Chairman Murphy and Ms. DeGette, thank you for inviting me to testify on this important issue. I am a psychiatrist specializing in the treatment of individuals with severe mental illnesses, especially schizophrenia and bipolar disorder. I am a retired career officer in the U.S. Public Health Service and currently the Executive Director of the Stanley Medical Research Institute, which spends $40 million each year in private funds for research on schizophrenia and bipolar disorder. I am also the founder of the Treatment Advocacy Center, a non-profit group which advocates for better treatment for individuals with severe mental illness.
I am here to testify regarding SAMHSA’s role in delivering services to the severely mentally ill. SAMHSA is a $3.5 billion agency which has been designated by the Dept. of Health and Human Services (DHHS) as the lead federal agency for services to individuals with mental illness and/or substance abuse problems.
When the federal government receives inquiries regarding mental illness issues, such as occurred following the tragedies in Tucson, Aurora, and Newtown, these inquiries are usually referred to SAMHSA for response. SAMHSA defines its core mission as reducing “the impact of substance abuse and mental illness on America’s communities.” This is an important mission.
I will illustrate today how SAMHSA is failing badly in fulfilling that mission. SAMHSA is, in fact, a very troubled federal agency. But let me clearly state at the outset that this failure is not a Democrat or Republican failure. The failure of SAMHSA is a politically equal opportunity failure. SAMHSA was put together in 1992 from the remnants of existing failed programs from other agencies by President George H. Bush. It continued to be a failed agency under Presidents Bill Clinton and George W. Bush, and is now continuing this tradition of failure under President Barack Obama. I wrote critically of SAMHSA’s failed programs during the first Bush administration (“Hippie Healthcare Policy,” Washington Monthly, April 2002) and have also done so during the Obama administration (“Bureaucratic Insanity,” National Review, June 20, 2011). To politicize SAMHSA and blame its failure on one party or the other is to miss the point.
I will summarize the failures of SAMHSA by contrasting six types of activities SAMHSA should be doing with six types of activities SAMHSA actually is doing.
(1) SAMHSA should be concerned with the fact that mass killings associated with untreated severe mental illnesses are increasing in the United States.
This has now been demonstrated by three studies.1,2,3 The most extensive of the studies was done by the New York Times and showed a dramatic rise in mass killings between 1949 and 1999.
Number of mass killings, 1949-1999 (Chart missing)
All three studies concluded that a majority of the perpetrators were mentally ill, e.g. Seung-Hui Cho, Jared Loughner, and James Holmes, all of whom had schizophrenia.
Schizophrenia is one form of severe mental illness as defined by the National Advisory Mental Health Council in 1992, in response to a request from Congress. In addition to schizophrenia, severe mental illnesses were said to include schizo-affective disorder, bipolar disorder, autism, and severe forms of depression, obsessive-compulsive disorder, and panic disorder. SAMHSA acknowledges that 9.8 million American adults suffer from these illnesses.
What is SAMHSA actually doing? Severe mental illnesses appear to have a very low priority at SAMHSA. In its current three-year plan defining its priorities (“Leading Change: A Plan for SAMHSA’s Roles and Actions, 2011-2014”), a 41,804 word document, there is no mention whatsoever of schizophrenia, schizo-affective disorder, bipolar disorder, severe depression, or obsessive-compulsive disorder, and a single mention of panic disorder.
SAMHSA’s failure to focus on severe mental illnesses was also illustrated by its response to the Newtown mass killings. A Task Force under Vice-President Joseph Biden was convened to make recommendations regarding how such tragedies could be averted in the future. Pamela Hyde, Administrator of SAMHSA and a member of the Task Force, recommended that insurance coverage for mental illness treatment should be improved and that the early identification of individuals with mental illness should also be improved. In fact, insurance coverage and early identification were not problems for Seung-Hui Cho, Jared Loughner, James Holmes, Adam Lanza, or most other perpetrators of these tragedies. The SAMHSA response therefore completely missed the core problem, which is how to guarantee treatment for such severely mentally ill individuals once they are identified.
To support the SAMHSA position it invited a psychiatrist, Dr. Daniel Fisher, to testify before the Biden Task Force. SAMHSA had to invite an outside psychiatrist because it has nobody among its 574 staff who has expertise on severe mental illness. For the past 3 years, it has employed only one psychiatrist but his expertise is exclusively substance abuse treatment. Dr. Fisher stated categorically to the Task Force that mental illness and violence are not linked, an assertion that is contradicted by more than 20 studies.4 Dr. Fisher, whose organization receives $330,000 each year from SAMHSA, is unusual in his belief that schizophrenia is not a disease of the brain, an assertion that is contradicted by literally hundreds of studies. This picture of identical twins, one of whom has schizophrenia, is illustrative.
Rather Dr. Fisher describes the condition called schizophrenia as “severe emotional distress” or “a spiritual experience.” This is apparently consistent with SAMHSA’s position.
(2) SAMHSA should be promoting treatment programs which have been proven to decrease violent behavior in individuals with severe mental illnesses.
An example of such a program is conditional release which, in a study in New Hampshire, was shown to reduce violent episodes by half. 5 Assisted outpatient treatment (AOT) has also been shown to be highly effective in reducing hospitalizations, incarcerations, and episodes of violence. In North Carolina AOT reduced violent behavior from 42 to 27 percent.6 In New York AOT reduced the number of individuals who “physically harmed others” from 15 to 8 percent in one study.7 In another study, AOT reduced by 88 percent the chances of the mentally ill individual being arrested for a violent crime.8
What is SAMHSA actually doing? SAMHSA’s three-year plan includes no mention whatsoever of these effective treatment programs. Ignoring such programs is bad enough, but it gets worse. SAMHSA actually funds many programs which lobby to block the implementation of these effective programs in the states. An example is the California Network of Mental Health Clients which has been funded by SAMHSA for almost two decades with as much as $200,000 per year. This organization has actively lobbied to prevent the implementation of AOT, called “Laura’s Law”, in California. The California Network of Mental Health Clients lost much of its state money in 2012 when it was publicly revealed that its acting director had used the organization’s credit card to bail himself out of jail after being charged with drunken driving.9 SAMHSA has funded similar organizations under its consumer grant program and its Protection and Advocacy grant program that have actively impeded the implementation of improved treatment laws in many other states, including Connecticut, Florida, Maine, Maryland, Michigan, Nevada, New Jersey, New Mexico, New York, Pennsylvania, Utah, Vermont and Wisconsin.
Brain scans of two individuals with schizophrenia
(3) SAMHSA should be concerned about the fact that many individuals with severe mental illnesses—including Cho, Loughner, Holmes and Lanza—are unaware of their own mental illness and thus are very unlikely to seek treatment voluntarily.
This unawareness is a result of their brain disease and is referred to as anosognosia. At least 18 studies of schizophrenia have reported differences in the brains of individuals with and without awareness of their illness. This poses major problems for treatment; the need to treat such individuals before they commit an act of violence must be weighed against the protection of that individual’s civil liberties.
What is SAMHSA actually doing? SAMHSA does not acknowledge that some individuals with severe mental illnesses must be treated involuntarily because they lack awareness and are potentially dangerous to others as a result of their illness. Instead, SAMHSA sponsors an annual conference for individuals with severe mental illnesses at which individuals are encouraged to not take their medication. This federally-sponsored conference, called “Alternatives,” is the largest anti-psychiatry, anti-treatment meeting in the United States. Speakers at this conference make claims such as the following: “What is called schizophrenia in young people appears to be a healthy transformational process that should be facilitated instead of treated.” At the 2010 conference, at which the SAMHSA administrator gave the opening talk, one speaker claimed that schizophrenia is caused by the antipsychotic drugs used to treat it. Another speaker called severe mental illnesses “extreme states of consciousness that are mad gifts to be nurtured and cultivated.” Workshops such as “Coming off medications: A harm-reduction approach,” were widely available.
The annual “Alternatives” conference costs at least $500,000 in federal dollars each year; SAMHSA pays the conference sponsor $127,000 for administrative costs and many of the approximately 1,000 attendees use SAMHSA funds to pay for transportation and hotels. Early this month SAMHSA approved funds for a similar conference this year.
(4) SAMHSA should be concerned about the severe shortage in hospital beds for individuals with severe mental illness.
Over the past half century 96 percent of state mental hospital beds for treating mentally ill individuals have been closed. The United States now has the same number of such beds, per population, as were available in 1850. According to experts in these fields, we now have less than one-third the number of beds which are needed for adequate psychiatric care.10
What is SAMHSA actually doing? SAMHSA has publicly expressed virtually no concern about the severe shortage of psychiatric hospital beds in the United States. SAMHSA appears to be too busy with concerns about mental illness issues in other countries. SAMHSA has an International Office and in 2005 and 2006 “sponsored two Action Planning Conferences on Iraq Mental Health…in Amman, Jordan and Cairo, Egypt.” SAMHSA also sponsored 11 teams of “Iraqi behavioral health providers” who were brought to the U.S. in 2008 and 2010 to visit “trauma services, substance abuse services, and children’s mental health services.” One of the outcomes of the SAMHSA-sponsored meetings on Iraq mental health was a decision to close the Al-Rashad Mental Hospital in Baghdad, despite the already severe shortage of beds in that city. SAMHSA has also been involved in helping Afghanistan “build its mental health programs and capacity.”
(5) SAMHSA should be concerned that there are now more than three times more persons with severe mental illnesses in jails and prisons than in hospitals.
In the 1970s the percent of jail and prison inmates with severe mental illnesses was said to be 5 percent. In the 1980s it was 10 percent; in the 1990s 15 percent; and from 2000 to 2010 it was 20 percent.11 It is not unusual now to see estimates of 25 percent or more.
What is SAMHSA actually doing? The incarceration of mentally ill persons in jails and prisons is not a priority for SAMHSA. It appears to be too busy with what it apparently regards as more important problems. For example, it produces and distributes free of charge reading books for children such as “Play Day in the Park” and “Wally Bear and Friends.” It also produces online children’s games such as “The Great Weather Race” and “Boogie Band Studio” as well as children’s sticker sets with stickers saying “My Smile is Beautiful” and “I love you.” SAMHSA also makes available hundreds of brochures on a wide variety of topics, e.g. “Hurricane Recovery Guides Preparedness Planning”, “Oil Spill Response: Making Behavioral Health a Top Priority.” Almost none of the SAMHSA brochures include anything about severe mental illnesses.
(6) SAMHSA should be concerned that federal expenses for the care of individuals with severe mental illnesses are among the fastest growing federal budget items.
Federal Medicaid, Medicare, Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) associated with mental illness have risen sharply over the last three decades. “The total increase in these four programs between 1986-87 and 1997-98 was $2.6 billion per year, making them among the most rapidly growing programs in the federal budget.”12 Over the past decade these programs have continue to rapidly increase. Even allowing for inflation, the United States is now spending 12 times more per capita on mental illness than it was a half century ago.
What is SAMHSA actually doing? In 2010 I asked SAMHSA for information on why federal costs for mental illness were increasing so rapidly, including the following questions:
1. Why do some states have more than three times more mentally ill individuals, per population, on SSI and SSDI than other states do?
2. What is the percentage of mentally ill individuals on SSI and SSDI who are not receiving treatment?
3. What is the percentage of Americans with serious mental illnesses who are receiving SSI and/or SSDI?
The answers SAMHSA provided on November 19, 2010 were as follows: “We have no data”; “there is no source of this data to our knowledge”; and “SAMSHA does not have access to this information.”13 SAMHSA could collect such data if it wished to do so; its data collection branch is one of its few effective components. As the lead federal agency for mental health services, one might have expected SAMHSA to be interested in these questions, and to collect such information if it did not exist.
SAMHSA apparently had no interest in such questions since at that time it was focused on other projects which it apparently deemed to be more important.9 One of these was the commissioning in 2010 of a painting for $22,500 by New Mexico artist Sam English. This painting, which was officially unveiled on March 8, 2011, shows a group of Native Americans. According to the press release put out by SAMHSA at the time of the painting’s unveiling, it “was commissioned to help raise awareness about the roles of families and the community in mental and substance use disorder prevention.” I believe everyone is aware that families are important, but how this painting was supposed to “raise awareness”, and whose awareness was supposed to be raised, is unclear.
To try and answer these questions I went to the SAMHSA headquarter to see the painting. However the guard at the door would not let me in and told me that I would need to call ahead and get a special appointment to see the painting.
The other project that SAMHSA was preoccupied with in November 2010, was final preparations for the SAMHSA annual staff musical. This took place on Dec. 1-3, 2010, with three performances attended by most of SAMHSA’s 574 staff members. According to the SAMHSA news release, the musical depicted characters who use drugs and “experience consequences of their behavior, including addiction and HIV/AIDS,” and finally “recognize the need to seek help.” The cost of the musical was over $80,000, including staff time. It is unclear what the musical was supposed to accomplish. Since the average salary of SAMHSA’s 574 employees is $109,000, it can be presumed that they all were aware that alcohol and drug use may have adverse consequences, and they should not need a musical to tell them that.
In summary, SAMHSA is, and has been since its creation 30 years ago, a failed federal agency. It is not a Democrat or Republican failure but rather a joint political failure. What I wish to emphasize most strongly is that this failure has consequences that affect us all. The issue is not merely what SAMHSA is doing—the waste of taxpayer money on projects like antipsychiatry conferences, the commissioning of paintings, or staff musicals. Many federal agencies waste money. The important issue is what SAMHSA is not doing to improve the broken mental illness and substance abuse treatment system in the United States. Because people with severe mental illnesses are not receiving treatment, tragedies occur every day of which Tucson, Aurora and Newtown are merely the most prominent. And unless Congress acts to improve this situation, such tragedies will continue to occur.
Thank you for your attention.
1 Hempel AG, Meloy JR, Richards TC. Offenders and offense characteristics of a nonrandom sample of mass murders. Journal of the American Academy of Psychiatry and Law 1999, 27:213-225.
2 Fessenden F. They threaten, seethe and unhinge, then kill in quantity. New York Times, April 9, 2000.
3 Follman M, Aronsen G, Pan D. A guide to mass shootings in America. Mother Jones, December 15, 2012.
4 Torrey EF. The Insanity Offense: How America’s Failure to Treat the Seriously Mentally Ill Endangers Its Citizens. New York: W.W. Norton, 2008. Pp. 140-148, 229-234.
5O’Keefe C, Potenza DP, Mueser KR. Treatment outcomes for severely mentally ill patients on conditional discharge to community-based treatment. Journal of Nervous and Mental Diseases 1997, 185:409-411.
6 Swanson JW, Borum R, Swartz MS, et al. Can involuntary outpatient commitment reduce arrests among persons with severe mental illness? Criminal Justice and Behavior 2001, 28:156-189.
7 Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment (New York State Office of Mental Health, March 2005).
8 Link BG, Epperson MW, Perron BE, et al. Arrest outcomes associated with outpatient commitment in New York state. Psychiatric Services 2011, 62:504-508.
9 Branan B. $3 million in state contracts yanked from Sacramento mental health group. Sacramento Bee, November 11, 2012.
10 Torrey EF, Entsminger K, Geller J, et al. No room at the inn: trends and consequences of closing public psychiatric hospitals 2005-2010 (Treatment Advocacy Center, July 2012).
11 Torrey EF, Kennard AD, Eslinger D, et al. More mentally ill persons are in jails and prisons than hospitals: a survey of the states (Treatment Advocacy Center, May 2010).
12 Torrey EF, The Insanity Offense, pp. 168-169.
13 Letter from Frances M. Harding, Director of the Center for Mental Health Services, SAMHSA, Nov. 19, 2010.
Editors Note
Powerful Testimony by Joe Bruce is presented in a separate blog post. While the hearings were on Serious Mental Illness, SAMHSA Administrator Pamela Hyde presented testimony that was generic and did not really answer the question: "What is SAMHSA doing for the seriously mentally ill".
For more information visit http://mentalillnesspolicy.org
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