Recession Imposes New Challenges on Psychiatric Care

Few people in the United States have escaped the dramatic economic and social impact of the recession that has plagued the country for several years now. Many people with mental health problems, especially chronic disorders, have found themselves especially disadvantaged since they may possess lower skill sets and have fewer social supports than most of the U.S. populace.

Atlanta, where we are both residents, has turned out to be no exception to the economic downturn and its consequences, and since the recession began, we have encountered myriad difficulties in delivering the psychiatric care that our patients need.

With millions of jobs lost nationwide, many have found themselves not only losing their homes but also their health care coverage. This has led to more than 50 million Americans being uninsured, several million more than was the case just a few years ago. This rise has been coupled with an increased demand for psychiatric services, especially emergency and crisis services. Our outpatient clinics have historically served Georgia's uninsured indigent population, but staff are now seeing much greater diversity in the patient base. Our waiting rooms have teachers, business people, and academics sitting alongside our indigent patients, and in this economy some of those professionals may be indigent as well. Diversification in the patient population has presented new challenges for residents who now encounter different patient expectations, ideas, and concerns.

We have seen how disruption to patients' support networks can destabilize them in the community and negatively affect adherence to medications and attendance at psychiatric follow-up visits, which in turn increase the use of crisis intervention and inpatient treatment. For example, relatives and caregivers who are now dealing with more limited finances and time may struggle to provide their usual levels of support to our patients. A family's loss of its car can prevent a patient from being transported to an outpatient appointment or to get a prescription filled.

It has thus become routine that we need to inquire about patients' support networks and understand how recent financial changes may be related to our patients' current presentation. It is more crucial than ever that we work collaboratively with patients to produce plans that will safeguard their adherence to medications and psychiatric follow-up if circumstances have changed their support system. Our medications might not work for everyone, but left uncollected on a pharmacy shelf, they will certainly help no one. It is important to appreciate that our role can't end with the signing of a prescription but in collaborative efforts that enable our patients to receive the full care they need.

An important aspect of psychiatric treatment is continuity of care. Several media reports have indicated that many patients who need psychiatric crisis intervention have recently moved to Atlanta, either to find work or to move in with family members who can support them. Often patients have made few if any provisions for their mental health care needs in Atlanta prior to their move. As a result, patients frequently lose the continuity of their care, which is especially crucial for psychiatric patients. They experience decreased social support and find difficulty in obtaining medication refills in their new and unfamiliar environment. These factors, combined with the stress of moving and unemployment, create conditions that are ripe for causing a relapse or development of new mental health problems. It is important for us to recognize these stressors and be knowledgeable about local community services such as outpatient clinics and shelters. We should also remember to seek help from social workers experienced in connecting patients with appropriate resources.

Nationwide, our economic problems led to 32 state mental health agencies reporting budget cuts in 2009, despite a considerable rise in demand for services. This situation has forced both public and private hospitals to look closely at the services they provide, but even minor cutbacks affect accessibility of these services, often for people with few alternatives. An example of such a cutback was the loss of FOCUS, an intensive day program for uninsured adults with severe and persistent mental illness at Atlanta's largest public hospital, Grady Memorial. The program was widely acclaimed and provided a unique learning opportunity for residents, but it was not immune to the reorganization of services seen in many psychiatric hospitals in the last few years.

The loss of significant resources coupled with a rise in the need for psychiatric emergency services raises two points for residents. First, it illustrates how crucial it is that we take an active role in advocacy for our patients, our hospitals, and our profession. We must take the time to contact and meet with local and state policymakers to ensure that our voice is heard and our mental health resources are safeguarded. Second, we must remain up to date with local service availability and referral routes so we can minimize delays and obtain the care our patients need.

Thankfully, as residents we are fortunate to have the support and guidance of our experienced teachers to help us understand and navigate these new obstacles as well as traditional ones as we try to get the best care possible for our patients. At this especially difficult time, learning, resolve, and commitment will not only help our clinic practice but benefit our patients' lives.