Fixing the Mental Health System

Monday, September 19, 2016

Rush Medical College Dean discusses Vital Directions report

By Delia O’Hara

K. Ranga Rama Krishnan, MB, ChB, the dean of Rush Medical College and senior vice president of Rush University Medical Center, was one of 100 distinguished medical leaders who wrote the 19 papers that make up the compilation Vital Directions for Health and Health Care: An Initiative of the National Academy of Medicine, which will appear in the Journal of the American Medical Association Sept. 26. The National Academy of Medicine, formerly the Institute of Medicine, is issuing the Vital Directions package as a status report on American health care so far in the 21st century.

An internationally known psychiatrist, researcher and medical educator, Krishnan worked with nine other mental health and public health specialists on the Vital Directions paper “Improving Access to Effective Care for People Who Have Mental Health and Substance Use Disorders.” Here, he discusses the paper’s implications for mental health care in the U.S.

Why is the NAM issuing its Vital Directions?

Krishnan: These papers are designed to open a dialogue, not just with the government, but with nonprofits, donors and the public. Americans are spending a great deal of money on health care, but we’re not getting back what you’d expect in health status and life expectancy. The timing has to do with the 2016 election. No matter who gets elected, they’re going to have to address these issues.

Why were you chosen to participate in this project?

I have done quite a bit of research on the importance of considering medical illness in the context of mental health issues and substance use, which often accompany it.

You have done some pioneering work in integrating psychiatry and medicine.

Yes. I’ve been part of a number of studies that explored the interplay between the two. One 2005 study showed that most individuals with bipolar disorder have at least one other psychiatric or medical condition that can exacerbate the bipolar disorder — and vice versa.

At Duke University Medical Center, where I spent 34 years in a number of different roles, my department and faculty introduced routine alcohol screens in our medical units and followed up with early intervention when necessary. This initiative reduced our lengths of stay. As chairman of psychiatry at Duke, I started and promoted an integrated medical/psychiatric hospitalist service that improved outcomes and had a big impact on length of stay. We also built a premier combined medicine/psychiatry program.

How important are mental health and substance use issues to the overall health of the country?

As my co-authors and I note in our Vital Directions paper, behavioral health is an intrinsic part of overall health. One-third of the people we will see as inpatients at Rush University Medical Center deal with psychiatric problems or substance use. Nationwide, the number is more like 18 percent in the population, and one in 12 American adults has substance use issues. We have to start looking at how to build treatment for these conditions into the medical system because they are fundamentally linked.

What’s the situation now?

Our system of care in the United States is fragmented. As my co-authors and I point out in our part of the Vital Directions package, our country at present actually has three separate systems of care — general medical, mental health and one just for substance use disorders. People have to travel around to get help with each set of issues in a separate system.

But if the medical system ignores those non-medical problems, the medical outcomes will not be good. The patients who deal with these issues stay in the hospital longer than other patients and are readmitted oftener — and their care isn’t adequately reimbursed. With our payment system moving toward rewarding outcomes, addressing this fragmentation is critical.

As we note in our paper, the U.S. spends more than $200 billion a year just on mental health in the United States, but the impact of mental health and substance use issues on the medical system cost an additional $293 billion in 2012. Patients with these issues often don’t take their treatments; they don’t take care of themselves. At the same time, deaths from overdoses of opioids are the highest they’ve ever been. Our suicide rate is at its highest level in 30 years. It’s a sad story.

The paper points to serious shortages among health care workers in these fields.

Yes, our country has a shortage of psychiatrists now, and it’s going to get worse. They’re quitting earlier than they used to for a whole range of reasons, and young doctors are not going into psychiatry.

We don’t have enough psychologists, either, or behavioral-health nurses, counselors, care managers, social workers, or substance use counselors. Many members of that workforce are poorly paid and lack the specific skills for the jobs they’re trying to do. It’s difficult to contemplate creating the system of collaborative care we need without enough of those skilled workers.

What does this situation mean for Rush?

Our communities here on the South and West Sides of Chicago are telling us that mental health and substance use are their No. 1 social problem. To an extent, this speaks to the disparity of services available in different parts of the Chicago area. And here, those issues may include drugs, suicide, homicide — all of that.

We have to embark on a program that will allow us, when we see someone come into our medical health setting, to take care of the whole person. You can’t treat one problem and not the other, and expect to have good outcomes.

Are there solutions to these problems?

Yes. We know what to do. We simply haven’t been doing it. We need to have a strategic plan for integrating care for mental health issues and substance use into the medical system. We need to step up our training of these crucial mental health workers, and take advantage of the ideas, technology and other innovations that have been developed all over the world.

We talk about some of those in our paper, like the MoodGYM program developed in Australia. It’s an interactive, web-based therapy for depression that can help people who don’t have face-to-face access to mental health professionals.

The public thinks our health care system is good, but look at the data. Look at the enormity of the expenditure! We spend 18 cents of every dollar on health care — far more than any other country. Yet our system ranks 11th, dead last, among wealthier countries.

We’re not getting value for our money. The fragmentation of medicine, mental health and substance-use treatment is a big factor. We need to get a strategy to get these systems integrated. We need more effective care.