Stop the Madness
The incoming Trump administration has an opportunity to get the treatment of the seriously mentally ill right—finally.
A smart, well-designed mental-health bill passed Congress last week as part of the 21st Century Cures Act. But unless President-elect Trump “drains the swamp” at the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Mental Health Services (CMHS)—divisions of the federal Department of Health and Human Services—many of the new law’s useful provisions could be negated or undone by the permanent bureaucracy.
SAMHSA and CMHS are largely responsible for overseeing and implementing federal mental-health policy, and will remain so under the Cures Act. Unfortunately, those agencies are failures, as SAMHSA’s former chief medical officer, Elinore McCance-Katz, revealed in an op-ed after she left the agency in disgust in 2015. “SAMHSA does not address the treatment needs of the most vulnerable in our society…There is a perceptible hostility toward psychiatric medicine, a resistance to addressing the treatment needs of those with serious mental illness, and a questioning by some at SAMHSA as to whether mental disorders even exist—for example, is psychosis just a ‘different way of thinking for some experiencing stress?’”
SAMHSA and CMHS virtually ignore high rates of homelessness, arrest, incarceration, suicide, and hospitalization that occur when the seriously mentally ill are allowed to go untreated. Instead, they wrap the provision of social services in a mental-health narrative and divert funds to unrelated or ineffective programs. These agencies encourage states to spend part of the $500 million that they receive in federal mental-health block-grant funding, money that is required to help people with serious mental illness, on people who don’t even have mental illness and on preventing serious mental illnesses, even though schizophrenia and bipolar disorder have no known means of prevention. Nonprofit groups that depend on SAMHSA funding have lobbied states to close psychiatric hospitals, thereby making treatment more difficult. Recently, groups associated with SAMHSA convinced New York City to divert $8 million of city funds to Mental Health First Aid, a SAMHSA-promoted educational program that trains people to “better recognize the signs, symptoms and risk factors of mental illness and addiction and more effectively provide support.” The program does nothing to help the mentally ill because no treatment is made available, even when symptoms are identified.
SAMHSA and CMHS are failed agencies that have almost no support from anyone other than those whom they fund. Thanks to the leadership of Pennsylvania Republican congressman Tim Murphy, the mental-health provisions of the Cures Act attempt to refocus SAMHSA and CMHS on the seriously ill—as opposed to the less seriously ill like those with mild anxiety—and to rely on science rather than pop psychology. The Cures Act replaces the SAMHSA administrator with an assistant secretary for mental health and substance-use disorders. The person who fills this important job will be responsible for both SAMHSA and CMHS, and for coordinating mental-health policy with other federal agencies. Trump should appoint someone like McCance-Katz, who is committed to focusing on the seriously ill and ending the funding of nonsense. Or appoint a judge who is committed to reducing incarceration of the mentally ill.
Murphy, along with powerful Texas Republican senator John Cornyn, included in the bill many provisions that are designed to force SAMHSA and CMHS to focus on the seriously ill. In the past, however, these agencies have ignored congressional direction, especially as it relates to Assisted Outpatient Treatment (AOT). Known as “Kendra’s Law” in New York and “Laura’s Law” in California, AOT is court-ordered, out-patient treatment of the most seriously ill, who may be so sick that they are unaware of their own symptoms. AOT is reserved for a tiny group of patients who have historically failed to comply with treatment. By keeping such patients out of jails and hospitals, and ensuring that they take prescribed violence-preventing medications, AOT has improved outcomes and reduced the costs of care.
The Cures Act extends and modestly expands federal AOT funding through 2022. The last time Congress funded AOT, however, CMHS bureaucrats hijacked the grant-funding process, giving preference to states whose AOT teams employed a “peer-support worker.” In other words, the agency required state mental-health agencies to hire people with mental illness. There is no evidence that this improves outcomes, but it clearly increases costs.
SAMHSA-funded groups succeeded in watering down the final bill. Early iterations of the Cures Act contained provisions that would have allowed parents to access medical information about their seriously mentally ill adult children, as well as provisions to increase the number of hospital beds available to the seriously ill and reign in federally funded anti-treatment lawyers. But the bill is still a major step forward. It provides funding for mental-health courts, which can divert nonviolent, seriously mentally ill offenders to mandated treatment instead of jail. It provides funds to train police on how to deescalate interventions with the seriously ill. It provides for the collection and dissemination of data on the number and types of crimes committed by mentally ill individuals, the involvement of mental illness in deadly incidents involving law-enforcement officers, and the costs of imprisoning the seriously ill.
For too long, we have spent too much on trying to improve “mental wellness”—whatever that is—rather than delivering treatments that can reduce homelessness, arrest, incarceration, suicide, and hospitalization among the seriously mentally ill. We’ve sent the least ill to the head of the line and the most-seriously ill into the shadow mental-health system of jail and prison. Bullying and stress have been treated; schizophrenia and bipolar have been ignored. This bill attempts to end that insanity. And if the right person is appointed as assistant secretary, it will likely work.