What can we do to fix our broken mental health system? Psychiatric Times posed this question to some of the leading experts in the field.
Editor’s Note: We’ve asked various people with ties to the mental health community to contribute a list of what they consider the most important things needed to fix the mental health system in the US. We received suggestions from psychiatrists, mental health writers, mothers, and a former patient. In order to eliminate any suggestion of bias or priority, we’ve ordered the list in alphabetical order by contributor. We urge you to contribute your suggestions of what needs to be done to fix the mental health system.
-Natalie Timoshin, Managing Editor
Introduction: How Do We Fix Our Broken Mental Health NonSystem?
Sixty years ago, community psychiatry was the big new idea that would provide a much brighter future for people with severe mental illness. Warehoused inpatients would be liberated from antiquated, overcrowded, snake pit hospitals. Living in decent community housing, they would receive psychosocial support and benefit from the newly available psychiatric medications. And, as an added bonus, deinstitutionalization would be cost neutral because hospitals were more expensive than outpatient care.
The dream worked well in many countries, but turned into a bitter nightmare in the US. State governments reallocated much of the saved hospital funds to other purposes. Community mental health centers were either never realized at all, or starved, or privatized and allowed to cherry pick the healthier, wealthier patients.
I have written several blogs to describe the ensuing mess that makes this one of the worst times ever to be mentally ill. What's the solution? How do we create a compassionate, cost effective mental health system? Psychiatric Times posed this question to some of the leading experts in the field. The group is remarkably diverse in experience and orientation, but their answers turn out to be remarkably convergent.
Please post your comments, especially if you see important things that have been left out.
Allen Frances, MD
Dr Frances was the chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine in Durham, NC. He is currently Professor Emeritus at Duke.
Five Big Steps to Rebuild the System
1. Create single points of access: 24-hour hotlines for patient evaluation, treatment, family information as well as a federal website for referral to resources
2. Coordinate services for patients and their families: provide broad offerings for people with mental illness and facilitators for quick access to integrated care
3. Develop an array of community-based services: individual and group psychotherapy; marital and family therapy; substance abuse treatment; medication; rehab and supported housing options
4. Provide accessible crisis and inpatient services: rather than current resort to Emergency Room and in many cases jail/prison, we need timely crisis services, outpatient treatment linked to inpatient care and quicker access to beds
5. Build a stable funding stream: long-term state budget commitments; aggressive oversight of insurers’ coverage decisions; federal dollars to fill the gaps
Paul S. Appelbaum, MD
Dr Appelbaum is Dollard Professor of Psychiatry, Medicine, and Law; Director, Division of Law, Ethics, and Psychiatry; Director, Center for Research on Ethical, Legal and Social Implications of Psychiatric, Neurologic and Behavioral Genetics in the department of psychiatry at the Columbia University College of Physicians & Surgeons.
A Mother’s Perspective
1. Incorporate the ideas of psychiatrist Sandra Bloom and the Sanctuary Model of mental health care; Dr Bloom says the important question in psychiatry isn’t “What’s wrong with you?” but “What happened to you?”
2. Promote hope for a life worth sticking around for
3. Provide trauma-informed care
4. Help with reducing the dosage of or withdrawing from psychiatric drugs
5. Ban direct-to-consumer advertising of psychiatric drugs
6. Decent housing for patients, preferably within a therapeutic community
7. Partner with non-medical models of care such as Hearing Voices Network and Open Dialogue (University of Massachusetts Psychiatry is leading the U.S. effort with Open Dialogue for the treatment of psychosis)
9. Help in repairing frayed relationships with family and significant others
10. Explore the patient’s “psychiatric” issues in the context of his/her life experiences
Suzanne Beachy is a mother, musician, writer, and activist, who advocates for more recovery-oriented approaches to treating the kind of mental/emotional distress which gets labeled as “severe mental illness.” She writes, “Any diagnosis of a mental disorder can result in a complicated and uncertain fate for those it strikes. When you lose a son as a result of such a diagnosis, it ignites a painful and prolonged search for answers.”
Forget About Improving Mental Health: Treat Serious Mental Illness
1. Target the sickest: those who need help the most, rather than the least.
2. Increase the number psychiatric hospital beds by ending the IMD [institutions for mental diseases] exclusion in Medicaid and 190 day cap in Medicare.
3. Ensure easy access to doctors and medications for the seriously ill.
4. Re-evaluate direct-to-consumer pharmaceutical advertising to end medicalizing normality.
5. Reform HIPAA and FERPA [Family Educational Rights and Privacy Act] so families can get info they need to help ill relatives.
6. Implement civil commitment reform so people can be treated before they become ‘danger to self or others’ rather than being forced to wait until after.
7. Enact and implement AOT (assisted outpatient treatment) programs to create a less expensive, less restrictive, more humane alternative to inpatient commitment and incarceration.
8. Reform PAIMII (protection and advocacy program) so it helps the seriously ill get into treatment rather than out of treatment.
9. Increase the number of mental health courts
10. Listen to criminal justice experts instead of mental health industry as they have more experience with the seriously ill.
11. Focus research on the most serious mental illnesses.
12. Fund what does work: assertive community treatment; supported housing; clubhouses.
13. Stop funding what doesn’t work: suicide and stigma advertising; programs that claim they prevent mental illness; peer support.
14. Eliminate SAMHSA to end public funding of antipsychiatry and non-evidenced based practices.
Mr. Jaffe is the founder of Mental Illness Policy Org, (http://mentalillnesspolicy.org) which provides media and public officials with unbiased information about “serious” mental illness from a pro-treatment perspective: @MentalIllPolicy.
Child and Adolescent Issues
1. Assisted outpatient treatment
2. Case worker/central care coordinator
3. Early intervention (train pediatrician to recognize signs)
4. Crisis intervention team (CIT) training for police
5. Housing and employment (eg, Housing First)
6. End Medicaid Institutions for Mental Diseases exclusion
7. Education for special needs
8. Research funding for more effective treatments
9. Community supports for families (including respite care)
10. Efforts to end stigma and discrimination (I think the most effective way to do this is for people to interact with those who have mental illness rather than isolating them and their families)
Ms Long is the mother of four children, one of whom has bipolar disorder. She is the author of The Price of Silence: A Mom’s Perspective on Mental Illness from Hudson Street Press.
A Former Patient’s Perspective
1. The provision of holistic, person-centred care-truly bio-psycho-social
2. Formulating the nature of difficulties and distress in a way that feels valid and useful for the client, identifies ways to move forward, and is developed with a sense of empathy, respect and optimism
3. Providing continuity of care with the same team, and supporting the growth of dedicated, caring and compassionate alliances between clients and workers
4. Improving access to peer-support groups and networks
5. Greater collaboration between clients and workers that facilitate shared decision-making and informed choices about care
6. Supporting the development of active coping strategies, including the provision of hopeful, empowering information (eg, recovery stories)
7. Developing crisis houses as alternatives to hospital
8. Exploring clients’ needs, wants and wishes (eg, social and occupational goals, cultural/spiritual needs)
9. Improving physical healthcare, including better monitoring of medication side effects
10. Forging active connections with formal and informal supporters - families, friends and community
Eleanor Longden, MSc
Eleanor Longden is a postdoctoral researcher at the University of Liverpool Psychosis Research Group and a trustee of Intervoice (www.intervoiceonline.org). She lectures and publishes internationally on aspects of psychosis, trauma, and recovery and is the author of Learning from the Voices in my Head (TED Books, New York: 2013).
A Blast From the Past
Psychiatry has a record more than two centuries long. On the basis of that record, here is what needs fixing today:
1. Use the medical model, not the “biopsychosocial model” to delineate diseases in psychiatry. This means a careful psychopathological circumscription of disease entities, their verification with biological tests, their validation with differential response to medication (we can at least make a beginning at this, as we have done with catatonia and melancholia).
2. Break the “Kraepelinian grip” upon diagnosis by abolishing the firewall he erected in 1899 between mood disorders and chronic psychosis.
3. Restore the Kraepelinian unity of the mood disorders by lumping major depression, bipolar disorder, and the manias into the same pot, which we will now call “Kraepelin Disease” (there will be much psychosis in this pot since we have abolished the firewall).
4. Complete the liberation of catatonia as an independent disease entity by calling it “Fink Disease” after Max Fink, who fought against great odds to have catatonia removed as a “subtype” of schizophrenia and given a home of its own that it now partially has in DSM-5.
5. Take the classification of disease away from the American Psychiatric Association and its “DSM,” and give it to an independent agency, such as the Karolinska Institute or the NIMH for a completely new beginning (the WHO would not be a candidate for this mission since its ICD has now been largely corrupted by DSM).
6. Abolish psychoanalysis from the psychotherapy training of residents (it is like making a course in astrology requisite for the training of astronomers).
7. Vastly increase the psychopathology content of residents’ training (and ditch the “operative criteria” of DSM).
8. Firm up cross-training between psychiatry and neurology, so that “clinical neuroscience” ceases to be dominated by neurology and psychiatry gets another shot at being scientific.
9. End the hysteria about not accepting ballpoint pens and the like from industry on the grounds that such tokens will bias clinical judgment.
10. Restore the history of psychiatry to a prominent place in the postgraduate curriculum (and in the leisure reading of practitioners) because it is historical wisdom that tells us how fragile are our diagnoses today, how inadequate our treatments.
Edward Shorter, PhD, FRSC
Dr Shorter is Jason A. Hannah Professor of the History of Medicine and Professor of Psychiatry at the University of Toronto.
1. Vigorous enforcement of mental health parity
2. Federal support for supported housing programs
3. A federal or state mental health service corp for underserved communities, such as Teach for America
4. Subsidized training in evidence-based practices
5. Availability of ACT to any in need via Medicaid and private insurance
6. Assisted Outpatient Treatment as a Medicaid-covered service
7. Regional depot clinics created and incentivized
8. Regional clozapine clinics created and incentivized.
9. Free telemedicine psychopharmacology consultation clinics create
10. End the IMD exclusion in Medicaid for hospitals that demonstrate adequate medical services on-site
Marvin Swartz, MD
Dr Swartz is Professor of Psychiatry and Behavioral Sciences at the Duke University School of Medicine in Durham, NC.
The Ten Commandments
To implement the lessons learned from our past quarter century of failure at deinstitutionalization, I propose 10 commandments or basic rules to govern our future actions.
1. Before patients are discharged, there must be an adequate number and range of community services and facilities to provide patients with treatment, care, and community support.
2. Barriers to full participation in health and mental health delivery systems must be removed so that existing eligibility and reimbursement practices that discriminate against the chronically mentally ill are not perpetuated.
3. Chronically mentally ill patients must have full civil rights and opportunities, including equal access to housing, education, vocational rehabilitation, income maintenance, and adequate care in the community.
4. Money must follow patients. That is, funding must be as flexible as patient populations, and if there are further shifts in the locations of care or treatment, monies must accompany the patients to meet their needs.
5. Medical-psychiatric money should be separate from but coordinated with funding for community support (for example, housing, food, income support, social services, and vocational and social rehabilitation). It is especially critical to keep this requirement in mind when considering what benefits are to be included under national health insurance.
6. A system that ensures continuity of care must be developed. To date, the degree of achievement of this truism is inversely related to its utterance.
7. A case management system must be established. Such a system should not create a whole new profession or paraprofession but should make use of existing manpower and resources.
8. Services should be provided by the smallest local entity that is capable of delivering such services. Such entities must designate a specific person or facility as the core service agency of the service delivery system.
9. Federal, state, and local governments should divest themselves of the conflict of interest inherent in both contracting for services and operating services themselves. If local entities operate services, city and county governments can monitor and plan them on their level, states can coordinate a statewide plan, and the federal government can oversee a national effort.
10. There must be a concerted national effort that would increase and continue existing research into the causes of chronicity, its prevention, effective treatment, and model service systems for the chronically ill.
John A. Talbott, MD
Dr Talbott is Professor of Psychiatry at the University of Maryland School of Medicine in Baltimore, Maryland.
10 Ways to Improve Mental Illness Treatment
1. Abolish the IMD (Institution for the Treatment of Mental Disease) exclusion and block grant all existing federal funds used for the support and treatment of mental illness and substance abuse (Medicaid, Medicare, SSI, and SSDI) to the states.
2. Designate state governors as ultimately responsible and accountable for all mental illness and substance abuse services in their state.
3. Every 2 years the federal Government Accountability Office (GAO) will issue a report card rating the states on quality of care for individuals with mental illness and substance abuse.
4. Abolish federal Substance Abuse and Mental Health Services Administration (SAMHSA) and transfer its $3.5 billion budget to the National Institutes of Health (NIH) to do research on services for mental illness and substance abuse.
5. Each state establishes an independent commission, reportable directly to the governor, to make unannounced inspections of all treatment facilities and housing for persons with mental illness and substance abuse, and issue public reports of its findings.
6. Establish a federal program to fund the training of additional psychiatrists, psychologists, psychiatric nurses, and psychiatric physician assistants with mandated payback obligation in underserved areas in the state in which they are trained.
7. Modify state involuntary treatment laws and increase use of assisted outpatient treatment (AOT) and conditional release for the 1% of severely mentally ill individuals who need such treatment.
8. Modify the Health Insurance Portability and Accountability Act (HIPAA) as recommended by Rep. Tim Murphy’s proposed legislation (Helping Families in Mental Health Crisis Act, HR 3717).
9. Increased funding for NIH institutes for research on improved treatments for severe mental illness and substance abuse.
10. Public funding of all programs for mental illness and substance abuse should be restricted to government agencies and non-profits; for-profit entities should not be eligible for public funds.
E. Fuller Torrey, MD
Dr Torrey is a research psychiatrist who specializes in schizophrenia and bipolar disorder. He is founder of the Treatment Advocacy Center and Associate Director of the Stanley Medical Research Institute, which supports research on schizophrenia and bipolar disorder, and he is Professor of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md. He is the author of American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System.
10 Most Important Things to Fix the Mental Health System
Effective and lasting improvement in mental health care will occur when our civil discourse has moved beyond fear and misunderstanding. The Foundation for Excellence in Mental Health Care emphasizes 3 overarching themes:
• Supports and treatments are most effective when they are designed and implemented in partnership with the people we are trying to help
• We need to recognize the important role social determinants play in the development and persistence of psychological distress
• Cultural and ethnic diversity should be honored and embraced
The many forms of mental health challenges are complex and social determinants play a major factor in their etiology, course, and outcomes. The dominant paradigm at present, which includes the rapid assignment of a diagnosis and quick application for Social Security disability insurance, emphasizes a medical model that places the problem almost entirely within the individual and ignores the contribution of social factors.
We propose the following immediate changes derived from people with lived experience and practice-based evidence to fix the mental health system:
1. The guiding principle for all care should be “People First.”
2. Transform current systems of care to a recovery-orientation that is humane and trauma-informed.
3. Provide more opportunities for people suffering from extreme psychological distress and their families to meet with people trained in approaches that emphasize a person-centered, needs adapted approach to care
4. Address data on the dangers of long-term use of drugs and significantly reduce the use of high-dose, polypharmacy practices and the long-term overuse of psychiatric medications. This would require further research to better understand optimal pharmacotherapy including questions regarding who may be more effectively treated with short-term as opposed to long-term medications as well as who is likely to recover without them.
5. Increase understanding of/education and access to good nutrition and opportunities for exercise.
6. Develop more programs that divert people with mental health challenges and substance abuse disorders from jail.
7. Increase support and education for families and new parents. This should include the provision of early childhood education and offering access to solid, safe and engaged adults, creation of secure attachments for infants, and toddlers, and supporting young parents to break generational vulnerabilities. We should provide key support for junior high, high school, and college age youth who struggle with mental health and/or substance use issues.
8. Engage with media to create a series of public health campaigns specifically targeted to reduce discrimination and educate the public regarding the dangers of long-term use of psychiatric medications as well. Partnering with media would show the value the engagement of private philanthropy has and emphasize the importance of its role in helping to create change. The Foundation for Excellence in Mental Health Care is the leadership of a community change process that is designed to engage private philanthropy for the purpose of improving mental health care. www.mentalhealthexcellence.org.
9. Provide funding for supported education and employment to help distressed people finish their education and to get to work in order to find purpose and meaning in their lives and have avenues to make contributions to their communities.
10. Convene national meetings with key peer leaders and national mental health leaders to articulate a recovery-oriented system of supports and services followed by:
• Appoint a council of peer monitors for each state and community to assess the re-organization of service systems including changes in funding and hold leaders and staff at all levels publicly accountable for reformulating the system at all levels.
• Redistribute research dollars to ensure that adequate funding is devoted to developing and evaluating new pathways to promoting resilience, recovery, and overall health rather than limiting funding to seeking answers that are based solely and narrowly on a brain disease hypothesis. A commitment to a biopsychosocial model should be operationalized through providing research funding for all three components.
Gina Nikkel, PhD
Dr Nikkel is President and CEO of the Foundation for Excellence in Mental Health in Wilsonville, Oregon.