Saturday, August 17, 2013

Straight Talk About the Government Dismantling Care for Serious Mental Illness

The ShrinkRap blog posted a link to an E. Fuller Torrey and D.J. Jaffe editorial in the National Review about how the government has dismantled mental health care for serious mental illnesses and some of the repercussions.   Since I have been saying the exact same thing for the past 20 years, they will get no argument from me.  Only in the theatre of the absurd that passes for press coverage of mental illness and psychiatry in this country can this subject be ignored and silenced for so long.  It was obviously much more important to see an endless stream of articles trying to make the DSM-5 seem relevant for every man.  The stunning part about the Newtown article is the commentary about what government officials responsible for policy have actually been saying about it.

The authors waste very little time examining the sequence of events in the Obama administration following the Newtown, Connecticut mass shooting.  President Obama initially stated he would "make access to mental health care as easy as access to guns." and set up a Task Force under Vice President Biden to make recommendations.  The authors argue that the agency that was consulted, the Substance Abuse and Mental Health Services Administration (SAMHSA) promotes a model of treating mental illness that has no proven efficacy, does not discuss serious mental illnesses in its planning document, ignores effective treatments for serious mental illnesses and actually goes so far as to fund programs that block the implementation of effective treatment programs.  In an example of the obstruction of effective programming by SAMHSA funded programs following the Newtown mass shooting:

"But, alas, the situation is even worse. SAMHSA does not merely ignore effective treatments for individuals with severe mental illness. It also funds programs that attempt to undermine the implementation of such treatments at the state and county level. One such program is the Protection and Advocacy program, a $34 million SAMHSA program that was originally implemented to protect patients in mental hospitals from abuse. It was kidnapped by civil-liberties zealots and has been used to block the implementation of assisted outpatient treatment, funding efforts to undermine it in at least 13 states. For example in Connecticut, following the Newtown massacre of schoolchildren, the federally funded Connecticut Office of Protection and Advocacy for Persons with Disabilities testified before a state-legislature working group in opposition to the proposed implementation of a proposed law permitting court-ordered outpatient treatment for individuals with severe mental illness who have been proven dangerous. The law did not pass."  (page 3, par 2.)

In other words, a SAMHSA funded program was opposed to a law in Connecticut that could potentially reduce violence from persons with severe mental illness.

SAMHSA administrators are quoted at times in the article. Any quote can be taken out of context but the characterizations of severe mental illness as "severe emotional distress", "a spiritual experience" and "a coping mechanism and not a disease" reflect a serious lack of knowledge about these disorders.  The idea that "the  covert mission of the mental health system social control" is standard antipsychiatry philosophy from the 1960s.  How is it that after the Decade of the Brain and the new Obama Brain Initiative  we can have a lead federal agency that apparently knows nothing about the treatment of serious mental illnesses?  How is it that apart from  some fairly obscure testimony, no professional organizations have pointed this out?  How is it in an era where governments at all levels seem to demand evidence based care, that a lead agency on mental health promotes treatment that has no evidence basis and ignores the treatment that is evidence based?

Having been a long time advocate for the prevention of violence by the treatment of severe mental illnesses my comments parallel those of the authors.  Inpatient bed capacity in psychiatry has been decimated.  They point out that there are only 5% of the public psychiatry beds available that there were 50 years ago.  It is well known that people with mental illnesses are being incarcerated in record numbers and some of the nation's county jails have become the largest psychiatric institutions.  Where are all of the civil liberties advocates trying to get the mentally ill out of jail?

Only a small portion of the beds available can be used for potentially violent or aggressive patients and that number gets much smaller if a violent act has actually been committed. Most of the bed capacity in this country is under the purview of some type of managed care organization and that reduces the likelihood of adequate assessment or treatment.  The discharge plan in some cases is to just put the patient on a bus to another state.

Community psychiatry is a valuable unmentioned resource in this area.  In most of the individual cases mentioned in this article, the lack of insight into mental illness or anosognosia is prominent.  It is not reasonable to expect that a person with anosognosia will follow up with outpatient appointments or even continue to take a medication that treats their symptoms into remission.  Active treatment in the community by a psychiatrists and a team who knows the patient and their family is the best way to proceed.  All of this active treatment has been cost shifted out of insurance coverage and is subject to budget cuts at the county and state level.

Civil commitment laws and proceedings are probably the weakest link in treatment.  Further cost shifting occurs and violent patients often end up aggregating in the counties with the most resources.  Even while they are there, many courts hear (from a budgetary perspective) that they are committing too many people and the interpretation of the commitment law becomes more liberal until there is an incident that leads to the interpretation tightening up again.  Bureaucrats involved often become libertarians and suggest that commitment can occur only if an actual violent incident has happened rather than the threat of violence.

Although Torrey and Jaffe are using the extreme situation of violence in the seriously mentally ill to make their point, the majority of the seriously mentally ill are not violent.  They need the same resources.  It has been thirty years of systematic discrimination against these people, their families and the doctors trying to treat them that has led to these problems.  I pointed out earlier on this blog the problem I have with SAMHSA and the use of the term "behavioral health".  The problems with SAMHSA and current federal policy are covered in this article and I encourage anyone with an interest to read it.  If history is any indication, I don't expect anything serious to come of the criticism.  I anticipate a lot of rhetorical blow back at Dr. Torrey.  But as a psychiatrist who has worked in these environments for most of my career, his analysis of the problem is right on the mark.

George Dawson, MD, DFAPA

E. Fuller Torrey & D.J. Jaffe.  After Newtown.  National Review Online.

White House.  Now Is The Time.  The President's plan to protect our children and our communities by reducing gun violence.  January 16, 2013.

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