Chapter 56: Public Psychiatry

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Welcome back to the Deep Dive.

Today we're diving into, well, a really foundational piece of psychiatric literature.

It's a key chapter from Kaplan and Sadok's Comprehensive Textbook of Psychiatry.

A dense one for sure.

Definitely dense, but it maps out the entire history of how mental health services developed in the U .S.

Really crucial stuff.

Absolutely.

So our mission today is basically to chart that journey for you.

We'll go from those early philosophical ideas in the 19th century right through the market -driven chaos and into the reforms we're grappling with now.

And it's quite a story.

It shows how clinical goals keep getting tripped up by, you know, money and bureaucracy.

Exactly.

And maybe the best way to understand why the system feels so broken today is to see where it started.

You mentioned this tension right at the beginning.

Yeah, this fundamental conflict between the ideal of, let's say, moral treatment, ethical care, and the sheer unavoidable reality of huge institutions.

Right.

So let's start there.

Moral treatment.

It wasn't about locking people up as punishment, was it?

No, not initially.

The idea was more about

restoring a person's capacity for ethical behavior.

How?

Through a specific environment, kind of pastoral, rural, calm.

They actually called the ideal setup the retreat.

Sounds almost

quaint.

Noble, maybe?

It had noble aims, yeah.

A social -ethical approach,

but like a lot of ideals.

They ran into reality.

Pretty quickly.

Especially when reformers like Dorothea Dix pushed for funding for scaling it up nationally.

Which led to the big state hospitals.

Exactly, the age of the state hospital.

And the source we're looking at makes a really sharp point here.

As those hospital populations just ballooned,

the actual treatment function got pushed aside.

It was like eclipsed.

By what?

Just managing people.

Yeah, by care and custody concerns, as the text puts it.

The superintendent, who might have started as a doctor focused on treatment, became more of a manager, an administrator.

Okay, so the institution itself starts to fail the patient, in a way.

The field needed a new direction, something more, medical.

Right, and that's where you see figures like Adolf Meyer becoming really influential.

He actually trained as a neurologist first.

And he developed something called psychobiology?

Yes, psychobiology was a different way of looking at things.

Sort of a genetic dynamic view.

What does that mean, dynamic?

It means moving away from just thinking about fixed diseases.

Meyer stressed the constant interaction, you know, between the person and their environment.

Okay.

And he often framed mental disorders in behavioral terms,

like as a result of accumulating defective habits.

Defective habits?

Wow, that phrasing sounds pretty harsh today.

It does, yeah.

But that focus on behavior, on learned patterns, that was partly why dynamic psychiatry took off in the early 20th century.

How so?

Well, if you see mental illness as existing on a continuum,

not just a biological breakdown, but maybe maladaptive behaviors.

Ah, it blurs the line between health and illness.

Exactly.

And that blurring allowed practice to move outside the asylum walls.

You could start working with troubled people in the community, maybe before they needed locking up.

Makes sense.

But did it go too far?

Sometimes, definitely.

The book points out that this expansion led to some serious scientific overreach, like promoting ideas.

Well, the classic example is the schizophrenogenic mother.

Oh, right.

Blaming mothers for schizophrenia.

Which was incredibly damaging later on.

Hurt the field's credibility quite a bit.

So the field tries to expand, maybe stretches itself too thin scientifically, and then the money issue hits hard.

That's the next big turn.

After that mid -century push for community mental health centers, the CMHCs,

healthcare costs just started soaring across the board.

And that led to this massive market -driven takeover of mental health care.

Enter managed care.

Right.

Managed behavioral health organizations, MBHOs, they moved in fast.

Yeah.

And private psychiatric hospitals, they became a prime target for investors.

Why?

Well, profits could be pretty substantial.

And compared to building a general hospital, the investment costs were lower, especially once inpatient psychiatric care got widely insured.

And the source mentions a pretty shocking statistic about that.

It does.

It says investor chains acquired something like 43 % of private psychiatric hospital market share.

43%.

And how long?

In just four years.

Wow.

Okay.

That kind of rapid consolidation, purely for profit, that has to change patient care, right?

Absolutely.

And the text highlights a particularly, well, dark aspect of this.

Which is?

Add psych.

Adolescent psychiatry units.

They became incredibly lucrative.

More than adult units.

Apparently so.

The text notes that corporate strategy often involved closing down adult units, specifically to open more adolescent units.

Basically chasing the higher profit margins from treating teenagers.

That feels really problematic.

Shifting resources based on profit, not need.

It raises huge ethical questions.

Alongside this, the book points out another trend among psychiatrists, especially those in private practice during the CMHC era.

What trend was that?

They tended to gravitate towards a certain type of patient.

Someone they nicknamed the YAVS individual.

YAVS.

What's that stand for?

Young, attractive, verbal, insightful, and successful.

Huh.

The ideal therapy patient, maybe.

Easy to work with.

Perhaps.

But that preference had huge knock -on effects.

It meant that many professionals focusing on milder issues in relatively well -off patients.

Ended up neglecting others.

Exactly.

They inadvertently sidelined people with SMI serious mental illness.

The very who needed the most intensive outreach, the most comprehensive community support.

And the financial system made that worse.

Brutally so.

Think about those insurance benefit limits.

The text gives an example.

A $50 ,000 lifetime limit for mental health care.

Okay.

For someone with SMI needing intensive care, that could be completely wiped out in just, say, 60 days of private hospitalization.

And then what happens?

Then they're discharged.

Often right back into the public sector system, which was already underfunded and overwhelmed, the sickest patients got pushed onto the system least equipped to handle them.

Okay.

So the system is clearly fracturing under these financial pressures and, frankly, quality issues.

That brings us to the more recent reforms.

21st century stuff.

Yeah.

There was a realization that this wasn't just about cost containment anymore.

It was about a fundamental failure in the quality of care being delivered.

Was there a key moment that triggered this?

A major one was the Institute of Medicine's report in 2001, crossing the quality chasm.

Right.

I've heard of that.

It's a bombshell really.

Yeah.

It laid bare this huge gap between what we knew worked effective, evidence -based treatments, and what patients were actually getting.

It forced a hard look at systemic change across all of American medicine, not just mental health.

Okay.

So that sets the stage.

And then the ACA, the Affordable Care Act, comes along and tries to build a new foundation for reform.

It does.

It codified this concept called the triple aim.

The triple aim.

Let's break that down for listeners.

It wasn't just about saving money, right?

No, that's key.

Cost was the third aim.

The first two were, one, improving the actual experience of care for the patient.

Okay.

And two, improving the health of entire populations, not just individuals.

And then reducing per capita costs.

So a shift from just paying for more services volume to paying for better outcomes value.

Precisely.

That was the goal.

And absolutely central to achieving that value, especially in mental health, was the concept of parity.

Parity.

Meaning equality.

Essentially, yes.

The Dental Health Parity and Addiction Equity Act of 2008 was huge.

It legally mandated that insurance benefits for behavioral health,

so mental health and substance use treatment,

must be equivalent to the benefits offered for general medical and surgical care.

No more separate, much lower limits for mental health.

The intent was full integration.

Okay.

The intent sounds good.

Equality on paper.

But what about in practice?

Did it fix the access problem?

That's where it gets troubling.

The source gives a really stark statistic that shows how far we still have to go.

What is it?

Fewer than 50 % of psychiatrists accept Medicare.

Less than half compared to other medical specialties.

It's the lowest acceptance rate for public insurance among all physician specialties.

So even if the law says benefits must be equal.

If you can't find a provider who accepts your insurance, especially public insurance like Medicare, which covers many vulnerable people,

then parity doesn't mean much in reality.

Exactly.

Access remains a massive barrier.

Okay.

So we've got these huge systemic problems, funding, access, market forces.

Given that reality,

what clinical tools or approaches does the textbook suggest for actually managing mental health at a population level?

Well, it talks about applying a public health model.

Thinking about prevention on different levels.

Right.

The three types of prevention.

Can you quickly outline those?

Sure.

First is primary prevention.

This targets basically healthy people before any problems develop.

Trying to address root causes.

Think of like big media campaigns to reduce stigma around mental illness.

Okay.

Stopping it before it starts.

Then there's secondary prevention.

This is about early identification and quick treatment for people who are identified as high risk.

Like screening programs.

Or intervening right when someone first shows, say, prodromal symptoms of psychosis.

The goal is to catch it early and reduce the severity or duration of the illness.

Makes sense.

And the third.

Tertiary prevention.

This focuses on people who already have an established, often chronic disorder.

The aim here is rehabilitation,

managing symptoms, reducing disability, and improving quality of life.

And fitting into that tertiary prevention and just modern care generally is the idea of recovery, right?

As defined by Sam H .S.

Absolutely crucial concept.

And it's important to understand what recovery means in this context.

It's not necessarily about a cure or just eliminating symptoms.

So what is it about?

Sam H .S.

defines it as a person -centered process of change.

It's about individuals improving their health and wellness, living a self -directed life, and striving to reach their full potential, even with the challenges of their illness.

So the focus shifts to the person's strengths and goals.

Exactly.

It demands a move away from the old paternalistic, institution -led approach towards empowering the individual.

Okay.

Now, when we talk about recovery and functioning, the textbook makes a distinction between two things.

Functional capacity and functional performance.

What's the difference there?

It sounds a bit technical.

It can sound that way, but it's a really useful distinction.

Think of capacity as the underlying potential or skill set.

Does the person possess the basic ability to do something?

Like, can they technically learn to balance a checkbook?

Do they have that cognitive capacity?

Okay, the raw ability.

Right.

But performance is about whether they actually do it in the real world.

You might have the capacity to balance your checkbook, but if you're struggling with severe negative symptoms of schizophrenia, like abolition, that frowned lack of motivation or drive your real -world performance,

actually doing the task, managing your finances, holding a job, might be very poor.

Ah, okay.

So capacity is the can -do, performance is the does -do, and symptoms or environment can get in the way of performance.

You got it.

And systems are adapting, too.

The book briefly mentions the rise of the specialized psychiatric hospitalist.

Like a hospitalist in general medicine.

Exactly the same model.

A psychiatrist dedicated solely to managing complex, acutely ill patients while they're in the hospital.

The focus is often on efficiency, coordinating care, and reducing the length of stay.

We talked about the failures of the old system, especially deinstitutionalization without adequate community support.

The textbook points to a really tragic outcome of that failure, doesn't it?

It does.

The criminalization of serious mental illness.

Meaning?

Meaning that jails and prisons have tragically become the sort of unofficial replacement facilities for the old state hospitals that were closed down.

That's a shocking statement.

Is there evidence for that?

Yeah.

Studies confirm it.

A high percentage of incarcerated individuals have a serious mental illness, often untreated.

And frequently, their first point of contact with any system isn't health care, it's law enforcement.

The police become first responders for mental health crises.

Often, yes.

But there are ways to improve that interaction.

The book highlights

programs for police.

You've probably heard of crisis intervention teams, CIT programs, sometimes called the Memphis Model.

I have, yeah.

Do they work?

The evidence suggests they do.

CIT -trained officers are much better at deescalating situations and diverting people towards treatment instead of jail.

Arrest rates for encounters involving CIT officers are way lower.

The book quotes rates around 2 % to 13%.

It's impaired.

So it makes a difference.

But even with diversion, treating this population within the justice system or trying to get them into treatment must be incredibly hard.

The book mentions a specific challenge.

Anasognosia.

What is that?

Anasognosia is a really critical concept here.

It's essentially a neurological symptom, biologically based, that results in an inability for the person to recognize that they have an illness.

So they genuinely don't believe they're sick.

Correct.

It's not denial in the psychological sense.

It's a lack of insight stemming from the illness itself, often seen in conditions like schizophrenia or bipolar disorder.

If you don't think you're sick, why would you take medication or engage in treatment?

Exactly.

It makes compliance incredibly difficult and is a major reason why some individuals become treatment resistant and repeatedly cycle through the correctional system.

This whole issue of access, compliance, and how people are treated brings us to another major systemic challenge.

Inequity in health services.

The textbook uses the socio -cultural framework, the SCF, to define this.

Right.

And the SCF definition is important.

It defines health service inequities as differences in access, quality, or outcomes between different racial or ethnic groups that are not explained by the patient's clinical needs or preferences.

So differences that are systemic,

avoidable, unjust?

Precisely.

They result from how the system operates, from policies, and sometimes from bias.

What kind of bias?

The text discusses provider bias.

This is an always conscious prejudice.

It can be subtle, things like stereotyping or even just clinical uncertainty when dealing with patients from different cultural backgrounds.

And how does that lead to inequity?

It can lead to misdiagnosis in a couple of ways.

For example, a provider might misinterpret culturally specific expressions of distress,

maybe religious or spiritual experiences common in some communities.

And label them as hallucinations, leading to overdiagnosis of psychosis.

That's one potential pathway.

Conversely, a provider might fail to adequately ask about or recognize emotional problems in minority patients, perhaps due to discomfort or assumptions, leading to underdiagnosis of things like depression or anxiety.

So either way, the patient doesn't get the right care.

Correct.

Which underlines the absolute need for what the book calls cultural and linguistically appropriate services, the CLAS standards.

Things like providing interpreters, understanding cultural contexts, ensuring care is delivered in a way that respects the patient's background.

It's essential for bridging these gaps.

So when you look at this long history laid out in the chapter, you really see this pendulum swing, don't you?

Back and forth between trying to confine people and trying to integrate them into the community.

Yeah, it's a constant tension.

But what the source material makes so clear is that these economic roadblocks and systemic problems,

things like really low Medicaid reimbursement rates that discourage providers or just persistent bias, institutional and personal, they constantly get in the way.

They sabotage the goal.

They really do.

They obstruct the path towards what we ideally want.

Comprehensive, equitable care that's truly focused on recovery.

So taking a step back, what's the big takeaway here for you?

What does this history tell us?

For me, it underscores that you can't just focus on the clinical side on finding better treatments in isolation to actually help the most vulnerable people.

You have to fix the system around them.

Exactly.

You have to fix the administrative systems, the financial incentives, the cultural biases.

The challenge isn't just knowing what works.

We have plenty of evidence -based practices.

The bigger challenge is how you actually implement those practices effectively with fidelity across all the diverse populations who need them, especially those who've been historically underserved.

That leads perfectly into our final provocative thought for you, our listeners.

We heard that statistic.

Fewer than 50 % of psychiatrists accept Medicare, the lowest rate of any specialty.

So if the specialists trained to treat the most complex mental health conditions have the lowest participation rate in public insurance,

what does that really say about the state of parity in our healthcare system and who ultimately is left to care for the individuals bearing the highest burden of severe mental illness?

Something to really think about.

Definitely something to chew on.

Thank you for joining us for this deep dive into the complex history and structure of mental health services.

We really appreciate you tuning in.

Thanks, everyone.

We'll talk to you next time on The Deep Dive.