Friday, November 23, 2012

Why I No Longer Support NAMI

For the past several years my wife and I have been regular donors to our state branch of the National Alliance on Mental Illness (NAMI).  We decided to do it initially as a memorial to family members who suffered from mental illness.  I just got two letters in the mail encouraging me to donate again.  One was a "Dear Friend" letter from NAMI reminding me of the plight of the mentally ill.  The other was from the Medical Director and CEO of the American Psychiatric Association.  Dr. Scully apparently thinks he is reminding me of how fragmented the system of care is and "The treatment system that confronts families seeking care is too often fragmented, unorganized and, despite the efforts of many, is uneven at best in its quality."  After working in that "system" for over 25 years and witnessing its decimation by the managed care industry - both letters are insulting.

The only time I was impressed with NAMI was during an attempt to secure resources for a patient in another state.  At that time I contacted NAMI in Illinois and was almost immediately faxed, about 50 pages of resources that my social worker and I could use to come up with a discharge plan.  The fragmented system often resulted in us spending long stress filled hours trying to piece together a plan that we hoped would work while we were being pressured to discharge the person to the street.  Managed care companies were not helpful.  I can still recall a patient with complicated problems.  The managed care company did not acknowledge the serious nature of the problem and wanted immediate discharge.  When we tried to get a discharge appointment for the patient the earliest appointment was 6 months away and they refused to give any priority based on the recent hospital discharge.  

A local NAMI walk for fund raising was disappointing.  Psychiatrists tended to walk with their own organizations, but the dimension that was unnerving to me was the corporate presence.  It seems that the no free lunch movement for doctors is not as concerned about corporate sponsorship of NAMI and any conflicts of interest that might arise.  Why would anyone raise the issue of conflict of interest?  There are two obvious issues.  NAMI has long been an advocate for access to psychiatric care and psychiatrists.  The managed care companies listed as sponsors have been the primary drivers in restricting access not just to psychiatric care but any kind of evaluation or treatment for mental illness or addiction.  In the Twin Cities they currently use case managers to control admissions and discharges.  Those case managers make those decisions based on proprietary guidelines that have little to do with the modern practice of psychiatry.

A second issue is pharmaceutical sponsors.  Psychiatry has been singled out for the appearance of conflict of interest whenever there have been sponsorship or payment of researchers or speakers by pharmaceutical companies.  The real effect of this sponsorship is on the public.  There is no clearer example than National Depression Screening Day.   This event began across the country over 20 years ago.  I was the organizer for two years for the Minnesota Psychiatric Society.  The event was sponsored nation wide by the company who had the most expensive and widely known antidepressant on the market.  It was a field day for the idea that antidepressant medications treat depression.  That bias is still present today and is probably one of the single greatest reasons why treatment of mental illness is typically reduced to a cure in a pill.

Despite my reservations, I decided to support NAMI with an annual check and was listed as a professional member of the organization.  NAMI is a politically powerful organization and I often heard that they had interests that were similar to psychiatric professional organizations.  Then a few months ago Minnesota Public Radio came out with a story on the Minnesota Security Hospital.  It is the state facility that is used to house and treat patients with severe mental illnesses who are also dangerous on an ongoing basis.  Most of the patients are there because they have been adjudicated after committing a violent crime or they are there for an evaluation.  There have been severe administrative problems that have resulted in the resignation of most of the psychiatric staff and an increased number of injuries to staff.

According to that report:

"Sue Abderholden, the executive director of the mental health advocacy group NAMI Minnesota, said despite the concerns, she thinks Barry and other officials are doing a good job of addressing serious, long-standing issues at the facility. She said the decrease in the number of psychiatrists is not necessarily a problem, as long as the facility hires qualified nurse practitioners. Ideally, she said, patients would always see the same provider, but she said that's not realistic for most facilities."

The opinion given in that story is certainly at odds with my opinion.  The state and NAMI seem to believe that psychiatrists are there to prescribe medications and can be easily replaced in that department.  I don't see anything that reflects psychiatric training in how to treat aggressive patients (what else is needed besides medication?) and what needs to happen from a systems or administrative standpoint.  Psychiatrists are the only staff with that kind of training and I wonder about whether they can use that training in a system that seems to suggest that an administrator can develop programs to deal with aggression.  The executive director's opinion seems quite consistent with that approach.  Wasn't that the problem in the first place?

I don't expect any support from NAMI.  Psychiatrists should be able to  support their own positions and members.  At the same time, I don't see any benefit to financially supporting an organization that has radically different goals than my professional goals and sees psychiatrists as easily replaced by people with much less training.  As far as the position of administrators dictating clinical care goes, that is a psychiatrist replaced by someone with no training.  If anyone can act like a physician - then physicians become superfluous.  It is tantamount to running the place with a managed care company and creating the illusion that serious care is being done by seeing people for a few minutes and talking about their medications.

The time has come to not renew my professional membership in NAMI.  With mental health parity still in question, any advocacy organization needs to have higher standards than a managed care company.

George Dawson, MD, DFAPA

Madeleine Baran.  More injured employees, fewer doctors at Minnesota Security Hospital.  August 29. 2012.

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