Sunday, January 26, 2014

Fixing What's Broken: What to do About Mental Health Care in America

Tonight’s episode of CBS “60 Minutes” really touched a nerve for me. It discussed how broken our mental health system is through the lens of one family’s tragedy. Virginia State Senator Creigh Deeds told CBS’ “60 Minutes” news program about the loss of his son Gus, who had been diagnosed with Bipolar Disorder.  Last November, the Deeds family had tried to find inpatient mental health care for their son Gus, but no beds were available. Gus went home with his family. He subsequently attacked his father, inflicting multiple stab wounds, before shooting and killing himself.
Senator Deeds spoke with “60 Minutes” since it was “the biggest megaphone I could think of to talk about the system’s failings.” He has declared it is his mission to protect other families from the horrible misfortune he has experienced. As a state senator he is committed to changing Virginia’s mental health laws to keep anything like this from happening again.
I wish it didn’t take a personal catastrophe of this magnitude to enlighten government officials about the need for change. I wish it didn’t take Mr. Deed’s attack and disfigurement and the suicide of his son to raise awareness. The fact that it usually takes something this extreme to bring the need for change to the forefront is just more compelling evidence as to how broken the system really is.
I started graduate school in 1981 as a National Institute of Mental Health (NIMH) fellow. The NIMH fellowship program was set up as part of Lyndon Johnson’s great society, which recognized that good mental health care was an integral part of a successful, productive, enlightened country. After Reagan took the presidency, he redlined the NIMH fellowship program out of the federal budget. The loss of my fellowship created a challenge for me as to how I was going to pay for my graduate education. Instead, I worked as a research assistant on a federally funded grant that paid my tuition and provided a stipend. I was fortunate. Many others weren’t able to find an alternative and had to give up their dreams of helping others as mental health professionals.
Throughout my early career, I watched as the residential treatment system was dismantled. I don’t remember many homeless people as a child but the homeless have been a fixture in my adult life, mostly because there were no longer residential treatment programs or institutions to house and care for them. I’m not implying the old institutional system was perfect. But needy, fragile, patients were turned out into the streets, with nothing in place to fill the resource gap.
During my years as a clinical psychologist, I’ve been frustrated by the increasing fragmentation of care and the lack of emergency and support services. I’ve watched care plans dictated by limitations imposed by insurance coverage rather than patient’s treatment needs. I’ve seen the number of psychiatrists dwindle. Most psychiatric medications are now handled by internists, family practitioners and pediatricians, who are already overburdened and freely profess to a lack of confident expertise in managing psychiatric medications.
The multiple failures of our current  mental health care system isn’t news to me or anyone else interacting with the system as a health care professional, patient or family member. A crisis of this severity, breadth and magnitude can only be solved by government mandates and intervention. Insurance companies won't freely provide the coverage needed for adequate services and hardly any one can afford the level of care needed for serious mental illness without being incredibly wealthy. This moment has been inevitable ever since Ronald Reagan started dismantling the system during my first year in graduate school. Nothing has ever trickled down to restore it. It is so heartbreaking to bear witness at the front lines.

Instead of shaking our heads in helpless frustration we need to ask, “What can be done?” We can legislate the availability of more affordable long-term residential treatment resources funded by insurance, government programs or grants. Lawmakers need to step up and push for programs that will once again fund training for psychiatrists and other mental health professionals, particularly those who can provide services in rural, impoverished or blighted areas, We must have enforceable mandates for true parity of insurance coverage for mental health. Emotional and physical health are so intertwined, there should be no question that the standards of coverage should be the same. We used to have government programs to fund residential and outpatient treatment and scholarships and grants to fund education and training for mental health professionals. It wasn't a perfect system but it was vastly better than what we have now. So far, no for-profit model has worked effectively for mental health services except for those who cater to patients with sufficient wealth to pay for care or who have exceptionally good health insurance that has far-better-than-average mental health coverage. 

Let’s fix what’s broken before more high profile tragedies occur. The consciousness raised by the horrors we’ve already witnessed, as well as what we’ve learned about the day-to-day heartbreak of families and patients currently struggling with mental illness, should be sufficiently motivating for us all.

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