2. We need to stop dichotomizing people as being mentally ill or not. The “us” versus “them” mentality and the idea that there are specific chronically mentally ill folks who are somehow different from the rest of humanity is not helpful. Yes, there are people who cycle in and out of institutions and whose symptoms are resistant to treatments, but some very sick people end up becoming very well and very successful. Sometimes they get better because of the treatment they receive, and once in a while, their improvement is tied to a spontaneous remission. Part of being human is going through rough spots where many people don’t adapt perfectly and don’t behave well during crises. The problem with reallocating resources to the sickest of the sick – those who don’t know they are ill – with a “treatment before tragedy” approach, is that it advocates forcing people who will never hurt anyone into care and pulls resources away from those whose illnesses are somehow dismissed as “the worried well,” who misuse services they don’t really need. People with less obviously severe, debilitating, and retractable illnesses can prove to be very disturbed and very tormented: a teenager who is heartbroken by a breakup and unexpectedly dies of suicide is no less deserving of care than a psychotic individual on his fourth admission. And a graduate student with no history of hospitalization or violence may well be the one to unexpectedly massacre a theater full of moviegoers. We need to offer help to those who ask for it and not suggest rationing our care to the sickest mentally ill, as though there were an obvious line in the sand. This dichotomy does not bear out clinically.
3. We need new and better treatments with fewer side effects and greater efficacy that target the truly disabling symptoms of low motivation, executive dysfunction, and deterioration of social interactions. Only with tolerable and effective treatments will we truly eradicate stigma. As long as we see that the effects of untreated or inadequately treated psychiatric symptoms lead people to frankly embarrassing behaviors, stigma will exist in a way that colorful billboards cannot counter.
4. Since our resources are precious and overextended, we need to eliminate red tape for psychiatrists (and all physicians) that does not lead to improved patient care. Maintenance of certification exams that are not relevant to what the physician sees, time spent catering to clicks on required screens of electronic health records, time spent justifying obviously needed treatment, preauthorization requests for inexpensive medications, meaningful use, clinical notes catering to insurer requirements that do not encourage better treatment, PQRS and MACRA (whatever they may be!) are diversions of physician time. They lead to burnout, job dissatisfaction, and early retirement, and they worsen the shortage of psychiatrists – all while decreasing the number of patients any individual doctor can see. At this point, we are asking our physicians to both treat their patients and to serve as government data collectors, and this is simply too much.
5. Any conversation of noncompliance by people with mental disorders moves quickly to the realm of forced care. Patients who have no insight into their illness are presumed to be unwilling to take medications, and psychiatry has become a series of 15-minute medication checks, where time can’t be devoted to understanding the patient and his hesitations to taking medications. Often, if the patient feels understood and has a sense of trust in the clinician, this noncompliance can be overcome. We need to understand our patients and work with them – and sometimes admit that our treatments just don’t work for everyone – with the hopes of making them more comfortable. Obviously, in emergency situations or when someone is violent, there may be no choice but to use force, but that needs to be a true last resort. It is a disgrace that our current system goes so quickly to talk of involuntary treatment when there are so many people in this country eager to accept voluntary care, and it is so difficult to access.
There you have it, my five bullet points of the most important issues in psychiatry. To those who contributed, both named and unnamed, thank you.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” forthcoming from Johns Hopkins University Press in fall 2016.