On the mental health system. What is that really?

When people use the term mental health system they may mean many different things.  Some people identify it with psychiatrists and frequently see them as kind of all powerful creatures prescribing medication for everyone they see.  Some people think of psychiatric hospitals.  Some people think of mental health centers and community based programs.  For some people its primary characteristic is coercion.  For others it is opportunity, the ability to get help that helps save the quality of their life.  Some people have experienced it as remarkably helpful.  Their experience is that “treatment works.”  Others disagree and seem to feel that the “system” was as much a source of stress and problem in their lives as the mental health issues they were trying to deal with.  The only thing I am sure of is that each of this characteristics has a measure of truth to it.  Your experience…. my experience …all be very valid, but the important thing to remember is that they are not the only valid experiences.

This post takes a look at figures published in the most recent publication by the Kaiser Family Foundation from April 2011 (http://www.kff.org ) entitled “Mental health financing in the United States: A primer”.  This report is also discussed in the most recent post of my other blog- “Every life matters” (http://everylifematters.wordpress.com ).

Several figures stand out and give some real indications about what is really real:

• According to the figures from 2009 (the most recent available I think) about 30 million people were served by the mental health system.
• 60% of the people with a diagnosable mental illness and 90% of those with a diagnosable substance abuse  received no services at all.
• According to a 2005 study there was a total of 135 billion dollars in spending.
• Of the 30 million served about 85% received psychotropic medication.  49% received nothing but psychotropic medication.
• Although it was a service received by 85% a study quoted from 2005 said that it was only 27% of the total expenditures.  This is a huge rise in spending though.  In 1986 it was only 7% of spending.
• By way of contrast only 49% of people served received outpatient treatment.  Yet it accounted for 33% of the expenditures.  Pills are cheaper than people.
• Only 5%  of people received inpatient treatment.  Yet it accounted for 19% of expenditures.  It is by far the most expensive service.
• 13% of people received outpatient treatment only.  32% received outpatient and medication.  Over 60% of people who receive outpatient treatment also receive medication.
• !% of the people receiving services receive inpatient and outpatient treatment with no medication.  The other 4% of the people receiving services who receive inpatient also get medication.  If you go inpatient there is an 80% chance you will also receive medication.
• According to a 2003 study more people receive mental health treatment from non mental health specialists like primary care providers than from mental health providers.  Quoting from the study, “The high proportion of people receiving treatment from non-specialist medical providers has grown significantly over the last decade and reflects…..a shift to psychotropic drugs (perhaps without combined psychotherapy).
• According to a 2009 study from those who reported not being involved with treatment the primary reason had to do with lack of access to services.  Over half cited financial restraints.  Another third simply did not how to find the services they needed.  The two other major reasons cited were lack of perceived need or questions about effectiveness and concerns about stigma and what labeling would do to their life.

So what can you draw from this?

Medication-  If you consider the amount of negative publicity that psychotropic medication gets why is the use of medication so high?  At least on the internet stories about it being much less effective than advertised are everywhere.  Stories about people who suffer absolute tragedies because of side effects are also everywhere.  Pharmaceutical companies have been caught in lie after lie after.  Lawsuits from virtually every psychotropic medication are everywhere.  Pharmaceuticals are paying fines that stagger the ordinary human imagination.  Yet 85% of people who received mental health services received medication.  Why?

• It works.  For many people, for reasons that I am not sure that anyone understands, medication gives some measure of symptom management that people have not been able to find, in their experience anywhere else.  I know many people who, from their own personal experience, see medication as a horror and a torture.  But I know many others who, from their personal experience, see it as an integral part of their recovery.  And they see what they gain as worth the risk of what they are told may be the ultimate side effects.
• To some extent, the messages of those who are most verbal about their negative perceptions of medications, are most convincing to those who already agree with them.  Most people judge from their personal experience and if their personal experience is positive they are unlikely to buy much of what they are told against drugs.  My own perception is that too often those who preach against the use of psychotropic medication are too often intolerant of those who disagree with them and prone to personal attacks on the integrity of those who disagree.  I know many people who have told me that is their personal experience.  I have changed my opinions radically over the last years becoming much more cynical about the use of psychotropics, but it has to some degree been despite what the anti-drug people have said, rather than because of it.
• Default-  Personally this is what I believe the biggest reason.  Medication “wins” by default in many situations.  As one study above pointed out, more people are treated by non mental health people than by mental health people.  A larger and larger part of mental health care is provided by primary care physicians and I believe this is reflected in the statistics that talk about almost half the people served receiving nothing but medication.  Primary care physicians give pills.  That is what they do.  Medication wins by default.  Another source of default is the lack of “competing resources.”  For example, most people in jail who need care according to everything I have read largely are limited to psychotropic medication.  Whatever therapy or counseling that is provided is usually few and far between and no where close to the level of need.  In many rural or small towns medication wins by default.  Other services simply dont exist.  The small town mental health system and the city mental health system are simply not the same thing.
• Budget cuts-  This was kind of alluded to above.  Cuts in mental health services are not cuts in psychotropic medication.  That is largely paid for by another pile of money.  It is cuts in community based social programming that make it harder for those in real need to make it and the use of medication often fills the vacum.  Paradoxically the neutering of the public mental health system that so many states are facing will increase the amount of psychotropic medication given not decrease it.
• Treatment models.  The medical model is more and more seen as being incomplete or simply wrong.  The recovery model or transformation model is getting more and more of a toehold.  However ultimately the mental health system is whatever the funding sources agree to pay for  and newer services have a harder time gaining traction when services in general are  under attack.

The importance of access-

• A staggering amount of people who could probably benefit from effective treatment dont participate in the system and the most outstanding reason is simply the lack of financial access, knowledge of resources, or the existence of services needed for recovery.  And this is a problem that will only grow with the financial constraints that most states face.  The costs will not go away.  They will simply be shifted.  People who need treatment and dont get it end up in jail, on the street or dead.  Those who dont find their lives ruined in one way or another.  You can choose not to pay for mental health services.  You cannot choose to not pay for the consequences of untreated mental health issues.

The importance of stigma:

• Many people do not seek treatment because of what they think that says about them and what it means for their lives.  Prejudice is real and tangible.  It is an issue that seems to have eternal life.  The more you beat it down the more it comes up.

The importance of credibility.  The mental health system has a real problem with credibility.  A lot of people it serves find it confusing and an unfriendly place.  They have serious questions about the effectiveness about many of the services offered them.  They believe their questions and concerns are often simply written off as symptomatic of their “illness” and ignored.  I think the over-reliance on medication and then blaming clients when the medicines dont work as well as those who prescribe them think they will is common and a large part of the problem.  Another problem is that other services are frequently absent of insufficient.  The system for many is not what it could be or what it should be.

I dont know how much you agree with some of my conclusions.  The Kaiser Family report has a lot of information in it not touched on in these post and I hope you will read it.  I look forward to hearing some of your feedback.

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