Understanding the Behavioral Healthcare Crisis

The Promise of Integrated Care and Diagnostic Reform

Nicholas A. Cummings, William T. O'Donohue, Nicholas A. Cummings, William T. O'Donohue

• Publisher: Routledge
• Year: 2012
• eBook ISBN: 9781136805844
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Understanding the Behavioral Healthcare Crisis is a necessary book, edited and contributed to by a great variety of authors from academia, government, and industry. The book takes a bold look at what reforms are needed in healthcare and provides specific recommendations. Some of the serious concerns about the healthcare system that Cummings, O'Donohue, and their contributors address include access problems, safety problems, costs problems, the uninsured, and problems with efficacy. When students, practitioners, researchers, and policy makers finish reading this book they will have not just a greater idea of what problems still exist in healthcare, but, more importantly, a clearer idea of how to tackle them and provide much-needed reform.

One

Where We are, How We Got there, and Where We Need to Go

The Promise of Integrated Care

Nicholas A. Cummings and William T. O’Donohue

Introduction

This is the era of health reform, stemming from a growing consensus that our broken system cannot be sustained. The percent of the overall budget for mental health has steadily declined in the past decade, and when one deducts the expenditures for psychotropic medications, all behavior care services comprise but 1.5% of the total national health budget (see Chapter 3 in this volume). The American Psychological Association, which is usually reticent about the dismal statistic on psychotherapy, was unusually candid in a recent article by its president. In the past decade, when healthcare went from 7% to almost 16% of the gross domestic product, mental healthcare remained static at 1% even though the number of people receiving services has increased dramatically, according to Goodheart (2010). She goes on to state that, in 2006, 51% of mental health spending was for prescription drugs, 16% went to hospitalization, and the 33% remaining had to cover all other mental health services.

The recent health reform legislation (Patient Protection and Affordable Care Act, the PPACA, signed by President Obama in 2010) has recognized the importance of behavioral health as an integral part of primary care; to accomplish this, the legislation places the primary care physician in charge of behavioral health delivery (Dentzer, 2010). This reflects the urgency and the need, but while legislation can enable, it cannot deliver. It is the responsibility of behavioral health to transcend its current moribund status and thus to deliver effective, quality services.

This volume addresses the advances needed in the various areas of behavioral practice and will demonstrate how the profession can meet the challenge of twenty-first century health reform through the development of effective, evidence-based interventions. This would restore the rightful place of behavioral health, which is to be integrated into the mainstream healthcare system. In the broadest sense, this is what is proffered as integration, with the specific term “integrated behavioral/primary care” regarded as a prime specific, as delineated in Chapter 3.

An Historical Perspective of Where We are and How We Got There

In the early 1980s, the profession of psychiatry began to “remedicalize”—its own word for a process in which it was to transition from a psychotherapeutic treatment profession to one it considered akin to medicine. It abandoned psychotherapy, which it disdainfully began to call “talk therapy,” in favor of becoming what it named “biological psychiatry.” The concept intended that, by prescribing medication instead of dispensing talk therapy, it would be treating actual diseases, as did fellow physicians and that psychiatry would be more aligned with medicine than with psychologists, who had matured as a profession and were rapidly becoming the nation’s premier psychotherapists. By becoming “biological,” psychiatrists would eliminate competition from psychologists, who could not prescribe medications. The psychiatric residencies quickly fell in line and the transition was made in a remarkably short time.

As of this writing, five outcomes of this transition, affecting all mental health, have evolved:

1. It is very rare to find a psychiatrist under age 50 who performs psychotherapy.
2. Psychiatry has become an “every fifteen minute per patient pill-pushing” profession (Shorter, 2010) that has proven unattractive to medical school graduates, who shun it as a career. Consequently, there is now a severe shortage of psychiatrists.
3. As a result, 85% of all psychotropic drugs are prescribed by nonpsychiatric physicians, an inevitable outcome predicted by psychiatrist Stan Lesse 30 years ago (Lesse, 1982).
4. The vast majority of mental health simply involves the dispensing of psychotropic medications, with the portion attributable to behavioral care services continuing to shrink.
5. Masters-level psychotherapists have proliferated to where they far outnumber doctoral psychologists. They are now licensed to practice and, because their fees are somewhat less than doctoral-level providers, they now perform the vast majority of psychotherapy in America. Because psychiatrists by virtue of being physicians are in control of most mental health delivery systems, they supervise these masters-level providers in the “talk therapy” they long ago gave up and in which they are no longer experts. This is tantamount to a kiwi (a nonflier) telling pilots how to fly.

And where has psychology been all this time? In its fervent antagonism to psychiatry and in rejecting what it calls the “medical model,” it isolated itself from mainstream healthcare by creating its own separate silo. The result has been lack of access, the stigmatization of the referral for psychotherapy, and a decline in funding.

The consequences to mental health and its failure to deliver appropriate behavioral care parallel and are largely reflected in the challenges of the peculiar diagnostic system in which mental health operates.

The Advent of the DSMS

The Diagnostic and Statistical Manual of Mental Disorders, known as the DSM for short, has undergone a series of iterations in the past half century since the inception of DSM-I by the American Psychiatric Association. Known colloquially as the “psychiatric bible,” the DSM is the basis for reimbursement for services, as well as the nomenclature by which government and other agencies collect statistical data on aspects of mental and emotional illness. In spite of its seemingly universal utility, however, it has been fraught with controversy. As the DSM proceeds through it iterations, the controversy has increased steadily, now reaching a crescendo as DSM-5 is being constructed.

Few if any mental health professionals practicing today are aware of the void—perhaps better described as incredulity— that existed in diagnosis prior to the inception of the first DSM. The senior author entered independent practice in California in 1948, and, thumbing through some early diagnostic reports, he has gleaned a host of archaically colorful diagnoses that were once accepted parlance. Consider, for example, “anal retentive personality culminating in rectal cancer.” Or you can look at the one that would be resented by every woman living today: “Exaggerated female masochism, conveniently married to a sadistic husband who emotionally rewards her by becoming contrite after each occasion in which he beats her.” Often these atavistic diagnoses sought to embody causation, such as “severe Oedipus complex inevitably resulting in homosexuality and effeminate personality.” And, of course, there is the all-time favorite: “idiot, imbecile grade.”

But the now apparent absurdity of these diagnoses reflects the fact that each school of psychiatry (and even of then budding clinical psychology) used its own esoteric nomenclature. In other words, diagnoses were parochial, with each “system” disdaining all others. That this was hampering interchangeability among various practitioners soon became subordinate to the greater problems that emerged in the 1950s as government and private insurance began to reimburse for psychiatric services. (Note that reimbursement of psychiatric services preceded that for services of psychologists by a number of years, with that for social workers and counselors occurring much later.) Diagnoses were so diverse that third-party payers struggled to discern which claims were proper and deserving of reimbursement. Hence, the real impetus for DSM-I was unmistakably economic, which in time propelled the DSMs to the status of the “psychiatric bible.” As will be seen in this chapter, the economic purpose remains the dominant impetus inasmuch as the so-called diagnostic categories are collections of symptoms rather than reflective of actual disease processes such as those seen in medical diagnoses.

DSM-I: The Age of Anxiety

Published in 1952, the first Diagnostic and Statistical Manual was a relatively succinct and simple document compared to its most recent successors. In the 1950s and 1960s, when psychiatry was still under the influence of the European scientific tradition, there was a striving for reasonably accurate diagnoses, as is reflected in the DSM-I (Shorter, 2010). Furthermore, it must be remembered—although this has grown more difficult to believe in the last two decades—that psychiatry was still psychotherapeutically oriented. “Psychoneurosis” was the principal diagnosis of the day; simply put, if a patient complained of being “blue, uneasy or generally jumpy, ‘nerves’ was the common diagnosis. To the psychotherapeutically oriented psychiatrists of the day, ‘psychoneurosis’ was the equivalent of nerves” (Shorter, 2010, p. 1). There was no reason to delineate this further as both doctor and patient understood “a case of nerves.”

The DSM-I was not widely used in the 1950s, which is in stark contrast with the must-use dictum since the 1980s. It did serve as a centrifugal force, bringing order to the jumble of nomenclatures proffered by what Cummings long ago named the “psychoreligions”; its simplicity seemed to satisfy widely divergent practitioners. The notion that anxiety was central to all psychological conditions was the subject of two widely read and generally highly regarded books: Rollo May’s The Meaning of Anxiety (1950, 1977) and Hans Selye’s The Stressors of Life (1956). In coining the term “stressor,” Selye added a word universally invoked by the psychiatrists (and psychologists) of the era (Menand, 2010).

The then universal nature of anxiety fostered the fiasco of the earliest psychotropic medications. In 1955 meprobamate (brand name: Miltown) was introduced as an anxiolytic, and soon it became the largest selling drug in American history up to that time (Tone, 2009). In fact, it accounted for one third of all prescriptions written by American physicians. It is startling to recall that Miltown was soon eclipsed by two other anxiolytics, Librium and Valium, introduced in 1960 and 1963, respectively. By 1968, Valium had become the most prescribed drug in the Western world, and the stock of its manufacturer, Hoffman-La Roche, increased in 1972 to $73,000 a share (Tone, 2009).

Although these anxiolytics were marketed with FDA approval as nonaddictive, the senior author became alarmed as a legion of patients heavily addicted to them filled his practice. His early attempts to sound an alarm were dismissed by both the manufacturer and the FDA, but by 1980 the research findings were incontrovertible and the FDA issued a warning label that stated the stressors of everyday life did not warrant the use of such addictive drugs (Tone, 2009). The crash of Librium and Valium sales marked the end of the age of anxiety, but there was an overlap with the introduction of DSM-II.

DSM-II: A Freudian Document, While Personality Disorders Become Mental Illnesses

The second DSM was more complicated and it was based on the concepts put forth by Sigmund Freud and Adolph Meyer, who came to the United States from Switzerland (Menand, 2010). Thus, it was based on psychoanalytic theory and reflected Meyer’s emphasis on the importance of the patients, which led to the inclusion of a vast population that had not been regarded as patients.

Introduced in 1968 as Axis II disorders, the second DSM gave character disorders the new name of personality disorders and made them the province of psychiatric treatment. Heretofore, they had been termed “characterological” because they were regarded as enduring aspects of one’s character and impervious to treatment. Changing the designation added millions of new potential paying patients to psychiatry. This forever cluttered the field with intractable but demanding patients to the detriment of non-Axis II patients and the severely mentally ill, both of whom do not bombard the besieged system with vociferous demands for immediate attention. But this was only the beginning of the now self-serving expansion of psychiatric diagnoses into aspects of daily life’s vicissitudes.

DSM-III: The End of Psychopathology

The publication of the third iteration in 1980 brought about a sea change and destined mental health to the eventual crisis in which it now finds itself. With energetic and engaging psychiatrist Robert Spitzer at the helm, it was determined to solve the problem of reliability so that every practitioner given a set of symptoms would come out with the same diagnosis. In so doing, however, the manual did not address an even greater problem—namely, validity, which is defined as the correspondence of symptoms to organic conditions (Greenberg, 2010; Menand, 2010). In other words, rather than diseases, the end result was a set of “conditions” or “syndromes” characterized by common signs and symptoms, often loosely woven, whose existence and validity could not be proven.

Spitzer did accomplish one positive reform: He purged the DSM of the Freudian jargon that had plagued the previous editions. In so doing, however, he threw out the baby with the bathwater. Psychoanalysis at least struggled to base itself on psychopathology, but Spitzer inadvertently omitted psychopathology altogether. Consider where medicine would be without pathophysiology: exactly where it was over a century ago, dealing with conditions and syndromes instead of diseases. This is perhaps why psychiatry has paradoxically gone overboard in espousing psychopharmacology before there are any known diseases to medicate (Kirsch, 2010).

DSM-III also began the process of “diagnoses by ballot,” which would be perfected in the next iteration.

DSM-IV-TR: Our Beleaguered Present

The current manual comprises a series of controversial and arbitrary positions that have not abated but rather have increased the questionable aspects of its predecessors. It has led to a groundswell of dissatisfaction both inside and outside the profession.

The series of signs and symptoms that comprise our syndromes do not lead to behavioral interventions, but rather facilitate the prescribing of medication. For every symptom there is ostensibly a medication. Although a large inventory of psychotropic drugs exists, there are a limited number of different classes, and often the same medication is prescribed for a variety of different conditions. For example, antidepressants may be prescribed not only for depression, but also for obsessive-compulsive disorder, smoking cessation, job dissatisfaction, low libido, premature ejaculation, eating disorders, or whatever else the diverse but questionable literature might suggest. Furthermore, depression and anxiety are not diagnoses any more than a headache or fever is, as these are symptoms manifest a disease. Because the current DSM constitutes a reshuffling of the same old symptoms to describe conditions with new names, this has led critics like Menand (2010) to ask whether we may not be dealing with one yet unnamed disease (mental illness) with a variety of stages and symptoms.

The current DSM has resulted in an “age of depression” similar to the “age of anxiety” with its Miltown, Librium, and Valium in the 1960s; predictions are that we may be heading for the same train wreck with antidepressants (Greenberg, 2010; Herzberg, 2008; Kirsch, 2010). In addressing the propensity to prescribe antidepressants for the problems of daily living, Wakefield and Horwitz (2007) deplore the elimination of sadness as a normal and informative emotion in daily living. These same authors have summarized the growing body of literature revealing the relative ineffectiveness of antidepressants, especially in milder cases, along with the startling array of harmful side effects, many of them quite serious. Psychiatrist Carlat (2010) concludes flatly that psychotherapy might be more effective and less physically destructive than antidepressants, a position espoused by an ever increasing number of critics both inside and outside the profession.

Diagnosis By Consensus: Political Correctness Trumps Science

In the absence of validity and with the emphasis on reliability alone, determination of diagnoses by consensus is perhaps as good as it can get. Yet this is far from scientific validity, bringing with it flaws that expose the consensus to well-meaning biases that reflect the social and political pressures and beliefs of the time more than actual diseases that require specific medicating. To be sure, the consensus may be the result of extensive clinical experience, but the ability to diagnose a fever gives only limited knowledge. For a skilled clinician the symptoms throwing out ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Contents
• Acknowledgment
• Editors
• Contributors
• Chapter 1. Where We Are, How We Got There, and Where We Need to Go: The Promise of Integrated Care
• Chapter 2. Our 50-Minute Hour in the Nanosecond Era. The Need for a Third “E” in Behavioral Healthcare: Efficiency
• Chapter 3. The Financial Dimension of Integrated Behavioral/Primary Care
• Chapter 4. Mental Health Informatics
• Chapter 5. E-health and Telehealth
• Chapter 6. Can Prescribing Psychologists Assist in Providing More Cost-Effective, Quality Mental Healthcare?
• Chapter 7. Diagnostic System Innovations
• Chapter 8. Evidence-Based Treatment
• Chapter 9. The Quality Improvement Agenda in Behavioral Healthcare Reform: Using Science to Reduce Error
• Chapter 10. The Behavioral Health Medical Home
• Chapter 11. Reforms in Professional Education
• Chapter 12. Pay for Performance and Other Innovations in Reimbursement for Behavioral Care Services
• Chapter 13. Trends in Behavioral Healthcare for an Aging America
• Chapter 14. Failure to Serve: The Use of Medications as a First-Line Treatment and Misuse in Behavioral Interventions
• Chapter 15. Reforms in Treating Children and Families
• Chapter 16. Reforms for Ethnic Minorities and Women
• Chapter 17. Wellness and Prevention: Key Elements in the Next Generation of Behavioral Health Service Delivery Systems
• Chapter 18. Reforms in Veteran and Military Behavioral Health
• Chapter 19. Biofeedback
• Index