1. A post by one of
my esteemed colleagues on Twitter – Emily Deans, MD. I have never met Dr. Deans and know her work
primarily through her blog, Substack, and Twitter posts. I cannot recall ever disagreeing with
her. Today she began a thread with: “The
US allows people with terrible brain illnesses to languish on the streets and
get murdered on the subway.” She built
upon that theme.
2. I was working on
a presentation for Friday May 5 on “Everything You Wanted To Know About Psychiatry
in 30 Minutes or Less.” That got me into
a historical frame of mind.
3. I had the
occasion to pick up my copy of Sylvia Nassar’s biography of John Nash “A
Beautiful Mind” and reread the description of his civil commitment to a state
hospital where he received insulin shock treatments at age 33.
4. During my work on
the presentation I suddenly got the bright idea to create a couple of new
timeline graphics – one of which was about European influences on American
psychiatry (protopsychiatrists, transitional self-taught psychiatrists, and
psychiatrists) and that led to thinking about the current state of psychiatric
affairs in the United States.
That all came together to produce the following paragraphs
that I have discussed here before but seems reinforced by the current
confluence of information.
Psychiatric care in the US is abysmal and it is not due to
the lack of bright and highly motivated psychiatrists. It is due to a lack of access. It is possible to find those psychiatrists and get treatment but good luck with that. Dr. Deans is correct that people are
currently dying due to the lack of humane laws to treat people with severe
mental illnesses. In many jurisdictions those laws are interpreted in the context of the lack of resources. In other words if there are no facilities available, legal action is dropped. That problem lies squarely on several entities that are far
outside of psychiatry. The problem is so chronic it is hard to prioritize which
of these entities came first and is the worst (although I have provided a few
timelines). Let me take them point by point as they come to mind.
The antipsychiatry movement needs to finally get credit for
its destructive nature. Psychiatrists tend to respond either by ignoring them
and hoping they will go away or by wasting their time trying to argue against
their repetitive rhetoric. The pandemic
and the last election highlighted the use of misinformation in social media.
The antipsychiatry movement are experts in misinformation and they have been
using the same tactics for the past 50 years.
Part of those tactics include getting their rhetoric and opinions in the
mainstream psychiatric literature. In 1986, Martin Roth and Jerome Kroll had
the following observation:
“We have argued in this section that the concept of mental
illness has definable boundaries and that medical forms of care are appropriate
and efficacious only in circumscribable portions of those who present a danger
to society. But recent trends if allowed to continue, can only culminate in a
society in which prisons again contain a large portion of those who suffer from
mental illness because there is no appropriate or alternate form of care or
accommodation for them. If such a situation should materialize, the distinction
between prison and hospital will become once again blurred and obliterated like
it was 133 years ago when Bucknill held out optimistic hopes of a new era in
which science and humanity would jointly seek to surmount the problems
presented by morbid mental suffering. The hard-won and remarkable progress
achieved by psychiatry during the past half century in particular, will then
have been set into reverse.” (p. 114).
There has not been a more prophetic statement in the
field. The largest psychiatric hospitals
in the United States are currently county jails. The state hospital systems
that were in some cases flagships for treatment of people with severe mental
illnesses are no longer functional and exist at the margins to alleviate
pressure on community hospitals to accept involuntary patients. It is more of a blockade than a bottleneck
since the latter would suggest movement once the obstacles have been
passed. There is no movement and the
association of state mental health directors has made it very clear they are
not interested in movement.
The basic paradox of the system is that the necessary
infrastructure necessary to treat even average numbers of persons with severe
mental illnesses and those who are under civil commitment is not there. It is atrophied or rotten and there has been
no wide sustained effort to improve it since The Community Mental Health Act of
1963. Even though the Mental Health Parity and Addiction Equity Act (MHPAEA)
was passed in 2008 – it is clear to anyone working in the field that there is
no enforcement to ensure mental health parity or adequate substance use
treatment. The healthcare industry has sent a clear message that it takes more
than a law on the books – it takes concerted and very expensive legal
action. In the past some activist attorney
generals had some success – but there are not many of them around anymore.
It is not hard to imagine how a fragmented system of care has withered
during a time of continuous antipsychiatry rhetoric. Money is always cited as a limiting factor,
but the amount of money especially compared with the ballooning number of
administrators at the state and health plan levels does not seem great. State
hospitals and departments of human services seem to run on a managed care
rationing model rather than a model focused on helping the most vulnerable
citizens. It is not a coincidence that both antipsychiatry and business
rationing for profit both depend on Libertarian values – the most basic being
“you are only worthwhile if you are living what I determine to be a worthwhile
life.” That same value system criminalizes
aggression and violence secondary to mental illness and sees incarceration as
the only beneficial outcome. That is consistent with the current model of
county jails as psychiatric hospitals that do not deliver any psychiatric care.
That brings me to the Nash biography. He was hospitalized in
about 1961 at Trenton State Hospital.
According to Harcourt’s graphs of deinstitutionalization – this was the
beginning of a time of rapid decline in mental hospitalization rates that has
continued unabated to the present time. Trenton was overwhelmed by the large
number of patients seeking help there – 4,000 after World War II dropping and
then rising again in the 1960s to about 2,500 when Nash was there. Psychiatrist
staffing ratios varied from 1:100 patients in the acute ward to 1:500 patients in the chronic ward. Length of stay for
most patients was about 3 months. Rationing clearly existed even before
deinstitutionalization. One of the psychiatrists who worked there described the environment as “crummy.” In terms of personal
relationships with patients – it could be expected to be rare with those
staffing ratios. Nasar describes the hospital
as “overcrowded, underfunded, and understaffed.”
 |
Figure 1. Rates of Institutionalization in Mental Institutions and State and Federal Prisons (per 100,00 adults) from the paper by Bernard E. Harcourt, " REDUCING MASS INCARCERATION: LESSONS FROM THE DEINSTITUTIONALIZATION OF MENTAL HOSPITALS IN THE 1960s," 9 Ohio St. J. Crim. L. 53 (2011), available at: https://scholarship.law.columbia.edu/faculty_scholarship/639 |
The exception noted was the insulin unit. Apparently, Nash was recommended to go to
this hospital because it had this modality. It was a 44-bed unit – half men and half women
in separate wards. Patients on that unit received special diets and special recreation. That is where Nash got insulin treatments 5
days a week for the next 6 weeks. Nash later described the agony of these
treatments in detail including what may have been long tern effects on his
dietary pattern. In retrospect, the
question is whether it was necessary or not.
Manfred Sakel had discovered insulin shock treatments (IST)
in 1935 by accidentally administering too much insulin to a patient with
morphine addiction resulting in seizures and a coma. The patient awoke with more mental clarity. That led to further trials and wider
application. Nassar suggests that by 1960, IST had been phased out in most hospitals and replaced with electroconvulsive therapy (ECT).
Max Fink did a direct study of chlorpromazine versus IST in 1958 (2) and
noted that the results clearly favored chlorpromazine. That resulted in the IST unit at his hospital
closing within 6 months (3). Even though Nash had not been able to work for the
previous 3 years he was widely regarded and his intelligence was described as a
national security asset. As he was recovering, he started a paper on fluid dynamics
while he was at Trenton that he subsequently finished and published in 1962 French mathematical journal. He was awarded the Noble
Prize in economics for game theory in 1994. His original two page paper at
age 22, was part of the basis for the Nobel determination (5,6).
Nash’s tenure at Trenton is a good example of rationing
prior to managed care. The rationing resulted in both the abysmal conditions
and a lack of state-of-the-art care. Some might say that you can’t argue with
results. Nash recovered and was able to
go back to research and publishing in mathematics, despite his dissatisfaction with
treatment. Later in his biography he was
treated with a number of second generation antipsychotic medications that were
described as helping him stay out of the hospital but “have not given him a life.”
That brings me back to Dr. Dean’s comment at the top of
this post. We have people with severe mental illness dying on the streets. A
small number become aggressive and violent, but a much greater number are
victims of violence and exploitation. They do not have stable living situations
and there are associated problems with substance use disorders. This is a gross
level of neglect compared with way other healthcare problems are addressed
requiring more resources than psychiatric care. About 1 in 300 people get
retinal detachments during their lifetime. In any mid-sized city in the United States
access to state-of-the-art retinal care is not a problem. The same thing is
true for orthopedics, gastroenterology, and cardiology. Psychiatric care is
fragmented across private pay systems, public pay systems, and managed care
systems. The last two are managed by
large bodies of administrators that are focused on rationing rather than an
adequate system of care. In many ways, the landscape of psychiatric care is approached
with the same level of recklessness as firearms. We all have to pretend that
something useful can never be done and therefore maintain the status quo.
George Dawson, MD, DFAPA
References:
1: Roth M, Kroll
J. The Reality of Mental Illness. Cambridge University Press. Cambridge,
England 1986: 82-144.
2: Fink M, Shaw R, Gross
GE, Coleman FS. Comparative study of chlorpromazine and insulin coma in therapy
of psychosis. J Am Med Assoc. 1958 Apr 12;166(15):1846-50. doi:
10.1001/jama.1958.02990150042009. PMID: 13525160.
3: Fink M. Meduna
and the origins of convulsive therapy. Am J Psychiatry. 1984
Sep;141(9):1034-41. doi: 10.1176/ajp.141.9.1034. PMID: 6147103.
4: John F. Nash Jr.
– Facts. NobelPrize.org. Nobel Prize Outreach AB 2023. Sun. 7 May 2023. https://www.nobelprize.org/prizes/economic-sciences/1994/nash/facts/
5: Holt CA, Roth
AE. The Nash equilibrium: A perspective. PNAS. 2004; 101 (12) 3999-4002. https://www.pnas.org/doi/10.1073/pnas.0308738101
6: Nash Jr JF.
Equilibrium points in n-person games. PNAS. 1950 Jan;36(1):48-9. https://www.pnas.org/doi/full/10.1073/pnas.36.1.48
Graphic Credit:
I took this photo of the Rum River Dam in Anoka, MN about 30 minutes after I gave my presentation on May 5, 2023. Anoka happens to be where the Anoka Metro Regional Treatment Center is located. It is the last state mental hospital in Minnesota. Since 1978 Minnesota has closed 10 of its 11 state hospitals and only AMRTC remains. There have opened 6 - 16 bed units called Community Behavioral Health Hospitals that have reduced capacity and apparently do not accept referrals from major metropolitan hospitals. https://mn.gov/dhs/people-we-serve/adults/services/direct-care-treatment/programs-services/community-behavioral-health-hospitals/
With the Lanterman-Petris-Short Act of 1967 in California, The longest you could hold mental patients against their will was 17 days (28 if they were actively suicidal), with patients having the right to judicial review within 72 hours. Many of the details in the bill were then adopted in states across the country,
ReplyDeleteAn individual with a mental illness could be hospitalized involuntarily if they were a danger to themselves, a danger to others, or "gravely disabled." This last term meant that they could not provide for their own food, clothing and shelter. And this included patients who were living in cardboard boxes on the street, which at the time the bill was passed were relatively rare. Now, because of patients’ rights idiots, that no longer is the case - it seems like someone literally has to be starving because of their illness in order to qualify as gravely disabled.
Patients who were unable to work because of their illness could be put on social security disability (SSI). This would then pay for housing for them in numerous “board and care” homes - which seemed to have disappeared for the most part. Reagan tried to kick people with schizophrenia off the SSI roles because he didn’t believe in mental illness. The courts eventually stepped in to stop him.
And the biggest difference from now is that there were a whole lot of community health centers we could refer them to for treatment after they were discharged. These now seemed to have disappeared. Paradoxically, it costs more to incarcerate people in jail than commit them to a mental hospital
The disappearance of community resources has been an interesting phenomenon. When I was working in acute care in downtown St. Paul there were many more resources than when I moved on from that position in 2010. By that time a large multi-house group home with central nursing had shut down, referrals to home health nurses were no longer possible, structured group home for children were essentially eliminated, several county community mental health centers were either scaled back or shut down, and course state hospitals were closed and there was a significant backlog to get into Anoka Metro Regional Treatment Center (AMRTC). At one point the county Sheriffs had priority over inpatient psychiatrists in transferring people to AMRTC - increasing the backlog. There was also a rule passed that psychiatric patients were responsible for a cash copay on expensive medications - despite the fact that their disability income was basically subsistence level. A case manager was placed in my team meetings to encourage me to discharge patients rather than treat them. All of those factors lead to increasingly compromised care during the 22 years I worked in a hospital.
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