An article was published in the JAMA recently where three ethicists argue for the return of asylum care. It has become an expected flash point for the antipsychiatry movement as well as some psychiatrists who still think that the word asylum has some meaning. I thought I would add a more realistic opinion and solution. I refer readers to the original article or many that I have written here about the reduction in bed capacity in long term psychiatric care. The reductions are indisputable and well documented. I am more interested in elucidating the mechanisms behind this reduction and the lack of effective care in the remaining community hospital beds. The authors allude to the underlying dynamics as captured in the sentence "For the past 60 years or more, social, political, and economic forces coalesced to move severely mentally ill patients out of mental hospitals." They discuss the well known euphemism for incarcerating psychiatric patients or "transinstitutionalization" and rotating the chronically mentally ill in and out of emergency departments.
The authors even go so far as pointing out the bloated estimated inpatient costs for care in Michigan at $260,000/year/patient and Washington, DC at $328,000/year/patient. For comparison they include a state of the art facility the Worcester Recovery Center and Hospital that has 320 beds at a cost of $60 million per year or or $187,500/bed/year. It is difficult to figure out why what may arguably be the best public hospital in the United States has the lowest cost of care for what may be more comprehensive services. But that is part of the problem. Most of these institutions are managed by human services agencies through the states and the real fiscal status is always difficult to ascertain. State and business accounting frequently provides calculations for bed or per patient rates that seem to include unrealistic estimates of overhead costs (often for subpar facilities). The administration of many of these facilities also seems to depend on restricting psychiatric care at several levels. In many cases the managed care concept of "medication management" or a "med check" mentality is applied, often with the overall plan of replacing psychiatrists with "prescribers". Any notion of quality is trumped by a managed care notion of "cost-effectiveness" that typically includes removing psychiatrists from management positions and delegating policy and management at the institutional level to people with no training in psychiatry.
The authors accurately describe the problems of severe mental illnesses. People have very complex neuropsychiatric disorders and will either not be getting well soon or will never recover enough functioning to do well in any community setting. They were some of the first victims of "medical necessity" criteria. I was a Peer Review Organization (PRO) reviewer for Medicare hospitalizations in the states of Minnesota and Wisconsin in the 1980s and 1990s. For at least part of that time I was sent boxes of medical records from state hospitals for review. If I looked the the records and decided the patient should continue to be hospitalized, I would get a call from the Medical Director of the PRO suggesting that I should consider the medical necessity criteria. In the case of long term care, that meant that the patient was "stable" meaning that I would not expect them to change significantly with additional treatment. If I could say that, the hospital was notified that the patient did not meet criteria for continued long term hospitalization and they needed to be discharged. In fact, it was very likely that although they were not changing at a rapid enough pace, they would still present formidable problems for community placement. It may be impossible to discharge them. In many cases discharge resulted in almost immediate readmission to an acute care hospital and the cycle emergency department to brief hospital admission to homelessness to jail or readmission occurred. At least until the person was sent back to the state hospital.
In her opinion piece, Dr. Montross suggests that these patients have been abandoned in the name of autonomy or treating people in the so-called "least restrictive alternative." That seems at odds with frequent sustained incarcerations for minor and in some cases trivial offenses. What is really going on here and why do people continue to ignore it? I have analyzed the problem many times and it is apparently so institutionalized at this point that nobody sees it as a problem anymore. The problem that I continue to point it out is managed care and all of the rationing mechanisms that they employ. The very first one in the paragraph above is the so-called medical necessity criteria. Any managed care company physician reviewer can deny care based on their own proprietary guidelines or a purely arbitrary and subjective interpretations of those guidelines. Managed care companies can harass physicians with mountains of unnecessary paperwork and deny payment or demand payment back based on more subjective interpretations. Even more problematic, states have incorporated some of these same management techniques and almost uniformly have completely abandoned quality in favor of "cost-effective" care which is quite frankly - care on the cheap.
The end result of all of this cost cutting, rationing, and insurance company profiteering at the expense of patients with mental illness or substance use problems is extremely poor quality care. One of the authors suggests longer inpatient treatment may be the solution. Right now practically every psychiatric hospital does their best to get patients discharged in 5 days or less. Outpatient psychiatrists see patients who have not been stabilized after a 5 day admission. That is business as usual in acute care psychiatric hospitals. If that discharged patient makes it to an out patient clinic, they are seen for 10 - 15 minutes in a medication management visit (another fabrication of the managed care industry and the US government) and if they are lucky they discuss the medication and whether it is effective for symptoms or causing side effects. The problem is that there are important areas in the patients life - like their cognition and social behavior, that are never discussed or evaluated in any productive way. Very few patients with severe mental disorders receive any kind of psychotherapy despite the evidence it is useful to them.
Putting all of these problems back into the asylum will have predictable results. The medication management mentality is basically now inside the walls of an institution. There is no enlightened, research driven treatment that addresses all of the problems that the person has. The asylum is typically administered by a bureaucrat, bound by the same arbitrary budgeting that comes down from the Governor's office. Across the board spending cuts by a certain percentage and no adjustments when the cash flow is positive. Money "saved" on asylum care transferred to the state's general fund and used to build roads or whatever was stated in campaign promises. Suddenly the asylum is an overcrowded bottleneck due to cost shifting by every county in the state who does not want provide services for serious mental illnesses.
The alternative? How about doing things the right way for once. We seem to have people who recognize that mental illnesses are not going away, that the current care is atrocious and inhumane, and that it is time to do something about it. Estimates for the number of people in each state with severe mental illnesses are out there. Consistent reasonable funding is necessary. That includes the state, but also it is time to not allow managed care companies to dodge these costs and transfer them to the tax payers. Finally, it it time to eliminate stakeholder meetings and develop systems of care for the people who it matters the most to - patients, families, psychiatrists, and the other mental health and medical professionals involved in providing this level of care.
Without those conversations, an asylum is just a poorly managed building.
George Dawson, MD, DFAPA
References:
1: Sisti DA, Segal AG, Emanuel EJ. Improving long-term psychiatric care: bringback the asylum. JAMA. 2015 Jan 20;313(3):243-4. doi: 10.1001/jama.2014.16088. PubMed PMID: 25602990.
2: Christine Montross. The Modern Asylum. New York Times February 18, 2015.
