I have two recent posts on the issue and thought I would add this as a better summary. The media refrains at this point are tiresome and not helpful. Just yesterday I heard arguments about how the current Clancy case is or is not an indictment of the mental health system. That was followed by a poll that said most men consider filicide cold blooded murder and most woman are more sympathetic. There are of course social media influencers amplifying those extremes to get likes and improve their revenue streams and politicians doing the same. All of this occurs in the context of highly publicized incidents of violence perpetrated by persons with obvious severe mental illness on the streets in New York and other large cities. Those incidents have resulted in loss of life of both victims and perpetrators.
Any consistent reader of this blog over the years should get
the strong message that there is no system of care for mental illnesses in the
US and that the system of care for physical illnesses is rapidly going down the
same tube. Disproportionate rationing of care for mental illnesses started out
as a profit maker for the managed care industry and that has expanded to all
medical care. As a result, there has
been an explosion in the number of administrators compared with people doing
the work and a transfer
of a trillion dollars a year to management.
It is more than profit making at this point. It leads to a current lack
of quality care for those who can access it and it is unsustainable.
Here are a few thoughts on getting an actual system in place
that might be able to address the real problems rather than focusing on all of
the non-functional political rhetoric.
There is some overlap between points.
That is intentional to place more of a focus on postpartum care.
1: Improve mental
health and the care of mental illnesses in general – The first time the
federal government took a direct role in the provision of mental health
services was the Community Mental Health Act of 1963 signed by President
Kennedy. The goal was to move mental
health care out of asylums and back to communities. It led to the creation of many Community
Mental Health Centers. Even as late as
1988, I was providing care at a rural hospital so they would not default on a
grant they obtained though that original Act.
Since then many CMHCs have been closed.
Some have been assimilated by other non-public systems of care. New certified community behavioral health
clinics (CCBHCs), were established under the Protecting Access to Medicare Act
of 2014 rather than continuing the CMHC category. This changing landscape has made facilities a
poor proxy for access to mental health care.
|
Metric |
What it measures |
Key statistics |
References |
|
1. Treatment rate
/ minimally adequate treatment |
Whether care
reached the person and met a guideline-based quality threshold |
Of 24.9% of US
adults with a past-year disorder, 60.7% received any treatment but only 34.0%
received minimally adequate treatment (MDPS, SCID-5). Historically ~47.7%
of adults with serious conditions received no treatment; only ~44.8% of
adults with any mental illness treated in 2019 |
[1-3] |
|
2. Workforce
supply per population (HPSA) |
Provider capacity
relative to population; shortage-area designation |
>1/3 of
Americans live in a behavioral health workforce shortage area; majority of counties lack any practicing psychiatrist,
psychologist, or social worker; psychiatrists per 100,000 fell ~10%
(2003–2013) while PCP/neurology supply grew |
[4-5] |
|
3. Timely access
(availability & wait times) |
Whether providers
accept new patients and how long the wait is |
Only 18.5% of
sampled psychiatrists available to new patients; median wait 67 days
(in-person) vs 43 days (telepsychiatry); worse for Medicaid than private
insurance |
[6] |
|
4. Two-dimensional
geographic access (availability + affordability) |
County provider
supply per 100,000 AND cost of a treatment course vs disposable income,
mapped simultaneously |
Reveals counties
where providers are physically present but financially inaccessible; income
was the strongest predictor of both dimensions; rural and Southern
counties carry dual burdens |
[7-8] |
|
5. Medicaid
acceptance & out-of-pocket burden |
Whether existing
providers accept Medicaid/new patients and cost-sharing faced by patients |
~Nearly half of
psychiatrists do not accept insurance due to poor reimbursement eliminates SMI patients who hit benefit limits; SMI care
is disproportionately publicly financed |
[5] |
|
1: Edlund M, Guyer H, Ringeisen
H, Stambaugh L, Dever J, Carpenter L, Olfson M, First M, Geiger P, Liao D,
Peytchev A, Carr C, Zangeneh S, Chwastiak L, Dixon L, Monroe-Devita M, Stroup
TS, Swanson J, Swartz M, Gibbons R, Bareis N, Kessler RC. Treatment of Mental
Disorders Among U.S. Adults: Findings From the Mental and Substance Use
Disorders Prevalence Study. Psychiatr Serv. 2026 Jul 22:appips20250398. doi:
10.1176/appi.ps.20250398. Epub ahead of print. PMID: 42482274. 2: Olfson M, Wang S, Wall M,
Marcus SC, Blanco C. Trends in Serious Psychological Distress and Outpatient
Mental Health Care of US Adults. JAMA Psychiatry. 2019;76(2):152–161.
doi:10.1001/jamapsychiatry.2018.3550 3: Askari, M.S., Mauro, P.M., Kaur, N. et al. Age, Period, and Cohort
Trends in Perceived Mental Health Treatment Need and Differences by Mental
Health Severity in the United States, 2008–2019. Community Ment Health J 59,
631–640 (2023). https://doi.org/10.1007/s10597-022-01044-3 4: Substance Abuse and Mental
Health Services Administration. Expanding Behavioral Health Teams in Care Deserts With Community Health Workers
and Peer Support Specialists. Publication No. PEP26-07-001. Substance Abuse and Mental
Health Services Administration. 2026. 5: Huskamp HA, Iglehart JK.
Mental Health and Substance-Use Reforms--Milestones Reached, Challenges
Ahead. N Engl J Med. 2016 Aug 18;375(7):688-95. doi: 10.1056/NEJMhpr1601861.
PMID: 27532837. 6: Sun CF, Correll CU, Trestman
RL, Lin Y, Xie H, Hankey MS, Uymatiao RP, Patel RT, Metsutnan VL, McDaid EC,
Saha A, Kuo C, Lewis P, Bhatt SH, Lipphard LE, Kablinger AS. Low
availability, long wait times, and high geographic disparity of psychiatric
outpatient care in the US. Gen Hosp Psychiatry. 2023 Sep-Oct;84:12-17. doi:
10.1016/j.genhosppsych.2023.05.012. Epub 2023 May 25. PMID: 37290263. 7: Park J, Kim HR, Duffy RD,
Vogel D, Keum BT, Lee S, Tomé NL. Two dimensions of access: Availability and
affordability of mental health care across the United States. Am Psychol.
2026 Jun 4. doi: 10.1037/amp0001735. Epub ahead of print. PMID: 42241094. 8: Cummings JR, Allen L, Clennon
J, Ji X, Druss BG. Geographic Access to Specialty Mental Health Care Across
High- and Low-Income US Communities. JAMA Psychiatry. 2017;74(5):476–484.
doi:10.1001/jamapsychiatry.2017.0303 |
|||
The data for postpartum depression in various clinical
settings is that only 6.3% of women with the disorder receive adequate
treatment and only 3.2% of that cohort achieve remission (1). Similar rates are not available in those
populations for postpartum psychosis, but there is no reason to expect the
numbers would be better. In a study of
postpartum psychosis where all of the cases were identified as a cohort treated
by the same research group the remission rate was 82-94% (2) illustrating the
rates of treatment response with a comprehensive program.
The first metric is the clearest indicator of a
non-system. Less than half of anyone
with a serious mental disorder or any mental disorder receives minimally
adequate care in this country. For some conditions like depression that number
goes as
low as 10% when considering effective treatment for depression. With those
numbers it should not be surprising that people with acute symptoms are obvious
at times. Metrics 2 – 5 explain why the gap exists (capacity, timeliness,
geography, and financing). There are
concrete ways to address every one of those problems.
2: Develop state
of the art guidelines for treatment - the existing system has evolved to
ration access and shift costs to non-mental health care settings like jails,
shelters, and county detox units. This
impedes access to medical providers with the most resources and access to
referrals. The standard crisis approach
at most hospitals creates a boarding situation in emergency departments (ED),
excessive congestion, and slows access to mental health care. Many people end up leaving without treatment.
3: Develop
adequate inpatient units for care – bed requirements to produce the same
wait time and access to care that medical and surgical patients get have been
determined. States and health care
systems have been reluctant
to build and staff those adequate numbers and there is some indication that
medical and surgical beds are also in short supply. Granted there is more ambulatory care than in
the past – but it clearly has been inadequate at alleviating pressure on both
the ED and hospital admissions. Many
outpatient mental health providers use the ED for after hours crisis referral
and in many cases it is the only way to access more intensive services like
electroconvulsive therapy. The ED services that I am familiar with do not provide crisis care. They provide a decision about whether a person should be admitted to the hospital or not and the bias is on the not side.
4: Adequately fund treatment maternal care including
replacing the Medicaid funding that has been cut - Medicaid is the largest
single payer of maternal care, mental health and substance use treatment – even
before additional funding is considered.
The current administration cut this funding source by $1trillion over
the next decade. Even before those cuts
directly impact all of those millions of individuals – hundreds of rural and
safety net hospitals and other facilities will be closed. In the process all health care premiums will
increase fueling the ongoing cycle rationing and cost-shifting to increase
corporate profits. Safety net hospitals
are generally critical components of the treatment of severe mental illnesses
and psychiatric emergencies. Every hospital
with a large obstetric component needs mental health consultants that know
about perinatal care.
5: Educate medical
professionals about the disorder – most of the physicians I have discussed
this disorder with have encountered some form of maternal mental disorder that
compromised the safety of the mother or child at some point in their training
and career. In my experience it first happened
during my clinical rotation though obstetrics and gynecology (OBGYN) in medical
school. At that time there was no
discussion of the mental disorder or what care was necessary. Even as a
psychiatric resident, I saw patients with the disorder but there was no
discussion of specific evaluation or treatment. I did not start to see that information until
about a decade into clinical practice.
My next post will have the top groups worldwide studying this disorder
as well as some of the top references.
6: Promote
maternal mental health as a necessary subject in primary care and psychiatric
specialties – the full array of psychiatric disorders associated with the
peripartum state has become a lot clearer with research. It is a frequent topic
at psychiatric research and continuing education conferences. All primary care specialists need to have a
good idea about necessary care and available resources. The psychopharmacology of these disorders is
also a necessary topic and the experts in that area do not necessarily overlap
with postpartum psychosis experts (3).
7: Prioritize
prophylactic treatment of severe mental disorders before and during pregnancy
– in woman with known preexisting psychiatric disorders there is a lot known
about effective prophylaxis that is safe at all stages of pregnancy. Pregnancy is a known cause of rapidly
worsening pre-existing mental disorders and there should be a plan in place to
prevent that disruption.
8: Educate the
general public about the disorder – in one of the studies I referenced in a
previous post the partner involved was unaware of pregnancy related mental
health disorders and was often concerned about the loss of the relationship or
future with the woman involved. All of
that can be addressed in education about peripartum and postpartum care and the
appropriate educational materials made available.
Social media is a very poor format for these discussions
because of the level of misinformation out there about psychiatric disorders as
well as the political posturing involved.
That has resulted in moralistic
positions being taken that have no basis in reality. And yes – I am saying as a psychiatrist that
mental conditions can affect consciousness, insight, judgment, and agency to
the point that a person will make a decision that they would not otherwise make
in the commission of a crime. And
further I am saying that is a qualitative change and not a quantitative
one. In other words it is not getting
excessively angry or emotional in the heat of the moment, it is an entirely
different state of mind.
9: Adequately fund
research on the disorder – like most people reading this I do not have a
scorecard on what research programs or scientists were cut doing research on
this disorder. I think there is a
general bias with the new political movement against women up to an including
the criminalization of pregnancy complications in some states. Those laws place the lives of women at risk
and the careers of professionals trying to treat them at risk. With that level
of overt bias against women, I would not be shocked to see research grants in
this area defunded. After reading some
of the research from groups with organized research efforts – I do not want to
see that happen.
10: Add postpartum
psychosis and depression to the DSM – this was an ongoing debate in the
research I reviewed for my posts on the topics.
As noted in the graphic at the top
of this post – ICD has discrete diagnoses for both postpartum depression
and postpartum psychosis. The DSM uses a “peripartum” specifier for 11 pre-existing
categories most of which are mood disorders.
There is always debate about what codes to include in a DSM – but my
reading of the literature suggests that there are clearcut cases that only
occur postpartum and that is a critical distinction in terms of whether
maintenance medication is required. The
only non-mood disorder diagnosis in the DSM with a peri-partum specifier is
brief psychotic disorder. Based on the cases I have seen and treated my
speculation is that the group of women in that category who are postpartum is
extremely small.
A section on women’s mental health in the DSM listing these
disorders and other considerations would be a welcome addition. It fulfills the goal of mapping onto the ICD
codes and could be a valuable source of education about these disorders.
These are a few of the thoughts I have about what is needed
to improve mental health care in the US. I am painfully aware of the The
Mental Health Parity and Addiction Equity Act (MHPAEA) and its unfulfilled
promise. It also illustrates that as long as governments allow for profit
businesses to run the healthcare system – the only expectation should be
continued deterioration in care and higher expenses. The current stance of most companies denying
care is they will ignore you until you either get a national news organization
to look into their care denial or you sue them.
That is not a way to run an ethical healthcare company or
have an actual system of care.
George Dawson, MD, DFAPA
Supplementary 1:
I have posted my experience in his area many times on this blog and
therefore did not include it in the above post.
When I started working at a major medical center in 1989, the department
heads were all physicians who were doing clinical work, teaching, and
research. The only business people present
were business managers who answered to the head of the department. Over the
next 20 years – department heads were physicians in name only who mostly did administration. There was still a business manager. And now there was an entire tower of
executives managing all of us by basically giving us the message that we were
not working hard enough. We were
routinely called up to implement bad ideas from management. When I tried to contact the tower directly I
was told: “You should think of a firewall between the clinicians and us”. Translation: don’t ever call us – just listen
to us through your physician/manager and business manager.
Supplementary 2:
I will have a major post out in the next few weeks looking at all of the
top research groups in the world on postpartum psychosis and a few of their
references. I will have a separate post
on peripartum psychopharmacology since I have attended several of these meetings
and have first hand knowledge of many of these researchers.
References:
1: Cox EQ, Sowa NA,
Meltzer-Brody SE, Gaynes BN. The Perinatal Depression Treatment Cascade: Baby
Steps Toward Improving Outcomes. J Clin Psychiatry. 2016 Sep;77(9):1189-1200.
doi: 10.4088/JCP.15r10174. PMID: 27780317.
2: Kamperman AM, Veldman-Hoek MJ, Wesseloo R, Robertson
Blackmore E, Bergink V. Phenotypical characteristics of postpartum psychosis: A
clinical cohort study. Bipolar Disord. 2017 Sep;19(6):450-457. doi:
10.1111/bdi.12523. Epub 2017 Jul 12. PMID: 28699248.
3: Bourke CH, Stowe
ZN, Owens MJ. Prenatal antidepressant exposure: clinical and preclinical
findings. Pharmacol Rev. 2014 Feb 24;66(2):435-65. doi: 10.1124/pr.111.005207.
PMID: 24567054; PMCID: PMC3973612.
Photo Credit: Rick Ziegler - sunset over Panama City, Florida, March 29, 2024.
.
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