WASHINGTON – Senate Finance Committee Chairman Chuck Grassley is calling on the Department of Health and Human Services (HHS) to explain why it hasn’t adopted recommendations to improve accountability of grants awarded through the Substance Abuse and Mental Health Services Administration (SAMHSA).  His inquiry comes as recent government reports on trends in mass violence highlight serious mental health issues as a common element among many perpetrators of mass violence.
In a letter to HHS Secretary Alex Azar, Grassley cited a recent report by the U.S. Secret Service’s National Threat Assessment Center (NTAC), which indicated that nearly half of the perpetrators of mass attacks in the last two years had been diagnosed or treated with mental illness prior to the attack.  Last year alone, 67 percent of all perpetrators of mass attacks exhibited mental health symptoms prior to the attack.
While the vast majority of people who have mental illness are not violent, it is critical to ensure that limited federal resources are targeted to the most effective behavioral health services. However, the Government Accountability Office (GAO) and HHS Inspector General found that SAMHSA, which makes grants to support these services, has not adequately tracked and evaluated all of its grant programs. The agency also did not consistently document funding decisions related to its grant awards in prior years, according to GAO, suggesting a continued need for enhanced internal oversight. SAMHSA has been slow to adopt recommendations by the government watchdogs to improve its program oversight.
In his letter, Grassley called on HHS to adopt these watchdog agencies’ recommendations to enhance grant program oversight and better promote access to treatment of childhood trauma.  Grassley also requested an inventory of grant programs to prevent violence as well as metrics on grantee vetting and program performance.
Grassley is the author of the EAGLES Act, which expands access to NTAC’s threat assessment and training programs to better identify and help individuals inclined toward violence so they do not become a threat to themselves or others.
Text of Grassley’s letter to Azar follows:
September 3, 2019
The Honorable Alex M. Azar II
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Secretary Azar:
In the wake of multiple mass attacks in communities across the United States, I write with concern that the Department of Health and Human Services (HHS) and its federal partners are not doing enough to coordinate and effectively target federal resources to the most effective behavioral health programs. To this end, I encourage HHS to promptly adopt the recommendations of two government watchdog agencies in support of the goal of enhanced grant program oversight.
Those who have analyzed recent mass attacks in the United States cite similarities in many perpetrators’ personal histories, offering insights that could help inform our efforts to improve behavioral health approaches in school, university, and workplace settings.  According to the U.S. Secret Service’s National Threat Assessment Center (NTAC), close to half of the perpetrators of mass attacks over the last two years either had been diagnosed or treated for a mental illness prior to their attacks. [1]  Even those without such a diagnosis often have a personal history of childhood trauma (which can lead to anxiety or depression), and in the months prior to committing their mass attack, may have experienced a personal crisis—often evidenced by identifiable behavioral changes or the issuance of violent threats in the same period. [2]  That is not to say that those who have mental health problems or a history of childhood trauma are inherently violent.  But because mental health problems can be a factor in mass attacks, it is important that federal behavioral health programs function effectively as part of a broader strategy to combat targeted violence. [3]
To illustrate:  last year alone, there were 27 mass attacks in the United States, and NTAC reports that 67% of the attackers exhibited mental health symptoms prior to committing the attacks. [4]  As stated in NTAC’s most recent report on this subject:
“Regardless of whether these attacks were acts of workplace violence, domestic violence, school-based violence, or inspired by an ideology, similar themes were observed in the behaviors and circumstances of the perpetrators, including:  “[m]ost of the attackers utilized firearms…[t]wo-thirds had histories of mental health symptoms, including depressive, suicidal, and psychotic symptoms…[plus] [n]early all made threatening or concerning communications and more than three-quarters elicited concern from others prior to carrying out their attacks.” [5]
NTAC’s report also emphasizes the need to target resources to the most promising or evidence-based behavioral health services in the United States, since a “multidisciplinary approach that promotes emotional and mental wellness” should be part of any community violence prevention strategy, according to NTAC. [6]  This and related research underscores the importance of HHS embracing the following steps, with the goal of improving the emotional and mental wellness of those in crisis and hopefully preventing additional tragedies:
Enhanced Grant and Program Oversight.  The Department must continue to ensure that the Substance Abuse and Mental Health Services Administration (SAMHSA) enhances its grant accountability and program oversight efforts.  Several years ago, GAO noted that SAMHSA had properly evaluated only seven of its 30 programs specifically supporting individuals with serious mental illness. [7]  Last year, GAO indicated that SAMHSA has yet to fulfill a 2018 recommendation that it implement a new tracking tool for overseeing mental health protection and advocacy programs. [8]  In addition, this year, the HHS Office of Inspector General (OIG) has reported that SAMHSA did not timely resolve any of the OIG’s audit recommendations, and, although SAMHSA had draft policies and procedures in place to ensure audit recommendations were resolved, as federal law requires, it “did not generally follow them.” [9]  These reports suggest a need for closer attention to this agency’s oversight of grant documentation, program-specific guidance, and program performance data.
Promoting Access to Services to Treat Childhood Trauma.  Media reports suggest that counties in rural states have struggled in recent years to meet the demand for top notch behavioral health care providers. [10]  Iowa, for example, has a tremendous shortage of child psychiatrists. [11]  To help meet this need, HHS must find innovative ways to target the behavioral health resources Congress annually provides to help promote better identification of, and response to, individuals coping with childhood trauma or childhood exposure to violence and related behavioral health conditions.  Again, it is crucial that HHS devote greater attention to ensuring that its components, especially SAMHSA, properly document grant funding decisions and that HHS accords higher priority to grant oversight.  To illustrate:  GAO noted in 2015 that SAMHSA’s Center for Mental Health Services did not consistently maintain “appropriate documentation to support funding decisions” with respect to the Community Mental Health Services Block Grant Program. [12] 
To better understand HHS policies and practices, I request that you please provide written responses to the following questions no later than September 20, 2019:
  1.  Please provide a list of SAMHSA or other HHS grant programs and activities that proactively promote the violence prevention strategies suggested by NTAC (including, e.g., programs that support confidential behavioral health crisis lines, peer-to-peer crisis support services, crisis mobile teams, or initiatives to train school personnel, first responders, and leaders of faith-based communities on the development of systems for identifying and responding to individuals in crisis). 
  1. Describe the purpose of each program, how it contributes to SAMHSA’s mission, and recent funding information. 
  1. Please also describe the efforts, if any, made by HHS and its federal partners to inventory all other federal programs supporting individuals with mental illness, as GAO has recommended, and to facilitate intra- and interagency coordination with respect to these activities.
  1. If available, please provide materials and checklists used in determination and vetting of a grantee.
  1. How does HHS currently evaluate SAMHSA’s decisions to award funding to programs targeting individuals with mental illness?   
  1. For example, on what internal mechanisms does SAMHSA rely to determine the appropriate timing of an evaluation to measure each such program’s effectiveness? 
  1. Please summarize any additional actions that have been taken in response to GAO’s 2014 and 2015 findings relating to SAMHSA’s lack of completed program evaluations.
  1. Has HHS ensured that SAMHSA implemented monthly reconciliations of its audit resolution records with the appropriate oversight offices, as recommended by the HHS OIG in its 2019 report?  If not, please explain, and if so, please list the dates when the reconciliations were performed in the current calendar year as well as any related procedure(s) for identifying and completing unresolved audit recommendations.  
  1. According to the most recent report issued by the HHS OIG, SAMHSA had 188 outstanding audit recommendations as of September 30, 2016, which have yet to be resolved. [13]
  1. What corrective actions has SAMHSA taken to ensure that the backlog of audit recommendations, which were not resolved in a timely manner during FYs 2015 and 2016, are now resolved?
  1. Additionally, has the July 2015 draft version of the SAMHSA Internal Policy and Procedures for Resolution of Audit Findings document been finalized?  If so, please provide a copy of the finalized version.  If not, please provide a detailed explanation for why the policies and procedures were not finalized by the July 31, 2019 deadline.
  1. How many of the 188 outstanding audit recommendations have been (1) resolved and (2) for how many has SAMHSA initiated audit resolution efforts, as of September 20, 2019? 
Thank you for your attention to this important matter.  If you or your staff have any questions, please contact Evelyn Fortier or Rachael Soloway of my Committee staff at (202) 224-4515.
Charles E. Grassley
Committee on Finance

[1] U.S. Dep’t of Homeland Sec., U.S. Secret Service, National Threat Assessment Center [hereinafter NATC], Mass Attacks in Public Spaces–2018 (Jul. 5, 2019), available at https://www.hsdl.org/?view&did=826876.
[2] Id. at 2.  See also Jillian Peterson & James Densley, “Op-Ed: We have studied every mass shooting since 1966. Here’s what we’ve learned about the shooters,” L.A. Times (Aug. 4, 2019) (citing the Comprehensive School Safety Initiative (CSSI), and further noting that “[m]ost mass public shooters are suicidal, and their crises are often well known to others before the shooting occurs”), available at https://www.latimes.com/opinion/story/2019-08-04/el-paso-dayton-gilroy-mass-shooters-data.
[3] As articulated by the Consortium for Citizens with Disabilities, “[t]he current public dialogue is replete with inaccurate stereotyping of people with mental disabilities as violent and dangerous…[.]”  See Letter from CCD Task Force dated Jan. 26, 2017 to Hon. Mitch McConnell and Hon. Chuck Schumer, U.S. Senate, 163 Cong. Rec. 15 (Jan. 30, 2017).    
[4] See Mass Attacks in Public Spaces–2018, supra note 1, at 6 (finding that “[t]he most common symptoms observed were related to depression and psychotic symptoms such as paranoia, hallucinations, or delusions.  Suicidal thoughts were also observed.”).
[5] Id. at 2.
[6] Id. at 13.
[7] U.S. Government Accountability Office, GAO-15-405, Mental Health: Better Documentation Needed to Oversee Substance Abuse and Mental Health Services Administration Grantees (Jun. 11, 2015), available at https://www.gao.gov/assets/680/670148.pdf.
[8] U.S. Government Accountability Office, GAO-18-450, Mental Health: Federal Procedures to Oversee Protection and Advocacy Programs Could Be Further Improved (May 24, 2018), available at https://www.gao.gov/products/GAO-18-450.
[9] U.S. Dept. of Health and Human Serv., Office of Inspector Gen., A-07-19-03233, The Substance Abuse and Mental Health Services Administration Resolved Approximately One-Third of Its Audit Recommendations, None in Accordance with Federal Timeframe Requirements (Jul. 18, 2019), available at https://oig.hhs.gov/oas/reports/region7/71903233.pdf.
[10] See, e.g., “Iowa Shortage of Child Psychiatrists Reflects National Problem,” The Iowa Gazette (Jan. 4, 2014), available at https://www.thegazette.com/2014/01/04/in-iowa-shortage-of-child-psychiatrists-reflects-national-problem.
[11] Natalie Krebs, “Iowa Struggles to Fill Child Psychiatrist Shortage,” National Public Radio (Jun. 27 2019), available at https://www.iowapublicradio.org/post/iowa-struggles-fill-child-psychiatrist-shortage#stream/0.
[12] See supra note 8, at 11 (stating that “CMHS did not document its application of criteria for about a third of the grantees we reviewed.”).
[13] Id. at 1 (“[w]ithout resolving all audit recommendations in a timely manner, SAMHSA runs the risk of noncompliance with Federal requirements and mismanagement of Federal funds”).