Q&A: Elinore McCance-Katz, Head of SAMHSA

Last week, MedPage Today spoke with Elinore McCance-Katz, MD, PhD, assistant secretary for mental health and substance use — the top official at the federal Substance Abuse and Mental Health Services Administration (SAMHSA) — about her views on the nation’s response to the coronavirus, “health versus health,” and the country’s continuing problems with substance abuse and suicide.

A press representative was present during this interview, which has been edited for brevity and clarity.

MedPage Today: On a recent HHS podcast, you spoke about the challenge of “health vs health” — the risk of COVID versus mental health and other issues. Can you expand on ways to balance those risks?

McCance-Katz: It is the seminal question around the whole issue of coronavirus and actions taken and/or contemplated. And what I mean by that is Americans have many health issues…. We know that there is isolation imposed by quarantines, and stay-at-home orders, and the closure of businesses, where we see financial ruin for millions of Americans. [There are] Americans who are out of work … and children that are out of school … who have lost their ability to socialize with friends, which is so important developmentally.

These are issues of whole health and we have an infectious disease … what is called a coronavirus. Coronaviruses are also viruses that cause the common cold…. We know that people get colds all the time. With coronavirus very unfortunately there is a deadly aspect to this…. I don’t have to tell you how many American lives have been lost. But what I do have to tell you is that we cannot simply pay attention to a virus. And while we needed to take the actions that we took early on to get time to have our healthcare system be able to address the needs of our people who become infected with the virus, we cannot, in my opinion — we should not, in my opinion — not return to some aspect of normalcy in our society.

And what I mean by that is we need to make our healthcare facilities available to people who have other medical issues … We have to pay attention to what are also life-threatening illnesses: serious mental illness and major depression with suicidality that’s a life-threatening disorder. We know that before the COVID virus, before we even knew about this pandemic, we had over 180,000 Americans every year that die of suicide, of drug overdoses, and of alcohol related problems…. Those numbers are going to go up because of the restrictive measures that have been taken and are really not relenting in many areas.

We need to protect our vulnerable. We need to make use of safety measures, social distancing, mask-wearing — and to do that very routinely, but in doing that we really need to open up our society. We need to let people be people. We need to let people be together, to show warmth and caring and love for each other, which they’ve not been allowed to do for months on end. And we continue to hear people who are called public health experts tell us that it should remain that way. I would argue that a public health expert needs to consider all aspects of health. I will tell you mental and substance use disorders are public health issues, just like COVID.

You received some pushback on that same HHS podcast when you described children not returning to schools as “nonsense.” Are you saying that all schools should reopen? If not, under what circumstances should schools reopen for in-person learning?

I think it’s a tragedy that we’ve politicized this issue to the degree we have, because this is an issue that wreaked havoc on American children and American families. I don’t take back anything I said, but what I will say is this: I have never said that children should go back to school without safety measures in place. And so when I say it’s “nonsense” that children can’t go back to school, what I mean is it is nonsense that they cannot go back to school with safety measures in place.

Use social distancing; children can use masks. Children can be taught and take pride in learning about good hygiene and making sure that they are part of the solution. There are ways to make school safe, and these school administrators frankly have had since last March to think about that, and so I would like to see them really come to the table and talk about ideas for how they can make their schools safe because they can, and we should let children go back to school.

Now, if you have an area of the country that has high rates of COVID infection, then I will let the CDC comment on those risks of infection [at which] they would recommend not putting kids back in school. Then I would go along with that, but otherwise, children need to return to school. You will see far more children die of suicide than you will COVID.

Is there a level at which you believe a shutdown or a partial shutdown is reasonable? And should schools be prioritized over other settings? Should we consider closing bars and restaurants, so we can contain the virus and reopen schools?

I don’t believe we should use a blunt instrument in the form of a general shutdown. I think that one of the reasons there’s so much coronavirus fatigue is that people have been subjected to shutdowns in areas where there hasn’t been much virus.

I also think that this is a virus that is going to spread. And all you need to do is look at what’s going on in Europe, where we were told they were the example early on … and you can see the virus has come back and it’s not because they all of a sudden stopped doing what they were doing.

This is a virus that is going to spread, so given that we have a lot of information now about how to make the vulnerable safe, how to put safety measures in place, and we have treatments available, we should use all of that knowledge to avoid shutdowns, because the cost of shutdowns to Americans in every other aspect, be it mental health, be it physical health conditions, be it substance use issues — those costs are enormous and are not being adequately considered.

There are places that will need to have some form of restriction, if the virus level is high and hospitalizations and deaths are high, but I think we need to look at hospitalizations and deaths over numbers of cases, because particularly now, with cases spreading in younger people, we won’t see as much in the way of terrible outcomes. What we have to worry about, for example, is when a college student goes home where there are people that are vulnerable.

So why don’t we think that through and [not] send them home?… There are certain types of restrictions that we will need to have, and it will be based on viral spread in particular areas but the blunt instruments, the general shutdown, regardless of what’s going on in a community, I think is wrong.

You have been very intentional about your agency’s focus on reducing adult suicide, particularly among older adults. What progress have you seen with the Zero Suicide initiative? What challenges have there been to addressing suicide in the midst of the pandemic?

SAMHSA has a very substantial interest in suicide prevention, and we have a number of programs that address suicide prevention…. The Zero Suicide program is one that trains healthcare practitioners on how to ask about suicidal thinking, thoughts and plans, and — if an affirmative answer is given — how to get that person to additional medical attention, care, and to basically follow up to help make sure that the person does not try to take their lives…. We think that it’s a very successful program, and that it’s helping to impact suicide.

In 2019, for the first time in many years, there was actually a small reduction in suicide in this country. I’d like to think that SAMHSA had a major role in that through its programs such as Zero Suicide … and the Garrett Lee Smith prevention program for younger individuals and also through our suicide prevention lifeline…. We also are expanding into text services. We know that a lot of younger people like the use of texting over telephone, and so we are funding those kinds of newer modalities as well.

You asked about the pandemic — it’s very, very worrisome. The restrictions that have been put into place to try to address the spread of the virus have resulted in substantial isolation for many people. For those with mental health issues, this can really exacerbate those conditions if people have not been able to go their providers that they usually go to for mental health services. And for many, they’re fortunate if they have telephone contact or telehealth contact. But really we know that the most effective services, the evidence we have is based on face-to-face interactions. So while we are proponents of telehealth and we want to see that stay … We know that’s not enough.

Do you think that physicians aren’t well-trained in this area of assessing somebody’s risk of self-harm and suicide?

I absolutely think they’re not trained…. I’m a physician, so I think I can speak to that with some authority. I can tell you that in medical school, you do have a rotation in psychiatry where you, depending on what type of clinical rotation you have, may be exposed to individuals with acute suicidality, but in general, this is not an area of emphasis in medical education. And for other types of practitioners it is not an area of great emphasis…. One of the really excellent resources we have at SAMHSA is our Suicide Prevention Resource Center, that does a lot of training and technical assistance on suicide prevention that is directed toward providers… to help them get those skill sets in place.

Last Updated November 04, 2020