Most Impactful Mental Health Leader In 2018

Dr. McCance-Katz’s Tour de Force Leadership At SAMHSA Makes Her My Choice For Most Impactful Mental Health Leader In 2018

 

by Pete Earley

 

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(12-28-18) Dr. Elinore McCance-Katz is my choice for the person who has had the biggest impact in mental health during 2018.
Appointed by the Trump administration in September 2017 as the first Assistant Secretary for Mental Health and Substance Use, Dr. McCance-Katz has dramatically changed the focus at the Substance Abuse and Mental Health Services Administration.
She has made serious mental illnesses a priority and has directed SAMHSA to create and fund programs based on clinical results and science.
Her leadership is a much needed breath of fresh air from the previous administrator who was harshly criticized by Congress for reportedly showing little interest in serious mental illnesses and whose leadership resulted in SAMHSA employees ranking morale inside their agency as among the lowest in the entire federal government.
SAMHSA received a budget increase of 35% under the Trump administration, allowing it to more than double the number of grants that it awarded in 2018 from 600 to 1,300. Simply distributing money is no solution, especially if it goes to wasteful programs, which is why one of Dr. McCance-Katz’s first orders was a thorough review of what constitutes an evidence based practice worthy of funding. Given that some so-called evidence based practices in the past were based on little or no real evidence, this was a major directional change. At the same time, SAMHSA streamlined its application review process, cutting the application from 25 pages to 10 and the number of questions for applicants from 25 to a mere 9 so that federal funds could be released more quickly to those programs that deserve them.
Making the process more vigilant, efficient and easier to use might not seem sexy, but awarding grants is how the federal government helps steer states. (For example, SAMHSA recently awarded $61.1 million for suicide prevention programs.) Having someone as assistant secretary who actually is making Americans with serious mental illnesses a prime concern is a godsend.

SAMSHA was blasted by Congress for not employing a single psychiatrist  at one point under its previous director. Under McCance-Katz, SAMHSA’s Office of the Chief Medical Officer now employs psychiatrists, a clinical psychologist and nurse so the agency can benefit from professionals with real world experiences.
Dr. McCance-Katz is an addiction specialist and she was ordered by Congress to prioritize the opioid crisis, which she has. But she has not done that at the expense of untreated serious mental illnesses.
With urging from the non-federal members of the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC), she was able to persuade U.S. Health and Human Services Secretary Alex M. Azar II to allow states to apply for Medicaid waivers to the IMDs, or institutions of mental disease. Put simply, states are not allowed to seek reimbursement for services at facilities that hold more than 16-beds. Granting states waivers will help combat our current national treatment bed shortage. This shift comes with conditions that still could be difficult for states to meet. Waivers must be budget neutral, meaning that the “demonstration cannot cost the federal government more than what it would have paid absent the demonstration.” Restrictions remain on what Medicaid will and will not reimburse.
Despite these limitations, getting the federal government to open the door and pay for residential treatment in larger facilities is a major change.
Under Dr. McCance-Katz’s leadership, representatives from HHS, Justice, the Veterans Administration, Labor, HUD, Education and the Social Security Administration have begun talking to each other to better coordinate their agency programs that provide services to Americans with mental disorders. This cooperation, especially between HHS and HUD, is extremely important. For too many years, the federal government has failed to acknowledge how mental health recovery is dependent on housing and other non-medical help. Getting these agencies to coordinate  their actions was ordered by Congress under the 21st Century Cures Act. That law also created ISMICC, on which I serve. Its 14 non-federal members released a detailed list of recommendations at the end of 2017. Under Dr. McCance-Katz leadership, our federal partners from each of the previously mentioned departments have divided themselves into five workgroups to address such problems as the inappropriate incarceration of individuals with mental illnesses.
SAMHSA also has launched an effort in 23 states to create real-time bed registries to identify available beds and post crisis follow-up services for those living with serious mental illnesses.
Dr. McCance-Katz’s decision to reassigned a senior staff member, who was a nationally known leader in the peer movement, raised questions about her support of peer services. But under her leadership, opportunities for peers have increased and she has often spoken of peers’  importance in the recovery process.
Taking charge of any large federal bureaucracy is daunting. When I covered Congress, it was widely known that it took many newly elected members a year to learn the basic ground rules of Capitol Hill and, jokingly, where the bathrooms were located. Federal agencies with their unwritten rules and internal allegiances are equally difficult to herd. Dr. McCance-Katz benefited from spending two years at SAMHSA as its first Chief Medical Officer before resigning and writing a scathing review of the agency.
She has returned as a tour de force to be reckoned with, quietly determined, and intent to use her four years to implement much needed changes. Most importantly in my eyes,  she genuinely cares about individuals with serious mental illnesses and those of us who love them. She is being joined in that effort by many dedicated SAMHSA employees who have been fighting for decades to be heard.
As I write this, I have received a tweet that she just posted. It says it all.
“Thousands of Americans with serious mental illnesses are receiving no #treatment, no services, and no supports—this is another public health crisis that has serious consequences.” @DrMcCance_Katzbit.ly/RightToTreatment…

We must come together to establish a mental health system that includes robust services at all levels and that provides a full continuum of care for those with the most severe mental illness.

The Real Civil Commitment Crisis and How To Solve It

• John Snook

May 21, 2018 

A recent column highlighted the longstanding debate around the role of civil commitment laws, occasioned by the inartful response of President Donald Trump to the tragic school shooting in Parkland, Florida. The need to strike a proper balance between guarding one’s civil liberties while ensuring the public welfare is an important discussion, especially in light of what appears to be an increasing number of high-profile tragedies that might call for commitment law reform. Yet, the authors conflated this important discussion with a second argument against providing inpatient psychiatric care. This conflation is too frequently exploited by decision makers as a cynical means of reducing desperately needed mental health resources. Given the dire state of our inpatient treatment system, the issue is deserving of careful interrogation and consideration.

Civil Commitment Trends Are Clear

It is important to first define what is meant by “expanding” civil commitment laws. By “expanding,” the authors most likely meant moving from a standard requiring overt or immediate danger to self or others to one that considers other factors such as the person’s need for treatment as a basis for civil commitment.
Civil commitment is by tradition a state purview, with little role for the president or federal government. In state legislatures, the debate over dangerousness standards has largely ended.
Over the past 20 years, my organization, the Treatment Advocacy Center, has worked with more than 30 states to modernize their civil commitment standards to include factors beyond overt dangerousness. This reform effort gained vital advocacy support from families who had faced the nightmare of seeing an obviously ill loved one denied care simply because they had not yet become violent. As evidenced by these families’ experiences, demanding immediate evidence of danger delays the provision of care, often leading to unjustifiable deterioration and unnecessary criminalization.

Dangerousness Standard Stigmatizes

Moreover, an overreliance on dangerousness may actually reinforce the damaging stigmatization of mental illness. A study in the journal Social Psychiatry and Psychiatric Epidemiology noted that “widespread public knowledge of the dangerousness criterion … might indeed have fueled the stereotype that people with mental illnesses are dangerous.” For the general public, it stands to reason that if mental illness is the only condition in which an individual’s care is predicated on evidencing dangerousness, those with mental illness must logically be more dangerous.
In “expanding” their commitment laws, states have moved from determinations of danger and violence to what could now be termed a medically informed model. For example, Arkansas expanded its interpretation of “clear and present danger” to include a person whose illness causes them to be unable to understand their need for treatment and who needs care to prevent a relapse or harmful deterioration. Washington State’s “gravely disabled” standard has been repeatedly “expanded” to address various types of harm and deterioration that have little to do with overt violence. And, after recently clarifying its treatment standards to make clear that its treatment standard explicitly considers more than a person’s current level of danger, California is now debating additional updates to help serve its chronically homeless population.

The Bed-Shortage Crisis

Despite the importance of reforming civil commitment standards, debating these laws in isolation obscures a vital point: Facilities that provide needed inpatient care have been under assault from policy makers, with devastating consequences for the most severely ill and for society at large.
A 2017 analysis of psychiatric inpatient capacity by the National Association of State Mental Health Program Directors (NASMHPD) detailed a 77.4 percent decline in psychiatric beds since 1970. Similarly, my organization found that state psychiatric hospital beds are now at their lowest level since the 1850s, with less than 12 such beds per 100,000 population nationally.
With fewer beds available for those in need, patients stay lengths have shortened and readmission rates have climbed. In 1980, the median length-of-stay for an acute episode of schizophrenia was 42 days. In 2013, it was less than one week.
Schizophrenia and mood disorders account for more readmissions of Medicaid patients than any other medical conditions. Schizophrenia hospitalizations alone cost $11.5 billion in 2013, of which $646.0 million resulted from readmission within just 30 days of discharge.

Consequences Of Nontreatment

The weakening of the inpatient care system has placed an increasingly heavy burden on systems of care that are not designed to address psychiatric crisis. A survey of emergency department physicians by the American College of Emergency Physicians found that nearly 9 of 10 doctors reported psychiatric patients being held in their emergency departments while waiting for an inpatient bed.
Nearly 95 percent of jails report housing inmates with serious mental illness. In fact, at least 45 states now house more people with serious mental illness in jails or prisons than in the largest remaining state psychiatric hospital in each of these states. A majority surveyed reported maintaining wait lists for mentally ill inmates in jail who needed care in a psychiatric inpatient facility, but for whom no bed was available. In numerous states, mental health officials have even been threatened with contempt of court owing to their lack of available beds.

A False Choice

Unfortunately, deep budget cuts have pitted well-meaning advocates against each other, allowing the debate about how to solve this crisis to become focused on providing either community-based services or more inpatient facilities—a false distinction that serves no one.
For example, organizations such as the Bazelon Center for Mental Health Law have regularly opposed the Centers for Medicare and Medicaid Services regulatory changes that would free up state resources to rebuild inpatient crisis care, because “it would be particularly damaging to a state’s ability to rebuild community capacity … for the state to invest in increasing institutional services.” By contrast, groups such as the National Alliance on Mental Illness have supported such changes specifically because they would “create an incentive to create additional options for psychiatric care.”
Both inpatient and outpatient services are necessary for a functioning system. A solution thus lies in the middle, with a system that provides a continuum of needed psychiatric services, including community, crisis, and inpatient care.

A Continuum Of Care

In a joint report released by the Substance Abuse and Mental Health Services Administration, my organization joined with the NASMHPD in recommending that we prioritize and fund the development of a comprehensive continuum of mental health care that incorporates a full spectrum of services, including both robust community services and inpatient psychiatric beds.
These sentiments were echoed by the recently formed federal Interdepartmental Serious Mental Illness Coordinating Committee, whose first report to Congress noted that “most states report insufficient crisis response capacity as well as insufficient numbers of inpatient psychiatric beds.”

Conclusion

Communities across the country are facing a mental health crisis of unimaginable proportions. Our safety nets—jails, emergency departments, and homeless shelters—are stretched beyond their breaking point. In the face of such urgency, our task should be clear: We must come together to establish a mental health system that includes robust services at all levels and that provides a full continuum of care for those with the most severe mental illness. That this position could be seen as controversial is a testament to the severity of the problems we face. We can and must do better.

John Oliver Uses Humor To Focus Attention On The Need For Mental Health Reform

(3-16-18) From My Files Friday: I posted this segment about the need for mental health reform by John Oliver three years ago and it remains one of the best. 

About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.

“Anosognosia Is Clearly Biological In Origin” Dr. E. Fuller Torrey Argues That Science Proves It

by Pete Earley

(3-13-18) An article entitled The Perplexing Semantics of Anosognosia: Why an obvious phenomena has sparked controversy, written by Dr. Dinah Miller, co-author of COMMITTED: The Battle Over Involuntary Psychiatric Care,  drew strong reactions yesterday after I posted it.  Among them was this reply from Dr. E. Fuller Torrey, who has been described by The Washington Post as “perhaps the most famous psychiatrist in America.”

By E. Fuller Torrey, M.D.

Dear Pete,

Dr. Miller questions the appropriateness of using the term “anosognosia” to describe the lack of awareness of illness in individuals with schizophrenia or other psychosis.  In The Study of Anosognosia (G.P. Prigatano, ed., Oxford University Press, 2010) anosognosia is defined as “a complete or partial lack of awareness of different neurological…and/or cognitive dysfunctions” which would appear to cover psychoses. She contacted the late Dr. Oliver Sacks who in fact had given an eloquent description of anosognosia in The Man Who Mistook His Wife for a Hat: 

“It is not only difficult, it is impossible for patients with certain right-hemisphere syndromes to know their own problems – a peculiar and specific ‘anosognosia,’ as Babinski called it. And it is singularly difficult, for even the most sensitive observer, to picture the inner state; the ‘situation’ of such patients, for this is almost unimaginably remote from anything he himself has ever known.”

Dr. Miller is also incorrect in saying that “we know nothing of the fundamental neural dysfunction” for individuals with anosognosia.  Studies of stroke patients have demonstrated that the inferior parietal lobule plays a critical role, especially on the right side. Since 1992, there have been 25 studies comparing the brains of individuals with schizophrenia with and without anosognosia. In all but three studies, significant differences are reported in one or more anatomical structures. Since anosognosia involves a broad brain network concerned with self-awareness, a variety of anatomical structures are involved, especially the anterior insula, anterior cingulate cortex, medial frontal cortex, and inferior parietal cortex. Three of the positive studies included individuals with schizophrenia who had never been treated with medications, discounting the likelihood that the observed brain changes resulted from treatment.

For example, here are descriptions of two recent studies: 

 In Canada at the University of Toronto, 52 individuals with schizophrenia were assessed for awareness of illness (using the relevant item on the Positive and Negative Syndrome Scale (PANSS)) and underwent MRI. Lack of awareness of illness (anosognosia) was strongly correlated with both severity of illness (p<0 .01="" and="" angular="" anosognosia="" anterior="" are="" associated="" asymmetry="" awareness="" consistent="" cortex="" dorsal="" end="" evident="" findings="" gyrus="" hemisphere="" hemispheric="" illness="" impaired="" in="" individuals="" inferior="" is="" lateral="" left.="" left="" less="" likely="" lobe="" matter="" more="" nbsp="" occurrence="" occurs="" of="" p="0.05)." parietal="" patients="" prefrontal="" right="" schizophrenia="" showing="" some="" span="" specifically="" stroke="" suggests="" temporal="" than="" that="" the="" these="" to="" total="" volume="" was="" when="" white="" with="">

The authors of the study noted that persons with schizophrenia vary in their degree of anosognosia: “They can have equally bizarre delusions or perceptual disturbances but can be quite dissimilar in their ability to recognize that these experiences arise from their mind rather than a part of objective reality.” This combination of insight with profound mental disturbances is one of the most puzzling aspects of schizophrenia for family members.” Reference: Gerretsen, P., Chakravarty, M.M., Mamo, D., Menon, M., Pollock, B.G., Raiji, T.K., Graff-Guerrero, A. (2013). Frontotemporoparietal asymmetry and lack of illness awareness in schizophrenia. Human Brain Mapping, 34, 1035—1043.

In Canada, researchers at McGill University used magnetic resonance imaging (MRI) to assess 66 individuals with chronic schizophrenia and 33 healthy controls. The Scale to Assess Insight (SAI-E) was used to assess insight into symptoms. Patients with low awareness of symptoms had significantly thinner right insula cortex. The insula is increasingly thought to be a key structure for self-perception. Ref:  Emami, S., Guimond, S., Chakravarty, M.M., Lepage, M. (2016). Cortical thickness and low insight into symptoms in enduring schizophrenia. Schizophrenia Research, 170, 66—72. 

Thus anosognosia is clearly biological in origin, in contrast to denial which is psychological in origin.

           Dr. Miller is correct about one thing—anosognosia is merely a neurological observation and, by itself, has no implications for treatment, involuntary or otherwise.  Decisions regarding treatment should be made separately.  Thus a woman with Alzheimer’s disease and anosognosia who wants to walk outside in the winter without shoes or socks can be allowed to do so or can be involuntarily prevented from doing so.  The fact that she has anosognosia does not, by itself, dictate a course of action.  Similarly a woman with paranoid schizophrenia and anosognosia may or may not be treated involuntarily depending on other factors.

Dr. E. Fuller Torrey needs no introduction. He is the author of Surviving Schizophrenia: A Family Manuel, an early leader and supporter of the National Alliance On Mental Illness, and the founder of the Treatment Advocacy Center.