We’re taking a week off from our Sunday night Faces of the Movement series. Instead, we’ll look at the complexity of problems facing America’s system of mental health care and preview a series we plan to run in 2014 examining in more depth the challenges families face in obtaining effective mental health care for their children and teens.
Lots of media attention has been devoted to the failings of our mental system in the aftermath of the mass shootings (Congresswoman Gabrielle Giffords, the Aurora theater massacre, Newtown, Washington Navy Yards) perpetrated by individuals with poorly treated or untreated mental illness.
The reality is that our mental health system fails millions of families in less spectacular ways on a daily basis.
The system is so dysfunctional, figuring out where to start can be an overwhelming intellectual exercise…not unlike the challenge I sometimes face when families bring kids with extremely complicated histories to our practice.
If we expect churches to do a better job of ministry with families impacted by mental illness, some awareness of the struggles families face in finding good care may be helpful. Having served in many different capacities in the system…as a child and adolescent psychiatrist in private practice, as Medical Director of a large, inner city children’s mental health center, as a consultant for our university hospital’s privately owned insurance company, as an investigator on several Federally-funded clinical research studies, as the Chairman of the Private Practice committee for my national specialty society, as Clinical Director of a large residential treatment center for teens and as the Board Chairman of our county’s community mental health center, here’s a formulation as to why our mental health system in the U.S. is failing so many of the families it was created to serve.
- We don’t have a good understanding of the underlying brain and nervous system pathology foundational to specific mental illnesses, much less anything other than a rudimentary understanding of how environment impacts genetic expression in mental illness. The National Institute of Mental Health has launched its’ Research Domain Criteria initiative to stimulate the science necessary to better delineate the underlying causes of mental illness. The downside of the initiative is that in an era characterized by an emphasis upon “evidence-based medicine”, we’ll have very little new evidence to guide our treatments under the recently-released DSM-5 diagnostic system.
- We don’t have the tools to accurately predict who among our population suffering from mental illness or psychopathy is most at risk of committing severe acts of violence, or to predict with any certainty who may act upon suicidal thoughts.
- Medication used to treat common mental illnesses doesn’t work nearly as well as most people have been led to believe, and is associated with more side effects than many patients who respond positively to medication can tolerate.
- We have three systems of mental health care, with flaws inherent in each. Our public mental health system offers the broadest range of services at low or no cost to families below or near the poverty line, but is difficult to access and prohibitively expensive for middle class families who fail to qualify for large, sliding scale discounts. Commercial insurance pays for brief hospital stays, a limited number of outpatient visits with clinicians willing to massively discount their services and brief medication visits with psychiatrists disincentivised from scheduling longer appointments. Concierge practices offer rapid access to highly qualified clinicians, but generally provide a limited range of services and are prohibitively expensive for many families in need of more frequent or intensive care.
- Mental health services are often very difficult to access when they’re needed. Many insurance websites fail to indicate when practitioners are closed to new patients. Waits for a psychiatrist in many cities are measured in months. Appointments are scheduled at times of the day more convenient for clinicians and institutions than for patients, requiring that parents miss work and kids miss school. I was teaching at a local children’s hospital a couple of months ago and was quite surprised to see the waiting room in the child psychiatry clinic empty shortly after 5:00 PM, when kids and families are generally most available for appointments on weekdays. Insufficient incentives exist for clinics to become more “consumer-friendly”.
- Our methods of paying for mental health care greatly contribute to the overall dysfunction in the system. Psychiatrists can earn much more money for running an “assembly line” of patients through brief medication appointments than by spending time on lengthier evaluations. A colleague in my office works full-time at our local community mental health center. The center needed to hire two full-time nurses (and foot the bill for salaries and benefits) simply to fight with managed Medicaid plans and commercial insurers so that patients of the three psychiatrists can fill prescriptions written during their appointments. While patients wait weeks and months for appointments, clinicians spend large chunks of time completing the reams of paperwork necessary to survive Medicaid audits. Rates of reimbursement paid by the state to community mental health centers skyrocket to reimburse for the overhead costs connected to paperwork completion.
- The geographic distribution of our most highly trained mental health professionals is highly uneven. The vast preponderance of child and adolescent psychiatrists practice in large, urban areas, heavily concentrated on the coasts. Access to specialized mental health services may be very limited in rural areas across the heartland.
- Mental health services for special populations are in extremely short supply. Shortages of child psychiatrists and geriatric psychiatrists are especially acute. Families struggle to find qualified mental health care for adults with intellectual disabilities, geriatric patients with concomitant medical illness, or children and teens with inappropriate sexual behaviors.
- Major obstacles exist to care coordination with other service providers or service systems. Time spent coordinating treatment with clinicians from other practices, school officials, and primary care physicians is almost never reimbursed. Uncompensated time in care coordination doesn’t count toward required productivity quotas for staff employed by clinics or large institutions.
- We persist in employing an acute care medical model that has demonstrably failed in serving the chronically mentally ill. In our area, the average length of a hospital stay is four days. The moment a patient no longer has an active suicidal or homicidal plan discharge is mandated by insurance companies, before most medication response can be adequately assessed. Patients covered by private insurance have difficulty accessing the continuum of care they need following an acute crisis.
- Great inconsistencies are present in the quality of available mental health services. This is especially true with non-medical mental health professionals, where less uniformity exists in training and supervision requirements.
- We spend much of our resources seeking to address the consequences to individuals living in toxic environments in a declining social system. We can’t expect counseling or pills to help when kids are living in homes where they’re physically or sexually abused, witnessing ongoing domestic violence or neglected by chemically dependent parents or caregivers. Mental health services tend not to be successful when kids are suffering the consequences of the maladaptive choices of parents seeking to fill the emptiness in their lives at the expense of their families.
We’ll look at this topic in more detail in a blog series during the first quarter of next year. Given the tidal wave of change approaching the healthcare system in general, the shape of our mental heath service delivery systems in the next few years is anything but certain.
Photo courtesy of the Washington Post
Confused about all the changes in diagnostic terminology for kids with mental heath disorders? Key Ministry has a resource page summarizing our recent blog series examining the impact of the DSM-5 on kids with mental health disorders. Click this link for summary articles describing the changes in diagnostic criteria for conditions common among children and teens, along with links to other helpful resources!
Thanks, Steve! Your expertise and wisdom is a gift especially to those of us on the frontlines of being servants to individuals and families with special needs! This is really helpful stuff/information!
You must not forget consideration of SSRI drugs, and as you can see with the large number of cases like this, that obvious it is real.
Thanks for your comment. I did need to remove the link you included because it tends to sensationalize the data, but allow me to include this one…
The truth is that SSRIs don’t appear to be terribly effective as antidepressants, and there’s a good possibility that the rates of increased suicidal thinking/behavior may be a little higher in the real world (as a result of patients having other comorbid conditions associated with poor impulse control/emotional self-regulation) than reported to date in the published research. Parents need to be very thoughtful and ask lots of questions before agreeing to a trial of an SSRI for their child or teen.
Your refusal to face the real data that you said is sensationalized, and as to the reality of what goes on, that is apparent. Actually the absents of even a mention of that data and causation factor, makes your article here missing a major portion of needed public information. I won’t bother to submit any more informational sources for you; because obviously you will only delete it.
Thank you so much for this accurate, well conceived and timely article. I own one of the largest practices serving children in Delaware. The obstacles we face in trying to help children access services are overwhelming to us as professionals. I can’t imagine what it is like for the parents of children we serve. At times, I’m up for the fight but recently, I feel like I’m running low on wind.
You’re not the only professional who feels the way you do. The administrative burdens faced by those of us who work in the trenches become more and more daunting every day. In a field already short of the professionals we need, I’m expecting the burden to become so great that many good clinicians will choose to retire earlier than planned. I recently returned from the child psychiatry meetings…I’d place the age of the average attendee at around 60. This is not good for the field.
I am a child therapist (LLMSW) at a behavioral health center in Michigan. We work with Community Mental Health and with children who are Medicaid recipients. I found myself agreeing and nodding my head to the majority of what you have written. I find that many lawmakers do not realize the extent of the barriers and common problems that our consumers face and what we face as providers. Thank you for sharing your thoughts on the matter. I am right there with you!
Thanks for your comments. I just returned from the American Academy of Child and Adolescent Psychiatry’s annual Meeting. I’m more concerned than ever that the looming cuts in funding for medical services will jeopardize many of the existing mental health care services in existence for kids and negatively impact plans to better integrate mental health services for kids and teens with the pediatric health home model envisioned by many proponents of healthcare reform.