Published December 20, 2012
It is time to rebuild America's mental health care system, and to build it stronger than ever. As I have said before on this site, the current system is shattered, on its knees and a profound national embarrassment.
The tragedies in Aurora, Colorado and in Newtown, Connecticut and the shooting of Congressman Gabrielle Giffords and President Reagan and thousands of murders around the country might well have been prevented if the mental health care system were appropriately robust and paid special attention to those at risk for violence.
Just as promising, a reliable mental health care system could offer real hope to the many millions of Americans currently untreated, under-treated or incompetently treated, saving thousands more deaths from suicide and many billions of dollars each year in lost productivity.
In order to accomplish this, psychiatrists must be placed back at the center of the mental health care system. Psychiatrists are trained during four years of college (preparing to meet stringent medical school admission requirements), four years of medical school and four years of residency training in hospitals to properly diagnose mental disorders, properly consider the impact of underlying medical problems on those disorders and properly balance the potential impact of treatments, including psychotherapy and psychopharmacology and new technologies, including repetitive transcranial magnetic stimulation (rTMS). Social workers, psychologists, nurses and non-psychiatry physicians can each have an extremely important role to play in rendering care to psychiatric patients, but they should not be the orchestrators of such care.
Largely to save money, insurance companies are most responsible for decimating the mental health care system in America by demanding such low payment scales that social workers and nurses have been trying to do the heroic work of trying to act like psychiatrists, while psychologists have been agitating for the right to prescribe medications so they can make more money and while internal medicine physicians and family physicians have too often tried to treat complex mental illnesses with medications alone, ignoring the fact that psychological factors fuel those illnesses and must be addressed.
The pharmaceutical industry has vigorously pursued this downstream transfer of knowledge—with online "educational" symposia, for example—to place as much prescribing power in the hands of non-psychiatrists as possible.
A psychiatrist, therefore, should be--by state legislation--available to any psychiatric patient, no matter what that person's insurance coverage. That psychiatrist should be--by legislation--compensated not only for quick medication visits, but also as the coordinator of the patient's care, being duty-bound to check in and advise on the work of anyone treating a psychiatric condition. This coordinator role should include not only paid outreach to counselors, social workers, nurses or internal medicine (or other) physicians by phone or confidential email, but also actual, hour-long meetings with each patient, not less than monthly (even if medication visits by the psychiatrist are ongoing at the rather indefensible clip of 10 or 15 minutes a month). The practice of medication management being limited to once every 90 days by insurance companies should be prohibited by law.
In order to prevent psychiatrists from emerging from training only prepared to write prescriptions, psychiatry residency training programs should not be certified if they do not provide sufficient training to residents in psychotherapy techniques. It is a profound loss to the American people that a profession based in empathy has been coerced to abandon its listening arts in favor of turning out many graduating psychiatrists who have never been in psychotherapy themselves and do not know how to perform it reliably, either.
Non-psychiatrist clinicians (other than psychologists) should also be advised by state departments of public health that it is undesirable for them to treat complex cases of major mental illness without the direct supervision of a psychiatrist.
The practice of insurance companies withholding payment for patients' inpatient hospitalizations for mental disorders (including substance dependence) must be substantially curtailed. I propose that an insurance company reviewer be contacted prior to admitting a person to the hospital, but that no further contact be permitted (or, at minimum, "required") with that insurance company until the patient is ready for discharge. The only real reason such contact is now made while a person is being treated is so that insurance companies can pressure psychiatry units into prematurely discharging patients. Once a decision to admit the patient has been made, the insurer should get out of the way and prepare to pay the bill. Furthermore, I propose very substantial penalties to any insurer for any case in which inpatient hospitalization coverage was denied, and in which an appeal to two independent psychiatrist reviewers shows that, on clinical grounds, it should not have been denied. These independent psychiatrist reviewers would be retained by the hospital from a panel of such psychiatrists certified by each state to review those cases in which patients were admitted despite denial of insurance coverage.
Intermediate care "crisis units" should be established in much greater numbers within community mental health centers and in as many private hospitals as wish to create them. These crisis units would replicate the "unlocked" or "open" psychiatry units of the past (now almost extinct) and serve as healing centers for those not ill enough for a locked inpatient unit, or those who have partially recovered after an inpatient stay, but are not yet ready to go home.
I would leave it to individual states to determine how to relieve insurance companies of the burden of long-term hospitalizations. But it stands to reason that if a psychiatric inpatient team cannot complete its work within a month (despite the availability of new and powerful psychiatric medications) that revamped state hospital systems must be prepared to step in. These revamped systems would charge sliding scale fees to clients to defray their costs. The fees would sometimes be zero, but would almost always be far, far less than the $20,000 or $40,000 or $80,000 a month now charged by quality private psychiatric facilities that offer long-term psychiatric hospitalization.
In order to increase the quality of the work conducted on such psychiatry units, I propose that each inpatient hospitalization result in a complete psychiatric history being generated that includes documentation of outreach to outpatient clinicians currently treating the individuals, outreach to prior outpatient clinicians who have treated the individuals, interviews with at least two first-degree relatives and a psychological history and plan that focuses on defining both the emotional forces and the medical issues that may have impacted the patient in the past and may be impacting the patient currently. Sadly, most inpatient hospitalizations are no more today than a rush to switch medications and get patients to "contract for safety" (to promise they won't kill themselves or others—even if they don’t mean it) so they can be thrown out by insurance company reviewers and the clinicians who too often blindly do their bidding.
The current knowledge base available to identify the relatively small percentage of psychiatric patients at risk to commit violence toward others is woefully inadequate. Hence, I believe a "future violence assessment tool" should be developed by the National Institute of Mental Health to help screen for those individuals who may be most at risk to hurt themselves or others (many of whom will admit readily to their violent thoughts--if asked appropriate questions). Restricted grants from the federal government to states should fund the dissemination of such a tool, once it is available. This assessment should be part of the complete psychiatric history noted above.
Prior to discharge of any patient who is rated as a significant risk for lethal violence toward others, a consultation by a forensic psychiatrist or psychologist should be obtained.
"Court clinics" which are currently maintained by states should be expanded, with clinicians available to route defendants with serious psychiatric symptoms to state psychiatric units for assessment. These clinicians should also weigh in as expert witnesses to help put in place treatment plans that will be incorporated into the terms of probation for psychiatrically ill individuals convicted of violent crimes. These plans could include enforced psychotherapy, medications, drug testing, or all of these.
Because many psychiatric patients who have been violent in the past (or who are clearly at risk for violence) refuse treatment as outpatients, states should be encouraged to rapidly pass legislation that allows for "outpatient commitment" of such individuals when stringent standards for dangerousness are met. This would allow clinicians (or concerned family members working with a clinician) to rapidly petition courts to enforce psychotherapy and medication treatment in the community and immediately hospitalize those individuals who discontinue such treatment.
All this would be a beginning. We have allowed the disassembling of the mental health care in America, giving into the lowest common denominator of treatments and handing control of our gutted system to insurance companies and drug manufacturers. Some may argue we did this in hopes of dialing back overzealous treatment strategies during the period of "deinstitutionalization." But I believe the real decline was fueled by the stigma still indefensibly associated with mental illness. Because such a shoddy system of care would never be allowed to exist in the world of cardiology or endocrinology or oncology.
This is by no means a complete plan. Elements of it may be challenged, and should be challenged. I hope others could contribute more creative and comprehensive solutions to some of the shortcomings I have noted. Perhaps it would be wise for the President to appoint a Deputy Surgeon General wholly dedicated to the task.
Six days ago 20 children were killed by yet another mentally ill man who I believe we will learn was inadequately treated. Enough is enough. Mental illness is rampant in our society, and we have no real system with which to fight it.
Let us build such a system, again.