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Bureaucratic Insanity
From the June 20, 2011, issue of NR.


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Some federal-budget cutters claim that we have already picked all the low-hanging fruit. Those of us who work in Washington know better, although it is not considered polite to say so. One counterexample is SAMHSA, a federal health agency distinguished by the fact that the health of its clients would improve if it went out of business.

The acronym stands for the Substance Abuse and Mental Health Services Administration, a $3.6 billion component of the Department of Health and Human Services. It employs 537 people, who have an average salary of $107,760; almost three-quarters have jobs rated a 13 or higher on the General Schedule, meaning their salaries start above $70,000. Its official mission is to reduce “the impact of substance abuse and mental illness on America’s communities” and increase access to treatment services.

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Given this mission, one might think that SAMHSA would have a major interest in the two most serious mental illnesses — schizophrenia and bipolar disorder — which together affect 7.7 million Americans, according to the National Institute of Mental Health.

An increasing percentage of homeless persons, as well as individuals in jails and prisons, are diagnosed with serious mental illnesses. This is a direct consequence of the continuing decline in the number of state mental-hospital beds, combined with our failure to provide treatment once these patients return to the community. However, judging by the just-released document “Leading Change: A Plan for SAMHSA’s Roles and Actions 2011–2014,” such individuals not only are not a priority for the organization, they do not even exist. Not once in the 41,804-word text of this three-year plan is either schizophrenia or bipolar disorder even mentioned. Instead, the nation’s mental-health ills are all subsumed under a vague category called “behavioral health problems.” Assuming this broad mandate has allowed SAMHSA to dabble widely and ignore the most serious disorders.

One might also think that SAMHSA would be concerned that 4.7 million individuals receive Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) because they suffer from “mental disorders, other” (as the category is named). The total federal cost for such support for these mentally ill individuals in 2009 was $45.7 billion. When I recently queried SAMHSA about what it knows about these 4.7 million people and why some states have three times as many mentally ill individuals per capita on SSI and SSDI as other states, the agency replied, “SAMHSA does not collect this information. . . . We have no data.”

One might also expect SAMHSA to exhibit concern about the fact that 3.5 million out of the 7.7 million most severely mentally ill individuals in the U.S. are not being treated, according to the National Institute of Mental Health. This includes a small number of individuals like Jared Lee Loughner, who become dangerous if not treated. It also includes many of those on SSI and SSDI, and one wonders how many of them could be removed from those rolls if they were properly treated. Yet SAMHSA gives many grants to organizations that oppose forcing the severely mentally ill to receive treatment.

For example, the Pennsylvania Mental Health Consumers’ Association, which receives a recurring grant of $70,000 from SAMHSA, is currently opposing a bill that could make it easier to treat seriously mentally ill individuals in Pennsylvania. Another SAMHSA grantee, the California Network of Mental Health Clients, has lobbied successfully to block the use of assisted outpatient treatment (AOT) in the state, even though AOT targets the sickest individuals who are not taking their medication and are potentially dangerous, and has been shown to decrease rehospitalization, incarceration, and violence among such individuals. SAMHSA-supported consumer groups in Maine and Vermont have also opposed improving their state’s mental-illness-treatment system within the past two years. Perhaps the best measure of SAMHSA’s lack of commitment to treatment of severe mental illness is the $330,000 per year it gives to the National Empowerment Center in Lawrence, Mass. Daniel Fisher, its director, has written that “the covert mission of the mental health system . . . is social control.” Laurie Ahern, a former co-director, believes that “mental illness is a coping mechanism, not a disease.”



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