Repairing the Mental Health System
Repairing the Mental Health System
Editor's Note:
In the aftermath of the tragic death of 26 people (including 20 children) in Newtown, Connecticut, on December 14, 2012, much needed attention is being paid to mental health care in the United States. Additional stress on the system has resulted from major disasters like Hurricane Sandy and the recent wars, which have severely taxed civilian and service populations, further affecting already limited psychiatric resources. Many of those directly and indirectly affected by mass shootings, war, or disasters will need mental health treatment. And, of course, large portions of our population independently suffer from serious psychiatric disorders. Unfortunately, those in need of psychiatric care often have very poor access to appropriate management due to lack of resources; others don't seek out care due to real or perceived societal stigma. Together, these barriers represent a major inadequacy in US mental health care. Medscape recently spoke with psychiatrists Richard H. Weisler (UNC-Chapel Hill and Duke University Medical Center), Henry A. Nasrallah (University of Cincinnati College of Medicine and University Hospital), and Joe Parks (Missouri Institute of Mental Health) about the status quo of mental health care in the United States and what can be done to repair the system.
Medscape: It seems like every week we hear about another psychiatric hospital or unit closing its doors, or another state cutting mental health care funding. Can each of you comment on the worsening lack of psychiatric resources in the United States and the impact that this worrisome trend might have?
Dr. Weisler: If you do an online search, you'll find article after article from small towns to big cities -- and also at the state level -- about the impact of all of the recent closures. Chicago's Tinley Park Mental Health Center closed this past summer while Cedars-Sinai in Los Angeles closed its psychiatry department. Also this past summer, in North Carolina, the final patients left the storied Dorothea Dix Hospital. This is happening around the country, leading to a shortage in psychiatric services.
There is also a severe shortage of mental health providers in the United States, and it's getting worse. This is in part because half of US psychiatrists are over age 55 years, and not as many new people are entering the field as are needed. There is also a shortage in researchers.
Dr. Nasrallah: In the '60s and '70s, the National Institute of Mental Health provided additional residency stipends prompting many medical students to enter the field of psychiatry. Now there is a bottleneck due to inadequately funded residency positions. There are also a lot of very good international medical graduates out there desperately trying to get into psychiatric residency programs. But for various reasons, many of them are being turned down. If there were more slots available, I think they would be filled. We can train 50% more psychiatrists a year than what we are currently producing, which is roughly 1200 psychiatrists a year, which barely keeps up with the attrition on the other end with retirement and mortality.
Dr. Parks: I don't think we do well at the local level because we tend to separate ourselves -- the "mental health group" -- and don't join and assist others, such as primary care providers or even the police, with their issues. All we do is ask for help with our needs and our problems -- it's not an effective approach to partner with somebody like that. If you want a partner, you go and find out what their needs and problems are, take care of them, and then you ask for something for yourself.
Dr. Weisler: That's an excellent thought, Joe. It should be easy for us to find partners. For example, and I've done this recently, one contact to make is with your local emergency department (ED) providers and administrators. The EDs are frequently filled with psychiatric patients waiting for beds. It's even worse than when we talked about it a couple of years ago here on Medscape. They'll wait for days and sometimes for weeks. There's usually a huge waiting list, and there are also what they call "no admit" lists. If a patient is aggressive, it often feels like nobody really wants and/or feels that they have the staff to care for them. If you have a demented patient with psychosis, it's also much harder to find a bed, especially if they are agitated. Remember, we have no US Food and Drug Administration (FDA)-approved treatments for psychosis or agitation in dementia, yet the numbers of patients who will require such treatment are rapidly increasing as our population ages.
Dr. Parks: To that point, I have a problem with EDs saying they're choking or they're backed up with mentally ill people or substance abusers. I ran some 10-year trend numbers on Missouri from 2000 to 2009, the last year we have complete data posted on our Website. During that time, the number of mental health ED visits went up about 43.9%, and the total ED visit rate went up 17.4%. If you look at the numbers, the increase in ED mental health visits was about 19,732 from 2000 to 2009, which is only 6.1% of the total ED visit increase of 324,585 visits from 2000 to 2009. Overall mental health ER visits went from being 2.40% of total ER visits in 2000 to 2.96% of total ER visits in 2009. How can they be choking on mental health patients when we represent 6.1% of the total ER volume increase and a net proportional increase of 0.56%?
Dr. Weisler: You may be right about the numbers, but it's often true that there is no place to send these patients in many cases, especially if state mental health beds are full.
Dr. Parks: So why do these hospitals not have inpatient psychiatric units? If they had more women delivering babies than they could handle, they would open more obstetrics capacity. If they had more people with broken legs than they could handle, they would open more orthopedic capacity.
Dr. Nasrallah: You're absolutely right, Joe. There seems to be no feedback loop in mental health. It's just a one-way street, and there doesn't seem to be a correction for anything, which tells me that the entire field of mental health may go downhill very fast. And no one is trying to pull it back and approach care in a rational manner based on data such as patient and population needs. If 25% of the US population has a recognizable, diagnosable, and treatable mental disorder, why is this happening? A total of 80 million people in the United States are not being well represented, namely because, as Joe said and Rick insinuated, we're not partnering. We're not doing our job collectively in order to fight the current crises at the local level. But we need to scream loudly that for everything that happens around the country, and that communication pattern, we're failing to communicate and to have rapid response, and therefore those who are cutting mental health budgets are continuing to cut unabated because they don't face any tangible resistance.
Dr. Parks: I think the ED is an excellent feedback loop for identifying what's needed in a local healthcare delivery system. I think making the problem the lack of public beds is exactly the wrong message. It says that it's okay to push these people off to the side; the local hospital doesn't want to deal with them. And that is unacceptable. These hospitals, these people with mental illness in the EDs are members of their community, and these are community hospitals. If there's a medical need, they should be developing that capacity.
Editor's Note:
In the aftermath of the tragic death of 26 people (including 20 children) in Newtown, Connecticut, on December 14, 2012, much needed attention is being paid to mental health care in the United States. Additional stress on the system has resulted from major disasters like Hurricane Sandy and the recent wars, which have severely taxed civilian and service populations, further affecting already limited psychiatric resources. Many of those directly and indirectly affected by mass shootings, war, or disasters will need mental health treatment. And, of course, large portions of our population independently suffer from serious psychiatric disorders. Unfortunately, those in need of psychiatric care often have very poor access to appropriate management due to lack of resources; others don't seek out care due to real or perceived societal stigma. Together, these barriers represent a major inadequacy in US mental health care. Medscape recently spoke with psychiatrists Richard H. Weisler (UNC-Chapel Hill and Duke University Medical Center), Henry A. Nasrallah (University of Cincinnati College of Medicine and University Hospital), and Joe Parks (Missouri Institute of Mental Health) about the status quo of mental health care in the United States and what can be done to repair the system.
Introduction
Medscape: It seems like every week we hear about another psychiatric hospital or unit closing its doors, or another state cutting mental health care funding. Can each of you comment on the worsening lack of psychiatric resources in the United States and the impact that this worrisome trend might have?
Dr. Weisler: If you do an online search, you'll find article after article from small towns to big cities -- and also at the state level -- about the impact of all of the recent closures. Chicago's Tinley Park Mental Health Center closed this past summer while Cedars-Sinai in Los Angeles closed its psychiatry department. Also this past summer, in North Carolina, the final patients left the storied Dorothea Dix Hospital. This is happening around the country, leading to a shortage in psychiatric services.
There is also a severe shortage of mental health providers in the United States, and it's getting worse. This is in part because half of US psychiatrists are over age 55 years, and not as many new people are entering the field as are needed. There is also a shortage in researchers.
Dr. Nasrallah: In the '60s and '70s, the National Institute of Mental Health provided additional residency stipends prompting many medical students to enter the field of psychiatry. Now there is a bottleneck due to inadequately funded residency positions. There are also a lot of very good international medical graduates out there desperately trying to get into psychiatric residency programs. But for various reasons, many of them are being turned down. If there were more slots available, I think they would be filled. We can train 50% more psychiatrists a year than what we are currently producing, which is roughly 1200 psychiatrists a year, which barely keeps up with the attrition on the other end with retirement and mortality.
Dr. Parks: I don't think we do well at the local level because we tend to separate ourselves -- the "mental health group" -- and don't join and assist others, such as primary care providers or even the police, with their issues. All we do is ask for help with our needs and our problems -- it's not an effective approach to partner with somebody like that. If you want a partner, you go and find out what their needs and problems are, take care of them, and then you ask for something for yourself.
Dr. Weisler: That's an excellent thought, Joe. It should be easy for us to find partners. For example, and I've done this recently, one contact to make is with your local emergency department (ED) providers and administrators. The EDs are frequently filled with psychiatric patients waiting for beds. It's even worse than when we talked about it a couple of years ago here on Medscape. They'll wait for days and sometimes for weeks. There's usually a huge waiting list, and there are also what they call "no admit" lists. If a patient is aggressive, it often feels like nobody really wants and/or feels that they have the staff to care for them. If you have a demented patient with psychosis, it's also much harder to find a bed, especially if they are agitated. Remember, we have no US Food and Drug Administration (FDA)-approved treatments for psychosis or agitation in dementia, yet the numbers of patients who will require such treatment are rapidly increasing as our population ages.
Dr. Parks: To that point, I have a problem with EDs saying they're choking or they're backed up with mentally ill people or substance abusers. I ran some 10-year trend numbers on Missouri from 2000 to 2009, the last year we have complete data posted on our Website. During that time, the number of mental health ED visits went up about 43.9%, and the total ED visit rate went up 17.4%. If you look at the numbers, the increase in ED mental health visits was about 19,732 from 2000 to 2009, which is only 6.1% of the total ED visit increase of 324,585 visits from 2000 to 2009. Overall mental health ER visits went from being 2.40% of total ER visits in 2000 to 2.96% of total ER visits in 2009. How can they be choking on mental health patients when we represent 6.1% of the total ER volume increase and a net proportional increase of 0.56%?
Dr. Weisler: You may be right about the numbers, but it's often true that there is no place to send these patients in many cases, especially if state mental health beds are full.
Dr. Parks: So why do these hospitals not have inpatient psychiatric units? If they had more women delivering babies than they could handle, they would open more obstetrics capacity. If they had more people with broken legs than they could handle, they would open more orthopedic capacity.
Dr. Nasrallah: You're absolutely right, Joe. There seems to be no feedback loop in mental health. It's just a one-way street, and there doesn't seem to be a correction for anything, which tells me that the entire field of mental health may go downhill very fast. And no one is trying to pull it back and approach care in a rational manner based on data such as patient and population needs. If 25% of the US population has a recognizable, diagnosable, and treatable mental disorder, why is this happening? A total of 80 million people in the United States are not being well represented, namely because, as Joe said and Rick insinuated, we're not partnering. We're not doing our job collectively in order to fight the current crises at the local level. But we need to scream loudly that for everything that happens around the country, and that communication pattern, we're failing to communicate and to have rapid response, and therefore those who are cutting mental health budgets are continuing to cut unabated because they don't face any tangible resistance.
Dr. Parks: I think the ED is an excellent feedback loop for identifying what's needed in a local healthcare delivery system. I think making the problem the lack of public beds is exactly the wrong message. It says that it's okay to push these people off to the side; the local hospital doesn't want to deal with them. And that is unacceptable. These hospitals, these people with mental illness in the EDs are members of their community, and these are community hospitals. If there's a medical need, they should be developing that capacity.
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