This week, over 900 people died of opioid overdoses, and 400,000 mentally ill spent the night behind bars. But next year could be different if Congress continues its support of changes being made at the Substance Abuse and Mental Health Services Administration (SAMHSA) and its Center for Mental Health Services (CMHS).
Historically, SAMHSA and CMHS have been part of the problem, not the solution. They spent mental-health resources on improving mental wellness among the masses, rather than on lowering rates of homelessness, arrest, incarceration, and needless hospitalization of the seriously mentally ill. In 2016, to focus SAMHSA and CMHS on the most seriously mentally ill and better address the opioid crisis, Congress passed the 21st Century Cures Act — and in 2017 it confirmed addiction expert McCance Katz as the first assistant secretary of mental-health and substance-use disorders (working under Alex Azar in the Department of Health and Human Services). Those two actions are starting to have an impact.
SAMHSA has now funded 18 Assisted Outpatient Treatment programs. Assisted Outpatient Treatment is perhaps the most successful program for the most seriously mentally ill who fail to comply with treatment. By keeping them in one year of mandated and monitored treatment while they continue to live at home, it reduces homelessness, arrest, and incarceration of the seriously mentally ill by about 70 percent and saves taxpayers 50 percent of the cost of care. Before the 21st Century Cures Act and McCance-Katz’s arrival, the program was ignored and CMHS funds were actually funding opposition to it.
In fact, prior to the 2016 and 2017 congressional actions, SAMHSA and CMHS ignored all the institutionalized mentally ill by failing to even count them. They counted and focused their efforts on those well enough to live in the community. That is changing. SAMHSA recently convened a panel of experts to ensure that the mentally ill in hospitals, jails, prisons, group homes, adult homes, and other institutional venues are counted so SAMHSA and CMHS can take steps to reduce their numbers. She included members of the criminal-justice community, who had historically been shut out of SAMHSA, because they are in a position to help. Secretary Azar took steps supported by McCance-Katz to improve care for the institutionalized mentally ill when he recently announced a process that would allow states to receive Medicaid funds for them, a process previously prohibited.
Perhaps most important, McCance-Katz removed Paolo del Vecchio as head of the Center for Mental Health Services (CMHS), the unit directly responsible for mental-health spending. Del Vecchio did not have a science or medical background and often diverted SAMHSA funds to pop-psychology programs for the highest functioning rather than devoting them to programs that would help the seriously ill. Under del Vecchio, CMHS required states to spend federal funds on “prevention” programs even though there is no way to prevent schizophrenia and bipolar disorder, which afflict the bulk of the seriously mentally ill. For his replacement, she tapped Anita Everett, the immediate past president of the American Psychiatric Association, who has extensive experience in treating patients and systems reform. McCance-Katz simultaneously hired more doctors to ensure important expertise was available in-house and restructured the Technical Assistance Programs so SAMHSA expertise would penetrate the entire treatment community not just the those who had tentacles into SAMHSA.
SAMHSA has also started to demand evidence that federally funded programs work. In the United States, anyone can claim to have invented an education module or talk therapy that works, and SAMHSA historically helped such people by listing them as “evidence-based” and encouraging states to use federal funds to buy the listed programs. But few of the listed programs were actual treatments, and the “evidence” often came straight from those who invented, sold, and profited from them. Programs and practices included coloring books and sing-a-long songs. McCance-Katz eliminated the registry and replaced it with a more scientifically oriented process to evaluate interventions.
While the major science-based organizations trying to improve care for the seriously mentally ill hail these changes, organizations used to receiving funds without any obligation to treat the seriously ill or provide evidence their programs work are opposed. So are some in the agency who object to having their fiefdoms held accountable.
The question is: Will Congress continue to support progress, or will it defer to those who were part of the problem?