June 20, 2016

No Codes for Mental Health Failure

By

EDITOR’S NOTE: Last week’s nightclub shooting in Orlando once again generated a call for mental health screening to help keep firearms and assault weapons out of the hands of the mentally ill. In the aftermath of the shooting, ICD10monitor Publisher Chuck Buck checked in with nationally renowned psychiatrist H. Steven Moffic, MD. An edited transcript of that interview follows:


 

 

CB:

Last week’s shooting at the Orlando gay club Pulse, in which 49 people were killed, has focused renewed attention on mental health. Many people believe that the country’s mental health infrastructure is broken and that the mentally ill are slipping through the cracks.

When did the system start to crumble and what might be some of the causes?

  • National and state funding of mental health programs?
  • Pressures on payers to reduce costs?
  • Inadequate reimbursement?
  • Mental illness symptoms being not easily diagnosed and going undetected?
HSM:

Chuck, as you note, once again, after another horrendous mass murder in Orlando, the most deadly in our country's history, our mental healthcare system is on the radar. Partially, that is because some of the perpetrators have had untreated or under-treated mental illness. Let me emphasize “untreated or under-treated” because the mentally ill who have been successfully treated, which is the bulk of those coming for help, have a very low rate of committing violence compared to the general public. On the other side of the coin, the mentally ill are subject to receiving violence at a rate higher than the general public.

Unfortunately, though, all it takes is the widespread media coverage of a mass murderer with suspected or known mental illness to skew the public's understanding of the mentally ill. Fortunately, perhaps, (there is) the opportunity to examine how we can better our treatment of the mentally ill, an opportunity that you are once again providing.

History shows us that mental illness in the United States has always been stigmatized and responded to differently than the rest of illness. Some of that comes from our historical cowboy cultural value to "pull yourself up by your bootstraps." If you are depressed, just get out of bed and go to work, as if you could will yourself to get better. 

Another part of that difference is that it took so long to appreciate that mental illness was indeed like any other body disorder, but in this case involving the brain. The delay is because the brain is the most difficult organ to research, so our understanding of how it works is still behind other organs like the heart or lungs.

Consequently, until the 1960s, the more seriously mentally ill were generally warehoused in state hospitals, while those with less severe (conditions) had inadequate private insurance for treatment.

All that changed with President Kennedy. In 1963, Congress passed the Mental Retardation Facilities and Community Mental Health Center Construction Act – note that he had a mentally disabled sister – beginning a new era in federal support for mental healthcare services.

Patients were transferred out of the state hospitals into newly available – if somewhat inadequate at times – outpatient community mental health centers, a process which was called deinstitutionalization. At its worst, those state hospitals, sometimes called "snake pits," resembled the one depicted in the famous movie "One Flew over the Cuckoo's Nest." At the same time, private insurance for psychiatric treatment also improved.

However, as much as politicians can giveth, they can taketh away. By 1980, about half of the desired centers had been built and (were) functioning. I had even served at a beautiful and comprehensive center in the small town of Anniston, Ala. However, in 1981, President Reagan signed the Omnibus Budget Reconciliation Act, in essence repealing the 1963 Act and leaving states with block grants that could be spent on whatever public services they desired, say, roads instead of mental healthcare, in effect more often than not significantly reducing funds for mental healthcare and stopping the building of new centers.

On the private side, President Nixon, before President Reagan, got laws passed that allowed for the development of for-profit managed healthcare, which essentially enabled for-profit companies to make such a profit that they ended up being traded on Wall Street. Of course, those who could self-pay or needed emergency care still got what they needed. Mental healthcare was an early and convenient target for reducing services and reimbursement. I ended up trying to convey what happened in the book The Ethical Way: Challenges & Solutions for Managed Behavioral Healthcare (1997), which was unfortunately re-reviewed in recent years because it was still relevant.

In the most terrible irony, in late 1981, President Reagan was shot by John Hinckley, Jr., who suffered from untreated mental illness and ended up staying indefinitely in a federal mental hospital. He didn't, however, try to repeal his own law.

The eldest President Bush, indicating that this was not a clear-cut Republican-versus-Democrat juggling of the mental healthcare ball, tried to help by designating the 1990s as the "Decade of the Brain." More research was funded, but progress (was) slow.

So, where did these public and private sector developments leave us today? For starters, we are still the only highly "developed" country not to have a national healthcare system that covers all of the basic health and mental healthcare of its citizens. More specifically, we are left with inadequate state and private psychiatric hospital beds and outpatient services. Due to (fewer) resources for patient care, many more end up incarcerated in jails or prisons, if not homeless on the streets, a phenomena not seen in other countries … which also have strict gun control laws.

Although healthcare reform under President Obama has reduced the number of the uninsured, now about half of the previous 50 million, that hasn't translated into more and better services for the mentally ill. States and counties can vary quite a bit as to the availability of services, which can often limit the application of improved treatments, as well as slowing down the recovery movement that emphasizes patient choice – that is, if you choose the best treatment, you may be unlikely to get it!

CB:

You have written about the reluctance of some in your profession to identify themselves publicly as psychiatrists. Does your profession suffer from an image and/or credibility problem?

HSM:

The stigma about the mentally ill incorporates those of us who treat them. Psychiatrists, then, are stigmatized among physicians. That is one of the reasons we don't often share in public that we are psychiatrists. But there is one other factor that is even more important. The public tends to think that we have the ability to read their minds and thereby discover things they'd rather keep to themselves. While there is a grain of truth in this, in fact in public we tend to not think and act like psychiatrists. Deep inside, we appreciate that we are trying to care for those that society generally disowns. We have a lower burnout rate than the epidemic rate of burnout in most other medical specialties, a Pyrrhic sort of achievement in this land of need.

Our country could show that it is a healthy country by eliminating these disparities in care and value.

About H. Steven Moffic, MD

Over a 45-year career in psychiatry, H. Steven Moffic, M.D. has won numerous awards for his educational, ethical, clinical, administrative, and artistic work, including two from the American Psychiatric Association (APA), the one-time Hero of Public Psychiatry Award and the intermittently awarded Administrative Psychiatrist Award, the latter to be presented to him at this Fall's APA meeting in Washington, D.C.
Chuck Buck

Chuck Buck is the publisher of ICD10monitor and is the executive producer and program host of Talk Ten Tuesdays.

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