Screening and Entry Into Mental Health Treatment: Balancing Help for the Individual and the Community

Background

The National Institute of Mental Health estimates that one in 10 children suffer from mental illness severe enough to result in significant functional impairment. An estimated 26.2 percent of Americans ages 18 and older — about one in four adults — suffer from a diagnosable mental disorder in a given year.¹ Even though we have made marked progress in recent years in identifying and providing services to individuals with mental illness, the fact remains that nearly two-thirds of all individuals with a diagnosable mental disorder fail to seek treatment due to the stigma associated with mental illness.²

In 2003, President Bush’s New Freedom Commission on Mental Health published recommendations which included the promotion of early mental health screening, assessment and referral. Their reasons sited new understanding of the brain indicating that early identification and intervention could sharply improve outcomes, and that longer periods of abnormal thoughts and behavior have cumulative effects which could limit the capacity for recovery.³ The report recognizes that currently there is no agency or system responsible for young people with serious emotional disturbances. Children with mental disturbances have the highest rates of failure in school, with more than 50 percent of this population dropping out of high school.⁴ The report recommended systematic screening procedures in all settings in which children, youth, or older adults are at high risk for mental illnesses.

After the Virginia Tech shootings in the spring of 2007, community leaders found themselves grappling with the question of how to balance helping those with mental illness while at the same time assuring the safety of the community and preserving privacy and liberty for the individual. In the next year many state legislators will consider these questions and more as they examine their existing state systems and how they provide for the needs of all populations.

Federal Recommendations

In the weeks following the Virginia Tech shootings, President Bush directed Secretaries Michael Leavitt and Margaret Spellings and Attorney General Alberto Gonzales to meet with educators, mental health experts, law enforcement, and state and local leaders to discuss the events that transpired and make recommendations for change. Key findings which came out of these discussions are as follows:

Critical Information Sharing Faces Substantial Obstacles: Education officials, healthcare providers, law enforcement personnel, and others are not fully informed about when they can share critical information on persons who are likely to be a danger to self or others, and the resulting confusion may chill legitimate information sharing.
Accurate and Complete Information on Individuals Prohibited from Possessing Firearms is Essential to Keep Guns Out of the Wrong Hands: State laws and practices do not uniformly ensure that information on persons restricted from possessing firearms is appropriately captured and available to the National Instant Criminal Background Check System (NICS).
Improved Awareness and Communication are Key to Prevention: It is important that parents, students, and teachers learn to recognize warning signs and encourage those who need help to seek it, so that people receive the care they need and our communities are safe.
It is Critical to Get People with Mental Illness the Services They Need: Meeting the challenge of adequate and appropriate community integration of people with mental illness requires effective coordination of community service providers who are sensitive to the interest of safety, privacy, and provisions of care.
Where We Know What to Do, We Have to be Better at Doing It: For the many states and communities that have already adopted programs, including emergency preparedness and violence prevention plans, to address school and community violence, the challenge is fully implementing these programs through practice and effective communication.

All concerned parties in the discussion agreed that state and local community mental health systems should be evaluated to ensure their adequacy to provide a full array and continuum of services, including mental health services to students. State legislators should review emergency services and commitment laws to ensure the standards are clear and strike the proper balance among liberty and safety for the individual and the community. They should also evaluate any mechanisms in place to enforce legal rulings which mandate a course of treatment and make sure procedures are in place to ensure thorough follow-up.

Unfortunately there is a great deal of social stigma associated with mental illness which discourages individuals from seeking treatment. For example, the Substance Abuse and Mental Health Services Administration (SAMSHA) has reported that 61 percent of Americans feel that individuals with schizophrenia are likely to be dangerous to others. In truth, individuals with severe mental illness are more likely to be the victim of crime than the perpetrator. SAMSHA provides information for communities to aid in the development of stigma reduction initiatives. Information on these resources may be accessed online at http://mentalhealth.samhsa.gov/publications/allpubs/sma06%2D4176/.

The National Institute of Mental Health recently approved funding to test the effectiveness of an early intervention in children at high risk for developing bipolar disorder. Though early in the research process, the long-term goal of this study is to reduce or delay the development of bipolar disorder in at-risk youth, heading off the effects of the disorder before it disrupts healthy development and functioning. Family-focused therapy (FFT) involves teaching patients and their families about bipolar disorder and disease management, improving communication skills, and developing problem-solving skills. The study will be conducted at the University of Colorado, led by David Miklowitz, Ph.D.; and Stanford University, led by Kiki Chang, M.D.. Studies like this one will help determine the importance of early intervention and the course of practice standards in mental health services.

Screening Programs

Various proposals nationwide to implement mental health screening for children and adolescents, inclusive of the president’s New Freedom Commission on Mental Health, have been met with criticism concerning the ultimate impact such a program may have on parental rights and fears over false-positive screening and how a stigmatizing diagnoses of mental illness would follow a child or individual for the rest of their life. Advocates argue that a large-scale mental health screening program would result in benefits for the individual as well as the community if an individual is treated before their condition becomes too severe. Schools have been cited as a perfect venue for these large scale public health programs since they make it possible to screen a large number of individuals quickly and it would facilitate an early identification process.

The Substance Abuse and Mental Health Services Administration (SAMSHA) reports that 39 of 50 state mental health authorities (SMHA) or 78 percent have initiatives for the early detection of mental health problems: 39 States for children, 17 for adults, and 17 for older adults. Thirty-three SMHAs (67 percent) operate or fund prevention/early intervention programs for children, 16 operate or fund such programs for adults, and 10 operate or fund them for elderly persons. Thirty-four of 44 SMHAs (82 percent) work with schools to expand and improve mental health services for children.

Voluntary and Involuntary Treatment

The vast majority of individuals with mental health needs in the United States receiving services receive them in an outpatient setting. One usually enters outpatient treatment voluntarily, and can do so as a result of self-referral or by the encouragement of family and friends. Many individuals enter outpatient treatment after consulting a trusted friend, pastor, or family member, who then encourages him to seek professional treatment. On a college campus the individuals that often have the capability to encourage a student to seek mental health assessment and treatment are roommates, resident advisors, coaches, and professors. In the work setting, coworkers and supervisors, if educated on identifying mental health needs, can persuade individuals to seek mental health treatment.

An individual receives inpatient care as a result of being committed to a hospital. This may happen in any of three ways.

An individual may be deemed a danger to himself or others by family, police or another individual and can be involuntarily civilly committed, which is how approximately 80 percent of people enter inpatient treatment.
An individual may be involuntarily criminally committed after he or she has committed a crime but is not deemed responsible or capable of standing trial due to mental illness. This accounts for approximately 20 percent of individuals receiving inpatient treatment.
Finally, an individual may voluntarily commit himself to inpatient treatment, although this occurs only rarely.

In the most common form of commitment, when an individual is deemed to be a danger to himself or others, a judge may civilly commit him, forcing him to receive inpatient treatment at a hospital. A psychiatrist must assess the individual initially, then regularly perform reassessments to determine whether the individual remains a danger to himself or others. The involuntary commitment order is reviewed periodically by a judge.

When many individuals are released from the hospital after their condition has improved, judges will continue to commit them to continued treatment in the community. A condition of release from inpatient care is often participation in outpatient treatment. Involuntary outpatient treatment forces an individual to participate in treatment in the community. Forty-two states have involuntary outpatient commitment laws. These policies were developed partly in response to the highly publicized acts of violence that have been committed by a small number of individuals with serious mental illness. However, studies have found that individuals with serious mental illness are not at higher risk for violence than the general population.

State Initiatives

Several states are working to improve mental health on campuses. To support the effort, SAMHSA provides suicide prevention grants to states, and are required to work with colleges and universities. More information on statute suicide prevention plans and the SAMHSA grants can be found at http://www.sprc.org/stateinformation/index.asp.

The University of California system completed a review of campus mental health programs in September 2006. A report was published with the findings and recommendations for improvement. Funding has already been allocated to make many of the recommendations. The report can be found at http://www.universityofcalifornia.edu/regents/regmeet/sept06/303attach.pdf.

The Missouri Partners in Prevention, which was originally formed to promote substance use prevention, has recently expanded its focus to address broader mental health issues. The website is http://pip.missouri.edu/index.html.

The Massachusetts Department of Public Health is working with campuses to promote college mental health, and has a staff person designated specifically to address college health issues. The Suicide Prevention Resource Center will be working closely with the campuses on the initiative.

Montana, Virginia, and Pennsylvania have planned events and meetings for the fall to promote mental health on campuses.

Restrictions Under Federal Law

Under federal law, the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) provides protection for personally identifiable records. This includes all health records maintained by school employees who provide school health services. FERPA provides a basic framework for protecting and disclosing student records, but leaves wide discretion to school districts for interpretation and implementation of the FERPA regulations.

Two essential components of the Health Insurance Portability and Accountability Act (HIPAA) address standard code and transaction sets for electronic transmissions of "individually identifiable health care information" (Transaction Rule) and security protections for protected health information (Security Rule). Schools that receive no federal financial assistance and the health professionals that work in them may or may not be directly subject to the HIPAA Privacy Rule but, in any event, are advised to employ HIPAA standards as minimum criteria for practice.

The National Association of School Nurses has broken down the general implications of the HIPAA Privacy Rule for student health records in public schools, and non-public schools covered by FERPA, as follows:

The fundamental ethical and legal principles underlying FERPA and HIPAA are the same. FERPA protects student information in education records, while HIPAA protects individually identifiable health information, in any form, that is used or disclosed by a covered entity.
HIPAA privacy requirements, which are more detailed and directive than FERPA privacy requirements, provide useful reference standards for school district policy, procedures, and practices related to the protection and disclosure of student health information. Guidelines for developing school district policy and procedures, using HIPAA, FERPA, IDEA, and ethical standards, are currently being developed by the American School Health Association in collaboration with the National Association of School Nurses, National Association of State School Nurse Consultants, and a national task force comprised of 12 national organizations, with funding from the Division of Adolescent and School Health in the Centers for Disease Control (Schwab et al., 2004⁵). [Au: Change OK? Should the Schwab et al., 2004, be changed to 2004 in the references?]
The HIPAA Privacy Rule excludes from its definition of "protected health information" education records covered by FERPA. As such, student records in schools and school districts that receive federal funding are generally not subject to HIPAA privacy provisions (USDHHS, 2000, p. 82483⁶).
School nurses are HIPAA-covered entities if they engage in HIPAA transactions, but the FERPA-covered records they are responsible for are not covered by the Privacy Rule. Thus, the records that are transmitted are subject to the HIPAA Transaction Rule, but not the Privacy Rule (Bergren, 2003⁷; Campanelli et al., 2003⁸; Grimms & Cordy, 2002⁹).
Clarification is still required in many states regarding the permissibility of communications between students’ health care providers and school nurses about student health procedures that are mandated by state statute for public health policy reasons (e.g., immunization status, the results of health assessments that are required for school attendance, and communicable disease reporting). Some states have provided guidance or passed clarifying legislation.
Education is required regarding the Privacy Rule provision that permits the disclosure of protected health information (PHI) by HIPAA-covered entities without specific informed consent, if the disclosure is for "treatment" purposes. Representatives of the Office of Civil Rights of the U.S. Department of Health and Human Services interpret the Rule’s language to permit disclosures of PHI to school nurses who are providing treatment to a student (Campanelli et al., 2003), because school nurses meet the definition of "health care provider" under HIPAA. Nevertheless, many providers and their attorneys believe that they cannot disclose PHI, even for treatment purposes, to noncovered entities, even other health care providers. This becomes a barrier to care and is especially critical when physicians, or other authorized prescribers, issue a "medical order" for a student to receive a medication or medical treatment in school and the nurse, according to the state’s Nurse Practice Act, may only carry out the treatment under the order of an authorized prescriber. The safety and efficacy of the treatment plan can be compromised if communication between the prescriber and nurse, related to a medical order and its execution in school, is hampered.
Practice dilemmas continue for FERPA-covered entities related to conflicts between minors’ legal rights to privacy in the health care system and parental rights to access and control the release of all education records of their minor children. HIPAA-covered entities, such as school-based health centers, have no such conflict, because HIPAA defers to state laws and professional practice standards in the health care community to determine when minors, rather than their parents or legal guardians, may give consent for the release of their own PHI (e.g., treatment for sexually transmitted diseases or drug and alcohol dependence). FERPA, however, does not recognize minor consent-to-treatment statutes, either in state or federal law. Thus, when student health records are covered by FERPA and a minor student consults the nurse for counseling or referral related to a health care need for which the minor student has the right under state law to consent to treatment, conflicts regarding documentation, access to, and release of related records remain. See Schwab and Gelfman (2001) for a more in-depth discussion of confidentiality, conflicts in the law, and related practice issues.

Resources

Mental Health Services Locator (state by state) http://mentalhealth.samhsa.gov/databases/
Mental Health Statistics Improvement Program's Consumer-Oriented Mental Health Report Card http://www.mhsip.org/reportcard/reportcard.html
ChildStats.gov http://childstats.gov/americaschildren/hea2.asp
Framework for Developing Institutional Protocols for the Acutely Distressed or Suicidal College Student, The Jed Foundation
http://www.jedfoundation.org/framework.php
Ulifeline, The Jed Foundation
http://ulifeline.org/main/Home.html
Promoting Mental Health and Preventing Suicide in College and University Settings
Suicide Prevention Resource Center
http://www.sprc.org/library/college_sp_whitepaper.pdf
CampusHealthandSafety.org Mental Health Pages
http://www.campushealthandsafety.org/mentalhealth/
US Air Force Suicide Prevention Program: Suicide Prevention Resource Center Registry for Evidence-Based Suicide Prevention Programs
http://www.sprc.org/featured_resources/ebpp/pdf/airforce.pdf
Active Minds on Campus: Student-run mental health awareness, education, and advocacy organization designed for the college campus.
http://www.activemindsoncampus.org/
NCSL Mental Health Frequently Asked Questions
http://www.ncsl.org/programs/health/forum/faqpreface.htm#mental

Notes

1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.

2. Mental Health: A Report of the Surgeon General. Department of Health and Human Services, U.S. Public Health Service. (1999)

3. Shonkoff, J. P. & Phillips, D. A. (2000). From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington, DC: National Academies Press.

4. United States Department of Education Office of Special Education Programs (2001). Twenty-third Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act: Results. U.S. Deptartment of Education, Office of Special Education Programs (OSEP).

5. Schwab, N.C., Ruben, M., Maire, J. A., Gelfman, M. H. B., Bergren, M. D., Mazyck, D., & Hine, B. (2004). Protecting and sharing student health information: Guidelines for developing school district policies and procedures. Kent, OH: American School Health Association.

6. USDHHS. (2000, December 28). Preamble to the Standards for Privacy of Individually Identifiable Health Information [HIPAA Privacy Rule]. Federal Register, 65(250). Retrieved January 2004 from http://www.hhs.gov/ocr/part1.pdf.

7. Bergren, M. D. (2003). National Conference on HIPAA Privacy Rule, NASNewsletter, 18(4), 20–22. Available at http://www.nasn.org.

8. Campanelli, R., McAndrew, S. D., Altarescu, L., Heide, C., Mayer, D., Kaminsky, S., & Seeger, R. K. (2003, March). Presented at the National Conference on the HIPAA Privacy Rule. Chicago, IL: U. S. Department of Health and Human Services. [Video. Available for $50 from: Workgroup for Electronic Data Interchange, 12020 Sunrise Valley Dr., Suite 100, Reston, VA 20191 (703) 391-2743.]

9. Grimms, L., & Cordy, G. (2002). Medicaid reimbursement of school-based health care at the state-operated schools and HIPAA. Memorandum from the Oregon Department of Justice, Office of the Attorney General, to Alm, J., at the Oregon Department of Human Services and Hunt, M., at the Oregon Department of Education, November 12.

NCSL Staff Contact:

Rachel Morgan RN, BSN, Senior Policy Specialist,
Office of State-Federal Relations, Washington, DC
(rachel.morgan@ncsl.org or 202-624-3569)

Sarah Steverman, MSW, Policy Associate
Forum for State Health Policy Leadership, Washington, DC
(sarah.steverman@ncsl.org or 202-624-3583)

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