President Trump’s pick to run federal mental health services has called for a bold reordering of priorities — shifting money away from education and support services and toward a more aggressive treatment of patients with severe psychiatric disorders.
The proposal has some psychiatrists — a generally liberal bunch — cheering despite their distrust of the Trump administration.
But it’s also sparked concern among other health professionals, who worry that the administration will put too much emphasis on medicating and hospitalizing patients, and remove supports that might help them integrate successfully into society.
If confirmed by the Senate, Dr. Elinore McCance-Katz will take the helm of the Substance Abuse and Mental Health Services Administration, a federal agency with a budget of about $3.6 billion a year, most of it dispensed in grants to help states pay for mental health and addiction treatment.
She will be the first to assume the title of assistant secretary for mental health and substance abuse — a near-cabinet position which reports directly to Health and Human Services Secretary Tom Price. Congress created the post to bring order to a scattered system; this is the first time mental health and substance abuse have received such a weighty emphasis in D.C.
“We’ve never had someone coordinating the fragmented mental health services in this country,” said clinical psychologist Xavier Amador, who has written several books for patients with mental illness. “There are huge cracks that people get pushed through. They don’t fall through — they literally get pushed, because the right supports aren’t in place.”
McCance-Katz, a psychiatrist who specializes in opioid abuse, hasn’t spoken publicly since her nomination, and declined to talk to STAT. But she has had a long career in mental health, and her writings — as well as a fact sheet put out by the Department of Health and Human Services — give insight into her priorities. Among them:
- Increase the number of inpatient beds for patients experiencing serious psychiatric symptoms.
- Reconfigure health privacy laws to give families access to information about patients who are severely mentally ill.
- Reevaluate federal funding for suicide hotlines and programs that train patients with psychiatric disorders to help their peers.
About 4 percent of Americans live with serious mental illness, but about one-third of them receive no treatment — and McCance-Katz firmly believes that they are the people most in need of federal support. She calls the current gap in care for severely ill patients, such as those suffering from schizophrenia or bipolar disorder, a “fixable problem.”
A ‘change agent’ poised to make big changes
Generally speaking, there are two schools of thought in approaching mental illness. The “medical model” emphasizes intervention with drugs and other medical treatments. The “recovery model” focuses more on providing peer support.
“There’s a tension in our field between two models — and it’s sad,” said Ron Honberg, senior policy director for the National Alliance on Mental Illness. “I think both the medical model and recovery model apply — and it’s not an either/or proposition.”
Indeed, most health providers advocate a balance of both approaches — but SAMHSA has long been criticized for focusing too much on softer, “recovery” programs rather than medication and medical treatment. McCance-Katz is expected to shift that emphasis.
And even some liberals say they’d welcome it.
“The mental health industry is mainly full of liberals — and I’m to the left of Bernie [Sanders],” said DJ Jaffe, founder of the think tank Mental Illness Policy Org. “But they don’t want to admit the unpleasant truths involved in treating the seriously mentally ill.”
Liberals “don’t want to admit the unpleasant truths involved in treating the seriously mentally ill.”
DJ Jaffe, Mental Illness Policy Org
McCance-Katz, he said, has “been a change agent” over the course of her career. He said he’s “astounded and elated” about her nomination.
“My only concern about Dr. Katz: I hope that she does not alienate the peer recovery movement,” Amador said. “I hope she realizes that the pendulum shouldn’t swing in the opposite direction: It needs to be right in the middle.”
Searing words for federal mental health policy
McCance-Katz first became interested in caring for people with mental and substance disorders as a third-year medical student. She treated a woman in the midst of a severe episode of depression and psychosis — but saw that as her patient received medical treatment and emotional support, she was able to move forward successfully with her life.
In the ensuing decades, McCance-Katz, 60, has built a lengthy résumé, treating both mental illness and substance abuse. She served as state medical director of the California Department of Alcohol and Drugs Programs for eight years, before a two-year stint as chief medical officer of SAMHSA. Since then, she’s led the Rhode Island department in charge of behavioral health care. She’s also a professor of psychiatry at Brown University.
So McCance-Katz easily would be the most qualified leader of SAMHSA in recent years. Her predecessor, Pamela Hyde, was an attorney by training — yet led the mental health unit of federal government from 2009 to 2015. She stepped down amid swirling criticism of the direction she’d taken SAMHSA.
One of the leading critics? McCance-Katz, who served under Hyde for two years. After leaving the agency, McCance-Katz penned a scathing critique in Psychiatric Times, saying she was “greatly disappointed” with the unit:
“SAMHSA’s approach includes a focus on activities that don’t directly assist those who have serious mental illness,” she wrote.
The federal government “has lost its way and largely ignored the needs of people with psychotic disorders such as schizophrenia and bipolar illness.”
Dr. Elinore McCance-Katz, Trump nominee
McCance-Katz doubled down on the indictment in a 2016 article in the National Review, a conservative news outlet. She opened the piece by asserting: “The election of Donald Trump is an exciting turn of events for people afflicted with mental illness.” She went on to explain that she hoped he would be able to expand access to treatment and reform SAMHSA.
Under President Obama, she wrote, the agency “has lost its way and largely ignored the needs of people with psychotic disorders such as schizophrenia and bipolar illness.”
She added: “There is within SAMHSA a perceptible hostility toward psychiatric medicine” that she blamed for a failure to serve patients with serious disorders.
Representative Tim Murphy (R-Penn.) agrees with that perspective. He’s no fan of McCance-Katz; he’s argued that she was ineffective during her years at SAMHSA and failed to exercise proper oversight over grant recipients.
But he’s also eager to see the agency shift gears. Murphy, who has consistently pushed for mental health reform, has accused the federal mental health bureaucracy of being “anti-psychiatry” and operating from a “feel-good space” rather than focusing on evidence-backed treatments. “Right now, there is no science at SAMHSA,” he told Clinical Psychiatry News in 2015.
If confirmed, McCance-Katz will be in a position to change that.
Health care providers just hope she doesn’t go too far. Psychiatric medication, after all, just isn’t always effective — and hospitalization is just a temporary solution for what’s often a lifelong disorder. Statistics vary, but about 30 percent of people with schizophrenia don’t respond to any medication whatsoever. Another third only respond partially.
“I think the reality is, medical treatment — particularly for the more serious mental illnesses — is part of the equation, but there’s much more that is needed,” said Honberg, the policy director at NAMI. Patients also need help with employment, housing, case management, and navigating day-to-day life.
McCance-Katz will get a chance to explain her priorities — and her plans for federal spending — at her confirmation hearing. It hasn’t yet been scheduled, but already she has lined up some high-powered support.
“President Trump has nominated a qualified and experienced leader who will make mental health reform a reality,” said Republican Senator Bill Cassidy, a physician who worked for decades with low-income patients in Louisiana’s public hospital system. He added: “We look forward to her swift approval in the Senate and working closely with her to bring about needed change.”