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Sonia Rapaport, MD, is the Director of Haven Medical and is certified by the American Board of Family Medicine, the American Board of Integrative and Holistic Medicine. She is a Shoemaker Protocol Certified Physician.

Mental Health Care: The Rising Crisis

By Sonia Rapaport, MD, MFA
Medical Co-Editor of Health&Healing

“There is no mercy in a system that makes health care a luxury. There is no mercy in a country that turns their back on those most in need of protection: the elderly, the poor, the sick, and the suffering. There is no mercy in a cold shoulder to the mentally ill. This is not an act of mercy. It is an act of malice.”
Joe Kennedy III, on Trumpcare. 03/8/17

Sonia Rapaport, MD, MFA

In 1820, Washington Irving published his ghost tale, “The Legend of Sleepy Hollow,” the story of Ichabod Crane, a school teacher run out of town by the headless ghost of a Hessian soldier. For years, medicine has approached the body as if it were headless as well. Specialties such as orthopedics, cardiology, and dermatology are considered legitimate, career-worthy fields, while psychiatry is held with less esteem than even primary care. Doctors with no training in psychiatry feel free to diagnose physical symptoms with the catch-all label “depression.”.

Mary’s story is typical. She had filed for disability for chronic fatigue, respiratory problems, and chronic pain (due to work-related mold exposure) and her insurance company sent her for a second opinion. The insurance company’s doctor (not a psychiatrist) refused to look at several test results and despite documenting several neurological findings, decided that because she cried during the three-hour long examination, she had major depression, said she merely needed anti-depressants, and denied her claim.

Medically-induced PTSD: “It’s All in Your Head”

I don’t ever remember being taught the expression, “It’s in your head,” in any of my psychiatric rotations, yet it is one of the most often repeated phrases heard by patients whose doctors haven’t been able to find answers to their illness. And sad to say, heard more often by women than men. The end result is misdiagnosis, delayed diagnosis, and overuse of psychiatric medication; when a doctor labels an individual’s symptoms as somehow not based in their body and therefore imaginary, the individual begins to mistrust their perceptions of their own body. The process results in a medically-induced post-traumatic stress disorder (PTSD).

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I wish I could say this form of PTSD is rare, but I find myself apologizing on behalf of doctors everywhere far too often. Apparently many of my colleagues believe that “Above all, do no harm,” is limited to the physical body and not their patients’ spirits and minds.

A Problematic System

Yet I cannot place all the blame on the shoulders of physicians. I typically spend an hour with patients at their follow-up visits; new appoint-ments are longer. I can afford to do so because I don’t take insurance and charge individuals by the amount of time spent on their care. Our insurance system reimburses physicians by diagnoses, which dictates how much time a doctor can spend with a patient. With insufficient time to explore the underlying cause of illness, finding the appropriate diagnostic label becomes the goal. The diagnosis is treated, not the patient.

When treatments don’t work, doctors may turn to anti-depressants, a highly profitable class of medications. The story behind Eli Lily’s relabeling of Prozac (which we were taught requires three weeks of continuous use for its effect) as Sarafem (a pink and purple pill that is taken for two weeks out of the month) for Pre-Menstrual Dysthymic Disorder is a story of profit and loss in the face of an expiring patent. Eli Lily went so far as to create the diagnosis in order to sell its product, which it marketed heavily, promising to make a woman “more like the woman you are.”

Selective Serotonin Reuptake Inhibitors (SSRIs) such as Prozac were initially thought to work by increasing the amount of serotonin at the nerve synapse, resulting in increased serotonin activity. But while this effect is immediate, SSRIs require 2-3 weeks for their anti-depressant effect. Studies suggest that a subsequent decrease in the serotonin transporter (SERT) or even improvements in brain growth factors are responsible for the drugs’ anti-depressant effects. These are powerful medications with action on brain cells via unclear mechanisms, which can be used appropriately by mental health providers and may be inappropriately used when prescribed because a doctor doesn’t know what else to do.

Mental Health Care and the ACA

Bizarrely enough, when psychiatric medications are indicated, individuals have had a harder time getting care. Chronic mental illnesses and substance abuse did not routinely qualify for insurance benefits until the Affordable Care Act (ACA) was passed in 2010. As a result of the ACA, 20 million previously uninsured Americans gained health insurance, which was mandated to include mental health and substance abuse services as one of 10 essential health benefits.

It’s easy to forget what mental health care was like before Obamacare: insurance companies treated mental health care differently than care for other illnesses, levying annual or lifetime limits on coverage that were either unrealistic or absent. Before Obamacare, many individuals with mental health challenges were denied insurance due to the diagnosis of their pre-existing condition. In the pre-Obamacare era, I hesitated putting psychiatric diagnoses in patients’ charts for fear of the resultant stigma that would follow them forward.

The recently defeated GOP bill threatened health care services to over 1.28 million people who currently receive mental and behavioral benefits thanks to the Medicaid expansion. Writing in the New York Times, Richard Friedman, MD, argued that if Trump is able to repeal the ACA, “he will effectively strip millions of Americans with mental illness overnight of the most medically rational and humane benefits they have ever had—without giving them any indication of what, if anything, will replace them” (Friedman, R, “The Mental Health Crisis in Trump’s America.” NY Times, 12 Dec 2016).

What will mental health care look like without Obamacare? Psychiatric and psychological organizations predict:

  • Decreased access to care: individuals with mental health and substance abuse illnesses have greater dependence on Medicaid; the repeal of the ACA will have a greater impact in this population.
  • Increased ER visits: more individuals will seek care through emergency rooms rather than the optimal care provided through an ongoing relationship with an established provider, with the significantly greater costs associated with ER care.
  • Increased suicide: Depression is an illness with a high mortality rate. Without sufficient treatment, more individuals will lose their lives through suicide.

Effective mental health care encompasses far more than medication. A 2010 study in the Journal of the American Medical Association concluded that the benefit of antidepressant medication compared with placebo “may be minimal or nonexistent, on average, in patients with mild or moderate symptoms (Fournier, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA 2010. 303(1):47-52). Yet access to clinical care is increasingly at risk with the changes proposed by the Trump administration.

As Representative Joe Kennedy, III, in paraphrasing scripture, said, “we are judged not by how we treat the powerful, but by how we care for the least among us.” We are on the verge of a health care crisis, which will deny care to individuals without a voice, individuals whose illness prevents them from advocating for themselves. Health care in all its forms is a right, not a privilege. And it is up to each of us to stand up for those who cannot stand for themselves, and acknowledge that no patient is a body-only, headless ghost rider, but a complete human: body, mind, and spirit.