The Future of Mental Health: Radical changes ahead
by Fred Baughman Jr
USA Today Magazine 3/1/97
Today article - making an attack on biological psychiatry in a
very widely read popular American news-magazine, and outlining
the view (by Baughman, M.D.) that managed care in the U.S. is
shaking the biological psychiatry tree.
"Managed care is putting a halt to
open-ended diagnosis and therapy and is reducing mental health
expenses sharply." OVER THE PAST 30 years, psychiatry has
denigrated and jettisoned the human willpower-coping model and
psychotherapy. It claims instead that all character flaws and
emotional pains are "diseases," the result of
biochemical imbalances of the brain, to be "balanced"
with drugs. Were organized psychiatry not "one" with
the pharmaceutical industry, with drugs to sell, the espousal of
"biopsychiatry" and of one-dimensional drugging for
illusory diseases might be difficult to understand. In an
editorial, "In Bed Together at the Market--Psychiatry and
the Pharmaceutical Industry," psychiatrist Matthew Dumont
urged that psychiatry declare itself an arm of the pharmaceutical
industry. Typical of efforts to biologize and pathologize human
emotions, the Yale University Anxiety Clinic announced active
research programs in the "clinical neurobiology,
psychopharma-cology, etiology, genetics, and
neuroendocrinology" of anxiety. In a quid pro quo
relationship with American public schools, child psychiatry has
made "learning disabilities," "brain
diseases," and "special education" out of the
illiteracy, alienation, and discomfiture that are the result of
massive educational malfeasance. On the 1994 National Assessment
of Educational Progress, just 25% of fourth-graders, 28% of
eighth-graders, and 37% of 12th graders were
"proficient" readers. Child psychiatry urges its
members to establish service contracts with schools. For-profit
psychiatric hospitals place personnel in schools, targeting
children by providing free assessments--a sham and prelude to
drugging and hospitalization. Not only do they invent diseases,
they invent entire epidemics. Attention-deficit disorder
(ADD)--invented, in-committee, at the American Psychiatric
Association, but never proven to be a disease--has burgeoned,
from 500,000 diagnoses in 1988 to 4,400,000 today. In drug
company- sponsored physicians' seminars and parent-teacher
presentations, ADD is portrayed as an actual disease, "like
diabetes or cancer," and the drug Ritalin as "safe and
non-addictive." These assertions are untrue and fraudulent.
Both the Food and Drug Administration and the Drug Enforcement
Administration have acknowledged that ADD is not a disease or
anything organic or biologic. The United Nations' International
Narcotics Control Board has expressed concern to U.S. officials
over the level of Ritalin consumption in America--90% of the
world supply, up sixfold from 1990 through 1995. Lewis Judd,
former director of the National Institute of Mental Health, urged
inclusion in the APA's Diagnostic and Statistical Manual (DSM-
IV) of a new "disease"--sub-syndromal symptomatic
depression (SSD). He claimed that SSD affects 24,000,000
Americans and that it responds to Prozac. With no proof
whatsoever that SSD is a disease, real and biological, it wasn't
included--this time. No matter, child psychiatrists have found a
new market for Prozac and for all psycho-pharmaceuticals-
-infants and toddlers. Paula Caplan, author of They Say You're
Crazy, observes that "rocketing costs result from ballooning
definitions of mental disorders and by implication, necessary
treatments." From 1987 to 1994, the Diagnostic and
Statistical Manual swelled from 297 to 374 diagnoses. Carol
Tarvis, author of Mismeasure of Woman, suggests that the DSM's
authors suffer from "delusional scientific diagnosing
disorder." Psychiatric admissions for children and
adolescents to private hospitals tripled between 1980 and 1986.
Irving Phillips, professor of psychiatry at the University of
California, San Francisco, School of Medicine, pointed out that
"Excessive hospitalization of troubled young people has been
a problem for some time, but had increased in the 1980s."
Congressional hearings published in 1992 under the title
"How Inpatient Psychiatric Treatment Bilks the System and
Betrays Our Trust" were told of children kept in for-profit
hospitals for periods determined not by medical needs, but
duration of insurance benefits, as well as bounties paid for
referrals to school, emergency room, and law- enforcement
personnel and even to clergy. Psychiatrist Walter Afield
testified that, according to "The DSM III... everyone in
this room will fit into two or three of the diagnoses.... Every
new disease. .. gets a new hospital program, new admissions, a
new system, and a way to bilk it...."
Whistleblower psychiatrist Duard Bok was fired and labeled "impaired." He testified that "Most of the doctors... for the past three to four years, have been much more dependent on the hospital's marketing department to refer patients to them, rather than they referring patients to the hospital. Ethical physicians who refused to keep patients in the hospital longer than necessary have seen the number of patient referrals dwindle to almost nothing, while physicians, some just having completed their residencies, who order treatments and therapies that the administrative staffs direct, are rewarded with numerous referrals. "
In 1994, National Medical Enterprises, owner of Psychiatric Institutes of America, settled Federal claims for insurance fraud for $375,000,000, then changed its name. In Texas, site of much of the fraud, not a single physician lost his or her license.In Texas, one of the few states that keeps records on such things, 65-year-olds get 360% more electroconvulsive therapy than 64-year- olds. Are Medicare dollars the difference?
Having testified that one Reno, Nev., hospital had "two and a half times as many patients as all of the hospitals in Seattle [Wash.] combined," physician Kenneth Clark concluded: "Just as the Soviet Union was driven into bankruptcy by expenditures on arms, so might the United States be facing bankruptcy through excessive and unnecessary expenditures on health care."
The managed care "fix" of mental health is further along than in any other specialty. With the managed care staffing ratio at four psychiatrists per 100,000 patients, it has been predicted that half of the nation' s 36,000 psychiatrists (16 per 100,000) will not be needed in a total managed care system.
The steady drop of U.S. medical school graduates applying for psychiatry residencies, with 45% of slots now held by international medical graduates, is a further sign that all is not well with psychiatry. Its anti- scientific claims of "disease" where none actually exist seem sufficient to deter anyone of a scientific bent.
The 12 corporations controlling 85% of mental health managed care are in a position to dictate terms. They adapt their own clinical criteria and mandate treatment objectives and target dates. Costs are ratcheted down, and the glut of caregivers, psychiatrists included, allows plans to use less costly psychologists and social workers to perform most of the therapy. Compounding the plight of psychiatrists, primary care physicians--"gatekeepers"--provide two-thirds of care for the severely depressed.
According to Monica Oss of Open Mind, a behavioral health think tank, "It's a period of incredible change in mental health care and a very trying time for psychiatrists.... Critics and supporters alike credit managed care with reducing the expensive and dehumanizing institutionalization of the mentally ill." Managed care is challenging other long-held, unproved assumptions as well, the efficacy of long-term therapy among them. Enormous savings have been generated in hospital treatment. Managed care systems in Southern California have cut hospital stays for commercially insured patients from 350 days per 1,000 enrollees a decade ago to between 125 and 150 today.
In the most severe cases in child-adolescent psychiatry, cuts in hospitalization have been proven not only possible, but beneficial. "Mobile triage" systems with physicians assessing children in their homes, intensive family counseling, and 24-hour beeper accessibility have achieved 95% success rates in diverting hospitalizations. When safety can not be assured, two- to three-day "respite beds," half the cost of hospitalizations, are utilized. The majority of hospitalizations of 10 years ago are proving avoidable, reducing the length of treatment per episode and cutting the 90-day recidivism rate by one-third. Hospital stays and the number of psychiatric beds are declining steadily.
Contrary to assertions by fee-for-service psychiatry, treatment goals and timetables can and must be articulated in terms understandable to all. What will managed care tell the public of the validity of psychiatry's brain "diseases," "chemical imbalances" and their "epidemiology, " and one-dimensional "psychopharmacology"? Barry Nurcombe, director of child and adolescent psychiatry at Vanderbilt University, admits that "the best [psychiatric] diagnoses are provisional and somewhat fictional."
Would it not be more scientific and pragmatic for psychiatry to revert to the "organic-not organic" determination, to which all physicians are obligated, but which psychiatrists refute, concluding that patients with psychological symptoms and no organic disease have real-life, situational problems for which psychotherapy is needed. To represent them as biologic and to proffer pharmacology is neither scientific nor "treatment" in a Hippocratic sense.
For health care to be affordable for all, costs must be controlled. To do so, the supply and distribution of physicians must be regulated. This is the first thing that managed care does, making sure that every physician has enough patients and sees enough real disease to stay competent and has no motivation to overtreat in defense of the bottom line.
I am not a fan of managed care. I do not want "bigger and better" managed care for-even There is no doubt, however, that we will need managed care to contain costs for the 10 to 15 years it will take to mitigate the physician glut. As physician supply and distribution are brought under control, I foresee a resurgence of private practice and a lessening of the level of managed care required. I do not envision that the managed care genie ever will be put back in the bottle, though.
Finding chronic hospitalization counter to satisfactory patient outcome, managed care enacted change. Over the protests of the psychiatric establishment, finite treatment plans with explicit goals have been enacted and have succeeded. General practice physicians, psychologists, and social workers are replacing "biopsychiatrists."
How long will it take managed care to discover the lack of a scientific basis of virtually all psychiatric diagnosis prognosis and psychopharmacology? How long will it take managed care to discover that all of the so- called learning disabilities are educational and parenting problems, not medical at all, and to jettison them?
The psychiatric lobby Who are those lobbying on psychiatry's behalf?. What are their ties and credentials. Should health policy of any sort be driven by the testimony of believers and collaborators or by scientific outcomes? What weight should be given the fact that some politician's sister, brother, or niece had committed suicide or was schizophrenic, institutionalized, or "cured" ? What weight should be given to the personal experiences and beliefs of celebrities such as Rod Steiger, Mike Wallace, William Styron, Roseanne, or even the millions that have come to believe it safe and essential to take Prozac, Zoloft, or one or several psychotropic drugs daily for life? What weight should be given the testimony of those who prescribe Ritalin daily to rear and educate 4,400,000 wholly normal children? Are they anything but believers-turned-proselytizers?
Wallace states, "I will take Zoloft for the rest of my life. I'm not going to lose anybody's respect." That he believes proves nothing. Millions, in lesser circumstances, have the same belief in amphetamines and crack cocaine. Does Wallace have proof of the safety of lifelong use of Zoloft?
One 12-year-old was offered no such proof when placed on the antidepressant desipramine for ADD. He died from the drag. Five other troubled, troublesome, normal children have died from desipramine, and four from the combination of Ritalin and clonidine.
What of the testimony of so-called patient advocacy groups in the policy debate on psychiatry? Who do they really advocate for? Children and Adults with Attention-Deficit Disorder, with 600 chapters and 35,000 members nationwide, has received nearly $1,000,000,000 from Ritalin manufacturer Ciba-Giegy. The pharmaceutical giant has acknowledged that "CHADD is essentially a conduit for providing information to the patient population."
Just as in industry-sponsored physicians' seminars, CHADD's message to the public unfailingly portrays ADD as a real disease, "like a brain tumor or diabetes," and Ritalin as "safe and non-addictive." Both are tacit misrepresentations that, were they to come from a physician, would constitute flawed informed consent and de facto malpractice. The International Narcotics Control Board has suggested that CHADD is in violation of regulations that prohibit direct-to-the-public marketing of an addictive controlled substance.
"Science has demonstrated that [mental illnesses] are just as real as heart disease or cancer," says Laurie Flynn, executive director of the National Alliance for the Mentally Ill. The organization is parroting the "big lie" of biopsychiatry, its raison d'etre and reason for drugging. Riese v. St. Marys, which was to expand the rights of legally competent patients to refuse antipsychotic drugs, was beaten back by NAMI in collaboration with the California Psychiatric Society. State Assemblyman Bruce Bronzan, who led the fight against Riese, was said to have received contributions from the Pharmaceutical Manufacturers Association as well as a host of pharmaceutical firms and hospital and psychiatric associations.
Psychiatrist Peter R. Breggin suggests that the failure of psychiatry to attract voluntary patients is the main impetus for the "disease- drug" biopsychiatry model. I would add that this is the reason behind psychiatry's efforts to have psychiatric care required by law wherever possible, as in public schools, the social welfare system, the juvenile and adult justice systems, and now, perhaps, Medicare and Medicaid as well.
While it has been charged that managed care mental health results in more drugging, this is not necessarily the case. Consider the declining numbers of psychiatrists and their displacement by general practice physicians, social workers, psychologists, and marriage and family counselors, none beholden to the disease-drug m odel. Managed care is putting a halt to open-ended diagnosis and therapy and is reducing mental health expenses sharply. This has made mental health coverage affordable and available for larger numbers of patients in and out of the workforce. Although mental health under managed care is not what psychiatry and the pharmaceutical industry want to see, they will be pragmatic if nothing else, opting for what works and for a fraction of the price.
By Fred A. Baughman, Jr., M.D. Dr. Baughman, a pediatric neurologist in La Mesa, Calif., is medical advisor for the National Right to Read Foundation and a Fellow of the American Academy of Neurology.
Baughman Jr., Fred, The future of mental health: Radical changes ahead, Vol. 125, USA Today Magazine, 03-01-1997, pp 60.
Copyright 1997 by
Society for the Advancement of Education.
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