From “60 Minutes,” CBS Television, January 26th, 2014
Creigh Deeds: There’s just a lack of equity in the way we as a society, and certainly as a government and insurance industry, medical industry, with the way we look at mental health issues.
Scott Pelley: Don’t want to fund it. Don’t want to talk about it. Don’t want to see it.
Creigh Deeds: Absolutely. That– that’s exactly right. But the reality is, it’s everywhere.
If inadequate access to mental healthcare in the US is a disease, and I would argue that it can certainly be seen that way in terms of the toll it has taken on American society, then medical school did next to nothing to prepare me to understand its causes; or, to deal with them. After 15 years of treating thousands of patients with psychiatric disorders, I have long struggled to concisely understand and articulate the confluence of factors that determine why my patients do (or do not) have access to mental healthcare.
Recently, whilst watching 60 minutes all that changed. From the story of a young man named Gus Deeds, a clear and concise picture emerged of cause and effect, depicting the factors that largely determine whether a patient in need of mental health care is likely to receive that care.
In this segment, Scott Pelley interviewed Virginia State Senator, Creigh Deeds, about his son Gus, who was 24 years old and had been living with serious mental illness. His struggle culminated, last November, in a tragic ending. The Deeds’ predicament with their son was echoed by other family members of mentally ill children and adults who were also interviewed for this segment.
I was deeply saddened and perturbed by the story and although I had never met any of the people involved and had no inside knowledge of the situation, Senator Deed’s narrative was all too familiar to my ears as a litany of causes for an avoidable tragedy : inadequate mental health resources; resistance to care by the patient; additional obstacles presented by insurance companies, and fragmented treatment options.
Watching the interview, my head reverberated with all the questions I had asked myself when attempting to provide care for patients with serious mental illness.
These were the types of questions that plagued me during the earlier days of my career. Why am I not able to stop them falling through the cracks in the system? Why do I have to spend so much time persuading insurance companies to pay for their basic care? What am I doing wrong? What can I do better? Why does the opinion of their loved ones not seem to count?
The causes behind inadequate access to mental health care in the US must be described with a terminology not taught in medical school. They hail from different worlds than the one in which I was trained: the worlds of law, healthcare policy, sociology and the insurance industry.
Gus Deeds and Craig Deeds, 2009
If this situation is going to change, the Gus Deeds story provides a tragic, teachable moment for all Americans.
Here are 3 key lessons we can all learn from what happened to the Deeds family.
#1 Despite reforms, mental health care services are inadequate or nonexistent to large segments of American Society
Access to mental healthcare starts with the premise that, if services are available and there is an adequate supply of services, then the opportunity to obtain health care exists, and a population may ‘have access’ to services. Unfortunately, this assumption of adequate supply cannot be made with regards to services provided by mental health professionals. There is a shortage of mental health professionals in the United States, And the situation is particularly dire in rural and underserved parts of the Nation. Add to this the fact thatfunding for community resources such as inpatient psychiatric beds and long-term behavioral health facilities has been shrinking for decades and it is not hard to imagine why the issue of access has become problematic for many who are in urgent need of psychiatric attention.
# 2. Because of stigma and denial surrounding mental illness, patients who most need care don’t always seek it
Stigma can be societal and manifest as discrimination towards people with mental health problems. A response from one of the other parents interviewed by Pelley, says it all: When Pelley asked her what the difference between being the mother of a child who has mental illness and the mother of a child who might have heart disease or cancer was, she answered with one word. Sympathy.Predisposing factors such as patient race, age, and health beliefs also influence an individual’s decision to access mental healthcare. Specifically, in the case of those living with serious mental illness, it is not uncommon for the patient to deny that he/she is ill and, therefore, think that they do not need help or medical treatment, i.e. they choose not to access mental healthcare. This denial brings with it a layer of complexity to interactions between mental health professionals and the patients they serve for, unlike many other illnesses, our patients may hide or not fully disclose essential aspects of his/her symptoms for fear of the consequences of such disclosures.
Another layer of complication is that federal and state laws, surrounding the involuntary hospitalization of individuals with mental illness, whilst designed to protect patient’s rights, often leave loved ones and mental health professionals who understand the patient and their illness with no voice, and minimal sway and influence over decisions that get made in courts. This situation emphasizes why it is so important that mental health professionals have the necessary time to carefully evaluate patients; be able to provide them with the continuity of care they need so that they can, eventually, develop a trusting relationship with their patient. Often, it is through this trust that some aspects of denial can be challenged to ensure a better outcome for the patient. And this brings us to the next lesson
#3. Current insurance policies create barriers to patient access and encourage providers to offer reductionist mental health care services
The issues surrounding access to mental healthcare are further compounded by discriminatory, and often illegal, barriers to mental health and addiction services imposed by the health insurance industry. One of the most consistentdebates that have raged in the psychiatric community, since the advent of managed care, has surrounded such insurance company policies and procedures.
Professional organizations have argued (successfully) that such policies appear to be designed to encourage psychiatrists to provide services that are reductionistic (as they are less time consuming and hence less expensive) and discourage approaches or treatments that: take more time; preserve continuity of care and build trust between patient and the professional caring for them. Americans with mental health disorders have been routinely discriminated against when they are required to pay higher copayments, allowed fewer doctor visits or days in the hospital, or made to pay higher deductibles than those that apply to other medical illnesses.
Whilst the signing of the 2008 Paul Wellstone and Pete Domenici Mental Health Parity Act has been viewed as breakthrough legislation to combat this discrimination it is important to note that the Act does not require employers to offer mental health or substance use disorder benefits, only that IF they are offered they must be offered on par with medical/surgical benefits. From 2014, under the Affordable Care Act, new individual and small group plans in and outside of the mandated insurances will be required to offer coverage. Barriers to the effective implementation of such requirements remain to be seen.
If a picture (in this case a 20 minute segment of TV news reporting) is worth a 1,000 words (in this case a 5,000 research or sober policy document) then this 60 minutes segment is that picture. I would encourage anyone with an interest in mental healthcare to watch it.
This work, unless otherwise expressly stated, is licensed under a Creative Commons Attribution 3.0 Unported License.
About Shaili Jain, MD
Shaili Jain, MD serves as a psychiatrist at the Veterans Affairs Palo Alto Health Care System, is a researcher affiliated with the National Center for Posttraumatic Stress Disorder and a Clinical Assistant Professor affiliated with the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine. Her medical essays and commentary have appeared in the New England Journal of Medicine, the Journal of the American Medical Association, public radio and elsewhere. The views expressed are those of the author and do not necessarily reflect the official policy or position of the Department of Veterans Affairs or the United States Government.