With all of the blinding detail in the 1,116-page "Big Beautiful Bill" and the attention to the legislative jousting between the House and Senate, it’s too easy to lose sight of the devastating budget cuts in the bill. The major ones, such as Medicaid and food stamps, have gotten a lot of notice, but many more have received too little attention.

One is mental health.

A notable achievement of the Biden years, thanks to smart public policy, has been a sharp reduction in drug overdose deaths. You would think this would be of interest to Trump, since he used fentanyl smuggling and related deaths as his excuse to punish Canada (a trivial source of fentanyl) with high tariffs.

As of the end of the Biden administration, there was a large amount of money provided to the states via the Mental Health Block Grant and the Substance Abuse Prevention and Treatment Block Grant. According to Al Guida, longtime behavioral health policy strategist, on a recent episode of the No Notes podcast, when Biden left office about $1.3 billion in unspent funds was still available to the states, which had until September 30 to spend that money. But the Trump administration terminated all those resources on March 24. The proposed budget would eliminate 42 more programs.

On May 14, the CDC’s National Center for Health Statistics reported that, in 2024, there were 80,391 drug overdose deaths in the U.S.—down 27 percent from 110,037 in 2023. The number of annual drug overdose deaths is now projected to hit the lowest level since 2019, according to the CDC.

The agency responsible for funding these and other such programs faces a cut of 20 percent, or over a billion dollars. The Substance Abuse and Mental Health Services Admimistration (SAMHSA), which is part of HHS, is being folded into a newly created Administration for a Healthy America.

SAMHSA grants were responsible for the reduction in drug deaths. But according to the budget proposal, SAMHSA grants in the previous administration "were used to fund dangerous activities billed as ‘harm reduction,’ which included funding ‘safe smoking kits and supplies’ and ‘syringes’ for drug users."

SAMHSA has also provided the lion’s share of funding for one of the great breakthroughs in preventive mental health, the Portland Identification and Early Referral (PIER) program. The PIER program, which has inspired and provided training for similar programs in most states thanks to federal funding, reflects the research findings of Dr. William McFarlane, former chief of psychiatry at Maine Medical Center.

Dr. McFarlane and his colleagues found that if an initial psychotic break can be prevented, people with schizophrenia and other major mental illnesses can lead relatively normal lives. In other words, it was the psychotic break, not the illness, that was so devastating in terms of social isolation, inability to work, and future repeated breakdowns.

Dr. McFarlane told an interviewer in 2014, "Our theory was that if you could identify these young people early enough, you could alter some of those family patterns. Then you could work with the family to start behaving not just normally, but in a way that was smarter." PIER brings families in for twice-monthly multifamily group therapy sessions. Sometimes the program uses anti-psychotic medication, but a lot less than conventional approaches.

The onset of these illnesses is typically in the teen years. The PIER program trains high school guidance counselors, deans, teachers, and others who engage with teens to spot early signs of kids at risk. It educates kids themselves. Then the program offers early therapeutic intervention. Dr. McFarlane estimates that the lifetime cost of one case of full-blown schizophrenia is $10 million, so the PIER prevention strategy saves many billions of dollars as well as saving lives from being stunted.

The cuts in funding for the Department of Education will end funding for the training of high school conselors and teachers. The cuts at SAMHSA will cripple support for PIER-style theraputic interventions nationwide. Dr. McFarlane says he sees his life’s work going up in smoke. In California, where PIER-type efforts are funded statewide by the revenue from that state’s millionaire’s surtax, the program will survive.

Readers of Franz Kafka may appreciate that SAMHSA is pronounced "Samsa," which happens to be the surname of Gregor Samsa, the character in Kafka’s The Metamorphosis, who wakes up one morning to find that he has been turned into a giant cockroach. Trump’s infestation of public policy is a plague worthy of Kafka.

Trump’s Republicans are not only promoting lunatic policies. They are literally promoting mental illness.