Politics & Policy

The Way Forward on Federal Mental Health Policy

(Photo: Vedran Vidovic/Dreamstime)
A federal agency’s report on the problem of serious mental illness is a good start.

Last Thursday, the Trump administration issued the first iteration of its congressionally mandated Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) report. Titled “The Way Forward,” the report is intended to be a blueprint for how the federal government can improve care for the most seriously mentally ill. It is a step in the right direction.

The ISMICC, working under the leadership of Dr. Elinore McCance-Katz, the assistant secretary of Mental Health and Substance Use Disorders, comprises ten federal members representing different agencies and 14 members representing the public- and mental-health industries. These officials were tasked with evaluating the nation’s response to the seriously mentally ill and proposing improvements to Congress.

The problem with our mental-health policy is huge. As I documented in Insane Consequences: How the Mental Health Industry Fails the Mentally Ill, despite $147 billion of annual spending in federal funds and another $40 billion or so in state funds, 140,000 seriously mentally ill individuals are homeless while 390,000 remain incarcerated. Thankfully, the ISMICC defined the rates of homelessness, arrest, incarceration, violence and needless hospitalization as the biggest problems facing the seriously mentally ill.

Helping the most seriously ill, those who can’t help themselves, is a legitimate core function of government. Unfortunately, both the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Mental Health Services (CMHS) remain headed by Obama holdovers who refuse to focus on the most seriously ill or address the most-pressing issues like violence, fearing that doing so will cause a “stigma” by highlighting the association between violence and untreated serious mental illness. Instead, these officials focus their agencies on pumping out pop-psychology webinars, publications and grants to improve “mental wellness” among the higher functioning. President Trump and acting HHS secretary Eric Hargan should replace the leaders of SAMHSA and CMHS with doctors like Dr. McCance-Katz who are committed to using taxpayer dollars for the most important issues that affect the seriously ill, not for the sideshows.

Beyond defining the problem, this first report contains initial recommendations made by the public members of the committee. Many are relevant to reducing homelessness, arrest, incarceration and needless hospitalization, but others are not. This is likely the result of the committee having very little time to sort through their ideas: The final report is not due until four years from now. So there is plenty of time to modify the recommendations and prioritize the most-important ones. Hopefully, the committee members will.

On the plus side, the public members called for ending one provision in Medicaid (the IMD Exclusion) and one in Medicare (the 190-day limit on psychiatric inpatient hospitalization) that discouraged states from hospitalizing the most seriously mentally ill. Relatedly, the committee urged the establishment of a minimum standard under the Emergency Medical Treatment and Labor Act (EMTALA), which precludes hospitals from turning away emergency-room patients without stabilizing them. Almost all hospitals routinely turn away the seriously mentally ill before they are stabilized — much to the chagrin of the police who bring them in for care, only to find them released while still psychotic.

There is plenty of time for the committee to modify its recommendations and prioritize the most-important ones.

The report thoughtfully takes a strong stance and recommends the wider use of clozapine, an atypical antipsychotic medication that, for people with schizophrenia, is often superior to other medications. It also recommends long-acting injectable medications, which have higher compliance rates. The committee should also encourage greater use of electroconvulsive therapy (ECT). ECT can benefit those who haven’t been helped by other treatments, have a high risk of suicide, or don’t want to ingest medications (like the elderly or pregnant). Likewise, the final report should support group homes and the expansion of clubhouse programs such as New York’s Fountain House, perhaps the finest treatment model for the most seriously ill.

On the criminal-justice side, the report calls for the implementation of science-based competency-restoration procedures. Many people who have serious mental illnesses sit in jail for months because they are not competent to stand trial. Speeding up the restoration of competency could dramatically and safely reduce the number of seriously mentally ill Americans who are sitting behind bars at great public expense.

The report also calls for eliminating federal policies that impede access to care, but committee members did not name the programs. The federally funded Protection and Advocacy (PAIMI) Program and the Department of Justice’s Civil Rights of Institutionalized Persons Act (CRIPA) program are two programs that should be reined in. These laws make it difficult to reduce homelessness, arrest, and incarceration. When doctors, parents, police and judges determine that someone needs civil commitment, federally funded PAIMI lawyers rush in to overturn that decision by arguing that being psychotic is a civil right that must be protected, rather than an illness that ought to be treated. And it is hard to hospitalize those who need hospitalization when federal CRIPA lawyers busy themselves suing states to force the release of patients.   

The public members recommend reforming civil-commitment laws, but they were vague as to what that means. Current civil-commitment laws often require someone to become “dangerous to herself or others” before she can be treated. Laws should prevent violence, not require it. The assistant secretary’s section of the report clearly supports expanding the use of Assisted Outpatient Treatment (AOT), and so should the public members. AOT is perhaps the most effective program government has for the subset of the seriously mentally ill who have already accumulated multiple instances of becoming homeless, arrested, incarcerated, violent, or needlessly hospitalized. It allows judges, after full due process, to order them to stay in one year of monitored treatment while they continue to live in the community. It is less expensive, less restrictive, and as effective as the alternatives, inpatient commitment or incarceration. Expanding the use of AOT should be a priority.

There are some troubling recommendations in the report. It focuses on screening children, which could result in more overdiagnosing and medicating. Its calls for public education serve no purpose. Unlike AIDS, which can be acquired through unsafe sex, and cancer, which can be acquired through smoking, serious mental illnesses like schizophrenia and bipolar are neither preventable nor communicable. That’s why the National Academies of Science rejected the use of public education as a tool to address serious mental illness.

“The Way Forward” is a good first step to restoring sanity to federal policy. But until the right recommendations are prioritized by the committee, adopted and funded by Congress, and signed by the President, it remains a baby step.

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