Time to Improve Mental Health Care
The case of 17-year old Jordan “Jordie” Binion highlighted once again the heartbreak of mental health care in the US. This week, NBC News’ Cynthia McFadden interviewed the young man’s parents, following their son’s death by suicide in 2010. The parents, Will and Deb, worked to improve mental health in the state of Washington. The profoundly sad circumstances remind us how mental health does not have the same straightforward approach as virtually every other illness. With other diseases we say: diagnose and treat, and your insurance is probably good-to-go, subject to your deductibles and copays. In psychiatric care, however it’s a mix of medications, medical care, social work and the legal system.
Jordie’s case hinged on his ability to legally check himself out of the adolescent psychiatric unit at Seattle Children’s Hospital, the day after he was admitted. This was allowed because in Washington, one can refuse treatment at age 13. Laws are similar in many other states. Because mental health care is still a subject kept more in the shadows than other conditions, most people have no idea how parental rights can be severely diminished. Parents learn the hard way.
It turns out that the parents had an option to petition the court to keep Jordie hospitalized for 72 hours. But the hospital didn’t tell them that. Two years later, Jordie’s parents were successful in getting a Washington law passed that requires mental health professionals to inform parents of their right to commit their mentally ill child for treatment.
Equally disturbing was that a complete psychiatric evaluation was unable to be scheduled until five months out. On the day before the appointment, Jordie died from self-inflicted violence. The mental health system had months to get this right, but it was not enough.
Mental Illness – How Common is It?
Mental illness was estimated to affect nearly 45 million adults in 2016. To understand how many people that is, it’s close to the combined populations of our four largest metro areas – New York-Newark, Los Angeles, Chicago and Dallas-Fort Worth. Millions upon millions.
One type of mental disorder is Major Depressive Episode (MDE). For both adults and adolescents, MDE was defined as having a period of 2 weeks or longer in the past 12 months when they experienced a depressed mood or loss of interest or pleasure in daily activities. In addition, they had to have at least some additional symptoms, such as problems with sleep, eating, energy, concentration, and self-worth. In 2016, more than 3 million adolescents (12.8 percent) aged 12 to 17 had an MDE during the past year. Yet, only about 41% of them got treatment, up slightly from the situation in 2010 when Jordie sought help. The picture was improved for adults – 65% got treatment in 2016. Unfortunately, adult treatment rates for MDE were down slightly from 2010.
One in Five Young Adults Experienced Mental Illness in 2016
Much attention for young adults has been given to the opioid epidemic. It’s something the healthcare system accepted at least a portion of responsibility for, and progress has been made.
But what we haven’t done is address rising rates of reported mental illness for young adults ages 18 to 25. In 2016, more than one in five young adults (22.1%) experienced any mental illness (AMI) in the past year. This rate was now higher than the 26 to 49-year olds, and well over the rate for those age 50 and up. Just over a third (35%) of young adults received mental health services. For young adults with a serious mental illness (SMI), only half (51.5%) received care. We should not be comfortable with this situation.
When patients or their families try to make an appointment with a psychiatrist or a mental health counselor, they readily find out how difficult it is. If they try to find residential care after being hospitalized for an acute psychiatric episode, families will frequently hear “Waiting List”. Sometimes patients even need to be held overnight in an Emergency Room while hospital staff search for an available psychiatric hospital bed.
A recent story highlighted the challenges of finding a bed for transferring a patient out of the ER. The article noted that a patient from Shakopee, MN, south of the Twin Cities, might wake up and find out s/he is in Fargo – some 250 miles away in North Dakota. All because, that’s the closest place an appropriate bed was available.
Shortage, Shortage, Shortage
A major contributor to the access problem is a shortage of trained doctors and mental health facilities. A 2017 report The Psychiatric Shortage: Causes and Solutions outlined concerns with psychiatrists not having enough time with patients – that 15 minutes just isn’t enough. Doctors themselves mention lack of time to review all relevant clinical information. They aren’t always able to provide expert guidance to or supervise other behavioral team members. The report said, “Without a psychiatrist’s guidance, these teams are less likely to note early onset of psychiatric symptoms … and correctly assess the interactions of medications.”
The physician recruitment firm Merritt Hawkins identified psychiatrists as their second highest number of searches. They noted a “severe shortage of mental health professionals nationwide”. It’s a shortage that could well become more severe, since 60% of active psychiatrists are age 55 or older.
Research by Health Affairs pointed out that the supply of psychiatrists stayed at about 38,000 in practice from 2003 to 2013. But during that same period, the US population increased, thereby reducing access. The number of people who perceived their mental health as “fair” or “poor” also increased substantially during that time, from 18.2 million to 21.5 million people.
The problem isn’t new. It’s just getting worse. Thirteen years ago, about two-thirds of primary care physicians reported they could not get outpatient mental health services for patients, according to Health Affairs research. As mental health comes out of the shadows and becomes equally regarded with broken bones and heart disease, the demand for services will increase. We will need to fix the shortage of mental health professionals and services.
Three Things Healthcare Systems Can Do to Improve Mental Health
Hospitals can help mental health consumers and their families by adhering to accepted measures of performance:
1. Follow-Up After Hospitalization for Mental Illness. At present, the percentage of members who received follow-up within 7 days of discharge was just 50% for the commercially-insured PPO member, 53% for HMO members. Medicaid HMO members fared worse, at 45.5%; Medicare member follow-up was just 35%. Hospitals should be certain that appropriate follow-up care is arranged before the patient is discharged. Seven-day follow-up has been an accepted quality measure for more than 15 years. For young adults dependent upon family resources, and who may be carried on their parents’ insurance plans, parental involvement may be essential. Evidence has been established that outcomes are poorer when follow-up does not occur.
2. Create a Complete Continuing Care Plan for post-discharge. Just what should be in a continuing care plan? According to National Quality Forum (NQF), who catalogs and endorses quality measures, the plan must have four minimum elements:
a. Reason for Hospitalization
b. Principal Discharge Diagnosis
c. Discharge Medications, Dosage and Indication for Use, and
d. Next Level of Care Recommendations – The next level of care provider is the clinician or another hospital that will be primarily responsible for managing the patient’s medication plans. If there are no medications, then the primary care provider is acceptable.
The Joint Commission which accredits hospitals stewards this measure.
3. Send the Continuing Care Plan to the Next Level of Care Provider by the fifth post-discharge day. Getting the complete plan to the next provider promptly within 5 days was included in the measure endorsed by NQF. This ensures the provider has the information before the 7-day patient follow-up visit. For reference, in non-mental health hospitalizations, the care plan is expected to be sent to the follow-up doctor within 24 hours of the patient’s discharge.
Mental Health Policy – Three Things Policymakers Can Do
Policymakers and strategic planners can help improve the state of the industry.
1. Support training more psychiatrists and mental health counselors. This will in turn improve access.
2. Support research that brings greater sophistication to psychiatric care. We need to reduce the time of trial and error for many mental health patients.
3. Encourage the development of psychiatric residential services, intensive outpatient therapy, and mental health home care. A continuum of services might be able to reduce the frequency of Emergency Department visits and hospitalizations. Just imagine, if we had no capacity to transfer older people with congestive heart failure, or stroke, or broken hips, to a skilled nursing facility. Imagine no assisted living care. Imagine there was no home care for our seniors. Those services are a vital part of the medical-surgical healthcare system for continuous care today. It is time to envision a broader, more supportive system of mental health care for our loved ones.
We welcome your comments and experiences with mental health care.