c

In order to have full access of this Article, please email us on thedocumentco@hotmail.co.uk

The Starvation of Our Mental Healthcare System: In early Spring I received an urgent call from a managed care company asking me if I could make time that day for a sixteen year old girl who was ‘too exhausted to attend school, had lost 10 lbs. in the past three months, cried for hours on end, and thought constantly about death and dying.” A brilliant student in the advanced track of her high school, a member of the debate team, and working part time in a card and gift shop, this young lady explained that she was “burned out” and saw no reason to carry on. Her parents were divorced and her father, a drug addict, had been diagnosed with HIV. This kind and compassionate sixteen year old was going to school and working while attempting to care for a dying father. Clearly overwhelmed, we withdrew this teenager from school, placed her on a homebound educational program, referred her for anti-depressant medication, and initiated weekly psychotherapy. Three months later, I was told by the managed care company to finish up the therapy by the tenth session.

The mental health system has been broke for decades and we are no closer to fixing it than we were ten years ago before the forces of managed care promised to reform the system. A more accurate statement may be that the mental health system has never really been in good shape and we as a nation have struggled to face the reality of disordered behavior, emotions, and impulses that frequently run rampant in our society.

The Binge and Purge Cycle in our Mental Healthcare System

Over the past decade, the behavior of the mental health system has resembled a patient diagnosed with anorexia nervosa, alternately bingeing and purging the public’s appetite for mental health services.

Just a decade ago, private psychiatric facilities were multiplying at a dizzying rate to accommodate the numbers of individuals, particularly children and teenagers, who were referred for psychiatric inpatient hospitalization. The more patients these hospitals treated the more money they made in the unfettered, unmanaged days of fee for service medicine. Money poured into the coffers of these corporate psychiatric facilities and the companies that operated them. A significant number of admissions were unnecessary and some of these large hospital chains were investigated by the government for utilizing practices that were not always in the best interests of their patients.

Ten years later the pendulum has swung in the opposite direction. Patients are regularly discharged from the hospital within days of a severe suicide attempt. Research findings are beginning to identify an increased risk for those suicidal patients who are discharged from a hospital prematurely or without adequate outpatient support. In the days of managed care, often more profit seems to flows to those who restrict or deny care than those who provide treatment. Ironically, some of the corporate hospital chains that heavily promoted their psychiatric inpatient facilities throughout the 1980s have purchased managed care companies and are now in the business of denying the very same care in the 1990s.

The Starvation of Mental Healthcare

One chilly winter night I evaluated a young adult male to determine whether he met the criteria for an emergency commitment to an inpatient unit. In my state, to be committed to a psychiatric facility against one’s will one must be in imminent danger of hurting oneself or someone else and suffer from a mental disorder that could not be better addressed in a less restrictive setting. 48 hours earlier this gentleman was rushed to an emergency room after overdosing on various medications in an attempted suicide. Once medically stabilized the patient’s physician referred the gentleman to an inpatient psychiatric facility. The patient voluntarily sought admission to the hospital, however his managed care company would not approve his admission to an inpatient unit. Instead, the care manager directed me to admit this deeply depressed individual to a program where patients attended during the day and return home in the evening. Despite the managed care directive, I supported the patient’s admission into a psychiatric inpatient unit.

Right now our mental health system is in trouble….deep trouble. According to a recent study by the World Health Organization, the World Bank, and Harvard University, mental disorders account for 4 of the 10 leading causes of disability in the more established market economies throughout the world. Research has estimated that the cost of mental illnesses in the United States, including indirect costs such as days lost from work, was $148 billion in 1990, the last time the total costs were measured. In the meantime, our state’s are spending a third less money on their citizens mental health needs today than they did in the 1950s after adjusting for inflation and population growth.

Violence and Mental Illness

The largest state supported facilities for the mentally ill in this country are not hospitals but prisons. There are now far more mentally ill in our nation’s jails and prison’s than in state hospitals. A Justice Department survey indicated that the nation’s prisons and jails held an estimated 283,800 mentally ill inmates in 1998, and they were more likely than other offenders to have committed violent offenses. Substance abusing criminals were also found more likely to engage in violent offenses. In contrast, there are approximately 61,000 seriously mentally ill in our nations state psychiatric facilities. The findings that the prison population of behaviorally disordered inmates is growing and that mentally ill and substance abusing criminals are more likely to be violent suggests that an important contributor to violent crime may be untreated mental illness and substance abuse. Although the forces involved in violence are likely manifold and complex, could there be a relationship between the cutbacks in treating the mentally ill and the increase in mass violence and murder in the United States? The prevention, early identification, and treatment of mental illness seems especially crucial in a culture that grapples with the containment of violence, yet prizes freedom of thought, speech, and behavior.

The Disappearance of Mental Health Services

Mental health services are not just disappearing in the public sector, there are indications that privately funded behavioral health resources are evaporating at an ever increasing rate as well. Sam Muszynski, JD, follows payment trends for the American Psychiatric Association. He says that typically about 80% of the premium dollar is spent on patient care by a health plan. However, some companies that provide managed behavioral services only return 50 cents on the premium dollar to actual treatment, a trend that Muszynksi portends as “frightening.”

In what may be the first national study of managed care’s impact on the coverage of mental health services, researchers acknowledged there have been profound treatment cuts, not only for hospitalized patients, but also for outpatients. Co-author of the paper Douglas Leslie, PhD, a health economist in the Yale School of Medicine’s department of psychiatry, West Haven, Conn., described the findings as startling. “We actually knew that inpatient care was falling, and falling dramatically, but then what was surprising about this study was the outpatient care was also falling,” says Leslie.

The study, published in the August issue of the American Journal of Psychiatry, reviewed the mental health claims of nearly 4 million individuals who had private health insurance through big corporations. For the 3-year study period between 1993 through 1995, the researchers found that mean costs for psychiatric inpatients dropped $2,507 or 30.4%. The key factor apparently was a nearly 20% decline in the number of days a patient spent in the hospital on a yearly basis. During the same period, the study shows for those getting only outpatient care costs also dropped by nearly 15%.

A concerted, systematic and sustained examination of this country’s mental health delivery system has never been undertaken and as a result, our views and approaches toward mental illness remain largely informed by myth, fear, and our financial appetites. Even today, with our splendorous scientific and technological advances tendencies to trivialize and oversimplify the problem abound. The media, in their rush to judgement, to obtain ratings, and increase advertising revenues often demand reflexive and premature answers to questions about the violent tragedies in our schools, workplaces, and communities.

Treating Our Disordered Mental Health System

How should we go about caring for our disordered mental health care…