The New York Times somehow let an all too true story about the treatment of mental illness slip through today instead of one of their more typical speculative pieces. It is a story of a family desperately trying to get their father and husband assistance after he develops acute bipolar disorder with psychotic symptoms. It is a reasonable discussion of some of the issues behind deinstitutionalization, involuntary treatment, and the sad state of affairs that currently exists in trying to get treatment for those with severe mental illness.
Probably the best quote in the article follows:
“The lack of resources has triggered a devolution of the standard,” says Robert Davison, executive director of the Mental Health Association of Essex County, a nonprofit group that connects patients to services in northern New Jersey. “Twenty years ago, ‘imminent danger’ meant what most people think it means. But now there’s this systemic push to divert people away from inpatient care, no matter how sick they are, because we know there’s no place to send them.”
I will refrain from the typical term applied to the situations whose definition is: "a particularly bad or critical state of affairs, arising from a number of negative or unpredictable factors". The reason I will refrain is that it is not exactly accurate. The entire debacle has been totally predictable. It is the predictable result of applying managed care rationing techniques to the private and public mental health sector and denying care to those people with the most severe forms of mental illness. When your only perspective is rationing care to make money - there are no standards.
So what are the solutions?
They are fairly straightforward. First off, there needs to be reasonable commitment standards with a more appropriate balance than "imminent dangerousnessness". From the article it is clear that even that standard is interpreted widely. There needs to be a three part standard for danger to self, danger to others, and gravely disabled and not able to care for oneself. Some states accomplish the same goals by separating civil commitment from protective services/protective placement statutes. The latter approach has the advantage of avoiding the use of commitment courts for issues that come up in the course of Alzheimer's disease and other dementias.
Secondly, the statutes need to be uniformly interpreted. My experience working with probate courts from a 3 county area illustrates that no two judges would make the same decision on a particular case. In many counties, the social workers screening the cases had much different philosophies. The only time that changed was when there was a bad outcome. That outcome was typically a person released by the court who attempted or committed a homicide or suicide.
Third, there needs to be recognition that state hospital beds are not the only solution. The main reason that state hospital beds don't work is that there are no local resources. Once a person is ready for discharge, there is no place to send them. More and more people accumulate at the state hospital and nobody is discharged. There needs to be housing resources and community teams to actively work with people to facilitate discharge and maintain them in the community. Just building state hospital beds has the predictable outcome of building more state hospital beds.
Fourth, financial conflicts of interest must be eliminated. They exist at multiple levels and are the predictable outcome of rationing techniques that originated in the managed care industry 30 years ago. The basic premise of managed care is that a "medical necessity" standard can be developed that will be subjectively interpreted by the company in order to ration care and save the company money. One of the major loopholes has been any person that needs involuntary treatment. The managed care company can simply say this care is no longer "acute" or "medically necessary" and transfer the financial burden of care to the taxpayers. Huge cost savings to the managed care company. That doesn't happen if you need a heart transplant.
The financial conflicts of interest occur at every level in the system. Another example is the interpretation that at an aggressive or self endangering event has to have occurred in order to meet the commitment standard. The author here does a good job of providing examples. What is not obvious is the financial conflict of interest that is present in these situations. In almost all cases - the hearing occurs at the county level and the judge presiding knows the county's financial status and access to resources. That significantly biases decisions especially in the case of counties where there are limited resources.
The only solution to avoiding these pure conflicts of interest is to have the money follow the patient and have it in a dedicated fund. It is too easy to move funds around that should be designated for the treatment of severe mental illness if they move in and out of a general fund.
Fifth, there need to be better managers of the systems responsible for the care of patients with severe mental illnesses. Managed care companies clearly do a very poor job. On the other hand every state generally has a large Department of Human Services and second to education they are usually the largest budget in the state. Despite significant constant and high demands they are generally managed like any other state agency. If there is a revenue shortfall and everybody has a 6% across the board spending cut, DHS also has a 6% spending cut. These departments usually employ cost center accounting that is also a detriment to coming up with an adequate plan of care across treatment settings. Finally it is also common these days in both managed care and state systems to see managers with no clinical experience attempting to hold clinicians accountable to subjective standards and implementing plans to change care delivery - even though they have no expertise.
These are a few changes that would make a world of difference for families and patients like those mentioned in the NYTimes article today. I am not very hopeful that they can happen because it would also involve changing a culture that has been the most insidious aspect of managed care. That culture is quite simply - bureaucrats and business people telling psychiatrists what to do and restricting the resources needed to provide adequate care.
George Dawson, MD, DFAPA
Jennen Interlandi. When My Crazy Father Actually Lost His Mind. NYTimes June 22, 2012.