Mental Health System 'Close to Fracture'

In the wake of healthcare reform, Mark Newton, CEO of Swedish Covenant Hospital, in Chicago, IL, points out in HealthLeaders Media's June intelligence report, Better Care and the Bottom Line, that the country's mental health delivery system is "close to fracture."

For the American public, the January 8 shooting of Rep. Gabrielle Giffords, (D-AZ) and the killing of six people at a Safeway supermarket in Phoenix, where she was meeting constituents, focused attention on the mental health system in Arizona and elsewhere in the states. Her alleged shooter, a 22-year-old college dropout, was declared by a federal judge incompetent to stand trial. Mental health experts say he suffers from schizophrenia.

Community-based mental health service providers are reducing services, and relying more on hospitals to provide psychiatric care. The National Alliance of Mental Illness (NAMI) notes in a statement that economic conditions in the U.S. have "dramatically impacted an already inadequate public mental health system." From 2009 to 2011, "massive cuts" to non-Medicaid state mental health spending totaled nearly $1.6 billion, with deeper cuts anticipated through next year, which also impacts community and hospital-based psychiatric care and patient access to medication, according to NAMI.

Newton says dealing with mental health is among the "deeper, more fundamental issues" at play for healthcare leaders as they address other issues, such as accountable care organizations, physician integration, and overall planning for healthcare facilities.

 "We see a lot of mental health issues involved with patients coming through the emergency rooms, and then there are co-existing conditions as well," Newton told me. "I actually think that mental health is underplayed."

Adding to the debate, a study reported in Health Affairs shows that mentally ill people may face "barriers" to receiving elective surgical procedures as a result of societal stigma and the cognitive, behavioral and interpersonal deficits associated with mental illness. Some of those barriers include the attitudes of the treating physicians, Yue Li, an assistant professor in the Department of Internal Medicine at the University of Iowa in Iowa City told me the other day.

Those disparities, he says, could be linked to communication difficulties as well as negative attitudes on the part of the physicians. So when medical issues revolve around people with mental illness who have physical conditions, patients can be shortchanged in the process. Li and his colleagues write in Health Affairs that mentally ill people are up to 70% less likely than others to receive high cost surgeries like hip and joint replacements, pacemakers, and other organ transplants, which often require referrals from physicians

As a result, Li says these patients are at a "heightened risk" for developing medical morbidities such as coronary heart disease, compared to other patients. In addition, mentally ill patients may have poorer outcomes following treatment of their medical conditions.

As Li sees it, the mental issues often conflict with the physical issues, and sometimes physicians have trouble ensuring that the mental aspect of care is fully covered.

The actual "presence of mental and behavioral abnormalities could complicate the physicians' referring decisions by distracting attention away" from the physical issues, Li writes. And that has a snowball effect, leading to a "negative attitude on the part of the referring physician," he says.

Patients afflicted with mental illness also may have their communication efforts thwarted, in part, by their mental condition. "Mentally ill patients may be less able than others to communicate proactively with the physicians," Li and his colleagues wrote. "Accordingly, they may be less able to assert their preferences for more aggressive surgical treatment when they do wish to go that route. Taken together, these factors could place patients with coexisting mental illnesses at a disadvantage when their doctors are deciding what type of treatment to recommend."

Such conditions, as Li notes in the study, have an impact on healthcare systems, related to longer length of stays, worse post-operative outcomes and more frequent 30-day readmissions, as well as higher risk of short and long term mortality, all issues that healthcare reform is trying to address. Among the mental health diagnoses includes schizophrenia, other psychosis, major depression, bipolar disorder, substance abuse and post-traumatic stress disorder.

As the aging population continues to grow, the number of older people with psychiatric and substance abuse disorders is projected to double in the next decade. Mental illness is prevalent among the Medicare population. About 26% of Americans aged 65 or older have a major psychiatric condition such as depression or anxiety and more than 1.7 million have an active substance abuse disorder.

Li notes that other studies have shown that mentally patients with coronary heart disease may also face barriers in receiving diagnostic catherization and revascularization procedures.

"Physicians in general practice have to pay increased attention to mental health issues," says Li.

Hospital systems, as well as physicians, also must address the evolving economics in mental healthcare. As an example, the Stormont-Vail West Hospital, in Topeka, KS, recently began to try to fill the void created by the closure of two psychiatric hospitals in the area. "When I think about the future of psychiatric care, I'm worried because of the budget cuts to community mental health centers," Julie DeJean, administrative director for behavioral health services at Stormont-Val Health Care, told the Topeka Capital Journal. "We could end up taking care of patients who don't have services anywhere else."

Some hospital systems are taking steps to improve psychiatric care within their buildings. The Mineral Area Regional Behavioral Health Center in Farmington, MO, has initiated a geriatric unit and adult unit under a new behavioral health center for improved psychiatric treatment in the community.

Co-existing conditions wrapped around mental health issues of patients are among the crucial problems healthcare systems face as they embark on healthcare reform, according to Newton.

 "I don't think (mental health)" is on the healthcare radar across much of the country, says Newton. "It's a perplexing issue. It is something difficult to diagnose, a little amorphous. When someone has diabetes, you look at the glucose levels. There is no quantitative assessment for mental health."

"I just think people tend to forget that mental health conditions are often co-existent with other problems, and the country's healthcare system does not easily accommodate the treatment of mental illness," Newton says.