All psychiatrists do is push drugs!”
I have heard this repeatedly, from students, wary patients, even family members who don’t pick up on a carefully worded hint that they just might benefit from getting help. For some reason, no one makes the same complaint about infectious disease specialists, or oncologists, though I wager that the success rates of our drug treatments are roughly equivalent.
As a psychiatrist, I try to treat people with diseases, not diseases that happen to occur in people, but combining drugs with other modes of therapy requires a daily, even hourly balancing act. Add the effects of pharmaceutical marketing, especially direct to consumer advertising (followed by direct potential litigant recruitment)–some days I don’t want to get out of bed.
Beyond a general temptation to rely on drugs as the primary mode of treatment, psychiatrists feel particularly pressed to use the newest, most expensive drug. Many psychiatric patients receive their care in publicly funded clinics, under excruciatingly tight budgets. Having free samples to distribute allows us to provide a few patients with high end drugs. Clinical decision making in psychiatry is difficult because of our lack of objective measures of response. Newer psychotropic medicines do sometimes work where older ones have failed. The side effects of newer medications typically differ from those of older ones, though the overall burden of adverse consequences is arguably the same. These background forces are invisible. In the clinical moment, the selection of a particular remedy is often based more on nonmedical influences—the patient’s response to advertising, the clinic’s necessary concern with costs—than upon the prescribing professional’s careful assessment and detailed discussion with a patient.
Aggressive pharmaceutical marketing has exacerbated the problem of responsible prescribing…
Although radical reform is still a long way off, section 6002 of the Patient Protection Affordable Care Act requires manufacturers of drugs, devices, supplies and biological materials that are covered under various federal health programs to disclose on an annual basis the payments (of various kinds) they have made to physicians and teaching hospitals.
- Is Psychiatry Commiting “Professional Suicide”? (recoverynetworktoronto.wordpress.com)
- Is psychiatry committing ‘professional suicide’? (cnn.com)
[Abstract] Introduction: As the U.S. population undergoes continuous shifts the population’s health profile changes dynamically resulting in more or less expression of certain psychiatric disorders and utilization of health-care resources. In this paper, we analyze national data on the psychiatric morbidity of American patients and their summated cost in different age groups. Methods: The latest data (2009) on the number of hospital discharges and national bill (hospital charges) linked with psychiatric disorders were extracted from the Nationwide Inpatient Sample (NIS). Results: National data shows that mood disorders are the largest diagnostic category in terms of percentage of psychiatri-crelated discharges in the 1 – 17 years age group. The proportion decreases gradually as age progresses while delirium, dementia, amnestic and other cognitive disorders increase exponentially after 65 years of age. Schizophrenia and other psychotic disorders as well as alcohol and substance-related disorders peak in the working age groups (18 – 64 years). From an economic point of view, mood disorders in the 18 – 44 age group has the highest national bill ($5.477 billion) followed by schizophrenic and other psychotic disorders in the same age group ($4.337 billion) and mood disorders in the 45 – 64 age group ($4.310 billion). On the third place come schizophrenic and other psychotic disorders in the 45 – 64 age group ($3.931 billion). Conclusion: This paper illustrates the high cost of psychiatric care in the U.S., especially the large fraction of healthcare money spent on working-age patients suffering from mood disorders. This underlines psychiatric cost-efficiency as a vital topic in the current healthcare debate.
- Major Depressive Episode among Full-Time College Students and Other Young Adults, Aged 18 to 22 (US Substance Abuse and Mental Health Administration, May 2012)
The Diagnostic and Statistical Manual of Mental Disorders (DSM), long the master reference work in psychiatry, is seriously flawed and needs radical change from its current “field guide” form, according to an essay by two Johns Hopkins psychiatrists published in the New England Journal of Medicine.
“A generation ago it served useful purposes, but now it needs clear alterations,” says Paul R. McHugh, M.D., a professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine and co-author of the paper with Phillip R. Slavney, M.D., a professor emeritus in the same department. “They say they can’t do any better. We disagree and can show how.”
The original DSM, published in the 1950s, was intended as a public health service documenting the incidence and prevalence of mental illnesses. By its third edition in 1980 (DSM-III), however, it had evolved into a reference book prescribing how clinicians should identify and classify psychiatric disorders.
Today, the Johns Hopkins psychiatrists say, DSM provides checklists of symptoms, offering few clues to the underlying causes of mental disease and making it difficult to direct treatment or investigate the disorders it details. A new edition, DSM-5, is due out in 2013.
The manual, put together by the American Psychiatric Association, currently identifies hundreds of conditions via lists of diagnostic criteria and symptoms, functioning exactly as does a naturalist’s field guide but for mental illness. It offers no way to make sense of mental disorders and no way to distinguish illnesses that appear to be similar but actually are quite different and require different treatments, the psychiatrists argue.
“If you just name things and don’t explain what the causes are, you do not know how to rationally treat or study the diseases,” says McHugh, former director of Hopkins’ psychiatry department. “The DSM gives everything a name but not a nature.”….
- Johns Hopkins Experts Say Psychiatry’s Diagnostic Manual Needs Overhaul (tricitypsychology.com)
- Does Everyone Have a Mental Illness? (madinamerica.com)
- Psychiatrists say diagnosis manual needs overhaul (vancouversun.com)
- ‘Label jars, not people’: Lobbying against the shrinks (newscientist.com)
- ‘Label jars, not people’: Lobbying against the shrinks (newscientist.com)
- Profit Motive? Big Psychiatry Invents and Redefines Mental Illnesses (sott.net)
- ‘Label jars, not people’: Lobbying against the shrinks (newscientist.com)
- Two proposed changes dropped from DSM-5: Media round-up (dxrevisionwatch.wordpress.com)
This is a brand new published interview-series (7 parts), with psychiatrists Dr. Joe Parks, Dr. Richard H. Weisler, and Dr. Henry A. Nasrallah on the magnitude, impact, and means of addressing this critical situation. I highly recommend not only reading this synopsis but to read through the entire series as well.
- Evidence shows that this country is short 45,000 psychiatrists.
- According to the National Association of State Mental Health Program Directors (NASMHPD), mental health spending dropped 5% from 2009 to 2010 and it is predicted to go down another 8% in 2011.
- The National Alliance on Mental Illness study in North Carolina found that there were 3000 people on a waiting list for admission in only the first 6 months of the year; 212 people out of 3000 waited more than a week and 900 just quit looking — they just left.
“The United States is facing a severe lack of psychiatric care resources. Given the current economic crisis, the problem is only getting worse as state budgets for mental health care continue to be cut.”
Evidence shows that this country is short 45,000 psychiatrists.
At times of stress, like we have had in the last few years with the economy, there is an increase in psychiatric demand, particularly in terms of depression, anxiety, suicidality, and drug abuse.
The seriously mentally ill patients are not well served for numerous reasons. Beyond just a lack of resources, the system is a problem unto itself.
Psychiatry is the number-one area in which more professionals are needed.
According to the National Association of State Mental Health Program Directors (NASMHPD), mental health spending dropped 5% from 2009 to 2010 and it is predicted to go down another 8% in 2011.
Is the Economy to Blame?
“The economy is an easy scapegoat for the recent decline in mental health resources, but it sounds like the consensus is that the system has been at least partially broken for quite a while. “
The single biggest cause of suffering for many of our patients is that they cannot be admitted to a hospital when they relapse during medical treatment. According to a 2010 report by the Treatment Advocacy Center, there was 1 bed per 300 people in the United States in 1955; currently, we have 1 bed for every 3000 people.
There are wide variances in overall funding for mental health resources, whether it’s hospital beds or community resources. There are huge maldistributions in terms of psychiatrists per 100,000 people.
There are about 3 or 4 times the number or psychiatrists in New York or Massachusetts per capita, compared with states like Texas. There are fewer psychiatrists for severely ill patients than it appears because only a small percentage of them are really seeing the very sick patients. Relatively few psychiatrists choose to work in community mental health centers or state or VA hospitals, where the sickest and most disabled patients are.
The key thing is not to treat patients in isolation, you have to reach out and develop relationships.
The recent removal of consultation codes for Medicare and some other insurance providers may undermine efforts to increase interdisciplinary consultations and collaboration because of reduced reimbursements.
Model of collaborative care.
The primary care of the seriously mentally ill is in this country, especially after the CATIE study found that a large proportion of persons with schizophrenia in the outpatient setting in the United States had their serious medical problems ignored. There is hardly any relationship between community mental health centers and primary care clinics.
The CATIE study showed:
● 60% of patients with schizophrenia who had frank hypertension had never received an antihypertensive drug.
● 90% of those who had high cholesterol or triglycerides had never received a statin.
● 30% of those with clinical diabetes have never received treatment for diabetes.
“This reflects an unconscionable neglect of the physical health of the mentally ill, and it is a result of this lack of bridging between primary care and psychiatry, especially in community mental health centers.”
Prisons: The New Psych Ward.
What are the ramifications of inadequate mental health resources?
There needs to be about 40 beds per 100,000 people, there is only 17 per 100,000. Hundreds of thousands of psychiatric patients are now being sent to correctional facilities.
According to some studies and statistics:
● 35%-54% of prisoners have symptoms of mania.
● 16%-30% have major depression.
● 10%-24% have some psychotic symptoms, such as delusions or hallucinations (Table 2).[4,12]
● Even more conservative estimates reflect that 16% of prisoners have mental illness.
Many of the people with mental illness have co-occurring substance abuse and disorders, and many of their convictions are substance abuse related. Prisons are releasing to the community people with chronic mental illness; this only predisposes them to repetitive rehospitalization for psychotic and manic episodes due to poor adherence or, more likely, incarceration.
The ER is where everybody goes when they have a medical illness but no primary care provider, and the same thing happens with the mentally ill. A substantial number of those who present to the ER have a mental illness.
The National Alliance on Mental Illness study in North Carolina found that there were 3000 people on a waiting list for admission in only the first 6 months of the year; 212 people out of 3000 waited more than a week and 900 just quit looking — they just left.
Is Healthcare Reform the Answer?
By improving the reimbursement for mental illness — the hospitalized mentally ill — would definitely incentivize hospitals to stop closing those units and maybe even to open new ones.
A report entitled “Recommendations to Foster System Reform for Adults With Serious Mental Illness,” identifying 5 key priorities for legislative, policy, and program implementation as part of National Health Reform.
The 5 key priorities are:
● Developing a set of performance measures specific to treatment of mental illness.
● Designating persons with mental illness a health disparities population.
● Including mental health treatment providers in federal funding and policy related to health information technology initiatives.
● Making sure that the new healthcare home initiatives adequately address mental illness.
● Developing a national definition of “medical necessity” that adequately meets the needs of persons with mental illness.
- Konrad TR, Ellis AR, Thomas KC, Holzer CE, Morrissey JP. County-level estimates of mental health professional shortage in the United States. Psychiatr Serv. 2009;60:1323-1328. Abstract
- President’s mental health commission recommends transforming America’s mental health care system. Mental Health Commission Web site. Available at: http://www.mentalhealthcommission.gov/press/july03press.htm. Accessed September 13, 2010.
- As economy takes toll, mental health budgets shrink. Stateline Website. Available at: http://www.stateline.org/live/details/story?contentId=499181. Accessed September 3, 2010.
- Torrey EF. More mentally ill persons are in jails and prisons than hospitals: a survey of the states. Available at: http://www.treatmentadvocacycenter.org/storage/tac/documents/final_jails_v_hospitals_study.pdf Accessed September 3, 2010.
- Wing JK. How many psychiatric beds? Psychol Med. 1971;1:188-190.
- Goplerud EN. Assessing methods of predicting the need for psychiatric beds. Hosp Community Psychiatry. 1986;37:391-395. Abstract
- Häfner H. Do we still need beds for psychiatric patients? An analysis of changing patterns of mental health care. Acta Psychiatr Scand. 1987;75:113-126. Abstract
- Hirsch SR, Gerrard B, Malin H, et al. Psychiatric Beds and Resources: Factors Influencing Bed Use and Service Planning. Report of a Working Party of the Section for Social and Community Psychiatry of the Royal College of Psychiatrists. London: Gaskell; 1988.
- Davis GE, Lowell WE, Davis GL. Determining the number of state psychiatric hospital beds by measuring quality of care with artificial neural networks. Am J Medical Quality. 1998;13:13-24.
- Hagedorn H. A Manual on State Mental Health Planning. NIMH, DHEW Publication No. ADM77-473. Washington, DC: U.S. Government Printing Office; 1977.
- Nasrallah HA, Meyer JM, Goff DC, et al. Low rates of treatment for hypertension, dyslipidemia and diabetes in schizophrenia: data from the CATIE schizophrenia trial sample at baseline. Schizophr Res. 2006;86:15-22.Abstract
- Kuehn BM. Mental health courts show promise. JAMA. 2007;297:1641-1643.Abstract
- Lamb RH, Weinberger LE. The shift of psychiatric inpatient care from hospitals to jails and prisons. J Am Acad Psychiatry Law. 2005;33:529-534.Abstract
- Swartz MS, Swanson JW, Wagner HR, Burns BJ, Hiday VA, Borum R. Can involuntary outpatient commitment reduce hospital recidivism?: Findings from a randomized trial with severely mentally ill individuals. Am J Psychiatry. 1999;156:1968-1975.Abstract
- Biesecker M. Mentally ill often turned away, end up in ER. Raleigh News and Observer. August 7, 2010. Available at:http://www.newsobserver.com/2010/08/07/618475/mentally-ill-often-turned-away.html Accessed September 13, 2010.
- National Association of County Behavioral Health and Developmental Disability Directors. Recommendations to Foster System Reform for Adults With Serious Mental Illness. Available at:http://nacbhdd.org/content/Fostering%20System%20Reform%209-8-10.pdf Accessed September 14, 2010.
- Pies R. “Prescribing psychologists:” practicing medicine without a license? March 29, 2010. Psychiatric Times. Available at:http://www.psychiatrictimes.com/geriatric-psychiatry/content/article/10168/1545667 Accessed September 15, 2010.
Stetka B. “US Psychiatric Resources: A Country in Crisis” September 22, 2010. Medscape Psychiatry & Mental Health. Available at: http://www.medscape.com/viewarticle/728676 [Accessed 22 Sept 2010].
Please See More: Severe Lack of Psychiatric Resources in the US – Today on Milhealth’s Directory – MHD http://www.milhealthsdirectory.org/today-on-milhealths-directory/severe-lack-of-psychiatric-resources-in-the-us.html#ixzz10ivE2ipf
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- States slash $1.8 billion in mental health funds since 2009 (skwillms.wordpress.com)
- Giving family doctors the tools to treat mental illness (theglobeandmail.com)
- More mentally ill ending up in jail (thegazette.com)
- The Mentally Ill Should Be Diverted From Offending Rather Than Prison, UK (medicalnewstoday.com)
- How to make money off the mentally ill (kevinmd.com)
- Better Benefits Information Needed for Mental Health Parity (blogs.wsj.com)
- New Study Of The Mental Health Needs Of Post-Combat Military Servicemembers Shows Only Half Are Getting The Treatment They Need