Elinore F. Mccance-Katz, MD, PhD

There she was again-a middle-aged woman, disheveled, crouching in the doorway of a closed store, grasping a notebook and pencil and scribbling. Intermittently, her eyes darted around and she would mumble, then go back to her notebook. Her eyes never met mine, but I wondered why she was not getting help with what was clearly a severe mental illness. I would see her in that same doorway several times a week for a couple of years before I left Berkeley, California, to become the first Chief Medical Officer of the Substance Abuse and Mental Health Services Administration (

). In doing so, I hoped to help people living in the grips of cruel disorders that affect one’s thinking, one’s reasoning, one’s ability to relate, and one’s ability to even understand that one suffers from a disorder that can be treated.

The opinions or assertions presented here are the author’s own and do not necessarily reflect those of 

It is estimated that 10 million Americans (4.2%) are living with 

 However, only 68.5% of the most severely mentally ill will receive any type of mental health services. Whether those services are necessary and appropriate is not known. People with schizophrenia, bipolar disorder, depression, and other severe mental illnesses often complicated by substance misuse need effective, safe, evidence-based treatments as well as community resources where their clinical service needs can be met. The federal Department of Health and Human Services (HHS) is composed of numerous agencies that address the health care needs of Americans, but only one agency within HHS is charged with addressing the needs of those with serious mental illness and that is SAMHSA.

; much of that is in the form of block grants to states that are the arbiters of how the funds will be spent in support of the treatment of substance use and mental disorders. SAMHSA does, however, have the ability to focus on areas and issues that would improve the lot of individuals affected by severe mental illness. Unfortunately, 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, chooses to focus on its own definition of “recovery,” which generally ignores the treatment of mental disorders, and, as a major initiative under “recovery” services, focuses on the development of a “peer workforce.”

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?”

SAMHSA’s approach includes a focus on activities that don’t directly assist those who have serious mental illness. These include programs such as Mental Health First Aid, which seeks to teach people about the warning signs of mental illness in an attempt to provide support to those who are experiencing symptoms. Significant dollars are spent on hot lines for callers who may be experiencing suicidal thinking or who know someone who may be-yet suicide rates continue to climb in the US. SAMHSA supports integrated care programs that would bring some aspects of primary care to mental health services programs-worthy programs, but which do not address the treatment of serious mental illness. Programs that undertake the “re-education” of mental health practitioners who are assumed to be abusers of “consumer” rights and who dictate treatment to patients have been funded in the Recovery to Practice initiative.

Workforce issues focus in large part on the development of a “peer workforce.” This ideology purports that one can become a mental health professional by virtue of having a mental illness. Peer support can be an important resource for some, but it is not the answer to the treatment needs of the seriously mentally ill.

Lost in all of this are the real and pressing treatment needs of some of the most vulnerable in our society-those living with serious mental illness. Nowhere in SAMHSA’s 

 is psychiatric treatment of mental illness a priority. The occasional vague reference to treatment is no substitute for the urgent need for programs that address these issues.

What is needed is an agency soul-searching and a re-prioritization that places the treatment of serious mental disorders at the very top of the list of agency goals. SAMHSA needs leadership that acknowledges the importance of addressing serious mental illness. Initiatives that provide funding for new approaches to engaging the seriously mentally ill; for assisted outpatient treatment with enriched psychosocial services; and for additional psychiatric hospital beds, particularly for longer-term care given the severe shortage of such resources in the US, should be at the top of SAMHSA’s agenda.

Clinical education programs that address current, evidence-based treatment for serious mental illness, and new funding for the training of mental health professionals, including psychiatrists, advanced practice psychiatric nurses, and psychologists, should be a major focus. SAMHSA should develop closer ties with the National Institute of Mental Health, which is helping us to better understand the neurobiological underpinnings of mental illness every day. The real hope, change and ability to recover from these disorders, lies in their effective treatment. To ignore this is to leave a large segment of some of the most seriously ill in our society abandoned-indeed, discriminated against by the very agency charged with serving them.

What can be done to change the current course? Stakeholder groups that seek to ensure psychiatric treatment for all who need it should band together and exert pressure on SAMHSA, on political administrations, and on congressional representatives to address the needs of the seriously mentally ill. Skilled behavioral health providers with patient care experience-psychiatrists, psychologists, social workers, counselors-should consider committing a period of service to SAMHSA and to other federal agencies to inform policy decisions related to substance use and mental disorders. This is especially important because too many in the government have education in behavioral health fields but have never worked with patients, or if they have, it was many years in the past. Being inside the Beltway also imbues an artificial perspective that may be informed by lobbyists if at all. This does not serve the American people.

I left SAMHSA after 2 years. It became increasingly uncomfortable to be associated with an agency that, for the most part, refused to support evidence-based psychiatric treatment of mental disorders. It was also quite clear that the psychiatric perspective I brought-inclusive of assessment, diagnosis of mental disorders, utilization of evidence-based treatments, including psychotropic medication and psychosocial interventions as integral components of recovery-was a poor fit for the agency. SAMHSA needs a complete review and overhaul of its current mission, leadership, and funded programs. Congress should quickly address this through legislative mandate.

For too long the treatment needs of the seriously mentally ill have been ignored by SAMHSA, and this needs to change. In doing so, perhaps people like the woman in the doorway will be able to move out of the shadows to live full and productive lives in our communities.

Editor's note: The opinions or assertions presented here are the author’s own and do not necessarily reflect those of 

 or its editorial board. Comments not followed by full names and academic titles will either be removed or heavily monitored. –

Dr McCance-Katz was formerly Professor of Psychiatry at the University of California, San Francisco; currently she is Chief Medical Officer for the Rhode Island Department of Behavioral Health, Developmental Disabilities, and Hospitals. She is also Chief Medical Officer and Acting Chief Executive Officer of the Eleanor Slater Hospital in Cranston, Rhode Island. She reports no conflicts of interest concerning the subject matter of this article.

 US Department of Health and Human Services. Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings. 

http://www.hhs.gov/about/budget/budget-in-brief/samhsa/index.html

Articles

For too long the treatment needs of the seriously mentally ill have been ignored by SAMSHA, and this needs to change, says this psychiatrist. 

The Federal Government Ignores the Treatment Needs of Americans With Serious Mental Illness

Substance use disorder (SUD) plays a prominent role in the epidemiology, cause, and course of mental illness. It is estimated that 9.1% of our population, or more than 22 million Americans, have SUD; however, only 10% of these persons receive treatment. The incidence of SUD in persons with mental illness (21.3%) is significantly greater than for those without mental illness (7.7%). Of the more than 5 million Americans with comorbid mental illness and SUD, fewer than half received treatment at either a specialty mental health or substance abuse treatment facility. Only 8.5% received treatment for both mental illness and SUD; the rest received either one or the other.

 These statistics underscore the prevalence of comorbid mental illness and SUD and clearly show that the majority of patients are currently not receiving treatment for these disorders.

There are a number of reasons why patients with comorbid disorders do not receive necessary care. These include lack of treatment access, cost of treatment, stigma, separation of care for mental illness and SUD, a medical care system that de-emphasizes the importance of recognizing and treating SUD, and a medical education system that devotes very little time to this area. This Special Report addresses the latter problem by providing a series of 5 excellent articles that cover a wide range of issues in comorbid disorders.

We have selected topic areas of importance to practicing psychiatrists, including a pair of articles, one by Emma Barkus and the other by Ismene Petrakis, on the neurobiology of psychotic and substance use disorders, as well as pharmacologic management of psychosis in those with comorbid SUD. These articles lay the framework that supports the use of atypical antipsychotics in this population while also pointing out the need for continued research.

A timely and critically important article on the treatment of acute and chronic pain in the patient with SUD is presented by Penelope Zeigler. This topic is arguably one of the most difficult problems faced by physicians, and because of the epidemic of prescription opioid abuse and dependence in the United States, it is one of growing importance.

Some of the most challenging patients seen in psychiatry today are those with comorbid borderline personality disorder and SUD. Feske, Soloff, and Tarter present a state-of-the-art discussion on the relationship between borderline personality disorder and substance abuse, as well as a succinct discussion of promising therapeutic interventions.

And finally, the article on differential effects of substance abuse in women by Back, Contini, and Brady is an excellent review that brings together a wide literature to make a strong case for gender-based differences in vulnerability to substances and their effect on disease course.

This series of articles provides an evidence-based foundation for some of the more difficult areas of psychiatry today and should assist the practicing clinician in addressing these challenging problems.

Links to articles in the Substance Abuse and Addiction Series:

The Link Between Psychotic Disorders and Substance Use

Safe Treatment of Pain in the Patient With a Substance Use Disorder

Schizophrenia and Substance Abuse: Is There a Role for Atypical Antipsychotics?

Implications for Treatment and Prognosis of Borderline and Substance Use Disorders

Substance Abuse in Women: Does Gender Matter?

 Substance Abuse and Mental Health Services Administration. Results from the 2005 National Survey on Drug Use and Health: National Findings. Available at: 

http://oas.samhsa.gov/NSDUH/2k5NSDUH/2k5results.htm

Substance use disorder (SUD) plays a prominent role in the epidemiology, cause, and course of mental illness. Of the more than 5 million Americans with comorbid mental illness and SUD, fewer than half received treatment at either a specialty mental health or substance abuse treatment facility.

Elinore F. Mccance-Katz, MD, PhD

Articles

The Federal Government Ignores the Treatment Needs of Americans With Serious Mental Illness

Psychiatric Disorders and Substance Abuse