Psychiatrists' Advocacy Can Help Change System in Crisis

From the flood-ravaged Gulf states to the flood of service members in need of mental health services after returning from Afghanistan and Iraq, America's fractured mental health system is up against profound challenges.

Speaking at APA's Institute on Psychiatric Services in still-devastated but slowly recovering New Orleans, APA President Carolyn Robinowitz, M.D., pointed out that the crises of the past several years have brought out the best and the worst in the nation's mental health care system.

She noted that the institute's location was an auspicious one for its theme this year of “Recovery: Patients, Families, Communities.”

“Our location this year, determined long before Katrina, but all the more important now, provides a special venue in which to discuss primary and secondary interventions, resilience, and recovery for the community as well as individuals and their families,” Robinowitz said. “Other external circumstances, such as the wars in Iraq and Afghanistan, have produced similar special needs in providing care for returning wounded and their families. Both have highlighted our many successes in providing care and promoting recovery as well as the major problems that beset our health care system.

“Both the military and Department of Veterans Affairs are overwhelmed by the number of service men and women with depression, traumatic brain injury, and PTSD and must deal not only with limited resources but with a culture that discourages seeking mental health care as well as with issues of continuity.”

She emphasized that “reservists and National Guard members, particularly those from rural areas, may not have access to appropriate treatment, especially for later-appearing symptoms of PTSD, or may not be able to access appropriate care. Further, systems may deal only with the 'indicated patient' and not address the impact of multiple deployments on service families.”

But she said there is a silver lining in the crisis facing returning veterans. “The public discussion of mental health needs for our wounded warriors and their families has served to destigmatize mental illness, just as the disclosures by prominent politicians and entertainers did in the past decade.”

Robinowitz said that widening acceptance of the value of mental health services—as exemplified by the advance of federal legislation granting parity insurance coverage for mental health treatment—has been matched by an expanded scientific understanding.

“We now have ever more intricate and complex understanding of both brain and mind function, from the molecular and genomic to behavioral levels,” she said. “Sophisticated imaging techniques can not only localize functions but demonstrate the impact of therapies—psychotherapies as well as pharmacologic. There is scientific recognition that physical health and mental health go hand in hand.... We no longer need to feel inferior to our colleagues in other medical settings in terms of the evidence supporting our approaches.”

But she emphasized that these benefits have not been extended to large portions of the U.S. population, as evident in the staggering numbers of mentally ill people in the nation's jails and prisons and in the chronic underfunding of community mental health services.

And she referenced a study released this year by the American Psychiatric Institute for Research and Education documenting the dramatic impact—measured in emergency department visits, homelessness, and recurrence of disease in previously stable patients—of the transition to the Part D Medicare prescription drug program for dually eligible mentally ill patients who used to get their drug coverage under Medicaid (Psychiatric News, May 18, July 20).

Robinowitz also drew attention to a study appearing in the September American Journal of Psychiatry documenting a dramatic increase in youth and adolescent suicide coinciding with a sharp reduction in antidepressant prescribing in the period following the FDA's public health advisory and “black-box” warning regarding antidepressant use and suicide (Psychiatric News, October 5).

She emphasized the critical importance of advocacy efforts in meeting the challenges facing the mental health system at the federal and state levels, with the business community, and in partnership with other advocacy groups. She challenged APA members at the institute to question whether they were doing enough to improve the system.

“We believe we are part of the solution, but are we also contributors to these problems?” she asked. “How often, loudly, and effectively do we advocate for our patients? We are busy caring for them, but in this world, that is insufficient. We are the only ones who can integrate the needs of patients and our care systems. We are the only people who can provide access to care, assess the care, and ensure quality, integrating biological, psychological, and social factors. So we have an intellectual as well as moral authority to commit to our core professional values and protect our patients without being paternalistic or maternalistic.” ▪