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Key points
- The crisis in mental health care has been with us for decades
- Despite the ongoing crisis, very little has changed in the ways we provide this care.
- The crisis demands fundamental changes in the ways that we provide this care.
Our mental health system has been broken for decades. This is not news, or at least not new news, despite recent headlines. These same headlines have been appearing off and on for at least the last three decades.
Here’s some data: One study found that the average wait time to see a psychiatrist for an initial evaluation was 25 days. That’s more than three weeks. That same study found that some patients wait more than 90 days. The situation is even worse for those who need inpatient psychiatric care. Recent data from Massachusetts show that adult patients waited in emergency rooms or boarded on non-psychiatric medical floors for an average of 53 hours. Children and teens waited a whopping 59 hours on average.
These kinds of problems have been around for a very long time. As a psychiatrist, I’ve watched this situation remain stubbornly and ludicrously dysfunctional for the entirety of my career. I keep asking myself why? It’s not as if we’re not aware. If we know things are so bad, then why haven't we seen truly meaningful improvement?
I thought for a while that bias against psychiatric illness was the culprit. If we just could get more people to accept and believe in the existence of psychiatric suffering, then things would automatically get better. However, while it’s true that pervasive stigma persists, we have enjoyed a steady, impressive, and laudable lessening of this stigma. Clearly, these improvements have not been accompanied by a commensurate change in access to quality mental health care. Things are better, but only slightly, and in some parts of the country, things are a whole lot worse. This is especially the case in socio-economically challenged urban and rural settings, but not exclusively. Even wealthy universities have struggled to improve their mental health services.
We also know that if we did invest more in the prevention of psychiatric illnesses – that is, if we enacted community programs to stem the development of psychiatric problems in the first place – then we would stand to save literally millions and millions of dollars and countless lives. If people have better access to food, shelter, security, and community, then people will suffer less psychological problems. This might seem obvious, but it’s nice to know that we have all sorts of data in support of these endeavors.
To be sure, the infrastructure for mental health care is sorely in need of an overhaul, but increasingly I wonder whether the lack of change forces us to ask tough questions about mental health care itself. Is it possible that the ways we practice, and the ways we train others to practice, are simply not viable in light of the current need? To put it another way, I’m confident that when I care for patients the way that I was trained, I can deliver quality treatment. But I am not nearly as confident that this style of practice can meet the needs of the nation. This leads to a whole new set of sometimes uncomfortable questions:
1. Is the ongoing lack of access to quality mental health care a systems issue, we can’t get patients connected with clinicians, or a numbers issue, the number of clinicians fall far short of existing epidemiological demands despite any improvements we could make to the system.
2. If we suffer from both a systems and a numbers issue (as I suspect we do), then which of these issues is worth addressing most aggressively?
From a systems standpoint, let's consider the classic 50-minute psychotherapy session. Why is that number so immutable? It is certainly the case that sometimes people need 50 minutes. But sometimes they need more, and other times they need less. How could we change things to better match the allotted time to the need? After all, varying the amount of time would potentially make more time available. The same could be said for the 20-minute medication management visit. Sometimes we need way more than 20 minutes, and other times we need less than 10.
The problem with this approach, however, is directly related to the reasons someone seeks a psychiatrist in the first place. Seeing a psychiatrist isn’t like coming to a doctor with a sprained ankle. A unique combination of shame and old-fashioned denial foment a desire to hide the reasons someone is psychically hurting. This is the case for the patient and for the doctor. I worry that adjusting sessions to more variable amounts of time will create more harm than good. Also, and even more fundamentally, we have no real system in place to determine how to make these changes in real-time. To my knowledge, we’re not even really studying this particular inquiry.
I also wonder whether those of us in mental health has done enough to help clinicians in other fields to be more comfortable with mental health issues. Or, as many of my primary care colleagues assure me, what if these clinicians are entirely accepting of their role in treating mental health, but simply don’t know what they’re missing? Current research shows that primary care settings are ideally suited to address mental health challenges. What is the best way to ensure that primary care clinicians are comfortable and well-trained with regard to psychiatric diagnoses and interventions? There's a bit of research regarding these issues, but we still don’t have a good sense of best practices.
Now let’s look at the question of the numbers. Many mental health advocates have asked why we don’t incentivize careers in mental health care more aggressively. On the surface, this of course makes sense. Recent estimates of US population growth and corresponding psychiatric needs suggest that we will continue to face significant and worsening shortages of mental health professionals. Why don't we do everything we can to create more mental health experts? Possible solutions have involved loan forgiveness for medical or graduate training, increased utilization of public health services, and ongoing anti-stigmatization campaigns during undergraduate, medical and graduate school.
But here’s the problem: we are already doing all of these things. Loan forgiveness programs exist. Stigma is slowly but confidently being pushed aside. More people are choosing to devote their careers to mental health. It’s just that the gaps are too great. To continue to provide care as it is currently practiced, it is highly unlikely that we could in a timely fashion meaningfully increase the workforce numbers. We do have to produce more mental health clinicians, but given the gargantuan need, I don’t think that this solution, or at least this solution alone, has anywhere near the capacity to measurably change our current mess.
Why? Because things are really bad, and they’ve been that way for a very long time. It’s clear that we need to think big. Sure, we need to create more clinicians, and of course, we need to consider changes to the ways we provide clinical help in the first place. But we need to break away from old patterns. We need to test different methods for determining the correct amount of time for each mental health visit. We need to utilize big data in ways that are only now becoming possible. We need to get much better at identifying features that confer risk and resilience. We need to integrate environmental factors and community cohesion into mental health awareness.
In short, we need a new standard of care. The current standard works only for those patients who are lucky enough to find care in the first place, but this standard isn’t at all adequate to meet current demand. It’s time we rethink our paradigms.
I’m talking about getting way outside the box. Fundamental restructuring has got to be part of the solution. Anything less is way too little.
