NAMI and the Clinton Foundation Take The Bait On Managed Integrated Care

My views on "integrating" behavioral health and primary care are fairly well known.  They run counter to everyone including the American Psychiatric Association (APA) who has been promoting the advantages of "collaborative care".  I use quotes here to designate loosely defined terms that have multiple meanings to different special interest groups.  I should have also included the term behavioral health because outside of managed care companies, the word really has no meaning.  I got a post today in my Facebook feed that stated  The Benefits of Integrating Behavioral Health into Primary Care.  I encourage any interested readers to search directly for this page on the NAMI web site and take a look at the content.  It is in press release format that contains little detailed information.  It presents the chronic disease concept and how chronic diseases cause mental illnesses and make them worse.  It talked about practice models that look at putting therapists in clinics.  It talked about a model that brought a mental health clinician into immediate contact with a patient and clinician in a primary care physician's office, but stated that model lacked sustainable funding.   It talked about the promise of telemedicine.  Since this was a NAMI event, stigma and destigmatization were also on the agenda and the release ends in a global statement about how this will lead to everyone admitting that mental illness affects us all and at that point the stigma will evaporate.

With all of that good news, what do I have against this love fest for integrated care?  Just responding to the news release there are obvious problems with the ideas being mentioned.  The first is that many of these ideas have been around for at least 30 years.  I was hired as the medical director of a community mental health center in 1986 and part of what I was supposed to do was telemedicine through a cable TV and satellite hook-up in the town that I worked.  That never materialized.  Granted the resources today are much more sophisticated, but how many primary care clinics are really going to dedicate resources so that their patients will be seen in their clinic by an outside mental health clinician?  And what about the cost of those services?  There are currently networks of mental health clinicians eager to do telemedicine, but they are not eager to provide those services for nothing.  The economics of telemedicine is that it needs to be supported and there is no evidence that I am aware of that managed care companies support it.  The Veteran's Administration has supported it in some areas, but most health care facilities are not funded like the VA.

Putting therapists in clinics has occurred for more than the past 30 years.  Part of the problem is what those therapists will be doing in those clinics.   Will they end up doing acute assessments for suicide or aggression risk?  If they do identify those problems, are patients going to be cared for in those clinics or sent somewhere else?  In today's landscape of having no functional psychiatric units, will the primary care clinic now start to accumulate people with acute, subacute, and chronic suicidal thinking? Will there now be security issues related to the same problem with aggression?  Is the expectation in these clinics going to be follow up in 3-6 months like many other medical problems?  Will there ever be any effective therapy done?  Psychotherapy after all is probably a better treatment than all of those patients being put on antidepressants for acute adjustment disorders and grief.  Most people in those circumstances notice little effects from the medication.  Psychotherapy is after all a better treatment than benzodiazepines for most people put on those medications for situational anxiety and insomnia.  Therapists can do great work, but they are also rapidly saturated when they have to see patients for 6 - 10 sessions in follow up.  Is there really a managed care company who is going to put enough therapists in a clinic to do some good or are they going to be there just for looks?  You know - look here is the therapist for our integrated model.  Isn't it great?

There seems to be a collective amnesia about how this integrated care model really works and what it is really about.  This is really about continuing to ration care for mental illness and psychiatric care.  Refreshers on that can be found here and here.  Giving everyone in a primary care clinic a very basic screening checklist for anxiety and depression is one of the basic paradigms for all of the integrated care advocates.  The patients mentioned in the press release will be especially likely to score positive on these screens.  That is true not because they magically developed a new anxiety or depressive disorder, but because they have complicated conditions that are associated with anxiety and depression.  If a person has paroxysmal atrial fibrillation when their heart rate suddenly accelerates to a rate of 220 beats per minute, they tend to get very anxious both during those episodes and anticipating the next one.  The same thing is true for patients with heart attacks and emphysema.  Is checklist screening a good enough approach for these patients?  Is following a certain protocol with antidepressants a good enough approach with these patients?  So far, the checklist implementation of the "integrated" approach is a low quality assembly line approach that guarantees more exposure to antidepressants  and a limited differential diagnosis of what else might account for any psychiatric symptoms.  At least one group has determined that broad "screening" for depression (also mentioned in the press release) - does the exact same thing and is generally not a good idea.

This is really all about the money.  Managed care organizations and governments are still very interested in providing the appearance of care for mental disorders and that is about it.  In order to believe that they have some grander plan, an extremely naïve approach is required.  The last thirty years of managed care would need to be ignored.  That history would include the elimination of functional detoxification units for addictive disorders, the general elimination of psychotherapy, restricted access to psychiatrists and limiting psychiatric treatment to a 20 minute "med check", the elimination of functional inpatient units where difficult problems can be treated in a safe and humane environment, the elimination of resources to treat patients with severe aggressive behavior, and restricted access to medications that people may need due to their unique treatment requirements.  The basic concept that managed care was invented and supported by the federal and state governments would also need to be ignored.  The ultimate result of having record numbers of people with mental illnesses incarcerated rather than receiving appropriate care for mental illness cannot be ignored.  Even as I typed this paragraph additional evidence was building to support my theory that this is a huge subsidy for the insurance industry.  A colleague recently posted that there is no "out of network benefits" in New York State and she discusses the ramifications for psychiatric care and psychotherapy.  I see this as a flat out continuation of government sanctioned rationing of psychiatric services by the managed care industry.  They may want you to go to an integrated care clinic, complete a checklist and take an antidepressant rather than seeing your regular outpatient psychiatrist who is providing more than a medication.

Handing someone a depression checklist when they come in to a primary care clinic to get their blood pressure checked is reminiscent of the 1990s approach to pain as the "fifth vital sign", and we all know how well that turned out.

A final word about the stigma buzzword.  What is more stigmatizing - giving you the medical resources that you need for recovery or having you come to a primary care clinic where those resources will probably not be available and practically nobody in the clinic has experience working mental health problems?

That is the basic case against integrated care or what is sometimes referred to as collaborative care.  At this point like everyone else I will be leaning back and watching it unfold.  The insurance industry and government has so much power they can essentially do whatever they want now.  We seem to have a national political forum in health care that leads to an endless stream of bad ideas.  And it seems like we always listen to that endless stream of bad ideas rather than anyone who might know what they are talking about.
    

George Dawson, MD, DFAPA

Why I No Longer Support NAMI

For the past several years my wife and I have been regular donors to our state branch of the National Alliance on Mental Illness (NAMI).  We decided to do it initially as a memorial to family members who suffered from mental illness.  I just got two letters in the mail encouraging me to donate again.  One was a "Dear Friend" letter from NAMI reminding me of the plight of the mentally ill.  The other was from the Medical Director and CEO of the American Psychiatric Association.  Dr. Scully apparently thinks he is reminding me of how fragmented the system of care is and "The treatment system that confronts families seeking care is too often fragmented, unorganized and, despite the efforts of many, is uneven at best in its quality."  After working in that "system" for over 25 years and witnessing its decimation by the managed care industry - both letters are insulting.

The only time I was impressed with NAMI was during an attempt to secure resources for a patient in another state.  At that time I contacted NAMI in Illinois and was almost immediately faxed, about 50 pages of resources that my social worker and I could use to come up with a discharge plan.  The fragmented system often resulted in us spending long stress filled hours trying to piece together a plan that we hoped would work while we were being pressured to discharge the person to the street.  Managed care companies were not helpful.  I can still recall a patient with complicated problems.  The managed care company did not acknowledge the serious nature of the problem and wanted immediate discharge.  When we tried to get a discharge appointment for the patient the earliest appointment was 6 months away and they refused to give any priority based on the recent hospital discharge.  

A local NAMI walk for fund raising was disappointing.  Psychiatrists tended to walk with their own organizations, but the dimension that was unnerving to me was the corporate presence.  It seems that the no free lunch movement for doctors is not as concerned about corporate sponsorship of NAMI and any conflicts of interest that might arise.  Why would anyone raise the issue of conflict of interest?  There are two obvious issues.  NAMI has long been an advocate for access to psychiatric care and psychiatrists.  The managed care companies listed as sponsors have been the primary drivers in restricting access not just to psychiatric care but any kind of evaluation or treatment for mental illness or addiction.  In the Twin Cities they currently use case managers to control admissions and discharges.  Those case managers make those decisions based on proprietary guidelines that have little to do with the modern practice of psychiatry.

A second issue is pharmaceutical sponsors.  Psychiatry has been singled out for the appearance of conflict of interest whenever there have been sponsorship or payment of researchers or speakers by pharmaceutical companies.  The real effect of this sponsorship is on the public.  There is no clearer example than National Depression Screening Day.   This event began across the country over 20 years ago.  I was the organizer for two years for the Minnesota Psychiatric Society.  The event was sponsored nation wide by the company who had the most expensive and widely known antidepressant on the market.  It was a field day for the idea that antidepressant medications treat depression.  That bias is still present today and is probably one of the single greatest reasons why treatment of mental illness is typically reduced to a cure in a pill.

Despite my reservations, I decided to support NAMI with an annual check and was listed as a professional member of the organization.  NAMI is a politically powerful organization and I often heard that they had interests that were similar to psychiatric professional organizations.  Then a few months ago Minnesota Public Radio came out with a story on the Minnesota Security Hospital.  It is the state facility that is used to house and treat patients with severe mental illnesses who are also dangerous on an ongoing basis.  Most of the patients are there because they have been adjudicated after committing a violent crime or they are there for an evaluation.  There have been severe administrative problems that have resulted in the resignation of most of the psychiatric staff and an increased number of injuries to staff.

According to that report:

"Sue Abderholden, the executive director of the mental health advocacy group NAMI Minnesota, said despite the concerns, she thinks Barry and other officials are doing a good job of addressing serious, long-standing issues at the facility. She said the decrease in the number of psychiatrists is not necessarily a problem, as long as the facility hires qualified nurse practitioners. Ideally, she said, patients would always see the same provider, but she said that's not realistic for most facilities."

The opinion given in that story is certainly at odds with my opinion.  The state and NAMI seem to believe that psychiatrists are there to prescribe medications and can be easily replaced in that department.  I don't see anything that reflects psychiatric training in how to treat aggressive patients (what else is needed besides medication?) and what needs to happen from a systems or administrative standpoint.  Psychiatrists are the only staff with that kind of training and I wonder about whether they can use that training in a system that seems to suggest that an administrator can develop programs to deal with aggression.  The executive director's opinion seems quite consistent with that approach.  Wasn't that the problem in the first place?

I don't expect any support from NAMI.  Psychiatrists should be able to  support their own positions and members.  At the same time, I don't see any benefit to financially supporting an organization that has radically different goals than my professional goals and sees psychiatrists as easily replaced by people with much less training.  As far as the position of administrators dictating clinical care goes, that is a psychiatrist replaced by someone with no training.  If anyone can act like a physician - then physicians become superfluous.  It is tantamount to running the place with a managed care company and creating the illusion that serious care is being done by seeing people for a few minutes and talking about their medications.

The time has come to not renew my professional membership in NAMI.  With mental health parity still in question, any advocacy organization needs to have higher standards than a managed care company.

George Dawson, MD, DFAPA


Madeleine Baran.  More injured employees, fewer doctors at Minnesota Security Hospital.  August 29. 2012.