Maldistribution and Shortage of Psychiatrists and Child Psychiatrists

This is a reprise of a recent post on my other site “Pen and Psychiatrist.” I apologize to the the reader if you have already read this topic at the other site which deals in more cultural and social issues. But after I posted that entry not too long ago, I realized it more properly belonged on this site, since it deals with one aspect of the mental health reform puzzle in this country.

In my previous life some two decades ago as a young Turk clinical teaching and supervising faculty of psychiatric and child psychiatric residents and fellows in training at Duke Medical Center, I became interested in “manpower” (the vernacular then) or more properly speaking practitioner distribution and training issues of psychiatrists. This was in the so called Golden Age of mental health practice, even though the service delivery system in all disciplines, had serious issues, I and many many others could see the troublesome issue of maldistribution of mental health care professionals that was emerging three decades ago and worsening  year by year. Basically what was evolving was a situation in which desirable places to live, urban areas with urban amenities such as the symphonies, ballet and performing arts companies, university centers, and above all many colleagues around for support and lively continuing education meetings of regional psychology, social work and psychiatry societies, kept graduates of advanced training programs in the regions in which they trained. So over time, it evolved that areas like Boston/Cambridge MA, Raleigh-Durham-Chapel Hill NC (the Triangle Area), Ann Arbor MI, Dartmouth, New York City especially Manhattan, Stony Brooke, Long Island, Houston, Los Angeles, San Francisco, Seattle, Eugene OR, San Diego, Davis CA, Charleston SC, Atlanta GA, Birmingham AL, Albuquerque, Tucson AZ, and many other urban areas became the landing places where psychiatrists trained and often stayed to practice, in the university medical center cities. A good friend and colleague, now passed on Bruce Neeley MD of Duke and Emery, used to give lectures to residents nearing the penultimate stages of their training careers and were a year away from the decision of where to settle to practice. By then the 1980’s the trend had become set in concrete, only a minority of graduating psychiatrists left the training centers and set up practice in under-served areas.

Bruce Neeley and I separately in turn would give almost off the records seminars to the ‘senior residents,’ telling them in so many words, almost like the famous newspaper editor of the 1800’s, “Go West Young Psychiatrist,” In North Carolina we first meant go literally to western North Carolina which I knew very well because of my wife’s origin from Cherokee NC. But we also meant “get out of the urban centers, there are too many of us here already.”

WNC then and sadly still is vastly under-served by psychiatry with a chronic shortage that is almost criminal. I can count on the fingers of one hand the number of child psychiatrists in practice west of Asheville and that is a lot of territory. I used to tell senior residents to “Get out of the RTP [Research Triangle Park, another term used to denote the entire Raleigh-Durham-Chapel Hill area since each of those cities incredibly are only 8 to 15 miles from each other!

Continue reading “Maldistribution and Shortage of Psychiatrists and Child Psychiatrists”

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Closing State Psychiatric HosptalAs: Consequences, Good and Not So Good

As usual I always bow to my internal ethics and try to be as open and transparent as possible about the subject at hand, revealing attitudes, biases, views based on long term experience, and an almost “historical view” of the galloping phenomenon of “mental health care delivery reform” thankfully occupying the attention of the country finally. I am old enough to have practiced in the so called mental health age of oodles of resources, and have watched them atrophy, became extinct, go corrupt and get themselves prosecuted out of existence, lose funding for many many understandable reasons, lose their place of importance, watch the ever decreasing number of bright talented younger generations of “would have been social workers, psychiatrists, and psychologists” shy away from the training programs, and our numbers go down especially in child psychiatry. One could take an  inflammatory demagogic view and see is as necessary to prevent th abuse and horrors that indeed happened for decades shuttered away out of the light of public review and knowledge and responsible accountability and oversight. But that approach has nearly led to the old saw of “throwing the baby out with the bathwater because something was wrong with the bathwater, too dirty, too hot, whatever. I have seen the inhumane past and still in more restricted corners, inhumane treatment of patients in poorly run state hospitals that made me so mad I thought i would bomb them into the ground they were so bad, but of course after evacuating the helpless patients. I have helped to de-accredite the abominations of such hospitals, a few but enough to see first hand the decades old cultures of isolated facilities with poor faculty, psychiatrists who could work no where else due to histories of alcoholism, just plain bad practitioners and all the rest. I have had close colleagues since my residency days who presided  over the deserved federally mandated dismantling of closure of famous hellholes permitted to exist far too long and heard their stories of generations of horror stories.

But in the midst of all this, or in my case in the last quarter of my career, I still know and hold to the somewhat unpopular certitude that state psychiatric hospitals are needed, good ones and now more than every. One simply statistic is that out country’s population and mental health treatment burden has at least doubled if now tripled since World War II. And we have had new mental health phenomenon syndromes, traumatic brain injuries of unforeseen overwhelming magnitude outstripping the abilities of public and private psychiatric-neurological treatment worlds to receive, treat and comprehensively help them out of our IED head rattling new genre of injuries in the Middle Eastern conflicts we have had to enter, police and try to stabilize at little thanks from much of the rest of the concerned world with some exceptions.

State hospitals across the country have been marked for closure and destructions for decades with the trend accelerating greatly in the last 2o years or so. It was thought and expected the the monies saved from funding these “dinosaurs” would be responsibly shifted to the long known need for massive outpatient services for the CMI, chronically mentally ill for which the state hospitals had long existed and served, and served well in a surprising high number of hospitals. Remember the famous Meninnger family of three generations of nationally recognized humane psychiatrists practiced in a state public hospital, Topeka State in Kansas a venerable training and research facility itself.

Continue reading “Closing State Psychiatric HosptalAs: Consequences, Good and Not So Good”

Re-Admissions: The Big Problem in Psychiatric Hospitals

For once I am going to refer to a very recently published psychiatric literature article. It is published in the Efficacy and Safety of the 3-Month Formulation of Paliperidone Palmitate vs Placebo for Relapse Prevention of SchizophreniaA Randomized Clinical Trial,” by Joris Berwaerts MD, et.al. and “Long-Acting Injectable Risperidone for Relapse Prevention and control of Breakthrough Symptoms After a Recent First Episode of Schizophrenia: A Randomized Clinical Trial,” by Kenneth L. Subotnik, PhD, et.al.  However the editorial piece for that issue is what I will link the interested reader to as it has the “meat” of this topic and its lessons, written by William T. Carpenter MD, and, Robert W. Buchanan MD, titled, “Expanding Therapy with Long-Acting Antipsychotic Medications in Patients with Schizophrenia.”

First, the problem that these articles and editorial address. A huge percentage of psychotic patients, in this context, those with schizophrenia stop taking their oral medications that mostly prevent recurrent relapses of their illness. At the hospital level where i work, we call this “recidivism,” a term a I do not especially like as it comes from the correctional system [read jail/prison] but we are stuck with it. It means that a patient has again become ill and has to be readmitted and restarted on his/her medication and stabilized once again. This is a HUGE problem in psychiatry and costs untold tens if not hundreds of millions of dollars for each state hospital psychiatric system. Without an old fasshioned public health system as in the “old days,” where public health nurses went out to TB patients homes and saw to it that they took their anti-tubercular medicines daily in person, we do poorly with ensuring “compliance,” with chronically mentally ill (CMI) patients to ensure they take their oral medications everyday, and they relapse. Estimates from studies range all over the place but are often near or over 50%!

For more than three decades we have had older generation antipsychotic medications, that come in “depot” form, in which the medication can be administered in an injection in the arm or buttock and last from 2 to 4 weeks at a time. Administration and the right dosage are asssured; we know the patient receives the medication and relapses are much less common. These medications are Haldol, and Prolixin. But they are in the generation of antipsychotics that can cause muscle cramps and motoric restlessness (akathisia), both of which are unpleasant side effects. Medications can be given that largely prevent these but patients often do not like to stay on these two medicines long term though they work very well.

We have had  for several years recently two of the newer, “second generation,” antipsychotic medications, Abilify and Risperdol that come in long acting depot injectable forms. And while they have far less of the above side effects, they have other kinds of “metabolic,” side effects, but the big problem with them is that they are incredibly expensive. A dose of the Ability deopt from can cost up to $1700 a dose!

 

Bring Back the Asylums! Really?

This article will discuss the surprising but necessary and growing realization in this country that in order to adequate repair our broken national mental health care delivery system, we have to “bring back the asylums.” Instead of continuing to downsize and abolish inpatient beds, and close more and more state hospitals, we need more beds, more specialized units and more new, modern replacement state hospitals to replace our ageing physical plants of state hospitals that are on average, almost all over 100 years old!

I must also apprise/warn the reader that I have violated the big rule of blogging that I have read in every tutorial on blogging in the last three years, to keep your piece to say, 300-500 words maximum. I have ten-tupled that out of necessity to cover this complex and controversial subject fairly and adequately. I do not believe the batted about insulting Internet based concept that suddenly all American Internet readers have suddenly developed incredibly short attention spans. The blogging books and authorities all would hold me up, I am sure, as the Greatest Violator of Blogging Rules Ever. I would answer that if you are not interested in the crisis of mental health care, and/or mental health reform in this country, quit now, stop reading this piece, save yourself time and do something that fits and pleases you better. I will not mind. But if you are, I would hope you will find this piece informative, motivating and encouraging. I do not write from a pessimist’s heart, and am not the old character from the cartoon strip of Al Capp’s, Little Abner, now long out of print and unknown to anyone under 40 years old or so; this character was called “Joe #@?!” or something like that. He was a total gloom and doom guy, worse than Eyore of Winnie the Pooh. He was illustrated so well pictorially by Al Capp to give any reader of the comic strip an immediate recognition of this character’s constant and unfailing pessimism and even constant expectation that misfortune was waiting for him at any second, by drawing with a little black cloud just above his head that was already raining on him and no one else wherever he went. I am hoping to write and promote change in the opposite, optimistic, we can gradually make things better mode. And fortunately in my state of practice in North Carolina, no matter our present hurdles, we are working diligently on them, I think in the last few years we have turned a number of big policy and implementation corners, and I am proud of this state’s efforts under very very adverse circumstances. I also hope that by writing from that perspective, and by picking up and publicizing in my own small way, successes, victories and advances I find through my professional collegial grapevine of four decades of colleagues from my training years, different places I have practiced, and the wonders of my cool little Google Internet keyword army of helpful search bots, I can spread some good news of mental health reform efforts in other locales that are also fostering improvement and progress against the daunting odds and difficulties we face commonly all over this country. So get your favorite beverage, get you thinking and pondering cap on, and undertake to read [in as many sittings as it takes] this massive blog “missal” on “bringing back the state hospitals,” not exactly a popular or politically correct concept perhaps these days.

Continue reading “Bring Back the Asylums! Really?”

The Continuing Serious Shortage of Child Psychiatrists

I first have to make my disclosure statement: I am a child psychiatrist, in addition to being and adult, and geriatric psychiatrist. I trained and was board certified in all three subspecialties but I am a child psychiatrist and that will necessarily makes its way into this post and I wish the reader to know that up front.

The Arab news agency Al-Jazeera had a very recent article that caught my week several days ago. It was entitled: “Shortage of child psychiatrists plagues the US.” It appeared June 25, 2015. It was very fair and well done and I appreciated the factual, accurate and in depth reporting that went into it. But as an American and a child psychiatrist, it stung a little. One of our 30 year old problems that we have unconscionably neglected and is a big part of our present self inflicted, national “mental health crisis” is catching the attention of the foreign press more and more. This hurts. And part of why it hurts is that the venerable, sort of business-y conservative, Wall Street Journal has been reporting on the shortage of child psychiatrist now for well over a decade. If the reader will Google ‘child psychiatrist shortage Wall Street Journal’ you will get a few pages of listings of well done articles published in the past by the Wall Street Journal in past years.

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History of Michigan’s Mental Health System Continuing Crisis

Yesterday, July 2, 2015 I gave credit to a medical innovator and systems analyst, a physician, and a plastic surgeon, at that, at Henry Ford Macomb Hospital in Clinton Township MI, Dr. Vikram Reddy MD MAHS who as medical quality of care director of the hospitl, wrote in the Free Press and Bridge Magazine there locally of his pilot project to try to address the long standing, not improving problem of “frequent flyer,” high cost, not resolving ER patients that represent one of the growing and worst public health care crises in this country that plague every hospital in the USA large or small. He is making a superb effort to organize, energize, find and locate appropriate medical management services for these problematic medical consumers who seek highest cost care in the most inappropriate place, the hospital ER. This relates to many nationwide problems growing since the Reagan years that I will refer to later. But Dr. Reddy is trying an approach being looked at nationally as a solution to this issue, i.e., diversion/referral to appropriate services outside the ER that do much more good, are able to give these patients long term, continuing, consistent disease management that they need and deserve and that is where the healthcare dollars are really saved while at the same providing health maintaining and promoting care, care that prevents relapse of their conditions, and keeps them from going into crisis and having to seek inpatient care which is usually at least 10 to 20 times the cost of outpatient care. Now don’t you think that would motivate the planner and governments to seize upon these sensible solutions? “Not hardly” as they say here in the South.

Who are the patients? They can be easily identified as falling in approximately these groups: (and I apologize right now if my brain leaves out/omit significant groups as I will comment upon those I know and see the best and most and may omit others); 1) the drug prescription abuser/addict who has or utilizes inappropriately a pain condition to repetitively doctor shop, and nowadays “ER shop,” in  order to gain more prescriptions for opiates, to abuse until they run out and start all over again at the same or a different ER: 2) the chronic substance abuse who is not in recovery whether having been in “starter” substance abuse programs, like inpatient detox program/units, or AA/NA etc., and come in for acute treatment of intoxication and consequent often legal problems (assaults, disorderly conduct, impulsive threats while “out of their (rational) minds making temporary suicidal or homicdal or assaultive threats, or for worsening of many extremely serious comorbidities [accompanying serious recurrent medical problems from continued substance abuse: delirium, worsening of liver disease going into cirrhotic crisis, hepato-renal renal failure, bleeding from the esophagus’ enlarged “varicose like” veins, acute pancreatitis, comatose states from alcohol poisoning or just plain old overdosing on sedating, respiration suppressing drugs ranging from opiates to anti-anxiety medications like Xanax, 3) the young adult who is developmentally disabled and psychiatrically ill  who goes into acute psychiatric crisis, assaults their parents for no reasons, becomes destructive, leaves the home and starts dangerous behaviors like wandering in the woods and on the sides of high speed highways; and lastly 4) the mentally ill who come from homes, the streets, shelters and now ever increasing from the local jails, in acute psychotic crisis and demand immediate attention as much as patient having a myocardial infarction in progress.

So that is what Dr. Reddy is facing in his hospital in Clinton Township MI. Where did this start in Michigan? It started in the recession of the 1980’s when the Big Three automakers were really losing business to the foreign carmakers, especially VW and the Japanese brands who were building better quality cars, that were more efficient and cost less. As the American auto industry suffered massively so did Michigan since guess what? Michigan was ill suited to weather economic change ever if it were positive and revolutionary. Its economy like so many states in the South who suffered even more for even longer, was not diversified; it was based largely on manufacturing with a huge percentage of the machine shops all over SE Michigan serving the auto industry, and agriculture. Tourism, the state higher education university system and big time sports helped but not that much in reality. So the state had to cut revenues and one of the places it placed emphasis upon was the mental health cost center of the state government. Gov. Engler as is known slashed services all over Michigan and by 2000 was planning to privatize the entire system to get the state out of the mental health business which had become an article of faith by then at the National Governors’ Conference in those years. “Cut and Privatize Mental Health.” Nowadays the new mantra is to dismantle the state employees’ unions and workers’ associations and somehow transmogrify a pretty dedicated work force in the McDonald’s restaurant model of the not long term, disposable, LOW paid employee.

By 1999 and certainly by 2000 the Detroit Free Press had been running a series of articles on the dismantling of the mental health system since approximately 1992 or thereafter as the “privatization” ethos of those times from the era of Reagan deregulation as the solution to labor problems and inflation had taken hold of many politicians and policy planners, mostly of the Republican persuasion.

Ms. Wendy Wendland-Bowyer in the early 2000’s for the Free Press did creditable reporting on this evolving issues for a number of years. An example of an article of her, “State to unveil new plan for mental health system,” is a great example. In this she notes indirectly that at that point in time she state was having to “reverse” itself and retreat from its full privatization plan. This article ran on Sept. 1, 2000. But it noted the overriding principal was to convert the county mental health center based systems all over the state to full private competition in which privatized for profit mental health care provider business entities would eventually take over the delivery of mental health care. This was coming after the decade in which Gov. Engler had closed several state psychiatric facilities, Pontiac State, Clearwater, etc. She wrote: “the first phase of the waiver [a permission process from the Feds to do all this] required county mental health agencies to be run like manage care plans. The second phase was to open the county services to private competition.”

There was a feature based on population density, designed to promote business efficiency that has been coped in almost all states by now to eliminate small, supposedly inefficient service units in counties with sparse populations. “The new plan does require that county agencies meet certain goals in order to avoid private competition. For example, the agencies must have at least 20,000 Medicaid recipients in the geographic area – something 12 to 14 of the state’s 49 agencies have…” Of course the unforeseen consequence to this rule, was that with regional “centralization” of mental health centers usually into the county with the largest population of the several that had merged, services access became distant in all these mini-catchment areas for nearly a majority of clients, forcing them to travel longer distances to their ordinary appointments. Compliance went down, more appointments were not kept and guess what, clients ended up in ERs by the hundreds suddenly to all the bean counters’ surprise and have now been perplexing and occupying people like the good Dr. Reddy of Clinton Township with how to fashion a local solution to what is a state imposed system error.

I will apologize at this point. I have included the link to Ms. Wendland-Bowyer’s article, but it is hard to reach and you have to do some real “Search Box” or “Archive” searching to find it on the FREEP website as in the ensuing years the newspaper’s digital online edition has archived or taken down many many of the articles from that era. My sincerest apologies if it is no longer available.

In my next post on the history of the mental health plans and crises in Michigan, which serves as instruction and one of the true original examples for what has and is happening in most of the other states in this country currently, I will talk of the defunding issues of other sectors of the mental health care delivery system that the non provider, ordinary observer would not likely think of, nor realize who vitally important they are and always have been, and what enormous negative consequences they have also had behind the scenes further worsening the dumping of the mentally ill into systems that are not designed to adequately care for them.

 

Plastic Surgeon Describes Michigan Mental Health Delivery Issues: Mirrors Nationwide Problems

I would like to give creidt to Dr. Vikram Reddy MD MHSA, a plastic surgeon, NOT a psychiatrist who has lately been advocating in print for renewed reforms in the state of Michigan which is now over 20 years after the slash and burn cuts in that state’s public mental health care surgeon. You may find his timely and very thoughtful article in The Bridge Magazine or the trusty, still surviing Detroit Free Press.

You may ask why and how would a plastic surgeon of all physicians become so concerned about little ol’ mental health issues? Many reasons: 1) first and foremost he is a dedicated and committed physcician whose first priority is patient care, and primarily ensuring delivery of quality care; 2) he is “medical director of quality and clinical integration at his home hospital in Clinton Township, part of the Henry Ford Macomb Hospital system of great Detroit. His timely article, entitled, “Mental health care in has room for improvement, but will it?” says it all.

Dr. Reddy described a well thought clinical-analytic-management effort by his staff and himself to identify the problem patients of any kind who account in any hospital, especially in the ER departments, for utilizing, or in a more sarcastical-critical way of characterization, “using up,” the largest portion of such services for less than bona fide indiacation for the services they seek. And many of these services are costly procedures, and huge sinkholes of constantly recurring costs that do solve anything and ultimately do not “satisfy” or clnicmally meet the needs of the patients. Drug seeking pains who  claim pain, requires expensive workups by multiple specialistis, imaging studies, and then frustrating nonproductive earnest time spent with them thrying to divert them to more appropriate, and ultimately cost reducing services that appropriate address the problems of drug addiction. Also psychiatrist patients, for whom, like most every other state, there are not enough psychiatri residential or true 24 hour acute inpatient psychiatric beds and services manage and correct the issues that bring them repeatedly into ERs in crisis to get often the only timely help available to them. Dr. Reddy correctly alludes to, but does not specify, one of the historial causes of these typical nationwide problems, that has resulted in shorgages of outpatient services for psychiatric clients. I would inject the fact Republican Governor John Engle through the 1990’s’ reduced the statewide publc mental delivery system to a fraction of its former size. He, for instance, closed all but five of the major psychiatric state funded hospitals in the state. And like just about everywhere else, nowhere near a sliver of replacement community based services were responsibly created by the state. In fact this state was one of the first to start the Wild West, open the doors and let the private large and small business, not clinically oriented, agents of public psychiatric services take over. One would think that had this model worked which was exported by the same cadre of planners in Michgian to other states, notably the very next, North Carolina in 1999-2000 with very similar results except that NC did not close abruptly the four state hospitals, but instead “revamped” the community service universe by eliminating the county by county based mental health care delivery system, which while flawed through inadquate funing and other factors peculiar tot the geography and absurdity of having ONE HUNDRED often rural little bitty counties, and letting the privateeers decied what they would cherry pick and put in place. Buth states as well ass many others now face the second half of the equation of mental health care devliery, providing adequate and large, comprehensive multi-disciplinary relapse prevention of illness, whether it is substance abuse based, psychiatric or that of the developmentally disabled. North Carolina’s now causative “exacerbator,” was reducing almost by two thirds the public psychiatric beds in the whole state instead of closing hospitals, in order to save money.

Dr. Reddy has initiated a pilot project to identify frequent flyer costly mostly non=medically appropirate patients in the ER systems, and to responsibly divert, refer and get them to the services they need but often avoid, to stamp out maintenance of opioid additions through naive physician prescripbing and I suspect drug diversion but finds the outer system that needs in poorly organized and not up to the task.

He notes positively that the succeeding Democratic Governr Jennifer Granholm had to attempt to correct her predecessor’s Cossack approach, and I recall  her having to bravel condemn her political future by having to wring out of the state legislature and ailing economy, $500M to begin reorganize and stabilize the system. Dr. Reddy also refers to the more sensible long term positive approach of the current Governor Rick Snyder’s now comprehensive Mental Health Commision report and impetus of 2014 to begin to further “rehabilitate” the crippled Michigan system.

The reader who is intersted in the current nationahwie crisis of mental health care and its hobbled systems, both private and public would well advised to follow closely the developments in Michigan as the politicians, citizens, patients and their families, and their adovates and the providers, labor now to effect positive appropriate and responsible changes, that WILL cost money no matter what, and see if they are successful and can be a good example of a state’s corrective efforts for the rest of the states faciling simiilar issues.