Dr. Keith Albow, a psychiatrist and part of the Fox News medical team, is an outspoken critic of the deplorable state and disintegration of our mental health care system. He writes:
“The reason we see a surge of violent mentally ill people is that we have systematically dismantled the mental health care system in America so completely that it is now routine for psychotic people to be treated by entry level social workers in community mental health centers, turned away from emergency rooms or discharged from hospital inpatient units if they simply promise not to murder anyone. A person who believes the CIA is following him, has a history of violent crime, voices homicidal ideation and is on a half-a-dozen medications could easily spend only 48 hours in a hospital, be seen primarily by nurses and social workers (and only for a total of 30 minutes by a psychiatrist) and then be discharged with nowhere to obtain his medications and no one supervising those medications. That’s how bad things have gotten.
“In fact, prisons are now becoming de facto mental hospitals since mental hospitals have become revolving doors that medicate people for a few days or a week and then discharge them, at the insistence of third-party insurers, often without proper follow-up and on the wrong medications.
“The following list is not exhaustive, but, will give you an important window into just how bad our mental health care system has become.
“1) The art of helping understand psychiatric illness is not available to the vast majority of families but is reserved for people who can find the small number of professionals who are expert in that skill set, many of whom would never be paid by insurance companies at all, or given only three or six or a dozen hours to treat a very disturbed patient.
“Not only have insurance companies and the Medi-Cal system demanded that empathy be dispensed in tiny doses, in favor of ten minute medication appointments, but many training programs for psychiatric residents have responded by curtailing education in that healing art such that most new psychiatrists have never been in therapy themselves and have limited ability to perform it.
“2) The demands of insurance companies, including Medicare and Medicaid and every public insurance program, has been to push down the educational level of clinicians more and more.
“People with complex histories of abuse and neglect and extremely toxic interpersonal dynamics are now routinely in the case loads of mental health counselors with little more than college degrees and social workers and nurses, many of whom are very talented and extremely dedicated people, but simply do not have the training to do what psychiatrists trained for at least eight years in medical school and residency could do for them.
“3) The holistic view of the patient—essential to understanding his view of himself and others and assessing whether dangerous behavior could result—has all but disappeared, having yielded to simplifying and splitting the patient into someone with some emotional problems who should talk to a counselor about his feelings once a week (or less) and someone who needs medicine to think clearly or stop hallucinating or stop being paranoid who should visit a doctor or nurse ten minutes a month for prescriptions.
“4) The use of inpatient psychiatry units in which more sophisticated assessments of psychiatric patients are performed is now mostly relegated to rare hospitals that can cost as much as $20,000 or $40,000 or more per month, which people must pay themselves since insurance companies will not.
“5) There is no system in place—at all—that routes very sick mentally ill individuals, especially those at risk for violence, to forensic psychiatry professions truly skilled to evaluate them. In any case, the numbers of such professionals are extremely low and their use largely limited to evaluating and treating those who have already committed sex crimes or very violent acts, including murder.
“Clinicians in ERs and in clinics, whose resources are already stretched dangerously thin—are loathe to file the paperwork that would force hospitalization on the unwilling or force medications on individuals who need them and refuse them.
“6) There is no effective, ongoing line of communication between law enforcement officials and psychiatry professionals about the status of dangerous patients, even those who have already broken the law. The expectation of most probation officers foe sex offenders or those mentally ill people charged with violent crimes including guns is a letter faxed to them once a month stating that visits are ongoing—if that. And if the letter were not to arrive, many probation officials would not take notice or take action.
“7) In most communities, there are no real psychological/psychiatric resources available within the schools, nor any established and effective line of communication between the schools and outside mental health professionals or agencies.
“8) In most states there is no way to arrange court-ordered, involuntary outpatient use of medications even if someone is very violent or has reported extremely violent thoughts in the hospital, even if that person is psychotic and also addicted to cocaine or heroin, and even if that person is court-ordered to take such antipsychotic medications in the hospital.
“Once that person hits the streets, he or she is too often free to never visit a psychiatrist again, to never take another medication, and to never be drug-tested.
“The switch from talk therapy to medications has swept psychiatric practices and hospitals. A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to patients, a share that had been falling for years and has most likely fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.
“Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared to 20 years ago. Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. Additionally, a psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session. Counseling from psychologists and social workers—who, unlike psychiatrists, do not attend medical school—is the reason that their talk therapy is priced at a lower rate.”
Keep in mind, Dr. Albow is a psychiatrist, so his comments, although generally correct, are skewed from the point of view that he sees the need for more psychiatric care to be the biggest hole in the system.
Two other points should be noted: first, as in any medical scenario, an advocate is needed, perhaps more so, with mentally ill patients; and, second, some people have benefited by learning how to navigate the system, no easy task.
Next month in our series finale on mental health, we’ll try to outline what needs to be done, as well as what is being done to address this crisis.