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.

Shut Down The Psychiatric Gulags - Don't Build More!

On my drive home from work yesterday, I heard an outrageous story about a judge ordering LA County jail to build 3,200 psychiatric beds to treat mentally ill inmates in that facility.  As is typical of MPR, I could not find the link today but I did find the link to this LA Weekly story , that basically brings people up to speed.  It is a typical journalistic approach with the human interest component.  In this case the human interest portion was interesting to me, because I have heard these stories hundreds of times from people I have treated who have been incarcerated with a few variations.  The most significant variations have to do with suffering acute alcohol or drug withdrawal and not being assessed or treated for that problem and not having access to maintenance medications that have proven effective for the specific mental illness.  The current plight of the mentally ill in the LA County jail system and increasing judicial pressure on the basis of rights violations for the lack of treatment led county supervisors to vote to build what was called the most expensive building project in county history.  From the article:

"That day, county supervisors ........ voted to spend nearly $2 billion on a long-sought jail to replace notorious Men's Central, a facility that federal investigators say is plagued by suicides, abusive conditions and violence. The funds will build a two-tower compound given the ungainly name "Consolidated Correctional Treatment Facility."

According to the article it will be a 4,860 bed facility,  3,260 (67%) beds of which will be dedicated to treating prisoners with mental illness.  My most recent post on the matter includes information that LA County jail has 19,386 inmates and that recent epidemiological surveys suggest that 30-45% of inmates have problems due to severe mental illness and impaired functional capacity.   That suggests that unless public policy changes, the most expensive building project in LA County could be overwhelmed by demand before it gets started.  The author in this case points out the folly of building this tower.  It is basically the folly of building any large psychiatric facility in the absence of any other infrastructure, but in this case compounded by the fact that this is in fact a jail and not a treatment facility.  There is really no evidence that the problematic aggressive or suicidal behavior will be any better in a new "two-tower compound" with the same jail atmosphere and mentality.

I have previously posted about the plight of the mentally ill being incarcerated in America and the fact that county jails are currently our largest mental institutions.  It is a basic collusion between governments at all levels and the business community to enrich corporations that have been set up to "manage" the American healthcare system.  As usual, the most vulnerable people are "cost shifted" out.  Cost shifting refers to cost center accounting that basically leads divisions within the same organization to try to save money on their budget by shifting the costs to somebody else.  In managed care systems it can lead to all kinds of distortions in care.  It also happens with outside agencies.  I was told about a situation where workers in one county actually dragged an  intoxicated patient over the county line and into another county so that patient would no longer be their  financial responsibility!  Cost shifting is the end result of these perverse incentives.

There is perhaps no better example than incarceration rather than hospitalization.  There are estimates as recent as from a few days ago that treatment and possible hospitalization may cost $20,000/year as opposed to incarceration costing $60,000/year.  In both cases the taxpayers pick up most of the tab.  The cost shifting has occurred from insurance companies and health care systems to the correctional system.  If an insurance company can dump a patient with a severe mental illness into jail, it doesn't cost them a thing.   If that same patient is hospitalized they may receive a one-time DRG (Diagnosis Related Group) payment of about $5,000 irrespective of how long the patient stays.  The hospital incentive is to get them out in 5 days whether they are stable or not to maximize profit.  When they are discharged, the patients are generally expected to go to appointments to discuss their medications.  Clinic profits on these visits are minimal but the main problem is that many of these appointments are missed - in some cases up to 50-60%.  Many of these patients lack stable housing and they frequently end up back in the emergency department and back in the hospital.  Hospitals now have bottlenecks in the emergency department and many people are discharged back to the street.  The cycle of ineffective care continues.

I can attempt a brief analysis of the problem as I watched it unfold during 23 years of inpatient practice.  I will demonstrate how things have changed to the detriment of patients with severe mental illness.  Consider the hypothetical case of Mr. A.  He has diagnoses of depression, schizophrenia and alcohol dependence.   He recently ran out of his usual medications and started drinking.  He became progressively depressed and stopped talking with his family members.  They went over to see him and noticed he has a loaded handgun on his table and was talking about shooting himself.   They called the police who came, confiscated his handgun, noted that he was acutely intoxicated and sent him to the local hospital emergency department.  How has the management of this scenario changed over the past 30 years and why?

In the early 1980s, Mr. A would have been assessed as a person who was high risk for ongoing suicidal behavior (depression, schizophrenia, alcoholism and acute intoxication) and admitted to a psychiatric unit.  The psychiatrist there would have done everything possible to stabilize all three conditions even if it meant civil commitment to a long term care institution.  The length of stay (LOS) would have been on the order of 20-30 days comparable to many current psychiatric LOS in the European Union.

By the late 1980s, a managed care company would have called the hospital or psychiatrist in charge.  They would initially demanded that the patient be discharged to a county detox facility.  They would claim that alcohol withdrawal detoxification was not a psychiatric problem, and therefore the patient does not meet their "medical necessity criteria" for inpatient hospitalization.  If that was ineffective they might say that he was no longer "acutely suicidal" or "imminently dangerous" two additional medical necessity criteria.  In the end they always win, because they just stop paying and the administrators force the clinicians to discharge the patient.  The length of stay is now down to less than 1 week and the patient may not be stable at all at the time of discharge.

By the 1990s, the patient might not even make it to the inpatient unit.  By now psychiatric departments are continuously burned by managed care companies, especially in the case of any patient who is acutely intoxicated at the time of admission.  Many have closed their doors.  Many departments have strongly suggested that the emergency departments send any intoxicated patients directly to county detox units if they are available.  The counties respond by refusing to take any patients on any intoxicants than than alcohol and even then the patient has to blow a number on a breathalyzer consistent with acute alcohol intoxication.   At any point in this process a decision can be made to just send the patient home.  There are various ways the patient can access more firearms at that point or even get the original firearm that was confiscated.  There are also various ways that the patient can end up incarcerated including going back home, drinking and getting arrested for disorderly conduct or public intoxication.  A more complicated situation occurs if the patient is intoxicated and wanders into a neighbor's home or place of business.  I have seen people end up in jail for months on trespassing charges in these situations.   And that brings us in to the 2000s where it is much more likely that a person with severe mental illness will be incarcerated than even make it to the emergency department.  In the 2000s the patient may end up stranded in the emergency department for days or sent home with a bottle of benzodiazepines to handle their own detox if they can deny that the are "suicidal" consistently enough.  There is also the mater of inpatient bed capacity.  Fewer beds are full constantly because bed capacity has been shut down due to managed care rationing and people are often released because there will be no open beds in the foreseeable future.  The LOS in many cases is now zero days, even for people with severe problems.

How did all of this happen?  How did the care of mental illness and addictions fall to such a miserable standard?  It is documented in many posts on this blog.  Professional guidelines were compromised and treatment infrastructure was destroyed by the managed care industry and the politicians who actively supported and continue to support it.  Professional organizations don't stand a chance against pro business state statutes,  commissions stacked with industry insiders, and federal legislation that protects these companies from lawsuits for interference with care.  Even a travesty as basic as prior authorization for generic drugs is unassailable.  I don't understand why these basic facts are so incomprehensible to people in the field.  Just a few hours ago, 1BOM posted a Hall of Shame of entities the original authors claim are failing people with severe mental illness.  This list completely misses the mark and is probably a good example of how deeply entrenched the mechanisms are to prevent treatment  and shift costs away from states and health care companies.

There are countless easy solutions to the problems, but the companies in power literally do not want to spend a dime.  The patient with severe mental illness can receive comprehensive community services and be maintained in their own housing at a cost of $10, 000 to $20, 000/year for clinical services.  That same patient costs corrections departments $60,000 per year.  That patient currently costs managed care companies nothing if they can transfer their care to a local state-funded Assertive Community Treatment (ACT) team.  Managed care companies incur the same cost if the patient is transferred to the correctional system.  If ACOs come to fruition and all of the chronically mentally ill are enrolled, it should be an easy matter to make the managed care companies responsible for both the costs and the patient.  A simple court order to pick up the patient from jail and stabilize them in the community could suffice.

Erecting more gulags won't work.  They are effective only for enriching health care companies that profit by denying care for those with severe mental illnesses and addictions.  They are also another hidden health care tax on the taxpayers who are already paying far too much in hidden health care taxes.




George Dawson, MD, DFAPA

Graphics Credit:  ConceptDraw Pro - this graphic was included as an example with this software.

A Valentine from the President

I caught the link to this fact sheet from President Obama a couple of days ago on the APA's Facebook feed.  In the post immediately before it, the current President of the APA is seen rubbing elbows with Bradley Cooper.  My first thought is that these initiatives are always a mile wide and an inch deep.  They provide a lot of cover for politicians who have enacted some of the worst possible mental health policy, but also for professional organizations who have really not done much to change mental health policy in this country.  These are basically non-events as in we applaud the President and he applauds us.  In the meantime, patients and psychiatrists are never given enough resources for the job and the necessary social resources keep drying up.

Since the 1970s, the political climate in the US has focused on being as pro-business as possible.  Congress practically invented the credit reporting industry and in turn that industry made it easy for businesses to change your fees based on a credit report number.  What you have to pay for home and auto insurance can be based solely on your credit rating and independent of whether or not you have ever missed a payment.  It turns out that competitiveness is little more than political hyperbole.  But the politicians in Washington did not stop there.  The financial services industry is currently a multi-trillion dollar enterprise with little regulation or oversight that has essentially placed all Americans at financial risk.  There is no better proof than the fact that there are currently no safe investments and that some advisors are suggesting that prospective retirees need as least $1 million dollars in savings and $240,000 for medical expenses in addition to whatever is available in Medicare and Social Security.   Congress's retirement invention the 401K has surprisingly few accounts with that kind of money.

How can a government that puts all of its citizens at financial risk all of the time manage the health care of those same citizens?  It is a loaded question and the answer is it cannot.  The idea that an administration has an initiative to "increase understanding and awareness of mental illness"  at this point in time is mind numbing in many ways.  We  have had over two decades of National Depression Screening Day, we have Mental Illness Awareness Week, and we have had the Decade of the Brain.  There seem to be endless awareness initiatives.  I don't think the problem with mental health care is the lack of awareness or screening initiatives.  From what you can see posted on this blog so far, it might be interesting and productive to have some media awareness events that look at the issue of media bias against psychiatry and the provision of psychiatric services.  I don't think it is possible to destigmatize mental illness, when the providers of mental health care are constantly stigmatized.

What about the issue of screening at either a national level or at the level of a health plan?  A fairly recent analysis commented that there have been no clinical trials to show that patients who have been screened have better outcomes than those who are not.  Further, that weak treatment effects, false positive screenings, current rates of treatment and poor quality of treatment may contribute to the lack of a positive effect of the screening.  The authors also refer to a study that suggests that more consistent treatment to reduce symptoms and reduce relapse would lead to a greater treatment effect than screening.  A subsequent guideline by the Canadian Task Force on Preventive Health Care agreed and recommended no depression screening for adults at average or increased risk in primary care setting, based on the lack of evidence that screening is effective.  Why in the President's fact sheet are the AMA and APA recommending screening?  Why are there people advocating for "measurement based care" and the widespread use of rating scales and screening instruments?  Why does the State of Minnesota demand that anyone treating depression in the state send them PHQ-9 scores of all of the patient they treat?

The answer to that is the same reason we have political events that add no resources to the problem and make it seem like something is happening.  Screening everywhere makes it seem like somebody is concerned about assessing and treating your depression.   It makes it seem like we are destigmatizing mental illness and making diagnosis and treatment widely available.  The Canadian papers noted above suggest otherwise.  Nothing is happening, except people are being put on antidepressants at a faster rate than at any time in history.  In a primary care clinic, medications are the first line treatment and psychotherapies - even psychotherapies that are potentially much more cost effective than medications are rarely offered.

My professional organization here - the APA has chosen to advocate for an "integrated care" model that is managed care friendly.  A model like this can use checklist screening and essentially have consulting psychiatrists suggesting medication changes on patients who do not respond to the first medication.  I obviously do not agree with that position.  Only a grassroots change here will make a difference.

If you are concerned that you might have significant depression, you can't depend on your health plan or the government when they are both advocating for a screening procedure that has no demonstrated positive effect.  If somebody hands you a screening form for depression or anxiety or sleep or any other mental health symptom, tell them that you want  to be interviewed and diagnosed by an expert.  Tell them that you want the same approach used if you come to a clinic with a heart problem.  Nobody is going to hand you a screening form that you can complete in 2 minutes.  You are going to see a doctor.  Tell them that you want that expert to discuss the differential diagnoses, the likely diagnoses and the medical and non-medical approaches to treatment including counseling or psychotherapy.

Do not accept a cosmetic or public relations approach to your mental health and spread that word.

George Dawson, MD. DFAPA