Medscape Interview: Repairing the Mental Health System

Medscape: It seems like every week we hear about another psychiatric hospital or unit closing its doors, or another state cutting mental health care funding. Can each of you comment on the worsening lack of psychiatric resources in the United States and the impact that this worrisome trend might have?

Dr. Weisler: If you do an online search, you’ll find article after article from small towns to big cities — and also at the state level — about the impact of all of the recent closures. Chicago’s Tinley Park Mental Health Center closed this past summer while Cedars-Sinai in Los Angeles closed its psychiatry department. Also this past summer, in North Carolina, the final patients left the storied Dorothea Dix Hospital. This is happening around the country, leading to a shortage in psychiatric services. There is also a severe shortage of mental health providers in the United States, and it’s getting worse. This is in part because half of US psychiatrists are over age 55 years, and not as many new people are entering the field as are needed. There is also a shortage in researchers.

Dr. Nasrallah: In the ’60s and ’70s, the National Institute of Mental Health provided additional residency stipends prompting many medical students to enter the field of psychiatry. Now there is a bottleneck due to inadequately funded residency positions. There are also a lot of very good international medical graduates out there desperately trying to get into psychiatric residency programs. But for various reasons, many of them are being turned down. If there were more slots available, I think they would be filled. We can train 50% more psychiatrists a year than what we are currently producing, which is roughly 1200 psychiatrists a year, which barely keeps up with the attrition on the other end with retirement and mortality.

Dr. Parks: I don’t think we do well at the local level because we tend to separate ourselves — the “mental health group” — and don’t join and assist others, such as primary care providers or even the police, with their issues. All we do is ask for help with our needs and our problems — it’s not an effective approach to partner with somebody like that. If you want a partner, you go and find out what their needs and problems are, take care of them, and then you ask for something for yourself.

Dr. Weisler: That’s an excellent thought, Joe. It should be easy for us to find partners. For example, and I’ve done this recently, one contact to make is with your local emergency department (ED) providers and administrators. The EDs are frequently filled with psychiatric patients waiting for beds. It’s even worse than when we talked about it a couple of years ago here on Medscape. They’ll wait for days and sometimes for weeks. There’s usually a huge waiting list, and there are also what they call “no admit” lists. If a patient is aggressive, it often feels like nobody really wants and/or feels that they have the staff to care for them. If you have a demented patient with psychosis, it’s also much harder to find a bed, especially if they are agitated. Remember, we have no US Food and Drug Administration (FDA)-approved treatments for psychosis or agitation in dementia, yet the numbers of patients who will require such treatment are rapidly increasing as our population ages.

by Bret Stetka, MD, Richard H. Weisler, MD, Joseph J. Parks, MD, Henry A. Nasrallah, MD

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