My Opinion on Community Mental Health From 1989....

A friend of mine who also worked with me as an RN on an acute care psychiatric unit sent me this newspaper clip from 1989.  It is from the St. Paul Pioneer Press.  At that time I had just started working on an acute care inpatient unit at St. Paul-Ramsey Medical Center (SPRMC) after working in a community mental health center (CMHC) for three years.  The CMHC was in northern Wisconsin and SPRMC is in St. Paul, Minnesota.  In this brief letter to the editor, I was listing the style points between both systems.  Wisconsin was known to be an innovator in community mental health essentially inventing active outreach, providing meaningful crisis intervention services, and active case management with a goal of keeping people with severe mental illnesses in their own apartments in the community and out of hospitals.  Anyone with any experience at all realizes that this is the best approach to the problem.  We did not worry about it at the time, but it also kept people out of jail.  We had working relationships with law enforcement and would often see people in jail and facilitate their treatment there and transition back to the community.

As the medical director of a CMHC in Wisconsin in those days, I had a team meeting with case managers and nursing staff every morning.  We discussed crises and treatment plans for the 100 to 110 individuals under our care.  After that meeting everyone (except me) was driving off to meet our patients in the community.  We had an exemplary record of helping these folks stay out of the hospital and our case managers would go to the hospital and help get them discharged if they were at baseline.  We knew the resources, landlords, relatives, doctors, and local crisis housing.  We worked within a system that had a single-minded focus of supporting people in the community and at the administrative level we had state support mandated that the "money follows the client".  That did involve an incredible amount of paper work on the part of our case managers and needing to deal with a county bureaucrat but there were clear significant advantages over other systems.

Flashing forward 30 years has there been much progress?  I can say with certainly there has been absolutely no progress on the Minnesota side.  They have funded some assertive community treatment (ACT) teams but there is still a rationing mentality.  I heard the rationing mentality recently restated by the current head of the state hospital system.  Minnesota currently has a large steady state population of chronically mentally ill patients circulating through emergency departments, available beds, jails, and homelessness.  There is limited bed availability to the point that outpatient psychiatrists have to send their patients to the emergency department (ED) rather than referring them directly to affiliated hospital because they know there are no beds. That is also true for patients who need electroconvulsive therapy.  The constant stream of people to the ED creates a backlog there and getting patients out occurs only if they are held long enough for an inpatient bed to open, discharged untreated, or transferred to another hospital often several counties away.  In the meantime, the state hospital system has been reduced.

In a November meeting of the Minnesota Psychiatric Society (MPS), Kylee Ann Stevens, MD the Executive Director Direct Care and Treatment of the state hospital system provided some numbers for mental illness treatment but not addiction resources.  Those numbers are summarized in the graphic below.      

It is apparent by inspection that there has been a massive reduction is state hospital beds.  Just over the course of my career they have dropped by over 1,000%.  The bed situation is compounded by a "48 hour rule" enacted in 2014 that states that all patients with a question of mental competency in jails or correctional institutes must be admitted to a state facility within 48 hours.  That gives county Sheriffs preferred access to state hospital beds over treating psychiatrists.  Rather than look at recommended hospital beds per population the state does not plan to try to increase the beds.  A quote from the  National Association of State Mental Health Program Directors (NASMHPD) that "Building more inpatient bed capacity to meet demand is unsustainable" provided the rationale.  The conflict of interest there is obvious.  State Directors are basically accountable to politicians and bureaucrats who want to ration state supported health care especially to those with the least vocal advocacy. At one point in Minnesota over 11,000 beds were sustainable. The only thing different today is politics.

There is also a chronic unanswered question that has been hanging in the air for the last 20 years.  Did Minnesota intend to just shut down the state hospital system entirely? Certainly the trajectory of bed closures was on track to do that.  In the MPS meeting we never learned what the absolute minimum number of beds was.  In talking with doctors and nurses who worked in that system they certainly thought that was the goal.  The current minimalist system may be in place by default rather than design - the end product of a failed attempt to close down all of the state hospital beds.

So Minnesota continues to flounder.  What about Wisconsin?  I don't think that their inpatient bed capacity is much better but I don't have the exact number.  The community mental health movement is still alive and well but I am aware of no significant innovation.  The Wisconsin Mental Health Statutes appear to have expanded significantly and law enforcement seems to have assumed more of a gatekeeper role in emergency treatment.  I can't comment on whether the Wisconsin system is more cost effective and patient centered than Minnesota but I invite clinicians to comment on that.

Relative to the initial news clip - progress in general in the treatment of psychiatric disorders is not a word that can be used.  Politicians run these systems and not physicians.  As long as that is true we can depend on no progress.

George Dawson, MD, DFAPA  

See also:

Minnesota's Abandonment Of Severely Mentally Ill - Nearly Complete

News Flash From the StarTribune - Psychiatric Patients Have "Nowhere To Go"

Minnesota's Mental Health Crisis - The Logical Conclusion of 30 years of Rationing

Running the numbers Minnesota has 3.2 state hospital beds for 100,000 people.

Reductionism Is Not A Dirty Word...

A recent opinion piece in the New York Times, by George Makari, MD has me shaking my head.  The thesis was that a recent headline grabbing story (what's wrong with that criteria?) on the effects of comprehensive treatment of psychosis as opposed to treatment as usual surprised many and highlighted the problem with reductionism.  He bemoans the fact that the reaction to the story was one of surprise.  He doesn't specify who was surprised.  I certainly was not surprised.  I attended recent meeting and somebody in the audience asked Daniel Weinberger if he was surprised.  His response: "They spent $15 million dollars showing that good treatment is better than bad treatment."    He certainly was not surprised.  I have not heard about Eric Kandel's response, but based on his 1979 paper on plasticity and what happens in psychotherapy - I doubt that he would be surprised.  The exact population of who might be surprised by these findings seems poorly defined at this point in time but I doubt that it included any psychiatrists.

Speaking for myself, I will elaborate on why I was not be surprised.  At one point, I was the Medical Director of a community support program of a group of about 100 outpatients in the State of Wisconsin.  According to the state statutes, access to the program depended on diagnosis and degree of psychiatric disability.  You could only apply if you had a diagnosis of Bipolar Disorder, Major Depression, Schizophrenia,  or Borderline Personality Disorder had significant associated disability or were at high risk for hospitalization.  The clinical goal of the program was to reduce hospitalizations, maintain independent living, and facilitate employment.  The program was staffed by a psychologist, 2 social workers, three nurses and me.  When I arrived, one of the early dynamics was to frame problems in terms of medication needs.  That translated to increasing the dose of a medication (typically an antidepressant or antipsychotic) in crisis situations or other emotional crises.  The patients in the program had chronic problems and symptoms that did not necessarily respond to medication.  One of my first steps was to start to discuss problems and solutions with the patients.  I met with all of the patients and did supportive psychotherapy when possible.  We had team meetings every morning and problem solved around the needs of the patients in the community, how to solve any crises, and how to approach people in ways other than medications.  I tracked the total dose of antipsychotic medication and days of hospitalization as outcome measures.  At the end of three years, the days in hospital had gone down from about 14 days per person to less than 1, and the total dose of antipsychotic medication had gone down a total of 600 mg chlorpromazine equivalents.

My point is obviously that comprehensive care of patients with severe problems results in improved outcomes.  In this case lower doses of medications were used and the patients spent less time in the hospital and more time at home.  My orientation and ability to implement such a program was not an accident.  I was trained by Len Stein, MD at the University of Wisconsin.  Dr. Stein was a pioneer in the area defined as community psychiatry.  He was motivated by realizing that once people were in large state hospitals - it was very easy to warehouse them in overcrowded conditions.  Nobody seems to recognize it but overcrowding and suboptimal conditions were the state hospital equivalent of managed care rationing.  Once your state hospital is on the spreadsheet of a state bean counter with no accountability to patients or their families rationing and fewer and fewer resources are the order of the day.   In a community psychiatry seminar, Dr. Stein projected a slide of a gymnasium-sized room populated by male patients with hundreds of cots aligned edge to edge.  There was no room to walk between the cots.  That was his motivation for moving people out of these state facilities and into their own housing.  When I trained, there were three programs with independent living and quality of life as the primary goals and the staff involved in the programs was very good at it.  My effort just extended that skill set.  Contrary to the "surprising" results of the quoted study - I did the same thing back in 1986!

If it is true that we have known for 30 years that comprehensive care for psychiatric disorders trumps "treatment as usual" what is all of the rhetoric about?  Dr. Makari seems to want to make this into a mind-brain argument.  In other words, the biopsychosocial approach and the uncertain effect it has on the mind as opposed to a brain based approach that looks at specific mechanisms of action and seems to be focused on psychopharmacology.  He points out for example that the highlighted study would possible not qualify for current NIMH funding unless it looked at specific brain mechanisms.  He throws around the word "reductionism".  Anytime reductionistic or reductionism is used rhetorically in the same sentence with psychiatry it is pejorative.  My old psychoanalytic teacher would refer to anyone who talked about brain biology as a "dial twister".  The implication is that the reductionists are somewhat simple minded largely because they cannot accept the uncertainty of dealing with an organ that has poorly defined inputs and outputs.  Kind of a double whammy of rhetoric - you are a unsophisticated reductionist and you really can't see the big picture.  Are things really that simple?  Are these arguments accurate?  Are there problems with equating reductionism with "bad".

Of course there are major problems.  The first is the statement that inherent to the proposition that mental illness is a brain disease is "the implication that psychological and social events somehow are not also brain events."  This is a serious misreading of the definition of plasticity or experience dependent changes in the brain.  When I give my neurobiology of the brain lectures. I use Kandel's original New England Journal of Medicine article that discusses brain changes in a patient and a therapist conducting psychotherapy and how those changes are associated with brain plasticity.  I give further examples - weightlifting,  playing the violin, and how the typical stream of consciousness is profoundly altered by drug addiction.  There is no neuroscientist or biological psychiatrist I know who would suggest that psychological and social events are not brain events and there are numerous experimental paradigms that look specifically at how these events occur in the brains of animals.

The second aspect of Dr. Makari's argument has to do with reductionism.  His specific comment is:

"With luck, studies like Dr. Kane’s, which undermine these suppositions, will help move us away from such narrow thinking and embolden the substantial community within psychiatry that has never accepted such reductionism."

The suppositions in this case are that mental illness is a brain disease and that social or psychological events have no brain representation.  The argument is based on that false premise.  But further the use of the term "reductionism" is instructive here as previously noted.  By definition reductionism applies to many proposed etiologies of psychiatric disorders.  Those etiologies can be studied at a molecular level or at a higher level.  Schaffer (2) says that a model is reductive if it "employs standard biochemical and molecular entities to account for psychiatric symptoms and disorders".  Non-reductive models discuss "causal connections at higher levels of aggregation."  He illustrates these definitions by looking at Kendler's non-reductive account of major depression.  Kendler has used path analysis to look at clinical variables relevant to psychiatric disorders and although I do not have access to the one used in the book, here is a typical example.  The model looks at life stages, familial factors and psychological factors and all are higher levels of aggregation than molecular mechanisms.  At the reductive side of things he examines Harrison and Weinberger's proposed genetic susceptibility genes for schizophrenia.  At the time the book was written the author limited the discussion to 5 genes.  He also looked at the continuum of psychiatric genetic models ranging from basic and advanced genetic epidemiology being non-reductive, gene finding partially reductive, and molecular genetics fully reductive.  It seems perfectly logical to me that the study of brain biology proceeds in the same way that the biology of all living organisms proceeds.  The difference is that we are studying an infinitely more plastic organ with significant computational power.  There is clearly a lot of phenotypic heterogeneity that is unexplained in psychiatric diagnostic categories.  It is highly unlikely that refining diagnostic descriptors or applying clinical methods will lead to any significant change in the diagnostic or treatment process.  I don't understand the reluctance to go after more specific mechanisms or treatments.

The idea that a molecular or clinical focus in psychiatry is the problem with psychiatric services is also misleading.  As I hoped to point out by my mental health center example, psychiatrists know all about comprehensive care but they are rarely able to provide it.  They have known about how to provide it for decades.  State asylums became overcrowded and not therapeutic due to the financial management of the system by state governments.  The bean counters have moved out of the asylum and they are now integrated at every level in the health care system.  They all have a very strong bias against the comprehensive treatment of mental illness.  They insist that patients with severe psychiatric problems do not get comprehensive evaluations, that they are discharged before they have been adequately treated, and that any associated addictions are poorly treated.  They do not have the same biases against people hospitalized for medical or surgical illnesses.  They have in effect, moved the poorly run, overcrowded asylum model into the general health care system.  Any comprehensive care for severe mental disorders in such a system is an advertising phenomenon rather than reality.

The reductionism argument is good for New York Times opinion pieces.  It may sell a few more papers or get a few more clicks online.  Unfortunately it perpetuates an old pattern of blaming people and psychiatrists in particular for the shortcomings of a non-system of mental health care in this country that is set up to favor large health care businesses.  You can blame psychiatrists all you want for that - but until people realize that the real problems are the product of business and politics - and not the scientific interests of psychiatrists - nothing will change.


George Dawson, MD, DFAPA

References:

1.   George Makari.  Psychiatry’s Mind-Brain Problem.  New York Times.  November 11, 2015.

2.  Scaffner KF.  Etiological Models in Psychiatry - Reductive and Nonreductive Approaches in  Philosophical Issues in Psychiatry.  Kenneth Kendler, Josef Parnas (Eds), The Johns Hopkins University Press, Baltimore, 2008:  pp 48-98.

Attribution:

Image is Microscope 1 by Bill3t Hughes on Flickr.  Reposted as noncommercial via Creative Commons License on 11/14/2015.  The original work is not modified.

Public Sector Mental Health Continues to Be Squeezed Out Of Business

There was a story that shocked many in the local press earlier this week.  A local mental health center serving about 3,000 people in five counties shut its doors, leaving nobody to fill that void.  Although this appears to be scandalous news, it is really the logical progression of events that has been accurately described in E. Fuller Torrey's book.  It is the logical result of federal and state governments selectively rationing mental health benefits and closing down both inpatient bed and outpatient treatment capacity.

People always ask me: "Well - what should an ideal community mental health center look like?"  That is easy for me to answer because I was trained in community psychiatry, my first job out of residency was as the medical director of a community mental health center (CMHC) , and most of my career has been focused on helping patients who are largely in the public sector or certainly funded by those resources (Medicare/Medical Assistance).  I know exactly what an ideal CMHC needs to run and provide services to a broad range of people who do not have access to metropolitan style mental health services.  The vignettes provided in this article will also be addressed in the following points.

1.  The backbone of any CMHC should be services that focus on people with disabling mental illnesses and helping them live independently.  In the state where my original CMHC was located, statutes defined these conditions as schizophrenia, bipolar disorder, schizoaffective disorder, major depression, and borderline personality disorder.  Adequate resources to treat those conditions generally means nursing and case management services that can meet with people in their homes and in the community.  In the teams that I worked with over 20 years ago we also had a vocational rehabilitation component and we worked with a number of physicians and specialists to address medical problems.  In any treatment setting where a CMHC is responsible for treating all public patients over a county wide catchment area, there is of necessity a legal component.  That is typically focused on involuntary treatment like civil commitment, court ordered medications, guardianships, conservatorships and protective placement.  Depending on the size of the county it can also involve competency assessments for ability to proceed to a court hearing based on concerns about mental illness.

2.  A community trained psychiatrist with medical skills.  The psychiatrist involved should enjoy working with people with people who have severe mental illnesses and medical comorbidity.  The legal component of services means that this person also needs to be comfortable doing the necessary exams and court testimony.  Medical and neurological illnesses need to be recognized and treated.  In CMHC settings the psychiatrist generally has much more information available about the health of his or her patients and they know how to interview people to get it.  When I was a medical director I also provided consultation to nursing homes, hospital consultations, and I would also travel to patient homes with case managers to provide consultation in that setting.  A lot depends on geography and distances to the other facilities needing consultation.

3.  Psychotherapists are critical to the functioning of a CMHC.  It has been interesting to watch the government and managed care companies ration psychotherapy services as much as they ration access to psychiatrists.  Correct me if I am wrong but as far as I know there are no HMOs or MCOs offering standard research based psychotherapies for psychiatric diagnoses.  At the max, usually 2 or 3 "crisis counseling" sessions.  In some cases a generic dialectical behavior therapy (DBT) group where many people with personality disorders end up because more specific therapy is unavailable.  CMHCs could be leaders in the implementation of computer based therapies, and the argument against that would be the lack of information technology departments.  The argument in support of this would be the fact that all counties across the state could share the same resource.  With today's tech, it would be  easily scalable to support anyone who needed it.  It would be inexpensive, effective and a good way to not dilute the psychotherapy resources of the clinic.  The other major change int he past two decades has been the focus on psychotherapy for people with severe mental illnesses.  That should be a critical part of any CMHC function.
 
4.  Addiction treatment - many communities have more resources available outside of the CMHC for assessment and treatment or referral of addictions.  The CMHC resources need to be more focused on the issue of co-occurring disorders and probably chronic pain and co-occurring disorders.  This would be another opportunity for networking all of the CMHCs in a state to assure a standard of assessment, share treatment resources, consult on specific cases and assure that there is no deterioration in prescriber standards with regard to potentially addictive medications.

5.  Crisis intervention services - 24/7 availability is necessary to provide acute evaluations but more importantly to resolve crises in patients who are well known to treatment teams.  Ity reduces the likelihood of unnecessary hospitalizations when there are staff person available who know the  person in crisis very well.  It is much more efficient and patient centered than sending a person to an emergency department and asking them to start over there with professionals who do not know them.

In the CMHC I worked in we had a catchment area of about 100,000 people spread over a large rural county.  We had a little over 100 patients in our community support programs for the severely disabled.  We we staffed by 1 psychiatrist, 2 psychologists, 4 social workers, 1 occupational therapist,  4 psychotherapists, 1 RN, and 2 LPNs.

The progression noted in this article is very clear and it has been replicated thousands of times across the US.  Shut down the large hospitals and tell people that treatment will be available in the communities near their homes.  Then shut down community treatment.  You will notice that officials make it seem like this is some kind of mystery.

“We’re so tight in [psychiatric] beds that any change in the delivery system impacts the whole system,” said Assistant Human Services Commissioner David Hartford. “The agencies need to reorganize to get people the care they need.”

Sorry Commissioner but in case you didn't notice we are not talking about beds anymore.  All of the people involved here were living at home in their own beds.  Agency "reorganization" is not an option.  There are no agencies anymore and one that was providing a valuable service was just shut down.  The problem here is very clear, cost shifting by managed care and defunding by the state.  Corporate welfare in the form of a carve-out for psychiatric services.  Keep in mind that when the comprehensive and humanistic approach to community treatment is lost, the only alternative is going in to a large managed care clinic where the appointments are scheduled every 15-20 minutes, the focus is on a prescription, and the only thing the doctor knows about what is going on is exchanged in that visit and recorded in the electronic health record.  That is frequently a symptom checklist. 

I guess there is always the psychiatric hospital of last resort - the county jail.  At least until the Sheriff's department goes broke.

George Dawson, MD, DFAPA

Christopher Snowbeck.  Crisis mental health provider closes; 5 counties scrambling.  TwinCities.com  St. Paul Pioneer Press.  March 18, 2014.

Chris Serres.  Minn. mental health center shuts down, stranding thousands.  Minneapolis StarTribune.  March 17, 2014.

Supplementary 1: I e-mailed the author of the first article Mr. Serres to inquire about the recently released state report that he refers to in the article and got no response.  As far as I can tell it may be the "Health Services in State Correctional Facilities Report" available at this site.  The concerning highlights include the fact that there are units that provide intensive nursing and mental health services.  About 33% (67,456) of all of the health services encounters with staff are for mental health purposes.  That translates to 28% of the offenders receiving mental health services.  At some point in their stay 32% are diagnosed with a "serious and persistent mental illness" as defined by state statute.  The report provides an interesting overview of how mental health services are provided in Minnesota prisons and the special problems involved in treating mentally ill offenders.

Supplementary 2: According  to Minnesota Statutes 2013, 245.462, subd. 20(c)(4)(i), states that a person has serious and persistent mental illness if he or she is an adult and “has a diagnosis of schizophrenia, bipolar disorder, major depression, schizoaffective disorder, or borderline personality disorder.”