What This Blog Is About for the Student of Mental Health Reform

I am a dedicated veteran psychiatrist who is “triple boarded” meaning I have achieved specialty certifications in adult psychiatry, child and adolescent psychiatry and geriatric psychiatry. I started my training in 1974 which I count as when I start “practicing” as when one is a ‘resident’ in psychiatry, one starts seeing patients from day one. And as a harbinger of what was to come in my psychiatric training at Duke in Durham NC, I spent my first day “on call,” at the Durham Veterans Administration hospital across the street from Duke Hospital proper, and admitted 15 patients to the psych units and spent all night interviewing and ‘working them up.’

I practiced in some of the “Golden Years of Psychiatry” as many of us now senior psychiatrists call those decades from the sixties through the mid eighties. Then mental health and psychiatric care in this care started going into the “crapper” as my more salty southern buddies would say. Suicides went way up from inadequate treatment. In my years in training, three in adult and geriatric, two in child/adolescent, and half a year in forensic externship training as a freebie add-on, I had only one suicide. When I practiced for nearly five years in the early 2000’s in a unique ethnic community, I had more than one a month. That one piece of personal experience illustrates in a way how incredibly poor our quality of care is now and the crazy, illogical, senseless bureaucratic limitations that are placed on our delivery of care.

Another example is equally telling. Any psychiatrist with even the worst training imaginable, even in a coma, as I like to joke, could tell you, that it takes a minimum of several weeks for ANY antidepressant medicine [except nowadays for experimental use of intravenous of the oddball dissociative anesthetic ketamine] to manifest whether it will bring someone out of a severe depression. And a suicidal severely depressed, dangerous to themselves patient, if they have private insurance, nowadays almost universally has ‘length of stay’ limitations on their inpatient psychiatric stays. These usually are on the order of 5-7 days! So psychiatrists play a dangerous game of when to discharge a depressed patient who has ‘just been started’ in our view, five days ago on an antidepressant medication. No wonder our suicide rate as just one simple indicator of quality of care, has exploded upward.

Residency training programs in psychiatry have shrank dramatically since the Reagan Presidency years for a variety of factors, especially child psychiatry fellowship training programs.  There are only 6,500 total in the country. Some of western large less populated states have anywhere from half a dozen to a dozen to cover their entire state. As far as psychiatrists, as of May 2013 from the Bureau of Labor Statistics, there are only 25,040 in the entire country. Montana for instance [data can be seen at same above link] has only 120 psychiatrist, Wyoming has only 40, the lowest number in the country. On a personal note, Duke trained 16 adult general psychiatrists a year when I was in training, now it is half a dozen per year. Duke’s clinical inpatient wards decreased from six wards to one about 20 years ago and relies on the other community general hospital in Durham, with a unit of approximately two dozen beds for private patients. Duke’s beds primarily utilized for research protocol psychiatric patients. So these little example-factoids show  in a microcosm how many service “units” we have lost. Many of the far fewer private free standing psychiatric hospitals are now what is called “private pay,” facilities meaning that one pays the freight, the entire cost of the hospital stay out of pocket because many of the high quality, truly good inpatient psychiatric units, can actually not cover their overhead on the drastically reduced reimbursement rates that have been imposed on inpatient mental health care since the 1980’s when managed care became dominant.

Part of this was OUR fault. Some or a fair number of inpatient psychiatric hospitals were what I called “bandit operations.” In the 1980’s especially several national scope of scandals emerged in the good investigative media about the abuse of insurance coverage by chains of profiteering psychiatric free standing hospitals. I would refer the reader to Joe Sharkey, the long term superb prize winning investigative reporter for the New York Times newspaper who wrote the absolutely damning book called BEDLAM : Greed, Profiteering, and Fraud In A Mental Health System Gone Crazy, published in 1994 by St. Martin’s Press. It still can be found at Amazon.com. Sharkey’s book wrote about one of the great health care scams of modern times. A  company called Psychiatric Institutes of America, owned by the later infamous National Medical Enterprises Inc. company, figured out how to ‘harvest’ [my word] psychiatric patients by the bushels. A man in central Texas had figured out an unnoticed opening for this harvesting. In the state of Texas it was then possible for almost anyone to get deputized as a county deputy sheriff, an officer of the law, or more importantly, an officer of the court. This term is applied to attorneys, judges, bailiffs, police, etc. This man realized that if one was a Texas deputy, one also had the power to involuntarily commit any person to a mental institution. So the scam worked this way: in county and after county where there were established free standing psychiatric hospitals, ambulance companies were organized. All the drivers were deputized. They listened to police scanners for reports of domestic violence and reports of almost any type of disorderly behavior. Hearing the location or addresses of such reports, the deputy-ambulance driver would rush to the scene so fast that they would arrive before any other service personnel (real medical first responders, fire department personnel, police) and commit the person of interest on the spot and take them into custody. As deputies they could use force, handcuffs, etc. Then they would roll off to the local or nearby county’s free standing psychiatric hospital owned by the folks mentioned above and other unscrupulous companies and dump them at the “admission” offices who basically documented some sort of behavior and diagnosis, did a “wallet biopsy,” meaning confirm the person had health insurance and keep them involuntarily committed often until their insurance coverage was exhausted. The ambulance deputy drive was given an illegal kickback that could in those days range up to $450 a person. Everybody won except the poor captive patient/client/drug abuser/spousal abuser/hellraiser. This went on for years. In the 1990’s NME was finally exposed in a nationally publicized investigation largely as a result Sharkey’s book, reports of families, reports by ethical physicians to hospital and regulatory organizations as the stories of this financial robbery became commonplace. NME had to reimburse insurance companies, states, Canada, Medicare, Medicaid, Texas over $379 million dollars for false billings in just one criminal suit under this imaginative scam. As they would say in one of my homes states which happens to be Texas, “Hmmmm, doggies!”

NME went under after the settlement coming out of the settlements beginning in June 1994, was bought out by Tenet which assures us all is well now. One would hope so.

Consequently as these kinds of scams emerged in the virtually unregulated private psychiatric hospital industry, the insurors really bore down on health insurance costs for inpatient psychiatric care. In fact they went far too the other way. Even now when any MD does a review with an insuror’s reviewer, any doctor [ask your doc if you doubt what I say, watch their facial expressions change to controlled pain and anger, their blood pressure go up, and their detailing of how much time all this takes and its resultant idiotic costs), what it takes to fight for an extra day a patient honestly needs in recovery from surgery.

As reimbursements declined dramatically and sometimes deservedly so in psychiatry and mental health outpatient care, facilities closed beds or closed wards or closed their entire facilities altogether.

Now we have an intriguing situation. Where can one obtain inpatient psychiatric care that is good enough, and long enough without this kind of ignorant meddling and outside interference? It is not in the once high quality private facilities. They have had to change their models to “short term crisis stabilization” and get patients in and out often in less than 7 days or so whither they are ready or not. Sometimes they have to take a loss and keep a patient longer with no reimbursement but they realistically, economically can NOT do this very oten at all, otherwise they would quickly go under.

The result is something the idealists and anti-institutionalists would have foreseen. This mouthful about institutionalization refers to patients staying in (usually state) psychiatric hospitals so long they became “institutionalized.” The foremost proponent of this popular concept that scared the bejeebers out of everyone alike, liberal or conservative, was a psychologist named Erving Goffman who wrote in 1950 a very influential book describing what he felt happened to, and changed adversely people in all controlling, hopeless institutions such as state hospitals for the lifelong psychiatrically ill and inmates in prisons. Although there was enormous and voluminous criticism of Goffman’s observational methods, comparisons and far reaching conclusions, his work damaged enormously the already negative image of “state psychiatric hospitals.” This book,

Two movies also destroyed the ‘image’ of state psychiatric hospitals, The Snake Pit and of course Jack Nicholson’s early cinematic vehicle to stardom, One Flew Over The Cuckoo’s Nest. Public sentiment after the latter movie was ready for the “de-institutionalization” movement that began in the 1960’s with a vengeance. President Kennedy and Federal Policy weighed in with good intentions, enacting the Comprehensive Mental Health Center Care Act that mandated mental health clinics in every clinic in the country. It was envisioned that publicly supported quality and smaller psychiatric hospitals would be built all around the country covering reasonable regions, i.e., large enough MSAs, metropolitan statistical populations areas. The first and perhaps the only hospital that was built in the 1960’s was Marshall I. Pickens Hospital in Greenville SC. It was a great event and Vice President Hubert Humphrey was the main speaker and dedicating official from the national scene cutting the opening ribbon. Marshall Pickens Hospital is still there, still open and a fine hospital that I had the privilege of practicing within in the mid 1990’s. It is affiliated with the large Greenville Memorial Hospital system and the University of South Carolina School of Medicine in Columbia. But sadly, the Vietnam War was ramping up and sucked all the monies intended for the many dozens and dozens of facilities like Marshall Pickens that were to have been built. This highlights one of the main themes that has been repeated in the decades since in mental health care policies: a bright shining new idea, a revolution in treatment comes along and inpatient capacities on the local, state and national level get repeatedly reduced and the community based resources, to replace those are never built, fall by the wayside and politics and economics, one or another economic recessions hit repeatedly and the outpatient facilities never materialize.

The state hospital where I practice now has some 290 or beds. When the latest rounds of inpatient state hospital downsizing started in my adopted home state, it had approximately 790 beds. Sixteen community smaller inpatient psychiatric facilities were to have been built in the last 12 years in the large western part of this state and more in the rest of the state. Only three have been built so far since 2000, the start of this state’s official mental health reform effort.

This same pattern has been repeated in almost every state in this country. Critically needed inpatient psychiatric services, both privately and public, have been reduced in some areas but up to 80% and the outpatient replacement tools and facilities have not been built almost at all. I know of only one other in this region, Patrick Harris Hospital, a smaller state psychiatric hospital in Anderson SC serving the upper western part of that state. Look at Texas under the former Governor John Engler in the 1990’s for one of the most destructive reduction in public psychiatric resources in the country. This is going on everywhere and the media is full of desperate pleas from patient advocacy groups, the mental health practitioner professional organizations to begin to build back what we once had. And we have waited so long that now we have huge increases in the psychotic homeless, and our jails at every level are crammed full of the chronically mentally ill that states now face funding their care in jail settings instead of the state hospitals they closed. Harris County Jail in Houston, one of the largest jail systems in the country, has over 10,000 inmates; fully one fourth are chronically mentally ill after Governor Rick Perry went on a state hospital closing bender over his three terms to win votes by reducing expenditures and boasting of a smaller government. Unfortunately he has not been the only governor who has done this, but he is a good example that a reader will be able to call to mind quickly.

I shall cover over the coming months and years as I devote myself to this little personal crusade and long term interest of mine in public mental health care policy, books on the past and present history of this issue. I will highlight the trends and cries for reform that have repeated themselves ever several decades by persons who had compassion in their hearts for the mentally ill. The reader may be surprised by how long ago some of those advocates lived. Their words when not placed in their historical times, will sound as if their were on a current cable news investigative report that has aired recently. I will refer the reader to more than several books that chronicle this sad cyclical history. I will endeavor to explain my own views of the present ongoing consequences to our society and quality of life. I will point the reader to the same issues in other countries. I will ferret out and present many other strategies and attempts at solutions and novel approaches being tried in this country and not surprisingly in many other western countries who are humane and stable economically enough to attempt to address this societal task that will never go away. I will illustrate and ‘story-tell’ the tales of good intentions and efforts in the past that had “unintended consequences.” I will delve into the controversies such as gun control, mass and serial shootings and killers, gang violence, group hysteria (yes Salem witch trial stuff happens right here in supposedly Modern Non-superstitious America and elsewhere. I will try to sketch out the increasing conundroms and clashes of values and priorities that the under-addressed needs of the portion of the population that has mental illness pose for us all. I will attempt to praise those who are decent and selfless advocates, and sharpen and swing my scathing scythe of intellectual ridicule and call out the ideological, political, economic, bureaucratic, governmental, policy wonks and even misguided health care professionals who are part of the problem and are only making things worse. I will try to highlight positive efforts that I see everywhere, perhaps especially in the system and state I work in where we are building new state hospitals simultaneously at my estimated cost of over $600M, a wise and far sighted investment if I ever saw, even in the face of misled opposition to true reform. I will write of practitioners that I seen now and have seen for the last 30 or more years figure out ways to keep delivering the best quality care under truly unfair, undeserving and demoralizing circumstances wherever my voracious curating reading mind and all my dozens of searchbots can find them. I point out where things went wrong, and propose solutions, of which many will not be originating from me but from far wiser minds than mine.

I will do this because the Internet media is here and makes an effort like this possible, magnifying one voice for good that was not possible less than two decades ago. I will do this because I have to, I enjoy it, and it is the right thing to do. I do it because in my faith the phrase “Tikkun Olam,” do your part to repair the world little by little is an ethic and ethos I feel is worth trying to fulfill. I do it because I am a professional; I do not work by the clock and rush home at 5 p.m. I work as long as it takes to do the best I can for my patients to the best of my knowledge and abilities. I do it because I have also lost faith in many of the professional guilds’ effectiveness to counter these alarming trends. Years ago I dropped out of many of the psychiatric guilds. They had grown into self serving bureaucracies, their dues increased steadily and I could not see any guts and grit in them since I am a Southwesterner. So I am not a shill for the entrenched guilds. I am my own voice and I am going to make sure what I feel so strongly about is going to be heard and considered before I die walking down the halls of my beloved hospital wherever I am at that fateful time, on my way to do another consult, see another patient and offer myself to the best of my ability.





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