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Mental Health Care in America: Why politicians and pundits are missing the point

Mental Health Care in America: Why politicians and pundits are missing the point

As a mental health practitioner, I am increasingly worried about the public perception that there is a connection between mental illness and violence. The truth is that persons with severe and persistent mental illness are no more likely to be violent than the average person. It just happens that when it does occur, the person’s mental health becomes a major fact in the headline. In response to the recent tragedy in California, the debate about violence and mental illness has intensified. Sadly, politicians and pundits have reduced a complex and nuanced issue to arguments about gun control and involuntary treatment of persons with severe and persistent mental illness. As a result, they miss the bigger picture; the mental health care system in the United States is broken and dysfunctional.

To illustrate, here are a few facts. The number of U.S. medical students choosing psychiatry is declining, and has been for some time. Here in North Conway, New Hampshire for example, we lack a single board-certified psychiatrist in private practice. In the United States, people are more than likely to have their psychiatric care managed by their primary care physician versus a specialist. Psychiatric bed availability is at an all-time low across the country. Individuals in need of inpatient care end up sitting in hospital emergency rooms for days waiting for a bed to become available. Insurance companies, meanwhile, continue to tighten benefits for inpatient and residential care, making it more difficult to meet eligibility criteria. The result is that inpatient units, under pressure to handle admissions in a timely manner, are having to discharge individuals as fast as possible, leading to premature discharges and outpatient treatment of persons who, in actuality, need a higher level of care. Stripped of adequate funding, outpatient community mental health clinics are unable to meet the demand, leading to long waits and increasingly stringent admission criteria. The clinicians in these clinics are overworked, vastly underpaid, and often fresh out of graduate school (I know, I was one of them back when I started out as a therapist). Even more disturbing is that treatment is increasingly secondary to ensuring compliance with a morass of federal and state regulations that have little, if any, connection to the health and wellness of those seeking treatment.

Here is one example of the dysfunctional federal regulations that exists in the mental health system. Medicare will only pay for therapy provided by a PhD psychologist, or a Masters level clinician if there is a supervising psychologist or medical physician in the building at the time of the appointment. This is despite the fact that the vast majority of therapists are Masters level counselors or social workers (deemed competent enough by private insurance and [with a caveat] federally-funded Medicaid to provide therapy without the PhD or MD requirement). In the rural community mental health clinic where I used to work, we did not have a full-time psychiatrist (increasingly common these days), meaning that we could only schedule people with Medicare for therapy on certain days and hours depending when the psychiatrist was in the building. If the psychiatrist had to leave for any reason then we had to cancel the therapy appointment or sign off on a waiver stating that it was medically necessary that the individual be seen despite the physician not being present (only valid in the case of an emergency). Not only does this regulation cause havoc for community mental health centers, it also means that people with Medicare cannot get treated by Masters level clinicians in private practice, unless there is a psychologist or psychiatrist in the practice (highly unlikely). No one has ever fully explained to me why the regulation exists, but as best I can understand, Medicare believes patients will get better care if treatment is administered by a psychologist or psychiatrist. Apparently Medicare also believes in osmosis because that is the only way the sheer presence of a psychologist or psychiatrist in a building could possibly impact therapy administered by a Masters level clinician. It is an absurd regulation, and yet, it is the reality. More disturbing, this type of regulation is commonplace in the mental health care system.

Another great example is the nonsense involving treatment plans. If you know of someone who works in community mental health, ask them to explain the issues surrounding compliance with treatment plans and signatures. To try and explain it would result in this post being much longer, and much more boring. What I can tell you from personal experience is that in the years I worked in community mental health I spent more time in clinical meetings discussing how to comply with the regulations such as treatment plan signatures (yes, you are reading that correctly. Meetings, plural, about signatures on a treatment plan), than I ever did discussing actual patient care. In conversations with others in the field of behavioral health, I have learned that my experience was not an isolated one, that this type of bureaucratic farce is systemic. Individuals with severe and persistent mental illness face enormous barriers to accessing quality care without adding the additional regulatory obfuscation that is unique to mental health care. If the same kind of dysfunction occurred for those seeking treatment for cancer, the public furor would be like nothing this country has ever seen. It simply would not be tolerated. Yet for those with severe and persistent mental illness, those who have no voice and are so vulnerable, quality care is secondary. This is not for the lack of effort on the part of providers. Clinicians who work in community mental health have a thankless job. They work incredibly hard to provide quality care to those most in need. But, they’re being asked to do their job blindfolded with their hands tied behind their backs.

Here is the ugly truth about mental illness in America. No one wants to admit that it exists. Sure, people love to talk about how hard we have worked to reduce the stigma. How good deinstitutionalization was for the dignity of persons with mental illness. How advances in medication and psychotherapy have led to the overall improvement in the lives of persons with severe and persistent mental illness. This is all true and very important. In many ways we have made great strides since deinstitutionalization. However, there is another, very ugly, very disturbing reality. Many people with severe and persistent mental illness are living on the very margins of society. They are homeless. Destitute. Rejected by society. The families who support them are being asked to shoulder more of the burden as access to basic care is increasingly restricted. Research funding is nowhere near the levels needed to meet the demands of the system. The prison system has become our de facto hospitals. People have to wait months to get into treatment. People have to resort to extreme measures to try and get help. Once they get into treatment, the treatment they receive is often barely adequate, administered by providers who are vastly overworked, underpaid, and burdened by regulations that have little if anything to do with enhancing the quality of care. As a society we have failed people with severe and persistent mental illness. The asylums of yesteryear still exist, they just aren’t hidden anymore inside a hospital building. Now they are hiding in plain sight.

A recent study came out that showed mental illness poses a greater mortality risk than smoking. Read that sentence again and let it sink in. Mental illness poses a greater mortality risk than smoking. The study showed that drug and alcohol abuse, for example, resulted in a reduced life expectancy between nine and twenty-four years; schizophrenia was 10-20 years. Smoking? It was 8-10 years. So despite the fact that persons with severe mental illness are no more likely to be violent than the average person, despite the fact that they are at a greater risk of dying early because of their illness, despite the fact that disability from mental illness results in one of the highest economic burdens on our society, despite the fact that persons with mental illness are enduring inhumane treatment that violates basic human rights, politicians and pundits want to argue about gun control and involuntary treatment.

I am not suggesting that either issue doesn’t belong in the discussion of mental health care; both are topics to consider. But here is the terrifying truth; the enhanced ability to force involuntary treatment and increased gun control legislation will not prevent future tragedies such as the one that occurred in California recently. The problem is far more systemic and in actuality has little to do with guns and violence. A violent crime occurs every 26 seconds in this country. Violent crime is not a mental health issue, it’s a societal issue. If politicians and policy-makers are serious about fixing the mental health care system in America, then they will stop partisan debate and spend some time listening to those of us in the field trying to provide treatment. They might not like what they hear, the changes needed will likely be financially costly, but we might actually be able to make positive changes to the way we deliver mental health care in this country. Those who suffer from severe mental illness deserve no less than our best effort. We cannot afford to continue failing them.

Reforming the Mental Healthcare System

Mental health has been in the news a lot recently, mostly for the wrong reasons. What is most disturbing is how some commentators are using the recent mass shootings as evidence to further stigmatize mental illness. While they talk about reforming a broken mental health care system, what they are actually promoting is institutionalization for individuals with severe and persistent mental illness. This is unacceptable and distracts policy-makers from the fundamental issue; our current mental health care system is broken, underfunded and often criminalizes mental illness.

Why do we allow society to blame those who suffer from these devastating illnesses when they are the victims? It is no secret that even the best evidence-based treatments are still not good enough. Yet, they represent the latest research and should be widely available to patients. Sadly this is not the case. Community mental health centers are underfunded and lack the resources to offer such treatments. Training is expensive and access is limited. Insurance companies frequently balk at paying for treatment that they argue is questionable from an efficacy standpoint. The complexity of the mental health system, divergent opinions about treatment, and limited access to care often leaves family and patients confused, frustrated and marginalized. It is not exaggerating when people say the mental health system is broken and in crisis.

So what can be done? To start, our leaders need to stop using these isolated incidents of violence as evidence to support changes in the mental health system. However well meaning, it sends the wrong message and ultimately does more harm that good. Secondly, the government needs to get out of the way and let those who understand mental health care take the lead. There is far too much bureaucracy and inefficiency in the system (the current government shutdown an outstanding example). We need congress to appropriate funding at a level that meets the current needs of the system, without any stipulations or interference from special interest groups. Appoint a director to oversee a complete reformation of the system who is given the authority to implement the necessary changes (versus the usual congressional route of asking for a report that never goes anywhere). The director should bring together the National Institute of Mental Health, the Veterans Administration, the Substance Abuse and Mental Health Services Administration, the National Alliance on Mental Illness, the Center for Medicare and Medicaid Services, as well as various research and provider stakeholders to develop a comprehensive plan that aligns research, training, advocacy and treatment objectives on a national level. Simplify the process for accessing care and reduce the administrative burdens associated with providing mental health care. Stop kowtowing to special interest groups and make mental health parity a reality. Create a national standard for reducing the criminalization of mental illness through the use of mental health courts and mandated treatment for those most at risk for violence. Ensure that there is adequate access to various levels of care nation-wide. Prioritize the implementation of electronic medical records that allow for seamless communication between providers. Provide funding for training providers that includes national standards for graduate programs and licensing. Revamp psychiatric training programs to ensure that psychiatrists are thoroughly trained in psychotherapy as well as psychopharmacology. Mandate that insurance companies reimburse for psychiatrists who provide psychotherapy. Provide incentives for the development of novel treatments, including medications.

This is a daunting list and incomplete. Critics may call such a proposal idealistic, too expensive and unworkable. However, what other options do we have? The patchwork approach has not proven effective and there is little evidence that leaving the process in the hands of a partisan congress will produce acceptable results. Overhauling the mental health care system can only be effective if there is a comprehensive, long-term vision that aligns research, treatment, training and advocacy objectives. It will be difficult and expensive, but those who suffer from severe and persistent mental illness deserve our best effort.