RUTHFULLY YOURS

When it returns in June, house leadership has indicated it may take up a mental-health bill originally proposed by Representative Tim Murphy (R., Penn.), the Helping Families in Mental Health Crisis Act (H.R. 2646) as rewritten by Representative Fred Upton (R., Michigan). The well-intentioned Upton rewrite keeps some important provisions of the original bill, but it ignores the core finding of Murphy’s multi-year investigation of the mental-health system. Murphy found that we do not need to spend more money to cut the practice of incarcerating 365,000 seriously mentally ill, or to help the 140,000 seriously mentally ill who today go homeless. What’s required is for Congress to focus already-existing funding streams on treating adults known to have serious mental illness instead of using them to improve mental wellness in all others. It is the most seriously ill — not the worried well — who are most likely to become homeless or incarcerated or violent.

While some think more money is the only answer, the federal government already spends $130 billion annually on mental-health services, yet homelessness, arrest, incarceration, and violence related to untreated serious mental illness are all rising. That’s because the two agencies government charged with setting mental health policy — the Substance Abuse and Mental Health Administration (SAMHSA) and the Center for Mental Health Services (CMHS)­­ — moved away from a science-based system that spent mental-health dollars on delivering treatment to adults who were the most seriously mentally ill and who most needed treatment. Tragically, the system today largely ignores science and the seriously ill. Instead it works to improve the “sense of wellness” in the highest functioning. Under this new rubric, anything that makes you feel sad is now a mental illness.

National Review, the Wall Street Journal, and leading experts such as Dr. Sally Satel at the American Enterprise Institute, Dr. E. Fuller Torrey of the Treatment Advocacy Center, as well as my own organization Mental Illness Policy Org have extensively documented how SAMHSA and CMHS drive federal dollars away from the core mission of helping the most seriously ill. SAMHSA promotes prevention in spite of the fact that there is no known way to prevent serious mental illnesses such as schizophrenia and depression. “Preventing mental illness” is a great sound bite but lousy science. They use funds to address “trauma.” But everyone loses a parent and many people experience a trauma at some point. That is not a mental illness. It is part of life. Because SAMHSA and CMHS have no doctors at the top — or even on staff — they certify ineffective programs as being evidence-based. Virtually the only people who support SAMHSA or CMHS are those who receive SAMHSA and CMHS funds. That is not who Upton should listen to.

There are many ways to fix SAMHSA and CMHS. Some are heavy lifts, like eliminating the agencies altogether. The savings could reduce the debt, be block-granted to states without federal direction, or distributed to other agencies such as the National Institute of Mental Health (NIMH), the Centers for Disease Control (CDC), and the Department of Justice, all of which do a better job at helping the seriously ill.

But one idea is easy and free and deserves bipartisan support: require the heads of SAMHSA and CMHS to be medical doctors experienced in treating serious mental illness. They would have the knowledge to move those agencies toward a more evidence-based approach. All federal medical agencies except SAMHSA and CMHS are headed by doctors. The NIMH, the CDC, the National Institutes of Health and its components including the National Cancer Institute and National Eye Institute are all headed by doctors. SAMHSA and CMHS should be, too. It is incomprehensible that the two major agencies dedicated to mental illness are not headed by doctors and do not have doctors on staff. Both parties say they want to integrate health and mental-health care. Placing M.D.s at the head of these agencies would be an important first step.

In response to previous media pressure, SAMHSA did in the past hire a doctor. She lasted two years and recently wrote a scathing article, “The Federal Government Ignores the Treatment Needs of Americans with Serious Mental Illness,” explaining how the lack of doctors in leadership positions is creating mayhem:

SAMHSA does not address the treatment needs of the most vulnerable in our society. Rather, the unit within SAMHSA charged with addressing these disorders, the Center for Mental Health Services . . . generally ignores the treatment of mental disorders. There is a perceptible hostility toward psychiatric medicine: a resistance to addressing the treatment needs of those with serious mental illness and a questioning by some at SAMHSA as to whether mental disorders even exist — for example, is psychosis just a “different way of thinking for some experiencing stress?”

Various bills now under consideration propose to address the lack of informed medical leadership at SAMHSA and CMHS by creating new bureaucracies that put a doctor over or under SAMHSA and CMHS. But adding layers of medical bureaucracy over or under the administrator will not help if the officials at the top of SAMHSA and CMHS are not themselves doctors. The fish stinks at the top: That is what we must fix. The issue doesn’t have to be studied; it needs to be fixed.

The failure of Congress to force SAMHSA and CMHS to focus on the seriously ill continues to be costly and deadly, as Chief (Ret.) Michael Biasotti, the Chairman of the New York State Association of Chiefs of Police Committee on Untreated Severe Mental Illness, explained to a House subcommittee:

We have two mental-health systems today, serving two mutually exclusive populations: Community programs serve those who seek and accept treatment. Those who refuse, or are too sick to seek treatment voluntarily, become a law-enforcement responsibility. . . . Mental-health officials seem unwilling to recognize or take responsibility for this second more symptomatic group. Ignoring them puts patients, the public, and police at risk and costs more than keeping care within the mental-health system.

That’s the problem Murphy tried to fix. And Upton shouldn’t ignore it.

— D. J. Jaffe is Executive Director of Mental Illness Policy Org, a nonpartisan think tank on serious mental illness.