br />

Current data are consistent with<br />

the results <strong>of</strong> early evaluations <strong>of</strong><br />

favorable clinical outcomes with<br />

ACT. Data from CAIRS are being<br />

used to examine outcomes for ACT<br />

recipients after their first six<br />

months <strong>of</strong> ACT services. As <strong>of</strong><br />

November 2004, the results indicate<br />

a significant reduction in emergency<br />

room visits, from an average<br />

<strong>of</strong> 0.59 to 0.38 visits; a decrease in<br />

number <strong>of</strong> admissions to psychiatric<br />

hospitals, from an average <strong>of</strong><br />

0.79 to 0.61 admissions; and a dramatic<br />

decrease in length <strong>of</strong> hospitalization,<br />

from an average <strong>of</strong> 25.89<br />

to 10.07 days.<br />

The next phase <strong>of</strong> <strong>OMH</strong>’s ACT<br />

evaluation is focusing on obtaining<br />

additional feedback on implementation<br />

processes, including EBP trainings,<br />

licensing audits, field <strong>of</strong>fice<br />

technical assistance, monthly team<br />

leader conference calls, billing systems,<br />

documentation burden, and<br />

SPOA referrals. It is also assessing<br />

organizational factors that may be<br />

related to fidelity (e.g., cohesion,<br />

commitment, and leadership); examining<br />

factors that may contribute to<br />

staff continuity and burnout (e.g.,<br />

job satisfaction, skill variety and role<br />

ambiguity); and investigating recovery<br />

practices, an area <strong>of</strong> focus for<br />

policy development.<br />

As part <strong>of</strong> the ACT evaluation,<br />

<strong>OMH</strong> has been collaborating with<br />

seven other states in the national<br />

Implementation Toolkit Project, a<br />

project funded by SAMHSA to<br />

study the implementation <strong>of</strong> EBPs.<br />

The study is examining the implementation<br />

process, identifying barriers<br />

and strategies, and assessing<br />

specific observational criteria to<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 5: Services Research 57<br />

better inform implementation initiatives<br />

and policy development.<br />

Study findings will be used as a<br />

basis for revising and refining the<br />

national toolkits, which have been<br />

used by <strong>New</strong> <strong>York</strong> <strong>State</strong> providers<br />

and others in implementing EBPs.<br />

Family Psychoeducation<br />

ver the past 25 years, research<br />

Ohas clearly demonstrated that<br />

family psychoeducation interventions<br />

significantly improve the lives<br />

and independent functioning <strong>of</strong><br />

people with serious mental illness<br />

by reducing relapse and promoting<br />

personal goal attainment such as<br />

employment. Based on the work <strong>of</strong><br />

McFarlane (2002), 4 current initiatives<br />

aim to support the competent provision<br />

<strong>of</strong> evidence-based family psychoeducation<br />

approaches that combine<br />

education about mental illness,<br />

family support, crisis intervention,<br />

effective communication strategies,<br />

and problem solving skill training.<br />

The main goal in working with families<br />

is to help them develop the<br />

knowledge and skills to support the<br />

recovery <strong>of</strong> their family members.<br />

<strong>OMH</strong> is working with mental<br />

health providers and stakeholders<br />

to improve the quality <strong>of</strong> mental<br />

health services through the provision<br />

<strong>of</strong> comprehensive and recovery-oriented<br />

family psychoeducation<br />

and support services. The<br />

agency is currently involved in two<br />

different family psychoeducation<br />

implementation initiatives: the<br />

implementation <strong>of</strong> family psychoeducation<br />

in 41 programs statewide,<br />

in collaboration with the Family<br />

Institute for Education, Practice and<br />

Research at the University <strong>of</strong><br />

Rochester Medical Center, and the<br />

implementation <strong>of</strong> a federally funded<br />

family psychoeducation research<br />

project in three culturally diverse<br />

communities in <strong>New</strong> <strong>York</strong> City.<br />

<strong>State</strong>wide implementation<br />

MH has established a partner-<br />

with the Family Institute for<br />

Oship<br />

Education, Practice and Research at<br />

the University <strong>of</strong> Rochester Medical<br />

Center to support the implementation<br />

<strong>of</strong> family psychoeducation<br />

statewide. The newly formed Family<br />

Institute is educating mental<br />

health providers throughout <strong>New</strong><br />

<strong>York</strong> <strong>State</strong> concerning how to effectively<br />

provide family services to<br />

individuals with a mental illness<br />

and their families. An evaluation <strong>of</strong><br />

the implementation process is<br />

focusing on the identification <strong>of</strong><br />

factors associated with the successful<br />

incorporation <strong>of</strong> family psychoeducation<br />

among 41 participating<br />

programs. The evaluation will serve<br />

to inform further dissemination <strong>of</strong><br />

the model statewide.<br />

Three different models <strong>of</strong> implementation<br />

are being compared,<br />

including on-site, one-to-one consultation,<br />

and group supervision.<br />

The preliminary evaluation <strong>of</strong><br />

fidelity to the national model at<br />

baseline has shown that all three <strong>of</strong><br />

the conditions are equal. The three<br />

consultation models will have<br />

assessments <strong>of</strong> fidelity to the<br />

national model at 12, 18 and 24<br />

months post training. The 12-<br />

month fidelity scale assessments<br />

began in January 2005 and findings<br />

are expected to be available in<br />

September. As <strong>of</strong> November 2004,<br />

65% <strong>of</strong> the one-to-one consultation<br />

sites and 31% <strong>of</strong> the group supervision<br />

sites have had family psychoeducation<br />

workshops.<br />

Family psychoeducation<br />

training evaluation<br />

and implementation in<br />

three diverse communities<br />

AMHSA is funding a three-year<br />

Sstudy to explore how to best<br />

implement family psychoeducation<br />

in the African American, Chinese,<br />

and Hispanic communities. While<br />

evidence suggests that the effec-<br />

Notes<br />

4 McFarlane, W. R. (2002). Multifamily Groups<br />

in the Treatment <strong>of</strong> Severe Psychiatric Disorders.<br />

<strong>New</strong> <strong>York</strong>: Guilford Press.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


58 Chapter 5: Services Research<br />

tiveness <strong>of</strong> family psychoeducation<br />

generalizes to nearly all major cultural<br />

populations, there is awareness<br />

that culture and language can<br />

pose significant barriers to the provision<br />

<strong>of</strong> family psychoeducation,<br />

requiring culturally relevant adaptations<br />

and further study. <strong>OMH</strong><br />

researchers have designed the<br />

study to provide insights into culture-specific<br />

barriers related to<br />

accessing quality mental health<br />

services and to develop culturally<br />

based enrichments for the national<br />

Family Psychoeducation Implementation<br />

toolkit. The necessary cultural<br />

adaptations and “lessons<br />

learned” can be replicated in other<br />

settings in the <strong>State</strong> and incorporated<br />

into the final refinement <strong>of</strong> the<br />

national Family Psychoeducation<br />

Implementation toolkit.<br />

Consumer Assessment<br />

<strong>of</strong> Community-Operated Outpatient<br />

Services: Peer-Pr<strong>of</strong>essional<br />

Collaboration<br />

s part <strong>of</strong> our efforts to improve<br />

Aquality <strong>of</strong> care and promote<br />

recovery from serious mental illness,<br />

<strong>OMH</strong> is continuing to seek<br />

stakeholder input in promoting<br />

quality care. We are particularly<br />

interested in levels <strong>of</strong> satisfaction<br />

among persons receiving services<br />

and perceptions <strong>of</strong> how services<br />

have impacted their quality <strong>of</strong> life.<br />

Every two years, <strong>OMH</strong> conducts<br />

a statewide survey <strong>of</strong> consumer<br />

assessment <strong>of</strong> services. During the<br />

most recent survey in 2004, <strong>OMH</strong><br />

partnered with peer-run and peer<br />

advocacy programs to sponsor a<br />

consumer assessment <strong>of</strong> care in<br />

non-residential community programs<br />

in eight counties. The initiative<br />

examined the value <strong>of</strong> the<br />

assessment tool, the <strong>Mental</strong> <strong>Health</strong><br />

Services Survey (MHSS), and the<br />

partnership approach with consumers<br />

in the conduct <strong>of</strong> the survey.<br />

The MHSS, which was developed<br />

by <strong>OMH</strong> with extensive<br />

consumer participation, is used to<br />

evaluate the quality <strong>of</strong> services in<br />

four service domains: access,<br />

appropriateness, global satisfaction,<br />

and outcomes. The overall goal <strong>of</strong><br />

the assessment in non-residential<br />

community programs was to develop<br />

a basis for quality improvement<br />

in the full spectrum <strong>of</strong> communityoperated<br />

public mental health services<br />

for adults.<br />

To maximize diversity <strong>of</strong> the survey<br />

sample, evaluators divided the<br />

<strong>State</strong> into two upstate urban and<br />

rural regions and two downstate<br />

urban and suburban regions. Two<br />

counties were randomly selected in<br />

each <strong>of</strong> the four regions, with the<br />

single condition that a peer organization<br />

be present and operational<br />

in each county. Peer programs in<br />

each selected county chose two<br />

consumers who received one day<br />

<strong>of</strong> training and assisted <strong>OMH</strong> staff<br />

in administering the surveys in<br />

accessible locations. The peer<br />

advocates also publicized the surveys<br />

and pre-registered up to a<br />

maximum <strong>of</strong> 50 participants per<br />

site. <strong>OMH</strong> and peer program partners<br />

enlisted consumers from a<br />

stratified mix <strong>of</strong> different types <strong>of</strong><br />

non-residential community programs,<br />

such as case management,<br />

clubhouses, and psychosocial rehabilitation.<br />

In the eight counties, a<br />

total <strong>of</strong> 388 individuals participated<br />

in the anonymous survey and early<br />

results indicate that the initiative<br />

was successful in both the consumer<br />

partnership and its data collection<br />

methods.<br />

Among outcomes, the majority<br />

(81%) <strong>of</strong> survey participants rated the<br />

overall improvement they made as<br />

good or excellent and 83% indicated<br />

as good or excellent the likelihood<br />

that they would continue to use<br />

services when needed. Eight out <strong>of</strong><br />

ten respondents also rated as good<br />

or excellent the staff’s belief that they<br />

could change, grow and recover. A<br />

number <strong>of</strong> areas were also identified<br />

by respondents as opportunities for<br />

improvement; for example, in the<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 5: Services Research 59<br />

area <strong>of</strong> receiving assistance in obtaining<br />

housing, vocational or educational<br />

services, six out <strong>of</strong> ten survey participants<br />

gave this item a rating <strong>of</strong><br />

good to excellent.<br />

As has been documented in other<br />

evaluation studies, it appears that<br />

peer program co-sponsorship and<br />

peer participation in survey administration<br />

contribute to objective<br />

assessment and the identification <strong>of</strong><br />

opportunities for improvement by<br />

consumers <strong>of</strong> services. 5,6 Moreover,<br />

the Institute <strong>of</strong> Medicine Report,<br />

Crossing the Quality Chasm, 7 indicates<br />

that consumer participation is<br />

a key strategy in improving the<br />

delivery <strong>of</strong> healthcare in the U.S.<br />

Thus, in addition to planning quality<br />

initiatives around the findings<br />

from this survey, <strong>OMH</strong> plans to<br />

continue to expand peer participation<br />

to the annual evaluation <strong>of</strong><br />

community programs statewide,<br />

and, where possible, utilize Webbased<br />

protocols in facilitating the<br />

evaluation process.<br />

Forensic <strong>Mental</strong> <strong>Health</strong><br />

Services: Supporting<br />

Recovery<br />

n the forensic mental health sys-<br />

<strong>OMH</strong> services research is<br />

Item,<br />

directed toward minimizing the disabling<br />

effects <strong>of</strong> serious mental illness.<br />

Evaluations are lending support<br />

in modifications to the<br />

forensics system, including evaluation-informed<br />

changes for inmatepatients<br />

with serious mental illness<br />

in special housing units, and for<br />

inmate-patients re-entering communities<br />

from maximum security prisons.<br />

Additionally, a study is under<br />

way to investigate interventions to<br />

improve the discharge planning<br />

process for all inmate-patients<br />

returning to the community.<br />

Evaluation <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

Services for Inmates in<br />

Special Housing Units<br />

he <strong>New</strong> <strong>York</strong> <strong>State</strong> Department<br />

T<strong>of</strong> Correctional Services (DOCS)<br />

has more than 5,000 disciplinary<br />

Special Housing Unit (SHU) cells.<br />

Inmates who are transferred into<br />

these cells for the most serious<br />

infractions <strong>of</strong> prison rules receive<br />

mental health services. To better<br />

meet the mental health needs <strong>of</strong><br />

SHU inmates, an evaluation study<br />

was initiated in 2002 in the SHU<br />

cells <strong>of</strong> 11 maximum security prisons.<br />

The study examined the characteristics<br />

<strong>of</strong> inmates, their mental<br />

health needs and diagnoses, their<br />

disciplinary records, and the<br />

amount <strong>of</strong> mental health services<br />

they were receiving.<br />

Based on the 2002 results, a comprehensive<br />

plan was implemented<br />

to improve mental health services<br />

to patients in SHU cells. Important<br />

elements <strong>of</strong> the plan were the creation<br />

<strong>of</strong> private mental health treatment<br />

space to which patients<br />

would be escorted out <strong>of</strong> their SHU<br />

cells; a joint DOCS/<strong>OMH</strong> committee<br />

to review mental health needs <strong>of</strong><br />

inmates for possible transfer; a designated<br />

<strong>OMH</strong> SHU clinician; an<br />

increase in private mental health<br />

treatment to a minimum <strong>of</strong> two<br />

non-physician and one physician<br />

sessions per month; an increase in<br />

<strong>OMH</strong> cell-side visits to all inmates<br />

in SHUs to every work day to<br />

screen for mental health needs; and<br />

measurement <strong>of</strong> psychiatric functioning<br />

every 90 days. The study<br />

was repeated in 2004 to determine<br />

the extent to which the SHU plan<br />

<strong>of</strong> improvement was being implemented.<br />

Key results from the 2004<br />

study show the following:<br />

◆ A dramatic increase in private<br />

mental health treatment hours.<br />

Between 2002 and 2004, average<br />

patient private contact hours per<br />

SHU increased from .4 to 1.73<br />

Notes<br />

5 Polowczyk, D., Brutus, M., Orvieto, A., Vidal,<br />

J., & Cipriani, D. (1993). Comparison <strong>of</strong><br />

patient and staff surveys <strong>of</strong> consumer satisfaction.<br />

Hospital and Community Psychiatry,<br />

44(6).<br />

6 Campbell, J. (1997). Towards collaborative<br />

mental health outcomes systems. <strong>New</strong><br />

Directions for <strong>Mental</strong> <strong>Health</strong> Services, 71.<br />

7 Committee on Quality <strong>of</strong> <strong>Health</strong> Care in<br />

America, Institute <strong>of</strong> Medicine. (2001).<br />

Crossing the Quality Chasm: A <strong>New</strong> <strong>Health</strong><br />

System for the 21st Century. Washington,<br />

DC: National Academies Press.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

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60 Chapter 5: Services Research<br />

hours per month (a rise <strong>of</strong><br />

333%) for inmates classified as<br />

requiring the highest level <strong>of</strong><br />

mental health care, Level 1. The<br />

average private contact hours<br />

increased from .2 to 1.31 per<br />

month (a 555% increase) for<br />

inmates at the next level <strong>of</strong> mental<br />

health care, Level 2.<br />

◆ A significant increase in cell-side<br />

contact hours. The average cellside<br />

contact hours per inmate<br />

increased to 2.01 hours per<br />

month in 2004 from .81 in 2002.<br />

Inmates requiring Level 1 mental<br />

health care had an average <strong>of</strong><br />

2.57 cell-side contact hours per<br />

month in 2004 as compared to<br />

1.2 in 2002. Inmates receiving<br />

Level 2 mental health care had<br />

an average <strong>of</strong> 2.23 cell-side average<br />

contact hours in 2004 compared<br />

to 1.0 hour in 2002.<br />

◆ An improvement in compliance<br />

with psychiatric medication use.<br />

In 2002, 13% percent <strong>of</strong> inmates<br />

in SHUs refused psychiatric medications.<br />

By 2004, noncompliance<br />

had significantly decreased to 4%.<br />

◆ A major reduction in the percentage<br />

<strong>of</strong> inmates diagnosed<br />

with a serious mental illness.<br />

From 2002 - 2004, there was a<br />

47% decrease in the percentage<br />

<strong>of</strong> inmates with a serious mental<br />

illness diagnosis <strong>of</strong> schizophrenia,<br />

bipolar disorder, or major<br />

depression in SHU cells.<br />

The results indicate that the SHU<br />

plan <strong>of</strong> improvement was successfully<br />

implemented. <strong>Mental</strong> health<br />

contact hours increased dramatically<br />

both in the private treatment and<br />

cell side. Moreover, the reduction<br />

in number <strong>of</strong> inmates with major<br />

mental illness strongly suggests that<br />

the joint DOCS/<strong>OMH</strong> committee<br />

has been effective in moving or<br />

diverting persons with serious<br />

mental illness from SHU cells. The<br />

study will be repeated again in<br />

March 2005 and ongoing monitoring<br />

by <strong>OMH</strong> will continue with<br />

reviews <strong>of</strong> the DOCS/<strong>OMH</strong> committee<br />

minutes, functional assessment<br />

results, and charts <strong>of</strong> inmates<br />

in SHUs by <strong>OMH</strong> Unit Chiefs. Further<br />

study will also explore the<br />

outcome <strong>of</strong> additional contact<br />

hours in relation to reductions in<br />

mental health disability and disciplinary<br />

infractions.<br />

Evaluation <strong>of</strong> the Community<br />

Oriented Re-entry Program (CORP)<br />

oving from prison to the com-<br />

is difficult and pro-<br />

Mmunity<br />

vokes anxiety in inmates. It is even<br />

more difficult for inmates with serious<br />

mental illness. In 2003, a 30-<br />

bed Community Oriented Re-entry<br />

Program (CORP) was opened at<br />

Sing Sing Correctional Facility to<br />

assist inmates with serious mental<br />

illness in their transition to the<br />

community. Sing Sing was chosen<br />

because it is the maximum security<br />

prison closest to <strong>New</strong> <strong>York</strong> City<br />

where the majority <strong>of</strong> inmates will<br />

return after incarceration.<br />

CORP goals are to improve community<br />

living skills; increase the<br />

length <strong>of</strong> stay in the community for<br />

former inmates with serious mental<br />

illness; and increase access to and<br />

use <strong>of</strong> mental health services in the<br />

community. CORP provides a variety<br />

<strong>of</strong> supportive services including<br />

community preparation, vocational<br />

assessment, peer support, community<br />

linkage, discharge planning,<br />

orientation to parole supervision,<br />

and a psychiatric medications program.<br />

Community providers come<br />

on-site to participate in pre-release<br />

preparation and provide direct linkage<br />

to their programs on release <strong>of</strong><br />

inmates. An evaluation <strong>of</strong> the<br />

CORP program shows promising<br />

results:<br />

◆ A return <strong>of</strong> 77.4% <strong>of</strong> CORP participants<br />

to the community. Of<br />

those CORP participants not<br />

returning to the community,<br />

9.4% were transferred to a civil<br />

psychiatric hospital, 9.4% to<br />

inpatient services at the Central<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 5: Services Research 61<br />

<strong>New</strong> <strong>York</strong> Psychiatric Center,<br />

and 3.8% to prison.<br />

◆ A significant improvement in<br />

psychiatric functioning. CORP<br />

participants’ scores on the Global<br />

Assessment <strong>of</strong> Functioning<br />

Scale and the Carlson Psychological<br />

Survey subscales indicated<br />

significant improvement.<br />

◆ A significant improvement in all<br />

areas <strong>of</strong> resources and skills for<br />

community survival. At CORP<br />

intake, more than 2/3 <strong>of</strong> participants<br />

had a severe lack <strong>of</strong> financial,<br />

housing, and employment<br />

resources. Upon CORP termination,<br />

92% <strong>of</strong> participants had<br />

access to free medications in the<br />

community, and 87% were eligible<br />

for Social Security and 85%<br />

for Medicaid.<br />

Based on the evaluation <strong>of</strong> the<br />

Sing Sing CORP program, this program<br />

shows continuing potential<br />

for enabling former inmates with<br />

serious mental illness to remain in<br />

the community with improved community<br />

survival skills, psychiatric<br />

functioning, and access to entitlements<br />

and supportive community<br />

programs. Future research will also<br />

focus on following former CORP<br />

participants for longer periods.<br />

Discharge Planning for Individuals<br />

who are Leaving Prison and<br />

Returning to the Community<br />

ore than 3,000 persons who<br />

Mactively receive mental health<br />

services leave <strong>New</strong> <strong>York</strong> <strong>State</strong> prisons<br />

each year and return to the<br />

community. Many <strong>of</strong> these individuals<br />

have major mental illness diagnoses<br />

and require daily doses <strong>of</strong><br />

psychotropic medications to manage<br />

their illness. <strong>OMH</strong> staff develops<br />

discharge plans for all inmates<br />

with serious mental illness before<br />

they return to the community, with<br />

the goals <strong>of</strong> establishing community<br />

treatment services for the<br />

inmates that will help them function<br />

and cope with their mental illness,<br />

and thereby not return to<br />

prison. Discharge coordinators<br />

secure services in the community,<br />

including housing, financial entitlements,<br />

and access to psychiatric<br />

medication.<br />

In 2004, discharge services data<br />

collection was greatly improved<br />

and an evaluation study is currently<br />

in progress to determine the effectiveness<br />

<strong>of</strong> these services. The goal<br />

is to use the data from the evaluation<br />

to develop more effective<br />

strategies to engage inmates<br />

preparing for discharge.<br />

Children’s Services<br />

hree parallel <strong>State</strong> initiatives<br />

Thave been undertaken in the<br />

past few years to support expansion<br />

<strong>of</strong> EBPs for youth. First, “manualized”<br />

or standardized parent<br />

empowerment programs are being<br />

tested and linked to family support<br />

services in <strong>New</strong> <strong>York</strong> City. Second,<br />

manualized clinician engagement<br />

protocols are being linked to the<br />

implementation <strong>of</strong> EBPs in specialty<br />

mental health clinics. Third, the<br />

School <strong>Mental</strong> <strong>Health</strong> Support Programs<br />

are also being expanded to<br />

include a wider range <strong>of</strong> school<br />

mental health services, with<br />

statewide expansion planned over<br />

the next few years. As described in<br />

this section, the substantial <strong>OMH</strong><br />

investment in these three programs<br />

for children and adolescents and<br />

their families has yielded success.<br />

NYC Parent Empowerment<br />

Program (PEP)<br />

he Youth Services Evaluation<br />

TBureau in <strong>OMH</strong> is studying the<br />

effectiveness <strong>of</strong> the <strong>New</strong> <strong>York</strong> City<br />

Parent Empowerment Program. An<br />

important component <strong>of</strong> PEP is its<br />

manualized training program,<br />

which is designed to increase the<br />

self-efficacy 8 <strong>of</strong> minority families<br />

Notes<br />

8 Self-efficacy is defined as people’s beliefs<br />

about their capabilities to produce designated<br />

levels <strong>of</strong> performance that exercise influence<br />

over events that affect their lives.<br />

(See:Bandura, A. (1994). Self-efficacy. In V. S.<br />

Ramachaudran (Ed.), Encyclopedia <strong>of</strong> human<br />

behavior (Vol. 4, pp. 71_81). <strong>New</strong> <strong>York</strong>: Academic<br />

Press).<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

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62 Chapter 5: Services Research<br />

and their children, thereby facilitating<br />

improved access and quality <strong>of</strong><br />

mental health services through<br />

increased consumer demand and<br />

knowledge. Research shows that<br />

among children with an identified<br />

mental health problem who receive<br />

no treatment or services, unmet<br />

need is highest among minority<br />

children. 9<br />

PEP was developed following a<br />

systematic review <strong>of</strong> the literature<br />

and all available evidence concerning<br />

documented and manualized<br />

parent empowerment programs<br />

(Table 5.2). Its development has<br />

included input from all <strong>of</strong> the<br />

major mental health advocacy<br />

organizations, including the Federation<br />

<strong>of</strong> Families for Children’s <strong>Mental</strong><br />

<strong>Health</strong>, the National Alliance for<br />

the <strong>Mental</strong>ly Ill, the National <strong>Mental</strong><br />

<strong>Health</strong> Association, and Children<br />

and Adults with Attention-<br />

Deficit/Hyperactivity Disorder.<br />

PEP uses a “train-the-trainer<br />

model,” and it is through parent<br />

advocates that the content <strong>of</strong> the<br />

training manual is delivered. Parent<br />

advocates are “pr<strong>of</strong>essional” parents,<br />

<strong>of</strong>tentimes themselves parents<br />

<strong>of</strong> children with mental illness<br />

drawn from the communities in<br />

which they work. Advocates are<br />

knowledgeable about mental illness<br />

and how to advocate for and<br />

gain access to mental health treatment<br />

and other community<br />

resources.<br />

PEP has an Advisory Board where<br />

decision-making authority is shared<br />

equally among all partners, including<br />

parents and <strong>State</strong>/City policy<br />

representatives. The Board has<br />

sought and obtained broader stakeholder<br />

input on how the PEP manual<br />

might be most effectively adapted<br />

to the needs <strong>of</strong> <strong>New</strong> <strong>York</strong> City families,<br />

and it has identified several<br />

new content areas to be added to<br />

the manual. <strong>New</strong> content areas<br />

include self-efficacy exercises, roleplays,<br />

and general training on how<br />

to access <strong>New</strong> <strong>York</strong> City’s mental<br />

health, primary care and school<br />

services. Additionally, the Advisory<br />

Board has requested that specific<br />

information on common service<br />

issues related to depression, conduct<br />

problems, trauma/post-traumatic<br />

stress disorder (PTSD), attentiondeficit/hyperactivity<br />

disorder<br />

(ADHD), co-morbidity, and medication<br />

management be added. Thus,<br />

the manual is now conceptualized<br />

as containing a flexible set <strong>of</strong> content<br />

areas, to which modules can be<br />

added as needed to address the<br />

interests <strong>of</strong> specific parent groups.<br />

Table 5.2<br />

Parent Empowerment Program Goals<br />

Notes<br />

9 National Institute <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>. (2001).<br />

Blueprint for change: Research on child and<br />

adolescent mental health. Washington, DC:<br />

National Advisory <strong>Mental</strong> <strong>Health</strong> Council<br />

Workgroup on Child and Adolescent <strong>Mental</strong><br />

<strong>Health</strong> Intervention Development and<br />

Deployment.<br />

◆ Enhance parent advocates’ ability to engage parents who are seeking<br />

help; provide support and advocacy and help them to understand<br />

their children’s mental health problems; and provide information<br />

about specific child mental health problems and evidence-based<br />

treatments.<br />

◆ Improve the mental health <strong>of</strong> children by promoting parent partnerships<br />

with mental health providers and teachers.<br />

◆ Teach parents treatment management skills.<br />

◆ Increase parents’ knowledge about their children’s mental health<br />

needs and evidence-based service delivery options.<br />

◆ Strengthen parents’ self-efficacy in their interactions with mental<br />

health service providers.<br />

◆ Improve the communication and assertiveness skills <strong>of</strong> parents<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 5: Services Research 63<br />

Results from a small pilot test<br />

conducted in 2003 with 30 parent<br />

advocates suggested that participation<br />

in the PEP training program<br />

led to changes in knowledge about<br />

EBPs, improvements in collaborative<br />

skills, and increased self-efficacy.<br />

The National Institute <strong>of</strong> <strong>Mental</strong><br />

<strong>Health</strong> recently funded a two-year<br />

study to examine the impact <strong>of</strong> the<br />

PEP initiative on both parent advocates’<br />

knowledge, skills, attitudes,<br />

self-efficacy, and behavior, as well<br />

as the skills, attitudes and behaviors<br />

<strong>of</strong> the caregivers with whom the<br />

advocates work. The study, which<br />

began in the fall <strong>of</strong> 2004, will test<br />

PEP’s effectiveness with a group <strong>of</strong><br />

40 advocates and 180 caregivers <strong>of</strong><br />

children with mental health problems<br />

in <strong>New</strong> <strong>York</strong> City. Preliminary<br />

results will be available in one year,<br />

and final results in two years.<br />

Child and Adolescent Trauma<br />

Treatment Services (CATS):<br />

Engagement <strong>of</strong> families in services<br />

esearch has identified a lack <strong>of</strong><br />

Rclinician engagement with families<br />

as a key issue contributing to<br />

the high attrition rates <strong>of</strong> families<br />

from mental health services, especially<br />

among low-income populations.<br />

10, 11, 12 In <strong>New</strong> <strong>York</strong> City, similar<br />

to other urban populations,<br />

rates <strong>of</strong> attrition from mental health<br />

services range from 30-50%. 13<br />

In addition to the parent empowerment<br />

programs, <strong>OMH</strong> has been<br />

working to extend engagement<br />

strategies to a range <strong>of</strong> evidencebased<br />

implementation initiatives for<br />

youth. The Child and Adolescent<br />

Trauma Treatment Services program<br />

(CATS) is the largest evidence-based<br />

youth initiative in<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> in which engagement<br />

strategies to decrease attrition<br />

rates have been delivered and are<br />

being evaluated. The CATS program<br />

was implemented in response<br />

to the World Trade Center disaster<br />

<strong>of</strong> September 11, 2001, through a<br />

$3 million grant to <strong>OMH</strong>. Awarded<br />

by SAMHSA, the grant is focused<br />

on implementing evidence-based<br />

trauma treatments for school-age<br />

children affected by the disaster. A<br />

needs assessment commissioned by<br />

the <strong>New</strong> <strong>York</strong> City Board <strong>of</strong> Education<br />

determined that, six months<br />

after the terrorist attacks, as many<br />

as 75,000 children (10.5%) in the<br />

<strong>New</strong> <strong>York</strong> City school system had<br />

symptoms consistent with PTSD. 13<br />

Because the issue <strong>of</strong> family retention<br />

in services was considered critical<br />

to the success <strong>of</strong> the CATS program,<br />

<strong>OMH</strong> provided engagement<br />

training to the consortium <strong>of</strong> nine<br />

participating sites.<br />

Launched in 2002, the CATS program<br />

is a cooperative agreement<br />

study with <strong>OMH</strong> oversight. The<br />

CATS Consortium developed a<br />

common protocol, selected a core<br />

set <strong>of</strong> evidence-based screening<br />

and assessment instruments, and<br />

agreed to train, supervise and<br />

deliver cognitive behavioral therapy<br />

(CBT) trauma treatments to all eligible<br />

youth and families. Two<br />

empirically validated trauma treatments<br />

were selected for implementation<br />

in this project: Cognitive<br />

Behavioral Therapy for Traumatic<br />

Bereavement in Children, manualized<br />

by Cohen and colleagues from<br />

the Center for Traumatic Stress in<br />

Children and Adolescents in Pittsburgh;<br />

14 and Trauma/Grief-Focused<br />

Group Psychotherapy, developed<br />

for adolescents and manualized by<br />

Layne, Saltzman and Pynoos. 15 To<br />

date, 615 children and adolescents,<br />

ages 5-21 have been enrolled in<br />

the treatment study, which compares<br />

youth receiving the evidencebased<br />

trauma treatments to those<br />

receiving trauma treatments as usually<br />

delivered in standard care.<br />

The formal protocol for the CATS<br />

engagement intervention, developed<br />

by Dr. Mary McKay <strong>of</strong> Mount Sinai<br />

School <strong>of</strong> Medicine, was used to<br />

improve initial contact with the fami-<br />

Notes<br />

10 <strong>New</strong> <strong>York</strong> City Department <strong>of</strong> <strong>Health</strong> and<br />

<strong>Mental</strong> Hygiene and the Mailman School <strong>of</strong><br />

Public <strong>Health</strong> at Columbia University. (August<br />

2003). Children’s needs assessment in the<br />

Bronx. <strong>New</strong> <strong>York</strong>: <strong>New</strong> <strong>York</strong> City Department<br />

<strong>of</strong> <strong>Health</strong> and <strong>Mental</strong> Hygiene. Retrieved<br />

November 30, 2004 from<br />

http://www.nyc.gov/<br />

html/doh/pdf/pub/na-cmh0803-bx.pdf.<br />

11 Armbruster, P., Gerstein, S. H., & Fallon, T.<br />

(1997). Bridging the gap between service<br />

need and service utilization: A school-based<br />

mental health program. Community <strong>Mental</strong><br />

<strong>Health</strong> Journal, 33, 199-211.<br />

12 McKay, M. M., Pennington, J., Lynn, C. J., &<br />

McCadam, K. (2001). Understanding urban<br />

child mental health l service use: two studies<br />

<strong>of</strong> child, family, and environmental correlates.<br />

Journal <strong>of</strong> Behavioral <strong>Health</strong> Services<br />

& Research, 28(4),475-83.<br />

13 Applied Research and Consulting, Columbia<br />

University Mailman School <strong>of</strong> Public <strong>Health</strong>,<br />

& <strong>New</strong> <strong>York</strong> <strong>State</strong> Psychiatric Institute.<br />

(March 2002). Effects <strong>of</strong> the World Trade<br />

Center attack on NYC public school students.<br />

Retrieved November 30, 2004, from<br />

http://www.nycenet.edu/<strong>of</strong>fices/spss/wtc%5<br />

Fneeds/firstrep.pdf<br />

14 Cohen J.A., Mannarino, A.P., & Deblinger E.<br />

(2002). Child and parent trauma-focused cognitive<br />

behavioral therapy: treatment manual.<br />

Unpublished manuscript.<br />

15 Layne, C.M., Saltzman, W.R., & Pynoos, R.S.<br />

(2002). Trauma/grief-focused group psychotherapy<br />

program. Unpublished manuscript.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


64 Chapter 5: Services Research<br />

Figure 5.1<br />

Engagement Rates at CATS Sites<br />

100<br />

90<br />

80<br />

70<br />

60<br />

50<br />

40<br />

30<br />

20<br />

10<br />

0<br />

89 86 89<br />

Assessment Treatment TOTAL<br />

Figure 5.2<br />

Engagement Rates by CATS<br />

Service Setting<br />

100<br />

90<br />

80<br />

70<br />

60<br />

50<br />

40<br />

30<br />

20<br />

10<br />

0<br />

89<br />

98<br />

90<br />

School Community Hospital/School<br />

Notes<br />

16 McKay, M. M., Stoewe, J., McCadam, K., &<br />

Gonzales, J. (1998). Increasing access to<br />

child mental health services for urban children<br />

and their caregivers. <strong>Health</strong> and Social<br />

Work, 23(1), 9_15.<br />

17 McKay, M. M., McCadam, K., & Gonzales, J.<br />

(1996). Addressing the barriers to mental<br />

health services for inner city children and<br />

their caretakers. Community <strong>Mental</strong> <strong>Health</strong><br />

Journal, 32(4), 353_61.<br />

ly and youth and improve retention<br />

over time. This engagement intervention<br />

was modified to reflect<br />

recent research findings with innercity<br />

families on salient factors associated<br />

with keeping child mental<br />

health appointments. Specifically,<br />

the engagement intervention in<br />

CATS targets empirically defined attitudes<br />

toward mental health care,<br />

while simultaneously helping parents<br />

gain confidence in their ability<br />

to bring their child to a mental<br />

health appointment. In addition, the<br />

intervention encourages discussions<br />

with members <strong>of</strong> each family’s social<br />

support network about help seeking<br />

before the first appointment.<br />

Thus far at each <strong>of</strong> the sites, four<br />

to eight staff members, including<br />

clinical and administrative staff,<br />

have received a two-day training<br />

focused on engaging youth with<br />

mental health needs and their families<br />

in clinic services. In addition, at<br />

each <strong>of</strong> the sites an “engagement<br />

team” has been organized, consisting<br />

<strong>of</strong> the site’s intake workers,<br />

representatives from the clinical<br />

and administrative staff, and supervisors.<br />

This team oversees the<br />

implementation <strong>of</strong> the intervention<br />

at each site. Further, monthly meetings<br />

are held with each site team<br />

to fine tune interventions and to<br />

collect child mental health outcome<br />

data. Preliminary data from the<br />

CATS study on retention rates for<br />

296 caregivers at eight weeks, as<br />

shown in Figure 5.1, demonstrate<br />

that this approach to enhancing clinicians’<br />

skills in engaging families<br />

was highly effective, with overall<br />

engagement rates <strong>of</strong> 89% across the<br />

nine sites.<br />

These rates are particularly<br />

impressive for treatment, considering<br />

that prior research indicates that<br />

rates for initial appointments can<br />

range from the rate <strong>of</strong> 72% to 85%<br />

at the high end with some type <strong>of</strong><br />

engagement interventions 16 and as<br />

low as 40% to 50% in standard care<br />

conditions. 10, 17 These data also indicate<br />

that engagement rates are high<br />

regardless <strong>of</strong> service settings, but<br />

are highest in community-based<br />

programs (Figure 5.2).<br />

School Support Projects (SSP):<br />

Strengthening School-Based<br />

<strong>Mental</strong> <strong>Health</strong> Services<br />

he largest school initiative in<br />

T<strong>New</strong> <strong>York</strong> <strong>State</strong> involves a joint<br />

partnership between <strong>OMH</strong> and the<br />

<strong>State</strong> Education Department (SED).<br />

The School-Based <strong>Mental</strong> <strong>Health</strong><br />

Demonstration Project, called the<br />

School Support Projects (SSP), was<br />

launched in 2001. Originally in<br />

seven schools, it was expanded in<br />

2003 to 60 schools. The purpose <strong>of</strong><br />

SSP is to support inclusion <strong>of</strong> mental<br />

health services, including EBPs,<br />

in schools. SSP mandates that at<br />

least one parent advocate and at<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 5: Services Research 65<br />

least one school mental health pr<strong>of</strong>essional<br />

be employed to deliver<br />

mental health services.<br />

After a series <strong>of</strong> consultations, the<br />

Steering Committee selected a common<br />

core assessment battery for<br />

use across all <strong>of</strong> the sites. Pilot testing<br />

was undertaken to determine<br />

its acceptability and usefulness to<br />

clinicians and families. Providers at<br />

all sites were trained in the use <strong>of</strong><br />

measures included in the battery<br />

and routine monitoring procedures<br />

were put into place to ensure that<br />

complete data were collected. The<br />

Steering Committee then selected a<br />

set <strong>of</strong> EBPs targeted at the identified<br />

problems. These included CBT<br />

for anxiety (the Coping Cat program)<br />

18 and interpersonal therapy<br />

for adolescents (IPT-A) for depression,<br />

19 as well as classroom consultation<br />

methods and algorithms for<br />

the optimal use <strong>of</strong> medications for<br />

children with ADHD and other disruptive<br />

behavior disorders.<br />

To illustrate how these methods<br />

have been used to increase the<br />

application <strong>of</strong> EBPs, specific clinical<br />

decision points were built into<br />

assessment and treatment algorithms<br />

and then used as quality<br />

indicators to track decision making<br />

and treatment implementation. Indicators,<br />

for example, were developed<br />

to encourage school-based<br />

mental health specialists to implement<br />

classroom-based behavioral<br />

therapy methods and to consider<br />

medication referrals earlier in the<br />

course <strong>of</strong> treatment, with the goal<br />

<strong>of</strong> improving outcomes. A database<br />

registry developed by SED to track<br />

all participants allows all cases and<br />

records to be flagged when they<br />

meet specific symptom-level thresholds<br />

on teacher or parent behavior<br />

checklists. The tracking system<br />

combined with the quality indicators<br />

allows school mental health<br />

staff and supervisors to receive<br />

case-level feedback. Group supervision<br />

<strong>of</strong> school mental health staff is<br />

provided by expert clinicians.<br />

An evaluation is being completed<br />

to assess the feasibility <strong>of</strong> implementing<br />

these procedures. Preliminary<br />

data indicate that, after one<br />

year <strong>of</strong> intensive technical assistance<br />

and consultation, five <strong>of</strong> the<br />

original seven SSP schools are fully<br />

operational and have routinely<br />

incorporated EBPs. Examination <strong>of</strong><br />

the two other clinics reveals that<br />

organizational factors at the school<br />

such as staff turnover have hampered<br />

efforts to implement the program.<br />

Among the five schools that<br />

are implementing EBPs, administration<br />

rates <strong>of</strong> the assessment battery<br />

to eligible students range from 70%<br />

to 95%, with a mean rate <strong>of</strong> 89%.<br />

An analysis <strong>of</strong> data from a school<br />

clinician survey showed that<br />

between two-thirds and four-fifths<br />

<strong>of</strong> the clinicians who had been<br />

trained to deliver a set <strong>of</strong> evidencebased<br />

interventions in the schools<br />

agreed or strongly agreed that the<br />

training they received in EBPs had<br />

been valuable and helped them in<br />

their work with students.<br />

Innovative Care<br />

Coordination Initiatives<br />

ew <strong>York</strong> <strong>State</strong> is committed to<br />

Nidentifying and evaluating innovative<br />

supportive clinical practices,<br />

thereby increasing the pace <strong>of</strong> new<br />

treatment development and applying<br />

knowledge drawn from basic<br />

behavioral sciences. Consistent<br />

with recommendations in the President’s<br />

<strong>New</strong> Freedom Commission<br />

on <strong>Mental</strong> <strong>Health</strong>, enhanced care<br />

coordination places a heavy<br />

emphasis on the development <strong>of</strong><br />

individualized plans <strong>of</strong> care for<br />

adults with serious mental illness<br />

and children with serious emotional<br />

disturbance and the involvement<br />

<strong>of</strong> individuals and families in working<br />

toward recovery.<br />

Notes<br />

18 Kendall, P.C., Flannery-Schroeder, E.,<br />

Panichelli-Mindel, S.M., Southam-Gerow,<br />

M., Henin, A., & Warman, M. (1997). Therapy<br />

for youths with anxiety disorders: a second<br />

randomized clinical trial. Journal <strong>of</strong> Consulting<br />

and Clinical Psychology, 65(3):366-80.<br />

19 Mufson, L., Weissman, M.M., & Moreau, D.<br />

(1993). Interpersonal Psychotherapy for<br />

Depressed Adolescents. Roslyn Heights, NY:<br />

Libra Publishers.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

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66 Chapter 5: Services Research<br />

Decision Support<br />

for Care Coordination:<br />

Single Point <strong>of</strong> Access (SPOA)<br />

he SPOA process is the mecha-<br />

by which Local depart-<br />

Tnism<br />

ments <strong>of</strong> mental health statewide<br />

have centralized their intake and<br />

referral systems to prioritize access<br />

to services based on need. The<br />

SPOA infrastructure is designed to<br />

improve access to services for individuals<br />

with the greatest need,<br />

thereby enabling county mental<br />

health departments to manage<br />

resources with a greater recognition<br />

<strong>of</strong> who is being referred to<br />

and receiving services. Counties<br />

have considerable flexibility in<br />

structuring their SPOA systems as<br />

long as the general purposes <strong>of</strong><br />

SPOA are addressed.<br />

All SPOAs are required to establish<br />

the following major components:<br />

a system for identifying and<br />

prioritizing individuals with the<br />

highest needs; a screening process<br />

to identify the specific service<br />

needs <strong>of</strong> each individual; and<br />

mechanisms for coordinating and<br />

making available an array <strong>of</strong> service<br />

options to meet the needs that<br />

are identified. In addition, the children’s<br />

SPOAs are expected to<br />

develop the capacity to conduct<br />

comprehensive functional assessments<br />

that support the tailoring <strong>of</strong><br />

service plans to the strengths and<br />

needs <strong>of</strong> individual children and<br />

their families.<br />

Counties are beginning to use the<br />

<strong>OMH</strong> Child and Adult Integrated<br />

Reporting System (CAIRS), a critical<br />

decision support system used by<br />

<strong>State</strong> and local providers, to coordinate<br />

and manage care to high-risk<br />

mental health clients in the community.<br />

To date, 10 counties have<br />

become active in using CAIRS and<br />

submitting data. Other counties are<br />

currently reviewing their Local<br />

referral processes to determine<br />

how best to utilize CAIRS. <strong>OMH</strong><br />

continues to work intensively with<br />

all counties to detail Local referral<br />

practices and determine the best<br />

technical solution to their needs.<br />

All counties in Upstate <strong>New</strong> <strong>York</strong><br />

and Long Island have SPOAs for<br />

children. In <strong>New</strong> <strong>York</strong> City, a<br />

SPOA initiative in the Bronx has<br />

developed algorithms based on<br />

John Lyons’ Child and Adolescent<br />

Needs and Strengths Survey<br />

(CANS). These algorithms are guiding<br />

the objective assignment <strong>of</strong> a<br />

service level based upon the completion<br />

<strong>of</strong> a valid and reliable functional<br />

assessment instrument. Plans<br />

are also progressing to expand the<br />

SPOA system for children to the<br />

remaining boroughs.<br />

Throughout the <strong>State</strong>, approximately<br />

20,000 children and families<br />

have had service plans coordinated<br />

through SPOAs, with county mental<br />

health authorities reporting a variety<br />

<strong>of</strong> positive outcomes. In Livingston<br />

County, for example, 30 different<br />

agencies are participating in its<br />

SPOA initiative, the Youth Assessment<br />

Committee. At intake the<br />

average score for a child on the<br />

Child and Adolescent Functional<br />

Assessment Scale had been 109,<br />

demonstrating a level <strong>of</strong> functioning<br />

that would require intensive services<br />

from multiple sources. After<br />

three months, however, the average<br />

score fell to 83, indicating a significant<br />

increase in the level <strong>of</strong> functioning<br />

and a reduction in the risk<br />

for out-<strong>of</strong>-home placement and<br />

intensive service provision. Similarly,<br />

in Genesee County, the Family<br />

Court Diversion Project, which is an<br />

organized effort between the Coordinated<br />

Children’s Services Initiative<br />

(CCSI), SPOA, Family Court, probation<br />

and law enforcement agencies,<br />

has resulted in a cost savings <strong>of</strong><br />

approximately $35,000 annually due<br />

to a reduction in court-ordered psychiatric<br />

admissions. The reduction<br />

was made possible largely by<br />

improved assessment <strong>of</strong> clinical<br />

functioning by the county SPOA,<br />

and a close working relationship<br />

with Family Court judges who<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 5: Services Research 67<br />

relied on the determinations and<br />

used them in lieu <strong>of</strong> court-ordered<br />

psychiatric evaluations.<br />

Assisted Outpatient<br />

Treatment: Kendra’s Law<br />

n August 9, 1999, Governor<br />

OGeorge Pataki signed Kendra’s<br />

Law (Chapter 408 <strong>of</strong> the Laws <strong>of</strong><br />

1999), creating a statutory framework<br />

for court-ordered Assisted<br />

Outpatient Treatment (AOT) to<br />

ensure that individuals with mental<br />

illness and a history <strong>of</strong> hospitalizations<br />

or violence participate in community-based<br />

services appropriate<br />

to their needs. Kendra’s Law was<br />

named in memory <strong>of</strong> Kendra Webdale,<br />

a young woman who died in<br />

January, 1999 after being pushed in<br />

front <strong>of</strong> a <strong>New</strong> <strong>York</strong> City subway<br />

train by Andrew Goldstein, a man<br />

with a history <strong>of</strong> mental illness and<br />

hospitalizations. The law became<br />

effective in November <strong>of</strong> 1999.<br />

Since that time, <strong>OMH</strong> has been<br />

evaluating the impact <strong>of</strong> Kendra’s<br />

Law on individuals receiving courtordered<br />

services. In January, 2003<br />

<strong>OMH</strong> issued an Interim Report<br />

required by Kendra’s Law, which<br />

reviewed the implementation and<br />

status <strong>of</strong> AOT and presented findings<br />

from <strong>OMH</strong>’s evaluation <strong>of</strong> the<br />

program. 20 A Final Report on the<br />

status <strong>of</strong> AOT in <strong>New</strong> <strong>York</strong> <strong>State</strong> is<br />

available on the web at http://<br />

www.omh.state.ny.us/omhweb/<br />

Kendra_web/finalreport/.<br />

Implementation <strong>of</strong> Assisted<br />

Outpatient Treatment<br />

Kendra’s Law established new<br />

mechanisms for identifying individuals<br />

who, in view <strong>of</strong> their treatment<br />

history and circumstances,<br />

are likely to have difficulty living<br />

safely in the community without<br />

close monitoring and mandatory<br />

participation in treatment. It also<br />

established mechanisms for ensuring<br />

that local mental health systems<br />

give these individuals priority<br />

access to case management and<br />

other services necessary to ensure<br />

their safety and successful community<br />

living.<br />

The statute created a petition<br />

process, found in <strong>Mental</strong> Hygiene<br />

Law section 9.60, designed to identify<br />

at-risk individuals using specific<br />

eligibility criteria, assess whether<br />

court-ordered outpatient treatment<br />

is required, and if so, develop and<br />

implement mandatory treatment<br />

plans consisting <strong>of</strong> case management<br />

and other necessary services.<br />

Kendra’s Law requires that each<br />

county in <strong>New</strong> <strong>York</strong> <strong>State</strong> and <strong>New</strong><br />

<strong>York</strong> City establish a local AOT<br />

program to implement the statute’s<br />

requirements, and charges <strong>OMH</strong><br />

with the responsibility for monitoring<br />

and overseeing the implementation<br />

<strong>of</strong> AOT statewide. Implementation<br />

<strong>of</strong> Kendra’s Law and<br />

AOT has been a joint responsibility<br />

and collaboration between <strong>OMH</strong><br />

and local mental health authorities.<br />

Eligibility Criteria for AOT<br />

Kendra’s Law contains the following<br />

summary description <strong>of</strong> the<br />

AOT target population:<br />

“...mentally ill people who<br />

are capable <strong>of</strong> living in the<br />

community with the help <strong>of</strong><br />

family, friends and mental<br />

health pr<strong>of</strong>essionals, but who,<br />

without routine care and<br />

treatment, may relapse and<br />

become violent or suicidal, or<br />

require hospitalization.”<br />

The statute further defines specific<br />

eligibility criteria, which are listed<br />

below.<br />

An individual may be placed in<br />

AOT only if, after a hearing, the<br />

court finds that all <strong>of</strong> the following<br />

have been met. The individual<br />

must:<br />

1. be eighteen years <strong>of</strong> age or<br />

older; and<br />

Notes<br />

20 <strong>OMH</strong>’s Interim Report on Kendra’s Law is available<br />

on the <strong>OMH</strong> Web site at http://www.omh.state.<br />

ny.us/ omhweb/Kendra_web/interimreport/<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

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68 Chapter 5: Services Research<br />

2. suffer from a mental illness; and<br />

3. be unlikely to survive safely in<br />

the community without supervision,<br />

based on a clinical determination;<br />

and<br />

4. have a history <strong>of</strong> non-adherence<br />

with treatment that has:<br />

a. been a significant factor in his<br />

or her being in a hospital,<br />

prison or jail at least twice<br />

within the last 36 months; or<br />

b. resulted in one or more acts,<br />

attempts or threats <strong>of</strong> serious<br />

violent behavior toward self<br />

or others within the last 48<br />

months; and<br />

5. be unlikely to voluntarily participate<br />

in treatment; and<br />

6. be, in view <strong>of</strong> his or her treatment<br />

history and current behavior,<br />

in need <strong>of</strong> AOT in order to<br />

prevent a relapse or deterioration<br />

which would be likely to<br />

result in:<br />

a. a substantial risk <strong>of</strong> physical<br />

harm to the individual as<br />

manifested by threats <strong>of</strong> or<br />

attempts at suicide or serious<br />

bodily harm or conduct<br />

demonstrating that the individual<br />

is dangerous to himself<br />

or herself; or<br />

b. a substantial risk <strong>of</strong> physical<br />

harm to other persons as<br />

manifested by homicidal or<br />

other violent behavior by<br />

which others are placed in<br />

reasonable fear <strong>of</strong> serious<br />

physical harm; and<br />

7. be likely to benefit from AOT;<br />

and<br />

8. if the consumer has a health<br />

care proxy, any directions in it<br />

will be taken into account by<br />

the court in determining the<br />

written treatment plan. However,<br />

nothing precludes a person with<br />

a health care proxy from being<br />

eligible for AOT.<br />

Program Evaluation Findings<br />

MH’s ongoing evaluation <strong>of</strong><br />

OAOT examines the outcomes <strong>of</strong><br />

AOT judicial proceedings; how<br />

many individuals have received<br />

court-ordered AOT; how long individuals<br />

typically remain under<br />

court-ordered treatment; the characteristics<br />

<strong>of</strong> AOT recipients and<br />

outcomes for AOT recipients.<br />

These findings derive from several<br />

sources:<br />

◆ <strong>OMH</strong> Central and Field <strong>Office</strong><br />

staff record basic information on<br />

each court order and the status<br />

<strong>of</strong> each order in an electronic<br />

tracking system. This system is<br />

used to generate regular aggregate<br />

reports on the volume <strong>of</strong><br />

court orders throughout the state<br />

and the number <strong>of</strong> individuals<br />

receiving AOT.<br />

◆ <strong>OMH</strong> collects additional information<br />

concerning AOT recipients<br />

from their case managers via a<br />

paper-based survey data collection<br />

process. Case managers<br />

complete a standardized assessment<br />

for each AOT recipient at<br />

the onset <strong>of</strong> the court order<br />

(baseline), at the end <strong>of</strong> the initial<br />

court order (six month follow-up),<br />

and, if the court order<br />

is renewed, every six months for<br />

the duration <strong>of</strong> the order. The<br />

assessments capture: demographic<br />

characteristics <strong>of</strong> AOT<br />

recipients; their status in areas<br />

such as living situation, services<br />

received, engagement in services,<br />

and adherence to prescribed<br />

medication; incidence <strong>of</strong> significant<br />

events such as hospitalization,<br />

homelessness, arrest, and<br />

incarceration; functional impairment<br />

in the areas <strong>of</strong> self-care,<br />

social skills, and task performance;<br />

and any incidence <strong>of</strong><br />

harmful behaviors. These assessments<br />

are sent to <strong>OMH</strong> and the<br />

results entered into an evaluation<br />

database. <strong>OMH</strong> uses the<br />

resulting data to assess outcomes<br />

for all AOT recipients as a<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 5: Services Research 69<br />

group. Due to time lags inherent<br />

in paper-based survey data collection<br />

and processing, and the<br />

limited scope <strong>of</strong> the data collected<br />

on the standardized assessments,<br />

<strong>OMH</strong> does not use the<br />

evaluation database to monitor<br />

the clinical status <strong>of</strong> individual<br />

recipients.<br />

Summary <strong>of</strong> AOT Proceedings<br />

Referrals/Investigations, Petitions,<br />

Court Orders and Service<br />

Enhancements<br />

Between November 1999 and<br />

December 31, 2004, 10,078 individuals<br />

were referred to local AOT<br />

coordinators for investigation to<br />

determine potential eligibility for<br />

an AOT court order. Referrals<br />

resulted in petitions filed for the<br />

issuance <strong>of</strong> an AOT court order for<br />

4,041 individuals (40% <strong>of</strong> all individuals<br />

referred); <strong>of</strong> these, petitions<br />

were granted and court orders<br />

issued for 3,766 individuals (93% <strong>of</strong><br />

all individuals with petitions filed).<br />

Investigations led to service<br />

enhancements rather than court<br />

orders for 2,863 individuals (28% <strong>of</strong><br />

all investigations).<br />

Court orders and service<br />

enhancements have been issued in<br />

all regions <strong>of</strong> <strong>New</strong> <strong>York</strong> <strong>State</strong>, with<br />

58% <strong>of</strong> all court orders and service<br />

enhancements occurring in <strong>New</strong><br />

<strong>York</strong> City. Table 5.3 summarizes<br />

data on outcomes <strong>of</strong> the judicial<br />

procedures associated with AOT.<br />

Table 5.3<br />

Summary <strong>of</strong> AOT Judicial Proceedings<br />

Through December 31, 2004<br />

Referrals/Investigations..................10,078 individuals<br />

Petitions Filed ....................................4,041 individuals<br />

Petitions Granted.............................. 3,766 individuals<br />

Percent <strong>of</strong> Individuals for whom Petitions<br />

were Filed and Granted ........................................93%<br />

Length <strong>of</strong> Time in AOT<br />

As noted in Table 5.3, as <strong>of</strong><br />

December 31, 2004, 3,766 individuals<br />

had received court ordered<br />

treatment through AOT. Initial<br />

court orders for AOT recipients are<br />

generally six months in duration.<br />

Court orders, however, can be<br />

renewed and recipients may<br />

receive additional court orders after<br />

previous orders expire. About one<br />

third <strong>of</strong> AOT recipients spend six<br />

months under court order. Court<br />

orders for most AOT recipients<br />

(64%) are renewed and so the<br />

majority <strong>of</strong> individuals remain<br />

under court order for more than six<br />

months (Table 5.4).<br />

Table 5.4<br />

AOT Court Order Renewal Rates<br />

Through December 31, 2004<br />

Court Orders Eligible<br />

for Renewal ....................................3,493 individuals*<br />

Court Orders Renewed......................2,236 individuals<br />

% with Court Orders<br />

Renewed ................................................................64%<br />

* This number excludes all initial court orders that, as <strong>of</strong><br />

December 31, 2004, were still in effect (and thus not yet eligible<br />

for renewal).<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

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70 Chapter 5: Services Research<br />

Figure 5.3 Table 5.5<br />

Time Recipients Spend in AOT<br />

November 1999 - December 2004<br />

Incidence <strong>of</strong> Hospitalization, Homelessness,<br />

Arrest and Incarceration Three Years Prior<br />

to Issuance <strong>of</strong> Court-Order<br />

Over 30<br />

months<br />

(7%)<br />

Over 18 months<br />

to 30 months<br />

(17%)<br />

Over 12 months<br />

to 18 months<br />

(21%)<br />

O to 6 Months<br />

(36%)*<br />

Over 6 months<br />

to 12 months<br />

(19%)<br />

* Persons for whom an initial court order was not renewed.<br />

Figure 5.3 shows<br />

the total amount <strong>of</strong><br />

time spent by recipients<br />

in AOT. The<br />

average length <strong>of</strong><br />

time recipients<br />

remain under court<br />

order is 16 months.<br />

Psychiatric Hospitalizations<br />

Mean number in last 36 months ..........................3.08<br />

Percent hospitalized (at least one episode) ........97%<br />

Number <strong>of</strong> admissions (range) ............................0-13<br />

Homeless Episodes<br />

Mean number in last 36 months ..........................0.27<br />

Percent homeless (at least one episode) ............19%<br />

Number <strong>of</strong> episodes (range) ..................................0-6<br />

Arrests<br />

Mean number in last 36 months ..........................0.52<br />

Percent arrested (at least one episode) ..............30%<br />

Number <strong>of</strong> arrests (range) ....................................0-10<br />

Incarcerations<br />

Mean number in last 36 months ..........................0.35<br />

Percent incarcerated (at least one episode) ........23%<br />

Number <strong>of</strong> incarcerations (range) ........................0-10<br />

Notes<br />

21<strong>OMH</strong> derives its estimates <strong>of</strong> the number <strong>of</strong> people<br />

served annually by the public mental health system<br />

from its Patient Characteristics Survey (PCS). The PCS,<br />

which is administered every other year, gathers information<br />

about the demographic and clinical characteristics<br />

<strong>of</strong> persons receiving mental health services in<br />

programs operated, funded, or certified by <strong>OMH</strong> during<br />

a one-week period. The data presented in this<br />

section are derived from the 2003 PCS, which is the<br />

most recent available.21 <strong>OMH</strong> derives its estimates<br />

<strong>of</strong> the number <strong>of</strong> people served annually by the public<br />

mental health system from its Patient Characteristics<br />

Survey (PCS). The PCS, which is administered every<br />

other year, gathers information about the demographic<br />

and clinical characteristics <strong>of</strong> persons receiving<br />

mental health services in programs operated, funded,<br />

or certified by <strong>OMH</strong> during a one-week period. The<br />

data presented in this section are derived from the<br />

2003 PCS, which is the most recent available.<br />

Incidence <strong>of</strong> Hospitalization,<br />

Homelessness, Arrest<br />

and Incarceration.<br />

Table 5.5 summarizes the incidence<br />

<strong>of</strong> hospitalizations, homelessness,<br />

arrest and incarceration<br />

for persons in AOT prior to courtordered<br />

treatment. In the three<br />

years prior to the court order, 97%<br />

<strong>of</strong> individuals had at least one psychiatric<br />

hospitalization. On average,<br />

these individuals had been hospitalized<br />

approximately three times<br />

during that period with some individuals<br />

having had as many as 13<br />

hospitalizations. Nineteen percent<br />

<strong>of</strong> individuals had experienced at<br />

least one episode <strong>of</strong> homelessness<br />

in the three years preceding their<br />

court order. Thirty percent were<br />

arrested at least one time in the<br />

three years prior to AOT. These<br />

individuals had as many as ten<br />

arrests during that time. Twentythree<br />

percent were incarcerated at<br />

least once in the three years prior<br />

to their court order. Some individuals<br />

had as many as ten incarcerations<br />

in those three years.<br />

When compared with a similar<br />

population <strong>of</strong> mental health service<br />

recipients, 21 AOT recipients were<br />

twice as likely to have had a previous<br />

episode <strong>of</strong> homelessness and<br />

50% more likely to have had contact<br />

with the criminal justice system<br />

prior to their court order. In addition,<br />

AOT recipients were 58%<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 5: Services Research 71<br />

more likely to have a co-occurring<br />

substance abuse problem.<br />

Outcomes for Recipients during<br />

the First Six Months <strong>of</strong> AOT<br />

nitial court orders for AOT recipi-<br />

are usually six months long.<br />

Ients<br />

The six month milestone is critical<br />

because it is at this juncture that<br />

decisions are made regarding<br />

renewal <strong>of</strong> the court order. Outcome<br />

findings presented in the next<br />

section focus on change between<br />

the onset <strong>of</strong> the court order and the<br />

status <strong>of</strong> recipients after six months.<br />

The results presented below are for<br />

AOT recipients for whom both<br />

baseline (onset <strong>of</strong> court order) and<br />

six-month follow-up assessments<br />

were available in the <strong>OMH</strong> evaluation<br />

database at the time <strong>of</strong> this<br />

report’s preparation.<br />

AOT was designed to ensure<br />

supervision and treatment for individuals<br />

who, without such supervision<br />

and treatment, would likely be<br />

unable to take responsibility for<br />

their own care and would be<br />

unable to live successfully in the<br />

community. For persons in AOT,<br />

Table 5.6<br />

Services Received by AOT Recipients<br />

Participation Rates Prior to AOT and During AOT<br />

the goals are to increase access to<br />

the highest intensity services and to<br />

better engage them in those services.<br />

An additional goal is to reduce<br />

the incidence <strong>of</strong> behaviors harmful<br />

to themselves or others. Participation<br />

in AOT should result in<br />

improved adherence to prescribed<br />

medication and decreased hospitalization,<br />

homelessness, arrests, and<br />

incarceration. In addition, AOT<br />

recipients should benefit through<br />

improved functioning in important<br />

community and personal activities.<br />

Increased Participation in Case<br />

Management and Other Services<br />

Table 5.6 compares participation<br />

in services by AOT recipients prior<br />

to and subsequent to the initial<br />

court order. For all categories <strong>of</strong><br />

service, a greater percentage <strong>of</strong><br />

individuals are participating in the<br />

service while under court order<br />

than were receiving it prior to thecourt<br />

order. A dramatic example is<br />

in the area <strong>of</strong> case management. As<br />

prescribed by the legislation, all<br />

individuals receiving a court order<br />

are enrolled in case management.<br />

Percentage <strong>of</strong> AOT Recipients<br />

Percent<br />

Service Prior to AOT At Six Months Increase<br />

Case Management 53% 100% 89%<br />

Medication Management 60% 88% 47%<br />

Individual or Group Therapy 51% 75% 47%<br />

Day Programs 15% 22% 47%<br />

Substance Abuse Services 24% 40% 67%<br />

Housing or Housing Support Services 19% 31% 63%<br />

Urine or Blood Toxicology<br />

(adherence to medication) 18% 37% 106%<br />

Urine or Blood Toxicology (substance abuse) 17% 35% 106%<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


72 Chapter 5: Services Research<br />

Figure 5.4<br />

However, prior to AOT, only 53%<br />

<strong>of</strong> these individuals were receiving<br />

this service.<br />

In addition, the percentage <strong>of</strong><br />

AOT recipients who are receiving<br />

substance abuse services increased<br />

by 67% as a result <strong>of</strong> their courtordered<br />

treatment plan, increasing<br />

from 24% to 40%. Similarly, the<br />

percentage <strong>of</strong> persons in AOT who<br />

receive housing services as a result<br />

<strong>of</strong> their court-ordered treatment<br />

plan also increased from 19% to<br />

31%. Substantial increases are also<br />

seen for urine or blood testing<br />

used to assess adherence to medication<br />

or substance abuse.<br />

Increased Engagement<br />

in Services and Adherence<br />

to Prescribed Medication<br />

Two important goals <strong>of</strong> AOT are<br />

increased engagement, i.e., active and<br />

regular participation in services; and<br />

increased adherence to prescribed<br />

medication, i.e., taking medications<br />

Changes in Service Engagement<br />

and Adherence to Medication<br />

At Onset <strong>of</strong> Court Order vs. Six Months<br />

75%<br />

60%<br />

45%<br />

30%<br />

15%<br />

0%<br />

41%<br />

62%<br />

Individuals<br />

Exhibiting Good<br />

Service Engagement<br />

34%<br />

Individuals<br />

Exhibiting Good<br />

Adherence<br />

to Medication<br />

At Onset <strong>of</strong> Court Order<br />

At Six Months<br />

69%<br />

necessary to manage psychiatric<br />

symptoms as directed by the treating<br />

physician. To assess engagement,<br />

case managers were asked to rate the<br />

engagement <strong>of</strong> persons in AOT using<br />

a scale ranging from “not at all<br />

engaged in services” to “independently<br />

and appropriately uses services.”<br />

Recipients were considered to have<br />

“good engagement” if they received a<br />

rating <strong>of</strong> either “good - able to partner<br />

and can use resources independently”<br />

or “excellent - independently and<br />

appropriately uses services.” Data collected<br />

since the onset <strong>of</strong> AOT show<br />

the percent <strong>of</strong> individuals who exhibit<br />

good engagement in services<br />

increased significantly from 41% to<br />

62% at six months.<br />

To assess medication adherence,<br />

case managers were asked to rate<br />

adherence <strong>of</strong> persons in AOT using<br />

a scale ranging from “taking medication<br />

exactly as prescribed” to<br />

“rarely or never taking medication<br />

as prescribed.” Recipients were considered<br />

to have “good adherence to<br />

medication” if they were rated as<br />

either “takes medication as prescribed<br />

most <strong>of</strong> the time” or “takes<br />

medication as prescribed.” The<br />

resulting data show that the percent<br />

<strong>of</strong> individuals with good medication<br />

adherence increased significantly<br />

from 34% to 69% after six months.<br />

Figure 5.4 displays the improvement<br />

in engagement in services and<br />

adherence to medications after six<br />

months <strong>of</strong> AOT participation.<br />

Improved Community<br />

and Social Functioning<br />

The evaluation database also<br />

documents changes in AOT recipients’<br />

day-to-day functioning. Measures<br />

that are used for this assessment<br />

are the Global Assessment <strong>of</strong><br />

Functioning (GAF) and three sets<br />

<strong>of</strong> items that assess individuals’<br />

abilities in specific functional areas:<br />

self-care, social and community living<br />

skills, and task performance.<br />

The GAF is a commonly used<br />

measure <strong>of</strong> overall functioning. It<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 5: Services Research 73<br />

includes social, occupational, academic,<br />

and other areas <strong>of</strong> personal<br />

performance and results in an<br />

overall numerical rating score<br />

which can range from 0 to 100. A<br />

score <strong>of</strong> 50 or below denotes serious<br />

impairment in social, occupational<br />

or school functioning. At the<br />

onset <strong>of</strong> an AOT court order, 39%<br />

<strong>of</strong> individuals had a GAF score<br />

below 50. After receiving services<br />

under an AOT court order for six<br />

months, the percentage <strong>of</strong> persons<br />

with a GAF score below 50<br />

dropped to 33%.<br />

AOT recipients’ functioning in<br />

the area <strong>of</strong> self-care and community<br />

living also improved after six<br />

months <strong>of</strong> program participation.<br />

Table 5.7 displays the change in<br />

these measures. The table compares<br />

the percentage <strong>of</strong> persons in<br />

AOT who were reported as having<br />

difficulty at the onset <strong>of</strong> their court<br />

ordered treatment with the percentage<br />

reported as having difficulty six<br />

months later. For all items, there<br />

were fewer individuals rated as<br />

having difficulty, and in all measures<br />

the change was statistically<br />

significant. Although changes are<br />

relatively small in magnitude for<br />

any single measure, a consistent<br />

pattern <strong>of</strong> overall improvement<br />

(reduction in difficulties) is seen<br />

across all areas <strong>of</strong> self-care and<br />

community functioning.<br />

Among the items included on<br />

Table 5.7, some measures can be<br />

linked to the AOT program’s goals<br />

Table 5.7<br />

Improvements in Self Care and Community Living<br />

Percent <strong>of</strong> AOT Recipients with Difficulties<br />

Percent<br />

At Onset <strong>of</strong><br />

Reduction<br />

AOT Court Order At Six Months in Difficulties<br />

Access community services 23% 16% 30%<br />

Prepare meals 17% 12% 29%<br />

Take care <strong>of</strong> own possessions 14% 10% 29%<br />

Maintain adequate personal hygiene 7% 5% 29%<br />

Follow through on health care advice 26% 19% 27%<br />

Make and keep appointments 27% 20% 26%<br />

Manage medication 36% 27% 25%<br />

Take care <strong>of</strong> own living space 16% 12% 25%<br />

Maintain adequate diet 9% 7% 22%<br />

Handle finances 29% 25% 14%<br />

Avoid dangers 7% 6% 14%<br />

Shop for food, etc. 16% 14% 13%<br />

Access transportation 9% 8% 11%<br />

Average Percent Reduction 23%<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

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74 Chapter 5: Services Research<br />

Table 5.8<br />

Improvements in Social, Interpersonal, and Family Functioning<br />

Percent <strong>of</strong> AOT Recipients with Difficulties<br />

Percent<br />

At Onset <strong>of</strong><br />

Reduction<br />

AOT Court Order At Six Months in Difficulties<br />

Ask for help when needed 28% 20% 29%<br />

Effectively handle conflict 50% 36% 28%<br />

Manage assertiveness 44% 33% 25%<br />

Engage in social/family activities 34% 26% 24%<br />

Communicate clearly 13% 10% 23%<br />

Respond to social contact 20% 16% 20%<br />

Maintain support network 40% 33% 18%<br />

Manage leisure time 28% 24% 14%<br />

Average Percent Reduction 22%<br />

Table 5.9<br />

Improvements in Task Performance<br />

Percent <strong>of</strong> AOT Recipients with Difficulties<br />

Percent<br />

At Onset <strong>of</strong><br />

Reduction<br />

AOT Court Order At Six Months in Difficulties<br />

Understand and remember instructions 19% 14% 26%<br />

Perform in coordination with or in proximity<br />

to others without being distracted by them 28% 21% 25%<br />

Sustain an ordinary routine<br />

without special supervision 33% 25% 24%<br />

Perform activities within a schedule,<br />

maintain regular attendance and be on time 33% 25% 24%<br />

Maintain attention and concentration spans 25% 19% 24%<br />

Complete tasks without assistance 28% 22% 21%<br />

Perform at a consistent pace<br />

without unreasonable rest periods 27% 22% 19%<br />

Complete tasks without errors 27% 22% 19%<br />

Average Percent Reduction 23%<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 5: Services Research 75<br />

<strong>of</strong> increasing adherence to medication<br />

and increasing engagement in<br />

services. In particular, the percent<br />

<strong>of</strong> AOT recipients who had difficulty<br />

managing medication decreased<br />

from 36% to 27% between the<br />

onset <strong>of</strong> the court order and six<br />

months. Similarly, the percent <strong>of</strong><br />

recipients who had difficulty following<br />

through on health care<br />

advice and making and keeping<br />

appointments declined from 26% to<br />

19% and 27% to 20% respectively.<br />

Tables 5.8 and 5.9 display the<br />

changes during the initial six<br />

months <strong>of</strong> AOT in the areas <strong>of</strong><br />

social, interpersonal and family<br />

functioning and task performance.<br />

On 15 <strong>of</strong> the 16 measures for these<br />

areas, the reduction in difficulties<br />

experienced by AOT recipients<br />

between the onset <strong>of</strong> the court<br />

order and at six months was statistically<br />

significant. For instance, the<br />

percent <strong>of</strong> recipients who had difficulty<br />

effectively handling conflict<br />

and managing assertiveness<br />

dropped from 50% to 36% and 44%<br />

to 33% respectively. Similar to the<br />

findings noted above for self care<br />

and community living, an overall<br />

pattern <strong>of</strong> reduced difficulties and<br />

therefore improved functioning<br />

characterizes the findings concerning<br />

social, interpersonal and family<br />

functioning, and task performance.<br />

Reduced Incidence<br />

<strong>of</strong> Harmful Behaviors<br />

Case managers also reported<br />

reductions in the incidence <strong>of</strong><br />

harmful behaviors for AOT recipients<br />

at six months in AOT when<br />

compared with a comparable period<br />

<strong>of</strong> time prior to AOT. Table 5.10<br />

shows significant declines in the<br />

incidence <strong>of</strong> behaviors harmful to<br />

self, behaviors harmful to others,<br />

Table 5.10<br />

Reduced Incidence <strong>of</strong> Harmful Behaviors<br />

(Percent <strong>of</strong> Persons with One or More Events Reported in the Past 90 Days)<br />

Percent <strong>of</strong> AOT Recipients<br />

with Harmful Behaviors<br />

Percent<br />

Reduction<br />

At Onset <strong>of</strong><br />

in Harmful<br />

AOT Court Order At Six Months Behaviors<br />

Physically Harm Self/Made Suicide Attempt 9% 4% 55%<br />

Abuse Alcohol 45% 23% 49%<br />

Abuse Drugs 44% 23% 48%<br />

Threaten Suicide 15% 8% 47%<br />

Physically Harm Others 15% 8% 47%<br />

Damage or Destroy Property 13% 7% 46%<br />

Threaten Physical Harm 28% 16% 43%<br />

Create Public Disturbances 24% 15% 38%<br />

Verbally Assault Others 33% 21% 36%<br />

Theft 7% 5% 29%<br />

Average Percent Reduction 44%<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


76 Chapter 5: Services Research<br />

and harmful behaviors directed at<br />

property. Similarly, substantial<br />

declines are also seen in alcohol<br />

and substance abuse. In summary,<br />

during the first six months <strong>of</strong> courtordered<br />

treatment, individuals in<br />

AOT showed a significant decline<br />

in the incidence <strong>of</strong> harmful behaviors.<br />

The average percent decrease<br />

in harmful behaviors was 44%.<br />

Adult Homes: A <strong>New</strong> Care<br />

Coordination Model <strong>of</strong> Support,<br />

Empowerment and Collaboration<br />

dult homes are residences in<br />

Athe community licensed by the<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> Department <strong>of</strong><br />

<strong>Health</strong> (DOH), and ranging in size<br />

from less than 20 beds to more<br />

than 300. The majority <strong>of</strong> individuals<br />

served by <strong>OMH</strong> live in a cluster<br />

<strong>of</strong> homes <strong>of</strong>ten referred to as<br />

“impacted adult homes,” meaning<br />

that either 25 residents or 25% <strong>of</strong><br />

the total resident population<br />

received mental health services.<br />

In Spring 2002, Governor Pataki<br />

appointed an Adult Home Workgroup<br />

comprised <strong>of</strong> key stakeholders,<br />

including advocates, home<br />

operators, DOH, <strong>OMH</strong>, the <strong>State</strong><br />

Commission on Quality <strong>of</strong> Care for<br />

the <strong>Mental</strong>ly Disabled, and the<br />

<strong>State</strong> <strong>Office</strong> for the Aging. This<br />

Workgroup was charged with making<br />

recommendations to improve<br />

conditions for residents living in<br />

DOH-licensed adult care facilities.<br />

Consistent with the Workgroup’s<br />

recommendations for change,<br />

<strong>OMH</strong> and its sister agencies developed<br />

a comprehensive service<br />

package to support adult home residents,<br />

improve their access to<br />

mental health services, and help<br />

them meet their recovery goals.<br />

The package includes provisions<br />

and activities that focus on health<br />

and safety, appropriateness <strong>of</strong> care,<br />

quality <strong>of</strong> care, quality <strong>of</strong> life, housing,<br />

and public awareness.<br />

To promote resident recovery<br />

and independence, a new model<br />

<strong>of</strong> on-site case management and<br />

peer support services was proposed<br />

for adult home residents.<br />

The model is a unique combination<br />

<strong>of</strong> coordinated and integrated<br />

services that focuses on resident<br />

strengths and needs and the provision<br />

<strong>of</strong> supports to ensure independence<br />

and personal choice.<br />

Rehabilitation principles and values<br />

that emphasize support, empowerment,<br />

and collaboration are expected<br />

to result in a merger <strong>of</strong> consumer<br />

and pr<strong>of</strong>essional<br />

perspectives. <strong>OMH</strong>’s commitment<br />

to this initiative has been strengthened<br />

by a recent increase in the<br />

rate for blended case management,<br />

as well as the issuance <strong>of</strong> two<br />

Request for Proposals aimed at the<br />

development <strong>of</strong> supportive case<br />

management, utilizing supportive<br />

case managers and peer services.<br />

The first was issued in 2003 with<br />

services beginning in 2004, and the<br />

second was issued in November<br />

2004 with services to begin in<br />

2005. When fully implemented, the<br />

case management/peer support initiative<br />

will be providing services to<br />

approximately 3,500 individuals<br />

residing in adult homes in <strong>New</strong><br />

<strong>York</strong> City, Long Island, and various<br />

Upstate counties.<br />

Under this initiative, existing<br />

adult home treatment services are<br />

being restructured to provide an<br />

evidenced-based set <strong>of</strong> services<br />

focusing on wellness and self management<br />

techniques. The case<br />

management/peer support program<br />

engages service recipients and<br />

involves family and friends by providing<br />

educational information<br />

regarding the range <strong>of</strong> multiple<br />

community resources available.<br />

On-site social and recreational<br />

opportunities enhance the quality<br />

<strong>of</strong> life for residents <strong>of</strong> adult homes<br />

and opportunities are created for<br />

participation in a variety <strong>of</strong> home<br />

and community activities. The case<br />

management/peer support initiative<br />

has resulted in the facilitation <strong>of</strong><br />

numerous groups and activities not<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 5: Services Research 77<br />

Table 5.11<br />

Case Management/Peer<br />

Support Program<br />

Enhanced Group Activity Areas<br />

◆ Stress management<br />

◆ Developing coping skills<br />

◆ Self-esteem<br />

◆ Family support<br />

◆ Time management<br />

◆ Computer classes<br />

◆ Anger management<br />

◆ Arts and crafts<br />

◆ All-male interpersonal skills<br />

◆ Life skills development<br />

◆ Wellness for residents whose<br />

psychiatric conditions restrict<br />

their ability to care for cooccurring<br />

medical conditions<br />

previously available to residents <strong>of</strong><br />

adult homes (see Table 5.11).<br />

Many community-based and onsite<br />

enrichment activities are attended<br />

by residents on a regular basis.<br />

Attendance at on-site activities at<br />

four adult homes averages 300 residents<br />

per month. Some events are<br />

coordinated and supported by case<br />

managers and peers, while others<br />

are coordinated through the <strong>OMH</strong><br />

<strong>Office</strong> <strong>of</strong> Consumer Affairs.<br />

The <strong>OMH</strong> <strong>Office</strong> <strong>of</strong> Consumer<br />

Affairs also plays a key role in<br />

<strong>of</strong>fering support to a number <strong>of</strong><br />

self-governing, resident-run Resident<br />

Councils. The councils meet<br />

regularly to discuss issues and concerns,<br />

which are communicated to<br />

staff designated to serve as liaisons.<br />

The <strong>Office</strong> <strong>of</strong> Consumer Affairs<br />

provides training and technical<br />

assistance to the Resident Councils<br />

and other adult home staff and has<br />

also worked to identify community<br />

partners for the Councils. 20 As<br />

requested by Resident Council<br />

leaders, the <strong>Office</strong> <strong>of</strong> Consumer<br />

Affairs is coordinating training on<br />

hope. This training will be provided<br />

by the <strong>Mental</strong> <strong>Health</strong> Empowerment<br />

Project as a pilot project to<br />

five adult homes in <strong>New</strong> <strong>York</strong> City<br />

over the next year.<br />

The <strong>OMH</strong> <strong>Office</strong> <strong>of</strong> Consumer<br />

Affairs is supporting an initiative in<br />

Queens, where residents are being<br />

<strong>of</strong>fered information about community<br />

resources and assistance in<br />

linking to groups in their neighborhoods.<br />

Adult home operators, case<br />

managers and peer specialists provide<br />

support for a range <strong>of</strong> guests<br />

and activities, including faith-based<br />

groups, computer literacy groups,<br />

volunteer opportunities, and voter<br />

registration activities. Approximately<br />

150 residents per month attend<br />

these programs. Additionally, traditional<br />

mental health services such<br />

as supportive employment agencies<br />

have been introduced, but with a<br />

focus on securing jobs outside <strong>of</strong><br />

the mental health system, for<br />

example, a volunteer opportunity<br />

available at a local museum. Based<br />

on the success <strong>of</strong> the Queens initiative,<br />

this pilot project will be<br />

replicated in three homes in <strong>New</strong><br />

<strong>York</strong> City and one in each region<br />

<strong>of</strong> the <strong>State</strong>.<br />

The provision <strong>of</strong> rehabilitation<br />

and recovery training to the case<br />

managers and peer specialists was<br />

a primary focus <strong>of</strong> 2004 and will<br />

continue into 2005 and beyond.<br />

Training has been aimed at effectively<br />

assisting residents <strong>of</strong> adult<br />

homes to successfully attain and<br />

maintain their personal recovery<br />

goals and to develop and or<br />

strengthen natural community and<br />

social supports. Building on these<br />

efforts, the Adult Home Monitoring<br />

and Training Team, which is<br />

responsible for facilitating the mental<br />

health component <strong>of</strong> the<br />

statewide interagency team, will<br />

provide training programs to case<br />

managers and peer specialists on<br />

strategies for effective education <strong>of</strong><br />

adult home residents who have<br />

mental illness. The training will<br />

focus on engaging participants in<br />

skills development that will enable<br />

Notes<br />

22 In <strong>New</strong> <strong>York</strong> City, there is an Adult Home<br />

Caucus <strong>of</strong> all the resident councils that is<br />

supported by the Coalition <strong>of</strong> Institutionalized<br />

Aged and Disabled.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


78 Chapter 5: Services Research<br />

them to work toward their recovery<br />

goals. Importantly, residents<br />

who identify educational and vocational<br />

goals now have the opportunity<br />

to attain these goals under a<br />

vocation and education initiative,<br />

which is organizing job fairs and<br />

providing GED opportunities.<br />

Translating Evaluation<br />

and Services Research<br />

Findings into Practical<br />

Clinical Treatments<br />

and System Supports<br />

O<br />

MH research is also improving<br />

the quality <strong>of</strong> care by translating<br />

research findings into practical clinical<br />

tools, treatments and services in<br />

our communities and <strong>State</strong> psychiatric<br />

hospitals. Below, we highlight<br />

several initiatives conducted by<br />

<strong>OMH</strong>’s two research institutes that<br />

illustrate the immediate, real-world<br />

translational benefits <strong>of</strong> research.<br />

We include some examples that<br />

have been widely disseminated in<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong>, as well as demonstration<br />

projects that serve specific<br />

target populations in small geographic<br />

areas. <strong>OMH</strong> is examining<br />

the possibility <strong>of</strong> expanding successful<br />

demonstration projects to<br />

broader populations.<br />

Child and Adolescent Psychiatric<br />

Evaluation Service<br />

he Child and Adolescent Psychi-<br />

Evaluation Service (CAPES)<br />

Tatric<br />

fills a noticeable gap in evaluating<br />

children for psychiatric illness. The<br />

service provides expert consultation<br />

to primary care physicians and<br />

families with children ages 3 to 17<br />

years who may suffer from behavioral,<br />

emotional and developmental<br />

problems. CAPES is partnering with<br />

pediatricians throughout <strong>New</strong> <strong>York</strong><br />

City, and has evaluated over 600<br />

individuals to date. In addition to<br />

psychiatric consultation, children<br />

referred to CAPES are guaranteed a<br />

free and thorough evaluation comprising<br />

a psychological interview,<br />

structured diagnostic assessment,<br />

child cognitive screening, a multifaceted<br />

symptom assessment, and<br />

expert consensus on diagnosis and<br />

treatment recommendations.<br />

Cultural Competence<br />

he President’s <strong>New</strong> Freedom<br />

TCommission on <strong>Mental</strong> <strong>Health</strong><br />

cited the lack <strong>of</strong> culturally competent<br />

mental health services as a key<br />

factor in creating disparities in<br />

access to care for various racial and<br />

ethnic groups. <strong>OMH</strong> researchers<br />

have developed an 11-item scale<br />

for behavioral healthcare agencies<br />

to assess their cultural competency.<br />

Use <strong>of</strong> the scale is intended to<br />

motivate agencies to develop culturally<br />

competent behaviors and to<br />

guide the development <strong>of</strong> culturally<br />

competent adaptations <strong>of</strong> EBPs.<br />

NIMH has awarded funds to study<br />

the psychometric properties <strong>of</strong> this<br />

scale. Future plans include the<br />

development <strong>of</strong> an instrument<br />

applicable to mental health authorities<br />

or umbrella agencies and a<br />

version <strong>of</strong> the scale for agencies<br />

that serve a single culture.<br />

Memory Education<br />

and Research Initiative<br />

he Memory Education and<br />

TResearch Initiative (MERI) is a<br />

<strong>State</strong> and Local collaborative project<br />

that <strong>of</strong>fers at no cost a memory<br />

and cognitive evaluation to individuals<br />

with memory complaints who<br />

live in Rockland County. Since its<br />

inception, the program has<br />

screened more than 300 individuals.<br />

Many <strong>of</strong> these individuals had<br />

concerns about memory loss or<br />

were worried because they had<br />

close relatives with Alzheimer’s disease.<br />

Most <strong>of</strong> those screened did<br />

not, in fact, have the disorder but<br />

were reassured by the positive<br />

results <strong>of</strong> the evaluation. These<br />

individuals will be followed annually<br />

in an effort to look for some <strong>of</strong><br />

the earliest predictors <strong>of</strong> decline. In<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 5: Services Research 79<br />

cases where the evaluation determined<br />

that individuals were at the<br />

early stages <strong>of</strong> the disorder, the<br />

individuals were able to benefit<br />

from early diagnosis and treatment.<br />

Movement Disorders<br />

ome individuals who take<br />

Santipsychotic medications over<br />

extended periods are at risk for the<br />

development <strong>of</strong> tardive dyskinesia,<br />

a medication side effect characterized<br />

by repetitive and abnormal<br />

involuntary movements and may<br />

occur in the face, mouth, tongue,<br />

hands and or feet. The efforts <strong>of</strong> an<br />

<strong>OMH</strong> researcher have produced an<br />

amino acid food product (classified<br />

by the FDA as a medical food) that<br />

is reported to <strong>of</strong>fer a safe and<br />

effective treatment for the disorder<br />

among men, reducing symptoms<br />

by as much as 86%. The rights for<br />

this novel treatment have been<br />

assigned to <strong>OMH</strong>, the Research<br />

Foundation for <strong>Mental</strong> Hygiene<br />

(RFMH), the organization responsible<br />

for administering and directing<br />

the conduct <strong>of</strong> all sponsored<br />

research programs carried out by<br />

scientists at <strong>OMH</strong> research institutes<br />

and facilities, and the National<br />

Institutes <strong>of</strong> <strong>Health</strong>.<br />

RFMH has entered into a licensing<br />

agreement with an international<br />

company to manufacture and market<br />

the food that is now available<br />

commercially under the trade<br />

name, Tarvil. Patents have been<br />

obtained and work has begun to<br />

extend the same formulation to a<br />

second disabling dyskinetic disorder,<br />

L-dopa induced dyskinesia,<br />

seen in individuals who suffer from<br />

Parkinson’s disease. Work has also<br />

begun to study the same product<br />

as a treatment for schizophrenia<br />

and bipolar disorder.<br />

T<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

Post-Traumatic Stress Disorder<br />

(PTSD)<br />

he aftermath <strong>of</strong> the 9/11 attacks<br />

made it clear that more clinicians<br />

needed training in evidencebased<br />

treatments for post-traumatic<br />

stress disorder (PTSD). The Trauma<br />

Studies Program led the effort to<br />

train mental health pr<strong>of</strong>essionals in<br />

treating trauma-related problems in<br />

<strong>New</strong> <strong>York</strong> City after 9/11. Between<br />

2002 and 2004, the team <strong>of</strong> experts<br />

trained roughly 400 clinicians in<br />

the latest in cognitive behavioral<br />

therapy (CBT) techniques for<br />

PTSD. The Trauma Studies Program<br />

has also launched the first largescale,<br />

nationwide, Web-based survey<br />

<strong>of</strong> individuals bereaved as a<br />

result <strong>of</strong> the 9/11 attacks. In addition,<br />

researchers partnered with<br />

primary care physicians in Manhattan’s<br />

Washington Heights community<br />

after 9/11 and the subsequent<br />

crash <strong>of</strong> American Airlines flight<br />

587 to help them meet the<br />

demands <strong>of</strong> individuals dealing<br />

with these traumas.<br />

Prime-MD<br />

rimary care physicians <strong>of</strong>ten see<br />

Pindividuals with psychiatric<br />

problems in their practice, but<br />

<strong>of</strong>ten lack the base <strong>of</strong> special<br />

knowledge and skills for proper<br />

psychiatric assessment and diagnosis.<br />

<strong>OMH</strong> researchers knew that by<br />

simply asking a few pointed questions,<br />

primary care physicians<br />

could flush out underlying problems,<br />

like depression, which would<br />

otherwise go untreated. This led to<br />

the development in 1993 <strong>of</strong> Prime-<br />

MD, the first standardized questionnaire<br />

designed by both psychiatrists<br />

and primary care physicians<br />

to help screen, evaluate and diagnose<br />

mental health disorders most<br />

commonly seen in primary care<br />

settings. A self-administered version<br />

<strong>of</strong> the test was introduced in 1999<br />

and is still widely used today.<br />

Telepsychiatry<br />

n <strong>New</strong> <strong>York</strong> <strong>State</strong>, as in other<br />

Iparts <strong>of</strong> the country, psychiatrists<br />

practice almost exclusively in urban<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


80 Chapter 5: Services Research<br />

and suburban areas, and mental<br />

health care providers in small<br />

towns generally have no or little<br />

access to expert consultation. The<br />

Telepsychiatry Consulting Program<br />

allows nationally recognized clinicians<br />

to examine consumers in virtual<br />

face-to-face interviews via<br />

videoconferencing. It provides realtime,<br />

psychiatric consultations to<br />

rural practitioners (non-psychiatric<br />

physicians, non-medical mental<br />

health clinicians, and adult psychiatrists<br />

working at community health<br />

programs, correctional facilities, or<br />

<strong>OMH</strong> facilities). These clinicians are<br />

located in 25 sites throughout <strong>New</strong><br />

<strong>York</strong> <strong>State</strong>, including 12 mental<br />

health units in correctional facilities<br />

and 12 in community mental health<br />

programs.<br />

This method <strong>of</strong> delivery to outlying<br />

areas is gradually gaining<br />

acceptance in other areas <strong>of</strong> medicine,<br />

as well as in psychiatry. After<br />

over 180 consultations with individuals<br />

between the ages <strong>of</strong> 5 and 65,<br />

with common to fairly unusual disorders,<br />

and with varied behavioral<br />

interventions, the program has<br />

amassed an impressive videotape<br />

library that could function as an<br />

excellent teaching tool. An in-depth<br />

assessment <strong>of</strong> consumers’ reactions<br />

to this form <strong>of</strong> service delivery is<br />

under way.<br />

Conclusion<br />

E<br />

valuation and services research<br />

are critical to determining the<br />

degree to which mental health<br />

services support individuals served<br />

in the public mental health system.<br />

Through these activities, <strong>OMH</strong> continues<br />

to employ shared goals and<br />

objectives for measuring performance<br />

and relying on the results to<br />

improve the quality <strong>of</strong> care. Evaluation<br />

and services research are<br />

instrumental to the creation <strong>of</strong> a<br />

culture at all levels <strong>of</strong> the public<br />

mental health system where continuous<br />

quality improvement and<br />

data-driven, decision making are<br />

the principal standards <strong>of</strong> practice.<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 6: Children and Depression 81<br />

Children and Depression Chapter 6<br />

Background<br />

hild and adolescent depression<br />

Cand bipolar disorder, also<br />

known as mood disorders, are serious<br />

medical illnesses that affect<br />

more than 20 million Americans <strong>of</strong><br />

every race and ethnic group. 1 Mood<br />

disorders are considered to be<br />

brain disorders because they are<br />

mediated through the brain. These<br />

illnesses affect individuals at all<br />

stages <strong>of</strong> life, including childhood.<br />

If left untreated, mood disorders<br />

can be fatal: nearly one in six persons<br />

with severe untreated depression<br />

will die by suicide. 2, 3 According<br />

to the WHO and the World<br />

Bank, major depression is the leading<br />

cause <strong>of</strong> disability in the U.S.<br />

and other countries with developed<br />

economies. 4 Because <strong>of</strong> the pr<strong>of</strong>ound<br />

public health consequences<br />

associated with these disorders,<br />

<strong>OMH</strong> is committed to improving<br />

the recognition, early intervention,<br />

and treatment <strong>of</strong> mood disorders in<br />

children and youth.<br />

Among the most significant scientific<br />

advances in the last three<br />

decades has been the discovery<br />

that depression and bipolar disorder<br />

not only exist in children but<br />

are as debilitating for them as they<br />

are for adults. Major depression<br />

affects an estimated 6% <strong>of</strong> children<br />

ages 9-17. 5 As children become<br />

adolescents, it becomes more common<br />

in girls than in boys. 6 Epidemiological<br />

data are lacking on<br />

the extent to which bipolar disorder<br />

affects children, but early indications<br />

suggest that some proportion<br />

<strong>of</strong> children and adolescents<br />

who have major depression will be<br />

found to have bipolar disorder later<br />

in life. The likelihood increases if<br />

the depressed child has a family<br />

member with bipolar disorder. 7<br />

Recent scientific advances from<br />

neuroscience, genetics and clinical<br />

trials have demonstrated that the<br />

brain is the primary organ affected<br />

in depression and bipolar disorder.<br />

Modern brain imaging technologies<br />

have revealed neural circuits<br />

responsible for the regulation <strong>of</strong><br />

moods, thought, sleep, appetite and<br />

behavior. When these circuits fail to<br />

function properly, critical neurotransmitters–chemicals<br />

used by<br />

nerve cells to communicate–are<br />

<strong>of</strong>ten out <strong>of</strong> balance. Recent work<br />

has delineated several neurotransmitter<br />

and other neurochemical systems<br />

that are involved in mood disorders,<br />

including systems that<br />

modulate gene transcription. These<br />

discoveries provide clues to potential<br />

neurochemical targets for effective<br />

treatments. In addition, genetics<br />

research indicates that vulnerabilities<br />

to depression and bipolar disorder<br />

<strong>of</strong>ten result from the interaction<br />

<strong>of</strong> multiple genes and environmental<br />

factors. Numerous treatment<br />

studies are currently under way to<br />

examine brain chemistry and the<br />

mechanisms <strong>of</strong> action <strong>of</strong> both psychosocial<br />

and pharmacologic treatments<br />

to improve the efficiency and<br />

effectiveness <strong>of</strong> these interventions.<br />

Notes<br />

1 Kessler RC, McGonagle KA, Zhao S, Nelson<br />

CB, Hughes M, Eshleman S et al. (1994).<br />

Lifetime and 12-month prevalence <strong>of</strong> DSM-<br />

III-R psychiatric disorders in the United<br />

<strong>State</strong>s. Results from the National Comorbidity<br />

Survey. Archives <strong>of</strong> General Psychiatry,<br />

51:8-19<br />

2 Goodwin FK, & Jamison KR. (1990). Manicdepressive<br />

illness. <strong>New</strong> <strong>York</strong>: Oxford University<br />

Press.<br />

3 Guze, S. B., & Robins, E. (1970). Suicide and<br />

affective disorders. British Journal <strong>of</strong> Psychiatry,<br />

117, 437-438.<br />

4 Murray CJL, Lopez AD, eds. (1996). The global<br />

burden <strong>of</strong> disease and injury series, volume<br />

1: A comprehensive assessment <strong>of</strong> mortality<br />

and disability from diseases, injuries,<br />

and risk factors in 1990 and projected to<br />

2020. Cambridge, MA: Published by the Harvard<br />

School <strong>of</strong> Public <strong>Health</strong> on behalf <strong>of</strong> the<br />

World <strong>Health</strong> Organization and the World<br />

Bank, Harvard University Press.<br />

5 Shaffer D, Fisher P, Dulcan MK, Davies M,<br />

Piacentini J, Schwab-Stone ME, Lahey BB,<br />

Bourdon K, Jensen PS, Bird HR, Canino G, &<br />

Regier DA. (1996). The NIMH Diagnostic<br />

Interview Schedule for Children Version 2.3<br />

(DISC-2.3): Description, acceptability, prevalence<br />

rates, and performance in the MECA<br />

study. Journal <strong>of</strong> the American Academy <strong>of</strong><br />

Child and Adolescent Psychiatry, 35(7), 865-<br />

877.<br />

6 Angold A, Costello EJ, Farmer EMZ, et al.<br />

(1999) Impaired but undiagnosed. Journal <strong>of</strong><br />

the American Academy <strong>of</strong> Child and Adolescent<br />

Psychiatry, 38, 129-137.<br />

7 National Institute <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>.<br />

(2000).Depression in children and adolescents:<br />

A fact sheet for physicians. Bethesda,<br />

MD: Department <strong>of</strong> <strong>Health</strong> and Human Services.<br />

<strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong><br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services


82 Chapter 6: Children and Depression<br />

Notes<br />

8 National Center for Injury and Prevention<br />

Control. Suicide: Fact sheet. Accessed online<br />

January 12, 2004, at http://www.cdc.gov/<br />

ncipc/factsheets/suifacts.htm<br />

9 <strong>Office</strong> <strong>of</strong> the Surgeon General. (1999). The<br />

Surgeon General’s call to action to prevent<br />

suicide. Washington, DC: Department <strong>of</strong><br />

<strong>Health</strong> and Human Services.<br />

What are the Symptoms<br />

<strong>of</strong> Depression and Bipolar<br />

Disorder in Children<br />

and Adolescents?<br />

nlike normal changes in mood<br />

Uthat are common among most<br />

individuals at different times <strong>of</strong> life,<br />

the symptoms <strong>of</strong> depression are<br />

extreme and <strong>of</strong>ten incapacitating.<br />

The symptoms include a persistent<br />

sad mood; loss <strong>of</strong> interest in activities;<br />

significant change in appetite<br />

or body weight; difficulty sleeping<br />

or oversleeping; physical slowing<br />

or agitation; loss <strong>of</strong> energy; feelings<br />

<strong>of</strong> worthlessness; difficulty thinking<br />

or concentrating; and recurrent<br />

thoughts <strong>of</strong> death or suicide. A<br />

diagnosis <strong>of</strong> depression occurs if<br />

an individual has five or more <strong>of</strong><br />

these symptoms every day during a<br />

two-week period. In bipolar disorder,<br />

an extremely debilitating illness,<br />

episodes <strong>of</strong> depression alternate<br />

with periods <strong>of</strong> persistently<br />

elevated mood or irritability, sometimes<br />

accompanied by a decreased<br />

need for sleep, increased talkativeness,<br />

racing thoughts, distractibility<br />

or extreme physical agitation.<br />

The consequences <strong>of</strong> untreated<br />

depression can be devastating. A<br />

2004 report from the American<br />

Academy <strong>of</strong> Child and Adolescent<br />

Psychiatry documented that suicide<br />

is the third leading cause <strong>of</strong> death<br />

for 15 to 24 year olds, and the sixth<br />

leading cause <strong>of</strong> death for five to<br />

14 year olds. In fact, in 2001 nearly<br />

4,000 teenagers between the ages<br />

<strong>of</strong> 15 and 24 killed themselves. 8<br />

Depression is responsible for over<br />

500,000 suicide attempts by children<br />

and adolescents a year. 9<br />

How and When Does<br />

Depression Develop<br />

in Children?<br />

uberty appears to be the time at<br />

Pwhich children, and in particular<br />

girls, are at increased risk for<br />

developing depression. The changing<br />

levels <strong>of</strong> hormones that occur<br />

during puberty may affect brain<br />

function. There is some evidence<br />

that exposure to increased levels <strong>of</strong><br />

hormones at puberty, particularly<br />

under conditions <strong>of</strong> social stress,<br />

can predict heightened risk for<br />

depression.<br />

Depression among children or<br />

adolescents is <strong>of</strong>ten preceded by<br />

other mental disorders, most<br />

notably anxiety. Anxiety disorders<br />

are eight times more common in<br />

depressed than non-depressed children<br />

and adolescents, while behavioral<br />

problems (e.g., conduct disorders<br />

and oppositional disorders)<br />

are six times more common. Attention<br />

Deficit Hyperactivity Disorder<br />

(ADHD) is five times more common<br />

among youth with depression<br />

than youth unaffected by it. In fact,<br />

the onset <strong>of</strong> depression usually follows<br />

the onset <strong>of</strong> other disorders.<br />

Consequently, prevention <strong>of</strong><br />

depression is directly linked to the<br />

prevention or treatment <strong>of</strong> these<br />

other psychiatric disorders.<br />

Depression is also significantly<br />

associated with abuse, maltreatment<br />

and trauma. Stress exposure,<br />

as has been well documented in<br />

both animal and human studies,<br />

can produce persistent effects on<br />

brain structure and function. For<br />

example, in animal studies, exposure<br />

to extreme adversity during<br />

critical periods <strong>of</strong> development<br />

leads to changes in perceptions <strong>of</strong><br />

and responsiveness to environmental<br />

events. The interactions among<br />

stress exposure, genetic vulnerabilities,<br />

and development are complex<br />

and these interactions are still<br />

being examined. However, effective<br />

treatments for stress-related<br />

2005–2009 <strong>State</strong>wide Comprehensive Plan for <strong>Mental</strong> <strong>Health</strong> Services <strong>New</strong> <strong>York</strong> <strong>State</strong> <strong>Office</strong> <strong>of</strong> <strong>Mental</strong> <strong>Health</strong>


Chapter 6: Children and Depression 83<br />

disorders in young persons, particularly<br />

trauma, exist and have been<br />

studied for more than a decade. It<br />

is likely that providing early and<br />

effective interventions to children<br />

who have been exposed to abuse,<br />

maltreatment or trauma may<br />

improve their long-term outcomes<br />

by providing them with necessary<br />

coping strategies for handling subsequent<br />

stressors and decrease the<br />

likelihood that they will develop<br />

severe depression later in life.<br />

Other risk factors for early-onset<br />

depression include family history.<br />

Children <strong>of</strong> parents with depression<br />

are three times more likely to have<br />

an episode <strong>of</strong> depression during<br />

their lifetime than children <strong>of</strong> parents<br />

without