Guest post By Aaron Krasner, M.D.
Psychiatry, psychology, and social work (among others) are the principal disciplines responsible for diagnosing and treating mental disturbances and it has been this way for a long time. Our allied mental health fields are fundamentally humanistic and caring guilds that prioritize the well-being of clients who struggle with a broad range of problems, often requiring an integrated approach to helping patients across the age spectrum. We are (mostly) good at what we do. We know a lot about mental illness. And we truly care. Then why do we need a designated month? I’m not sure there’s a month for nephropathies (though admittedly I haven’t checked) or congestive heart failure…
So what’s up?
I have a couple of thoughts. Though I disagree with much of his agenda, Dr. Thomas Insel of the NIMH knows one big part of what’s up: no biomarkers. No fundamental understanding of pathophysiology of any mental illness, no specific disease mechanism, no consistent mechanism to explain why our medications work (which they do!) and no blood tests to corroborate diagnoses in complex cases. So you’re left with a field that is overly operator-dependent. That is, one skilled clinician (from any of those disciplines) can diagnose, treat, and implement treatment plans technically in such a way that a given patient improves either more rapidly or in a way that patients and family can better understand. This is pretty different from those other fields that don’t get a month. Biopsies, EKGs, blood tests, imaging – all biomarkers – ease diagnosis and treatment. Algorithms derived from years of experience with these biomarkers make treatment implementation straightforward – to the point that third-party payers can meaningfully weigh in on reimbursement based on treatment plans and outcomes. Insel is no dummy: We really need a biomarker. Some experts argue they are around the corner, but who knows, we’ve been saying that for a while, both in the fields of neuroimaging and behavioral genetics.
Given the absence of biomarkers, we are left with competing values systems to explain, diagnose (or not), treat (or not), and manage mental illness. Values are important, don’t get me wrong, but they are a sorry substitute for evidence-based science, especially in a society that consistently devalues the mentally ill, those who treat mental illness, and those who contend with its traumatic legacy. Why does our society do this? It’s not different from any other society, really – what we don’t know, we fear. Behavioral disturbances are confusing and frightening and for most of us, we would just rather attribute the problems to environmental insults or "weakness" of character or lack of spiritual integrity. So addressing values systems (i.e., President Obama’s decision to make our drug Czar a person in recovery as opposed to a senior member of law enforcement) is one reason we get a month. I’ll take it, we need it.
We also get a month because we’re really behind the eight ball. We have effectively cost shifted the burden of caring for the 5 percent or so of utterly incapacitated mentally ill patients to the penal system where corrections psychiatry, despite its best intentions, could not possibly withstand the crush of patients. When I rotated through Cook County hospital in psychiatry, we saw sixty patients an hour – a rate that sounds more like a speed limit than appropriate care for our trans-institutionalized, vulnerable patient population. Being behind the eight ball in our field also means that unfunded mandates have prevailed. Our community mental health system is beleaguered by hardworking, often underpaid professionals whose commitment to people is indefatigable. I stand in awe of them. And our psychiatric institutions, now decimated by draconian insurance policies that make running psychiatric hospitals and services financially insoluble, are tattered, battered, and reeling. These are the programs and institutions that train the professionals whose idealism drew them to a field where the landscape is pretty barren. A patient’s mother told me last week told me there was no adolescent bed for her suicidal teen within 100 miles of where they live. Wow. Maybe we really do need a month.
And finally, we get a month because the mentally ill form a wobbly constituency. They are not great advocates, their illnesses -- given that they are brain-based -- decimate their capacity to make the kind of money and marshal the kinds of resources necessary to change the status quo. Many advocacy organizations, including NAMI, APA, AACAP and many others work with this, but that fact remains. We as patients are anonymous; we don’t advertise our problems on our sleeve, we don’t brag about the clinical acumen of our therapists, and when we give big money to support the institutions that have saved our lives, we often do it anonymously. There are few “Abraham Lincoln” departments of psychiatry (University of Illinois, Chicago) or even Roosevelt or Harkness or Weill departments. Those families give, that much I know, but they may not want their name besmirched by association with mental illness. Who can blame them? It would only bring them trouble.
And yet the field is paradoxically poised for success. We do have emerging biomarkers, there are substantive grants (the BRAIN initiative, also under Obama) for studying mental illness, there are thousands of elegant studies substantiating evidence-based treatments (from medications to psychosocial interventions) and there is a rising tide of interest in the brain-mind collaboration. Discussions about nature vs. nurture, brain vs. mind – this is all obsolete. Constellations of epistatic (gene x environment), psychological, and cultural variables determine thoughtful diagnoses, treatments, and treatment plans and people’s symptoms really do improve. Sometimes they are cured. However these treatments are not quick – on the contrary, they are slow. And one day, we’ll know why – inevitably neuro-circuitry takes time to change and adapt, especially when insults (either from within or from without) occur early in development. New trainees have an arsenal of tools that older generations could have only dreamed about.
So I say long live Mental Health Awareness Month (for now). Let’s encourage big philanthropy, let’s address stigma, let’s get our most vulnerable the help they need to function in society, let’s de-mystify behavioral disturbances and divest of this fantasy of recovery without help (a.k.a. the “boot straps myth”), and let’s be brave together in acknowledging that we all have problems – some worse than others – and that seeking help is to the good… And not just individual good, common good. Appropriate access to treatment has the potential to prevent the kinds of tragedies that ultimately kindle disease processes in a vicious, recidivistic cycle of pain, loss, and pursuant maladaptive behaviors that limit our capacity to – in the inimitable words of Freud – work and love.
Aaron Krasner, M.D., is Adolescent Transitional Living Service Chief at Silver Hill Hospital in New Canaan, CT.