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.

Continue reading “The Continuing Serious Shortage of Child Psychiatrists”

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.

 

More on Milwaukee County mental health services facility crisis

On June 18, 20 the able reporter Ms. Meg Kissinger for the Milwaukee Journal Sentinel newspaper that has been superbly documenting this now 15 year old story, wrote of the latest repair efforts by the County to fashion a feasible plan to resurrect and restructure this facility and its services to its clients. She documents the new effort in her article, “County considers closing Mental Health Complex, privatizing care.” In my distant uninformed opinion they do deserve a lot of credit for toiling under years of stress, failed plans, recurrent crises and scandals. If anything they are to be commended for long term public service efforts, through I am sure, multiple sets of officials.

As it is reported currently, there are a number of short and long term plans to try to create better services. Ms. Kissinger details this in her latest article, “County considers closing Mental Health Complex, privatizing care.”

The major elements of the plan appear to be to get the county government out of the operation of the center and the judgment appears to be that this level of system change is needed to have a chance of success and improvement when the newspaper’s own series, “Chronic Crisis: A System That Doesn’t Heal,” referred to in recent posts has failed in part because of poor political leadership, division and poor follow through as well it appears just poor paltry efforts at reorganization inadequate to the task.

The main elements appear to be: 1) “turning over direct patient care to a private organization as is done in most other counties across the country;” 2) delivering psychiatric services at two separate locations at two different and hopefully dispersing and easing access to services; 3) including multiple services at each “access hub,” including a mental health clinic, peer-run services (where patients having achieved high levels of recovery and stability can help give on the spot support and guidance to new and continuing patients–a very effective mode of service and means of helping sustain compliance and continuing attendance and contact; 4) intensive  outpatient services, 5) a crisis line, 6) care coordination with I expect designated staff specialized in obtaining, scheduling and referring to diversified services, long known as case managers, essential parts of any such outpatient mental health organization that did not exist decades ago; 7) and a medication management clinic. Additionally, and very significantly, the long nationally neglected truly essential component of local inpatient crisis psychiatric care, a 60 bed inpatient unit “for patients that need around-the-clock care will be included. On the face of it, this sounds like a very well thought out plan.

Further the article notes that apparently the plan was put together with extensive consultation with all the needed stakeholders essential to the enterprise, patients, families, advocated, clinicians. Workers and current clinicians are to be afforded apparently every opportunity to retain their jobs and continue to work. In past efforts I have witnessed in a number of states, the private organizations would come in and ape Frank Lorenzo’s original model with bankrupting and reorganizing Continental Airlines in the 1980’s of essentially firing everyone, then making them re-apply for their jobs, and then paying them if they consented to be rehired–at far lower salaries wages, taking cruel advantage of their needs like everyone else not inherently wealthy like big Cheeses like Mr. Lorenzo, to go back to work at any cost to themselves, establishing the model of screwing the working class (I now disavow being a radical, Commie, or goof ball Socialist or any of the other epithets used to discredit anyone who notes the consequences to now depleted “middle working class).”

What I have seen happen over and over in now TWO different states who reorganized their “mental health center” based systems with this costs at any cost rehiring approach and vile treatment of committed clinical staffs, is that many of the staff who face losing up to say 40% of their pay, in many instances, much of their retirement and vestments, is that they quit and move on….Then the private corporate re-organizers happily, as this HAS seemingly been their intended plan, hire new clinicians, like Mr. Lorenzo did, desperate to get jobs in a recession economy, willing to settle for lower pay, but also altering job descriptions and required clinical qualifications to a lower level, from  Master’s levels counselors, social workers and psychologists, to those with 2 or 4 year Associates’ or Bachelors’ degrees, far far less actual patient centered exposure and clinical experience and “rotations,” as those are very expensive for these lower level training programs to provide, and the privatized “behavioral centers,” end up with often very less qualified staff who nonetheless work hard and are happy to be fulfilling their own mental health worker aspirations. Later many of them find they have been locked into near permanent lower pay servitude with not much of a ladder of career and earning power advancement, a cruel but now pervasive employment practice in so many industries. Quality of care suffers.

Other cost cutting measures usually follow. Less well trained “prescribers,” and experienced therapists with less experience than Masters’ level, and PhDs and MDs manage acute and chronically mentally ill patients’ psychotherapeutic and psychopharmcological treatment needs. Patients are seen in medication groups instead of individual as much as possible to further save money, are seen often only on walk in basis in crisis. Patients are smart, and they migrate to the ERs where they can see more skilled practitioners, and get better care and we end up with mess we have now, patients flooding local hospitals’ ERs.

One cautionary note and quote in Ms. Kissinger’s June article is by the County Executive Mr. Chris ABele, who was quoted as stating: “Uncontrollable expenses significantly influence the cost of doing business as a county entity.” This kind of mantra used to be heralded as justifiable and ethical as it was long repeated all over the county in this now overwhelmingly utilized of mental health local system of care delivery, would save costs by ‘getting the meddlesome government out of it.’ What has evolved instead is that clinical services are cut in every manner conceivable in addition to the honest expense saving approach of consulidating administrative services, and unifying the management components into a central cost effective entity. That was done and almost always promotes honest savings, more unified management, better oversight, etc. But the other hack and slash approaches are just too tempting for most organizations to resist and almost universally quality of care has declined in the last two decades dramatically. Just ask patients older than 40 or parents of adult mentally ill, or patients trying to seek more than piecemeal, silo’ed services in which the client/family has to apply separtely for every service they need and processes of delivery take far longer than they did before in the organizations that have followed this kind of recipe. It is repairable and correction and refinement of service delivery organization is finally beginning to evolve in enlightened centers.

But when privatization evolves to equal profits over service expenditures and funding sources, i.e., the local and state government start the Nixon approach of decreasing funding annually, then quality declines in synchrony with those cuts as governemnts handily and happily get out of the “mental health business.” Recently Obamacare has taken the aporach that an interim solution is to expand Medicaid. Right now that is the only visible solution but it should be temporary. And it has rightly generated enormous controversy as it shifts costs to the federal level, WILL result in cuts elsewhere in the Federal budget at time when we need to be rebuilding everywhere, infrastructure and God knows what else, or means the dreaded rabies inducing reaction to “higher revenue streams,” the euphemism for higher taxes. The reality is that the public mental health client cannot fully pay for their mental health services they need and few in the world of economic governmental reality are paying responsible attention to that undeniable reality. And again the powers that be seem to still be forgetting the old American ideal of the “common weal,’ the good of the majority, the ‘help thy neighbor ethos.’

Let us hope the folks, all concerned in Milwaukee learn from the mistakes of the rest of the country’s floundering experiment with “mental health reform,” and do it better and differently. They certainly sound as if they have a sound plan, if only they make it work RIGHT.

More on Milwaukee county mental health overhaul

I would remind previous, and inform new readers to this blog that I have been loosely covering recently (as this blog is NOT very aged…) the very long sad of the saga of the Milwaukee County’s combined mental health services. These actually started being chronicled in the Milwaukee Journal Sentinel in 2000. There is a comprehensive website at that paper’s website that contains the easily listed and read articles since those began in earnest in about 2006 when things really started falling apart there. I am primarily interested in the long term struggle to modernize, and fashion a new sensible integrated system of mental health care delivery in my home state of North Carolina where I have practiced since my training at Duke in 1974 with the exception of 9 years spent in two other states for family reasons.

Continue reading “More on Milwaukee county mental health overhaul”