Academy Comments to SAMHSA re Primary and Behavioral Health Care Integration Program

June 13, 2016

SAMHSA Desk Officer
Office of Information and Regulatory Affairs
Office of Management and Budget
New Executive Office Building
Room 10102
Washington, DC 20503

Re: Primary and Behavioral Health Care Integration Program Data Collection

Dear Sir or Madam,

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Behavioral Health Statistics and Quality (CBHSQ) regarding its May 12, 2016 information collection for the Primary and Behavioral Health Care Integration (PBHCI) program. Representing over 90,000 registered dietitian nutritionists (RDNs),1 nutrition dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation's health through food and nutrition across the lifecycle. RDNs can and do play integral roles in improving the lives and health of people with serious mental illness (SMI) through chronic care management and preventive services.

The Academy strongly supports the PBHCI and recognizes limitations of the program and its funding that prevent people with SMI from fully taking advantage of RDNs' ability to treat and manage obesity, diabetes, and other conditions. We wholeheartedly agree with our colleagues at the Dietitians of Canada that "[d]iet therapy should be recognized as a cornerstone of mental health interventions in clinical practice guidelines and standards of care . . . [and that] [a]dequate funding is needed for nutrition services in mental health care, with monitoring and evaluation for effectiveness and efficiency."2

Nutrition and SMI

SAMHSA recognizes that "[p]oor diet, which is characterized by lower consumption of fruits, vegetables and fiber, and greater consumption of calories, nutrients and saturated fats, is more prevalent among these individuals compared to the general population."3 Specifically, "[c]ompared with people without mental illness, individuals with SMI (e.g., schizophrenia, other psychoses, bipolar disorder, and severe depression) have higher rates of chronic medical conditions, including hypertension, diabetes, obesity, cardiovascular disease, and HIV/AIDS; higher frequency of multiple general medical conditions; and more than twice the rate of premature death resulting from these conditions.4 Notably, these are all conditions that RDNs are uniquely skilled at effectively treating, but of the recently evaluated PBHCI programs, only 7 percent reported hiring an RDN to work with participating consumers.5 Access to the standard of care is a significant problem.

Too often, the lack of consistent or sufficient funds to hire an RDN in those programs and group homes means less qualified and less effective workers are providing general wellness or general nutrition education instead of the RDN-provided medical nutrition therapy proven to produce significant results. SAMHSA should evaluate the extent to which limited access to RDNs in this population is leading to poor health outcomes, placing them at greater risk for a continued need of higher levels of care.

In 2013, the International Society for Nutritional Psychiatry Research (ISNPR) was formed and released a position paper noting the neglect of integrating diet-based protocols for the treatment of mental health conditions. The opening paragraph in the ISNPR report states:

"Present treatment of mental disorders is achieving sub-optimal outcomes; in addition little attention is given to preventative efforts. Due to the immense burden of mental disorders, there is now an urgent need to identify modifiable targets to reduce the incidence of these disorders. Diet and nutrition offer key modifiable targets for the prevention of mental disorders and have a fundamental role in the promotion of mental health. Epidemiological data, basic science, and clinical evidence suggest that diet influences both the risk for and outcomes of mental disorders."6

Specific nutrients or combinations of nutrients have been investigated as a therapeutic target for mental health conditions; omega-3 fatty acids, zinc, B vitamins, Vitamin D, S-adenosyl methionine (SAMe), and N-acetyl cysteine are examples.7 Despite the evidence showing the positive impact of these bioactive food components, there is minimal evidence demonstrating the specific foods or dietary patterns that are supportive for improving mental health. Investigating a simple nutrient or even a combination of nutrients has been criticized as creating a reductionist view of the experience of eating food.8 However, a Western dietary pattern consisting of highly refined sources of carbohydrates, low levels of omega-3 fatty acids, low levels of antioxidants due to minimal fruit and vegetable consumption, and high levels of pro-inflammatory omega-6 fatty acids has been correlated with the presentation of symptoms consistent with compromised mental health status.9,10,11

Nutritional care is vital to behavioral health outcomes due to malnutrition effect on cognitive reasoning. Psychotropic medications often contribute to excessive weight gain, and people with depression often rely on less than ideal food choices and food preparation processes.12 At present, one of the most beneficial recommendations for someone who exhibits any symptom related to a mental health condition is to consume a Mediterranean diet pattern.13 The utilization of food-based interventions as a therapeutic tool in the treatment of mental health begins with a RDN who has specialized training in psychiatric nutrition inquiring about the daily eating patterns and barriers (i.e., socioeconomic, self-efficacy, culinary skills, etc.) to the consumption of nutrient-dense foods.

Importance of Nutrition Assessments

Assessment of clinical malnutrition (stages 0-5) by an RDN is essential for developing an effective treatment plan for ALL individuals with mental health conditions. This skill set is part of the clinical training for becoming an RDN. Staging malnutrition along with corrective nutritional interventions can accelerate the rehabilitation process by addressing the core biological variables inhibiting cognitive restoration. Additionally, the identification of environmental factors that negatively contribute to a compromised nutritional state (e.g., co-morbid conditions) offers increased opportunities to improve interdisciplinary care.

The symptoms of mental health distress often present prior to the manifestation of a diagnosable illness. An assessment of dietary patterns and nutritional habits of individuals with mental health conditions by an RDN with specialized training is essential to the stabilization and cognitive rehabilitative process for all individuals with a mental health condition.

Insurance and Billing

The RAND Corporation's 2013 evaluation of PBHCI programs ("the RAND Evaluation") notes that "people with SMI are less likely to have health insurance than people without mental illness, they perceive more barriers to obtaining preventive and general health care, and they report that providers dismiss their somatic complaints."14 Other barriers to integration include long-term financial sustainability, particularly for non-billable services (such as wellness programs) and the lack of a requirement that counseling and wellness services be provided. SAMHSA should continue to enable grant money to be used to enroll individuals with SMI into available public or private insurance plans, with guidance to select a plan with more robust nutrition therapy benefits.

The RAND Evaluation also revealed that "[f]rom the site visits . . ., it was evident that financial barriers differed widely based on consumers' insurance status and state-specific Medicaid regulations about the type and intensity of reimbursable services."15 The Academy has found similar problems in the lack of consistency among states' Medicaid coverage and a shocking lack of coverage for critical services in several states. Given the difficulties the Academy and other researchers16 have had in identifying the extent of Medicaid coverage in each of the states, we encourage SAMHSA to track and identify state-specific Medicaid coverage issues to assist stakeholders in working to improve coverage in those states.

In addition, we note that many individuals with SMI have a dual diagnosis of a developmental disability, but Academy members report that some State Agencies have limited diagnosis conditions for counseling, meaning there is no coverage for many of these people needing assistance for undesired weight gain or general eating problems. The success achieved by including medical nutrition therapy as a core service for people with HIV/AIDS in the Ryan White Program demonstrates the benefit of ensuring individuals' access to the entire spectrum of services needed to thrive. One member recently expressed the impact of grants ending at his program: "The program sees the importance of the service, but doesn't have the money or the requirement to get assistance such as what I was providing." As a result, the individuals with SMI in the program no longer receive the effective care he was providing.

Conclusion

The Academy appreciates the opportunity to comment on the information collection to highlight the importance of effectively integrating RDNs in these grant programs. We would be grateful for the opportunity to discuss these recommendations in greater detail in the near future with you. Please contact either Jeanne Blankenship at 312-899-1730 or by email at jblankenship@eatright.org or Pepin Tuma at 202-775-8277 ext. 6001 or by email at ptuma@eatright.org with any questions or requests for additional information.

Sincerely,

Jeanne Blankenship, MS, RDN
Vice President
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Pepin Andrew Tuma, Esq.
Senior Director
Government & Regulatory Affairs
Academy of Nutrition and Dietetics


1 The Academy approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.

2 Davison KM, Ng E, Chandrasekera U, Sengmueller E for Dietitians of Canada. Nutrition and Mental Health: Therapeutic Approaches. Toronto: Dietitians of Canada, 2012. See also, Davison KM, Ng E, Chandrasekera U, Seely C, Cairns J, Mailhot-Hall L, Sengmueller E, Jaques M, Palmer J, Grant-Moore J for Dietitians of Canada. Promoting Mental Health through Healthy Eating and Nutritional Care. Toronto: Dietitians of Canada, 2012.

3 Health Promotion Resource Guide: Choosing Evidence-Based Practices for Reducing Obesity and Improving Fitness for People with Serious Mental Illness (September 2014). Center for Integrated Health Solutions website. Accessed June 9, 2016.

4 Evaluation of the SAMHSA Primary and Behavioral Health Care Integration (PBHCI) Grant Program: Final Report, December 2013. Accessed June 10, 2016 (internal citations omitted).

5 Ibid. at 24

6 Sarris J et al. (2015b). International Society for Nutritional Psychiatry Research consensus position statement: nutritional medicine in modern psychiatry. World Psychiatry, 14, 370-.

7 Rucklidge JJ and Kaplan BJ. (2013). Broad-spectrum micronutrient formulas for the treatment of psychiatric symptoms: a systematic review. Expert Rev Neurother.,13, 49-73.

8 Jacka FN et al. (2010). Association of Western and traditional diets with depression and anxiety in women. Am J Psychiatry, 167, 305-11.

9 Logan AC and Jacka FN. (2014). Nutritional psychiatry research: an emerging discipline and its intersection with global urbanization, environmental challenges and the evolutionary mismatch. J Physiol Anthropol., 33, 1-16. 22.

10 O’Neil A., et al. (2014). Relationship between diet and mental health in children and adolescents: a systematic review. Am J Public Health, 104, e31-42.

11 Sarris J et al. (2015a). Nutritional medicine as mainstream in psychiatry. Lancet Psychiatry, 2, 271-4.

12 Rao TS, Asha MR, Ramesh BN, Rao KS. Understanding nutrition, depression and mental illnesses. Indian J Psychiatry. 2008;50(2):77-82.

13 Hibbeln JR and Gow RV. (2014). The potential for military diets to reduce depression, suicide, and impulsive aggression: a review of current evidence for omega-3 and omega-6 fatty acids. Mil Med., 179, 117-28.

14 Evaluation of the SAMHSA Primary and Behavioral Health Care Integration (PBHCI) Grant Program: Final Report, December 2013. Accessed June 10, 2016 (internal citations omitted).

15 Ibid. at 37

16 See, e.g., Gates A, Ranji U and Snyder L, Coverage of preventive services for adults in Medicaid, Issue Brief, 2014. Accessed June 10, 2016.