Book Review: Breakdown: A Clinician's Experience in a Broken System of Emergency Psychiatry by Lynn Nanos

This impressive book goes into detail concerning the horrifying deterioration in the psychiatric care of the Severely and Persistently Mentally Ill (SPMI’s - primarily people with schizophrenia) in the United States that I have personally witnessed since I was a resident in psychiatry in the late 1970’s in California.

By the time I had started my residency, the passage in California of the Lanterman Petris Short (LPS) Act in 1972 - followed by the passage of similar laws in many other states - had for the most part cleared up a lot of the abuses in the state hospital system that anti-psychiatry groups still go on and on about as if they were still common. It insured that the cases of patients who had been hospitalized involuntarily would be reviewed by the courts within 17 days or sooner. Psychiatrists in the system could no longer just let patients languish in the hospital forever by merely following what a previous doctor had said without doing their own personal evaluation, or avoid closely following the patients’ condition to see if there were any changes.

No longer would patients linger in hospitals for years because of a misdiagnosis. For example, patients with the very treatable bipolar disorder (in which psychotic episodes are often relatively short-lived) had often been diagnosed with the far less treatable schizophrenia (especially if they were African American) Occasionally someone had been hospitalized for decades because unscrupulous relatives conspired to steal their money by labeling them with a mental illness with the help of a gullible or greedy psychiatrist.

After the laws mandating court review were in place,  people who were hospitalized back then often agreed to stay much longer than 17 days -  because their paranoid delusions and hallucinations had been somewhat controlled with anti-psychotic meds. Up until then they had anosognosia - the lack of awareness that anything might be wrong with them. After they became less delusional, they began to understand that they needed treatment.

Psych meds often take two to three weeks just to kick in, or need to be changed to something else after that period of time because one agent was ineffective while another might not be - which in a sense would restart the whole clock - so often they had to remain hospitalized for several weeks. 

This time frame also allowed psychiatrists in training to see first hand the course of major psychiatric illnesses and monitor longer term responses to it. It also allowed doctors time to make a better determination about whether the patient’s primary issue was drug abuse rather than some other chronic mental illness, and refer drug abusers to appropriate rehab treatment.

Committed psychotic patients at that time could be forced to take anti-psychotic meds even if they refused prior to their court review. That has since changed in most jurisdictions. I cannot for the life of me see the point of committing a patient involuntarily  if the doctors cannot then treat them.

Even though the state hospitals were beginning to discharge their long-term patients under the justification that the meds would allow for effective outpatient treatment, hospital stays were long enough to allow ward social workers to arrange for placement in board and care type living situations, get the patients enrolled in Social Security Disability (SSI) to pay for it, and make follow-up appointments in community mental health centers so that patients could continue to receive their medications. Community mental health centers were also far more numerous and available for this purpose than they are today.

The LPS criteria for hospitalizing someone against their will were very reasonable: mentally ill and a danger to self, a danger to others, or gravely disabled. The latter meant that due to their mental illness they were unable to provide for their own food, clothing, and shelter. A cardboard box on a street did not qualify as the ability to provide for their own shelter as it seems to today. 

A “danger to self” did not just mean suicidal, also as it seems to today; it could refer to dangers to self due to delusions and poor judgment, such as walking naked into someone’s house who might mistake them for a burglar and shoot them. Sometimes doctors considering a “603” 72-hour commitment holds had to pump relatives for information they could use to justify that. I recall one patient’s family finally tell me, after I asked many follow-up questions, that the patient had tried to get out of a moving car.

The author of Breakdown, Lynn Nanos, is a social worker who works for a psychiatric emergency services team, and has seen and documented the monstrous changes in the previously described public mental health treatment of chronically ill SPMI’s. She provides sad, disturbing, and hair-raising case studies of suicides and murders of both family members and strangers due to the premature discharge of dangerous, delusional patients who did not think they were ill and refused treatment.

Due to the mutual biases of the so-called patients’ rights advocates on the left of the political spectrum, and tax-phobic politicians and government agencies on the right of the political spectrum, hospital stays have been whittled down to just a few days, so that anosognostic patients are either not  referred for psychiatric follow-up at all, or do not show up even if they had been. Many are discharged with no prescription medication to take after they leave.

Nanos makes the case that the commonly-heard idea that chronic psychiatric patients are less likely to commit violence than others is highly misleading. It ignores the significant minority of mentally ill folks who do have violent propensities – and who are often more dangerous than others -  when their violent episodes could have been stopped if they had received proper medication. Not to mention that the violence-prone mentally ill are highly unlikely to participate in the epidemiological studies that are the basis of the misleading argument. Dead family members have lost all of their rights. Many suicides of those who are “dying with their rights on” could also likely have been prevented.

Many of these patients now end up in jail. The patients’ “rights” warriors never seem to inquire as to why this might be the case. Could it be that such patients don’t realize they are mentally ill and are responding to command hallucinations to assault others, or are committing nuisance crimes like disturbing the peace or trespassing because they do not know any better? Even when they kill someone, the not-guilty-by-reason-of-insanity defense seldom succeeds (particularly after John Hinckley tried to kill President Reagan, who himself did not appear to think mental illness was real when his administration attempted in the early 1980’s to kick all the chronic schizophrenics off SSI until the courts stepped in), and they of course are sent to jail rather than to a hospital.

According to the author, private hospitals often tend to favor hospitalizing malingerers who fake mental illness in order to have a place to stay and receive food, over the more highly disturbed and potentially violent SPMI’s who really need the beds. This, along with drastic decreases in the number of available beds, has led to a situation in which patients are stuck in hospital emergency rooms  - manned by staff that are ill-equipped to handle them - for days at a time until a bed is finally found or until they are in frustration discharged by the facility to the streets. There are also financial incentives to treat “easier” patients due to the fact that they have shorter hospital stays and hospitals are financially incentivized to keep stays short.

Government agencies often listen to “peer support groups” comprised of individuals who think the signs and symptoms of schizophrenia and other psychoses are just some variant of normal.

Nanos makes a good case for assisted outpatient programs (AOTs), which help patients stay with treatment despite not being forced to take their medication. Mental health professionals attempt to persuade the recipients to adhere to their prescribed medications and attend their clinical outpatient appointments with psychotherapists, psychiatrists, and case managers. All AOT involves intensive case management services and comprehensive supervision.

In court-ordered AOT, judges order seriously mentally ill patients to adhere to their outpatient regimens. AOT’s seem to be even more effective when judges are involved, probably due to what the author refers to as “black robe syndrome.”

Several studies indicate that AOT’s, particular those that last 180 days, significantly reduce violence, readmissions to hospitals, no-shows at outpatient appointments, arrests, jail time, self-harm, suicide attempts and substance abuse, while significantly improving the self care of SPMI patients. Nonetheless, even AOT’s are opposed by various special interests. In Massachusetts, its opponents even include the National Alliance for the Mentally Ill, which is supposed to be advocating for these patients.

Unfortunately, these patients are downright lousy at advocating for themselves, so it’s going to take a lot of other people speaking up before things go back to the far more functional way they were just a few decades ago.

Private Insurance Circumvents the Mental Health Parity Treatment Act

The Mental Health Parity and Addiction Equity Act of 2008 is a federal law that generally was supposed to prevent group health plans and health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable benefit limitations on such treatment than on other medical or surgical treatments. So far, it hasn’t come close to accomplishing its goal, although a recent court decision may possibly change that.

Supposedly, if a group health plan or health insurance coverage includes medical and surgical benefits and mental health benefits, the financial requirements (such as deductibles and co-payments) and treatment limitations (such as number of visits or days of coverage) that apply to the mental health must be no more restrictive than those that apply to the medical/surgical benefits.

However, insurers were easily able to "circumvent" the consumer protections intended in the legislation by imposing maximum numbers of doctor visits and/or caps on the number of days an insurer would cover for inpatient psychiatric hospitalizations. They played with the definition of “medical necessity” in psychiatry.

Insurance companies often make doctors and hospitals jump through hoops to even obtain a decision by the insurance company that their proposed treatment is “medically necessary.” For inpatient treatment, managed care companies adopted what amounts to a  code word: dangerousness. If a patient is not specifically and imminently homicidal or suicidal, the insurance company would mandate that  the patients be thrown out of the hospital and onto the street. Science and the best interest of the patients were really non-factors in this decision, which were basically based solely on greed and profiteering.

Suicide rates for patients soon after discharge from a psychiatric inpatient facility are much higher than suicide rates in the general population. This problem has gone up significantly in recent years due to patients having many fewer days in the hospital than they used to.

Yet another trick was companies deciding which psychiatric conditions were severe enough to warrant hospitalization, and which ones were not, irregardless of the severity of a patient’s symptoms and functional capacity. For example, doctors in a hospital near where I work appeared to have been pressured by the facility to make diagnoses that were more likely to be covered by insurance even if their patients did not meet criteria for those disorders. The result was that the patients were often put on medications that were ineffective, not indicated, and/or potentially toxic.

Within my own patient population of people with borderline personality disorder, “bipolar disorder” was the go-to option.

In the recent court decision mentioned above, on February 28, 2019 the US District Court for the Northern District of California found that United Behavioral Health (UBH), the country’s largest managed behavioral health care organization, illegally denied coverage for mental and substance use disorders based on flawed medical necessity criteria (David Wit, et. al. v. United Behavioral Health).

UBH was noted to have internally developed medical necessity guidelines that comprehensively fell short of accepted standards of care to deny outpatient, intensive outpatient, and residential treatment to UBH beneficiaries. They only paid for the alleviation of a patient’s acute symptoms, but not of any underlying condition – particularly chronic conditions.

The court said that the fact that a lower level of care is less restrictive or intensive does not justify selecting that level if it is also expected to be less effective. Placement in a less restrictive environment is appropriate only if it is likely to be safe and just as effective as treatment at a higher level of care in addressing a patient’s overall condition, including underlying and co-occurring conditions.

Effective treatment of mental disorders includes services needed to maintain functioning or prevent deterioration. Appropriate duration of such treatment should be based on the individual needs of the patient and not on some arbitrary guidelines regarding the duration of treatment for a given disorder.

Even though the plaintiffs in Wit v. UBH were enrolled in plans that are exempt from the federal parity law, the court recognized that mental disorders are chronic illnesses and rejected the insurers’ practice of treating only the acute symptoms. This may establish a precedent for plans covered by the parity law.

Will the recent court decision make any difference? I have my doubts. Insurance companies can be experts in not paying for the adequate care of their subscribers.

In an upcoming post, I will be reviewing a book about the even more disgusting horrors currently being inflicted on the severely and persistently mentally ill by the public mental health system.