January 2007 | Back to Table of Contents

Editor's Note

A Broken System

He had clearly changed. Previously well-groomed, his hair now sprouted at all angles, and his chin was covered with a three-day growth. Once athletic and spry, he now removed his coat with the glacial deliberation of a man 20 years his senior. The formerly facile mind now took painful seconds to answer even the simplest question. Weeks before, his successful life had started to unravel after an injury made pursuing his work and avocations impossible.
Disappointment led to despondency. He had first come to me complaining that insomnia, difficulty concentrating, and procrastination were interfering with his family and professional relationships. The antidepressant and sedative I had prescribed were too late to stem the downward spiral, and now I could see in his wife’s eyes that he had moved to a different level of depression.

I called a psychiatrist and found no appointments available for a week. I increased the dosage of his antidepressant and changed his sedative. Two days later, I got a call from a triage nurse at a local emergency room reporting that my patient’s wife had brought him in and that they had kept him overnight and were sending him home with plans for outpatient care. A day after that, I learned that he had been admitted to a closed psychiatric ward at another hospital—not eating, not talking, essentially vegetative. He started a course of ECT a few days after his admission.

Short on psychiatrists, psychiatric beds, and money to pay for either, Minnesota’s mental health system failed my patient, who had to fish for days to find appropriate care. Like states all over the country, Minnesota has a broken system. Routinely, patients referred to a psychiatrist encounter months-long waits or discover that psychiatrists have opted out of the insurance system and are taking cash only. As my patient discovered, hospitals have employed behavioral health triage organizations to screen possible psychiatric admissions with the goal of selecting only those patients who truly need inpatient care. In some instances, a psychiatric triage nurse will override an ER physician’s decision to admit. The delivery of mental health services is a microcosm of medicine, giving us a picture of what rationing can look like when financial considerations constantly hover over medical decisions.

For payers and hospitals, mental health has long been the “bad boy” of medicine. Since the early days of managed care, psychiatry’s long hospital stays and disabled patients with seemingly insolvable problems have sent insurance companies scurrying to find schemes to limit their liability. Physicians Health Plan (PHP), the forerunner of Medica, almost perished in its early years because of costs largely driven by mental health expenditures. To staunch the hemorrhaging, PHP created the first of many “carve-outs,” organizations with employed mental health professionals dedicated to delivering “cost-effective” mental health care. Referring physicians had to channel their patients through this organization, shunning the larger psychiatric community.

Today, psychiatry seems poised to enter a new age of understanding and treating mental illness. Untangling the human genome is leading to discoveries about the genetic basis for one’s response to psychiatric medications. Older, established therapies such as ECT and cognitive-behavioral therapy are being fine-tuned. It will be tragic if we fail to find ways to fund and deliver tomorrow’s advances in psychiatry to patients.

Regardless of breakthroughs, mental illness will never be easy. Schizophrenia and depression will never be the slam-dunk therapeutic triumph of a pneumonia or a strep throat. But the humans who suffer will always be our charge, and we need to treat them with compassion and in time.

Charles R. Meyer, M.D., editor in chief
Dr. Meyer can be reached at cmeyer1@fairview.org