We work closely with The Children’s Mental Health Network in developing the Consortium’s track of presentations for the annual Research & Policy Conference for Child, Adolescent, and Young Adult Behavioral Health (aka the Tampa Conference).
The entire network was activated by the following news:
Posted January 8, 2018
Last Thursday, at 2:05 pm, a research scientist colleague of mine received an email from the contractor who manages the SAMHSA National Registry of Evidence-based Programs and Practices (NREPP). The email was direct and to the point. It read:
NREPP, as described on the SAMHSA website, “is an evidence-based repository and review system designed to provide the public with reliable information on mental health and substance use interventions. All interventions in the registry have met NREPP’s minimum requirements for review. The programs’ effects on individual outcomes have been independently rated by certified NREPP reviewers.”
Getting a program or therapeutic approach to be recognized as an evidence-based practice on NREPP means that, in effect, you have SAMHSA’s approval that this is a recognized evidence-based practice. Mental health evaluators and program developers across the nation have come to rely on NREPP as a “go to source” when making decisions about which treatment strategies to use in their work.
So you can imagine the shock and surprise to program developers across the nation when getting a notice such as this, effectively telling them that the program or therapeutic approach they had been working so hard to get NREPP approval for would now no longer be reviewed.
After the notice went out, I began receiving calls and emails asking what the heck was going on. Was this the end of NREPP? Was SAMHSA moving away from evidence-based practice? Recent articles in the news about HHS encouraging the non-use of words such as evidence-based practice, diversity, transgender, etc., have had many in the mental health community on edge. Was this another step in that direction? And most important for program developers in the midst of NREPP review – What would happen to them? Would the reviews of their work continue or would they just stop?
Is NREPP Being Canceled? The Short Answer
The short answer is no, NREPP is not being canceled, per se. (There is a longer, more complicated answer. But let’s address the short answer first. It is so much easier!)
I spoke with a representative from SAMHSA about the email from the NREPP contractor that went out to program developers involved with NREPP notifying them of the termination of the contract. The representative was most helpful in clarifying that SAMHSA’s commitment to evidence-based practice had not changed, but that SAMHSA was re-evaluating the program, and that the overall program would now fall under the domain of the newly created National Mental Health and Substance Use Policy Lab (Policy Lab). At this point, the Policy Lab team is not yet in place, though a Director, Christopher M. Jones, PharmD., M.P.H., has been hired. As well, SAMHSA is working on an answer to the question of what happens to those programs currently in the review process. So a lot of “wait and see” while SAMHSA gets the Policy Lab set up. The representative from SAMHSA wrote:
“Although the current NREPP contract has been discontinued, SAMHSA is very focused on the development and implementation of evidence-based programs in communities across the nation. SAMHSA’s Policy Lab will lead the effort to reconfigure its approach to identifying and disseminating evidence-based practice and programs.”
What we can glean from this response is that SAMHSA is not moving away from evidence-based practice and programs, but they are most definitely going to reevaluate what that should look like. The SAMHSA representative assured me that the website is not going away anytime soon. However, decisions about the website (what it looks like, what is included, etc.) will be decided by the Policy Lab. At this point, there are no defined timelines for how or when these changes will roll out.
Sources informed me (after my conversation with SAMHSA representatives) that the NREPP website has been “frozen” since September 2017. Between then and now, close to ninety programs that have been reviewed and rated are not being allowed to be posted. I have not been able to independently verify this, but if it is accurate, it is chilling. Why would the website be frozen? What does that mean for the programs that have been reviewed and rated and are awaiting inclusion in the registry since September 2017?
Is NREPP Being Canceled? The Long Answer – Still No, but with a Twist
First, let’s revisit history. Way back in 2013, when then-Representative Tim Murphy was leading the charge to get the Helping Families in Mental Health Crisis Act through the House, he led a sustained campaign railing against SAMHSA, and specifically then Administrator, Pamela Hyde, for what he perceived as SAMHSA’s focus on soft science. The horrible massacre at Sandy Hook had sparked justified outrage and many questions about the state of the mental health system in America. Murphy seized on this, and suddenly the conversation about mental health was centered around a fuzzy, and oft ill-informed notion, of young adult mentally ill individuals who were a danger to society. The mantra became one that was continually drilled into the psyche of America, through a barrage of news editorials, that SAMHSA, as the lead mental health agency in Federal government, was overly focused on peer recovery programs and not nearly focused enough on “evidence-based” programs for addressing the treatment needs of the seriously mentally ill. At various congressional briefings, members of Murphy’s committee would openly disparage “feel good” programs, and were constantly berating Administrator Hyde for squandering money on various expenditures, often using out-of-context examples.
Did some of Murphy’s ire about perceived lack of focus on the seriously mentally ill merit attention? Of course. But the wholesale lumping of SAMHSA efforts to promote peer to peer support into a category of “wasteful” and “non-scientific” was the kind of us “good versus bad” debate that short-changed both sides and led to an “us against them” atmosphere among mental health advocates. And as we know, a divided community is a weakened community.
Murphy Inserts Proposed Structural Changes to SAMHSA in the Mental Health Bill
In a shrewd maneuver, amidst all of the public flame-throwing about guns, violence, mental illness and the need for more psychiatric beds, Murphy and his colleagues inserted three proposed structural changes to SAMHSA that would have an important impact on how SAMHSA would approach defining the criteria for evidence-based practice that would be used to award grants.
The Addition of the Assistant Secretary
As the openly public feud between Representative Murphy and Administrator Hyde continued, and it was clear that Administrator Hyde could give as good as she could take, the Murphy camp came up with a novel idea. Instead of spending energy on forcing Administrator Hyde to give the information they wanted or to force her out of her position, why not just create a position above her which would effectively subsume her role, making her position obsolete? Promoting the idea of an Assistant Secretary position that could coordinate efforts across federal agencies, while at the same time making the current Administrator position obsolete was a controversial stroke of pure genius. And who could argue with the expressed desire to better coordinate a federal approach to mental health and substance use across agencies? In August 2017, as a result of the passage of the CURES Act, Dr. Elinore McCantz-Katz was appointed Assistant Secretary for Mental Health and Substance Use.
The Addition of the ISMIC and Policy Lab to the Mental Health
But Murphy and his colleagues did not stop there. In addition to the proposal of the Assistant Secretary position, they added the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) and the National Mental Health and Substance Use Policy Lab (Policy Lab), further cementing significant structural changes to the way SAMHSA did its work, infusing congressional oversight into the management of SAMHSA work (in the case of the ISMICC), in ways that had not been done before. Both the ISMICC and the Policy Lab were adopted as part of the CURES Act.
All three of these structural changes to SAMHSA were conceived during a time of vitriol and polarization about what defined evidence-based practice, pitting advocates against advocates, and a congressional committee against SAMHSA. The big loser in all of the fighting was peer support, prevention services, and viewing evidence-based practice through a cultural lens. Peer support was routinely dragged through the mud, often with derogatory terms used to describe the practice, and prevention was a mere afterthought in discussions. Cultural context discussions about what worked best for different populations (i.e., practice-based evidence) was rarely, if at all, even discussed. And all three entities, in various ways, will have an important say in what defines evidence-based practice for SAMHSA.
Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC)
The Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) was created to “report to Congress and federal agencies on issues related to serious mental illness (SMI) and serious emotional disturbance (SED).” A key component of their work is the charge to make “specific recommendations for actions that agencies can take to better coordinate the administration of mental health services for adults with SMI and children with SED.” The committee was formed several months ago and has provided a preliminary report outlining their work plan for the near future.
National Mental Health and Substance Use Policy Lab
The purpose of the Policy Lab is to, among other things, “provide leadership in identifying and coordinating policies and programs, including evidence-based programs, related to mental and substance use disorders.” (42 U.S. Code § 290aa–0)
A primary focus of the Policy Lab is to “periodically review programs and activities operated by the Administration relating to the diagnosis or prevention of, treatment for, and recovery from, mental illness and substance use disorders, including identifying any such programs or activities that are duplicative and are not evidence-based, effective, or efficient.” (McCantz-Katz testimony before Congress) In addition, the Policy Lab plays the important role of working in coordination with the Assistant Secretary to “award grants to States, local governments, Indian tribes or tribal organizations (as such terms are defined in section 5304 of title 25), educational institutions, and nonprofit organizations to develop evidence-based interventions, including culturally and linguistically appropriate services, as appropriate.” 42 U.S. Code § 290aa–0 – National Mental Health and Substance Use Policy Laboratory
So let’s put it all together. The three prominent structural changes given to us via the CURES Act were the Assistant Secretary position, the ISMICC, which reports to Congress, and the Policy Lab. And the Policy Lab is a gateway to awarding grants, which makes its role as overseer of the government understanding of what defines evidence-based practice immensely important to researchers, practitioners and advocates alike.
Given that the Policy Lab, with its oversight of what will become SAMHSA’s guidance around evidence-based practice, will help drive grant award decisions, it should be one of the most important components of SAMHSA for us to pay attention to. We need to ensure that SAMHSA frames a comprehensive and culturally inclusive view of what encompasses an evidence-based practice and practice-based evidence approach. But let’s not forget the ISMICC and the Assistant Secretary, who are also critically important to shaping the SAMHSA worldview about evidence-based practice. We must share our thoughts and ideas with them as well.
Here are some specific things you can do:
- Encourage the Policy Lab to focus on understanding how the biomedical, public health, and social science evaluation fields interpret the meaning of evidence, and of evidence-based programs and practices specifically. This will begin an important dialogue around how to best examine research on culturally informed behavioral health interventions. There are likely studies being conducted on culturally responsive approaches that may not have the typical robust randomized control trials but are nevertheless thought to be effective by those giving and receiving services in the community. We need to encourage closer attention to these kinds of studies if we are going to be truly inclusive in our approach to meeting the mental health needs of the mosaic of constituencies across America.
- Encourage the Policy Lab to learn more about how different stakeholder groups understand the ideas of evidence-based practices and their implementation. Dig deep into questions about the expectations of policymakers and funders regarding the dissemination of specific evidence-based practices. Do communities have a realistic capacity to adopt evidence-based practices? Are certain evidence-based practices being over-promised as solutions to poor quality behavioral health services?
- Encourage the Policy Lab to share evidence about programs and practices with end users in a way that is accessible and actionable. The better job that can be done by encouraging the use of promising practices the better.
- Most important, share your questions and concerns with SAMHSA. Send your emails to NREPP@SAMHSA.hhs.gov.
- Mark your calendar NOW for all of the upcoming SAMHSA Advisory Committee meetings. Send an email to the appropriate committee and request that a discussion about the Policy Lab and NREPP be included on the agenda.
Please continue to send me your questions and concerns about the changes with the NREPP contract. We are in a fluid situation given that SAMHSA is just beginning to provide shape and structure to the Policy Lab. Despite my many concerns about the myriad of ways the focus of the Policy Lab could be steered in a narrow, non-inclusive way, I am hopeful that the coming weeks present an important opportunity for advocates to get involved with SAMHSA, ask a lot of questions (no question is a bad question) and stay vigilant on the importance of a culturally responsive approach to identifying, promoting and cultivating evidence-based practices that are available to all.
President & CEO
Children’s Mental Health Network
By SHARON BEGLEY, JANUARY 10, 2018
The Trump administration has abruptly halted work on a highly regarded program to help physicians, families, state and local government agencies, and others separate effective “evidence-based” treatments for substance abuse and behavioral health problems from worthless interventions.
The program, called the National Registry of Evidence-Based Programs and Practices, was launched in 1997 and is run by the Substance Abuse and Mental Health Services Administration. Its website lists 453 programs in behavioral health — aimed at everything from addiction and parenting to HIV prevention, teen depression, and suicide-hotline training — that have been shown, by rigorous outcomes measures, to be effective and not quackery. The most recent were added last September.
In an email dated Jan. 4 and sent to program developers, the contractor hired by SAMHSA to work on the registry said, “It is with great regret that we write to inform you that on December 28, 2017, we received notification from SAMHSA that the NREPP contract is being terminated for the convenience of the government. This cancellation means that we can no longer make any updates to your program profile. … We are deeply saddened by the government’s sudden decision to end the NREPP contract, under which we have been able to provide and strengthen science-based information about mental health and substance use treatment and prevention programs.”
A recipient shared the email with STAT. The contractor, Development Services Group Inc., of Bethesda, Md., did not reply to a request for comment. A SAMHSA spokesman did not reply to questions sent by phone and email. The agency is part of the Department of Health and Human Services.
The website of the now-frozen registry has not been taken down. In an online statement, SAMHSA said future work on the registry, including vetting new applications, would be moved in-house “to reconfigure its approach to identifying and disseminating evidence-based practice and programs.”
Despite the inclusion of the phrase “evidence-based,” the statement did not assuage critics’ concerns: The decision to freeze the registry comes as the Trump administration has advised agencies such as the Centers for Disease Control and Prevention to avoid using seven words — including “evidence-based,” “science-based,” “fetus,” and “transgender” — in budget documents and to instead use language that won’t antagonize members of Congress.
The guidance, for example, suggested that instead of describing a policy or decision as “evidence-based,” the CDC say that it “bases its recommendations on science in consideration with community standards and wishes.”
The coincidence of the “banned words” policy and the decision to freeze the behavioral health registry “should give us pause,” said Rosalyn Bertram of the University of Missouri, Kansas City, an expert on evidence-based practices in the social sciences.
Because SAMHSA has not explained how or when it will pick up the registry work, “I’m pessimistic,” said psychology professor Warren Throckmorton, of Grove City College in Pennsylvania, who teaches a seminar that includes lessons on evidence-based programs and practices. “Why did they stop something before they had something to put in its place? Why stop what was working reasonably well?”
The registry has long been “the first stop” for communities trying to figure out which programs to adopt to, say, battle teen alcohol use, said Suzanne Kerns of Denver University and executive director of the Center for Effective Interventions. “If you’re a community official in the middle of Kansas, you might not have access to all the scientific literature, or the time or resources to read and critique it. That’s the gift that NREPP offers.”
Some states have laws requiring that public programs for, say, children and family services use only evidence-based interventions vetted by NREPP. Because NREPP stopped vetting and listing new programs three months ago (90 were reportedly in the pipeline), “there are potentially effective programs that communities need to know about but that are sitting dead in the water,” Bertram said.
She and other researchers alarmed by the SAMHSA decision said it suggests that what they described as the administration’s skepticism about scientific evidence has now been extended.
Just as mainstream medicine has been embracing an evidence-based approach (testing assumptions that, say, arthroscopic surgery for knee osteoarthritis works) so that patients do not receive useless care, so has behavioral health, which includes mental health as well as things such as parent-child relationships and social functioning. Behavioral health has lagged behind, however, because some of the problems it addresses are partly subjective, making it “easy to convince yourself that something is effective when it’s not,” said Throckmorton. That’s harder to demonstrate for interventions meant to help with parent-child interactions than, say, to treat cancer.
Throckmorton said his interest in the field grew from his realization that “change therapy” — to alter people’s sexual orientation — has no scientific basis.
By identifying programs whose effectiveness is supported by evidence, the registry “has been a gold seal of approval,” said a physician at a child health program who asked not to be identified because he did not want to jeopardize his SAMHSA funding. And there is considerable work still to be done in spreading evidence-based programs: Only 3 percent of children with problems ranging from attention deficit hyperactivity disorder to disruptive behavior to suicidality receive evidence-based services, he said, partly because scientifically valid programs often have a high price tag.
Making it harder for people struggling with addiction and their families to see whether a treatment they’re being offered has been shown to work is especially worrisome, said the physician. “In the midst of an opioid epidemic, they’re suspending work on a registry that tells you this,” he said.