At last, Congress is moving on mental-health reform. On Wednesday the House Energy and Commerce Subcommittee on Health will mark up the Helping Families in Mental Health Crisis Act of 2015 (H.R. 2646). This bill — spearheaded by Representative Tim Murphy (R., Pa.), a child psychologist, and Representative Eddie Bernice Johnson (D., Tex.), a former psychiatric nurse — has garnered bipartisan support with 156 co-sponsors and is the most far-reaching and serious attempt at mental-health reform in recent memory.
Unfortunately, advocacy groups opposed to all involuntary mental-health care are putting up strong opposition. This small but vocal faction has the ear of some committee Democrats. Well-meaning though they may be, these critics, and the lawmakers who are receptive to their claims, don’t seem to grasp the vital difference between serious mental illnesses — conditions such as schizophrenia, bipolar illness, and severe depression, which are marked by psychosis, high risk for suicide, or both — and other, less disabling psychiatric conditions. The sad clinical reality is that some severely ill patients have periods, ranging from months to years, when they are too lost in delusions, hallucinations, and apathy to care for themselves.
Opponents of H.R. 2646 appear to believe that voluntary, community-based care is all that is needed — and in fact, for the majority of mentally ill people, this is indeed the case. To be sure, the psychiatric profession was once too pessimistic about patients who were actually capable of greater independence, and it was too dismissive of their potential for productivity. But there is no denying that a subset of patients needs intensive oversight and, at times, even benign coercion. Accordingly, the Murphy-Johnson bill would reorder the mental-health system for all patients, including individuals who, when left untreated, are at higher risk of violence, incarceration, re-hospitalization, and homelessness.
Because H.R. 2646 rattles the status quo, those with vested interests in the current system, along with others who share their ideological commitments, are out in force to oppose the bill’s important changes. Three areas stand out as particularly important.
First, there is the Substance Abuse and Mental Health Services Administration (part of the Department of HHS), or SAMHSA. It is the nation’s lead agency on mental health. SAMHSA manages block grants to states, funds discretionary programs, gives “technical support” to states, and expresses a general philosophy about the nature of mental illness and its treatment. In this regard, the agency has been a qualified failure. SAMHSA has supported and continues to fund advocacy groups such as the National Coalition for Mental Health Recovery that actively dissuade patients from taking needed medication.
SAMHSA also endorses a so-called recovery model in which “consumers” (the word “patient” was long ago jettisoned for being politically incorrect) work with clinicians to determine their care. This approach makes sense for patients who are able to collaborate, but not for those who are wildly paranoid or unable to concentrate, or who will not even acknowledge that they have an illness. Indeed, roughly half of all patients with schizophrenia are not even aware that they are ill, a condition called anosognosia.
The Murphy-Johnson bill calls for the creation of a new position to exercise oversight: an assistant secretary for mental health and substance abuse.
The agency considers “trauma” and “toxic stress” to be primary causes of severe mental illness. While these problems can certainly exacerbate symptoms, they play no known causal role. And treatment? The prescription is empowerment and “peer” support, neither of which has yet been validated empirically as a primary treatment for chronic, psychotic illness.
A 2014 GAO report found little evidence that SAMHSA was up to the task of serving the most severely ill. SAMHSA “has shown little leadership in coordinating federal efforts on behalf of those with serious mental illness,” the report concludes. In fact, the GAO discovered that only a few of the 30 federal programs specifically targeted at individuals with a severe mental illness were even under SAMHSA’s administrative umbrella. They were instead housed in agencies such as the Veterans Administration and the Department of Justice, whose chief missions don’t include mental health.
In response to such derelict leadership, the Murphy-Johnson bill calls for the creation of a new position to exercise oversight: an assistant secretary for mental health and substance abuse. The funding and authority of SAMHSA would be placed under this assistant secretary, who would focus on coordinating the federal government’s programs and elevating the importance of caring for the most debilitated patients.
Not surprisingly, radical “consumer” groups receiving funding from SAMHSA, and other constituents that endorse its mission, argue against the proposed assistant-secretary position as a new “bureaucracy.” This is embarrassingly transparent. In reality, this “new layer of government” would shine a spotlight on SAMHSA’s deficits, scrutinize the best use of funds, promote tested treatments, and exercise the kind of accountability that the nonpartisan GAO has determined is sorely needed.
#share#The second major area of concern is assisted outpatient treatment. AOT is a cost-saving and effective form of civil-court-ordered community treatment, aimed at individuals who have an established pattern of falling into a spiral of self-neglect, self-harm, or dangerousness when off medication. Judges can order these individuals into mandated and monitored treatment while they continue to live in the community. Violation of the court-ordered conditions can result in an evaluation of a patient’s need for further treatment. Data from multiple AOT programs indicate they reduce crime, violence (including suicide attempts), and victimization of the mentally ill when diligently enforced.
Patients are discharged too quickly, often deteriorate upon release, and end up cycling back into facilities or jails, in a classic revolving-door pattern.
Yet a group of 19 Democrats circulated a letter last week opposing AOT and attempting to pit passage of AOT against expanding services such as supported housing and peer-support services. This is a false choice. Patients should indeed receive quality social services, but a fraction of them will also need more supervision. Individuals overwhelmed by delusions, hallucinations, and the wholesale misery of extreme mental illness need a lot more than a place to sleep and other patients to talk to. Yet their only other option shouldn’t be one of a county’s few remaining hospital beds if they can do well with more freedom in the community under AOT.
Finally, there is a critical shortage of psychiatric beds. From a nationwide peak of around 560,000 psychiatric beds in 1955, the total has been whittled down to about 35,000 today, half the number experts estimate is needed. This problem can be traced in large part to an outdated 1965 law called the IMD exclusion, which prohibits Medicaid from paying for care delivered to patients between the ages of 22 and 64 if that care is provided in an “institution for the treatment of mental diseases,” or IMD.
The IMD exclusion was intended to spur momentum for community treatment by barring the doors to the asylum, but the pendulum has swung too far. Because of the woeful bed shortage, individuals get hospitalized when they are at their most ill. Then they are discharged too quickly, before their symptoms are sufficiently stabilized. The patients often deteriorate upon release and end up cycling back into facilities or jails, in a classic revolving-door pattern.
Aside from the turmoil and heartache that go along with chronic, psychotic illness, it is also very expensive. Schizophrenia and bipolar illness represent two of the top three causes of 30-day Medicaid in-patient re-admissions (as measured by diagnosis, not unique patients). Along with diabetes, these conditions resulted in about $839 million in hospital costs. And hospital costs are just the beginning. Without beds, patients flood emergency rooms, lying on gurneys for days or weeks, costing the state and federal government millions of dollars. One need only look to headlines from states as diverse as Washington and Mississippi, or this recent story from Minnesota, to know that this is a nationwide concern.
#related#Meanwhile, state jails and prisons are bursting at the seams with mentally ill prisoners who don’t belong there. In Pennsylvania, the lack of beds is so dire that the ACLU is suing the state for unconstitutionally jailing individuals for weeks or months as they await transfer to one of the state’s few remaining beds. The appalling upshot is that there are ten times as many mentally ill people in jails and prisons as there are in hospital beds.
The Murphy-Johnson bill has many other provisions as well. All are long overdue and clinically realistic — and they enjoy broad support from the mental-health community. Yet, remarkably, critics deem stronger oversight of SAMSHA, support for AOT, and more psychiatric beds to be harmful to patients. In truth, these provisions are vital to the reversing the marginalization of the sickest patients by SAMHSA and the inadvertent problems caused by Medicaid’s disincentives. Misconceptions about the needs of these patients must not be allowed to interfere with the bill’s mark-up, so it will emerge from the Health Subcommittee with its bold and much-needed provisions intact.
— Sally Satel, M.D., is a resident scholar at the American Enterprise Institute. E. Fuller Torrey, M.D., is founder of the Treatment Advocacy Center in Arlington, Va.