SAMHSA has let us down—Part One

When government becomes a reformer

NAMI has invited us to send in our comments on the latest strategies of the federal Substance Abuse and Mental Health Services Administration (SAMHSA), which you can find on the internet. Normally we stay away from the big shots but this is the agency that sets the leadership tone about how everybody can recover from serious mental illness and we know how to do this now when we didn't do it right before. I suggest that's setting the psychiatric world on its head.

So it bears watching where these ideas come from and who benefits. SAMHSA isn't really a research arm of government, it administers policy. It seems to blow in the winds of today's reform-minded politics surrounding mental health care. Somebody has pumped up these ideas into its collective head. One likely source is big business as the agency sets its sights on use of more technology and electronic data systems in hospitals and health care systems, as you will see below. And then there is the recovery crowd that already shows its influence in how SAMHA expresses its priorities.

These latest consist of eight strategies--like the eight wonders of the ancient world--as if eight wraps it up. Their ideas are at times remarkable, and call for spending billions. Key priorities include, for instance, Prevention of Substance Abuse and Mental Illness, Military Families, Housing, Electronic Data Record Keeping, and something like “social marketing” of success. My comments follow.

1.Prevention of substance abuse and mental illness is possible, SAMHSA tells us, by creating “prevention prepared communities to promote emotional health and reduce the likeliness of mental illness, substance abuse including tobacco, and suicide.” Now, prevention isn't for everybody. What we've learned over the last 30 years is that you can't prevent schizophrenia, bipolar and major depression, the serious illnesses. You can modify their impact on the individual and enable someone to have a relatively good life.

Here's the explanation, as best as I can do. The brain wiring and brain chemicals in somebody with schizophrenia are thought to be way off. We believe the causes are more genetic than environmental and someone has been predisposed to the illness by heredity. We've read that the natural tendencies of these disorders to show up are more likely when encountering stresses in life, perhaps such as noise and crowding in cities, bullying and harassment of children, and poverty in general. Those conditions aren't entirely preventable either. The most severely ill should take SAMHSA's priority, in my judgment, yet the agency is side stepping them.

By contrast, substance abuse and cigarette smoking are voluntary behaviors in my book. People can get hooked. But these are habits totally unlike schizophrenia, which the person doesn't bring on himself.

On another of the government's initiatives, mass screening of school children to detect early signs of defects in emotion or thinking is largely a waste of money, in my opinion. They're already doing it in Schenectady and it's costly, adding thousands of hours to children's health care costs. We know that some of these behaviors disappear with time, and we already intercept children with attention deficits and restlessness or inability to learn. We've simply tacked on an added comfort level for teachers.

2. Reduce trauma for people with substance abuse and mental health problems, SAMHSA exhorts us, “by integrating trauma-informed approaches throughout health and behavioral health care systems and by diverting people with these disorders from criminal and juvenile justice systems.” I think they're talking about educational and behavior modification theories for those individuals who are trouble for their classmates and neighborhoods. We do need to pay more attention to juveniles and adults with repeated behavior problems. Serious treatment for them in youth homes, jails and prisons is missing.

3.Help military men and women and their families “to ensure that needed behavioral health services are accessible and outcomes are successful.” Well, of course. But why mention the families? They're in the same boat with lots of others. And do the people at SAMHSA know how generous are VA benefits for service connected disabilities? These don't have to be in connection with combat. Veterans qualifying for disability receive a far higher monthly stipend than civilians on SSI or SSD for the same kind of illness. Veterans organizations, the medical lobbies and prescription drug companies stand to benefit grandly by including families in coverage. Some vets coming back from war zones need special help--mental and emotional counseling, medicine and support systems, job and housing help. But not all their conditions call for entitlements. Some conditions are temporary, I think, caused by the social dislocation of young people thrust into the business of fighting a war. I would put priority on those veterans coming back who have a history of a brain disease, and not the "worried well" whose main complaints are problems of living. (Roy Neville)