Archives

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.

Family-Based Therapy for Anorexia Nervosa

Having just returned from the 2-day training on FBT-AN, I thought now would be a good time to write a bit about this treatment. Originally developed at the Maudsley Hospital in London, Family-Based Therapy for Anorexia Nervosa (FBT-AN) is considered a first-line treatment for adolescents with AN. Some people find the treatment controversial and the topic certainly generates intense discussion among researchers and providers. However, I think that what makes it controversial is also what makes it so effective. The basic premise of FBT-AN is that inpatient hospitalization is traumatic, disruptive and has not proven to be very effective in treating AN over the long-term. It also makes the argument that most current treatment approaches disempower parents by removing them from the re-feeding process. The approach that FBT takes is that parents should be responsible for re-feeding their child, and the entire family should be involved in the treatment process. It is well documented in research literature that it is critical to achieve weight restoration as quickly as possible to reduce the risk of the illness becoming chronic. Furthermore, because cognition is severely impaired when an individual is dangerously underweight, traditional insight-oriented therapy is of no use. Cognitive difficulties and other symptoms that accompany low-weight anorexia (obsessionality, anxiety, depression) typically resolve once weight is restored. The underlying message in FBT-AN is “food is the medicine” and until the child is weight-restored and able to handle the responsibility of eating, it is up to the parents to ensure that this occurs. FBT also takes an agnostic view of AN; it does not delve into what might have caused the illness but rather on ensuring the child gets weight-restored as quickly as possible. The therapist is the expert consultant, always guiding and refocusing the family on the task at hand.

It should be noted here that FBT-AN is not a self-help approach, and parents should never attempt to implement the treatment without a qualified FBT therapist. Anorexia Nervosa is a serious illness with the highest mortality rate of any psychiatric disorder and required qualified medical and mental health providers to be effectively treated. FBT also recognizes that there are times when hospitalization is necessary due to acute medical risks and suicidality. To learn more about FBT-AN, please visit maudsleyparents.org. The developers of FBT also maintain a list of certified FBT therapists.

As with any new treatment approach that challenges current thinking, FBT has generated much discussion and debate regarding the approach and its effectiveness. Having had the opportunity to hear Daniel Le Grange discuss FBT-AN in comparison to CBT-E with Chris Fairburn at ICED 2013, and then to attend the intensive training, it is clear that no one is suggesting that FBT-AN is the only treatment option. However, with remission rates as high as 60% and long-term follow-up showing similar rates, the evidence indicates that is extremely effective for many individuals, and should be a first-line treatment for adolescents with AN.

If you or a loved one is suffering from an eating disorder and needs treatment, please contact Ascent Counseling today to schedule your initial consultation phone call.

Thoughts About DSM-5

As I discussed in a previous post, there has been much controversy about the DSM-5. Now that it has been released and people have a chance to review it, I think we can all take a deep breath. I do not believe that the changes to the manual are as dramatic or controversial as I think people were expecting. There are changes that may be disliked by some (such as the consolidation of Autism, Aspergers and Pervasive Developmental Disorder NOS), but one the whole, I think the APA did their best to find a balance in the changes they made. I doubt that most clinicians (or journalists for that matter) bother to read all the fine print in the introduction, but I recommend that they do. For one, the authors readily acknowledge the limitations of the current categorical system and splitting of disorders.

“The historical aspiration of achieving diagnostic homogeneity by progressive subtyping within disorder categories no longer is sensible; like most common human ills, mental disorders are heterogeneous at many levels ranging from genetic risk factors to symptoms (APA, p. 12).”

Further on they outline some of the problems with trying to diagnose a mental disorder based upon a categorical system:

“…it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder…it is well recognized that this set of categorical diagnoses does not fully describe the full range of mental disorders that individuals experience and present to clinicians on a daily basis throughout the world (APA, p. 19).”

The inclusion of dimensional measures of symptom severity that cuts across diagnostic category is a good start. I am pleased with the inclusion of assessment tools in the manual, as well as their availability online. I hope that this pushes more clinicians to include the use of standardized assessment tools in their daily practice.

One argument about DSM-5 that I have heard is this notion that it has pathologized normal behavior by expanding what constitutes a mental disorder. There is some merit to this concern, especially if you just read the names of the disorders and their respective diagnostic criteria. However, there are very clear cautionary statements included in DSM-5 (and previously in DSM-IV) about this very issue. A core feature of what defines a mental disorder is the concept of “clinical impairment”, or how the symptoms negatively affect an individual’s functioning in daily life. This can be a challenging question to answer, especially if the symptoms and/or impairment are not recognized by the individual (such as in the case of psychosis). In DSM-IV, clinicians used the Global Assessment of Function scale (or GAF as it is commonly referred to) as a means of quantifying impairment. In truth, the GAF was a very ineffective means of quantifying impairment, as the authors of the DSM-5 readily acknowledge:

“It was recommended that the GAF be dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., including symptoms, suicide risk and disabilities in its descriptions) and questionable psychometrics in routine practice (APA, p. 16).”

Instead, the DSM-5 recommends using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS). While it requires a bit more effort that the GAF, I believe it does a better job of capturing and quantifying this concept of “clinical impairment.”

One of the underlying problems with DSM-5 is less to do with the manual, and more to do with how it is viewed by both clinicians and the general public. I often hear people call the DSM the “bible” of psychological disorders. This is a most unfortunate term for several reasons. First, the word bible has obvious religious and cultural connotations that suggest the book is somehow sacred and immutable. The truth is the DSM is anything but; it is a living document, based on current research and always open to having the contents challenged and modified by new discoveries.

As stated by the book itself, “Diagnostic criteria are offered as guidelines (my emphasis) for making diagnoses, and their use should be informed by clinical judgment (APA, p. 21).”

The DSM is not the last word when it comes to diagnosing mental disorders. The diagnoses are simply the best way at present of understanding a set of symptoms. I always caution clients not to focus too much on what diagnosis they are given. While it is true that a diagnosis can help inform treatment, it is far more valuable to focus on the particular set of symptoms that are present and the suffering that comes with them. Ultimately, mental health treatment is about relieving suffering and not a diagnostic name. So while the new edition of the DSM is certainly interesting and important, it is only one facet of mental health treatment, and not the most important one at that.

Bibliography

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Washington, D.C.: American Psychiatric Publishing.

Latest NIMH Research News

There are three recent and exciting research study reports from NIMH I want to share. The first discusses the potential of modifying gene expressions to treat schizophrenia. While a major limitation of the study is that it was looking at the brains of mice, it still holds much promise for understanding the mechanisms associated with schizophrenia and developing novel treatments. The second study examined the relationship between bipolar affective disorder and influenza. Researchers have long suspected that prenatal exposure to the flu virus may be a risk factor in developing bipolar disorder and schizophrenia. This current study suggests there is a fourfold increased risk. Finally, over the past several years I have been watching with interest the research on ketamine as an antidepressant agent. Research has been taking place on the use of ketamine as a rapid antidepressant. One of the challenges with ketamine is that it has many unwanted side effects and is a drug of abuse. Researchers have now developed a molecular cousin to ketamine that seems to have similar antidepressant effects without these side effects. Such a medication could revolutionize the treatment of depression like Prozac did when it first came onto the market. One of the drawbacks to current generation antidepressants is that they can takes weeks to reach full effect. Imagine the benefit of a medication that achieved the same or better results in minutes or hours? It could lead to lower rates of inpatient treatment, decrease the risk of suicide, reduce time waiting for services and service utilization. There is still a long way to go before such a medication may be available, but it gives hope to all those affected by mental illness.

ICED Conference

I recently returned from the International Conference on Eating Disorders, which was held this year in Montreal. It’s my first time attending the conference, and I’m very pleased to have had the opportunity. The ICED is the annual conference for the Academy of Eating Disorders, and is attended by some of the best researchers and clinicians in the eating disorder field. The conference took place over 3 ½ days, and included numerous presentations and educational opportunities. I learned more than I could possibly put into a blog post, so instead, I thought I would comment on the theme of the conference, “Crossing Disciplinary Boundaries in Eating Disorders”.

The conference was kicked-off with a keynote address by renowned psychologist David Barlow. Dr. Barlow is well known for his research of cognitive-behavioral treatments for anxiety disorders, and focused his discussion on the idea that it may be more effective to investigate psychiatric disorders from the perspective of what they have in common, versus what separates them. He termed this “lumping” versus “splitting” and noted that the latest version of the DSM, DSM-5 has continued the trend of “splitting”. Interestingly, DSM-5 is slated to be released this month, and the director of the NIMH has gone on record as saying NIMH is moving away from researching psychiatric disorders using the DMS-5 nosology. His comments provoked a response by the American Psychiatric Association, who basically said, “This is the best we can do until you researchers give us better evidence.” Meanwhile, the shortcomings of DSM-5 have led some to question the biomedical framework for psychiatric disorders, while others argue that it encourages mental health practitioners to pathologize normal human behavior. I think this controversy is unfortunate and only serve as fodder for the anti-psychiatry movement. The mental health field has worked extremely hard at reducing the stigma around seeking treatment for mental illnesses. It would be devastating if the current DSM-5 controversy negatively impacted this effort.

Eating disorders, in my opinion, are an excellent example of the “lumping” versus “splitting” issue. Research has shown that for many individuals with eating disorders, their diagnostic presentation changes with time. It is not unusual to have someone develop Anorexia Nervosa during adolescents, but then continue to struggle with a variety of eating disordered behaviors over the course of the lifetime, including binging and purging. In fact, most individuals with an eating disorder end up in the Not Otherwise Specified category because, while clinically impaired, they do not meet the specific criteria for either Anorexia Nervosa or Bulimia Nervosa. This would suggest that there are strong commonalities between disorders that are conceptualized as being separate. On the other hand, Binge Eating Disorder, which is being added to DSM-5, may be more distinct from AN & BN. For example, prevalence rates for men are much higher for BED than for AN or BN and there does not seem to be the diagnostic “crossover” that occurs with AN & BN. However, the inclusion of BED in DSM-5 does continue the trend of “splitting” diagnostic categories, which may or may not be helpful to our understanding of eating disorders.

One of the fascinating things about eating disorders is the interplay between biology and psychology. A classic study informally referred to as the Keys Study showed how starvation can induce behaviors that mimic Anorexia Nervosa (the ethics of the study are a different story). It was one of the first studies to clearly demonstrate the biological underpinnings of eating disorders and how starvation can negatively affect psychological functioning. Another such example is the research that suggests there are different personality traits associated with Anorexia Nervosa and Bulimia Nervosa and how they may impact the development of these illnesses. We desperately need better research into the biological basis for personality traits and how these relate to psychiatric disorders. I think a major shortfall of the DSM-IV was the artificial separation of personality disorders and mental illness. The reality is that the two are intertwined and likely share common pathophysiology in the brain. So I am firmly in the “lumping” camp at this point, and hope that the NIMH RDoC effort helps us develop better dimensional models of psychiatric disorders that delineate the underlying biological mechanisms and associated environmental factors.