Still More Concerns for Psychiatrists?

Jeffrey A. Lieberman, MD


April 04, 2012

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This is Dr. Jeffrey Lieberman from Columbia University, talking to you today for Medscape. I would like to continue a commentary on a topic that I began speaking about in my last video blog, which was titled "Cedars-Sinai Nixing Psychiatric Services -- Now What?"

In the aftermath of that video commentary, I received a number of responses from psychiatrists who first thanked me for making the commentary and, second, echoed their concern about this trend of our country abdicating its responsibility for mental healthcare and services utilizing psychiatric medicine.

I wanted to amplify my comments in the wake of these responses that I received and subsequent events that have occurred, which have increased the level of concern that psychiatrists should be feeling and need to act upon in order to call attention to this very disturbing trend in the hopes of trying to reverse it.

What we are seeing in the context of this great recession that we are experiencing, the deficits that are occurring at the state level, and the changes in healthcare delivery that financial pressures are occasioning is a retreat from the mission of mental healthcare. This is occurring at the state level because the states find themselves in fiscal deficit, and they need to cover that deficit. Many states, such as New York (where I live), have a balanced budget requirement through law. In cutting the budgets of such agencies as the Office of Mental Health, there needs to be a reduction in services provided.

In some places, this is being done in a thoughtful and least damaging way possible, but in other states, it may be done in a more wholesale and detrimental fashion. In any event, this is resulting in a reduced number of state mental health beds and services being available to treat people with mental illnesses.

At the same time, this puts more pressure on nonstate public healthcare facilities, such as private, voluntary nonprofit, or academic medical center facilities, to provide these services. They become more pressured because they don't have the opportunity to effect dispositions to state facilities. People who would have been cared for in the state facilities now have to go to these nonstate services or clinics for care, and it is placing more pressure on them.

This is happening while hospitals are increasingly concerned about what implications the healthcare reform and changes in healthcare financing (the Patient Protection and Affordable Care Act and changes in Medicaid at the state level) are going to have for them. They start looking at the various healthcare services within their hospital or health system -- which of them are breaking even, producing profits, or are in deficit -- and invariably, psychiatric services look the least financially viable. So in some cases, as we saw with Cedars-Sinai, they decide to make that tough decision and drastically cut psychiatric services.

This creates a vicious cycle where the state cuts back, putting more pressure on the nonpublic healthcare providers. The healthcare providers are also under financial pressure. They are also looking for ways to reduce their financial vulnerability, and so they cut services. All of this leaves psychiatry and patients who need psychiatric services in the lurch and out in the cold.

In Los Angeles, where this most dramatic event occurred with the closing of services at Cedars-Sinai, we now see a metropolitan area of about 10 million people that has 4 major providers, nonstate providers. There is Los Angeles County, which has closed all of its beds and now refers patients to the Martin Luther King facility several miles away. We have the Harbor-UCLA Medical Center, Olive View Medical Center, and UCLA Neuropsychiatric Institute (NPI) that provide services.

This is a city, a metropolitan area of 10 million people. My colleague in North Carolina sent me some information indicating that the usual rate of beds per population should be about 44 beds per 100,000 people. So, if you have 10 million people, what you need is 4400 beds. The total of what Martin Luther King, Harbor-UCLA, Olive View, and UCLA NPI provide is not 4400 beds. This is 1 example of the consequences of this disturbing trend.

It seems that in our country, the policies and administrative decisions that are being made are focused solely on finances and seem to be divorced from human necessity and social reality. Where are these people going to be taken care of, and how are hospitals going to be able to provide the services necessary to take care of them if these decisions and policies to reduce the scope of psychiatric services (in the wake of financial pressures) are being made?

This is self-defeating, because what is going to happen is that even though this may address fiscal pressures in the short run, it's going to prove to be far more expensive in the long run, not just in terms of human suffering and life but also in terms of actual dollars and costs. As a profession, we are troubled by this and are trying to develop a strategy to cope with this, but I think we also have a responsibility to mobilize and speak out about this problem and bring it to the attention of healthcare systems, administrators, policymakers, and government officials. You can either pay now or pay later. If we let this go too far, the damage is going to be so extreme that it is going to be much more difficult and much more expensive, and will take a longer period of time to try and restore these services.

What I am encouraging people to do is to not simply watch in silence and inactivity, but to be more open, more outspoken, and active in this. We need to be able to express these concerns to the hospital administration and government, if possible. We need to communicate this, both in writing for the professional and scientific literature and in the lay media, through op-ed pieces, letters to the editor, and any form of media that we can to make the public aware and make the officials who are in positions of responsibility aware of what the consequences are.

There is no escaping the fact that the epidemiology of mental disorders and addictions is such that upward of one quarter to maybe one third of our society is, or will be, affected by them. There is no way around the fact that services must be provided. We need to figure out how they can be provided in a way that is most efficient and cost-effective, and how they can be adequately financed.

This is something that we don't have to become overly excited about, but we do have to regard it as an extremely serious and disturbing pattern that needs to be acted upon now. I will certainly be trying to do so in my own way, and I encourage you to do so in any way that you feel is feasible for yourself and your colleagues.

That is my message for today. Thank you for listening. This is Dr. Jeffrey Lieberman from Columbia University, speaking to you for Medscape.


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