A Confluence of Factors - Why There Is No Functional System of Care for Severe Mental Illnesses

 

 This post was stimulated by a confluence of factors.  I had no real concerns about what I would do in retirement and it seems that I have as much to think about as I did when I was working.  The factors included:

1.  A post by one of my esteemed colleagues on Twitter – Emily Deans, MD.  I have never met Dr. Deans and know her work primarily through her blog, Substack, and Twitter posts.  I cannot recall ever disagreeing with her.  Today she began a thread with: “The US allows people with terrible brain illnesses to languish on the streets and get murdered on the subway.”  She built upon that theme.

2.  I was working on a presentation for Friday May 5 on “Everything You Wanted To Know About Psychiatry in 30 Minutes or Less.”  That got me into a historical frame of mind.

3.  I had the occasion to pick up my copy of Sylvia Nassar’s biography of John Nash “A Beautiful Mind” and reread the description of his civil commitment to a state hospital where he received insulin shock treatments at age 33.

4.  During my work on the presentation I suddenly got the bright idea to create a couple of new timeline graphics – one of which was about European influences on American psychiatry (protopsychiatrists, transitional self-taught psychiatrists, and psychiatrists) and that led to thinking about the current state of psychiatric affairs in the United States.

That all came together to produce the following paragraphs that I have discussed here before but seems reinforced by the current confluence of information.

Psychiatric care in the US is abysmal and it is not due to the lack of bright and highly motivated psychiatrists.  It is due to a lack of access.  It is possible to find those psychiatrists and get treatment but good luck with that.  Dr. Deans is correct that people are currently dying due to the lack of humane laws to treat people with severe mental illnesses. In many jurisdictions those laws are interpreted in the context of the lack of resources.  In other words if there are no facilities available, legal action is dropped. That problem lies squarely on several entities that are far outside of psychiatry. The problem is so chronic it is hard to prioritize which of these entities came first and is the worst (although I have provided a few timelines). Let me take them point by point as they come to mind.

The antipsychiatry movement needs to finally get credit for its destructive nature. Psychiatrists tend to respond either by ignoring them and hoping they will go away or by wasting their time trying to argue against their repetitive rhetoric.  The pandemic and the last election highlighted the use of misinformation in social media. The antipsychiatry movement are experts in misinformation and they have been using the same tactics for the past 50 years.  Part of those tactics include getting their rhetoric and opinions in the mainstream psychiatric literature. In 1986, Martin Roth and Jerome Kroll had the following observation:

“We have argued in this section that the concept of mental illness has definable boundaries and that medical forms of care are appropriate and efficacious only in circumscribable portions of those who present a danger to society. But recent trends if allowed to continue, can only culminate in a society in which prisons again contain a large portion of those who suffer from mental illness because there is no appropriate or alternate form of care or accommodation for them. If such a situation should materialize, the distinction between prison and hospital will become once again blurred and obliterated like it was 133 years ago when Bucknill held out optimistic hopes of a new era in which science and humanity would jointly seek to surmount the problems presented by morbid mental suffering. The hard-won and remarkable progress achieved by psychiatry during the past half century in particular, will then have been set into reverse.” (p. 114).

There has not been a more prophetic statement in the field.  The largest psychiatric hospitals in the United States are currently county jails. The state hospital systems that were in some cases flagships for treatment of people with severe mental illnesses are no longer functional and exist at the margins to alleviate pressure on community hospitals to accept involuntary patients.  It is more of a blockade than a bottleneck since the latter would suggest movement once the obstacles have been passed.  There is no movement and the association of state mental health directors has made it very clear they are not interested in movement.

The basic paradox of the system is that the necessary infrastructure necessary to treat even average numbers of persons with severe mental illnesses and those who are under civil commitment is not there.  It is atrophied or rotten and there has been no wide sustained effort to improve it since The Community Mental Health Act of 1963. Even though the Mental Health Parity and Addiction Equity Act (MHPAEA) was passed in 2008 – it is clear to anyone working in the field that there is no enforcement to ensure mental health parity or adequate substance use treatment. The healthcare industry has sent a clear message that it takes more than a law on the books – it takes concerted and very expensive legal action.  In the past some activist attorney generals had some success – but there are not many of them around anymore.

It is not hard to imagine how a fragmented system of care has withered during a time of continuous antipsychiatry rhetoric.  Money is always cited as a limiting factor, but the amount of money especially compared with the ballooning number of administrators at the state and health plan levels does not seem great. State hospitals and departments of human services seem to run on a managed care rationing model rather than a model focused on helping the most vulnerable citizens. It is not a coincidence that both antipsychiatry and business rationing for profit both depend on Libertarian values – the most basic being “you are only worthwhile if you are living what I determine to be a worthwhile life.”  That same value system criminalizes aggression and violence secondary to mental illness and sees incarceration as the only beneficial outcome. That is consistent with the current model of county jails as psychiatric hospitals that do not deliver any psychiatric care.

That brings me to the Nash biography. He was hospitalized in about 1961 at Trenton State Hospital.  According to Harcourt’s graphs of deinstitutionalization – this was the beginning of a time of rapid decline in mental hospitalization rates that has continued unabated to the present time. Trenton was overwhelmed by the large number of patients seeking help there – 4,000 after World War II dropping and then rising again in the 1960s to about 2,500 when Nash was there. Psychiatrist staffing ratios varied from 1:100 patients in the acute ward to 1:500 patients in the chronic ward.  Length of stay for most patients was about 3 months. Rationing clearly existed even before deinstitutionalization. One of the psychiatrists who worked there described the environment as “crummy.”  In terms of personal relationships with patients – it could be expected to be rare with those staffing ratios.  Nasar describes the hospital as “overcrowded, underfunded, and understaffed.”

Figure 1. Rates of Institutionalization in Mental Institutions and State and Federal Prisons (per 100,00 adults) from the paper by Bernard E. Harcourt, " REDUCING MASS INCARCERATION: LESSONS FROM THE DEINSTITUTIONALIZATION OF MENTAL HOSPITALS IN THE 1960s," 9 Ohio St. J. Crim. L. 53 (2011), available at: https://scholarship.law.columbia.edu/faculty_scholarship/639

The exception noted was the insulin unit.  Apparently, Nash was recommended to go to this hospital because it had this modality.  It was a 44-bed unit – half men and half women in separate wards. Patients on that unit received special diets and special recreation.  That is where Nash got insulin treatments 5 days a week for the next 6 weeks. Nash later described the agony of these treatments in detail including what may have been long tern effects on his dietary pattern.  In retrospect, the question is whether it was necessary or not.

Manfred Sakel had discovered insulin shock treatments (IST) in 1935 by accidentally administering too much insulin to a patient with morphine addiction resulting in seizures and a coma.  The patient awoke with more mental clarity.  That led to further trials and wider application. Nassar suggests that by 1960, IST had been phased out in most hospitals and replaced with electroconvulsive therapy (ECT).  Max Fink did a direct study of chlorpromazine versus IST in 1958 (2) and noted that the results clearly favored chlorpromazine.  That resulted in the IST unit at his hospital closing within 6 months (3). Even though Nash had not been able to work for the previous 3 years he was widely regarded and his intelligence was described as a national security asset. As he was recovering, he started a paper on fluid dynamics while he was at Trenton that he subsequently finished and published in 1962 French mathematical journal. He was awarded the Noble Prize in economics for game theory in 1994. His original two page paper at age 22, was part of the basis for the Nobel determination (5,6).    

Nash’s tenure at Trenton is a good example of rationing prior to managed care. The rationing resulted in both the abysmal conditions and a lack of state-of-the-art care. Some might say that you can’t argue with results.  Nash recovered and was able to go back to research and publishing in mathematics, despite his dissatisfaction with treatment.  Later in his biography he was treated with a number of second generation antipsychotic medications that were described as helping him stay out of the hospital but  “have not given him a life.”

That brings me back to Dr. Dean’s comment at the top of this post. We have people with severe mental illness dying on the streets. A small number become aggressive and violent, but a much greater number are victims of violence and exploitation. They do not have stable living situations and there are associated problems with substance use disorders. This is a gross level of neglect compared with way other healthcare problems are addressed requiring more resources than psychiatric care. About 1 in 300 people get retinal detachments during their lifetime. In any mid-sized city in the United States access to state-of-the-art retinal care is not a problem. The same thing is true for orthopedics, gastroenterology, and cardiology. Psychiatric care is fragmented across private pay systems, public pay systems, and managed care systems.  The last two are managed by large bodies of administrators that are focused on rationing rather than an adequate system of care. In many ways, the landscape of psychiatric care is approached with the same level of recklessness as firearms. We all have to pretend that something useful can never be done and therefore maintain the status quo.

 

George Dawson, MD, DFAPA

 

References:

1:  Roth M, Kroll J.  The Reality of Mental Illness.  Cambridge University Press. Cambridge, England 1986: 82-144.

2:  Fink M, Shaw R, Gross GE, Coleman FS. Comparative study of chlorpromazine and insulin coma in therapy of psychosis. J Am Med Assoc. 1958 Apr 12;166(15):1846-50. doi: 10.1001/jama.1958.02990150042009. PMID: 13525160.

3:  Fink M. Meduna and the origins of convulsive therapy. Am J Psychiatry. 1984 Sep;141(9):1034-41. doi: 10.1176/ajp.141.9.1034. PMID: 6147103.

4:  John F. Nash Jr. – Facts. NobelPrize.org. Nobel Prize Outreach AB 2023. Sun. 7 May 2023. https://www.nobelprize.org/prizes/economic-sciences/1994/nash/facts/

5:  Holt CA, Roth AE.  The Nash equilibrium: A perspective.  PNAS. 2004; 101 (12) 3999-4002.  https://www.pnas.org/doi/10.1073/pnas.0308738101

6:  Nash Jr JF. Equilibrium points in n-person games. PNAS. 1950 Jan;36(1):48-9. https://www.pnas.org/doi/full/10.1073/pnas.36.1.48

Graphic Credit:

I took this photo of the Rum River Dam in Anoka, MN about 30 minutes after I gave my presentation on May 5, 2023.  Anoka happens to be where the Anoka Metro Regional Treatment Center is located.  It is the last state mental hospital in Minnesota.  Since 1978 Minnesota has closed 10 of its 11 state hospitals and only AMRTC remains.  There have opened 6 - 16 bed units called  Community Behavioral Health Hospitals that have reduced capacity and apparently do not accept referrals from major metropolitan hospitals. https://mn.gov/dhs/people-we-serve/adults/services/direct-care-treatment/programs-services/community-behavioral-health-hospitals/

How To Really Fix The Broken Mental Health System

A few weeks ago the Psychiatric Times posted an article called "How to Fix the Broken Mental Health System: Call For Suggestions."  I posted a link to one of my previous blogposts in the comments but decided to write a separate post here.  My reasons are several fold.  First off, any call for suggestions to me is really an invitation to generate web traffic to a particular site.  It is a standard tactic of bloggers.  For proof of that just Google the title and you will see hundreds of references in the last 2 years.  Second, I can do a better job and have done a better job here.  It gives me an opportunity to collect links under common themes.  Finally, it creates an opportunity to provide answers in one spot.  I may be wrong, but I think that the Psychiatric Times piece will be quickly forgotten.  Since hardly anyone reads this blog, that will probably also happen, but at least my thoughts are out there and include statements that you won't see posted by anybody else.   Here are  my point by point suggestions:

1.  Managed care and all that it involves including Accountable Care Organizations (ACOs), Pharmaceutical Benefit Managers (PBMs) and the Substance Abuse and Mental Health Services Administration (SAMHSA) must go.  It should be evident to anyone that these organizations have not contributed to cost effectiveness, innovation, quality or efficiency.  Instead they are largely responsible for an additional hidden tax on all Americans.  I am referring to the typical high deductible health insurance plans that results in thousands of dollars in copays and premiums before any health care has been received and the $250,000 in out of pocket costs that any 65 year old couple can expect to pay in additional health care costs.  Contrary to their advertising, managed care organizations disempower patients and their physicians and are the largest obstacle to care in this country.  Their disproportionate effect  on psychiatric and substance use disorder services has been well documented.

2.  Centers of excellence rather than collaborative care is the primary goal.  All of the managed care forces and their political backers in the first point above are making the argument that we cannot possibly produce enough psychiatrists to meet the need in this country.  They maintain that argument despite the fact that the US currently has about 1/4 the number of psychiatrists per capita as Switzerland, significantly fewer than 18 of 32 OECD countries, and is only 1 of 3 countries where the number of psychiatrists is decreasing.  Instead of developing a rational triage system, their solution has been to say that anyone can provide psychiatric services or that a psychiatrist reading screening checklists like the PHQ-9 is some kind of psychiatric care.   This is both an absurd characterization of psychiatry and a non-solution to the problem.  Psychiatric specialists need to be available to treat the most difficult to treat disorders.  They don't need to see everyone taking an antidepressant or everyone with insomnia.  They need to see people with difficult to diagnose problems and treatment resistant mood, anxiety, psychotic, neurocognitive, substance use, and psychotic disorders.   They need to see this population both for diagnostic clarification and treatment.  Centers of excellence need to be developed around these disorders and the associated treatment delivery.  There are current models that develop statewide systems of care around centers of excellence that seek to provide the highest quality of care to residents in that state.

3.  The administration of systems at the local level needs to be done from a clinical and not a financial point of view.  The split systems of care (administrative versus clinical) is one of many sources of poor quality care.   It has resulted in some situations as absurd as administrators believing that they can design systems of mental health care without input from clinicians.  This is especially problematic in treating patients who have  problems with aggression.  Psychiatric training needs to include specific instruction on how to clinically administer these systems of care.

4.  The psychiatric infrastructure needs to be rebuilt.  That includes both community and state hospitals.  Very clear criteria need to be established for admission to these facilities since state hospitals in recent times have been the only housing option for people with severe problems.  The concept of "treatability" has been inappropriately applied by federal regulators.  I worked for years as a Medicare reviewer and reviewed many state hospital records where I was asked whether or not the patient had achieved maximum benefit from hospitalization.  That would allow the administrative authority that I was working for at the time to deny any payment to the hospital from that point on.   The reality is that the patient was still severely disabled and could not live on their own, with their relatives, or in whatever residential facilities existed in the state.  Whether there was continued payment or not, there was no place to send the patient due to the presence of a chronic severe disorder.  That is still the problem today.  Rationing has resulted in a severely constricted infrastructure that does not match the needs of the patient population.  A state hospital system cannot exist in a vacuum.  There needs to be an established system of residential facilities apart from those hospitals that can accept people who may never acquire the skills to live in a group home setting or independently.

5.  An emphasis on independent living and competitive or supported employment needs to be the priority of any mental health system.  The community psychiatry movement introduced an important bias - that people with severe mental illnesses should always live independently rather than in an institution if possible.  That is a very important concept but it is time to move beyond that basic bias to a more comprehensive approach.  That includes not only the vocational rehabilitation aspects but a renewed emphasis on the cognitive and functional capacity aspects of severe mental illnesses.  We now have large detailed studies of cognitive deficits in groups of patients with schizophrenia, bipolar disorder and substance use disorders.  That knowledge has not been used to implement any innovative approaches to residential living or vocational rehabilitation.   Treatment rather than rehabilitative approaches to these deficits need continued emphasis and research.  The comprehensive treatment of any person with schizophrenia or a mood disorder should include an assessment of cognitive problems beyond the usual approach of treating symptoms.

6.  Increased availability of psychotherapy and case management services.  Medicalization has become a popular buzzword by journalists and critics of psychiatry.  If you ask any psychiatrist about the likely causes of increased prescribing and attempts to treat all problems with medications the likely response will be that there are no other resources left to treat the problems.  Many managed care systems have eliminated psychotherapists from their clinics or restricted access to available services.  Family and marital therapy is often not available at all.  Many counties have severely restricted the availability of placements for children with severe problems.   There are clear population based approaches that have not been implemented on a wide scale basis including computerized psychotherapy, brief cognitive behavioral therapies, mindfulness based therapies, basic behavioral approaches, and non-psychotherapy approaches like exercise.   These therapies can not only be applied to a wide variety of problems but also can be part of a rational triage system to reduce the prescription of medications and assure that psychiatrists are seeing only the most severe disorders.  This system would also be an asset to primary care physicians and provide them with viable options other than prescribing medications.

7.  Reform of the civil commitment process is necessary.  Civil commitment for involuntary treatment of mental illness and substance use problems is highly subjective and varies considerably from county to county within the same state.  That variance is largely due to variability in resources form county to county and interpretations of the statutes that generally are in line with the level of resources.  Civil commitment and associated legal functions such as conservatorship or guardianship can be life saving and life changing interventions.  A better infrastructure will give legal authorities more confidence that a viable intervention can be accomplished that will reverse the reasons why the person has entered the legal system.  But beyond that it has to be clear that managed care definitions of "dangerousness" and interpretations of "imminent dangerousness" are basically rationalizations to do nothing.  There also needs to be an avenue for preventing the incarceration of mentally ill and substance using patients for minor offenses and diverting them to treatment programs in the community.  Another area where legal interventions are critically needed is guardianship and conservatorship decisions for mentally ill patients in need of acute medical care.  Civil commitment, conservatorship, guardianship, and substitute decision makers all need to be rapid parallel processes done through the same probate court rather than different courts and different jurisdictions.  It is more likely that experienced judges and referees will be able to make better decisions.

8.  Better public health interventions for violence and aggression are needed.  There has been no progress in this area due to the political stalemate on gun control or gun access.  That never addresses the state of mind prior to the violent incident.  The necessary public health interventions need to come at that level and there needs to be centers where aggressive behavior can be addressed and treated before there are adverse outcomes.  Beyond that immediate need there is also very little dissemination of the information that is already known about childhood adversity and adult mental health outcomes.  There is so much critical information out there about the adverse impact of certain social experiences in childhood that are not public knowledge and that should be widely available.

9.   Pharmacovigilance and pharmacosurveillance services need to be developed in the same way that access to controlled substances prescriptions have been developed in many states.  We have been hearing about "Big Data".  Managed care systems have vast amounts of data that they consider to be proprietary that is analyzed from a business rather than clinical perspective.  Any clinician prescribing medications should get a monthly report on their prescribing patterns relative to all physicians and fellow specialists and subspecialists.  Statistical models of conservative prescribing and polypharmacy need to be developed.  Prescribing patterns associated with the highest complication rates need to be identified.   Feedback needs to occur at the level of the individual physician and the reports need an adequate amount of detail.  Literature based on data mining large PBM data bases is not useful to individual physicians.  With current pharmacy databases there is no reason why this system can not be developed nationwide.  

10.  Better neuroscience training for psychiatrists and psychiatric trainees.  We are past the point where a focus on pharmacology can inform a psychiatrist about how a prescription might affect brain functioning.  A detailed knowledge of signaling systems including many systems outside of the nervous system and how they affect plasticity is a requirement for the future.  A detailed knowledge of these systems is necessary to understand brain functioning and normal and abnormal conscious states.    There needs to be an emphasis on teaching neuroscience in psychiatric departments and correlating neuroscience with currently observed clinical phenomenon at a practical and theoretical level.

11.  Medical detoxification from substances needs to be widely available.  A lot of people forget that substance use disorders are in the DSM and there is a psychiatric subspecialty in Addiction.  Even though we have more addiction specialists than ever, the quality of acute detoxification is worse than ever largely because it is another rationed service.  People with significant withdrawal states are often sent home with a bottle of benzodiazepines or sent to a "social" detox setting with no medical supervision.  There are specific goals for detoxification from addictive drugs including the prevention of withdrawal seizures, the prevention of delirious states, the prevention of psychotic states, and the prevention of suicide during acute withdrawal.  It is a common expectation of the current system to expect a patient or their family to be managing withdrawal at home.   The secondary expectation of detox is to assist the patient with transitioning to a safe setting where they can stop using the drug they were just detoxified from.  My estimate from talking with primary care physicians is that only about 20% of the emergency departments and primary care physicians in any locale can refer people to functional detox units.  The non-medical powers that be in the health care system decided long ago that detox was  an "outpatient procedure."  In most cases the translates to sending a person home and hoping they will make it to an outpatient appointment or an AA meeting.

12.  The gross mismanagement of physicians has been a pathway to physician burnout, mass dissatisfaction, and a dumbed down assembly line approach to the practice of medicine and psychiatry.  Physicians don’t need to be told how many people to see in a day, what to document, or how to treat people.  The current collaborative care approach can be seen as being due (in part) to a mind numbing productivity approach that was invented by the federal government and the business world in the first place.   When I was trained as a physician, our teams knew what the resources were, knew what our tasks for the day were, and we could make a local resource allocation on that basis.  It was an extremely efficient way to practice medicine.  At some point, administrators developed “productivity” standards where physicians were expected to apply a totally subjective billing and coding scheme to a patient interaction and do that repetitively all day long.  There were rarely two interactions that were alike, but for the past 20 years physicians have pretended that they were and that this productivity concept had some real meaning.   Administrators could simply increase “productivity standards” to make it seem like more and more work was being done.  In some clinics this process reached an absurd level – 40 or 50 patients a day.  People with complex problems were being seen for minutes and physicians were going along with it because their salary depended on it.   Productivity is another managed care concept that needs to go. 

That is my top twelve list for fixing the broken mental health system.  They are obvious problems supported by my clinical experience.  They are consistent with the frequent problems I have had advocating for the resources I needed to treat patients with severe mental illness.  The government and business partnerships in health care have been obstacles to care.  As long as these partners continue to ration health care and siphon off large profits while rationing care and resources to the patients who are paying for them nothing will change.  This pattern has been most noticeable in psychiatric services.  Contrary to a lot of rhetoric, the problem with the mental health system is not the pharmaceutical companies behaving like other businesses.  It is not the DSM.  It can't be organized psychiatry because organized psychiatry is politically weak and ineffective.  It is not physician conflicts of interest because they are plentiful and the more important ones on the business side are never discussed.

This so-called system was brought to you by the government and the health care companies that lobby all politicians.  The idea that a system of medical care run by business people and politicians who know nothing about medicine or psychiatry is somehow a good idea, is an ongoing American pipe dream.

It is time for the country to snap out of it.


George Dawson, MD, DFAPA

Supplementary 1:  The photo credits here go to Ruzica Vuskovic, MD.

Supplementary 2:  I will be adding in links to previous posts at some point but ran out of time tonight.

Supplementary 3:  I added on Monday 11/17/2014.