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Calendar No. 336
111th Congress Report
2d Session 111-166
ESTABLISHING AN INDIAN YOUTH TELEMENTAL HEALTH DEMONSTRATION PROJECT,
TO ENHANCE THE PROVISION OF MENTAL HEALTH CARE SERVICES TO INDIAN
YOUTH, TO ENCOURAGE INDIAN TRIBES, TRIBAL ORGANIZATIONS, AND OTHER
MENTAL HEALTH CARE PROVIDERS SERVING RESIDENTS OF INDIAN COUNTRY TO
OBTAIN THE SERVICES OF PREDOCTORAL PSYCHOLOGY AND PSYCHIATRY INTERNS,
AND FOR OTHER PURPOSES
March 25, 2010.--Ordered to be printed
Mr. Dorgan, from the Committee on Indian Affairs, submitted the
R E P O R T
[To accompany S. 1635]
The Committee on Indian Affairs, to which was referred the
bill, S. 1635 to establish an Indian Youth telemental health
demonstration project, to enhance the provision of mental
health care services to Indian youth, to encourage Indian
tribes, tribal organizations, and other mental health care
providers serving residents of Indian country to obtain the
services of predoctoral psychology and psychiatry interns, and
for other purposes, having considered the same, reports
favorably thereon with amendment(s) and an amendment to the
title and recommends that the bill (as amended) do pass.
The purpose of S. 1635 is to give Indian youth suicide
prevention programs greater authorization to meet the federal
government's trust responsibility to provide health care to
Native Americans. This is accomplished by streamlining the
Substance Abuse and Mental Health Services Administration
(SAMHSA) grants for Indian youth suicide prevention;
authorizing tribal use of predoctoral psychology and psychiatry
interns for health care services to increase the availability
of mental health services and to recruit mental health
providers to Indian Country; authorizing an Indian youth
telemental health demonstration project for Native American
communities to increase the use of technology to enhance mental
health and prevent youth suicides; and authorizing a
demonstration project for youth suicide prevention curriculum
programs in schools serving Indian youth.
The incidence of suicide among Native Americans is 1.9
times higher than the national average and even higher among
Native American youth. Native American youth experience the
highest rate of suicide of any population group in the U.S.
Between the ages of 15 and 24, Native American youth have a
suicide rate 3.5 times higher than their peers of other races.
The incidence of suicide for Native American male youth is
especially extreme, with a rate four times higher than males in
other racial groups and up to eleven times higher than females
in other racial groups. Suicide is the second leading cause of
death among Native American youth.
According to testimony received by the Committee, there are
many risk behaviors and contributing factors for youth suicide.
The Centers for Disease Control and Prevention (CDC) lists the
following risk factors for youth suicide: history of previous
suicide attempts, family history of suicide, symptoms of
depression or other mental illness, alcohol or drug abuse,
stressful life event or loss, easy access to lethal methods,
exposure to the suicidal behavior of others, and incarceration.
Several of these factors are overrepresented among Native
American communities and, according to testimony received by
the Committee, may contribute to the high rate of suicide in
These issues are further compounded by a lack of mental
health services available to Native American youth. According
to research reported by the National Strategy for Suicide
Prevention, in the United States, ninety percent of all teens
who die of suicide suffer from a diagnosable mental illness at
the time of death and over half are never seen by a mental
health provider. The lack of access to mental health
professionals is especially problematic for Native American
youth. The Indian Health Service (IHS) experiences severe
mental health professional shortages.
Furthermore, the Committee has been informed that when
Indian tribes seek federal assistance for suicide prevention
programs, such as grants, they often lack the resources and
infrastructure necessary to successfully access federal
funding. The remote nature of reservations may hinder the
Indian tribe's ability to develop the telecommunication and
epidemiological infrastructure necessary to effectively compete
for a federal grant. For example, a tribe may be unable to
track, record, and evaluate the incidences and trends in youth
suicide over a number of years. Additionally, the Committee
received several complaints from tribes about the new federal
requirements for grants that required the applications be
submitted electronically and that hard copy or facsimile
applications were not acceptable. While the federal grant
process advanced with technology, the technological
capabilities on some remote Indian reservations were still
developing. Ultimately, this lack of administrative and
technological infrastructure impairs a tribe's ability to apply
and obtain federal funding for suicide prevention programs.
The heightened incidence of youth suicides in Indian
Country over the past few years led the Committee to examine
the issue in an effort to help Native American communities deal
with this epidemic. On February 26, 2009, the Committee held an
oversight hearing on youth suicide in Indian Country. The
hearing was intended to follow-up on a series of hearings held
on this topic since the 109th Congress. These hearings were
held to address growing concerns about the incidence of suicide
among Native American youth precipitated by the cluster of
suicides that occurred at the Standing Rock Sioux Reservation
On August 6, 2009, Chairman Dorgan along with Senators
Johanns, Johnson, Tester, Udall, Baucus and Thune introduced S.
1635, the 7th Generation Promise: Indian Youth Suicide
Prevention Act of 2009. This legislation builds upon prior
bills introduced to address Indian youth suicide prevention in
the 109th Congress, S. 2245, the Indian Youth Telemental Health
Demonstration Project Act of 2006, and 110th Congress, S. 322,
the Indian Youth Telemental Health Demonstration Project Act of
2007. S. 322 authorized the Secretary of Health and Human
Services to carry out a demonstration project to provide grants
for telemental health services to Indian youth who have
expressed suicidal ideas, have attempted suicide, or have
mental health conditions that create a risk of suicide. The
bill would have made telemental health service grants available
to Indian tribes operating one or more facilities; reported
active clinical telehealth capabilities; and offered school-
based telemental health services relating to psychiatry for
The bill gets its name from the belief in Indian Country
that you should consider the impact of your decisions on the
seventh generation yet to come. As with prior bills, the goal
of the 7th Generation Promise is to enhance the mental health
services and suicide prevention resources available to Native
Americans, particularly the youth. In addition to promoting
innovative, new programs and building upon existing successful
programs, S. 1635 also addresses barriers Native Americans face
in accessing federal funding.
The Indian Youth Telemental Health Demonstration Project
Act of 2006, S. 2245, was introduced by Senator Dorgan during
the 109th Congress. It was also incorporated into S. 1057, the
Indian Health Care Improvement Act Amendments of 2005 and H.R.
5312, the Indian Health Care Improvement Act Amendments of
2006. S. 2245 was co-sponsored by Senators McCain, Conrad,
Johnson, Murkowski, Smith, and Bingaman. S. 2245 authorized the
Secretary of Health and Human Services to carry out a
demonstration project to provide grants for telemental health
services to Indian youth who have expressed suicidal ideas,
have attempted suicide, or have mental health conditions that
create a risk of suicide. The bill would have made telemental
health service grants available to Indian tribes operating one
or more facilities; reported active clinical telehealth
capabilities; and offered school-based telemental health
services relating to psychiatry for Indian youth. The Committee
favorably reported S. 2245 on April 24, 2006, and the Senate
passed the bill by unaminous consent on May 11, 2006. The bill
was referred to the House Resources and Energy and Commerce
Committees but no further action was taken.
The Indian Youth Telemental Health Demonstration Project
Act of 2007, S. 322, was introduced by Senator Dorgan during
the 110th Congress. It was also incorporated into S. 1200, the
Indian Health Care Improvement Act Amendments of 2008, and H.R.
1328, the Indian Health Care Improvement Act Amendments of
2007, in that same Congress. S. 322 was cosponsored by Senators
Thomas, Baucus, Bingaman, Conrad, Inouye, McCain, Murkowski,
and Smith. On February 8, 2007, the Senate Committee on Indian
Affairs favorably reported S. 322 to the full Senate by a voice
vote. No further action was taken on S. 322.
On August 6, 2009, Chairman Dorgan, along with Senators
Baucus, Begich, Conrad, Johanns, Johnson, Murkowski, Tester,
and Thune introduced the 7th Generation Promise: Indian Youth
Suicide Prevention Act of 2009, S. 1635. On September 9, 2009,
the Committee held a legislative hearing on the bill. On
December 3, 2009, the Committee held a business meeting on S.
1635, and the bill was ordered to be reported favorably to the
full Senate with amendments. In addition, the Indian Health
Care Improvement Reauthorization and Extension Act of 2009, S.
1790, contains the text of S. 1635, as amended.
Indian Health Care Improvement Reauthorization and
Extension Act of 2009, S. 1790, was included in H.R. 3590 which
passed the Senate on December 24, 2009 and passed the House on
March 21, 2010.
SUMMARY OF AMENDMENTS TO S. 1635
Four amendments were offered to S. 1635 at the Committee
business meeting on December 3, 2009. All of the amendments
were accepted by voice vote of the Committee. The four
amendments are described below:
Chairman Dorgan offered a manager's amendment which made
several technical changes and two substantive changes to S.
1635. The first substantive amendment addresses concerns raised
by the SAMHSA regarding priority consideration required to be
given to Indian tribes for youth suicide prevention grants.
Instead, the manager's amendment requires SAMHSA to consider
the needs of Indian tribes in the application process. The
manager's amendment also includes a demonstration project,
developed by Senator Udall of New Mexico, to provide tribes
with grants for culturally compatible, school-based suicide
prevention curriculum to strengthen Native American teen ``life
Senator Murkowski offered three amendments to S. 1635. The
first amendment offered by Senator Murkowski clarified the
definition of ``Indian population'' to ensure that eligible for
services under the demonstration project was consistent with
those eligible for health care services under the Indian Health
Care Improvement Act, 25 U.S.C. 1601, et seq.
The second amendment offered by Senator Murkowski struck a
mandate in S. 1635 requiring States to consult with all tribes
in the jurisdiction when applying for a grant using any type of
tribal data. Instead the amendment required States ``to
exercise reasonable effort to collaborate with each Indian
tribe or tribal organization.''
The third amendment offered by Senator Murkowski struck the
definition of and one reference to the term ``Indian Country.''
The amendment clarified that the Secretary shall encourage all
federally recognized Indian tribes to use predoctoral
psychology and psychiatry interns to increase access to mental
SECTION-BY-SECTION OF S. 1635 AS AMENDED
Section 1. Short title
Section 1 provides the short title of S. 1635 as the 7th
Generation Promise: Indian Youth Suicide Prevention Act of
Section 2. Findings and purpose
Section 2 contains descriptions of current data, research,
and ongoing federal youth suicide prevention programs for
American Indians and Alaska Natives, conveying the purpose of
Section 3. Definitions
Section 3 includes definitions to be used for S. 1635. For
the purposes of S. 1635, ``Administration'' means the Substance
Abuse and Mental Health Services Administration;
``Demonstration Project'' means the Indian youth telemental
health demonstration project authorized under section 4(a) of
S. 1635; and ``Indian'' means any individual who is either a
member of an Indian tribe or eligible for health services under
the Indian Health Care Improvement Act. In addition, ``Indian
tribe'' has the meaning given to the term in section 4 of the
Indian Self-Determination and Education Assistance Act;
``Secretary'' means the Secretary of Health and Human Services;
``Service'' means the Indian Health Service; ``Telemental
Health'' means the use of electronic information and
telecommunication technologies to support long distance mental
health care, patient and professional-related education, public
health, and health administration; and ``Tribal Organization''
has the meaning given the term in section 4 of the Indian Self-
Determination and Education Assistance Act.
Section 4. Indian Youth Telemental Health Demonstration Project
Section 4 authorizes the Secretary of the Department of
Health and Human Services (HHS), through the IHS, to carry out
a telemental health services demonstration project targeted to
Indian youth suicide prevention. Telemental health services may
include mental health services provided to remote locations
through technological means; educational material distribution;
and data collection. The demonstration project will award up to
five, four-year grants to Indian tribes and tribal health
Indian tribes and tribal organizations that operate one or
more of the following facilities would be eligible for grants:
(1) facilities located in IHS regions with documented
disproportionately high rates of suicides; (2) facilities
reporting active clinical telehealth capabilities; or (3)
facilities offering school-based telemental health services
relating to psychiatry to Indian youth.
There is an authorization of $1,500,000 for each of the
fiscal years 2010 through 2013. The IHS is required to consult
SAMHSA in the development and progress of this demonstration
Section 5. Substance Abuse and Mental Health Services Administration
Section 5 is intended to enhance the provision of mental
health care services for Indian youth provided through SAMHSA
funding by decreasing the application barriers Indian tribes
and tribal organizations face.
This section requires SAMHSA to maximize the efficiency of
and streamline the process by which Indian tribes or tribal
organizations may apply for grants. This includes accepting
non-electronic grant applications from Indian tribes and tribal
organizations and ensuring that tribes are not required to
apply for grants through states.
In addition, this section asks that the unique needs of
tribal communities with a high youth suicide rate, regardless
of resources or infrastructure, be taken into consideration in
the application and award process of SAMHSA grants.
This section also requires states that include tribal data
in their grant applications to partner with tribes and tribal
organizations within the state throughout the implementation of
their programs. These states must provide a description of how
they will use a portion of the funds within the Indian
population and report on these efforts within a year.
A provision is included that prevents federal agencies from
requiring Indian tribes or tribal organizations to provide
matching funds in order to apply for a grant.
This section requires SAMHSA to monitor Indian Country
suicide rates. However, any SAMHSA response or activities in
Indian Country would require consultation with the respective
tribe. The provision also allows for any disadvantaged Indian
tribe (in terms of locality and/or resources) experiencing an
unusually high rate of youth suicide to be eligible for
assistance from SAMHSA. This provision includes an
authorization for funding amounts as the Secretary of Health
and Human Services deems necessary.
The last provision within this section requires that a
SAMHSA grant recipient, serving an Indian youth population,
provide training or education for individuals (including
teachers, parents, coaches, and mentors) working with youth.
The goal is to increase the early identification and
intervention of at-risk Indian youth, while utilizing the
already existing social network.
Section 6. Use of predoctoral psychology and psychiatry interns
Section 6 encourages Indian tribes, tribal organizations,
and other mental health care providers serving Indian Country
to utilize predoctoral psychology and psychiatry interns.
Indian Country faces extreme shortages of mental health
professionals and this provision will help increase the number
of patients accessing care and serve as a recruitment tool for
psychologists and psychiatrists.
Section 7. Indian Youth Life Skills Development Demonstration Program
Section 7 authorizes a demonstration grant program through
the Substance Abuse and Mental Health Services Administration
to provide grants to tribes and tribal organizations to provide
culturally compatible, school-based suicide prevention
curriculum to strengthen American Indian and Alaska Native teen
``life skills''. The section authorizes $4 million dollars for
each fiscal year, 2010 through 2014.
COMMITTEE RECOMMENDATION AND TABULATION OF VOTE
In an open business meeting on December 3, 2009, the
Committee on Indian Affairs, by voice vote, adopted S. 1635, as
amended, and ordered the bill reported to the Senate, with the
recommendation that the bill do pass.
COST AND BUDGETARY CONSIDERATIONS
To date, the Committee has not received a report on the
cost or budget consideration from the Congressional Budget
Office for S. 1635.
REGULATORY AND PAPERWORK IMPACT STATEMENT
Paragraph 11(b) of rule XXVI of the Standing Rules of the
Senate requires that each report accompanying a bill evaluate
the regulatory and paperwork impact that would be incurred in
carrying out the bill. The Committee believes that the
regulatory and paperwork impact of S. 1635 will be minimal.
CHANGES IN EXISTING LAW
In compliance with subsection 12 of rule XXVI of the
Standing Rules of the Senate, the Committee finds that the
enactment of S. 1635 will not make any changes in existing law.