Appelbaum Urges Psychiatrists To Be Part of Solution
Paul Appelbaum, M.D.: “Enlightened self-interest alone would suggest that this country should be investing a much greater proportion of its health care dollars in psychiatric care.”
“The inevitable result of this situation, as I demonstrated for you starkly one year ago, is a critical inability of patients to access needed psychiatric care,” said Appelbaum, referring to the speech that he had presented at last year’s Opening Session (Psychiatric News, June 21, 2002).
Not one to stop at cursing the darkness, Appelbaum told the audience about a major step he had recently taken to address the crisis: the appointment of a task force, led by APA Vice President Steven Sharfstein, M.D., to develop a vision statement for the U.S. mental health system. The statement was approved by the Board of Trustees and disseminated in April.
“Members of the media and government decision makers have already told me how useful they have found this document,” said Appelbaum, chair of the psychiatry department at the University of Massachusetts Medical School and director of its law and psychiatry program. “The document creates a set of benchmarks against which progress toward meaningful mental health system reform can be measured.”
Outgoing APA President Paul Appelbaum, M.D., presents APA’s new president, Marcia Goin, M.D., with one of the tools she’ll need to preside over meetings of the Board of Trustees. At left is Appelbaum’s daughter, Avigail.
Underpinning the task force’s vision, he said, is the following statement: “Every American with significant psychiatric symptoms should have access to an expert evaluation leading to accurate and comprehensive diagnosis that results in an individualized treatment plan that is delivered at the right time and place, in the right amount, and with appropriate supports such as adequate housing, rehabilitation, and case management when needed. Care should be based on continuous healing relationships and engagement with the whole person rather than a narrow, symptom-focused perspective. Timely access to care and continuity of care remain today cornerstones for quality, even as a continuum of services is built that encourages maximum independence and quality of life for psychiatric patients.”
Appelbaum shared his own thoughts about the structure of a system capable of achieving these goals.
“For most people with mental disorders,” he said to an audience of about 1,500 people in the Moscone Center, “care is best delivered in the context of the general health system.”
Many patients, he pointed out, already receive treatment for mental disorders from their primary care physicians. Moreover, demand for mental health services continues to be high, and “meeting this demand requires more access to medical expertise than psychiatrists themselves can provide,” he said.
Recognizing that primary care physicians may not be up to the task, however, Appelbaum said that they will need additional training and should have access to psychiatric expertise for consultations, preferably on site.
“Collaborative management of psychiatric disorders is the cornerstone of an effective, primary care–based system. Far from excluding psychiatrists from the treatment of most patients, it will tap their knowledge and skills to a much greater extent than is possible today. And no discipline without medical training can possibly substitute for the needed medical expertise,” Appelbaum said to loud applause.
For this collaboration to be successful, he continued, changes in reimbursement practices must be made as well. Because psychiatric treatment is often carved out from general care, primary care physicians often cannot get reimbursed for treating psychiatric problems. And most insurers do not pay for consults on patients whom a psychiatrist has not examined directly, he pointed out.
The success of this proposed system also requires that every person have health insurance and that coverage include treatment of psychiatric disorders on a nondiscriminatory basis.
Additional consideration must be made for people with severe and persistent mental illness. “They may require care management, social reintegration, employment training, assistance with housing, and other services that cannot be supplied in a primary care setting. In this extremely vulnerable group of patients, the most logical locus of care is a revitalized community mental health center network,” said Appelbaum, again to applause. “This CMHC network should be complemented by an adequate number of beds for acute and longer-term hospitalization.”
But how can the American public and political leaders be persuaded to fund such proposals? “Enlightened self-interest alone would suggest that this country should be investing a much greater proportion of its health care dollars in psychiatric care,” he said. Currently, mental disorders account for 20 percent of the total burden of disease in the United States, he noted, while only 5.7 percent of all health care expenditures go to the treatment of mental illness.
Apart from the personal suffering such figures imply, there is also another consequence of untreated mental illness that political leaders need to understand: the shifting of costs to other social institutions—such as the correctional, general health care, and social welfare systems—and to the families of people with mental illness, he said.
At the start of his speech, Appelbaum gave APA members reasons to remain hopeful about overcoming the obstacles they and their profession face. He noted that APA continues to campaign for parity and fought to block budget cuts in state and federal budgets for mental health treatment. Moreover, APA helped defeat psychologist prescribing efforts in five states.
Also, he noted, APA created tools to help members remain up to date with scientific and clinical developments, including online CME and a new journal called Focus: The Journal of Lifelong Learning in Psychiatry, and posted a variety of tools on APA’s Web site to help members comply with HIPAA’s medical privacy requirements. Also while Appelbaum was at the helm, APA hired a new medical director—James H. Scully Jr., M.D.
In ending his speech, Appelbaum challenged his listeners to “muster the courage” to follow through on creating a far more effective mental health system for this country.
“When the task seems too difficult, the outcome uncertain, our efforts unappreciated or ignored, we can draw inspiration in this quest from our patients, who often struggle to overcome precisely these feelings as they make their way through life. So I leave you with the words of the Chassidic master Rav Nachman of Bratzlav, who himself suffered from recurrent, intense depressive episodes. Rav Nachman would say to his followers: ‘Kol ha’olom kulo, gesher tsar m’od—The world in its entirety is a very narrow bridge; v’haikar lo lefacheid clal—And the most important thing is to have no fear.’ ”
The document “A Vision for the Mental Health System,” is posted on APA’s Web site at www.psych.org/news_stand/visionreport040303.pdf. ▪
