Allen Frances, MD

The COVID-19 pandemic is the most disruptive force in psychiatry since the deinstitionalization movement of the 1960s and 1970s. In just 3 months, the virus has changed the lives of our psychiatric patients and of psychiatry even more than did the forced discharge of hundreds of thousands of patients that occurred over a period of 10 years. It was horrible, 50 years ago, watching the deterioration of prematurely discharged patients. Even worse now is the despair of watching tens of thousands of our patients dying avoidable pandemic deaths.

The several decades of neglect since deinstitutionalization have rendered people with severe mental illness (SMI) particularly vulnerable to catching the disease and to having severe cases. Current neglect in the US pandemic response makes them helpless sitting ducks, dying in droves.

 will likely be with us a lot longer than cheerful optimists are predicting. Immediate effects will probably last only a few years-but it will almost certainly change forever the lives of our patients and how psychiatry is practiced. Our goal here is to predict how our patients may fare and how psychiatry might look in this not-so-brave new world.

Absent an unlikely miracle vaccine, I suspect the coronavirus will eventually spread throughout the country and cause great harm among most demographic groups. The worst hotspots and damage occur wherever people are forced to live or work in close quarters and in those who suffer from medical and/or economic disadvantage. Among all demographic groups, patients with SMI are perhaps the most vulnerable-both because of where they live and because of their pre-existing health problems.

Deinstitutionalization was haunted by a horrid paradox. Its original idealistic purpose-freeing neglected patients from crowded snake pits and providing them instead with decent housing and treatment in the community-was quickly abandoned in a mad rush to off-load public responsibility for the mentally ill. Money saved by closing state hospitals did not follow discharged patients into the community. Lacking adequate treatment and housing, patients dumped from the admittedly awful state hospitals were often subjected to much worse living arrangements in the community.

As society's neglect persisted through the ensuing decades, things have gotten progressively worse. Many patients now face the pandemic living in the most extraordinarily crowded of death traps-prisons, nursing homes, homeless shelters, group homes, hospitals, or on the street. In such settings, social distancing is impossible; hygiene is substandard; and exposure to the virus is inevitable.

Patients are also especially vulnerable because of the frequency and severity of their preexisting health problems. People with SMI died 20 years earlier than expected even before COVID-19-due to a combination of medical neglect; heavy smoking (which relieves symptoms and medication adverse effects); and high rates of obesity and diabetes (common medication adverse effects). It seems likely they will now have the highest rate of infection; the highest rate of transmission; and the highest rate of case mortality of any demographic group.

If, as I suspect, the total number of pandemic deaths in the US eventually reaches somewhere between one half and one million, more than a hundred thousand mentally ill patients may die mostly avoidable deaths.

The US response to the pandemic has been mismanaged in every way possible-particularly the lack of testing and contact tracing, as well as the callous neglect of high-risk groups. The federal government is 

 (and often wasting) trillions on the pandemic response-but less than one half billion dollars has been allotted to the desperate needs of patients with SMI.

 Testing for patients and staff is far too little and far too late; contact tracing is almost nil; and attempts to reduce overcrowding are more cosmetic than real.

Advocacy for patients with SMI, always muted, has been even more unaccountably silent in the face of the current life-and-death emergency. There is constant media buzz on how best to help mentally healthy people face their understandable, but normal, anxieties about the pandemic and quarantine-but almost nothing has been said about our responsibility to save the lives of those at desperate risk. I am puzzled and disappointed by the indifference of some professional mental health organizations and patient advocacy groups that no longer advocate actively for the vulnerable patients who lack a voice and most need one.

That the problems are so enormous is no excuse for ignoring them. We need a massive level of immediate support and housing for the homeless and for the additional army of people soon to become homeless (both because of the economic collapse and the rapid release of prisoners). We need extensive coronavirus testing, tracing, and contact isolation- especially in nursing homes, prisons, shelters, group homes, and for the homeless. Empty hotels should be converted to temporary housing to reduce crowding and allow separation of spreaders from the general population. We need federal and state funding for more psychiatric beds-ridiculously inadequate before the pandemic and now more necessary than ever to avoid over-crowding.

In a rational and compassionate world, the pandemic would be a much needed wake-up call warning us that we must end the shameful neglect of patients with SMI and other vulnerable and disadvantaged groups. There would be a new realization that investment in better services is not only the right thing to do but also the cost-effective thing. When we allow the virus to run wild among mentally ill patients, they become a reservoir for potential future reinfection of everyone else. The pandemic has highlighted, in the clearest and most tragic possible way, all the longstanding sufferings of people with SMI. The question now is whether this sharp societal shock treatment will result in long delayed societal regret and reform.

So far, sad to say, I detect no encouraging signs of a renewed social conscience stirring in our neglectful nation. And, adding to the gloom, federal and state governments will have very limited spending options during and after the pandemic. Balance sheets are in terrible shape because of all the lost revenue and the huge expenditures (often wasted) occasioned by pandemic.

It is still early days of the pandemic- so passively giving up hope is not an option. The virus has already killed well over 100,000 Americans in just over 2 months. As the toll rises inexorably in the coming year(s), our country may perhaps finally face the fact that economic and social policies have been badly skewed to promote inequality and ignore disadvantaged people. The next election will in large part be a referendum on national priorities. It will, or it will not, initiate the fundamental reforms needed to correct the grave and glaring inequalities and inequities of the current system. If the carnage of the pandemic does not at long last stimulate the national conscience, I can't imagine what will. And if not now, when?

The practice of medicine has always been greatly influenced by disruptive advances in transportation and communication technologies. Until 150 years ago, most medical care was delivered in the patient's home and doctors were pretty evenly distributed across the country. This changed rapidly with the availability of paved roads, railroads, telephones, public transportation, and cars-technologies that made it much easier and more cost effective for patients to get to doctors than for doctors to get to patients. Ease of travel and communication also made possible the growing cities that quickly absorbed most doctors.

Telemedicine is the latest disruptive communication technology to revolutionize medicine. It was first developed decades ago as a way to provide remote care in geographically isolated areas that suffered a shortage of doctors. Telepsychiatry pioneered telemedicine and before the pandemic constituted most of its practice. But remote care was, until a few months ago, just a small niche player in both medicine and psychiatry.

The pandemic has changed all that-suddenly causing the most dramatic change ever in how medical care is delivered. The dangers of face-to-face contact have now made telemedicine the main delivery mode for all nonessential medical care.

Necessity being the mother of invention, long sacred impediments to telemedicine magically disappeared. Insurance companies now reimburse it; relaxed regulations make out-of-state practice possible; and convenient apps allow easy compliance with HIPAA privacy rules. It is not yet clear the degree to which these changes are temporary or permanent, but my guess is that this genie will never go back into the bottle.

The pandemic has made Americans much more dependent on, and comfortable with, screen vs face-to-face contact in their work and social lives. Many patients will likely prefer to continue the convenience of telemedicine rather than return to the inconvenience of travel to doctors’ offices and sitting in waiting rooms. The switch in psychiatry from office practice to telepsychiatry has been incredibly smooth and rapid. Telepsychiatry saves time; increases efficiency; allows much greater scheduling flexibility; permits patients a wider choice of clinicians; and gives clinicians access to a wider pool of patients. Clinicians who feared the loss of face-to-face intimacy find a positive tradeoff in the increased intimacy of seeing the patient in a home context and easy access to family members.

My guess is that telepsychiatry will eventually establish itself as the preferred mode of care for most patients with mild to moderate psychiatric problems. It is not optimal for severely ill patients who suffer from complex psychiatric, medical, social, and economic problems that require face-to-face contact. And there will be a significant minority of patients and clinicians who do not like, don't have access to, or can't use, screens-but this fraction will likely diminish over time.

The clinical practice of telepsychiatry is based on almost no research. We do know that patients and therapists express high satisfaction-and little else. Research funding should be quickly reallocated to allow for the systematic study of efficacy; indications; adverse effects; dropout rates; acceptance; and determination of direct and indirect costs and benefits.

The tragedy of coronavirus pandemic death among persons with SMI dwarfs even the tragedy of neglect that accompanied their deinstutionalization 50 years ago.

 If anything will ever serve as wake-up call to our sleeping collective conscience and drive us to reform, this is it. Too soon to tell, but the early signs do not inspire confidence. Furthermore, telepsychiatry is not just a temporary emergency response to the pandemic- it is the wave of the future. Clinicians and systems are well advised to reorganize their practice habits around it.

 is Professor Emeritus and former Chair, Department of Psychiatry, Duke University; Chair, DSM-IV Task Force. He is the author of 

1. Saxena S, Aquila R, People with serious mental illness tend to die prematurely. We can fix that. 

November 8, 2018. Accessed June 2, 2020. 

https://www.statnews.com/2018/11/08/serious-mental-illness-premature-death/

2. National Association of State Mental Health Program Directors. COVID-19 Response CARES Act Includes $425 Million to Boost Mental Health and Substance Use Disorder Care in the Communities. Accessed June 2, 2020. 

https://www.nasmhpd.org/content/covid-19-response-cares-act-includes-425-million-boost-mental-health-and-substance-use

3. NYU Langone Health. Telemedicine transforms response to COVID-19 pandemic in disease epicenter. 

https://www.sciencedaily.com/releases/2020/04/200430150220.htm

4. Frances A. Repairing Our Broken Mental Health Care System: Advice for Policymakers. 

 January 7, 2020. Accessed June 2, 2020. 

https://www.psychiatrictimes.com/mental-health/repairing-our-broken-mental-health-care-system-advice-policymakers

5. Twenge J. New study shows staggering effect of coronavirus pandemic on America’s mental health. 

https://theconversation.com/new-study-shows-staggering-effect-of-coronavirus-pandemic-on-americas-mental-health-137944

Articles

In just 3 months, the virus has changed the lives of our psychiatric patients and of psychiatry forever. What are the next best steps?

Future of Psychiatry in a Post-Pandemic World

Fifty years ago, I heard the war horrors of many soldiers returning from Vietnam. Today, I'm hearing the medical horrors of many people on the COVD-19 frontlines. "Thank you for your service" simply doesnt cut it. We badly let down our 

The doctors, nurses, aids, food staff, and janitors are among the frontline heroes of the 

. They know its ravages best and are most at risk. It is perfectly normal to experience grief, sadness, fear, emotional numbing, insomnia and recurrent nightmares, loss of appetite, and even suicidal thoughts.

There is no real consolation and no magical advice, but here are a few words from me and list of sites ready to provide support and help. Please dont be too proud to ask. We all need help in time of crisis. And thank you so much for your service.

American Psychiatric Association Coronavirus Resources

New York State Office of Mental Health COVID-19 Resources

American Psychological Association (APA) Resources Page

American Medical Association: Managing mental health during COVID-19

Veteran's Administration National Center for PTSD Resources for Health Care Workers

Schwartz Center Resources for Healthcare Professionals Coping with the COVID-19 Pandemic

SAMHSA Disaster Distress Helpline: 1-800-985-5990

National Domestic Violence Hotline: 1-800-799-SAFE(7233)

National Suicide Prevention Lifeline: 1-800-273-TALK (8255)

The doctors, nurses, aids, food staff, and janitors are among the frontline heroes of the COVID-19 pandemic. They know its ravages best and are most at risk. We mustn't let them down.

Words of Wisdom to Soldiers of the Pandemic

Allen Frances, MD, delivers a powerful message for mental health professionals about the impact of the COVID-19 pandemic on mentally ill patients, clinicians, and the health care system. He offers solutions that may help you navigate these uncertain times.

Allen Frances, MD, delivers a powerful message for mental health professionals to help them navigate the COVID-19 pandemic.

Helping Patients and the Public Endure the Pandemic

Slideshows

In this 4-part collection, the author shares his experience and provides guidance to all involved in the mental health field-patients, physicians, families, and policymakers.

My 50 Years of Experience Condensed Into 50 Tips Each For Clinicians, Patients, Families, and Policymakers

Patients with severe mental illness (SMI) routinely have no access to adequate medication, psychological counseling, social support, and/or housing. The horrible result is that 600,000 patients are either prisoners or homeless-or rotate between the two. The past 50 years of neglect and criminalization have made the US one of the worst places in the world to have a mental illness.

Meanwhile, on the mild end of the psychiatric symptom spectrum, we have the opposite problem of massive over-treatment. About 20% of the general population regularly use psychotropic medications, most often prescribed unnecessarily and carelessly after brief visits with rushed primary care doctors eager to get the patient out of the office as quickly as possible.

 And, perhaps for too many of these patients, psychiatric medications may be no more than expensive placebos, wasteful and carrying the added burden of harmful adverse effects. With that in mind, I offer some advice to policymakers on how to solve the cruel paradox that haunts our mental health “nonsystem”-we are massively overtreating people who do not really need it, while callously neglecting those who desperately do.

The overall thrust of badly needed policy reform must be to correct this wasteful and inhumane misallocation of resources. We should be spending much less money on long-term medications for the worried well and for those with mild, transient problems. Watchful waiting and brief psychotherapy would be a much better (and cheaper) alternatives for them. And, we should also spend much less money on misallocated jail, prison, and police services. In contrast, we must spend much more money on psychiatric and addiction services to help patients avoid becoming prisoners or homeless. The following are my suggestions for policymakers in seven key areas.

1 The top and urgent priority must be to deinstitutionalize 350,000 mentally ill patients who are now inappropriately warehoused in jails and prisons and to rehouse 250,000 who are homeless. If we fail to correct this barbarity, nothing else we succeed in doing really matters.

2 Serious mental illness should be the focus of all publicly funded psychiatric treatment, social services, and housing-with a full push to provide universal and easy access to free services for the poor and the uninsured.

3 A high level and/or high priority mental illness (including addiction) task force composed of senior representatives from all pertinent federal agencies should be charged with developing a joint action plan to provide a nationwide system of community psychiatric, social, and housing services (along the lines of the Kennedy Community Mental Health Act of 1963). Legislation should receive urgent priority, speed through Congress with overwhelming bipartisan support, and be a feather in the cap of whichever president has the honor of signing it.

4 The funding mechanism should provide strong incentives for states and local jurisdictions to participate in the planning and implementation of the new programs and to provide matching funding over the long haul. Because there are so many stakeholders and moving parts, it is premature to speculate on precisely how funding would work and how it would be integrated with, or replace, current funding sources. It is essential that funding sources be bundled so that psychiatric, social, and housing services are integrated in seamless, wrap-around fashion. The chain of care is only as good as its weakest link.

5 Reallocate expenses to address today’s mental health issues. The US spends about $100 billion on corrections; more than one-third of which is for people with mental illness, many of whom would have avoided arrest and incarceration had adequate treatment and housing been available.

Ironically and tragically, jails and prisons have become the main providers of mental health services in the US. Mental illness is also the most worrying problem facing police officers, whose job has expanded to be the responsible first responders for untreated and potentially unpredictable patients.

Moneys saved from reduced expenditures for currently bloated jails, prisons, police, and emergency services should provide ongoing funding for community psychiatric, social, and housing services that will replace them. Deinstitutionalization from psychiatric hospitals failed so miserably 50 years ago, precisely because the large sums of money saved from closing hospital beds did not follow the patients once they were discharged into the community. After eliminating prison beds, there must be an increase in community services and psychiatric beds.

6 Integrated psychiatric, social, and medical services in the community should include enhanced emergency department (ED) psychiatry; 24-hour crisis teams that replace police first responders; walk-in clinics; easily accessed long term follow-up treatment; prompt and thorough medical care; job training; and specialized programs for the most severe mental disorders. Continuity of care must be emphasized every step of the way.

7 The number of short-term inpatient psychiatric beds needs to be increased. Preferably these should be in non-profit, general hospital settings-and not in free-standing, for-profit private psychiatric hospitals (which often deliver overpriced and less competent care).

8 Encourage dual diagnosis programs. The mentally ill are at increased risk for having comorbid substance abuse problems, and vice versa. It is vital to integrate treatment of mental illness and accompanying substance abuse. This is an especially high priority because the combination of untreated mental illness and addiction is the best predictor of violence, suicide, and other poor outcomes.

9 Increase the availability of Housing First programs, which are an essential response to the simple fact that it is impossible to adequately treat people who have no stable place to live. Homelessness is rapidly growing in cities throughout the country due to the shortage of affordable housing and the recent sharp and widespread rise in rents. The mentally ill constitute more than one third of our homeless population, now estimated at about 600,000 and are particularly vulnerable to our national housing crunch.

Warning note: President Trump recently suggested clearing the streets of the homeless by forcing them into what would amount to federal “concentration camps.” Hopefully, this unconstitutional proposal to involuntarily incarcerate hundreds of thousands of blameless people was no more than a transient publicity stunt.

10 Encourage the use of special courts for patients who are mentally ill and addicted to substances to ensure proper referral of minor offenders to rehabilitation programs that help remedy the problems that led to arrest and avoid inappropriate incarceration in jails. Diversion programs are especially crucial in the interim before easy access to integrated care protects patients from committing the minor crimes that currently get them jail time.

11 Integrate psychiatric and medical care with housing programs. People with severe mental illness usually die prematurely-on average 20 years before the general population.

 This is largely a function of psychiatric, medical, and social neglect and can be improved only by increasing access to integrated care.

12 Increase the availability and use of vocational and job placement programs, both of which can be great investments for the individual as well as the economy. Work is often the best therapy.

13 Tighten quality control and financial audits to ensure good care and value for money spent. Currently, there is the potential for waste and mismanagement in psychiatric and addiction programs-particularly in the private system where the profit motive may drive more decisions than optimum care.

High standards must be set for allowable billings and accountable treatment. It is especially important to monitor easy access to care and continuity of care (eg, by auditing number of days before first outpatient appointment after an ED visit or hospital discharge).

14 Encourage assisted outpatient treatment, which reduces incarceration, homelessness, relapse, suicide, and violence. The coercion of court-mandated psychiatric treatment is ever so much gentler and more temporary than the cruel and extended coercion of jail or homelessness.

15 Loosen confidentiality laws in the emergency and long-term management of serious mental illness. Although appropriate in other medical settings, strict laws can be detrimental in this setting. Family support and participation in decision making is needed to help patients whose judgment may be impaired. Laws must balance the value of confidentiality against the need for clinical common sense.

16 Temper the enthusiasm for universal screening for psychiatric disorders. This is a terrible idea in the general population, although it is extremely popular. The harms done (eg, overdiagnosis, excess medication, stigma, misallocation of scarce resources away from the severely ill) far outweigh the benefits. In contrast, screening in high-risk groups has a very good benefit-to-risk ratio (eg, mothers perinatally, victims of extreme stress, high risk families).

17 It is past time to stop fighting the long-lost supply side “war against drugs.” Instead, it is time to reduce demand by providing adequate treatment and prevention. All attempts at interdiction and prohibition have failed in the past and will always fail in the future. Where there is a strong will to get drugs, a clever way will be found to provide them.

18 Adopt harm reduction models-this is the only rational approach for street drugs. Fentanyl is an irrevocable game changer. There has never been a time when illegal street drugs have been so ridiculously cheap, lethally potent, varied, and convenient to smuggle and distribute.

By a combination of design and accidental contamination, illegal fentanyl now has become almost ubiquitous in street drugs and counterfeits. In just 6 years, it has grown from minor threat to disaster drug-responsible for almost half of all the exponentially growing overdose deaths.

Current drug policy is impotent to stop, or even limit, the rush toward fentanyl death and destruction.

19 Free market competition, not interdiction, is the best way to defeat cartels and reduce drug crime. Legalizing drugs (

) should be seen both as a safety measure for the users and an economic weapon against the cartels-not a revenue-raiser for states. For legalization to work, legalized drugs must be priced low enough to compete successfully against street drugs. Legalization can help states save big money on corrections; it becomes self-defeating if it also is used as a tax opportunity.

20 Get rid of the one-size-fits-all notion in treating drug addiction. Puritanical abstinence ideology should not be an exclusive guide to policy. The previous (morality-driven) emphasis on 12-step abstinence has created a great shortage of harm reduction programs using medically assisted treatment. Paradoxically and stupidly, government inaction in regulating the overuse of prescription drugs facilitated the opioid epidemic, while excessive government restrictions prevented the widespread use of the very medications (eg, suboxone) needed to reduce impairment and deaths. Abstinence is possible for some, an aspirational goal for many, but not a foundation for sensible drug policy.

21 Take control of the vaping crisis. The e-cigarette epidemic among young teenagers (started via candy-flavored nicotine products)
	has already become a gateway to the vaping of much more dangerous pot synthetics. The next logical step in this dangerous progression may
	be the lethal vaping of hard street drugs. We must hope that this cat is not already out of the bag.

Unscrupulous vaping companies must be sued and fined; schools need to regain control of their bathrooms; and well-funded public education campaigns should make vaping as uncool as smoking. Drug prevention has never been very successful in the past, but it has never been tried on the same massive scale that worked in making smoking tobacco a dirty habit rather than a rite of passage to adulthood.

22 It is crucial that opioid money awarded to state and local jurisdictions be used exclusively to fund addiction programs. There will be massive fines and settlements (my guess about $100 billion) imposed on the drug companies, distributors, and retailers that knowingly promoted the opioid epidemic. The tobacco settlement money (more than twice as much) never found its way to the victims, as states instead used it to reduce taxes or fund other programs (notably prisons).

23 We must not allow political and commercial foxes to guard the public health henhouse. Regulatory capture by industry contributed greatly to the damage done by the tobacco, opioid, and vaping epidemics. The FDA is 45% financed by the drug industry.

 Its staff and leadership may have a much-too-intimate, revolving door relationship with it.

The FDA’s independence and monitoring authority has also been steadily eroded by political pressure and Congressional statute. The Drug Enforcement Agency was a toothless tiger in controlling the prescription opioid epidemic because its leadership was subservient to industry.

24 Manage sociocultural and political issues that influence suicide risk. Suicide rates have increased 24% during the past 20 years, accounting for almost 50,000 deaths/year.

 Factors outside psychiatry probably have the most influence, particularly increased accessibility to the most common means (eg, guns, drugs); increasing economic inequality and job insecurity; and the contagious perils of social networking.

There will never be one solution to suicide and most of the effective measures taken to reduce overall rates are outside mental health policy and practice. The best suicide prevention is reducing access to guns and drugs; providing a better social safety net; and good treatment for people who are at high risk.

25 Reconceptualize Zero Suicide programs, which are poorly named because they set an unrealistic expectation and imply that caregivers or loved ones could have prevented the suicide had only they been smarter or tried harder. Suicide can be reduced, but never completely eliminated.

26 Keep in mind that the simple things work best in reducing suicide in high-risk groups: continuity of care; easy access to treatment; close follow-up every step of the way with timely and frequent appointments; involvement with family and other supports. There is no magic way to prevent suicide, but good care and caring go a long way.

27 Don’t forget the basic fact: guns kill people. The US has a remarkably high rate of gun death compared with peer countries. Each year guns are responsible for about 24,000 deaths by suicide, 15,000 deaths by homicide, 1000 deaths by accident, and an additional 70,000 non-lethal gun injuries. We do not have higher rates of mental illness than peer countries, but we do have remarkably lax gun regulation and 400 million guns in circulation.

28 Red flag laws that restrict gun access for people with severe and persistent mental illness or addictions make great clinical and policy sense, particularly in reducing deaths by suicide. However, such laws will not come close to solving America’s gun violence problem because only a tiny percentage of murders are committed by people with mentally illness (who are much more likely to be victims of gun violence than perpetrators).

29 Be wary of the National Rifle Association’s political support for better mental health care, which is a great good being done for a great evil. The NRA is attempting to distract attention from desperately needed gun control laws with the absurd and stigmatizing claim that most people who misuse guns are mentally ill.

Mental health advocates are understandably delighted to exploit powerful NRA political support for more mental health services. But we must not be deterred from simultaneously continuing the fight for desperately needed gun control. America would still have terrible gun violence statistics even if we could suddenly cure everyone with a mental illness. We need both much improved mental health services and better gun control laws.

30 Direct to consumer marketing of pharmaceuticals needs more oversight. The US is the only country in the world (aside from New Zealand) that allows direct-to-consumer advertising. This privilege has been abused and should be eliminated. Rules governing marketing to doctors should be tightened. The public needs to learn that a pill for every problem does not exist.

31 Ensure a separation of church and state-industry and the FDA.

There is a revolving door that creates an inherent pro-pharma bias-FDA leadership and staff are often recruited from industry and return to it.

 The result-ineffective, unsafe, and expensive new drugs are almost never rejected and, once approved, drugs are inadequately monitored for harm or not monitored at all. The only way to protect patients and taxpayers is to restore complete FDA independence from industry and political influence.

32 Ensure proper training of other specialties. Primary care doctors now prescribe 80% of all psychiatric medications-often after very brief visits for patients who do not need them.

 They would prescribe fewer unnecessary medications if they had more time to talk to their patients. Most of the emotional problems mistreated with medications may be better handled with advice, support, and watchful waiting.

33 Remove the diagnostic requirement for insurance coverage. Insurance companies require doctors to jump to premature diagnosis and treatment as the precondition for reimbursement. Instead, allowing for an extended period of evaluation would result in much more careful diagnostic and prescribing habits and less long-term use of unnecessary medications.

34 Deprescribing should be extensively taught during medical school and residency training as well as continuing medical education. Physician training includes extensive teaching on how to prescribe drugs and almost no teaching on how to deprescribe them. This is backwards-prescribing is fairly easy to learn and requires relatively little skill. Deprescribing is complicated and requires the finest clinical judgement.

35 There is an urgent need for unified medical care, which is essential and generally lacking. The more doctors a patient has, the more medications will be prescribed-particularly when each doctor neither knows nor cares what the others are doing. Medication adverse effects are the most common cause of new symptoms in someone taking multiple drugs, particularly common among the elderly, who clear and metabolize drugs much more slowly.

36 Make brief psychotherapy easily accessible. Psychotherapy is preferable to medications for most mild to moderate psychiatric problems. It is just as effective, much safer, and with an enduring positive impact.

 The misleading mantra that psychiatric problems all result from a chemical imbalance and therefore everyone requires a chemical cure is misleading.

37 Research budgets should be rebalanced to provide adequate funding for projects that contribute practical findings to improve people’s lives-even if they do not further scientific understanding of brain or gene functioning. The massive budgets of the National Institute of Mental Health, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism are focused on brain mechanisms-not on clinical and services research.

Not surprisingly, we have learned a great deal about brain function and genetics, which has very little of value in helping patients. The past 30 years of intense research and fascinating discovery has made it abundantly clear that the brain and genetics are far too complex to yield any simple answers or breakthrough cures. We must reduce patient suffering now, not wait for promised breakthroughs that never happen.

38 Top priority should be given to research studies and demonstration projects that reduce the incarceration and homelessness of people with serious mental illness and addiction. Public health significance, not just scientific interest, should be an important factor in selecting which projects are funded.

39 Keep in mind that there is an enterprise-wide bias hype positive results, ignore negative studies, and neglect to replicate study results. This distortion leads to tried-and-true treatments for mentally ill patients to be overlooked while the untried and untrue are prematurely promoted.

40 Advocacy has failed in the past and, unless radically changed, is likely to continue to fail in the future. We are the richest country in the world, but we shamelessly and barbarically neglect our most vulnerable citizens in a way that would not be tolerated in any of our peer countries. Politicians respond only to money, votes, and public shaming-patients with serious mental illness and addiction are often poor, don’t or can’t vote, and have no public voice.

41 Our current crisis makes this a potential moment of rare opportunity-don’t waste it. The armies of homeless living desperate lives in plain sight in most major cities are impossible to ignore. The “not in my neighborhood” reflex against treatment programs and housing becomes much less powerful when the homeless are already in your neighborhood.

The opioid crisis, that afflicts millions, and kills tens of thousands every year, is also impossible to ignore. The push for correctional reform occasioned by frequent police shootings and the prison crisis have made police officers and sheriffs the most effective advocates for better services and housing for those suffering from serious mental illness and addiction.

42 Remember that mental illness and addiction strike families indiscriminately across the political divide. This is one issue that can and should achieve universal bipartisan political support.

I would love to end on an uplifting “Yes we can” inspirational note. But the past 60 years of neglect would make it ring hollow. Our best (only) hope is that the most concerted efforts, occurring in what is now the most inescapably desperate context, will end the complacency and achieve what has heretofore been impossible: at long last, to force our country to do the simple and right thing, which also happens to be the smart thing.

 What advice would you share with policymakers, patients, and family members? What do you wish your colleagues in psychiatry or general medicine knew or did? And, what advice did you wish someone had shared with you? Send your thoughts to 

Dr Frances is Professor Emeritus and former Chair, Department of Psychiatry, Duke University; Chair, DSM-IV Task Force. He is the author of Saving Normal and Essentials of Psychiatric Diagnosis. Twitter: @AllenFrancesMD. The views expressed in this article are those of the author and do not necessarily reflect the opinions of

1. Miller SG. One in six Americans takes a ssychiatric drug. 

2. Treatment Advocacy Center. Research Weekly: Homelessness Increases Among Individuals With Serious Mental Illness. January 11, 2018.

3. National Institute of Health. Combating Early Death in People With Serious Mental Illness. November 4, 2015.

4. Centers for Disease Control and Prevention. Fentanyl.

5. US Food and Drug Administration. Fact Sheet: FDA at a Glance. October 2019.

6. Kaiser Health News. KHN Morning Briefing: Justice Department Report: DEA Let Painkiller Production Surge Even as Opioid Epidemic Alarm Sounded. October 2, 2019.

7. Centers for Disease Control and Prevention. Suicide Rising Across the US.

8. Pew Research Center. What the Data Say About Gun Deaths in the US. August 16, 2019.

9. Piller C. FDA’s revolving door: companies often hire agency staffers who managed their successful drug reviews. 

10. Cuijpers P, Quero S, Dowrick C, Arroll B. Psychological treatment of depression in primary care: recent developments. 

Repairing Our Broken Mental Health Care System: Advice for Policymakers

 on how best to cope with their psychiatric problems.

 This third in the series provides advice to families on how best to cope with the psychiatric problems of a family member.

In the near future, I will post the fourth and final installment in the series-advice to our society on doing a much better job of helping our mentally ill live safe and productive lives.

My 50 Tips to Families Based on 50 Years of Experience

1. It is completely natural to blame yourselves for the psychiatric troubles of your loved one, but most often it’s neither rational nor helpful.

2. Severe mental disorders have multiple and mysterious causes. Family stress, if involved at all, is usually only a minor contributor. More often, family stress results from, rather than causes, the individual’s psychiatric problem.

3. Feeling irrationally guilty not only hurts the family, it also reduces its ability to see things clearly and provide the optimal combination of supports and limits for the loved one.

4. If the family member has a psychiatric problem that’s only mild and transient, it will likely have little negative impact on the family and may even strengthen family bonds as everyone pulls together.

5. In contrast, psychiatric problems that are severe and persistent can create severe and persistent family stress and conflict and will likely have a profound and sustained impact on the lives of all close family members.

6. How well the family copes with the person’s psychiatric problem usually influences how well he will cope with it. And how well he copes with his problem will reciprocally influence how well the family copes with him and with it.

7. Having a family member with a severe and chronic psychiatric or addiction disorder is probably among the most challenging stresses any family can ever face-just as tough as dealing with chronic medical illness and severe financial problems. Some families get closer; some fall apart; only a few stay the same.

8. Family coping depends not only on the strength and resilience of its individual members, but also how well and consistently they work together and are able to support each other. Family therapy may help improve family coping.

9. Don’t feel you have to hide the family’s psychiatric problem. Societal stigma is rapidly diminishing and increasingly everyone is coming to understand that there is no shame in having a mentally ill loved one.

10. Seeking help earlier rather than later will greatly reduce the severity of symptoms, problematic behaviors, impairment in functioning, risks, burdens, and complications.

11. Be a very well-informed consumer. Learn all you can about the diagnosis; treatment alternatives; insurance coverage; housing; disability; navigating the mental health and medical systems; and how to access social services. Never be shy about asking questions and expect clinicians to have clear, convincing, common sense answers. The internet is a great source of information, but don’t believe everything you read.

12. Family sessions with clinicians are usually vital for the information they can convey to the clinician and the information she can convey to them.

13. Be unembarrassedly honest; open to learning new ways of understanding and relating to your loved one; and to developing new family coping skills.

14. Our society over-treats the worried well and mildly ill, while cruelly neglecting those with severe mental disorders. Be wary of getting too much treatment (especially medication) for problems that would get better on their own; and too little for those that will get much worse in the absence of immediate and thorough attention.

15. Psychiatric medications are not a good first choice if your family member has only mild, transient, and/or expectable symptoms of sadness, grief, anxiety, or stress. There is not a pill for every problem and most problems resolve on their own. Kids, in particular, are being over-medicated after quick and careless evaluations. Be skeptical, be informed, and always ask lots of questions before accepting a psychiatric med.

 in order to learn more about the role of psychotherapy and the uses and misuses of medication in the treatment of psychiatric disorders.

17. Be aware that there are lots of different forms of psychiatric treatment and that no one size fits all.

18. Many treatments have a strong base of supporting evidence, some do not. Whenever possible, evidenced based treatments are preferred.

19. Psychiatric treatments are about as effective (but also as ineffective) as most treatments in the rest of medicine. It makes sense to be optimistic they will help, but don’t expect miracles. Too-good-to-be-true claims for magical results turn out never to be true.

20. Treatment outcomes are very variable and impossible to predict precisely. Most people experience at least partial benefit from psychiatric treatment; some people enjoy a full recovery; a minority have no response at all; and, unfortunately, a few are harmed.

21. Things often go better if your family member allows you to contribute to discussions regarding choice of optimal treatment. Selecting a specific treatment plan among the plausible alternatives depends on the person; the nature of the problem; its severity; preferences; clinician training; availability; and the results of previous serial systematic trials aimed at learning what works best.

22. “No Treatment” may sometimes be the treatment of choice-especially if your family member is experiencing only the normal, expectable problems of everyday living or has had no or bad responses to previous treatment trials.

23. For mild symptoms, watchful waiting; the healing powers of time; stress reduction; and family support may be all that’s needed.

24. In contrast, severe/persistent symptoms require immediate attention. The longer you wait, the harder they may be to treat and the slower and less complete the treatment response.

25. Good clinician/patient match is crucial to good outcome. If possible, have your family member interview several different clinicians before picking the one he and the family are most comfortable with.

26. Try to find non-intrusive ways to promote close adherence to any treatment plan that’s working.

26. Stopping/erratically taking needed medication is the biggest cause of relapse and should be the first thought if symptoms start returning. The risks of stopping needed medications are great-if there is a full-blown relapse off medications, restarting them later may no longer be as effective or even work at all.

27. Learn to spot early symptoms of relapse and help your loved one promptly get help for them to avoid a full-blown episode.

28. People tend to stop the medications they need because of any combination of side effects; feeling better; use of alcohol or drugs; forgetfulness; resentfulness; and/or denial of illness. Identifying the reason(s) may shape effective responses that help the patient stay on an effective dose for the necessary duration.

29. Tragically, the lifespan of people with severe mental illness is 15 to 20 years shorter than for the general population. Causes are heavy smoking (done because it reduces symptoms and drug side effects); obesity/diabetes promoted by drug side effects; poor diet; lack of opportunity for exercise; poor access to health care; and suicide. It’s admittedly difficult to change any of these powerful health risk factors, but stay alert for points of leverage, especially in regard to need for good medical follow-up.

30. Excessively rigid medical privacy laws prevent mental health clinicians from providing information to families except with the patient’s permission or in extreme emergencies. These go into effect once your child reaches the tender age of 18 and can exclude you from knowledge of what’s happening; ability to provide support; and any participation in treatment decisions.

31. These confidentiality restrictions often create a potentially tragic missing link in the care of a loved one with severe psychiatric illness. You may be left out of the loop during psychiatric and medical crises even when you have crucial information to provide and crucial support to give.

32. Don’t get angry with clinicians withholding information-they are just following a dumb law. But do persistently stay in touch with them and give them all the information you can. The law may force them to be silent, but you don’t have to be at all silent with them. The more they learn from you, the better the treatment decisions will be.

33. In the midst of an acute episode, patients sometimes lose insight about their mental illness, need for treatment, and value of family involvement. Advanced Directives, written once they have recovered insight and judgment, are very useful to deal with the confidentiality issue; avoid family conflict; and facilitate prompt treatment when it becomes most desperately needed in the future.

34. The time to prepare for emergencies is before they happen. Know all the resources available in your area and how to best, and most promptly, access them.

35. The risk of suicide is probably what will scare you most. The suicide rate is greatly increased in people with significant psychiatric disorders but is still only about 10% to 15% over the course of an entire lifetime and is very low at any given moment.

36. Predicting suicide is therefore like finding a needle in the haystack. It is easy to predict a group of people at elevated lifetime risk of suicide-but impossible to predict which person within that group will do it, and when. Risk factors include the presence of psychiatric disorder; previous attempts; family history of suicide; friends who attempted or completed suicide; persistent suicidal thoughts and plans; urgency; lethality of means; impulsivity; substance use; and hopelessness.

37. Feel free to ask about suicidal feelings and encourage your loved one to discuss their nature, causes, cues, past actions, preferred means, and future plans.

38. Remove potential means of suicide whenever possible-especially guns and medications.

39. Encourage/insist that your suicidal loved one get help. Making the appointment as soon as possible and facilitating attendance will go a long way to initiating treatment and reducing risk. Do everything possible to facilitate close follow-up.

40. Every suicidal person who is still alive is at least somewhat ambivalent about suicide. Often the person may look for explicit and implicit external messages whether life is worth living. Make it clear it is very important to you that he stay alive; that his death would be a much worse burden than his life; and that you look forward to things getting much better in the future.

41. Ultimately, suicide is a personal decision that no family can take responsibility for preventing. The most appropriate reaction to a successful suicide is to miss the person and grieve the loss, but don’t blame yourself. Second guessing yourself is inevitable, but unproductive. Second guessing other family members often leads to family break-ups.

42. Caring for a family member with severe mental illness can be emotionally and physically exhausting, particularly if things aren’t going well; if there is family conflict; and as you age. Get as much help as you can. Other families in support groups, who have been through similar problems, can be great help. Family therapy may sometimes be needed. Social supports and respites can help keep you from being stressed out or burnt out.

43. Remember, it is often the illness talking, not your loved one. Interpersonal conflict (sometimes severe and persistent, sometimes transient) is almost inevitable between other family members and a patient suffering from mental disorder or addiction. Try to be patient, resilient, forgiving.

44. Court-ordered inpatient or outpatient treatment is rarely necessary, but sometimes crucial in acute emergencies; to promote long-term stability; and/or to avoid the much worse coercion experienced by the 600,000 people with severe mental illness currently in jail or homeless because they didn’t receive appropriate psychiatric and social services.

45. The most dangerous situations occur when your family member with a mental illness refuses treatment, uses drugs, and has a history of violent behavior.

46. It sometimes becomes impossible for a family to help a family member who is clearly incapable of taking care of himself. The court may appoint a guardian ad litem to take over responsibility for supervising care; living arrangements; and finances.

47. In rare and extreme situations, fierce hostility and/or physical threats may make it, at least temporarily, impossible to continue contact with your mentally ill or family member with a substance abuse problem. Protecting the rest of your family may have to take priority.

48. Know your limits. Do your best-but not more than you can do. Love can help, but by itself cannot cure all problems. Change what you can, but accept there are things in life you can’t change.

49. The lack of resources to help people with mental illness is scandalous. Get mad and get active. Bug your local politicians. Vote for national candidates who favor better health care. Join advocacy groups. Be heard. The mentally ill are so terribly neglected, precisely because their voice has been so silent.

50. Never give up hope. I have seen hundreds of miracle recoveries. It often gets darkest before the dawn.

Hope this is helpful. If I have left out valuable stuff, please let me know via Twitter: 

Dr Frances is Professor Emeritus and former Chair, Department of Psychiatry, Duke University; Chair, DSM-IV Task Force. He is the author of 

The views expressed in this article are those of the author and do not necessarily reflect the opinions of

This third in the series provides advice to families on how best to cope with the psychiatric problems of a family member.

Author | Allen Frances, MD

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