Frontpage Forensics

Law and order from the couch

The Upside of Mental Health Care

There are many good things about our mental health system and even more to come!

Today, I celebrated mental health care! And this was after a morning of battling with insurance companies, patching together community care plans, trying to create an inpatient bed for a suicidal patient where none existed, and arguing with agencies for better patient support.

I work on a busy inpatient psychiatric unit that provides a daily reminder of the beauty, heartache, and pain that define living with mental illness. The diverse stories of each patient I treat range from energizing to hilarious to heart-wrenching. They are always unique and ever compelling.

Lack of access, violence and escalating suicides suggest inadequacies within mental health care policy. But there is one more thing – there is hope!

Patients and their families succumb to overwhelming frustrations and feel nothing more than desperate on a daily basis. They are overwhelmed by the stigma of “madness” not to mention the poor funding and lack of resources that stunt their potential.

When psychiatry makes the news, it is usually due to some national catastrophe. We know about the extreme cases. We can also document those patients who manage to reach out for help during a lucid moment or are committed involuntarily. But of the estimated one quarter of the United States population that will suffer from mental illness, many suffer in the isolated dark because of their fear, shame, and helplessness.

Historically, a diagnosis of a severe mental illness meant a “grave” prognosis, or worse, indefinite commitment to the “madhouse.” Patients who got help took heavy-duty medications, the side effects of which were sometimes worse than the disease itself. The older antipsychotics, for example, might have given patients involuntary muscle spasms, thus necessitating other drugs. So began the Whack-a-Mole phase of living with mental issues. The pills might slow the ravaging of the cerebral cortex, but they would clobber the liver, requiring another pill, which put something else at risk … and so on and on.

Thankfully, psychiatric medications are improving, research is thriving, and clinical training is invariably rigorous. Diagnoses have also evolved from wastebasket terms like “hysteria” to a more thoughtful classification system. Although not perfect, the Diagnostics and Statistical Manual (DSM), in its fifth edition, arranges target symptoms interfering with an individual’s ability to work, play and love in a way that can be tracked, studied and modified.

Just like any other chronic illness, mental illness bends the arc of a patient’s life but it does not have to define it. Surviving a major mental illness and achieving success in this world are not dissonant. Ellyn Saks (law professor) and John Nash (Nobel Prize Laureate) are proof of success despite a major mental illness.

In 2013, The American Foundation for Suicide Prevention honored Sergeant Kevin Briggs for his tireless efforts with the California Highway Patrol. He is credited with stopping many suicides from the Golden Gate Bridge, an iconic structure and site of over 1,600 intentional jumps to death. He is one of many heroes who remind us that if one person can significantly impact a life, then collectively, the nation could effect a dramatic change.

The urgency for enhanced mental health services could not be more compelling. Congress has started to take notice. In 2008 they responded with the Mental Health Parity and Addiction Equity Act, intended to end longstanding insurance practices that discriminated against people with mental illness and drug and alcohol addictions. But parity legislation was only a first step to stopping discriminatory mental health coverage practices.

A new bill is being offered to Congress which is the most ambitious overhaul plan in decades for the mental health care system. It offers much hope to patients, families, and practitioners who work tirelessly every day in a system that is broken. The prospects for the bill were proposed by Representative Tim Murphy, Republican of Pennsylvania. Helping Families in Mental Health Crisis Act provides more than two dozen measures that could go a long way in fixing the nation’s mental health system.

The legislation does everything from clarifying the Health Information Portability and Accountability Act (HIPAA) privacy rule to fixing the shortage of inpatient psychiatric beds to promoting court-ordered “Assisted Outpatient Treatment” (AOT). The latter is by far the most controversial issue and most important.

Rather than curtailing a person’s civil rights, as opposition to the bill insist, it strips away the real force impinging on a patient’s freedom – their severe and disabling mental illness. These are not mild disorders. The targets of the bill are the seriously mentally ill who are at high risk for death, homelessness or incarceration if left untreated.

Despite the challenges, this is an exciting time to work in psychiatry and a very hopeful time for clinicians, patients, and families affected by mental illness. We are moving towards integrated care as practitioners, with primary care physicians and other specialists coordinating closely with behavioral health providers for everyone’s benefit.

At the same time, we need Congress to continue to pass legislation that closes that ever-widening chasm between fighting mental illness and achieving mental health!

Helen M. Farrell, M.D., is a psychiatrist with Harvard Medical School. She researches forensic psychiatry and violence.

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