APA President Carolyn Robinowitz, M.D., rings the ceremonial bell to
signal the opening of APA's 2007 Institute on Psychiatric Services held last
month in New Orleans.
Credit: Ellen Dallager
From the flood-ravaged Gulf states to the flood of service members in need
of mental health services after returning from Afghanistan and Iraq, America's
fractured mental health system is up against profound challenges.
Speaking at APA's Institute on Psychiatric Services in still-devastated but
slowly recovering New Orleans, APA President Carolyn Robinowitz, M.D., pointed
out that the crises of the past several years have brought out the best and
the worst in the nation's mental health care system.
She noted that the institute's location was an auspicious one for its theme
this year of "Recovery: Patients, Families, Communities."
"Our location this year, determined long before Katrina, but all the
more important now, provides a special venue in which to discuss primary and
secondary interventions, resilience, and recovery for the community as well as
individuals and their families," Robinowitz said. "Other external
circumstances, such as the wars in Iraq and Afghanistan, have produced similar
special needs in providing care for returning wounded and their families. Both
have highlighted our many successes in providing care and promoting recovery
as well as the major problems that beset our health care system.
"Both the military and Department of Veterans Affairs are overwhelmed
by the number of service men and women with depression, traumatic brain
injury, and PTSD and must deal not only with limited resources but with a
culture that discourages seeking mental health care as well as with issues of
She emphasized that "reservists and National Guard members,
particularly those from rural areas, may not have access to appropriate
treatment, especially for later-appearing symptoms of PTSD, or may not be able
to access appropriate care. Further, systems may deal only with the 'indicated
patient' and not address the impact of multiple deployments on service
But she said there is a silver lining in the crisis facing returning
veterans. "The public discussion of mental health needs for our wounded
warriors and their families has served to destigmatize mental illness, just as
the disclosures by prominent politicians and entertainers did in the past
Robinowitz said that widening acceptance of the value of mental health
services—as exemplified by the advance of federal legislation granting
parity insurance coverage for mental health treatment—has been matched
by an expanded scientific understanding.
"We now have ever more intricate and complex understanding of both
brain and mind function, from the molecular and genomic to behavioral
levels," she said. "Sophisticated imaging techniques can not only
localize functions but demonstrate the impact of
therapies—psychotherapies as well as pharmacologic. There is scientific
recognition that physical health and mental health go hand in hand.... We no
longer need to feel inferior to our colleagues in other medical settings in
terms of the evidence supporting our approaches."
But she emphasized that these benefits have not been extended to large
portions of the U.S. population, as evident in the staggering numbers of
mentally ill people in the nation's jails and prisons and in the chronic
underfunding of community mental health services.
And she referenced a study released this year by the American Psychiatric
Institute for Research and Education documenting the dramatic
impact—measured in emergency department visits, homelessness, and
recurrence of disease in previously stable patients—of the transition to
the Part D Medicare prescription drug program for dually eligible mentally ill
patients who used to get their drug coverage under Medicaid (Psychiatric
News, May 18, July 20).
Robinowitz also drew attention to a study appearing in the September
American Journal of Psychiatry documenting a dramatic increase in
youth and adolescent suicide coinciding with a sharp reduction in
antidepressant prescribing in the period following the FDA's public health
advisory and "black-box" warning regarding antidepressant use and
suicide (Psychiatric News, October 5).
She emphasized the critical importance of advocacy efforts in meeting the
challenges facing the mental health system at the federal and state levels,
with the business community, and in partnership with other advocacy groups.
She challenged APA members at the institute to question whether they were
doing enough to improve the system.
"We believe we are part of the solution, but are we also contributors
to these problems?" she asked. "How often, loudly, and effectively
do we advocate for our patients? We are busy caring for them, but in this
world, that is insufficient. We are the only ones who can integrate the needs
of patients and our care systems. We are the only people who can provide
access to care, assess the care, and ensure quality, integrating biological,
psychological, and social factors. So we have an intellectual as well as moral
authority to commit to our core professional values and protect our patients
without being paternalistic or maternalistic." ▪