Accomplishment, concern because the interim final rule published in 2010 left some Implementation Details on result. The administration publishes a final rule, how we address issues like the scope of services that must be covered because insurers have detailed guidance and need to implement the law . Thank you. As you know, the final rule published in 2010, part of what was requested by the public was in put on several topics, that was one. In the meantime we issued four or five sub regulatory guidance, we have also been meeting with stakeholders and industry trying to understand how the implementation is happening. We are ready to produce the final rag and were in the process now. Dr. Insel . I have some concerns and i know others have also. I have read a lot about these concerns and i hear them from constituents and other people who talk to me about the use of pharmaceuticals, particularly anti psychotic medication in children. What i hear sometimes does something, get them drug. Get some anti psychotic medication. What do we know about the safety and long term affect of these drugs . I have often said children are not just little adults. They are different. What might work in an adult, you say may reduce the dosage. It doesnt always correlate. I dont want to Practice Medicine without a license but nonetheless, what do we know about the safety and long term effect of these kids and what requires further research and study . There is a real concern because they use anti psychotics in children has gone up markedly over the last decade and what we do know is children are more sensitive to the side effects, particularly the metabolic sideeffects. That is a real concern because of a new drug abuse long term. There is an issue, a real issue about practice and improving the quality of practice in this regard. I should say some of this may be related to a reluctance of many clinicians to use antidepressants which are somewhat safer but there are concerns about suicide and violent behavior. The curious thing is if you look at the other side of this, we are not talking about Young Children but when we talk about adolescence and the example senator alexander used about the 15 or 16yearold beginning to hear voices and going down this path of psychosis what tends to happen most often is not the people getting overtreated but not getting diagnosed or treated at all. Specifically with respect to our concerns about violent behavior, we know that treatment reduces that. The most important thing you can do if you want to prevent new events like this that we have often talked about the last five or six years is to ensure that people who are on this half, becoming psychotic and paranoid and grandiose and dangerous are treated. The risk of violence is 15fold higher prior to treatment and after and treatment often does involve anti psychotic medication so it is not the whole treatment, but it is part of making sure people who are developing a psychotic illness are actually not going to become a risk to themselves or other people. We will hear testimony from the next panel about approaches like mine body connections and others in terms of especially as we get into prevention we start recognizing in Young Children, in schools and other places certain types of behavior. May be on interventions with Family Counseling and therapy might be more successful than just giving them an anti psychotic drug. Do you have any comments on that . There are only a few reasons to use an anti psychotic drug on a young child. The most common approved by the fda is autism where there are forms of what you might call temper tantrums in which children will hurt themselves or hurt somebody else, often very Young Children. In that case the fda has approved the use of two different anti psychotic drugs to control that behavior but for the most part the medications that are approved for use in children and show the greatest efficacy a in other classes particularly for children with attention deficit hyperactivity disorder or psychostimulants have been shown over and over again over the last four decades to not only be high efficacy but also high safety as well and we know from longterm studies that is helpful so i wouldnt say in any of these cases medicine is the whole answer but it is helpful as part of the answer. There are lots of interventions that are being developed and some need to be developed. That may be far more effective beyond medication so is part of the story. Thank you very much. My time is up. I was going to say from a population basis point of view there are interventions not for people identified with an issue but in classrooms, we support the Good Behavior game which has shown fairly remarkable ability to help teachers manage behavior in classrooms the does have a longterm impact. Thank you, senator alexander. Thanks, mr. Chairman. It looks like just looking at tennessee that maybe 1 4 to 1 3 of the funds that are available for Mental Health and Substance Abuse through the State Government are federal dollars. Does that sound about right . Is that your experience . Most of it goes through two big block grants, one big one and one smaller one. Is that about right . Sort of a rule of thumb somewhere around 1 4 of the funding for the nation. Dont know about tennessee in particular but that sounds about about right. If you take the medicaid dollars each state has different matches so that changes how much state dollars and how much not. Calfs the dollars that go for the Mental Health of the country as a whole are public dollars, federal and state. Do you regularly consult with the state mentalhealth directors about your two block grants and how they are administered and how the money is how you might improve the process of applying for that money and make it easier for them to help the people who need help . Absolutely. We put out a block Grant Application, uniform application that makes easier for states to apply for the funding. We go through a public process an informal process, the two state associations that represent state agencies in that process. I have heard the statutory deadline for the two block grants is september and october but you indicated that you moved that up to the spring and that is causing some states to have concern about being able to get ready for the applications because of the legislative sessions and that there is some confusion about how much information is requested, as much as it appears to be might be burdensome. Have you heard that from state directors . What are you doing about it . Interestingly enough we change that date initially in competition with the states. What we were trying to do was push up the dates so they could do it, theyre planning during their legislative process so as their legislature decided to match money or maintenance of effort it could be tied to the block grant dollars. Since the application is not yet out, we probably will change that date before the final application comes out. Could i encourage you to take a look at that and make sure it is not a burden on the states . Absolutely. You mentioned the Mental Health parity letter that came out earlier this month. Did the Mental Health parity law apply to medicate by its terms or does it apply to medicate by the terms of the new Health Care Law or is the letter something that expands the application of Mental Health parity to medicaid . The letter just explains and provides guidance to states about how the federal law about parity applies to certain portions of the Medicaid Program. Medicaid benchmark plants and equipment plans they are called or alternative plans are subject where the basic underlying Medicaid Program in this state there subject to other laws. It shouldnt be any surprise to governors who are evaluating the cost of Medicaid Expansion that the Mental Health parity law applies to medicaid. I dont know if it is a surprise. Certain portions of it. Part of the reason for the letter is to describe differences about where it applies and where it might not. That is helpful. I have heard of a number of governors who have made decisions about Medicaid Expansion, hard to make that decision without knowing the added cost of it to the states as medicaid has grown is a part of state budgets for example in our state from 8 when i was governor to 26 today. Did you detail in your letter what the added cost to the federal government or states would being as a result of the application of Mental Health parity to medicaid . No. The letter was not about cost although as Congress Went through the process of passing mpea or Mental Health parity dictions act, a significant discussion of costs and all the studies that occurred say the cost is negligible land in fact mpea does allow a plan to request an exemption if their costs go over a certain amount so that is part of the mpea law. Thank you, mr. Chairman. Thank you, senator alexander. A tradition or rule of this committee that senator is recognized in order of appearance and we have senator murray and senator enzi and we will go back and forth and senator baldwin, murphy, sanders, i would now recognize senator murray. Thank you for holding this important hearing. It is especially important to note obviously the issue of newtown focused everybody on it but this is an issue all of us have been working on a long time myself included and it is a great time to refocus, really important for the first hearing and i appreciate that. Senator alexander, welcome to the new Ranking Member position and look forward to working with you at all the new members. A lot of great talent here. And we will be able to do some good things with this committee. And to both of my witnesses, i did want to go back, mentioned it several times but in the president s recently released gun violence package he should three parity provisions, one clarifying parity for medicaid, spanish plants, and parity provision included in the finally essential Health Benefit role and one that committed to issuing a final rule on the Mental Health parity addiction equity act which you mentioned that didnt make clear and you havent made clear when we are going to see that. If these plans are supposed to be ready to go to exchange starting in october it is releasing shall we see a final rule on this before april. Let me go back to the question senator harkin asked again and ask about a date that you will see the final rule in place. Thank you. The president s proposals indicated the essential Health Benefits rule would be out next month. We are working on the mpea final rag and it will go through the regulatory process and in that process now, i cant give you a specific final date. I can tell you precisely what the date is but we are on it now. Our states are working on these exchanges and they need that clarity moving forward. I cant urge you strongly enough that that date is critical. One of the issues i have focused a lot on to Mental Health is military families and i continue to believe we have to do everything we can for our veterans and Service Members as they transition especially during periods of deployment and returning home transitioning into the civilian world but those that book also has to be on the family of these veterans and i am certain it is the same throughout all of the Mental Health military or talking about the number of other topics you have been talking about. The Mental Health access act that we wrote included provisions to expand some of the Mental Health services to family members. Can you tell me you have been progressing in implementing the Family Initiative . Yes. You may recall the president issued an executive order in the fall asking dod to work on improving Mental Health access for Service Members and veterans. We are actively working on that together, and a three department. Part of the way we are trying to get at the whole family and the whole need of the individual is looking at partnerships between Community Health centers, community Mental Health centers and be a organizations. There are times family members cannot access veterans administration. We are trying to look at pilots and meeting with stakeholder groups and some of the stakeholder groups, families of veterans, Service Organizations and others giving us their input about the best way to provide that. We have a report due to the president by the end of february so we are actively engaged in that process. Look forward to seeing and senator sanders is taking over the Veterans Committee and he has a strong interest in Community Health center as well so i know we will continue to push on that but i think it is important we focus on that for the military family. Dr. Insel, thank you for reminding us that Mental Health doesnt mean someone is silent. That is important remember as we go through this and we do need to focus on that population that has the potential of becoming violent, particularly at a younger age. That is why this hearing is so essentials. I look forward to hearing the testimony. Thank you. Senator enzi. Thank you, mr. Chairman. I want to congratulate senator alexander who gave up a leadership position to be Ranking Member on this committee. It shows his dedication to health and education and workplace safety. I know he will do an outstanding job and i appreciate you holding this hearing on Mental Health, the initial one. My first question is for administrator hyde. I want to know more about the coordination and collaboration of agencies at the federal, state and local level within your appropriate role as a federal agency, what needs to be done to better enhance that coordination and collaboration of agencies at the federal, state and local level . Thank you, we have been trying hard to recognize the relationship between states and local communities because the state of and will create laws, rules, regulations that the community has respond to so when we provide grants to our communities we are trying to say how does this relate to the state plan and direction . When providing grants to our states were trying to ask how are you bringing your communities into that process so we are by our grandmaking trying to bring them together through Community BlockGrant Application process and asking how these things really to what is going on at the Community Level and we have been providing significant Technical Assistance because theres a lot of change going on in the health the lip resistant to our states and provider agencies which provide the basic community infrastructure. We have county based programs that we do a significant amount of work with so we are trying to look at those relationships. I have had the opportunity to work at all these levels, city level, county level, state level and federal level and sometimes what you feel, where you sit, i understand probably only too well how much those relationships matter so we are working on them significantly. I look forward to any suggestions you might have. Dr. Insel, what do we need to do to close the gap between research and real world practice to make sure evidence based treatments are available in the Community Service setting. It is a question that we discuss a lot not just within the Mental Health arena but across all of the diseases responsible for providing better science. Typical response to your question or typical assumption is there is a 17 year gap between discovery and implementation and what we used to talk a lot about was how do you move from research to practice . I would say in the last two or three years there has been a transformation in how we talk about this and increasingly we are beginning to say how we move from practice to research . How do we make sure we develop not Just Health Care systems but learning Health Care Systems, Health Care Systems that are involved in the Research Process itself . We have created several efforts to do that involving millions of patients through large Health Care Systems like kaiser and many others in which we are doing research, actual practical trials in these very large groups, much reduced costs but the advantage of that is you are making discoveries in the place they will be implemented rather than doing it in an academic adapt to getting it into the community. The other piece of that that is so important and part of the new institute that was formed is bringing in the community at the get go and making sure the kinds of questions that are being asked by science are going to give you the kinds of answers people in the community are looking for. Reinvention is always appreciated for both of you. What type of oversight or financial controls are in place to insure that federal funding is being used effectively to prevent and treat Substance Abuse disorders and Mental Illnesses. What needs to be done . What changes are needed . I will start with that question. For almost all of our programs we do an evaluation of the programs to see what kind of outcomes we are getting and what the results are and we try to use those evaluation results and how we do the next round of program activities. We also provide some of the largest Surveillance Data in the area of Behavioral Health and trying to increasingly use that data to help us understand where we need to go. We are working on something called the National Quality framework which is a second step from the National Quality strategy that was recalled in the Affordable Care act and in that we will be laying out the framework for quality direction for Behavioral Health as a whole lot different levels. We also collect information and data from each of our grantees and we are trying to make some improvements in that by streamlining our Data Collection systems so we have multiple systems, we are trying to put into one that we hope is more effective and easier for states and communities to report into so there are number of activities we are going through a around accountability and evaluation and we work very well with aaa at the way their services, research they provided, how we can bring it into our practice as well. I use up more than my time. Also added a question about duplicative programs between all agencies. Look forward to it, thank you. Senator enzi and senator baldwin. Im delighted to join the committee and pleased that the first hearing in this committee of this session is devoted to this incredibly important topic. Insuring access to quality and Affordable Health care has been and will always continue to be a very high priority of mine and when i say health care i dont distinguish between physical health and Mental Health because to me they should be viewed as one and the same. The Mental Health parity act and the Affordable Care act both take important steps to make this vision a reality. Together, those two laws will both expand Health Care Insurance coverage to millions of previously uninsured americans and increase access to Mental Health care for millions more who have Health Insurance coverage. My first question relates to increased access to insurance coverage. As we speak, governors across this country including in my home state of wisconsin are grappling with the decision of whether to expand medicaid coverage under the Affordable Care act. In my home state around 200,000 wisconsinat ites could gain coverage to the Affordable Care act, Medicaid Expansion, should the governor make that decision. I want to appreciate the fact that in your testimony pointed out that medicaid is currently the no. One repay rear for Mental Health services in the United States. We know that many vulnerable americans do not currently qualify for medicaid coverage so in your opinion how might states that are grappling with this decision, states better choosing to expand medicaid coverage under the Affordable Care act improve Mental Health outcomes for their most vulnerable citizens or perhaps alternatively, what variation might you expect to see between states that expand, choose to expand medicaid and those that dont with regard to treatment of Mental Illness . Thank you and welcome. We are very optimistic that as states go through their processes that they will come to the decision to provide the opportunities for coverage for their citizens. In that process each state looks at it the Medicaid Program. The letter that we just recently put out was an attempt to try to help states understand how they should be looking at mentalhealth and substanceabuse treatment within those contexts. There are services we know can work. We are working closely with the medicaid agencies, our Partner Agency in putting out informational bulletins on how states can use their Medicaid Program to increase access and do better for Behavioral Health. Were working with them to do that. We also frank we are working on the enrollment and eligibility process with the department as a whole because we know people with Mental Health needs typically even after fuller coverage have a harder time staying covered. We are trying to get access to enrollment, eligibility commacks us to the type of service or the array of services that might be provided and try to provide information to help the states understand what is the most effective way to provide the services and the kinds of services the most effective for treatment. Thank you. One of the ways we have already seen expansion of access to care and talking in your testimony today about various cost and access etc. Is the provision in the Affordable Care act that allows young people to stay on their parents Health Insurance until they are 26, i worked very hard on that in the house, energy and Commerce Committee and we are pleased to see it in the final act. Im wondering especially given that your testimony talks a lot about the age of onset of many profound Mental Illnesses being between 16 and 25, whether you are already observing the positive impact of that increased level of assured us for that age population. We certainly know that the provision to allow young people to stay on their parents insurance and the provision to prohibit exclusion from preexisting conditions both help young people with Mental Health and Substance Abuse disorders stay on and keep in short or be able to get access to insurance when they may not have access to it. Millions of young people are covered through that process already. We know that those young people have these disorders are part of that group. Senator murkowski. I join my colleagues in thanking you for calling this hearing on an incredibly important subject. I am told by my staff and we havent had experience in the Health Committee on mentalhealth issues since 2007. Way past time. So thank you for your attention to this. I have been focused on the issue of suicide for years, particularly Youth Suicide in this country. In my state, troubling statistics in areas but the one that i find disturbing is our statistics when it comes to the uses in the country, a rate of suicide, 11. 5 suicides occur 1 hundred thousand people in alaska, looking at a suicide rate of exactly double that, 28 suicides per 100,000 people and even worse statistics as they relate to our alaska native young man between the ages of 15, and 24. And in the entire country, at a rate of 141. 6 suicides per 1 hundred thousand people per year. This is between 2,000, and 2009. It is something i find so troubling, everything we do, cannot seem to be making inroads here so i have long been focused on it and just reintroduced along with senator repeat legislation that will help to address suicide and this is garrick lisa Smith Memorial act reauthorization. We are seeking to do is provide a focus on Youth Suicide and several different areas. And all so in addition to providing these grants and organizations that you grant to colleges and universities. But question i would have for you as director is how we can do more with and our colleges and universities to provide identification, early treatment, intervention and Treatment Services for young people, we see these documented mentalhealth feed the. I am concerned that we dont have sufficient flexibility within a program that currently exists. Can you speak to your observations and what we could be doing better . And thank you for the question. The Surgeon General along with a very strong Public Private partnership lasted ever put out Surgeon GeneralNational Strategy for Suicide Prevention and in that strategy there were several high priority things identified. Dont have the time or memory to go through all of them but there were some key things like identifying even as we have been talking about in this Youth Age Group were raising awareness of people who know what to look for, having people be able to get help better, in gauging after care to use that term so when people do have risk of suicides or make a suicide attempt, followup to make sure, it is a high risk time, providing clinical standards so clinicians know how to do the screening and that includes campus based programs, proud to administer the program and see Great Results in terms of raising that awareness and part of the president s proposal also includes the idea of Mental Health firstaid approach trying to get people more aware especially focused on what to look for, how to get help, know that someone needs help and how to help him get that. I hope we would work on this. This is a key issue for us. Let me ask you a quick question. It has been noted, senator baldwin, the identification of Mental Illness in terms of recognizing what we are dealing with great on set come as early as age 14 and the early identification can really help with improving outcomes and yet most of our primary care providers that are out there are probably not adequately prepared to identify Mental Illness at its earliest stages to provide for the inappropriate care. What can be done . What is the administration doing to support primary care, improved training opportunities so that we can do that Early Intervention, early identification. Such an important question because as we talk about earlier, the lesson we have learned over and over again, about medical research is Early Detection and Early Intervention be the best outcomes so we need to do better at this and it is challenging because we do not have vital markers the way we do for Heart Disease or cancer or many other diseasess where we can take a blood test and know who is on highrisk have to develop something. And i age is invested in developing those kinds of tests whether their cognitive or biological, to know who is in a high risk state but that is a longterm plan and i dont think we can wait to make sure theres a better awareness. Project aware was announced last week by the president which is an attempt to increase awareness in school and primarycare and communities about the challenge we face, the need to detect the early signs. At the same time recognizing a lot of teenagers who are struggling and you dont want to label every one of them as having an illness and you want to be sensitive to Getting Better and better, more precise measures. Who really is at risk and knowing who to intervene with. Got to know how to find a right balance and hopefully science will bring better tools for that. Thank you. Now senator franken. Thank you, mr. Chairman. Like all members of this committee i thank you for calling this hearing. I want to welcome senator alexander as the new Ranking Member and look forward to working with you and i want to thank senator enzi for his work as the Ranking Member. Like everyone on this committee i was devastated by the tragedy in newtown and in the wake of this tragedy there has been a new focus on Mental Health issues which i have been working on for a long time. Paul wallstone held the seat that i held and i too share the sense of urgency about the rules being finalized. I am glad we are focusing on mentalhealth but it is important not to stigmatize people with Mental Health ward generalize about the connection between Mental Illness and violent behavior. I want to thank both of you for making it very clear that as i said in a written testimony most people who are violent do not have a mental disorder, most people with mental disorders are not violent. And dr. Insel said essentially the same thing. We should make sure everyone has access to mental and behavioral Health Services that they need because it will make our communities and families and them healthier and happier but it is absolutely vital that we not stigmatize Mental Illness in the process. It would not only be counterproductive but counterfactual. In the next week i am going to introduce two bills that will expand access to Mental Health services, introducing justice and Mental Health collaboration active reauthorization of and improvements i hope, and this is people with Mental Health issues encountered the criminal Justice System, seven republican sponsors including senator hatch on this committee. I am also going to introduce the Mental Health in schools act which dovetails project aware and this is where dr. Insels testimony is so important. It is about schools identifying and treating and giving access to treatment to kids. The statistics, only one in 5 of children who have a Mental Health issue get seen or treated. My legislation would allow all schools to collaborate with Mental Health providers, lawenforcement and other communitybased organizations, provide expanded access to Mental Health care for their students whose support school and Training Staff and volunteers, spot warning signs in kids and refer them to the appropriate services and i am glad project aware has the same kind of focus. I want to ask about the evidence in terms of with the caveat that both of you made about not stigmatizing Mental Illness and associating it with violence, if Mental Health issues go and treated, does that increase the chance that someone in a certain subsets of the type of Mental Illness will be more violent . Or will be a higher chance . Within that narrow band of the people were talking about which is small segment of the population of people with Mental Illness, those who have what we call First Episode psychosis, we know that the duration of been treated psychosis is related to the risk of having a violent act. That is studied quite carefully and theres a real correlation there. Closing that gap is one of the things we can do to increase safety. Innocence newtown did prompt this. In that very narrow that was one of the number of horrific occurrences where i think no one would question that in tucson, in newtown, talking about someone who is the rangderange, had that person bonds and treatment that theres a connection between making sure we are identifying and treating children early on with the tragedy that brought us here . Not going to speculate on those individual cases but the data, the published data are quite clear, the difference between severely violent acts like homicide between those who are and treated and those who are treated is 15fold. You drop the risk 15fold and it is vital that we detect earlier and intervene earlier with something that is effective. Thank you, mr. Chairman. Senator murphy. Senator sanders. I think senator murkowski had an engagement and wanted to ask one question. Thank you. I have a meeting with senator shelby to help organize the Appropriations Committee and that will take me thank you to the questions for dr. Insel and dr. Hyde. What we are hearing is effected intervention whether it is autism or chronic schizophrenia is research, treatment and the work force to make some. My question to each one of view, the issue of research and workforce, particularly research, dr. Insel, what are the consequences of sequester, work at the National Institute interNational Institute of Mental Health . You have talked about this outstanding work you are doing. What will happen . At this point what we are looking at is 6. 4 reduction in the 2013 budget and that will come if it happens in march or april. What are the consequences . Certain studies we would like to do are not going to be done and one of the major project we are involved with is highly relevant to this discussion today, has to do with how do we ensure that we have the kinds of predictors for early psychosis . We have a Large National study that we would like to scale up and that is probably not going to be done if we dont have funds to expand we are doing. The others one book said the operation and reorganization, what would be the consequence . You cant have Mental Health without Mental Health practitioners, training grants, educational grants, actual workforce at the state and local government with sequester having any impact on workforce issues . And what would they be . It goes without saying that we all hope that sequester which was never intended to happen doesnt happen. Samhsa does a lot Technical Assistance and training and without materials and practice improvement for the work force and to the extent that we dont have the same number of resources to do that, will be able to be done, less of the grants we put out as well. What will have a direct impact on training . It very well could. We have a fairly significant portfolio providing what i call workplace or practice improvement efforts and that includes training, Technical Assistance, materials, access to resources. Those take resources to do to the extent we have resources we do it and if we dont we do we will come back for more detailed questions. But the looming threat is severe and im sure it has tremendous impact, but senator sanders yielded his time to me and senator sanders, i appreciate your interest in that arianna as well. Let us just say the reason i ask about training is 1963, a bill was signed for Mental Health, was a social worker working as a child abuse worker. The cost of that, age 27 i was able to go to graduate school and get a masters in social work. I was specializing in community Mental Health. Many might not think i have a therapeutic personality. [laughter] but i did learn a lot and i learned about scholarships and so on that make a difference in lives, the consequences of welltrained people and what they produced in our society is important. We hope youre training is successful in the appropriations process as well. I tend to be very agitated about lot of things. Thank you very much, mr. Chairman. Newtown and other events have highlighted the importance of this issue and i very much appreciate your holding this hearing. Let me start off, i will approach the issue in a different way than some of our colleagues. The United States of america is the only country in the industrialized world that does not have a National Health care system. In my view, in the midst of Major Health Care crises in this country including fifty Million People today without any Health Insurance, hopefully that number will be significantly reduced under the aca. When you dont have a system you are not prioritizing. Not only are we not paying adequate attention to Mental Health in general, but the disparities based on income and where you live are also enormous. Senator murkowski mentioned problems in rural alaska, native american but i can tell you, if i am making half a Million Dollars a year and living in new york city and my kid has problems, the likelihood is i am going to be able to get reasonably good Mental Health treatment for that kid. On the other hand, i live in rural vermont, i am making 25,000 a year. You know what . I am going to have a very difficult time accessing the Mental Health care that my kids need. I suspect in tennessee and i suspect it is true all over america. The reality is right now, we have a primary Health Care System which is a disaster. Whether it is physical illness or you make the point we do well with Mental Health when people access the system when they need it. In my office i can tell you we get calls where family members say my husband, my kid, serious problems, i cant find Mental Health treatment now. Let me ask you a simple question. If our goal is to make sure that Mental Health care is available to all people who need it, how many thousands and thousands of Mental Health practitioners does this country need and how do we get them . Let me start with dr. Insel. I will turn to my colleague who is just completing a work force assessment and looked very carefully at this issue. How many thousands of Mental Health practitioners do we need . We dont have good studies that say how many we need. We have lots of data that tell us what we dont have. Lots of data that give us comparisons between certain areas and certain types of practitioners. We are just completing a report for congress on that. Before we get to the report, we need data. Tell me, is it fair to say that if i have a lowincome person living in Rural America or urban america, today i am going to have a very difficult time finding Mental Health care for my loved one. I was going to go right there so thank you for the question. It is not even so much although clearly in certain areas of practitioners we dont have enough but also the distribution. The distribution, i come from new mexico. We have major rural areas in new mexico and there are counties in new mexico the dont have any law practitioners, none, zero, we have 75 of psychiatrists in the rio grande corridor. Which let me guess, not knowing anything about it wealthier. It is more urban certainly. Rear the universities are. We dont have a lot of time. My question is if i am working class person, if i am unemployed in this country is it fair to save time living in Rural America that it will be very hard for me to access affordable Mental Health care in a timely manner . Is that a fair statement . It is fair to say world areas have a more difficult time. There are programs like Community Health centers. I work i apologize i worked very hard to double the funds of Community Health centers and cripple funding for the National Health service. We made progress. Would you agree that we need a long way to go to expand beyond where we have gone in recent years . I would agree we need more practitioners absolutely. I will add to that it is not only across the board but particular areas, one of them is children. We have been talking to lot about youth needs, child psychiatrists is a way incredibly important to build a work force. I think it is a class issue too, mr. Chairman. To some degree psychiatry is something that is accessible for urban upperincome folks. It is not accessible for low income rural folks. The point miss hyde made is an important one. We have to look at geography and make sure Mental Health is available to all people regardless of their income all over this country. Thank you. I might just add since ive focused so much on prevention and Early Intervention, school psychologists, National Average is 15001. Recommended ratio recommended by home . Is 700 to 800 students for psychologist. We need to double that to me to recommend level of kids in school. Senator whitehouse, senator warren. Welcome to the committee. Thank you very much. [inaudible] i want to apologize for coming in late. I had the best possible excuse. I was introducing my senior senator, senator john kerry to the Senate Foreign relations committee. I believe that will not be a recurring event. If that is your way of saying soon you will be the senior senator from massachusetts laughter] i have a similar interest in the question about research, evidence based medicine, accountability, funding for research. What i would like to do is start with dr. Insel and ask you to do two things for us. The first is a paint this picture of what we can do with research in the mentalhealth field. What can we learn that we dont know and talk a little bit about the funding levels are doing to research. I dont usually get an opportunity to talk about this and promise i will do it quickly. You are asking the question at a critical moment in time. In the case of where we were in some ways for studying cancer 20 or 30 years ago we are on the cusp of a revolution, we had this extraordinary tool here and for the first time we can approach problems of the mind through studying the brain and that gives us a precision that we never imagined we could have. For behavioral problems, parkinsons disease, the behavioral systems are a very late event. 40 psychosis and schizophrenia. We define these as behavioral disorders that they are Brain Disorders and the brain changes are occurring years earlier. If we want to detect and intervene earlier we have to develop ways to get at that to understand the mans Brain Disorders and the way we have done now in many areas of medicine. Where the science is taking us is towards the fundamental biology, we have not been there before. We have had a simplistic approach to this. Is more complicated, we have far better tools to one pack this. The question was about the funding. There are lots of things we would like to answer, the shift has largely moved much of our funding to people who ten years ago were studying cancer and Heart Disease and joining us because they feel autism and schizophrenia are the new frontiers. It is always frustrating because there is never enough funding to support the best ideas that come in. We try to support 20 of them so one in five get funded. I hope i am smart enough to pick the best 20 . I am afraid i am not. If i could do 30 i would have a much better hit parade. It is hard to know often. That is that challenge. You never have the funding you want to do all the science, some of which is spectacular, sitting in front of you. Can i ask about one more dimension . You describe your hit rate. If you really hit on some of these studies on autism, can you speak briefly about the financial impacts on the country . We know in the case of alzheimers that if we can just forestall the dementia by a matter of a year or two years which is within our grasp as we have got a better understanding of ways to intervene. Were talking billions of dollars that will not have to be spent which are going into the care of people with dementia. It is down to a question do you want to invest early or do you want to pay later . You dont know enough and are not doing this, we have tended to decide we will pay later, often a very large premium instead of making nearly investments in alzheimers, autism, schizophrenia to make sure we come up with better solutions. Thank you very much. Miss hyde, my time is expired but if you have a quick comment you like to add. Quick comment is these disorders have profound impact on our Justice System and our School System and Public Welfare systems and Child Welfare systems. Profound dollars are being spent because we are not intervening early because we are not providing of a support to young people and their families. Thank you very much. Mr. Chairman, thank you, i was on the floor with my senior senator on an issue of great importance to colorado so i missed the testimony and i will refrain from asking my questions now and submit some for the record if that is okay and there is a second panel but i want to thank you very much for holding this hearing and i want to julian senator frank and in saying how delighted i am to join our