SAMHSA Strategic Plan Falls Short on Serious Mental Illness

Several things are true about psychiatric disorders, regardless of their etiology. Because they cause disturbances in thinking, emotion, mood, and behavior, their experiential impact is both deeply personal and social. For many who have a psychiatric illness, the individual’s sense of self and well-being are injured, and important familial, social, and occupational relationships are disrupted. To experience one’s very core as ill or defective can also create deep pain and dissonance.

At the same time, when looked at from the outside—from the perspective of observation and syndromic coherence—these disorders are highly correlated with genetic and neurobiologic abnormalities as well as disruptive environmental events. Two recent studies (among many)—one on the genetics of schizophrenia based on the largest pool of genomewide studies and a smaller study of the genetic and neuropathologic basis of autism—reinforce this understanding.

Why is the tension between the experience of these illnesses and their etiology so important? In part because it is easy for psychiatry, and more broadly the mental health community, to come down strongly on one side or the other of this divide. This split can influence the research and public policy we need to develop treatments for mental illness and provide access to care.

Moreover, when this divide—which is sometimes inaccurately framed as a battle between the recovery community and a misunderstood “medical model”—affects the Substance Abuse and Mental Health Services Administration (SAMHSA), the impact can be of even greater significance. SAMHSA is the principal federal agency dedicated to leading public-health efforts to improve mental health and reduce the impact of mental illness, including substance abuse, on America’s communities. As a central component of its directive, SAMHSA recently released a draft of its FY 2015-2018 strategic plan, titled “Leading Change 2.0: Advancing the Behavioral Health of the Nation”.

There is much to support in SAMHSA’s draft. Efforts to reduce disparities in access to care, which disproportionately afflict minority communities, are laudable, as are efforts to reduce the number of those with mental illness in the criminal justice system. However, for an agency with such a broad responsibility, the proposed plan is striking for what it leaves out: a focus on the appropriate medical care of patients with serious mental illness and the development of a physician workforce that is essential for their care. In APA’s letter to SAMHSA Administrator Pamela Hyde, J.D., responding to the draft strategic plan, our CEO and medical director, Saul Levin, M.D., M.P.A., noted, “APA is strongly concerned about the lack of explicit recognition of the psychiatric treatment needs for Americans suffering from mental illness and substance use disorders, and in particular for the 13 million Americans who suffer from debilitating serious mental illnesses (SMI).” In addition, we urged SAMHSA to develop explicit goals for evidence-based medical care for serious psychiatric illnesses.

We also are very concerned with the risk of an aging and dwindling psychiatric workforce. In particular, we noted that “a recent report from the Health Resources Services Administration (HRSA) found that per capita declines are projected in the field of psychiatry by the year 2025. Due to the significant shortage of psychiatrists, it is of great concern that historically SAMHSA has not included psychiatrists in its proposals for increased workforce development.”

While there is an appropriate focus on integrated care, an area in which SAMHSA has already played a leadership role, there is a need for more attention to the medical psychiatric skills that psychiatrists can uniquely bring to these settings. The notion that the physicians who are most broadly trained to care for the total health needs of those with mental illness will not be central to this effort cannot be supported by any careful reading of the evidence or common sense. At a time when clinical care is increasingly being provided by physician-led teams, it would be inhumane for patients who are dying from treatable medical conditions years earlier than age-matched peers to not have access to psychiatric physicians.

The intimacy of psychiatric illnesses, especially given their onset just as young people are beginning to build their adult lives and sense of identity, makes them far more difficult to fully accept and understand than many other medical conditions. In particular, accepting that one may have an illness is very different from saying that they themselves—in their deepest and most true selves—are ill. As close as these things are in the experience of psychiatric illness, they are not the same, as Elyn Saks, among others, has eloquently reminded us. There is no reason we cannot be attentive to and respectful of the difficult experiences that mental disorders bring and, most importantly, the fundamental wholeness of our patients, while striving for the science that will make their enduring recovery possible.

The work undertaken by SAMHSA directly impacts millions of Americans who suffer from mental illness and substance use disorders, as well as the physicians and other providers who dedicate their professional careers to treat them. As this strategic plan is implemented over the next three years, it is incumbent upon SAMHSA and all federal agencies involved with mental health policy to support with rigor medical and evidence-based care that is both appropriately measured and integrated. It is essential to promote mental health policies that adequately address both the complex experiences and etiologies of mental illness and substance use disorders. Both are unequivocally necessary if we are to move forward in our collective effort to ensure the well-being of all those who suffer with these illnesses. ■