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                                                       Calendar No. 336
111th Congress                                                   Report
                                 SENATE
 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 
                               following

                              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.

                                PURPOSE

    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.

                               BACKGROUND

    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 communities.
    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 
in 2005.
    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 
Indian youth.
    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.

                          LEGISLATIVE HISTORY

    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 
skills.''
    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 
health services.

                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 
2009.

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 
this Act.

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 
organizations.
    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 
project.

Section 5. Substance Abuse and Mental Health Services Administration 
        Grants

    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.