MPS Meeting on Emergency Department Congestion

From the Flyer for this Meeting - Not an indication that MPS has anything to do with the opinions that follow. 

I attended the Minnesota Psychiatric Society 2019 Fall Program last weekend. The theme was addressing Minnesota’s Mental Health Access Traffic Jam: Coming Together to Build a Better Roadmap. That traffic jam has been there for the duration of my career in Minnesota and that is approaching 30 years. 

When I looked at the agenda and the speakers my first association was “stakeholders”. That jargon has found its way into the administration of medical and psychiatric systems over the past 20 years. It is basically a codeword to suggest that administrators, politicians, and everybody in between somehow has a “stake” in medical care and the relationship of physician has with the patient and their family is peripheral to all of these outsiders.  Nothing could be farther from reality – but that is the attitude we have to deal with from politicians and administrators.

The keynote speaker was the director of Psychiatric Emergency Services at the Denver Health Medical Center – Scott Simpson, MD. He was not able to make and his presentation was given by a colleague - Kristie M Ladegard, MD. Denver Health is a 525 bed Level I Trauma center. Psychiatric Emergency Services has a 17-bed psychiatric unit and a 60-bed detox unit.  The Emergency department also has mobile crisis services and consultation services.  For the last data they had in 2013 a little over half of their emergency visits were for “depression, anxiety, or stress reactions”. About 40% were for substance use disorders. An additional 20% were for psychosis or bipolar disorder. As expected, suicidal ideation led to a more complicated disposition plan. The incidence of delirium in elderly patients remaining in the emergency department and the high mortality rate of missed delirium was discussed. Factors leading to boarding in the emergency department were discussed. An interesting approach to substance use treatment was the “No Wrong Door” approach. Using approach intake for substance use treatment occurred right in the emergency department or at other points of contact within the medical system.  Medication Assisted Treatment for opioid use disorder was also started in the ED, with buprenorphine inductions. That resulted in a greater number of inductions and greater percentage of people retained in treatment.

Emergency services lecture also talked about four goals of implementation including access, quality, cost, and provider resiliency. The most interesting method discussed knew the end of the lecture was Dr. Simpson’s paper on single session crisis intervention therapy (1). The specific techniques are given in the open access paper in reference number one, and they should be familiar to people who are involved in crisis intervention especially with people who are suicidal in those situations. It was part of the overall message that I don’t think is emphasized enough. That message is-interventions need to be incorporated into the clinical assessment and not compartmentalized into the few minutes at the end. Experienced clinicians should be able to forgo entire sections of a standard template if an intervention is necessary and they can use the time to provide it.

There was a complementary panel in the afternoon that consisted of two psychiatrists and two emergency medicine physicians in a dialogue about what each discipline wanted to tell the other. Early in my career it was often a source of conflict. There always questions about “inappropriate admissions” psychiatry. Those questions faded away without any psychiatric presence in the emergency department. People were admitted to my service irrespective of their associated medical complexity. It was often my job to determine whether or not they needed to be transferred to a medical or surgical service. With this panel there was not a lot of controversy. Much of the concern had to do with nursing home and group home patients being sent to the ED with no hope that they could be placed anywhere quickly. The ED physicians had a very valid argument that it is no environment for boarding people until placements are available. The spaces are confining and there is very little to do. Communication about these patients and what the outpatient staff’s expectations are is critical. One of the psychiatric panelists pointed out during the session that all of the presentations indicated that additional beds within the system were necessary - but the state and managed care representatives were denying that basic fact.  This was later denied by a state representative who tried to say that there are a lot more beds that are not being counted but the basic fact is that just in terms of state hospital beds Minnesota ranks 49/50 states.

There was a Forensic Assertive Community Treatment (FACT) team representative there as well. There are currently 56 ACT teams in 43 counties in the state of Minnesota. There are approximately 90 patients per team. The FACT team specializes in seeing patients with severe mental illness who also have probation officers. The leader that team talk briefly about forensic cognitive behavioral therapy (CBT). Therapy focuses on a number of maladaptive cognitions that typically promote repetitive criminal behavior. One example was the error of “super optimism” or “negative consequences of this behavior do not apply to me”. Since the therapy for repetitive criminal behavior is generally considered futile to try to locate literature on this type of therapy but was not successful. The psychiatrist who headed the FACT team also talked about the importance of “felony-friendly housing” and “felony-friendly supportive services”. Both of the social features are critical for stabilizing people in the community but these resources are rare.

On the darker side there were presentations from both the MN Department of Human Services and managed care representatives.  Not a great deal of detail was provided by DHS.  They briefly described improvement in the physical environment of their forensic units.  They gave the current bed capacity of Anoka Metro Regional Treatment Center (AMRTC) – the largest non-forensic state hospital.  They described the number of facilities for the treatment of psychiatric and substance use disorders as including AMRTC, 6 much smaller Community Behavioral Health Hospitals (CBHHs), 5 Community Addiction Recovery Enterprise (CARE) programs, and 4 Minnesota Specialty Health System (MSHS) Programs.  AMRTC has a 96-bed capacity and has been under significant stress since a Priority Admission Statute allowed county sheriffs to send patients who were incarcerated but mentally ill as direct admissions. That results in longer lengths of stay for committed patients in community hospitals.  Compared with previous statistics provided by Kylee Ann Stevens, MD - Chief Medical Officer, Minnesota Department of Human Services, the bed capacity at AMRTC has decreased from 110 to 96 beds.  A newer Child and Adolescent Behavioral Unit is being built but there is no net increase in bed capacity.  There was no comparable data to the January 2018 post beyond that.

The DHS presentation emphasized the 40% of the patients at AMRTC Did Not Meet Criteria (DNMC) to be there. As a Medicare PRO reviewer for Minnesota and Wisconsin one of my jobs was to review patient stays in their hospitals and determine if they were actively being treated or it was more of a rehabilitative stay. The point at which clear progress was not occurring was an endpoint beyond which hospital care was no longer covered. The problem is that this is an almost totally subjective determination in patients with chronic mental illnesses.  If for example a person is highly aggressive and no medical treatments have worked – is that an acceptable end point to say they should no longer be hospitalized. I don’t think that it is. I have concerns about the robustness of the 40% figure for DNMC.  They presented some graphs of a Continuous Improvement Project that increased patient flow and decreased the DNMC to 19%.  Some external validation that large community acute care hospitals like Regions and Hennepin County medical Center were noticing the effect of this project would have been useful.

DHS also presented a few slides about “innovation” within the system.  They discussed Lean Six Sigma training as adding value in that it provides business skills to clinicians and leads to innovation. I remember they told me the same thing when we got that training in the managed care company where I worked. The problem is that managed care companies don’t really want to hear any ideas from physicians at least none that are not reflected back from management.   There were three bullet points on Michael’s Game, Ligature Mitigation, and Harnessing the Power of the EHR.  They suggested the Michael’s Game was useful to treat delusions for the purpose of competency restoration.  The only available literature I could find suggests it is useful to try cognitive behavioral therapy (CBT) in people with psychosis, especially if there is little familiarity with the technique. Ligature Mitigation is basically a Centers for Medicare & Medicaid Services (CMS) mandate to ensure the safety of the inpatient environment by policies and environmental inspection.  It seems more like a requirement than innovation.  In terms of the power of the electronic health record – I think there is finally a consensus that it is more of a burden than anything else. If there is some power there within the state hospital system – please demonstrate that.

There were a number of other speakers from the managed care industry and affiliated organizations.  There were diagrams about patient flow in the ED and what service availability can do to reduce ED congestion.  There were no inpatient psychiatrists there. The people with the most insight into the problem were absent.  After being an inpatient psychiatrist myself for 22 years I thought about why that might be.  Inpatient docs after all are subjected to all of the unrealistic expectations of everyone else.  Toward the end of my inpatient career I was being sent patients with severe medical problems and either no psychiatric disorders or stable psychiatric disorders.  I was getting these folks because everybody knew that they would get the care they needed – and the case managers who were ordering hospitalists to discharge people would be out of the loop. Inpatient psychiatry became a place where in addition to acute care psychiatry – everybody’s problems could be worked out there. And I had the added advantage of a case manager sitting in my team meeting reporting back to administrators on whether I got people out in 4 or 5 days.  The discharge process was intolerable because there were no discharge resources.  The availability of state hospital beds and group home beds were all shut down by many of the agencies represented in the room. Managed care was responsible for the intolerable work environment and a policy of discharging people before they were stable in order to optimize billing.  Basically, many of the people in the room who created the problem were now saying they could solve it. And I have heard these refrains for the past 20 years.

In a form of ultimate irony, there was a rumor at the meeting that one of the Twin Cities metro hospitals was going to be shut down by the managed care company that owned it taking another 105 psychiatric and substance use beds off line.  Since this question entered the Q & A session it seemed more than a rumor.  There was no comment from the managed care people.  

Besides the ACT psychiatrists there was another bright spot.  Dave Hutchinson, the Hennepin County Sheriff described the progress he was making at the policing level. Deputies were getting crisis intervention training (CIT). He made the point that I think a many don’t consider – crisis calls about obvious psychiatric problems that are being observed by the public go to the police twenty-four hours a day. He described the toll on the police including the statistic that 80% of officers who are involved in the use of deadly force – never return to work.  The jail in Hennepin County – like everywhere is inhabited by a large number of people with mental illness. Sheriff Hutchinson was very clear about the fact that this is a suboptimal situation and he would prefer that these people are in settings where they can get adequate care.

At the end of the session, I met briefly with one of my former residents.  She was a panelist for the meeting. She asked me what she was missing: “It seems that all indications point to needing more beds.”  I reassured her that she didn’t miss a thing.  It was the elephant in the room.  I have seen two decades of smoke and mirrors about why more beds aren’t necessary. It doesn’t seem that the state of Minnesota is any closer to recognizing that this is a real problem. It doesn’t seem that professional psychiatric organizations are any closer to confronting managed care or opaque state bureaucracies about how they are at the minimum unhelpful to people with serious mental illnesses and at the maximum harmful.

    

George Dawson, MD,

References:

1:  Simpson SA. A Single-session Crisis Intervention Therapy Model for Emergency Psychiatry. Clin Pract Cases Emerg Med. 2019;3(1):27–32. Published 2019 Jan 10. doi:10.5811/cpcem.2018.10.40443D

2: Khazaal Y, Favrod J, Libbrecht J, et al. A card game for the treatment of delusional ideas: a naturalistic pilot trial. BMC Psychiatry. 2006;6:48. Published 2006 Oct 30. doi:10.1186/1471-244X-6-48.   

3: Melnick ER, Dyrbye LN, Sinsky CA, et al. The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among US Physicians [published online ahead of print, 2019 Nov 12]. Mayo Clin Proc. 2019;S0025-6196(19)30836-5. doi:10.1016/j.mayocp.2019.09.024



Supplementary:

There are many estimate of optimal bed numbers and Minnesota does not come close on a number of them.  The Treatment Advocacy Center has a number of documents on their site that list Minnesota as 40/50 in 24 hr hospital inpatient and rseidential treatment setting beds, 41/50 in inpatient beds, and estimates that the state needs to add 1,165 beds to the system to establish an adequate base rate of available beds.

This document from the Pew Charitable Trust looks only at state hospital beds and shows Minnesota at 3.5 beds per 100,000 population with a ranking of 49/50 states.  

At least two panels of experts have concluded that 50-60 publicly funded beds per 100,000 is necessary to provide the same level of medical services and wait times for psychiatric patients in emergency departments as medical/surgical patients. 

NEJM Three Part Series - Severe Medical Illness In the Context of Severe Mental Illness

Lisa Rosenbaum, MD has written a three part series in the New England Journal of Medicine that should be read by non-psychiatric physicians, family members, patients, and policy makers.  It is focused squarely on providing medical care to patients with severe mental illness and all that involves.  It is really impossible for psychiatrists to avoid the issue.  At some point in your career you find yourself in a situation with a patient who has a severe medical problems and refuses to address it because of the way that their decision making process has been impacted by mental illness.  If you are an inpatient or ACT team psychiatrist - it is usually up to you to come up with a plan to address that problem,  Several of the scenarios she describes across this series are directly from those settings.  Like any other specialty, psychiatrists will all migrate toward a certain niche.  For many reasons being that person who has to confront mentally ill patients about the fact that they are seriously ill or dying is not a position that is in great demand.  But mostly it is because inpatient and ACT team positions are rationed and none of the payers or administrators want those psychiatrists to do what they are capable of.

This series is part of an overall increase in psychiatric topics that are discussed in the NEJM.  So far this year there have been three Case Records of the Massachusetts General Hospital and a review of the basic science of addiction and a number of other articles on addiction and mental health policy.  Although I have not attempted to quantify it, there does seem to be a general increase in the coverage of psychiatric topics that include reviews of diagnostic groups, basic science mechanisms, clinical trials, and articles of general interest from the field.  The search function of the web site allows for grouping according to specialty and there are generally 20-30 psychiatry references per year over the past 5 years.  Lisa Rosenbaum is a cardiologist and is a national correspondent for the NEJM and in that field has probably seen a number of cases of people with severe mental illnesses and cardiac problems.

In the first article in the series she discusses the issues of informed consent and coercion in treating patients with severe mental illness.  It is well known that this population is undertreated from the perspective of primary treatment that is focused on the mental illness.  She uses an estimate of 9.8 million people with severe mental illness and only 60% of those people receiving treatment.  She cites the systemic problems of a lack of bed capacity 11.7/100,000 currently compared with 337 per 100,000 in 1955.  The contrast is more striking if per capita health expenditures for health and the number of psychiatric care beds per 100,000 population are compared.  For OECD data per capita expenditures for healthcare rank the USA at the very top by far and the per capita number of psychiatric care beds near the bottom compared with other countries.  The article discusses how deinstitutionalization was supposed to be linked to more community resources and not less.  The underfunded systems is portrayed as somewhat of a mysterious problem rather than system-wide rationing of psychiatric services.  The author in this case ties the underfunding to problems that it can't fix namely severely ill patients not seeking treatment  and antipsychotic drug side effects.  The high discontinuation rates in the CATIE trial are cited as proof of this problem.  I think that underfunding due to rationing is the problem.  With adequate resources comprehensive care is possible when the focus is comprehensive care more than medication.

The philosophy behind ignoring psychosis due to a psychiatric disorder compared with other physical illnesses is discussed.  The author points out that given the severe disability of these illnesses they cannot be ignored and that unlike other illnesses there are no major campaigns focused on prevention or treatment.  From there she transitions into the issue of intervention against the patient's wishes.  She discusses Stone's theory of paternalistic intervention if the affected person is likely to be grateful after they have been stabilized.  The flaw with that theory is that in many cases only a degree of psychiatric stabilization can be achieved.  In many cases it is likely that the person will have continued problems with insight and medical decision making and will continue to disagree with any suggested treatment.  She discusses the flaws with "dangerousness" as a component but does not take that discussion to its logical conclusion.  Dangerousness is of course not a psychiatric concept.  It is used by the courts as a basis for the initial stages of civil commitment and by managed care companies to decide if they will pay for psychiatric hospitalizations.  Any inpatient psychiatrist has found themselves talking with an insurance company reviewer - usually many states away who wants to know "where's the dangerousness?" and who is quick to deny payment for the treatment of a severely disabled person on that basis.  Dangerousness is probably the single word in the English language responsible for shutting down psychiatric care bed capacity and driving skilled psychiatrists away from the treatment of severe psychiatric disorders.

Rosenbaum makes the mistake of overemphasizing the importance of stigma.  She accepts as a given that stigma causes "countless harms" when the real harm is caused by systemic discrimination by the government and insurance companies.  The dangerousness concept as a justification for no treatment has done far more harm than the stigma of mental illness.  She also connects the attempt to counter stigma with illness minimization behaviors such as treating a person with a severe mental illness and impaired decision-making capacity as a competent decision maker.  Stigma is of course tied in with the recovery movement and policy that flows from the Substance Abuse and Mental Health Services Administration (SAMHSA).  Overmedicalization and disregard for civil liberties is cited as a need for this recovery based model.  That cannot be reconciled with the fact that for at least 40 years, all states have had civil commitment and guardianship/conservatorship laws in place that are in place to assure the civil liberties of anyone where there is a suggestion of coerced treatment.  When people "die with their rights on" they are generally dismissed by courts and end up dead as the result of untreated mental illness.  Only psychiatrists are generally bound by these laws and not other physicians and that part is left out.

The other significant group left out of course are the antipsychiatrists and their considerable allies whose raison d'etre is basically to bash psychiatrists and make them look bad.  That group frequently uses the term overmedicalization and pretends that there has not been decades of legislation to protect the civil rights of the mentally ill.  She is patronising in suggesting that "most psychiatrists" recognize "peer support, structured activities, psychotherapy, employment assistance, and case management" might be useful -  ignoring essentially a century of research by psychiatrists on these elements of treatment.  It also ignores the truth that every psychiatrist knows and that is - people recover and people with severe illnesses recover.  I don't need a recovery movement to tell me that.  I have people walking up to me on the street who I treated decades ago who tell me that they are married, they have children, and they are working.  Despite that severe shortcoming, I give her credit for pointing out how recovery proponents "twist data to advance their agenda".  There is currently a lot of twisted data out there.

She ends the first discussion with commentary on whether a living will for treatment of psychiatric disorders, innovations like a "one-time autonomy violation for forced treatment", or civil commitment as usual is the best approach to forced treatment of severe mental illness.  That assumes that some innovation is necessary and that it will be universally applied.  Both assumptions are incorrect.  It is possible these days to look at the editorial pages of any major medical journal and of course the non-medical media and read endless suggestions about how "the system" of medical care should be changed.  The reality is that there is a loose system of medical care and for psychiatric care the system is non existent except in the minds of antipsychiatrists.  As far as I can tell the only thing wrong with mental health law is that it is subjectively interpreted and that interpretation is clearly affected by the attitudes of attorneys and judges and the resources of the county that is financially responsible for treatment.  That skews undertreatment more severely to the counties with fewer resources.  There is nothing wrong with the law as it is written.  Civil rights are protected and the decision about rights is made by the legal system and not psychiatrists or physicians.

The second article in this series (2) is focused on the mortality gap between persons with mental illness and those without.  Unlike recent authors Rosenbaum points out that the problem was first identified by a psychiatrist in 1932, long before there were any effective treatments or treatments that allegedly cause medical complications.  She almost avoids the accusation of some recent extremists that psychiatrists and psychiatric treatment are responsible for this increased mortality rate but does bring that point up.  Nobody can argue that a lot of this mortality is based on pessimism in dealing with the mentally ill.  I can still recall the obsessing about the decision go to smoke-free inpatient psychiatric units.  One of the arguments is that it would lead to much more aggression among patients and toward staff.  The  other argument was that smoking was "all they had" and it should not be taken away from "them."  Both arguments were advanced by trained mental health staff and are extremely demeaning.  It is not surprising that patients with mental illness have lower rates of guideline recommended care or disease altering interventions.  I have contacted many primary care physicians who were surprised to hear that their patient was still alive.  I have also found myself in the position of treating people with sustained very high blood pressures or people who were actively bleeding because the patient was refusing treatment.  The only advice I got from consultants was to call them back when something bad happened and in some cases it did.

The medical rather than psychiatric assessment of capacity to consent is discussed.  A study is presented that shows  that on a typical medical service 40% of patients lacked capacity to consent and the treatment team was aware of only 25% of those cases.  This implicit consent on medical and surgical services is widespread.  It is generally questioned only in the case of high risk procedures or if a patient illogically refuses routine care.  In hospitals with psychiatric consultation-liaison services - they are typically consulted with the question.   Rosenbaum suggests that in contested situations forced treatment results in brutal seclusion, restraint and forced medication.  That is an unlikely outcome in these situations.  Most people no matter how delusional agree to care if a judge orders it or they realize that just leaving is not an option.  The suggestion is made that more time and training for capacity to consent evaluations be considered.  That is not going to happen.  There is a reason that people avoid going into psychiatry.  Talking to patients and making these assessments is one of them.  And there is no way that hospitalists are ever going to have the time it takes to do this job in addition to their medical evaluations.  It is just another psychiatric resource rationed out of the system.

Rosenbaum concludes with a valentine to integrated care models.  She has access to some of the few internists who are adept are treating people with severe mental illness, including one internist who specializes in it.  The recent MGH Case Reports have discussed similar models.  The main model that was invented in 1974 by Len Stein, MD, Mary Anne Test, MSW and  others is never mentioned.  Since that time there are ACT teams that coordinate medical care for people with severe mental illnesses and help them stay healthy outside of hospitals.  As a psychiatrist trained in these community psychiatry interventions there was nothing about patient care in these three articles that was news to me.  There are plenty of psychiatrists trained in these interventions but very few settings to implement them.  That is because the rationed care approach has split psychiatric care off from managed care organizations and placed it under the purview of the state - usually as a way to justify shutting down state hospital bed capacity.   In states where the resource becomes state-run managed care poor outcomes can be expected to follow.  Since ACT treatment was originally focused on deinstitutionalization and quality of life it is easy to dismiss based on typical cost effectiveness arguments.  I can still remember Len Stein showing us the reason why ACT was invented.  It was a single slide showing a gymnasium sized room full of cots that were placed edge to edge.  The patients were all men wearing the same uniforms off to one side.  His question to the residents was whether it was better to help all of those men live independently or let them live in those state hospital conditions?  Unlike today - incarceration and homelessness were not acceptable options.      

The final article in the series suggests that inaction on the part of physicians in addressing the problem of medical illness in people with severe mental illness is a result of learned helplessness.  That refers to a well known animal model of depression where test animals are subjected to some insurmountable stressor and generally give up and stop trying.  That model alone provides an interesting disconnect between psychiatrists and the rest of medicine.  Since the days of German asylums, psychiatrists have wanted to talk to their severely ill patients - even before there were any effective treatments.  That drive is one of the most  compelling reasons for medical students to go into psychiatry in the first place.  I don't think that properly trained psychiatrists view these problems as hopeless situations, even though some of the inpatient units they work on are clearly repositories for problems that other physicians consider hopeless.

I have no problem at all talking with anyone who has a severe psychiatric problem, understanding them, and discussing treatment options for both their psychiatric and medical problems.  I have no problem understanding that the only reason I am the one offering help is a matter of genetics and good luck.

Any psychiatrist that I know can do that.      


George Dawson, MD, DFAPA



References:

1: Rosenbaum L. Liberty versus Need - Our Struggle to Care for People with Serious Mental Illness. N Engl J Med. 2016 Oct 13;375(15):1490-1495. PubMed PMID: 27732817.

2:  Rosenbaum L.  Closing the Mortality Gap - Mental Illness and Medical Care.  N Engl J Med. 2016 Oct 20; 375 (16): 1585- 1589.

3:  Rosenbaum L. Unlearning Our Helplessness - Coexisting Serious Mental and Medical Illness. N Engl J Med. 2016 Oct 27;375(17):1690-1694. PubMed PMID:27783917.

New England Journal of Medicine Discovers Assertive Community Treatment

I have been a reader and subscriber to the New England Journal of Medicine (NEJM) every year since medical school.  One of the first courses they taught us in those days was Biochemistry and being an undergrad chem major I had a natural affiliation with many of the biochem professors.  The format in those days was lectures focused on the major topics and seminars to take a more detailed look at the experimental and theoretical aspects of the field.  They were fairly intensive discussions and critiques of research papers selected by the professors.  The department head was the mastermind behind this technique and one days he discussed his rationale for it.  He hoped that every medical student coming through that course would continue to read current research.  He strongly recommended subscribing to and reading the NEJM not just in Medical School but for years to come.  In my case it worked.

One of the sections that you don't hear too much about is the clinicopathological exercise that comes out each week.  It is basically a publication of formal case records of Massachusetts General Hospital and the associated findings and discussions.  These case reports are interesting for a couple of reasons - they show patterns of illness that clinicians can familiarize themselves with and they show at least some of the diagnostic thinking of experts.  During the time I have been reading them, they also discuss psychiatric comorbidity of physical illness and medical etiologies of psychiatric symptoms.  At one point I was a member of an informatics group and was very interested in studying this section of the NEJM from a psychiatric perspective.  At that time it seemed that I was the only psychiatrist with that interest.  With modern technology a study like this is more possible than ever.  For example, searching the case records feature of the NEJM from December 1989 to December 2015 yields a total of 31 cases of psychosis.  The etiologies of these cases range from purely medical etiologies, to delirium associated with the medical condition to pure psychiatric disorders with no specific medical etiology.  I have never seen this referred to as a teaching source for psychiatric residents admitting patients to acute care hospitals or consultation liaison services, but I could see it serving that function.  Instead of the usual lectures on medical psychiatry that typically contain PowerPoint slides of the "240 medical etiologies of psychosis" - a discussion of common mechanisms noted in these cases might be more instructive and be a better source for acquiring pattern matching capacity to broaden diagnostic capabilities.  It also put the DSM approach to psychiatry in proper perspective.  Knowing the lists and definitions of psychosis is nowhere enough to be a psychiatrist in a medical setting.  A seminar including this material can make these points and teach valuable skills.

That brings me to the case this week A Homeless Woman with Headache, Hypertension, and Psychosis.  Two of the authors are psychiatrists and the third is an internist.  The authors describe a 40 year old homeless woman with a diagnosis of schizophrenia and severe hypertension and how they established care over a number of years using the Assertive Community Treatment (ACT) model of care.  The patient's history was remarkable for a 12 year history of psychosis characterized primarily by paranoid and grandiose delusions.  She was homeless sleeping in public buildings for about 4 years and that seemed to be due to the thought that she needed to stay outside to watch over people.  She had a brief episode of treatment with olanzapine during a hospitalization about 5 years prior to the initiation of care by the authors, but did not follow up with the medication or outpatient treatment.  She was also briefly treated with hydrochlorothiazide 4 years earlier with no follow up care or medication.   She was admitted for treatment of a severe headache and a blood pressure of 212 systolic.  At the time of the admission physical BP were noted to be 208/118 and 240/130 with a pulse of 95 bpm.  She had bilateral pitting edema to the knees and bilateral stasis dermatitis.  She had auditory hallucinations consisting of voice of God and Satan and grandiose delusions.  Lab data showed a microcytic anemia.  She had standard labs to rule out myocardial infarction and vitamin deficiency states.  Blood pressure was acutely stabilized and she was discharged on lisinopril, thiamine, multivitamin, omeprazole, and ferrous sulfate.  The final diagnoses include schizophrenia, cognitive impairment associated with schizophrenia, hypertension, and homelessness.

The authors provide a good discussion of diagnosis of primary and secondary psychotic disorders and provide some guidance on timely medical testing for metabolic, intoxicant, and neurological abnormalities.  Delirium is identified as more of a medical emergency and necessitating more scrutiny.  The idea that delirium can be mistaken for psychosis is a valuable point that is often missed during emergency assessment especially if the patient has a pre-existing psychiatric diagnosis on their medical record.  The authors sum up screening tests that are necessary for all patient with psychosis and the tests that  are reserved for specific clinical concerns like encephalitis, seizures, structural brain disease, and inflammatory conditions.  They also suggest screening for treatable conditions and inflammatory conditions.

There is a good section on the follow up care that this patient received.  She was seen in a clinic for the homeless, where problems were gradually noted and worked on with her full cooperation.  This is not the typical approach in medicine where it is assumed that the patient will tolerate a complete history and physical exam and then cooperate with any suggested medical testing and treatment.  In this case, the practical problems of foot care were addressed.  She was eventually seen in 60 visits over two years.  By visit 19 she described concerns about cognitive symptoms and by visit 33 she was accepting treatment for psychosis with olanzapine.  She eventually allowed a more complete treatment of here associated physical symptoms including an MRI scan of the brain and treatment for migraine headaches.  The authors point out that tolerating medical and psychiatric uncertainty is a critical skill in treating people who need to habituate to medical systems of care.  A more direct approach is alienating.  It does tend to create anxiety in physicians about what is being missed and not addressed in a timely manner.  There is always a trade off in engaging people for long term care in more stable social settings and pushing to maximize diagnosis and treatment in a way that they might not be able to tolerate.  The ACT model stresses the former.           

There are some very relevant ACT concepts illustrated in this article.  First and foremost the rate at which medical interventions are prescribed depends almost entirely on the patient's ability to accept them.  This is at odds with the timeliness of medical interventions that most physicians are taught.  I say "almost entirely" in this case because the authors were very fortunate that the patient cooperated with treatment of extreme hypertension.  One of the common hospital consultations for psychiatric is a person with a mental illness and life-threatening illness who is not able to recognize it.  Even on the subacute side of care there are many tragedies due to patient with mental illness not being able to make decisions that could have saved their life.

I think that there are also some very practical applications for psychiatry on an outpatient basis.  Most patients with severe mental illnesses are never going to see a primary care provider 60 times before starting treatment.  It only happens in a subsidized setting with physicians who are highly motivated to see a certain approach work.  The care model described in the paper is certainly not the collaborative care model that some authors, the American Psychiatric Association (APA), and the managed care industry keeps talking about.  There is also the obvious point that people don't go into primary care because they like talking with people who have severe mental illnesses.  Psychiatrists need to see these people either in ACT teams or community mental health centers.  It won't work in a standard managed care clinic seeing a patient who is this ill - 2- 4 times a year for 10 - 15 minutes. ACT psychiatrists need to know about primary care providers who work better with the chronically mentally ill or people with addictions and make the appropriate referrals.  All psychiatrists should be focused on blood pressure measurements and work on getting reliable data.  Funding for psychiatric treatment often precludes ancillary staff present in all other medical settings to make these determinations.  Existing collaborative care models in primary care clinics can get blood pressure measurements on the chart but restrict patient access to psychiatrists.  

This Case Report is a good example of what can happen with a real collaborative care model that focuses on the needs of a person with severe chronic mental illness.  It is a model of care that I learned 30 years ago from one of the originators and it is more relevant today than ever.  It is also a model of care that is currently rationed and provided in the states where it is available to a small minority of patients.  It is not the method of collaborative care that you hear about from the APA, the managed care industry, or government officials.  It should be widely available to all psychiatric patients with complex problems.


George Dawson, MD, DFAPA


References:

1: Shtasel DL, Freudenreich O, Baggett TP. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 40-2015. A 40-Year-Old Homeless Woman with Headache, Hypertension, and Psychosis. N Engl J Med. 2015 Dec 24;373(26):2563-70. doi: 10.1056/NEJMcpc1405204. PubMed PMID: 26699172.

2:  New England Journal of Medicine Case Records of MGH x psychosis (on Medline).  Shows 101 references as opposed to 31 on NEJM search engine and 10 on basic Medline search.

3:  Marx AJ, Test MA, Stein LI. Extrohospital management of severe mental illness.Feasibility and effects of social functioning. Arch Gen Psychiatry. 1973 Oct;29(4):505-11. PubMed PMID: 4748311.

4:  Stein LI, Test MA, Marx AJ. Alternative to the hospital: a controlled study.Am J Psychiatry. 1975 May;132(5):517-22. PubMed PMID: 164129.

5:  Test MA, Stein LI. Alternative to mental hospital treatment. III. Social cost.  Arch Gen Psychiatry. 1980 Apr;37(4):409-12. PubMed PMID: 7362426.

6:  Stein LI, Test MA. Alternative to mental hospital treatment. I. Conceptualmodel, treatment program, and clinical evaluation. Arch Gen Psychiatry. 1980 Apr;37(4):392-7. PubMed PMID: 7362425.

7:  Weisbrod BA, Test MA, Stein LI. Alternative to mental hospital treatment. II.   Economic benefit-cost analysis. Arch Gen Psychiatry. 1980 Apr;37(4):400-5. PubMed PMID: 6767462.


Attribution: 

Photo at the top of this post is by Jonathan McIntosh (Own work) [CC BY 2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons.  Original photo at https://commons.wikimedia.org/wiki/File%3ARNC_04_protest_77.jpg

Welcome To 1974

A colleague forwarded me a link to a newspaper article today about the latest Twin Cities managed care innovations for treating people with severe mental illnesses.  It had nothing to do with managed care companies trying to save money or avoid penalties.  Like most of these stories in the press there is a heavy human interest focus.  The treatment details are given of a man with schizophrenia and depression who is benefitting "from a fundamental shift in the way hospitals and health plans treat people with severe mental illnesses."  The author goes on to explain how social services including housing, transportation, and job training are being implemented prior to discharge and coordinated by social workers.   The article suggests that the reasons for this are two fold - to prevent the "revolving door" of readmissions to the hospital and a new Medicare penalty for readmissions during the first  30 days of discharge from a hospital.  The programs at a number of Twin cities hospitals are described.  The Minnesota law requiring admission to a psychiatric hospital from a jail within 48 hours of commitment is also cited as a complicating factor in the large group of patients that have no stable housing, no medical or psychiatric care, substance use problems and who continue to rotate in and out of psychiatric hospitals.  One of the managed care administrators describes it as a "sea change".

It turns out the "sea change" occurred in 1974.  It occurred in Wisconsin and not Minnesota.  That was the year that Len Stein, MD and a group of dedicated clinicians came up with the idea that patient with severe mental illnesses could be maintained outside of hospitals as long as they were provided with appropriate housing, support, and in some cases vocational services.  I know because I trained under Dr. Stein.  He was a personal supervisor and I did a training rotation at the Dane County Mental Health Center.  I can still remember the slide from his community psychiatry presentation that showed the overcrowded conditions at the state hospital - one of the reasons behind the community psychiatry movement.  My training occurred about a decade later and at that time there were three  different models of care that all involved community support.  The most well-known of those models is Assertive Community Treatment or ACT.   I was well versed in these models and providing the necessary care and for the first three years out of training I was the medical director at a community mental health center and spent have of my time working with the community support team.  That team provided crisis services and support on a 24/7 basis to patients with severe mental illnesses.  That was 30 years ago.

After the community mental health center,  I moved to the Twin Cities where I spent the next 23 years working in a metropolitan hospital primarily running an inpatient unit.  My focus for the first 10 years was trying to get people interested in community support services for patient we were discharging to the community.  At first, there was a patchwork of public health nursing and large housing units  with nursing supervision for our discharged patients.  But eventually there was nothing.  I was told point blank by various administrators that they really were not interested in hearing how things worked in Wisconsin.  They did things differently in Minnesota.  When I could no longer ask public health nurses to check on discharged patients - there was no help for them at all, except for an appointment to see a psychiatrist if they did not forget it.

That changed slightly when the state decided to shut down state hospital bed capacity and one of the psychiatrists there was able to get funding for ACT teams.  The rationale by the state was that some of the money to maintain state hospital beds would be diverted to the ACT teams.  Eventually that initiative increased but there was still not enough capacity.  There was still a large patient population without adequate housing or assistance.  The economic plight of many of these people was worsened by "spend down" provisions implemented by the state.  That meant that even though their income was 100% disability payments, they could be expected to pay up to 60% of it for medications.  That typically meant that the person went from poverty status to worse in order to continue recommended medications for their psychiatric disability.

Another problem was the bed situation and approaches that were being used to manage those beds.   That last half of my inpatient career, there was a continuous large pool of patients flooding Twin Cities emergency departments.  That resulted in initiatives to admit and discharge as soon as possible.  The entire focus of admissions and discharges was on "imminent dangerousness" even though there is no such legal standard.  It was a business standard of care.  Many people seeking admission because they were miserable realized this and said they were suicidal in order to get admitted.  Conversely, many people who still had significant problems and no good way to resolve them were discharge because they no longer met the "imminent dangerousness" criteria.  There were no quality approaches to care only a focus on rapid discharges of very ill people.

So I have to shake my head when I read about the "new" approach to treating mental illness and helping people to maintain themselves in the community.  There is really nothing here that was not done in Wisconsin nearly 40 years ago.  In the meantime there is a severely deteriorated infrastructure with fewer beds in both designated hospitals but also supportive housing.  I have significant doubts about the funding of these services since we know that managed care companies don't do community support services.  Who is paying for these social workers and psychologists?  Will they have to submit billing documents that are not practical to complete?  Even if they are being paid for by the state, that doesn't necessarily guarantee future funding.   At one point all of the public health nurses I was working with in the 1980s were told they could no longer see patients with psychiatric problems.  And what about the continued rationing by managed care companies now being made to look like it is innovation?

Welcome to 1974.

George Dawson, MD, DFAPA

Chris Serres.  Strategies shift for treating mental illnesses.  Star Tribune January 19, 2016.

Rampage Killing - The Public Health Approach Is Still Ignored

I was watching the news this morning on the latest rampage killing.  This news coverage features numerous replays of a YouTube video posted by the killer about twenty minutes before he started shooting.  I listened to an expert, (at least as much of an expert as you can be) talk about his approach to the problem.  He talked about the limitations of the post event "psychoanalysis" of the  killer and how a more functional approach would be to harden targets and warn the victims.  He talked about the false positive rate of how most people who threaten or post videos like this do not carry out the threatened violence making it impossible to detain all the people making the threats.  He said that it may be useful to talk to people with these problems but the psychology of this individual not only made that impossible, but even talking with mental health professionals was not likely to help him.

I had just finished reading the latest Psychiatric Annals.  This month's topic was Psychotic Rampage Killers.  Three of the four articles were written by C. Ray Lake, MD,  and the fourth by James l. Knoll, MD and J. Reid Meloy, PhD.  Dr. Lake also had an opinion piece on why mass murder diagnoses were justification for breaking the Goldwater Rule specifically the part ".... it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement."  He points out that this rule is currently routinely broken with speculative diagnoses about psychotic mass killers.  He also suggests that the correct diagnosis is still an open question.  He also points out that the inadequate care of individuals with psychosis is an issue and that has been one of the themes of this blog.

Lake's main contention is that Psychotic Rampage Killers are really bipolar and manic and do not have schizophrenia.  He briefly reviews some of the facts including that even though a small percentage of killers (<10%) are psychotic, there are a distinct number of correlates that cause them to differ from non-psychotic killers most notably a motivation that is delusional in nature, the fact that they are always caught (as opposed to 33% of non-psychotic killers never being caught), warnings  and plans prior to the act are common, and half attempt or commit suicide.  The psychotic killer basically focuses on the event as a final stage and does not plan to escape or benefit from the event.  He makes the point that all of the psychotic killers realize that what they are doing is illegal and that can exclude an insanity defense if they survive.  I think this is also a common misconception on the part of the public.  People who are psychotic can carry out detailed plans that are consistent with the logic of their psychosis.  It certainly does not mean that they are rational.  He briefly reviews the issue of violence and psychosis and takes on the political issue that "violence perpetrated by mentally ill is no greater than violence carried out by the non-mentally ill population."  This has always been a statistical fallacy balancing the violence by a subgroup of the mentally ill against the violence of high risk members in the general population.  By now there should be no doubt that some people with severe mental illness have a much higher rate of violence than the general population.   Further there are known diagnostic features within that subgroup that are associated with the increased risk of violence including alcohol and drug addiction, paranoia, command hallucinations, and a lack of treatment.

Lake's initial discussion of prevention points out that gun legislation is not likely to be a solution because of existing biases by legislators in this area to do nothing despite the fact that most rampage killer use firearms and 75% of them were legally acquired.  Civil commitment laws were described as "limited by our sensitivity to personal freedoms."  In my experience, it comes down to the courts involved and the administrative element through the involved counties.  I have been personally involved in thousands of civil commitments and decisions by the courts often depend on the most recent "mistake" defined as an adverse outcome that occurred when a potentially violent person was released.  Certainly any case involving firearms and hundreds of rounds of ammunition or an actual shoot out with the police needs very close scrutiny.  Any "welfare check" by the police of a potentially dangerous person should involve a search for weapons and actual threats especially if they were posted on social media.  Mental health professional contact was described as being potentially useful but also limited by the nature of the follow up of patients with psychosis.  In fact, violence needs to be incorporated into the treatment  plan for patients with psychosis and violence and addressed in a comprehensive manner.  An appointment for a ten minute discussion of medications is not acceptable and it really is not an acceptable level of care for anyone with psychosis whether they are potentially violent or not.  Lake points out that there is also a call to avoid using the names and other materials posted by rampage killers.  I think that is a good idea and therefore do not refer to any of these materials here.

The discussion of what is the proper diagnosis of these murderers is the next article. Lake reviews the evidence (largely from media reports) and concludes that psychotic mania is the most likely diagnosis.  He has an interesting diagram in the article that shows both psychotic depression and psychotic mania converging on the diagnosis of "paranoid psychosis from mood disorders".  He also has interesting graphic using Venn diagram approaches that range from Kraepelin's initial clear distinction between bipolar disorder and schizophrenia to the more spectrum based approach beginning with Timothy Crow's continuum with schizophrenia and bipolar disorder being at opposite ends of the spectrum.  He expressed some surprise that schizoaffective disorder was still in the DSM-5, but it also considers Schizophrenia Spectrum and Other Psychotic Disorders separate from Bipolar and Related Disorders.  In reviewing the details from the media of five Rampage Killers, he concludes that in all cases psychotic mania was a diagnostic consideration based on hyperactivity, insomnia, and delusional thinking.  In one case there was a family history of bipolar disorder.

Lake goes on to point out that without an accurate diagnosis of bipolar disorder, patients do not receive standard of care which he defines as mood-stabilizing drugs.  He digresses to talk about the legal profession changing the diagnostic habits of professional and uses false memory syndrome as a case in point.  He goes on to suggest that "Successful legal action in the form of a class action lawsuit filed on behalf of unrecognized bipolar disorder misdiagnosed with and mistreated for schizophrenia could quickly change psychiatric diagnostic practices.  Another potential class action lawsuit is possible from some of the mass murder victims families in cases where before the rampage, the psychotic murderer had been treated for schizophrenia and not bipolar disorder."  Dr. Lake considers the problem basically to be one of "obsolete diagnostic concepts that promote substandard medical care for psychotic patients."

In 30 years of practice, I have not made the same observations that Dr. Lake has made.  In the example of false memory syndrome, that diagnosis and the associated multiple personality disorder phenomena was really practiced by a small minority of psychiatrists.  It was actively criticized at the time by prominent psychiatrists in prominent journals.  I  doubt that lawsuits against anyone had any impact on the diagnostic concepts of the vast majority of psychiatrists.  On the issue of diagnosing bipolar disorder based on a spectrum concept and the features of hyperactivity and insomnia. I would suggest that is fraught with problems.  Having seen patients over time patients with schizophrenia can also have these features. The same problems occur when considering standard of care arguments for mood stabilizers.  All of them (lithium, divalproex, lamotrigine) have significant problems with both efficacy and side effects profiles.  Antipsychotic medication is probably necessary in at least 50% of bipolar patients (in addition to the mood stabilizer), and many antipsychotics are FDA approved for acute bipolar disorder and bipolar depression.  But the larger problem is that there needs to be a standard of care than encompasses much more than medication.  That is good for all patients with psychosis and potentially very good for those at risk for violence.

The recommendations I have discussed before on this blog that I think will have the most impact would be:

1.  Establish centers of excellence for treating psychotic disorders.  We know the outcome of rationing mental health services.  We end up with inadequate inpatient and outpatient care for patients with psychosis and bipolar disorder.  The focus of all for profit systems is to transfer the cost of care for these individuals to public systems including correctional facilities.  If they end up being cared for in a for profit system, the care is concentrated on their ability to see a physician or more appropriately a "prescriber" for about 10-20 minutes and accurately describe their problems.  It is well known that psychotic rampage killers do not consider their homicidal ideation to be a problem and may actively try to hide those thoughts from any interviewer.

2.  A standardized approach to law enforcement intervention.  Law enforcement has a number of possible interventions available to them that are not available to mental health professionals.  The duty to warn legislation has blurred these distinctions and essentially removed a lot of responsibility from law enforcement.  There is really no reason why a person posting obvious threats on the Internet should not be treated with the same degree of caution as perpetrators of domestic violence.  That would include proscriptions against owning and acquiring firearms, police surveillance and where necessary orders for protection.  Threats to kill should trigger a response that involves a search for firearms and materials showing a plan to perpetrate violence.

3.  A public health approach focused on the issue of homicidal ideation as a potential symptom of mental illness.  The public and the patients themselves need to be able to conceptualize this problem as an illness and a symptom that does not need to be acted upon.  The article reference here refer to outdated diagnostic concepts and I would include the idea that patients with psychosis especially delusions cannot modify their thinking by means other than medication.  It certainly happens in response to events but also as a result of psychotherapy.

4.  Comprehensive outpatient care.  Brief checks focused on medications are doomed to fail.  These patients and all patients with psychoses need comprehensive outpatient care that includes home visits when necessary, psychotherapy, comprehensive cognitive assessments, and vocational rehabilitation.  When I first started working these were all available in my clinic.  Today it is unheard of.

Psychosis and psychotic people who kill are the psychiatric equivalent of a heart attack.  Any middle aged person in the country with chest pain gets admitted and goes through about 24 hours of comprehensive testing and imaging.  I don't know the actual statistics but I would guess that most of these people are not having heart attacks and their hospital and Cardiology bill is about $30,000 - $50,000.  Our system of care expects a person with psychosis who is totally unaware of the fact that they have a significant disturbance in their thinking to want to actively manage that illness on resources that are trivial in comparison.  In the case of an identified heart attack, that person will receive hundreds of thousands of dollars of additional care.  By comparison a person receiving the most comprehensive level of community care - Assertive Community Treatment or ACT receives those services for about $10,000 per year.  That service is typically limited to a few hundred people in each state and not covered by medical insurance.

The best approach to rampage killers is to offer a much better standard of care to all people with psychosis.  If it the right thing to do from the perspective of psychiatry, public health, and humanism.

George Dawson, MD, DFAPA

Lake CR.  Rampage murders, Part I: Psychotic versus non-psychotic and a role for psychiatry in prevention.  Psychiatric Annals 2104 (44) 5: 216-225.

Lake CR.  Psychotic rampage murders, Part II: Psychotic mania, not schizophrenia.  Psychiatric Annals 2104 (44) 5: 216-225.

Supplementary 1:

"Charges for chest pain, for instance, rose 10 percent to an average of $18,505 in 2012, from $16,815 in 2011. Average hospital charges for digestive disorders climbed 8.5 percent to nearly $22,000, from $20,278 in 2011."

J Creswell, S Fink, S Cohen.  Hospital Charges Surge for Common Ailments, Data Shows.  New York Times; June 2, 2014.

American Psychosis - The Final Take

I finished reading E. Fuller Torrey's recently released book American Psychosis - How the Federal Government Destroyed the Mental Illness Treatment System .  I recommended it on the basis of a a quick initial read of a brief section on managed care but can provide additional details at this time.  I will start with the conclusion.  Criticizing an expensive, fragmented, and poorly conceived system of care for severe mental illness is a fairly easy task for any psychiatrist who tries to provide care for the target population of people with schizophrenia, bipolar disorder and severe mood disorders. This book concentrates many of the references about deinstitutionalization, incarceration of the mentally ill, victimization of the mentally ill, and aggression and violence by the mentally ill in one place.  In the conclusion Dr. Torrey also recommends some 10 potential solutions to the problems and more importantly suggests the some of these need to be implemented on a small scale rather system wide.  

I am sure that Dr. Torrey and the publisher of this book would not be very happy if I put all 10 of his proposed solutions on this blog, so I am going to focus on one that is consistent with my initial post and one of the major themes of this blog:

"For profit funding of of public mental illness services has been tried and it does not work." 

This is the real experience of anyone who has worked in psychiatric acute care and by that I mean the hospital in your community where people are brought in by the police on emergency holds.  Even in that setting there are levels of acuity.  In a metropolitan area there may be 8 or 10 psychiatric inpatient units but only one or two of them will accept patients with high levels of aggression or suicidal behavior.  In an ideal world these would be units where there are staff with high levels of expertise in treating these severe conditions, but the reality is that economic considerations are at the top of the list.  There needs to be adequate staffing for close supervision and the staff have to be able to deal with high levels of aggression toward self or others.  There also needs to be expertise in recognizing and treating alcohol and drug intoxication and withdrawal states.  There is usually minimal attention paid to the therapeutic aspects of the environment.

When I first started working in that environment it was the late 1980s.  I had just completed a three year stint as the medical director of a very good community mental health clinic that offered case management and Assertive Community Treatment.  I was well trained in community psychiatry at the University of Wisconsin Psychiatry Department and it was good to actually practice it with a team of highly motivated people.  
                                                                   
The first months on the inpatient unit resulted in several "denials" by insurance company intermediaries functioning to ration care.  Keep in mind that all of these patients were in the highest acuity unit in the hospital, had problems with suicidal and aggressive behavior, and many needed detoxification. The rationale of the "peer reviewers" was the the patient did not require acute care or the care could be provided at a less intensive facility.  Apart from county detox facilities that had policies against admitting suicidal or aggressive patients - no less intensive facilities existed.

When you are in that environment trying to provide care, it is pretty obvious that this peer review process is basically an insurance company game to make money.  In the small print in the denial letters there was an option to appeal all denials to an administrative law judge within the state.  I asked my colleagues and nobody had tried that route.  I collected 12 denials and requested a hearing in front of the administrative law judge.  I took a day of vacation to go to court.  A week before the hearing I was informed that my hearing was cancelled and the administrative law judge decided in favor of the insurance company.  I appealed to the Attorney General on the basis of conflict of interest stating that the peer reviewers worked for a competing organization and therefore this was anticompetitive activity.  The AG informed me that they were independent contractors.  How can you be an independent contractor if you collect a paycheck from the organization that is denying care by your competitor?  It was clear to me that the state government was very friendly to the managed care industry.

The whole managed care strategy for rationing care or in  extreme cases shutting down entire psychiatric units was outlined in my previous post on overutilization.  It is the basic money making strategy of managed care organizations.  It essentially doubles down on rationing.  That occurs because hospitals are paid a set amount for taking care of people regardless of how long they are there and that amount is denied in as many as 10% of cases.  If there is one deficiency of this book it is a lack of granularity on this issue.  Dr. Torrey approaches the problem as a top down problem of policy deficiency, driven by an ideology that bed capacity could be shut down and not missed either because of the toxicity of state hospital settings or too much faith in the federal initiated community mental health movement. 

Assuming that a patient can actually get the level of acute care that they need without being thrown out of the hospital by an insurance company, the fragmentation of care does not stop there.  Even though insurance companies say they are emphasizing outpatient care, getting an appointment may be impossible.  The prescribed medications may be denied.  Housing options or community case management for people with severe mental illness are not usually available unless the insurance changes to a public option.

American Psychosis covers the funding and policy issues on a global level before it gets to the suggested solutions.  Excellent examples are given to illustrate these points.  For example, North Carolina is given as the example of what happens when a state mental health system is privatized (p 158).  The parameters of the dramatic deterioration in services that resulted from this maneuver is a well documented example of what happens when a for-profit entity begins to manage care and shift the responsibility for care of serious mental illnesses to the correctional system.

American Psychosis is a well organized analysis of the problems that occurred as the result of an initiative in the Kennedy administration.  It contains a lot of information and references about what has happened as the result of these decisions.  There is also a subtext and that is it is written from the perspective of a psychiatrist who has been a thought leader on the issue of treating people with severe mental illness.  Only a minority of people in the United States understand that perspective and I think that there will be predictable backlash from the constituencies that believe a severe mental illness is a preferred state and that everyone should have the right to enjoy it.  

That is not the experience of any acute care psychiatrist and Dr. Torrey presents that perspective very well. 

George Dawson, MD, DFAPA