With Money in Short Supply, Psychiatrists Urged to Be Creative

Continued underfunding for mental health care in the United States by government agencies will require psychiatrists to become more innovative in the care they provide and to consider new and controversial approaches that improve patient treatment, according to a leading psychiatrist in the federal government.

Ken Thompson, M.D., associate director of medical affairs at the Center for Mental Health Services in the Substance Abuse and Mental Health Services Administration (SAMHSA), addressed the challenges facing publicly supported psychiatry during a symposium at APA's 2008 annual meeting in Washington, D.C., in May.

The problems facing mental health care delivery in America include the lack of resources to fund needed care and a system that leaves many mentally ill people without hope for recovery, he said. Although psychiatry is the“ canary in the coal mine” that warns about poor access to sufficient public and private health care, he said, psychiatrists cannot wait for the necessary yet “disruptive change” required to greatly increase psychiatric funding.

The need to look at new ways to deliver mental health care also is sharpened by the increasing shortage of all types of mental health workers and psychiatrists within public health systems, he said. In addition, the candidates for public health jobs frequently know little about the newer approaches that might benefit the communities in which they are working.

Thompson urged them to consider the wide range of practices and approaches that might make the current system more effective.

“People complain about the 15-minute med check, but I have seen no research on how to make it more effective,” Thompson said, offering it as an example of missed treatment opportunities. However, “I have heard from some doctors that they have discovered ways that a 15-minute med check is extremely productive.”

A growing body of evidence supports the consideration of less widely used practices, according to Thompson.

Among the alternative approaches he encouraged psychiatrists to consider was the controversial area of recovery-oriented services within psychiatry. Such services focus on attaining specific goals set by patients instead of on elimination of symptoms of mental illness. Although some psychiatrists have had a difficult time grasping this approach, with some resisting it or considering it a fad that will go away, he said, it offers important benefits.

Then there is intervention based in part on the patient's desires.“ Patient-centered care planning is really about helping people achieve what they want to in their lives and a little less [about] reducing symptoms or changing utilization patterns, such as whether people get rehospitalized or not,” Thompson said.

Such an approach is encouraged by feedback from patients who want to have a life as normal as possible, despite the presence of their disorder. Similarly, patients also have requested a role in making the decisions about their care. These patients can benefit from more knowledge to “help us help them decide what to do,” he said. Psychiatric advance directives and the use of peer support in mental health care also can provide patients with a greater role in their own treatment and that of other people with mental illness.

“How many people out in the community can be helpful to you when you are suffering and struggling? It's tremendously helpful and doesn't cost a whole lot of money,” Thompson said.

Another key recovery tool psychiatrists should consider is providing more employment assistance to their patients, according to Thompson. Most outpatient clinics put little or no resources into efforts to find employment for their patients.

“When you talk with consumers of mental health services, the thing that they tell you most often is that they would like an opportunity to contribute to society and they would like to be able to generate an income,” Thompson said.

Health care consumers would benefit from an increased effort to teach non-psychiatrist physicians basic psychiatric therapeutic approaches to include in their treatment of physical ailments, he said. Partnerships with other areas of medicine also could include increased cooperation with other areas facing spending cuts, such as primary care physicians, to address mental health “much more coherently.”

Among other intervention options are assertive community treatment and integrated treatment for co-occurring disorders. Information on all of these approaches is available through SAMHSA.

Innovation and alternative approaches will never take root and be allowed to overcome funding (and personnel) shortfalls without broad-based support in psychiatry, he said. That can happen only if psychiatrists accept that a massive funding injection may not be on the horizon and that they need to grapple with the feasibility of new alternatives.

“We are not having the conversations we need to have in order to move this forward,” he said.

Information on many of the approaches Thompson discussed can be accessed at the SAMHSA Web site at<http://mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/about.asp>.▪