This is the fifth in a six-part series that explores challenges people face when they seek treatment for mental health issues. This article explores reasons for problems with care and the sixth discusses how to help yourself and loved ones to get care that works.
According to the National Alliance on Mental Illness (NAMI) "One in four adults -- approximately 57.7 million Americans -- experience a mental health disorder in a given year ... (including) one in 10 children."
Yet people often tell hair-raising stories of trouble they've had getting useful care. If mental health issues are so common, why isn't good treatment easier to get?
Two issues that probably occur to you right away are the stigma associated with mental illness and the out-of-pocket cost of treatment. Since these are well known, this column will highlight other obstacles.
First, sometimes people are treated for mental health issues when the real problem is another medical condition. An article in the Wall Street Journal by Melinda Beck reported, "More than 100 medical disorders can masquerade as psychological conditions, according to Harvard psychiatrist Barbara Schildkrout." Further, Beck noted, "Studies have suggested that medical conditions may cause mental health issues in as many as 25 percent of psychiatric patients and contribute to them in more than 75 percent."
Said another way, treatment may not work if it doesn't go after the right problem. Assume that people are treated with talk therapy for depression. Suppose that the real problem is that they have underactive thyroids. They aren't likely to get great results.
Second, drug therapy may be overused, for several reasons. Most of the psychiatrists who created guidelines a number of years ago for treating people with depression, bipolar disorder, and schizophrenia got paid by pharmaceutical companies -- not for their work on the guidelines, but for help with research, for consulting services, for speaking, and so forth.
Is it bad for doctors to work with drug companies? Not necessarily. Who else has the experience treating patients that can be important in developing new drugs? No one.
But these connections can sometimes lead to skewed thinking. According to the Kaiser Daily Health Policy Report, "The guidelines focus heavily on medications and give little focus to non-drug treatments." The guidelines also don't talk about how to eventually get patients off the drugs, creating the impression that once people start taking them, they are on them forever.
Money issues throughout health care have led many health insurers to focus on the least expensive way to treat a problem. Typically, in the short term, that is with drugs rather than by talk therapy.
It is also common in health care for doctors to dismiss side effects as trivial, while patients may find them very disruptive. Thus, doctors may feel that the benefits of a drug for a given patient outweigh the downsides, but the patient may not agree.
Third, doctors who treat patients in psychiatric facilities may have little communication with doctors who treat them on the outside, so key information may be lost.
Dr. David M. Reiss, a psychiatrist with 25 years' experience, is now back in private practice in San Diego after a four-month stint as interim medical director of Providence Behavioral Health Hospital in Massachusetts. He explained this issue.
He noted that a number of years ago, most psychiatrists were in private practice. The doctor treating patients in a locked ward was the same one who treated them on the outside.
Now in many different facilities, he observes that generally the psychiatrists who see hospitalized patients are employees of the hospital. They may have so many patients that it is hard to spend meaningful time with each patient every day. The doctors in the hospital may have little chance to talk with patients' doctors on the outside. They may miss key background information, and the outside doctor may not hear what went on in the hospital.
Fourth, money issues mean that people getting inpatient care stay in psychiatric hospitals for an average of only 5-7 days, which is not long enough to detox them, diagnose them, and find a treatment that works.
Many people who enter a psychiatric hospital have drugs in their systems when they get there. These include alcohol, illegal drugs, and prescription medicines. In Dr. Reiss's experience, up to 70 percent of people admitted to psychiatric hospitals have been abusing mind-altering substances. These can mask the underlying problem. It's best to take a week or two to let these drugs work their way out of the patient's system. Then, once doctors can tell what is really going on, they can tell what drugs might help.
But it can take weeks to see if a new drug is actually helping a patient or not. Thus, detoxing someone and trying two or three drug treatments can easily take a month or two.
If insurance constraints limit stays to a week or so, then doctors are pressed to start new drug treatments before people are even detoxed, making it hard to come up with an accurate diagnosis or to see whether the treatment is working.
Dr. Reiss commented, "The more cutbacks there are. . .the more that we've gone to a short-term model. Basically, as soon as (patients) are not psychotic or not suicidal, they're discharged." And with this approach, he concludes, "The worse the system performs."
The goal of inpatient psychiatric care now is often simply to reduce people's symptoms so that they aren't a danger to themselves or to others. That's a useful target. But it means that people are often discharged without a meaningful plan to help them live their lives as well as possible. And without a good plan that goes beyond the short-term goal, psychiatric wards can be revolving doors -- the same patients may come back a few days or weeks later.
Regretfully, Dr. Reiss concludes, "It's s systemic problem that's getting worse and I don't see a good solution in the near future."
Fifth, the power disparity between the people being treated and the ones doing the treating can create obstacles to good care.
People with mental illnesses are at a serious disadvantage. They have even less power than do medical or surgical patients. They may be unreliable witnesses. They may be delusional or paranoid, and mix fantasy with reality. Sometimes they are not able to make good decisions on their own. If they are severely depressed, they may be entirely unable to muster the effort required to stand up for themselves.
As stories in this series have shown, sometimes doctors and other caregivers take advantage of that power difference. Studies have shown that very nice ordinary people can turn into monsters when given a lot of power over others. Sometimes people at their most vulnerable - whose minds have betrayed them - find themselves at the mercy of those nice people who have power over them, who aren't always nice at that point.
The movie One Flew Over the Cuckoo's Nest showed ugly power plays in a locked psychiatric ward where the doctors and nurses held all the cards. Jack Nicholson played a patient trying to level the playing field.
Sometimes reality comes uncomfortably close to fiction, and Dr. Reiss said of events in some psychiatric hospitals, "The only thing missing. . .is Jack Nicholson."