Cancer Care In Psychiatry - Yes It Happens

Great Case Records of the Massachusetts General Hospital in the New England Journal of Medicine this week.  A psychiatrist is presenting a case of complicated disorder and coordinating care with oncologists after a cancer diagnosis is made.  It must have taken an editorial change in the Journal to get psychiatry more front and center in this prominent medical journal.  This article has a lot of meaning for me, because the bulk of my career was spent on these issues.  When you are the inpatient doc or the psychiatrist staffing the case management teams - either Assertive Community Treatment (ACT) or some other case management model a lot of this important work falls to you because there is nobody else out there.  Contrary to the popular hype about collaborative care - people with severe mental illnesses generally avoid medical clinics and non-psychiatric physicians.  There are always some exceptions, but as I have said many times there are reasons that people do not go into psychiatry.  Talking to people with communication problems, irrational thought processes, and atypical social behavior are high on the list.  Some of the best primary care physicians recognize this and like the oncology clinic described in this paper give people with severe mental illnesses wide latitude in terms of appointments and treatment schedules,  but they can only do so much.

What is needed on the front end is a psychiatrist with strong medical skills to figure out the problem and get other medical staff involved.  I don't mean looking at PHQ-9 scores and suggesting medication adjustments.  I mean actually talking with the patients.  Very frequently a person with impaired judgment due to a psychiatric disorder will be fully cooperative in one setting but not another.  Consider a patient who is acutely admitted with very high blood pressure (260/140).  He has a history of schizophrenia and hypertension requiring moderate to high doses of two different antihypertensives.  In this case the patient has gone off of both medications and maintenance antipsychotic medication.  He is agitated and paranoid.  It is impossible to determine if he is also delirious due to the presence of cognitive disorganization from acute psychosis.  He will not allow testing or physical examination beyond the blood pressure determinations and eventually stop cooperating with that.  The inpatient psychiatrist makes an assessment and swings into action.  He tries to establish rapport with the patient to convince him that this is a medical emergency.  At the same time he has contacted the hospitalist service and there is agreement that he needs to go to an acute care bed as soon as possible.  The hospitalist reminds the psychiatrist that they cannot touch the patient unless he consents "or it is assault".  His advice is to call when he is ready to cooperate or call when he gets obtunded by encephalopathy or a stroke and they will treat him acutely.  In this case the psychiatrist eventually convinces the patient to check out the ICU and walks him over there.  Once he is in the bed - he is fully cooperative with all recommended measures including a complete physical exam.

In addition to the lack of a logical progression to the care of severe medical problems there can also be obstacles at the level of presenting the diagnosis to the patient.  I have presented diagnoses of cancer and diabetes mellitus to patients with psychiatric disorders only to be told that the diagnosis is impossible.  "I could not possibly have diabetes doctor, because I don't have a pancreas." comes to mind.  In terms of evidence, holding up an image of a lung or brain tumor may get the response: "I don't think that is my x-ray doctor.  That is somebody else's x-ray."  Those responses and the lack of ability to cooperate can be very frustrating for primary care physicians and specialists.  These patients are always very easy to get rid of.  All it takes is a comment like: "If you want me to treat you - you are going to have to stop smoking.  If you can't stop smoking - I can't treat you."  At the other end of the spectrum I have had Internists coach me over the phone on what to do for a patient, because they knew the patient would never come into their office or pick up a prescription.

The most frustrating cases are the ones that I saw too late.  The mistakes of informed consent as in:  "Mr. Smith you have colon cancer and need to have surgery to have the tumor removed.  At this stage you have an excellent chance for recovery but we have to operate in the next few months."  Mr Smith has schizophrenia.  He smiles and seems to understand everything.  He just wants to get out of the clinic and away from doctors back to his home where he will be much less anxious.  He never returns until two years later when concerned relatives call the police because of their concern about him.  The police find him alone at home.  The house is in disarray.  There is blood everywhere.  Mr. Smith is emaciated and has lost 35 lbs.  He is brought to the hospital and admitted to inpatient psychiatry.  He is seen by the oncologist who originally consulted on his case.  He now has widely metastatic colon cancer and no chance for survival.  That whole sequence of events can be prevented by a psychiatrist willing to discuss these potential outcomes long before the clinical picture worsens.

An infrastructure that allows for continued outreach and rapport building is also useful.  I had many patients with terminal cancer diagnoses admitted to my inpatient unit, not only because they were mentally ill and medical services would not admit them, but because there was no place else for a mentally ill person with terminal cancer to go.  Pulling all of the necessary resources and teams together with an initial acute admission potentially saves lives.  This paper is a good example of that, but acute care psychiatrists may still be held to the "acute dangerousness" standard for care and these admissions are actively discouraged.    

In the case of the NEJM article, the patient is a 63 year old woman with a history of lung cancer, chronic obstructive pulmonary disease (COPD), hypertension, hypercholesterolemia, asthma, insomnia, and restless leg syndrome.  She has also had two previous cancer diagnoses.  A previous diagnosis of lung cancer had been treated surgically with lobectomy and adjuvant chemotherapy six years earlier.    She had a past history of stage IIa estrogen-receptor positive and progesterone-receptor positive, HER2/neu negative invasive ductal carcinoma of the left breast.   The breast cancer was treated with lumpectomy, whole breast irradiation, and chemotherapy.  The patient had a previous psychiatric diagnosis of Attention Deficit-Hyperactivity Disorder treated at times with various stimulants and modafinil.  She was a admitted to the inpatient psychiatry unit for treatment of depression with electroconvulsive therapy.

In the process her psychiatrist comes up with a list of 13 factors that affect cancer care in patients with severe mental illness and cancer and strategies to approach them.  The factors follow initially what is known about cognitive and social behavioral deficits in the population with severe mental illness.  That would include an inability to understand the diagnosis or treatment.  In many cases, the patient is unable to provide informed consent due to cognitive deficits.  System wide deficits are identified at the level of the provider, the health care system, and society and culture.  Any physician who tries to provide medical or psychiatric care to these populations has seen most of these deficits.

In addition to the factors affecting cancer care there is a separate table of Differential Diagnosis of Depression in a Cancer Patient that every psychiatrist working in these settings needs to be aware of.
      
The psychiatrist in this case provides psychotherapy focused on the patient's understanding of the illness and their decisions to cooperate with care.  That included but was not limited to biological interventions for depression.  ECT and lurasidone were the main identified treatment modalities.  An enhancing mass was noted in the right breast on chest CT scan to follow up on previous cancer treatment.  That was subsequently diagnosed as ductal carcinoma of the  right breast.  In this case, the radiation oncologist modified the radiation treatment to maximize the flexibility of treatment for the patient.  She was able to complete all 5 treatments without difficulty.  

From a psychiatric standpoint she was discharged as improved after 19 days taking lamotrigine, gabapentin, quetiapine, and modafinil.  She had received 6 ECT treatments.  But as importantly, she had follow up oncology care, identification of a new cancer diagnosis, and coordination of that care also occurred in that setting.  This is a very compelling study at that level and a clear departure from the rationed inpatient care that people have come to expect when psychiatric units are run by business people.


George Dawson, MD, DFAPA


References:

1:  Irwin KE, Freudenreich O, Peppercorn J, Taghian AG, Freer PE, Gudewicz TM. Case 30-2016. N Engl J Med. 2016 Sep 29;375(13):1270-81. doi: 10.1056/NEJMcpc1609309. PubMed PMID: 27682037.

2: Shtasel DL, Freudenreich O, Baggett TP. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 40-2015. A 40-Year-Old Homeless Woman with Headache, Hypertension, and Psychosis. N Engl J Med. 2015 Dec 24;373(26):2563-70. doi: 10.1056/NEJMcpc1405204. PubMed PMID: 26699172.

Supplementary:

From the New England Journal of Medicine earlier this year:

New England Journal of Medicine Discovers Assertive Community Treatment. link

Admission, Discharge and Readmission Policies - No Better Example Of Business Driven Pseudoscience

One of the recurrent themes of this blog is that the application of science to medicine, especially at the public policy level has plummeted over the past three decades.  That has been directly attributable to the influence of business on all levels of government.  One of the more pervasive themes is that the behavior of health professionals is best accomplished by incentivization.  In other words financially punish physicians to get them to change their behaviors that you don't want or financially reward the behaviors that you want them to produce.  I haven't looked at the scorecard lately, but my guess is that the punishments greatly outweigh the rewards.  Maybe my perspective has been skewed by working for an HMO for many years that considered it a reward if they "held back" part of your salary and then gave it to you if all of the physicians in your group met the desired productivity targets.  I am sure it took the MBAs a while to dream that one up.  The equation seems to be as simple as -  "OK here is what we want the goal to be.  We don't want to pay out any rewards anymore.  Let's just penalize people for not meeting the goal until eventually everyone is compliant with the goal."  There is probably no better example than the Medicare Hospital Readmissions Program.

A recent editorial in JAMA notes that the 2013 readmission rates for Medicare patients is about 18% within 30 days (1).  That is associated with a potential cost of $26 billion.  Since 2010 Congress has levied a 3% of Medicare reimbursement penalty on hospitals who have readmission rates that are considered too high.  The problem is that 80% of hospitals are being penalized are safety-net hospitals or those that have a disproportionate share of low income patients.  Those hospitals are more likely to be penalized all three years since the penalty started  and they are more likely to be the hospitals with the lowest operating margins.  The likelihood of penalty also correlates with the percentage of patients treated who are elderly and live with poverty or disability.  

The authors opine that hospitals should not be penalized "because of the demographic characteristics of their patients."  They point out that the evidence suggests that is exactly what is happening and they conclude:  “Targeting hospitals for penalties, even if indirectly, simply because those hospitals care for more poor people is not good policy”.  They use this as a foundation to build their argument for a proposed policy initiative – The Hospital Readmissions Program Accuracy and Accountability Act of 2014.  It builds in safeguards for hospitals treating patients from a disadvantaged socioeconomic status.   

The obvious problem with the authors’ logic here is that they seem to not realize that discrimination against patients of the lowest socioeconomic status has been institutionalized and occurring for decades.  The people I am referring to are those people with addictions and severe psychiatric problems.  The facts are clear.  For the past 30 years, even though psychiatric disabilities rank as some of the top 10 disabilities by any measure, they get a much smaller fraction of the health care dollar for care.  I have used the example of a middle-aged man or woman being hospitalized through the emergency department for acute chest pain.  I don’t know the fraction of those people who are discharged the next day.  But consider that basic scenario if the evaluation of chest pain turns out to be non-cardiogenic.  In the hospital where I have worked that generally means an evening on telemetry and serial troponins and either a stress echocardiogram the next day or an echocardiogram and a stress test.  Price tag about $25-30,000 for less than 48 hours in the hospital.  On the other hand,  let’s say a person has an exacerbation of an affective psychosis and is not able to function at home or has put themselves at risk.  The will be hospitalized in a very low tech psychiatric unit, the goal of which is to discharge them when they are no longer “dangerous” or to discharge them upon request if they cannot be held involuntarily.  Irrespective of the price tag for this care the best available data I have on the DRG reimbursement for this care is about $4,800 irrespective of length of stay.  The economic incentives all line up to rarely provide them with the discharge resources they require to maintain even a subsistence life style and remain stable enough to stay out of emergency departments or jails.  Furthermore in many cases, states previously charged patients a for a portion of their medication costs per month out of their disability income.  The direct and indirect costs incurred by patients and families with severe mental illness and addictions are a travesty of the highest magnitude.  The rationing mechanisms that have been in place for the past three decades have results in care that is subpar relative to any other medical specialty.  It has created an entire population to patients with chronic illnesses that are discriminated against.  The financing of care for them has set a number of perverse incentives that would seem to be more destabilizing such as an incentive for hospital discharge in order to beat the designated days in the diagnosis related group (DRG) and readmit them if necessary.  If the entire DRG incentivization for admissions and discharges is pseudoscientific sleight-of-hand based on very crude demographic variables - why would we expect readmissions policies to be any different?

The second dimension of this care is just how unscientific care based on demographic factors is in the first place.  I was previously in a practice where “consultants” who had never practiced medicine came in and commented on the “complexity” of our patients.  At the time I was caring for many patients who I knew would never be admitted to other general psychiatric units in any other hospital in the state due to their medical complexity.  The consultants concluded that my patients were no more complex than any other patients in the state even though they could not define the measures they used to make that determination.  Nobody mentioned the inherent conflict of interest when a pro-discharge administration hires consultants that agree with their world view - discharge patients as soon as possible.

In another scenario and on a committee, I asked if the demographic determined characteristics and time lines for treating community acquired pneumonia led to any differences in mortality or complications – and nobody knew.  The original Big Data approach in medicine looked at HEDIS variables.  Any practicing physician knows this is an incredibly crude approach that in many cases is meaningless.  There is no better example than saying that treating acute and chronic psychosis in a few days makes no difference in outcomes, when nobody knows the best treatment approach and practically no hospital screens for functional or cognitive capacity - two well known areas of psychiatric disability.  In the outpatient sphere, it is the equivalent of saying that 10 or 20 minutes three or four times a year with an emphasis on medications that are not likely being taken by the patient can possibly affect their real life outcome.

In the case of patients with addictions the treatment is more dire.  When a person using heroin, alcohol, and excessive amounts of benzodiazepines cannot get admitted for detoxification or they cannot get admitted for residential treatment, society and its representative governments at all levels are saying that this is a situation where we can ignore conditions that are clearly life-threatening and in many cases fatal.  We can ignore them because businesses and governments say that this is a collection of disabling and life-threatening diseases that we can ignore so that they can either make money or divert money to treat more socially acceptable life-threatening and disabling diseases.  

This is all a clear pattern of discrimination that not only affects the elderly but anyone with a psychiatric disability or addiction.  If the authors want to do something about that – I say let’s start by reversing over 30 years of discrimination against those with psychiatric and substance use problems that is clearly based on socioeconomics especially the lack of a vocal political constituency, very poor research based on demographic variables rather than complexity, and a lack of innovative research based on poor resource allocation.

George Dawson, MD, DFAPA

References:

1: Boozary AS, Manchin J 3rd, Wicker RF. The Medicare Hospital Readmissions Reduction Program: Time for Reform. JAMA. 2015 Jul 28;314(4):347-8. doi: 10.1001/jama.2015.6507. PubMed PMID: 26219049.

Attribution:

Photo by Mark Buckawicki (Own work) [CC0], via Wikimedia Commons.

The Chai Man

Back in the 1970s I was in the US Peace Corps in Kenya East Africa.  I worked in an all boys school as a chemistry teacher.  The school was about 100 miles north of Nairobi on a high plateau next to Mt. Kenya.  On the weekends my fellow volunteers and I would drive over to the closest town for a Coke and an inexpensive snack at the White Rhino Hotel.  In those days a Coke or a bottle of beer would cost about a Kenyan Shilling (KES) and a meat pie or a samosa would cost about a Shilling and a half.  One Shilling was about 14 cents American.  Outside the hotel was an apparently homeless man.  He would beg for money often by creating disturbances.  He would obstruct people in the street going to and from the hotel.  He would shout out the word "Chai,  Chai..." repeatedly while spitting down the front of his shirt.  "Chai" is the Kiswahili word for tea.  He would appear agitated and tearful at times.  He was not tolerated very well by hotel security or the local people - people who could speak fluent Kiswahili and the local Kikuyu language.  Some of them would become physically aggressive toward him and cause him to run down the street.  At other times he would show up with a can of dirty water and try to clean auto windshields by wetting down a newspaper and wiping the water all over.  These attempts were always unsolicited and the drivers would become enraged because their windshields were always less clean than when he started.  We eventually referred to him as the Chai Man because nobody ever knew his name.  The Chai man clearly struggled, alienated practically every person I ever watched him interact with, and he got minimal assistance from anyone.  At the time he reminded me of homeless men I would see in my local public library.  It was the only they place they could go in a small town to get a break from the weather.  They would occasionally ask for money, but for the most part avoided people.  When  you are down and out and mentally ill, most people seem to know better than to ask.

By the time my fellow teachers and I made it to our placement north of Nairobi we had contact with hundreds if not thousands of people living on the street as beggars.  Many had physical deformities to the point that they were unable to walk.  Coming into town from the airport was enough contact to convince the most altruistic Peace Corps volunteer (PCV) that they personally did not have nearly enough resources to address the problem.  PCVs had to learn to not look at the people begging on the street and walk quickly by or risk people coming out and grabbing their leg or arm until they were given money.  Like the US, only certain streets and areas allowed for the aggregation of these homeless beggars.  PCVs were not rich by any means but when we got to our eventual destinations, they were usually places where there were no homeless people in sight.  We were rather scruffy ourselves but we could sit in classy places like the New Stanley Hotel and sip on a Coke.

I thought of the Chai Man last night as I listed to a program on "The World" on MPR about a mental health initiative in Kenya (reference 1).  The focus of the program was a young woman Sitawa Wafula started mental health crisis intervention service on her own.  It is a formidable problem.  The program describes how children and adults are "locked up" by their families and may not see the light of day.  Neighbors often do not know that a mentally ill brother or sister exists.  This is reminiscent of Shorter's description of the problem of psychosis in Europe and how it was handled in the early 20th century.   It also happened in my own family in the early 1950s.  In Kenya, there are currently 79 psychiatrists or one for very 500,000 people.  Ms. Wafula gets a number of calls to her crisis intervention service and says that if the problem involves suicidal thinking many people with that problem have had two previous suicide attempts.  The World Health Organization puts Kenya in the top quartile of suicide rates in all countries worldwide.    

I was picked up by a Kenyan physician once when I was hitchhiking back to Nairobi one  day.  I asked him what was available in terms of psychiatric services at the time.  He said there was only one hospital and that the basic medication being prescribed by physicians was chlorpromazine.  At that time, the chlorpromazine generation of antipsychotics were the only ones available and antidepressants were more difficult to prescribe.  Medical care in general was difficult to access.  I would typically get scabies at least one a month.  When I was initially infected I made the mistake of going to a local clinic and standing in line in the hot sun.  I was about number 300 in the line and it moved about 4 or 5 spaces every hour.  I realized that I could hitchhike 100 miles to Nairobi and back and pick up the appropriate treatment from the Peace Corps physician in less time than it took to go to the local clinic.  Eventually I just picked up a large bottle scabicide and applied it whenever I got infected.   At the time Kenya also had one of the fastest growing populations making it more difficult to provide medical and psychiatric care.

About 8 years after I left Africa, I was sitting in a seminar full of fellow psychiatry residents at the University of Wisconsin.  The topic of the day was whether or not the prognosis of schizophrenia was better in what was then called the "the third world" based on some outcome studies available at the time.  Our job was to critique the literature and it was apparent that there were technical differences in studies and in many areas the follow up and methodology was different.  At one point I suggested that exposure to antipsychotic medications may lead to negative outcomes and that raised an eyebrow or two.  I also pointed out that that at least half of the people I was treating had significant alcohol and drug problems and were not interested in quitting.  I doubted that many of the people in these studies had widespread access to street drugs that were known to precipitate psychotic states.  I remembered the Chai Man very well, but knew better than to introduce my anecdotal experience from Kenya.  That axiom about better prognosis in the developing world has since been re-examined (reference 2) and there are clearly more problems with that theory than originally thought.  Like many areas in psychosocial research it may depend more on your political biases before you read the research.  The Scandinavian research on brief psychosis and brief reactive psychosis from about the same time frame certainly suggested similar rates of spontaneous recovery.

These experiences make me smile at couple of levels.  Any time someone "confronts" me with the evidence of prognosis in schizophrenia and the World Health Organization (WHO) studies, I can point out I had a better and more thorough discussion about it with fellow psychiatrists in 1986.  I have also lived in a developing country and saw how people with presumptive mental illnesses were treated.  I have applied that experience and knowledge to clinical practice in this country.

There is the curious parallel of access to psychiatrists in both countries.  How do the citizens who need them the most get access to them?  The public radio story suggests that only people with resources (I take that to mean money) can get access to the limited number of psychiatrists in Kenya.  This country is headed in the same direction largely because rational psychiatrists do not want to be ordered around by insurance companies.  In the case of access for the severely disabled, individual states have different plans but the overall plan has been to ration access and incarcerate rather than hospitalize people with mental illnesses.  In the US, there is generally an order of magnitude greater number of psychiatrists, but that does not translate to more access.  I have talked to too many people who stop seeing a psychiatrist when their insurance stops.  The insurance industry, state governments, and the federal government all have an interest in restricting access to psychiatrists.   If people only see psychiatrists if they have poor insurance coverage and psychiatrists are fleeing insurance - this is a chronic problem that will only get worse.  

In the meantime, I hope that Ms. Wafula continues to be successful in her crisis intervention program and raising awareness that severe mental illness is a public health problem that needs to be addressed.  Families should have more resources and more help.  The WHO program to raise awareness about suicide also seems like a good idea.


George Dawson, MD, DFAPA


References:

1.  Emily Johnson.  Fighting the 'funk:' How one Kenyan battles her mental health problems by helping others.  PRI The World.  March 3, 2015.

2. Cohen A, Patel V, Thara R, Gureje O. Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr Bull. 2008 Mar;34(2):229-44. Epub 2007 Sep 28. Review. PubMed PMID: 17905787



Supplementary 1: The map graphic is from the CIA Factbook in the public domain.

Supplementary 2: WHO Infographic on Suicide.

Supplementary 3:  I mention the New Stanley Hotel in this post, but sometime after I was there it was blown up by terrorists.  The replacement versions (at least according to Google) continue to be threatened by terrorists, who apparently want to target the tourist business in Kenya.

A Return To Asylums Will Not Stop The Rationing

An article was published in the JAMA recently where three ethicists argue for the return of asylum care.  It has become an expected flash point for the antipsychiatry movement as well as some psychiatrists who still think that the word asylum has some meaning.  I thought I would add a more realistic opinion and solution.  I refer readers to the original article or many that I have written here about the reduction in bed capacity in long term psychiatric care.  The reductions are indisputable and well documented.  I am more interested in elucidating the mechanisms behind this reduction and the lack of effective care in the remaining community hospital beds.  The authors allude to the underlying dynamics as captured in the sentence "For the past 60 years or more, social, political, and economic forces coalesced to move severely mentally ill patients out of mental hospitals."  They discuss the well known euphemism for incarcerating psychiatric patients or "transinstitutionalization" and rotating the chronically mentally ill in and out of emergency departments.

The authors even go so far as pointing out the bloated estimated inpatient costs for care in Michigan at $260,000/year/patient and Washington, DC at $328,000/year/patient.   For comparison they include a state of the art facility the Worcester Recovery Center and Hospital that has 320 beds at a cost of $60 million per year or or $187,500/bed/year.  It is difficult to figure out why what may arguably be the best public hospital in the United States has the lowest cost of care for what may be more comprehensive services.  But that is part of the problem.  Most of these institutions are managed by human services agencies through the states and the real fiscal status is always difficult to ascertain.  State and business accounting frequently provides calculations for bed or per patient rates that seem to include unrealistic estimates of overhead costs (often for subpar facilities).  The administration of many of these facilities also seems to depend on restricting psychiatric care at several levels.  In many cases the managed care concept of "medication management" or a "med check" mentality is applied, often with the overall plan of replacing psychiatrists with "prescribers".  Any notion of quality is trumped by a managed care notion of "cost-effectiveness" that typically includes removing psychiatrists from management positions and delegating policy and management at the institutional level to people with no training in psychiatry.

The authors accurately describe the problems of severe mental illnesses.  People have very complex neuropsychiatric disorders and will either not be getting well soon or will never recover enough functioning to do well in any community setting.  They were some of the first victims of "medical necessity" criteria.  I was a Peer Review Organization (PRO) reviewer for Medicare hospitalizations in the states of Minnesota and Wisconsin in the 1980s and 1990s.  For at least part of that time I was sent boxes of medical records from state hospitals for review.  If I looked the the records and decided the patient should continue to be hospitalized, I would get a call from the Medical Director of the PRO suggesting that I should consider the medical necessity criteria.  In the case of long term care, that meant that the patient was "stable" meaning that I would not expect them to change significantly with additional treatment.  If I could say that, the hospital was notified that the patient did not meet criteria for continued long term hospitalization and they needed to be discharged.  In fact, it was very likely that although they were not changing at a rapid enough pace, they would still present formidable problems for community placement.  It may be impossible to discharge them.  In many cases discharge resulted in almost immediate readmission to an acute care hospital and the cycle emergency department to brief hospital admission to homelessness to jail or readmission occurred.  At least until the person was sent back to the state hospital.

In her opinion piece, Dr. Montross suggests that these patients have been abandoned in the name of autonomy or  treating people in the so-called "least restrictive alternative."  That seems at odds with frequent sustained incarcerations for minor and in some cases trivial offenses.  What is really going on here and why do people continue to ignore it?  I have analyzed the problem many times and it is apparently so institutionalized at this point that nobody sees it as a problem anymore. The problem that I continue to point it out is managed care and all of the rationing mechanisms that they employ.  The very first one in the paragraph above is the so-called medical necessity criteria.  Any managed care company physician reviewer can deny care based on their own proprietary guidelines or a purely arbitrary and subjective interpretations of those guidelines.  Managed care companies can harass physicians with mountains of unnecessary paperwork and deny payment or demand payment back based on more subjective interpretations.  Even more problematic, states have incorporated some of these same management techniques and almost uniformly have completely abandoned quality in favor of "cost-effective" care which is quite frankly - care on the cheap.

The end result of all of this cost cutting, rationing, and insurance company profiteering at the expense of patients with mental illness or substance use problems is extremely poor quality care.  One of the authors suggests longer inpatient treatment may be the solution.  Right now practically every psychiatric hospital does their best to get patients discharged in 5 days or less.  Outpatient psychiatrists see patients who have not been stabilized after a 5 day admission.  That is business as usual in acute care psychiatric hospitals.  If that discharged patient makes it to an out patient clinic, they are seen for 10 - 15 minutes in a medication management visit (another fabrication of the managed care industry and the US government) and if they are lucky they discuss the medication and whether it is effective for symptoms or causing side effects.  The problem is that there are important areas in the patients life - like their cognition and social behavior, that are never discussed or evaluated in any productive way.  Very few patients with severe mental disorders receive any kind of psychotherapy despite the evidence it is useful to them.

Putting all of these problems back into the asylum will have predictable results.  The medication management mentality is basically now inside the walls of an institution. There is no enlightened, research driven treatment that addresses all of the problems that the person has.  The asylum is typically administered by a bureaucrat, bound by the same arbitrary budgeting that comes down from the Governor's office.  Across the board spending cuts by a certain percentage and no adjustments when the cash flow is positive.  Money "saved" on asylum care transferred to the state's general fund and used to build roads or whatever was stated in campaign promises.  Suddenly the asylum is an overcrowded bottleneck due to cost shifting by every county in the state who does not want provide services for serious mental illnesses.

The alternative?  How about doing things the right way for once.  We seem to have people who recognize that mental illnesses are not going away, that the current care is atrocious and inhumane, and that it is time to do something about it.  Estimates for the number of people in each state with severe mental illnesses are out there.  Consistent reasonable funding is necessary.  That includes the state, but also it is time to not allow managed care companies to dodge these costs and transfer them to the tax payers.  Finally, it it time to eliminate stakeholder meetings and develop systems of care for the people who it matters the most to - patients, families, psychiatrists, and the other mental health and medical professionals involved in providing this level of care.

Without those conversations, an asylum is just a poorly managed building.    




George Dawson, MD, DFAPA



References:

1: Sisti DA, Segal AG, Emanuel EJ. Improving long-term psychiatric care: bringback the asylum. JAMA. 2015 Jan 20;313(3):243-4. doi: 10.1001/jama.2014.16088.  PubMed PMID: 25602990.

2:  Christine Montross.  The Modern Asylum.  New York Times February 18, 2015.

Minnesota Continues A Flawed Approach To Serious Mental Illness And Aggression

I was shocked to see this article posted on a CBS web site.  I was shocked because I was completely unaware  that such a law existed.  I was shocked because Minnesota has fairly well documented problems in their state hospital system.  The state security hospital has had numerous problems with containing violence and aggression and there is no evidence that situation has been resolved.  There are very few specialized units in hospitals in the state that could potentially deal with the problems of violence and aggressive patients.  There has been no effort to modify the limited infrastructure in the state that has been the result of managed care-like rationing over the past 20 years.

The story is a lot more involved than suggested by the news article.  When I read it I contacted my state legislators and asked for clarification primarily by pointing me to where the "12 hour rule" existed in the State Statutes.  The Minnesota State Statutes are generally easy to search but I could not find it.  My state Senator got back to me and suggested that this is the rule in 253B.10 PROCEDURES UPON COMMITMENT.  Chapter 253 is the civil commitment statute and reading through this chapter suggests that transfers from jail to state mental hospitals have to be adjudicated as mentally ill by civil commitment.  Other pathways include being found not guilty by reason of mental illness, and for examination or determination of competency to proceed to trial.  Apart from the time constraint, that part of the statute does not materially alter patient flow to state hospitals.  The statute gets more interesting with the following subdivision:

Subd. 4. Private treatment.

Patients or other responsible persons are required to pay the necessary charges for patients committed or transferred to private treatment facilities. Private treatment facilities may not refuse to accept a committed person solely based on the person's court-ordered status. Insurers must provide treatment and services as ordered by the court under section 253B.045, subdivision 6, or as required under chapter 62M. 

Private facilities refuse to accept court ordered and committed patients all of the time just based on the fact that severe mental illness cannot be treated on an 8 day DRG payment that in reality is treated like a 4 or 5 day length of stay.

The article itself focuses on Anoka Metro Regional Treatment Center.  That is a state operated psychiatric facility just north of the Minneapolis-St. Paul area.  If the intent of the legislature is to alleviate crowding in jails, the writing of a statute will not do that.  If I had to estimate, the majority of inmates in county jails with significant mental illness and addiction problems are not committed and do not meet the forensic criteria suggested in the statute.  The article also illustrates the ambivalence that the state government has toward state run hospitals.  Not too long ago, the legislature wanted to close this hospital down.  Many states have adopted the managed care rationing model to mental illness.  They reasoned that the best way to "save" money is to close down state-run hospitals and clinics.  I have no doubt that the state would close it down if possible but it occupies too central a role in the civil commitment process.  There is instead a detailed political process to manage the hospital (see first reference).  That document is current, 114 pages long with 41 references to "jail" and 37 references to "aggression".  It acknowledges the role of the state in treating aggressive patients with mental illnesses. 

I have no way of knowing if any of the patients mentioned in this article requested transfer to a private hospital.  I would consider any hospital in the state that is outside of the state hospital system to be a private hospital because at this point they are all parts of private health care systems.  Only a fraction of community hospitals in the state have psychiatric units and a smaller portion of those are equipped to treat violent or aggressive patients.

I have tried to elaborate on this blog the type of structure necessary to treat people who are violent and aggressive as a result of mental illness. Any time that correctional populations are considered, the problem is more complicated than mental illness or not.  There are many individuals with sociopathy or personalities that are anti-authoritarian and with a tendency to criminal behavior.  At the extreme end a variant of psychopathy has been described where criminal tendencies, combined with a lack of empathy leads to an individual who is potentially more dangerous.  Those individuals often have a history of repeated violence against others and a pattern of planned violence as way of life.  The associated issues are that patients who are predominately personality disordered criminals are better taken care of within the correctional system.  Patients with primary mental illness who are incarcerated for non-violent crimes or violent crimes that occur only an episode of discrete mental illness are probably better treated in a mental health setting - especially if that is a continuation of their ongoing care.  Those statements are generally true because the personality disordered mentally ill will demonstrate a pattern of threatening other patients and staff with physical violence.  They may also exploit more vulnerable patients and try to intimidate them into giving them money, information, or personal favors that they can use to their advantage.  Those behaviors are goal driven, reinforced by a life of crime, and not likely to change as a result of any psychiatric intervention.

The article states that 146 inmates have been transferred from Minnesota jails to state hospitals since July 2013.  There is an eye witness account of what has occurred and a description of some of the injuries to staff including facial fractures and a torn shoulder tendon as the direct result of assaults on staff.  There is also the following statement from the affected staff person:

 And though she agrees there are other factors behind the rise in workplace injuries — a hesitance to use force against potentially abusive patients chief among them — she said she and her co-workers believe the 48-hour rule is largely responsible.

The issue of the use of physical force in psychiatric hospitals was also the primary cause of the upheaval in the previously cited problems at the Minnesota Security Hospital. A change in administration occurred to address the issue of patient injuries due to physical interventions. According to news reports that and the associated administrative measures were associated with an increase in staff injuries. We are left with the impression that there have been no effective interventions to prevent patient and staff injuries in state hospitals and the problem of aggression in these facilities has been poorly addressed. Organized psychiatry in the state has been silent on these issues.

The bottom line in this article is that it illustrates that Minnesota politicians and bureaucrats have no understanding of what is required to treat people with mental illness and aggressive behavior.  Their misunderstanding is significant and it occurs at multiple levels.  First, they have no understanding that the current system of mental health care is based on a system of rationing designed to provide minimal to no mental health care.  That all starts with hospital systems that have been rationed to the point that there are often no detectable changes in the mental health of the people admitted compared with the people discharged.  Psychiatric care in rationed hospitals is designed to limit treatment to a brief period or reimbursement.  Second, they have a track record of using mental health jargon to come up with their own diagnostic category of "sexual psychopaths" that can be used for indefinite confinement of sex offenders.  This categorization allows for diversion away from a correctional system that is apparently unable to confine sex offenders to the satisfaction of politicians and their constituents.  Third, the state managed security hospital has had a number of problems in the past few years including the mass resignation of psychiatry staff and an increasing number of injuries to hospital staff.  Fourth, Deputy Human Services Commissioner Anne Barry is quoted in the article. She was also quoted in previous articles about the Security Hospital. She attributes the problem to unintended consequences. To me that suggests a complete misunderstanding of psychiatric services in the state of Minnesota. Any psychiatrist in this state, especially if they work on an inpatient unit would be able to predict this problem. Commissioner Barry has also been quoted in the articles about the Security Hospital (see below)  Fifth, the direct quote by State Sen. Kathy Sheran also illustrates a misunderstanding of the problem. The idea that state hospitals are holding large numbers of people who don't need to be there is longstanding political rhetoric. In the absence of environments that can assist severely disabled individuals the default environments are hospitals. It is glib to say that people should no longer be a hospital when they have no safe place to live outside the of the hospital. As a reviewer of hospital admissions and lengths of stay, the presence of acute symptoms is typically used to mark who should be in a hospital. Chronic severe psychiatric disorders have a number of problems with cognition and functional capacity that lead to an inability to care for self independently of acute symptoms.  The associated political problem is a lack of funding for community based programs to resolve the problem.  As I have previously posted in many cases these community based programs that are inadequately equipped to contain aggression place both patients and staff at higher risk.

I qualify this post with the same qualifications I have put on previous posts on the topic on state run facilities.  The only source of information I have on this issue has been the press and legislative reports on mental health services in correctional facilities and at Anoka.  Media reporting of psychiatric issues and services leaves a lot to be desired and typically vacillates between blaming psychiatrists for all of the problems and tragic cases that result from a lack of services.  The only corroboration in this article seems to be the reaction of state politicians to it.  We have seen similar reactions to these issues in the press.  Unless there are some outright denials about the scope of the problem, something needs to be done.  The last thing we need is a state run Task Force or Commission investigating  itself.  The second to last thing we need is consultants hired by the state to write another report.  At this point, I don't even think that a review of the incidents is possible.

Any hospital in the state should be required to prospectively flag records based on violence, aggression and whether they were transferred from the correctional system.  All of the staff in those cases should make a recording of their perceptions of the antecedents, intervention and why it failed or succeeded, and the outcome.  Those cases should be reviewed on a weekly or monthly basis by psychiatrists with experience in treating severe mental illnesses and aggression.  That panel of psychiatrists should be carefully screened for conflict of interests, especially any financial conflicts of interest with the State or any other entities responsible for providing the treatment in question.

It is time to solve this problem.  Having the problems analyzed time after time by the same people who do not understand the problem and who can not possibly come up with a solution has not worked in the past 5 years and it will not work in the future.  Instead we have a state official charged with solving the problem saying that fewer psychiatrists makes sense and psychiatric expertise at the systems level is not needed as the system continues to collapse.  The system of state hospital care for patients with serious mental illnesses and aggression may not be salvageable at this point without realistic backing by the state.

A key part of the miscalculation appears to be casting psychiatrists in the role of generic technicians.  Of course these technicians would not have any understanding of patient centered care or a therapeutic alliance despite the fact that they have been writing about it for over a 50 years.  This accomplishes two goals at least at the rhetorical level.  It makes it seem like untrained administrators can address systemic issues of violence and aggression.  It also makes it seem like the only thing psychiatrists can do it prescribe medications - often to "stable" people.  Far too many errors have been made and public statements on the issues are consistent with a lack of appreciation of the problem and a complete lack of appreciation that psychiatrists are the only people professionally trained to provide this level of care.  This is by no means only limited to state systems.  These attitudes are prevalent in any hospital or clinic that is under the direction of a managed care system.

Will the problem of aggression in people with severe mental illness be addressed by arbitrary rules on patient flow and a treatment program that is flowing down from politicians and bureaucrats?  Will the problem be solved by a consensus of stakeholders?  Will the problem be addressed by new age jargon and philosophy?

I don't think so.


George Dawson, MD, DFAPA

Refs:

Minnesota Department of Human Services - Direct Care and Treatment. Plan for the Anoka Metro Regional Treatment Center. Direct Care and Treatment and Chemical and Mental Health Services Administrations. February 18, 2014

From the above document:  "Jails also count on AMRTC to take people whose criminal behavior is determined to be the result of mental illness (a new law requires that AMRTC accept referrals from jails within 48 hours of referral). Because of insufficient capacity in the service system, there are lengthy waiting lists for AMRTC beds"  (p 61).

Supplementary 1:  A previous quote from Commissioner Barry: "DHS officials say the facility no longer needs as many psychiatrists because many of the patients are stable and only require psychiatric visits once every three months. In addition, Barry said, the importance of psychiatrists at the facility has lessened over the years. Psychiatrists are just one part of the treatment team, she said. Nurses and psychologists also play an important role in patient care, and in many cases, advanced practice nurses can handle many of the tasks that used to be the responsibility of the psychiatrists, she said."

Supplementary 2:  I was unable to find any statute that described this 48 hr transfer rule.  I have asked my state representatives for assistance since it may not be a statute.  Corrected as of 12/9/2014 with the statute posted above.

Supplementary 3:  If you currently work in a non-state funded psychiatric unit and have received these transfers from correctional facilities please post your experience in the comments section below.  Feel free to post them anonymously and in a way that does not indirectly identify you or the facility that you work at.

What Is Really Going On At The Minnesota Security Hospital?

The Minneapolis StarTribune posted a recent story about the Minnesota Security Hospital (MSH) on December 27, 2013 that was updated today.  The article raises concerns about patient treatment and safety at this facility both for patients and staff.  It should be read by everyone with an interest in how state mental hospitals function.  It is of particular interest to Minnesota residents who may have a relative being treated at this facility but also anyone concerned about the image of the state and how it treats residents with severe mental illnesses.  From a policy standpoint it should be an issue of great importance for both local psychiatric societies and the American Psychiatric Association (APA).

Let me preface my remarks by saying that I have no inside knowledge of what is occurring at the MSH beyond what I read in the papers.   The first concern is about the information base for the article and who is interpreting that information.  That is contained in the fourth paragraph of the article at the very end of that paragraph:

"Nearly two years after the hospital's professional psychiatric staff departed in a mass resignation, the state still has not hired a full complement of psychiatrists, documents show.  Basic medical record-keeping has been neglected, employees have been placed in danger and patients have been discharged with inadequate safeguards, according to internal memos, federal records, and agency files reviewed by the Star Tribune."

The problem here is that there is nobody at the Star Tribune who is an expert in the treatment of patients with severe mental illness and aggression.  The second problem is that there is a significant conflict of interest anytime a journalist has access to clinical material with a potential sensational interpretation.  From my experience journalists will make that interpretation out of ignorance or for the purpose of enhancing the dramatic impact of the story.  In this article the names of two patients are disclosed.  Journalists are not confidentiality bound to not disclose the names of patients and there may be some public documents with the names of these patients.  My experience with journalists has been that they want to talk to actual patients with real names, and really do not understand the problems with that.  There are always many potential weaknesses when considering a journalistic source.

There is a precedent for the review of confidential hospital records by expert unbiased reviewers and that was the Medicare Peer Review Organizations (PRO) system.  In that process, physicians who were experts in the field in question were rigorously screened for conflicts of interest.  As an example, they could not have any affiliation however peripheral with the hospital or clinic being reviewed.  The compensation for reviewing the records was trivial and you could not make a living at it.  Reviewers were expected to be practicing medicine full time and not be an administrator.  As a reviewer, I reviewed tens of thousands of pages of hospital records - many from state hospitals for both quality problems and utilization problems.  A newspaper reporter looking at a patchwork of records, memos, and files from multiple sources is hardly an adequate standard to draw any conclusions.  A reporter can make it seem like the hospital is a "bad" place for restraining people or in this case failing to restrain a person.

A potentially rich source of information is the hospital's former medical director - Dr. Jennifer Service.  She has one quote in the article about how the MSH is "broken", but it provides no details.  My speculation is that there is nobody who had a better front row seat to what happened than Dr. Service and possibly the previous medical director.  In the treatment of severe mental illness and aggression the medical director or clinical director has a critical role in making sure that there are no administrative factors that adversely affect the treatment team or their ability to provide care and a safe environment.  A common mistake is that administration believes it can effect change and they do not pay close enough attention to the impact on the clinicians providing care.  When treating aggressive people any environmental change like that can result in increasing aggression and chaos in the treatment environment.  The Legislative Auditor's Report suggests several areas where the therapeutic neutrality of the environment and staff cohesion were problematic.  During 23 years of conducting team meetings, my experience was that psychiatrists are an integral part of the team and should be the team member most experienced in team dynamics, countertransference, and approaches to violence prevention.  There is no indication that occurred on teams at the MSH and in fact, participation is described as marginal.

There are other potential conflicts of interest here that potentially bias the story.  Minnesota Department of Human Services apparently administers the place.  In this case Commissioner Anne Barry talks about the goal of increasing the likelihood of discharge by making community living environments more available.  Since DHS also administers all of those environments in the state it should be a relatively easy task.  Why is it not being done?  Are there people who realistically cannot be discharged without recreating a hospital environment for them in the community?  In the cases where that has happened have there been more adverse outcomes?  Are those environments more humane than the hospital environment where the patient was initially?  The Deputy Commissioner talks about accountability, but DHS seems like one of the most opaque state agencies out there.  Lately they seem to have moved into the area of micromanagement of the treatment providers especially around the issue of aggressive behavior.  Are the administrators of DHS responsible for the failed programs at the MSH?  Commissioner Barry talks about a more "therapeutic environment".  Is she qualified to determine what that is?  And finally the Legislative Auditor's Report alludes to a report by previous consultants.  Who were these consultants and where is that report?

Another good illustration of how conflicts of interest potentially bias the StarTribune article was the issue of accusations of maltreatment by professional staff.   The first is an allegation that a psychiatrist "committed maltreatment" by threatening an uncooperative patient with electroconvulsive treatment.  DHS investigators concluded that this happened but their finding was overturned by the DHS Inspector General.  The State Ombudsman for Mental Health and Developmental Disabilities apparently believed it happened and made a request for the DHS Commissioner to reconsider the finding.  The Inspector referred the matter to the Board of Medical Practice.  In the second case, 2 nurses were accused of maltreatment.  From the way the article is written it appears to be related to the incident where the patient was "slamming his head repeatedly into a concrete wall" and they were unable to get an order to physically restrain the patient.  The nurses were fined and reported to the nursing board.  Based on the incidents of maltreatment and another incident where a patient did not receive timely assessment for a stroke the DHS Commissioner extended the hospital's probation through 2014.  There are many problems with employees paying the price for chaos in the system.  Administrators often do not recognize the professional obligations of the staff.  I have personally seen quality psychiatric staff paralyzed by indecision that was brought about by administrative mandate or personnel problems.  The other problem here is that DHS appears to be the administrator, investigator and judicial process rolled into one.  We have a number of political appointees (DHS, Ombudsman, Board of Medical Practice) charged with deciding the professional fate of a physician who seems to be practicing in the worst of possible scenarios.  It should not be too surprising that MSH is unable to recruit and hire psychiatric staff.

The Legislative Auditor's Report is probably a better source of information than the newspaper report, but it has the same lack of input from experts.  It is useful from the perspective of bureaucratic information on the details that can be counted like the number of psychiatric contacts, number of hours of therapeutic contact, number of staff injuries for a certain period of time, etc.  One of the areas that is most interesting to me as a psychiatrist is the frequency of patient contact by psychiatrists.  The report gives an example of a recent census of 321 patients.  It provides an exhibit showing that from a policy standpoint the suggested frequencies of contact are monthly, quarterly, or semi-annually.  These frequencies are interestingly lower than the frequency of contact in some 19th century German asylums.  I can recall that Binswanger made a point of seeing all 200 patients in his asylum every week.  The report said that of the 321 patients in the study 45% had been seen in the previous month, an additional 24% 1-2 months earlier, 17% 2-3 months before and 4% greater than 3 months before.  Going from a full complement of eight psychiatrists to a total of two psychiatrists and 1 nurse practitioner is an obvious problem in terms of contact.  Actual contact with psychiatrist is an insufficient metric for treating patients and other quality measures need to be developed.  

If the article and the Legislative Auditor's report are even partially accurate with regard to facts, the glaring problem here appears to be that there is nobody in charge who knows how to run a hospital that treats people with severe mental illness and problems with aggression.  It is probably more correct to say that at this point we have not been presented with any positive evidence that there is a person in charge with the necessary qualifications.  The information presented in the StarTribune article does not suggest a clash of cultures.  There is no psychiatric hospital culture that I am aware of where there is confusion about whether or not a patient should be allowed to injure themselves.  The second problem is that this hospital needs psychiatrists who are trained to treat severe mental illness and aggression.  They do not need to be forensic psychiatrists, but they do need expertise in treatment of severe mental illness.  Forensic psychiatrists are basically needed to perform specific evaluations of criminal responsibility but the priority here is described as patient and staff safety.  The people needed in this situation currently work in a number of acute care and community settings.  They are very comfortable with the treatment of major psychiatric disorders and the associated medical comorbidity.  It is safe to say that they enjoy working with these problems and talking with the people who have them.  They are also sensitive to the needs of their co-workers and can establish the necessary environment of mutual trust and neutrality needed to succeed.

There may not be anyone around who remembers that Minnesota has solved a similar problem in the past.  The year was 1990 and there were significant problems staffing the major state hospital in the system - Anoka Metro Regional Treatment Center.  At that time, a Medical Director who was recently out of training was hired and he hired several colleagues from the same generation.  They were all enthusiastic and interested in providing quality care.  The state offered them competitive salaries.  Within a very short period of time a cohesive staff developed and they became a favored training site for medical students.  Treatment at the state hospital improved dramatically and several of the psychiatrists in that cohort went on to become leaders in the state in the provision of psychiatric services to patients with severe mental illness.

That still seems like a good idea today.


George Dawson, MD, DFAPA

Paul Mcenroe.  Minnesota Security Hospital: Staff In Crisis Spreads Turmoil.  StarTribune, December 27, 2013.

Office of the Legislative Auditor.  Evaluation Report: State-Operated Human Services.  February 2013.

Additional Clinical Note 1:  Looking back over my post it is clear that I do not answer the question that is the title.  Like most people I am speculating based on an imperfect data set.  The main difference is that I am also speculating as an expert based on what needs to happen to provide the safest scientifically based treatment for people who are mentally ill, aggressive, and may have failed most if not all of the available treatments.  I also recall that some past state hospital problems were resolved that has not been brought up in the discussion so far.

"Some Sort of Mental Health Issue"

I was getting ready for work yesterday morning and watching The Today Show in the background as usual.  Suddenly there was the story of a young woman trying to ram the security barriers at the White House and then being pursued in a high speed chase down Pennsylvania Avenue.  It eventually showed a direct confrontation with law enforcement and them opening fire on her through the window of her vehicle.  There was an initial report saying that she had fired shots but she was unarmed.  The police discovered her one year old daughter in the car and removed her.  The acute reaction captured on film was surreal.  There were descriptions of some of her recent behavior and thoughts.  A police official commented that the security barriers "worked" as though this was an assault by a terrorist.  A different official commented how her daughter was "rescued" by the police.  People were talking as though this was an actual assault by a terrorist.  The last person I heard was a politician who made the quote at the top of this post and finally suggested the real problem.

Confrontation between people with severe mental illnesses and law enforcement are very common.  During my years of acute inpatient work I have talked with many people who have been injured in every imaginable way during these confrontations.  In some cases they were themselves engaged in very dangerous and aggressive behavior as the direct result of a mood disorder or a psychosis.  In other cases law enforcement just misinterpreted their behavior.  That happened most commonly when the person refused to comply with what the officer wanted them to do.  These confrontations are always high risk situations because most people in society know that it is in their best interest to be law abiding and comply with the police.  The people who don't are criminals or people with impaired judgment due to mental illness or intoxication states.  Even if the police can make that distinction rapidly that does not mean they can easily use a different approach to the person with mental illness.  Police officers have been injured or killed in these situations.

There seems to be a great deal of misunderstanding and continued bias about how these situations can occur.  It can happen as rapidly as waking up one morning finding out that your entire state of consciousness has changed.   That  gas company truck across the street is there to monitor you and direct microwaves at you.  The phones and your computer are bugged.  Going to work that morning you decide you need to take evasive action because it seems like you are being followed.  Your anxiety levels build all day and that night at home you can't sleep.  You decide you need to move the refrigerator in front of the door because you had the thought that it would be too easy for government agents to kick the door down and grab you.  You do a Google search on microwaves and decide these people are trying to do a lot more than harass you - they are trying to kill you.  You start to make plans on that basis.

That is how paranoid delusions evolve and how they change your behavior.  You are no longer making rational assessments of the environment.  Your brain has come up with a theory and you are now interpreting all of the environmental information according to that theory.  When I approach the problem psychotherapeutically, I generally explain that delusional thoughts are very low probability explanations or interpretations of an event in the environment.  I illustrate this by asking the question:  "If we had 100 people in the room right now - how many of them would agree with what you just told me?"    Many people know that hardly anyone would agree with them, but that doesn't stop them from continuing to misinterpret the data or trying to cast me with everyone else who either doesn't believe them or is just saying that they are "crazy".

Before I outline an approach to the problem of people experiencing episodes of psychosis or mania and running into problems with law enforcement consider what gets in the way of any of early intervention?  Keeping with my cardiology comparison from a previous post - most people know that chest pain is a warning sign for a possible heart attack.  With continued public health interventions most people know cardiac risk factors.  Public health intervention has been so effective that the current campaign is focused on decreasing the denial in women and decreasing cardiac sudden death in women.  Two generations of public health intervention are associated with a decreasing rate of cardiac mortality.

How does that compare with psychosis and mania?  I have never seen a public service ad advising about the warning signs of psychosis or mania.  There are countless euphemisms for acute changes in a persons mental status.  The public treats it like a mystery.  When a tragedy occurs there is often no explanation or an inadequate one like "some sort of mental illness."  The cultural approach is an obstacle to a rational approach to helping affected individuals.  Stigma is considered to be a factor, but it could as easily be an artifact of the process.  What would be a better approach?

I have been advocating a public health approach to the problem for a long time now.  At a political level there is a lot of confusion about whether this is a firearms issue.  Firearms are just a subset of the problem.  The overriding public health goal is to get people the help that they need as soon as possible.  Our current system of care is set up to provide minimal care to people with severe mental illnesses.  The level of care and condition of the facilities where the care occurs is widely known in communities and most people do not want to access these facilities for help.    I hear a lot about the concern that someone is going to be stigmatized by treatment at a psychiatric facility.  I think it is as likely that many facilities are substandard physical plants that are poorly managed.  Based on the length of stay policies alone, nobody wants to bring their relative to a facility that has a reputation for discharging partially stabilized people back into the community.  The long term goal needs to be improving the quality of psychiatric facilities in addition to changing the culture about severe mental illness.

I thought of a public service announcement that would potentially have the same advertising power as some of the more popular health spots like the "7 warning signs of cancer".  I call it the 4 warning signs of severe mental illness.  A concerted effort to focus on severe mental illnesses that can potentially lead to errors in judgment is a logical way to approach this problem.  Based on my previous paragraph it takes a much more enlightened approach to treating the problem.  Health care systems in general are not friendly to people with severe mental illnesses.  There are no specialty centers designed to cater to their needs like the high margin businesses get.  Many of these health care organizations sponsor walks for mental illness and other programs like National Depression Screening day.  But none of them say - if you have these symptoms we want to see you and treat you in a hospitable environment.

That attitude has to change to prevent the loss of innocent lives as the direct result of severe mental illness.

George Dawson, MD, DFAPA

Buy This Book

I was out of town at a Mayo Clinic seminar and while I was gone, Amazon sent me an e-mail.  My copy of American Psychosis - How the Federal Government Destroyed the Mental Illness Treatment System by E. Fuller Torrey had shipped.  This is the only book I have really been eager to read for some time.  The title is almost exactly what I have been saying for the past 25 years.  At last I had somebody who was finally seeing the real problems with the treatment of mental illness in this country.  After putting up with obnoxious blogs about how psychiatrists had been bought and paid for by drug companies, manufacturing catastrophes designed by psychiatrists like the recent DSM-5 apocalypse, and an endless number of side shows I was looking for an anchor point that looked at the real problems and what to do about them.

For the purpose of this post I was interested in one thing.  What did Dr. Torrey say about managed care?  As any reader here should know by now I view managed care as the single worst thing (by far) that has happened to psychiatric care and the treatment of severe mental illness in the United States.  Managed care tactics are responsible for decimating psychiatric care, especially hospital based care.  Managed care has destroyed psychotherapy and removed practically all of the creativity and innovation from mental health care.  Managed care has rationed both access and treatment resources to my patients who have few resources themselves.  In order for this book to impress me, it would need to say something about managed care.

Turning to the index there were exactly two pages about "managed care organizations".   What exactly did Dr. Torrey say?  The introduction to the section is introducing Medicaid as "the largest single fiscal impediment to improving services for mentally ill persons in the United States."  The system is gamed by the states to optimize Medicaid reimbursement by the federal government.  The example given is the IMD (institute for mental disease) exclusion that disallows Medicaid reimbursement for state hospitals.   The states responded by closing down state hospitals and shifting admissions to Medicaid covered acute care settings in community hospitals.  According to Torrey cost shifting based on Medicaid has been the driving force behind public services for 40 years.

Managed care enters the picture in paragraph 2:  "At least 34 states deliver 'some or all mental health services through managed care arrangements, including care outs and comprehensive managed care organizations (MCOs).  States such as California, Utah, Colorado, Pennsylvania, New York, and Massachusetts have used capitation funding, under which providers are paid a fixed amount to deliver all necessary services."  Throw Minnesota in there.  And also throw in the idea that practically all states ration using managed care strategies to save money - even if there is no formal contract with an MCO.

He goes on to outline the three features that these programs have in common (my comments in italics):

1.  The priority is cost savings and not patient care.

Yes!  Managed care has nothing to do with increased access or quality.  It is all about rationing access to care including access to medications necessary to treat severe mental illness.  There is a reference from the NEJM from 1994 that illustrates that rationing these medications has an unfair impact on patient with severe mental illness and increases overall costs but the industry continued the practice unabated despite that study.  Cost savings after all is just a politically correct way to designate profits for the MCO.  After all, nobody  ever realizes any savings in health care it just ends up on the bottom line of the MCO, the pharmaceutical company or the provider.

2.  The sickest patients suffer the most under managed care rationing.

Yes!  It should be fairly obvious that if you move the group of patients with the most severe problems at a high rate into a rationed system, they are getting proportionately less resources than the severely disabled of any disease category.  Dr. Torrey points out that individuals with severe mental illness represent only 11% of all Medicaid beneficiaries but they are 1/3 of all of the high cost beneficiaries.

3.   This is a very profitable segment for managed care companies.

Yes!  The example given in the book is United Behavioral Health and their claim to 'oversee behavioral health benefits for more than 23 million beneficiaries' including Medicaid patients.  He goes on to illustrate the the difference in outcomes for executives of these companies and the mentally ill whose benefits they oversee and points out that the difference in patient outcomes is directly related to that disparity. (see par 19).

He goes on to conclude that the PPACA (aka Obamacare) will change nothing basically because: "It is likely to lead managed care companies finding new and creative  ways to not provide services to mentally ill individuals who need the services the most."  Talk about innovation.

I could not have said it better myself, but have said it in a number of ways in the past 20 years.  I plan to continue to read and analyze this book.  I have already purchased it and can certify that the managed care section is accurate if brief.  Any objective observer realizes that the government paying the managed care industry for not providing services is the central problem with the provision of treatment to persons with the most severe forms of mental illness.  These days it also extends to more common anxiety and depressive disorders treated in a primary care clinic and diagnosed by a very brief screening.

Keep that in mind when you are reading the latest trivia about the DSM, the pharmaceutical industry involvement with psychiatry, debates about clinical trials data for FDA approval, or any number of psychiatric non events that are furiously debated around the Internet.  Tax dollars given to an industry to ration services is money that should have gone to provide services to the mentally ill.

George Dawson, MD, DFAPA

Straight Talk About the Government Dismantling Care for Serious Mental Illness

The ShrinkRap blog posted a link to an E. Fuller Torrey and D.J. Jaffe editorial in the National Review about how the government has dismantled mental health care for serious mental illnesses and some of the repercussions.   Since I have been saying the exact same thing for the past 20 years, they will get no argument from me.  Only in the theatre of the absurd that passes for press coverage of mental illness and psychiatry in this country can this subject be ignored and silenced for so long.  It was obviously much more important to see an endless stream of articles trying to make the DSM-5 seem relevant for every man.  The stunning part about the Newtown article is the commentary about what government officials responsible for policy have actually been saying about it.

The authors waste very little time examining the sequence of events in the Obama administration following the Newtown, Connecticut mass shooting.  President Obama initially stated he would "make access to mental health care as easy as access to guns." and set up a Task Force under Vice President Biden to make recommendations.  The authors argue that the agency that was consulted, the Substance Abuse and Mental Health Services Administration (SAMHSA) promotes a model of treating mental illness that has no proven efficacy, does not discuss serious mental illnesses in its planning document, ignores effective treatments for serious mental illnesses and actually goes so far as to fund programs that block the implementation of effective treatment programs.  In an example of the obstruction of effective programming by SAMHSA funded programs following the Newtown mass shooting:

"But, alas, the situation is even worse. SAMHSA does not merely ignore effective treatments for individuals with severe mental illness. It also funds programs that attempt to undermine the implementation of such treatments at the state and county level. One such program is the Protection and Advocacy program, a $34 million SAMHSA program that was originally implemented to protect patients in mental hospitals from abuse. It was kidnapped by civil-liberties zealots and has been used to block the implementation of assisted outpatient treatment, funding efforts to undermine it in at least 13 states. For example in Connecticut, following the Newtown massacre of schoolchildren, the federally funded Connecticut Office of Protection and Advocacy for Persons with Disabilities testified before a state-legislature working group in opposition to the proposed implementation of a proposed law permitting court-ordered outpatient treatment for individuals with severe mental illness who have been proven dangerous. The law did not pass."  (page 3, par 2.)

In other words, a SAMHSA funded program was opposed to a law in Connecticut that could potentially reduce violence from persons with severe mental illness.

SAMHSA administrators are quoted at times in the article. Any quote can be taken out of context but the characterizations of severe mental illness as "severe emotional distress", "a spiritual experience" and "a coping mechanism and not a disease" reflect a serious lack of knowledge about these disorders.  The idea that "the  covert mission of the mental health system ...is social control" is standard antipsychiatry philosophy from the 1960s.  How is it that after the Decade of the Brain and the new Obama Brain Initiative  we can have a lead federal agency that apparently knows nothing about the treatment of serious mental illnesses?  How is it that apart from  some fairly obscure testimony, no professional organizations have pointed this out?  How is it in an era where governments at all levels seem to demand evidence based care, that a lead agency on mental health promotes treatment that has no evidence basis and ignores the treatment that is evidence based?

Having been a long time advocate for the prevention of violence by the treatment of severe mental illnesses my comments parallel those of the authors.  Inpatient bed capacity in psychiatry has been decimated.  They point out that there are only 5% of the public psychiatry beds available that there were 50 years ago.  It is well known that people with mental illnesses are being incarcerated in record numbers and some of the nation's county jails have become the largest psychiatric institutions.  Where are all of the civil liberties advocates trying to get the mentally ill out of jail?

Only a small portion of the beds available can be used for potentially violent or aggressive patients and that number gets much smaller if a violent act has actually been committed. Most of the bed capacity in this country is under the purview of some type of managed care organization and that reduces the likelihood of adequate assessment or treatment.  The discharge plan in some cases is to just put the patient on a bus to another state.

Community psychiatry is a valuable unmentioned resource in this area.  In most of the individual cases mentioned in this article, the lack of insight into mental illness or anosognosia is prominent.  It is not reasonable to expect that a person with anosognosia will follow up with outpatient appointments or even continue to take a medication that treats their symptoms into remission.  Active treatment in the community by a psychiatrists and a team who knows the patient and their family is the best way to proceed.  All of this active treatment has been cost shifted out of insurance coverage and is subject to budget cuts at the county and state level.

Civil commitment laws and proceedings are probably the weakest link in treatment.  Further cost shifting occurs and violent patients often end up aggregating in the counties with the most resources.  Even while they are there, many courts hear (from a budgetary perspective) that they are committing too many people and the interpretation of the commitment law becomes more liberal until there is an incident that leads to the interpretation tightening up again.  Bureaucrats involved often become libertarians and suggest that commitment can occur only if an actual violent incident has happened rather than the threat of violence.

Although Torrey and Jaffe are using the extreme situation of violence in the seriously mentally ill to make their point, the majority of the seriously mentally ill are not violent.  They need the same resources.  It has been thirty years of systematic discrimination against these people, their families and the doctors trying to treat them that has led to these problems.  I pointed out earlier on this blog the problem I have with SAMHSA and the use of the term "behavioral health".  The problems with SAMHSA and current federal policy are covered in this article and I encourage anyone with an interest to read it.  If history is any indication, I don't expect anything serious to come of the criticism.  I anticipate a lot of rhetorical blow back at Dr. Torrey.  But as a psychiatrist who has worked in these environments for most of my career, his analysis of the problem is right on the mark.

George Dawson, MD, DFAPA

E. Fuller Torrey & D.J. Jaffe.  After Newtown.  National Review Online.

White House.  Now Is The Time.  The President's plan to protect our children and our communities by reducing gun violence.  January 16, 2013.