Senators’ Letter To SAMHSA Is Misguided: Dr. McCance-Katz Is Doing What Congress Demanded

(1-25-18) Five U.S. Senators have sent a letter to HHS Assistant Secretary Dr. Elinore McCance-Katz asking her to explain why she has put the National Registry of Evidence-Based Programs and Practices (NREPP) on ice and terminated the contractor who oversaw it.

Chances are, you have never heard of NREPP, but it’s a big deal – a really big deal.

That’s because NREPP essentially determines which mental health and substance abuse programs are “evidence based practices” , opening the door for them to claim a piece of $2.2 billion in HHS block grant funding being doled out each year.

NREPP was created in 1997 to maintain a computer registry that rates practices according to available evidence about their effectiveness. Theoretically, it provides those who access it with helpful information about what they should be doing in their communities.

The five Democrat senators questioned why Dr. McCance-Katz chose to hit the hold button on NREPP, leaving in limbo at least 90 programs seeking “evidence based practice” ratings.

The Washington Post described her decision as a “Trump administration” effort to, “suspend a program that helps thousands of professionals and community groups across the country find effective interventions for preventing and treating mental illness and substance-use disorders.”

Hold on, that’s not what I see happening.

What Dr. McCance-Katz is doing is exactly what Congress told her to do when it passed the Helping Families in Mental Health Crisis Act as part of the 21st Century Cures Act.

The reason why Dr. McCance-Katz has closed the NREPP website is because it has been listing programs as being evidence based practices whose usefulness is questionable. It appears as if NREPP often rubber stamped any practice that popped into the heads of someone with a treatment program that they wanted to sell.

Seriously.

Here is part of Dr. McCance-Katz’s public statement explaining why she discontinued  NREPP. These comments begin with her describing what happened when you searched the NREPP registry for a list of evidence based practices that would help your community mental health provider better treat someone with a serious mental illnesses.

“The program as currently configured often produces few to no results, when such common search terms as “medication-assisted treatment” or illnesses such as ”schizophrenia” are entered. There is a complete lack of a linkage between all of the evidence based practices that are necessary to provide effective care and treatment to those living with mental and substance use disorders, as well. If someone with limited knowledge about various mental and substance use disorders were to go to the NREPP website, they could come away thinking that there are virtually no evidence based practices for opioid use disorder and other major mental disorders – which is completely untrue.

They would have to try to discern which of the listed practices might be useful, but could not rely on the grading for the listed interventions; neither would there be any way for them to know which interventions were more effective than others.

We at SAMHSA should not be encouraging providers to use NREPP to obtain evidence based practices, given the flawed nature of this system. From my limited review – I have not looked at every listed program or practice – I see evidence based practices that are entirely irrelevant to some disorders, “evidence” based on review of as few as a single publication that might be quite old and, too often, evidence review from someone’s dissertation.

This is a poor approach to the determination of evidence based practices. As I mentioned, NREPP has mainly reviewed submissions from “developers” in the field. By definition, these are not evidence based practices because they are limited to the work of a single person or group. This is a biased, self-selected series of interventions further hampered by a poor search-term system. Americans living with these serious illnesses deserve better…”

Pop Psychology 

In case you didn’t get the point, mental health advocate and author, D. J. Jaffe, was more blunt.

“NREPP is supposed to be a list of programs supported with evidence, but it was mainly filled with pop psychology learning modules that fail to help the seriously mentally ill,” he wrote me in an email.

Earlier, he’d published an editorial in The Hill newspaper saying much the same.

Little of what’s in NREPP are actual treatments, and few are based on science. 

For SAMHSA to list a program as being “evidence-based” it should require a program to have (a) independent proof that it (b) improves a meaningful outcome in (c) people SAMHSA is intended to serve, adults and children with serious mental illness or substance use disorders.

I discovered in my research (writing Insane Consequences: How The Mental Health Industry Fails The Mentally Ill)  is that little of what is in NREPP meets those three criterion. The studies lack independence and often come straight from those who invent, sell, and profit from them. The outcomes being measured are not meaningful, metrics such as reductions in homelessness, arrests, incarcerations, hospitalizations, and suicides.

They are soft measures like satisfaction, feeling of wellness, empowerment, hopefulness, and resiliency. In fact, a program promoter could measure ten outcomes, find nine are not improved or even made worse, and then submit the one positive finding as proof the program is evidence-based. Clearly something is wrong.

The studies promoters are submitting are often not conducted among the seriously ill or substance abusers SAMHSA was founded to serve. As Twitter has proven, show the public pictures of cute cats and they smile.

Now all you have to do is tabulate the results and submit them to SAMHSA and you’ve got an “evidence-based” program that “improves mental health.” Taking people bowling could probably gain NREPP certification because it makes people happier.

What Is An Evidence Based Practice?

Many of NREPP’s listed programs raised eyebrows during the House’s congressional probe of SAMHSA. In her testimony, Dr. Sally Satel of Yale  noted that “of the 288 programs listed, four by my count specifically designated people with severe illness as their recipients.”

When I was in Florida recently giving a speech, my host told me that Weight Watchers (R) had been credited as an “evidence based practice” in their federal funding because it helped people with mental illnesses lose weight caused by medications. Should that be a priority of SAMHSA or for a local health department?

This is wherein the conflicts arise.

On one end are critics who say SAMHSA wastes money on often “feel good” programs for the “worried well” that have no scientific basis for helping alleviate a serious mental illness. On the other end are those who argue that any program that helps an individual with a mental health or substance abuse problem feel better about themselves or have more social interaction in a community should be federally funded.

I’ve simplified the argument but you get the gist.

Dr. McCance-Katz has shuttered NREPP so that she and her top aides can develop a vetting process that is not based on a single, selected report or outdated studies. She is establishing standards that must be met to earn the “evidence based practice” credentials and be worthy of our taxpayers’ dollars.

Because she was appointed by President Trump, I suspect the five Democrats are wary that Dr. McCance-Katz actions are aimed at cutting social programs. The five Senators certainly have a responsibility to monitor the job that the assistant secretary is doing, but they should wait to see what she proposes as an alternative to NREPP before assuming the worst.

I’m not certain where Weight Watchers (R) will end up when Dr. McCance-Katz is done. But what I am certain of is that she is trying to steer SAMHSA in a different direction from when it was heavily criticized  during congressional hearings for being wasteful, ineffective, ignoring serious mental illnesses, and disparaging the use of medications.

Is that really such a bad idea?

I’d love to hear your thoughts on my Facebook page.

Meanwhile, here’s a list of the five senators who signed the letter:

The contact for New Hampshire Sen. Margaret Wood  Hassan (who organized the letter) is McKenzie Bennett 202 224-3324, [email protected] 

The contact for Connecticut Senator Richard Blumenthal is Brian Steele at [email protected].202-224-2841.

The contact for California Senator Dianne Feinstein is Megan Thompson Legislative Assistant [email protected] 202-224-384

The contact for New Hampshire Senator Jeanne Shaheen is Michelle Greenhalgh Health Legislative Assistant [email protected] 202-224-2841

The contact for Massachusetts Senator Elizabeth Warren is Julia Frederick Legislative Correspondent [email protected] 202-224-4543

Your can read a copy of their letter here.

 

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.