Healing the Broken Places

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Broken. Grossly underfunded. In crisis. That’s how psychiatric and behavioral health specialists describe the current state of mental health care in the United States. The problems that plague the health care system in general—workforce shortages, barriers to access, and inadequate reimbursement—are only exacerbated in mental health.

“Mental illness isn’t glamorous,” says Don St. John, MA, PA-C, who practices in adult outpatient psychiatry at the University of Iowa Behavioral Health in Iowa City. Taking an example from the academic medical center setting, he adds, “It’s nice to have the cardiac surgery wing dedicated to or named after your family—but nobody wants a mental health wing named after them.”

Stigma is perhaps the greatest challenge with this patient population. “Until this country really embraces the notion that mental health is inherent in every aspect of a person’s general health,” says Gail W. Stuart, PhD, APRN, FAAN, Professor and Dean of the College of Nursing at Medical University of South Carolina, Charleston, “I think the stigma issue is going to continue to make it difficult to overcome these problems.”

From Hospitals to Jails
The current state of mental health care in the US is perhaps a direct result of the deinstitutionalization that occurred in the 1980s. By that time, most mental health hospitals were overcrowded, and in the worst cases, patients were subject to neglect and even abuse. (Recall, if you can, Geraldo Rivera skulking through the dark at Willowbrook State School in Staten Island, NY; his 1972 exposé brought the issue to the forefront.)

Following the public outcry over the treatment of these patients who—mental illness or not—were people, there was a movement to reduce the number of long-term hospitalizations for mental illness. Along the way, the number of hospital beds available for mentally ill patients also declined, as freestanding hospitals and private facilities closed. What have these patients been left with?

“The thought was that people would be maintained in the community—there would be community support services, halfway houses, boarding homes, community-based programs,” says Catherine R. Judd, MS, PA-C, President of the Association of Psychiatric PAs, who works in the Department of Psychiatry at the University of Texas Southwestern Medical Center, Dallas. “The idea is good, but unfortunately, most of those programs have really not materialized to the extent or with the capacity to take care of the people who are out there.”

Without these services—and with an overtaxed health care system in general—many patients with mental illness find themselves adrift. And, eventually, incarcerated. An estimate from the US Department of Justice indicates that 24% of state and 21% of local prisoners have a recent history of mental illness. The largest psychiatric hospital in the country is the Los Angeles County Jail.

The problem is so widespread and so serious that both Judd and Jeanne Clement, EdD, APRN, BC, FAAN, President of the American Psychiatric Nurses Association (APNA), describe it in identical terms: “The jails and prisons have become the de facto mental health system.”

“More and more mentally ill people are in the streets, not receiving services, not taking medication as prescribed, with less-than-optimal case management in the community,” says Judd, who also works with the chronic mentally ill at the Dallas County Jail. “So, they are picked up on substance abuse–related charges or criminal trespassing or burglary. Consequently, they’re brought to jail.”

In Dallas, a divert court has been established, with the aim of getting chronic, persistent mentally ill patients “back to clinics and back on medication as quickly as possible without incarcerating them,” Judd notes. For such a program to succeed, of course, you need clinics—and providers—to divert these patients to.

Problems of Access
Talk with clinicians who work in psychiatry, mental health, or behavioral health settings, and you’ll hear a familiar litany of problems. For one thing, there is the shortage of providers. “Here in Iowa, we’ve got areas where we have one psychiatrist covering five counties,” St. John says. “It’s almost impossible to get in with someone, and then when you do, it’s a five- or 10-minute appointment, because they’re just so busy.”

The number of clinicians choosing psychiatry—particularly psychiatric nursing—has declined significantly, perhaps due to insufficient funding for educational programs. “The highest number we had going into psychiatric nursing was when the National Institute of Mental Health, which was then separate from the NIH, had training grants,” explains Clement, who is the Director of the Graduate Specialty Program in Psychiatric–Mental Health Nursing at Ohio State University, Columbus. “And many of us who had those training grants are getting way past retirement age!”


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