cover story two

Improving Psychiatric Health

Addressing the challenges

BY Todd Archbold, LSW, MBA

Shawna was finishing the second trimester of her junior year. She was getting top marks in her classes and recently began a part-time job at the local grocery store. She saw a therapist regularly for anxiety and depression and spent a lot of time online with social media. Her parents were helping her plan college visits this spring, with aspirations of being an artist. During dinner with her parents one evening, Shawna was unusually quiet. She unexpectedly became tearful and told her parents she hated her life and had been cyberbullied online by several classmates. She began to sob uncontrollably, and her sadness turned into anger and shouting about feeling controlled. She slammed the door to her room and told her parents she wanted to die. She was not responding to her parents’ pleas to talk through her locked bedroom door. They burst through, finding her hiding under her covers. She shouted to her parents, “Leave me alone! I took some pills so I don’t have to be here anymore!”

As a young adult embarking in a new chapter in life, Eugene was feeling good about his mental health. As a teenager he struggled with a learning disability and experienced traumatic racial discrimination. His longstanding therapist helped him through many challenging periods in his life. Now, upon starting a new job, he learned that his therapist was out-of-network with his insurance plan. Unable to afford the costs, he sought a new in-network therapist, but was unable to find a provider who shared the same race or ethnicity. Eugene began experiencing intense anxiety at work, and his new therapist failed to grasp the impact of his past life experiences. He lacked rapport with this new supervisor, who criticized his performance. His self-worth plummeted as he quit his job and subsequently dropped the new therapist. Eugene was able to rejoin his parent’s insurance plan and started a new job search.

Mental illness is real, common and treatable. Bryan and Shawna are experiencing extreme symptoms of some of the most common illnesses, anxiety and depression. Eugene is among the majority of BIPOC individuals who have been a target of racism in the US and are twice as likely to experience severe emotional distress than White Americans. Access to acute care, like Bryan and Shawna need, or specialized care, such as a BIPOC provider who specializes in trauma for Eugene, is increasingly difficult. All three are dealing with common and preventable challenges of our psychiatric health system.

National polls show 42% of teens are concerned about becoming severely depressed.

Psychiatric Emergencies

Bryan and Shawna represent nearly 14% of emergency department (ED) visits that are a result of a psychiatric crisis. Bryan is among the one-third of US adults who will experience a panic attack in their lifetime. On his way to the hospital, he will likely get an EKG in the ambulance. He will receive additional diagnostic testing upon arrival to the ED to rule out life-threatening medical conditions like cardiac arrest. He can expect being in the ED anywhere from 4 to 12 hours for observation and receive an anti-anxiety PRN medication for stabilization. Bryan will likely be discharged from the ED with a short supply of a medication with instructions to follow-up with a psychiatrist and psychotherapist. There is a 50% chance that Bryan will follow-through with those referrals. Shawna represents nearly a third of teens that report cyberbullying. Recent national polls show 42% of teens are concerned about becoming severely depressed, and nearly 1 in 10 teens who have attempted suicide. She will likely be boarded in the ED for anywhere from a day to a week while awaiting admission to a psychiatric bed for treatment, which will likely require a transfer to a different facility. There is a 40% chance she will be discharged while waiting for that much needed bed.

In both cases, their crises were very real and unfortunately common. Their symptoms are both highly treatable with the correct intervention. Most importantly, we can create systems that can prevent these crises from occurring, crises that not only stress our health care systems, but also create inherent trauma for the patients and family members involved. Both M Health and Centracare have opened special units for these cases called EmPATH (emergency psychiatric assessment, treatment and healing). Unlike traditional ED’s which need to manage a plethora of medical crises, the EmPATH units are designed to be low stimulation and have access to mental health professionals to help with calming and stabilization.

ED’s have become the most common entry point for those in crisis, and that number has grown by nearly 40% in the last 20 years, even more for youth. Nationally, this represents an estimated 50,000 mental health-related emergency room visits per day, or over 600 per day across Minnesota. The most alarming trends in recent years are the increase in suicidal thoughts or attempts and drug/chemical overdoses. While Bryan and Shawna’s cases are not uncommon, additional factors such as medical comorbidities, cultural differences, social determinants, family dynamics and parental issues (for youth) can quickly complicate situations–requiring more than just psychiatric treatment, but intensive social intervention and support. This is also where our health systems have a propensity to apply the empirical allopathic approach to medical care that often fails to address complex bio-psycho-social-spiritual elements. If Eugene should experience a crisis, the providers involved will need to be sensitive to his cultural background, past experiences with the US health care system and his previous trauma. While the psychosomatic symptoms of anxiety can easily be confused with a variety of medical conditions, providers must connect with patients in authentically compassionate ways to uncover often hidden mental health concerns.

According to the CDC, nearly 2.3% of all ED visits result in a transfer, yet in the case of a psychiatric crisis, independent studies have shown it is closer to 15%. The odds of a psychiatric patient waiting for care in an ED is nearly five times greater than for any other health condition–oftentimes resulting in days in an ED awaiting the appropriate care for their condition. The wait time to access psychiatric care can range from several hours to several days. This situation, known as “boarding,” has become increasingly common as a shortage of psychiatric care providers and barriers to accessing care have become amplified. A robust study conducted in 2014 showed that over 40% of psychiatric ED visits resulted in discharge, presumably without any meaningful treatment other than ad hoc medication administration and outpatient referrals, which are rarely followed up upon.

History of Psychiatric Hospitals

Throughout the United States in the late-1800’s, expansive federal psychiatric hospitals were built to create safety and sanctuary for those with severe mental illnesses. These hospitals, commonly known as insane asylums, provided care across the nation to nearly 560,000 individuals. These institutions often sprawled over half a million square feet and cared for nearly two thousand at a time. A psychiatrist named Thomas Kirkbride was the founder of moral treatment aiming to provide comfort and healing to patients who may have previously been considered untreatable. Some patients with conditions such as mania or bipolar disorder (though it was not called that at the time) were able to receive treatment for weeks to months at a time before returning to their communities, typically with increased family or social support. Many other patients with more severe conditions, like schizophrenia, developmental disabilities or autism, often became indefinite residents who built longstanding relationships and even had jobs within the boundaries of the hospital. Over time, some of the ideals of moral treatment became overstretched and ineffective, leading to poor care, mistreatment and even neglect. Overcrowding became an issue as care conditions deteriorated– leading to many of the ill-perceptions that exist in the modern day of psychiatric institutions.

The ongoing costs to treat behavioral health conditions contribute to nearly 45% of total health care spending.

In 1965, the introduction of Medicaid and Medicare sparked a series of policies that became known as “deinstitutionalization” aimed at replacing long-term psychiatric hospitals with community mental health services. Around this same time, more effective – and potent–psychotropic medications such as Thorazine became much more popular in treatments. Over the next 50 years, capacity in psychiatric hospitals decreased by nearly 90%, resulting in nearly 480,000 individuals with several mental illnesses leaving hospital settings to less intensive community treatment centers. While some of these individuals received appropriate and effective care, many found themselves struggling with homelessness and tangled in the US prison system. There have been numerous studies that illustrate the drastic increase in the number of individuals with mental illnesses in the prison system, with an uncanny correlation to deinstitutionalization. The nation’s goal of moving psychiatric care to less restrictive community settings was only partially realized and to the benefit of very few. The advent of managed care in the 1980s further exacerbated challenges in accessing care by allowing market forces, rather than population indices and epidemiology, to drive necessary capacity.



Psychiatric Health Care Today and Tomorrow

While the federal psychiatric hospital system of the past was not designed to respond to acute psychiatric crises, they did keep many vulnerable individuals with severe mental illnesses safe and prevent many crises altogether. Today, patients like Bryan, Shawna and Eugene are left navigating a fragmented and confusing spattering of mental health services and providers. As our understanding of mental health has advanced and become broader, there’s been a necessary focus on awareness, education and prevention–investing in upstream solutions. There’s now a wider breadth of care options ranging from online help, support groups, partial hospital programs and hospital care. However, many services remain siloed and often lack capacity for culturally diverse or competent care. As individuals seek more specialized care, access barriers and provider shortages become a major issue. Over half of individuals experiencing diagnosable symptoms of a mental illness will never get the treatment they require.

Some of the most innovative health systems provide a streamlined continuum of mental health services and integrative behavioral health services. Primary care providers are most often the first point of contact to identify and provide early intervention of a budding mental health condition. Most will admit to a lack of training or resources to either adequately assess or treat mental illnesses. Nearly 80% of psychotropic medications are prescribed in the primary care setting. Current evidence-based treatment protocols for anxiety and depression include the combination of medicine and the appropriate psychotherapy or psychosocial intervention–specific care paths that usually require up-to-date knowledge on provider access. The importance of culturally competent mental health care for individuals like Eugene is critical as well. The annual national investment in mental health research is an abysmal 4% of total health research funding, despite the fact that some studies have shown the ongoing costs to treat behavioral health conditions contribute to nearly 45% of total health care spending.

It is critical that mental health professionals are in tune to cultural differences and needs of all patients to develop a truly therapeutic relationship. These factors will influence how symptoms are experienced by individuals, how they are explained and ultimately cared for effectively. Studies have shown that promoting a strong sense of connection to culture and ethnicity is linked to lower suicide risks and higher resiliency. Our mental health systems must outwardly promote care settings that embrace a culture of equity and inclusion. This includes practicing a variety of culturally-sensitive ways to promote services in the community. This means using culturally and linguistically appropriate forms of talking about symptoms and treatment. Practice settings should display a variety of artwork, furniture and aesthetics that reflect multi-cultural awareness and appreciation. All care providers should be familiar with names, terms, and basic concepts of traditional and non-western healing practices; even a basic familiarity has proven to significantly improve outcomes. We need to ensure that access to training programs for aspiring mental health professionals is equitable and inclusive, and we need to take a hard look at possible implicit biases in these processes or other unconscious exclusion criteria that need to be eliminated. In Minnesota, far fewer BIPOC mental health professional trainees complete their supervision hours and licensure exams than their White trainees.

The mental health care system of the future requires fundamental parity and better access through robust care navigation. We can do this by integrating mental health providers in all health care settings and require all health care workers receive ongoing training in assessment of mental illnesses. Health care leaders must promote mental wellness among the workforce and normalize the conversation in our communities. When we can increase awareness of mental illness and decrease the stigma, we can begin providing earlier intervention and prevent crises. These preventative efforts can happen in schools through education, within households by having meaningful conversations about mental health, and at clinics and hospitals with better screening and assessment. Mental illness is real, it is common, and it is treatable.

Todd Archbold, LSW, MBA is the chief executive officer at PrairieCare.