Removing Shackles, Moving Boundaries
On May 24, 1797, legend has it that Dr. Philppe Pinel brought the values of the Enlightenment to the treatment of mental illness when he removed the iron shackles from the limbs of his patients at the men’s asylum of Bicêtre Prison, near Paris. In so doing, he initiated the era of “moral treatment” — the first humane approach to the mentally ill in Western society. This event was ultimately (more than 50 years ago) memorialized in the initiation of the yearly “May is Mental Health Month” celebration.
In fact, the hospital superintendent, Jean-Baptiste Pussin, had already initiated a more sensitive, psychological approach to treatment at the hospital. Though a layperson, Pussin served as Pinel’s mentor. And, although Pinel has traditionally been credited with “freeing” the inmates, in fact the shackles were often replaced by straight jackets and seclusion. Nonetheless, the era of moral treatment, which produced large, relatively benign, often rural institutions for the warehousing of the mentally ill — what became, in the United States, a system of state hospitals — was a huge advance over the previous fear and abuse of those with psychiatric disorders.
This Mental Health Month, we can celebrate many achievements, including new, effective therapies and medications for psychiatric illness, and the passage of the Mental Health Services Act (“Prop 63”) a few years ago, which provides a “millionaire’s tax” in California, meant to bolster and transform services in the public sector. But we still face major challenges.
In a 2006 study, the National Association of State Mental Health Program Directors (NASMHPD) revealed that, nationally, people with serious mental illness die an average of 25 years earlier than the general public. Suicide and injury account for only 30–40 percent of the increased mortality. On the other hand, 60 percent of the excess mortality for individuals with schizophrenia is due to largely preventable conditions and/or treatable illnesses: cardiovascular, pulmonary, and infectious. Among the factors contributing to the problem are limited access to physical healthcare and the deleterious effects of some of our newer psychotropic medications, which can cause metabolic syndrome.
Who are the mentally ill? Psychiatric illness is common enough, so there are few of us whose lives are untouched, who haven’t had at least one friend or relative who has experienced a serious psychiatric condition. Over the years I have consulted with, or treated, many members of the families of physician colleagues.
Most psychiatric illness is treatable, controllable, and often curable. People with mental illness can and do recover, all the time. Studies have shown that even “chronic,” long-term patients with schizophrenia, when followed after a number of years, ultimately wind up largely recovered from the worst manifestations of their illness and are able to engage in society in a constructive and meaningful manner.
If quality of life can be achieved by those with mental illness — even resumption of usual employment and relationships — why are these individuals not achieving “parity” of physical health status? The San Diego County Health and Human Services Agency (HHSA), of which I am a part, is dedicated to addressing this issue.
If any other minority group suffered such a dramatic, outrageous health disparity, there would undoubtedly be a very visible, public campaign to bring their mortality numbers in line. The reasons for society’s inattention to the medical plight of the mentally ill are complex. Stigma remains a major issue. There are few people of prominence who are willing to self-identify as mentally ill, leaving a relatively small group of social crusaders to champion the cause.
Funding is also a problem, as Medi-Cal and most health insurance providers found it economical to “carve out” mental health services years ago, creating a separate “silo” for psychiatric patients to obtain care. There is often little collaboration between primary and behavioral healthcare providers. A separate healthcare record magnifies the problem.
There’s a moral imperative to bring good, physical healthcare to the mentally ill. But there are several other reasons as well. First, as the Institute of Medicine made clear in its “Crossing the Quality Chasm” report of 2001 and in subsequent updates, efficient, “patient-centered” care is important for everyone. We need to be focused on the whole patient, and we must find ways to economize. As most readers are aware, the United States as a nation ranks number one in healthcare spending but is far from the top in healthcare outcomes. If we can find cost-effective ways to coordinate services around the patient’s needs, we should be able to save money and improve outcomes at the same time.
I believe we need to break down barriers between psychiatrists and other medical practitioners, and rethink how we provide behavioral health services. We in psychiatry need to see ourselves more as consultants, akin to other specialists, rather than as entirely separate providers. Doing so can allow us to leverage our mental health resources, to support the provision of more holistic, comprehensive care by primary care providers — care that can include behavioral healthcare even for individuals with serious mental illness whose need is not acute or complex. Isn’t this, after all, the way cardiologists work with primary care providers? The patient with compensated CHF will be treated by a PCP and sent to the cardiologist if there are problems. The cardiologist can take over the solo care of the patient if the cardiac condition becomes more complex or acute, but then, generally, he or she hands the patient back to the PCP.
In a sense, one could envision the boundary of traditional “mental health” extending to recognize that much behavioral healthcare is already provided in the physical health realm for the less psychiatrically ill. With the proper supports and incentivizations, I believe that comprehensive medical care — a “medical home” — can be provided within primary care, for at least some of those with more serious mental illness, to include more behavioral health treatment by the PCP and primary care team.
How do we accomplish this kind of strategic shift of services? In meeting with primary care clinic providers, I’ve started to identify an approach, requiring structural changes in the way we provide behavioral healthcare:
- Primary care clinics could use an integrated behavioral health consultant to provide assistance with diagnosis, brief treatment of behavioral illness, and a combination of case management and expedited referral for those situations where the patient’s behavioral health needs become more acute. This position could be either a masters- or doctorate-prepared clinician, but the important element is that the consultant must be trained in working flexibly within a primary care team, and must see that team as their “customer.” If it’s 5 p.m. and the PCP’s patient suddenly reveals that his or her psychiatric symptoms are substantially worse, the PCP must be able to hand the patient off to this consultant to do what’s needed for safety.
- PCPs need access to psychiatrists for informal and formal consultation, on demand — not the traditional “I’ll call you back later this afternoon between sessions,” but real-time conversations while the PCP has the patient in the office.
- PCPs need the time (or the financial incentive) to be able to spend more time with patients with behavioral illness when that illness requires.
- PCPs need educational support regarding the use of unfamiliar psychotropic medications.
These innovations could provide the incentives and support needed to allow primary care groups to work directly with a behavioral health system. There is a broader implication too for the fee-for-service sector, and we need to flesh out the ways in which Medi-Cal and other insurers might provide support for collaborative or integrated care.
As we enter Mental Health Month, I hope this discussion will stimulate our medical community to consider ways to move even further beyond iron shackles and straight jackets to commit to reducing the awful physical health disparity that still faces those in our community with mental illness. HHSA and I are looking forward to a positive dialogue with the medical community, aimed at better health outcomes for all.