The Crisis in Mental Health Care: Responsibility and Accountability

Dr. Appelbaum has addressed a troubling gap in the provision of mental health services that few can deny. Our contemporary systems do not have adequate resources, and therefore individuals with mental disorders and their families are disadvantaged. Although we can offer many explanations for the current situation, we in the field should not fail to look within ourselves. The sources of the problem are not all external.

As Dr. Applebaum noted, while we have seen a progressive "starvation," we have also seen a redistribution of support. In today's climate, the institutions and treatment modalities that have been unable to demonstrate or justify their value are at the greatest risk of losing some or all of the limited resources available. That is obviously not all good—nor is it all bad. Dr. Appelbaum's example of the elimination of inpatient beds illustrates both extremes. In the context of current business models, it is not realistic to expect inpatient psychiatric units to be substantial generators of revenue. When these units are well run, they serve a critical role in the protection and stabilization of individuals in crisis. However, administrators and clinicians in these units must be willing to be accountable for operating them in a manner consistent with good medical practices and subject to review by appropriate funding and accrediting bodies. Where that has not been achieved, consequences are inevitable.

As Dr. Appelbaum suggests, there is an undeniable public responsibility to support adequately sized and staffed facilities to address psychiatric emergencies in the community. That said, our field is obligated to provide high-quality care in these institutions and to be above reproach in doing so. In an environment of constrained resources, those who seek funding must demonstrate not only a need for support but also the ability to deliver meaningful outcomes. When there is more than one way to achieve an outcome, it is imperative to demonstrate value—the ability to achieve optimal results for the level of resources expended.

Psychiatry, and the delivery of mental health services, continues to be burdened by negative perceptions. Although some progress has been made, stereotypes continue to contribute to the "starvation" noted by Dr. Appelbaum. We should acknowledge that the mental health system has on occasion contributed to these perceptions by taking advantage of funded services. Lack of diagnostic rigor, protracted inpatient stays, failure to attend to postdischarge relapse prevention, unnecessary polypharmacy, subtherapeutic dosing, lack of attention to comorbid medical conditions and the needs of special populations, the provision of outpatient psychotherapy with little evidence of clinical progress, and the lack of patient education all contribute to the public's negative views. In the face of such perceptions, it is perhaps not surprising to see funding cuts as cited by Dr. Appelbaum.

In response, the mental health field might consider several objectives.

Increase the level and the effectiveness of public education about brain disorders when they are not diagnosed or when they are suboptimally treated. One cannot succeed in the court of public opinion by simply attacking old perceptions. Those myths must be replaced with new realities. The tremendous technological revolution in basic and clinical neurosciences provides us with compelling evidence of the biological substrate of major mental disorders and gives us a foundation for viewing them as treatable conditions on par with other health problems, such as heart disease, HIV infection, and cancer.

Our field must find ways to educate the public about these advances and about the consequences of leaving mental disorders untreated. The high level of morbidity and mortality associated with psychiatric disorders is not widely appreciated by the medical community—much less by the lay public. The field must find ways to increase consumer awareness and remove the stigma from treatment seeking. When we accomplish this mission, we will be able to demonstrate not only that our interventions improve the functional well-being of the individuals we treat but also that they produce cost savings over the long run.

Create more innovative models for an integrated delivery system. As Dr. Appelbaum points out, reimbursement for psychiatric services has declined to the point that the retention and recruitment of mental health care providers is threatened. I am not sure that managed behavioral health care is the culprit. Managed care has been a response to an existing system perceived by many to be expensive and ineffective. In its own zeal to achieve a profitable margin, managed care has in some cases compromised the ability of clinicians to deliver an optimal level of care and to be appropriately rewarded for doing so.

Why has this happened? Historically we have had a discontinuous system of care in which certain types of services—and providers—have been walled off from one another. This situation does little to benefit patients and has introduced inefficiencies into health care transactions. Moreover, it has made efforts to demonstrate that mental health services are a cost-effective means of reducing indirect costs a substantial challenge. Moving forward into the 21st century, we must strive to find models that better integrate the continuum of care. If we do not, others will.

For example, we should evaluate and support a systems-based approach that incorporates more centralized record keeping, requires the development and regular review of a progressive and coordinated treatment plan, assesses the relative value of various direct costs associated with disease management through the use of objective outcome measures, and exhibits enough transparency to allow funding sources to see the value of their investment.

Foster a partnership among parties interested in the public good and in the provision of mental health services. The solution to the many ills highlighted by Dr. Appelbaum will not be to our satisfaction if we sit back passively and wait for "them" to do something. Not that "they" will fail to act. Rather, they will act in a way that is not in the best interest of our patients or the field. As Dr. Applebaum puts it, we must "sound the alarm."

Thus an alliance of interested and informed parties is necessary—one with sufficient voice and vision to offer solutions that make sense, ensure proper quality of care, and are affordable. The crisis in our teaching hospitals, as noted by Dr. Appelbaum, is a real and present challenge for such an alliance to tackle. None of us can afford to see a falloff in the quality of new physicians. A concerted lobbying effort should call attention to the scope of the problem and to the consequences of not addressing it. Perhaps the American Psychiatric Association could launch such an effort.

Establish mental health parity and access for all as a minimally acceptable position. The creation of the organizational alignments that are necessary to support high standards of care and ready access to care will not occur passively. An active educational and lobbying campaign is needed, one that clearly articulates why it is in the best interest of business and government to get it done. Special interest groups can set the agenda, but the general public must recognize the objectives as a priority and make its collective voice heard.

Perhaps our greatest ally—or our worst enemy—in this mission is the media. A constructive partnership with all components of the media is essential. The partnership must be based on candid dialogue and intolerance of sensationalism or exploitation. We must all be concerned with the plight of mental health service delivery and of the innocent victims of an inadequate system of care and with the false perceptions and beliefs that foster stigma. Addressing these concerns must start among those of us in the field. Improving the quality of care, cost-effectiveness, and education of peers and patients—and insisting on professional integrity—are all the price of admission.