Yes, President Trump is shaking up Washington, but some things definitely need to be shaken up. Exhibit A is the nation’s mental-health services — or lack of same. As if we needed another reminder, when a man with a gun walks into an FBI office hearing voices and complaining that the CIA is pushing him to become a member of al-Qaeda, he is asking to be treated for his psychosis. Instead, he was given some anti-anxiety medication, released after three days, and given back his gun, which he then took to Ft. Lauderdale. Alaska or Arizona, Colorado or Connecticut — it is the same story, year after year, differing only slightly in detail and diagnosis. But the outcome is the same: innocent people needlessly killed and injured.
On the horizon of this bleak landscape, a light recently appeared. Within the 21st Century Cure Act, passed by Congress in an unusually bipartisan fashion in December, is a provision for an assistant secretary of mental health and substance abuse. This new position will have authority to coordinate efforts by the dozens of federal agencies that have mental-health programs. Equally important, the person will also have authority to reform the dysfunctional Substance Abuse and Mental Health Services Administration (SAMHSA), the $3.5 billion federal agency that is officially charged with reducing “the impact of substance abuse and mental illness on America’s communities.” Thus, it is critical that Representative Tom Price (R., Ga.), now confirmed as secretary of the Department of Health and Human Services, select as assistant secretary a mental-health professional who is strong, clinically and administratively experienced, and unafraid to rattle federal cages. Changing the direction of an aircraft carrier is simple compared with changing the direction of a federal agency.
What might we expect from successful leadership by an assistant secretary? We should expect improvement in the many measures of a failing mental-illness-treatment system that were brought to light by congressional hearings held by Representative Tim Murphy (R., Pa.), the author of the original legislation that proposed the creation of an assistant-secretary position.
These measures include homicides by people with untreated serious mental illness, suicides, homelessness, increasing numbers of mentally ill individuals in jails and prisons, increasing numbers sitting for days in emergency rooms waiting for psychiatric beds, and increasing encounters between mentally ill individuals and law-enforcement officials. Since SAMHSA came into being in 1992, the nation is significantly worse off on every one of these measures.
We should also expect the many federal agencies that have mental-health programs to speak to one another and meet regularly, which has not happened for years. Medicaid, Medicare, Social Security, and the Veterans Administration, for example, all spend huge amounts on mental-health care, but there is virtually no coordination among them or with SAMHSA’s mental-health block grant to the states. Since the states have the ultimate responsibility for delivering the services, there must also be coordinated, federally funded demonstration projects and data collection to identify the programs that are most effective in stabilizing and providing rehabilitation and recovery for mentally ill individuals. The funding of assisted outpatient treatment (AOT) programs under the recent legislation is a step in this direction.
Finally, we should expect better leadership within the federal agency that is supposed to be coordinating mental-health initiatives.
Under previous leadership, the psychiatrist called upon to represent SAMHSA denied that schizophrenia is a brain disease, calling it instead ‘a creative experience for growth development.’
Remarkably, among its 553 employees, SAMHSA has gone for months at a time without employing a single psychiatrist. Under previous SAMHSA leadership, the psychiatrist regularly called upon to represent the agency at public hearings, for example, denied that schizophrenia is a disease of the brain, calling it instead, “severe emotional distress,” “a spiritual experience,” and “a creative experience for growth development.” Indeed, SAMHSA’s previous chief medical officer, who resigned in 2015 in disgust, publicly claimed that some SAMSHA staff question “whether mental disorders even exist.”
All Americans are losers for having this lack of federal leadership, but the biggest losers are the people with serious mental illness and their families. The new assistant secretary, for the first time in many years, provides a ray of hope.
— E. Fuller Torrey, M.D., is the author of American Psychosis and the founder of the Treatment Advocacy Center. John D. Snook is the executive director of the Treatment Advocacy Center.