Magazine | June 20, 2011, Issue

Bureaucratic Insanity

The federal agency that wastes money while undermining public health

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.

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.”

#page#Another SAMHSA-supported undertaking is the $36.4 million Protection and Advocacy (P&A) program. Originally created by Congress to protect mentally ill and mentally retarded individuals from abuse, it has largely functioned to protect them from treatment. One failure of the program was William Bruce. A P&A lawyer “coached him on how to answer doctors’ questions” to get discharged from Maine’s Riverview Psychiatric Center, despite psychiatric testimony that his schizophrenia was not under control and he was still “very dangerous,” the Wall Street Journal reported in 2008. Once discharged, Bruce promptly killed his mother with a hatchet. Properly medicated after the fact, Bruce condemned the P&A program: “The [P&A] advocates didn’t protect me from myself, unfortunately. . . . None of this would have happened if I had been medicated.”

So what else does SAMHSA spend its $3.6 billion in taxpayer funds on? About half goes toward block grants to the states, which use it to fund mental-health and substance-abuse programs. Theoretically, SAMHSA is supposed to provide oversight for these funds, but in fact little oversight occurs. One reason is that the agency has few people with relevant training and experience. The SAMHSA administrator is a lawyer; the deputy administrator is a dentist; the director of its Center for Mental Health Services has a master’s degree in education; and the director of the Center for Substance Abuse Prevention has no listed degree. The directors of two of the three divisions of the Center for Mental Health Services have no listed degrees, and the director of the third has a degree in education. The director of the Center for Substance Abuse Treatment, who is a medical doctor and has a master’s degree in public health, is the only member of the senior staff who appears to be sufficiently trained to oversee the almost $2 billion in federal funds being sent to the states.

SAMHSA also supports conferences. In 2011 it is partially supporting the Fifth Annual Conference on Health Communication, Marketing, and Media. This conference is primarily funded by the Centers for Disease Control and Prevention (CDC), the federal agency that has the primary responsibility for disease-prevention programs. As with its other legitimate functions, SAMHSA’s contribution to disease prevention is duplicative of the functions of other government agencies. In the past, SAMHSA has supported and approved a conference at which one speaker claimed that “schizophrenia is a healthy, valid, desirable condition — not a disorder. . . . What is called schizophrenia in young people appears to be a healthy, transformational process that should be facilitated instead of treated.”

And SAMHSA puts out hundreds of publications — 194 on alcohol abuse alone. Its publications cover the spectrum of human behaviors, including bullying (two publications), peer pressure (five), grief (three), anger management (five), stress prevention (nine), and violence (48). Other publications discuss specific events, such as “Hurricane Recovery Guides Preparedness Planning,” “Oil Spill Response: Making Behavioral Health a Top Priority,” and “Helping Iraq Restore Its Mental Health System.” What does SAMHSA publish on schizophrenia and bipolar disorder? There’s one generic brochure called “Core Elements in Responding to Mental Health Crises,” but it is out of stock. Several divisions of the National Institutes of Health do publish brochures on these diseases — once again rendering SAMHSA’s efforts duplicative and unnecessary.

When looking for low-hanging fruit, then, budget analysts should peer closely at SAMHSA, whose branches are touching the ground. This agency should be abolished, with its few arguably worthwhile components, such as data collection, transferred to the National Institutes of Health. The agencies of NIH have research as their primary mandate, an appropriate federal role. SAMHSA, by contrast, is concerned with mental-health and substance-abuse services, which are best left to state and local governments. If SAMHSA were abolished, nobody would notice that it was gone, and the mental-health and substance-abuse treatment systems would improve.

– Mr. Torrey, a psychiatrist, is the founder of the Treatment Advocacy Center in Arlington, Virginia (www.treatmentadvocacycenter.org).

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