The bitter lessons learned in struggling to improve diagnosis, treatment, and delivery of care in the DoD and Veterans Affairs illustrate the many barriers that undermine the best-intentioned efforts. Recent experiences in trying to mitigate suicide and improve neuropsychiatric care for soldiers and veterans exemplify the obstacles and shortfalls in tackling these problems in society as a whole. Those of us working to help military, active and former, for the past 10 years acknowledge some progress on the most vexing issues, but have seen few substantive achievements and little that would inspire optimism for bigger goals and objectives. The number of tragedies keeps mounting-- suicide, homicides, broken lives, and devastated families and communities-- despite calls to action and increased funding.
The field of mental health differs fundamentally from the rest of medicine. Pointing out those differences involves debunking some of the great myths that have dominated psychiatry and psychology over the past 30 years – the disease model, effectiveness of drugs, and insurer-based financing.
Specialty-based medicine focuses on specific, and often narrow, diseases and offers sophisticated treatments that are coded for payment by insurance companies. The model is reductionist, drilling down to the causes of illnesses, genes, and biochemical aberrations that seem to directly link to diagnostic procedures, drugs, and surgery.
The paradox has been that the quality of life for each individual patient, has been obfuscated by sophisticated technology, fragmented by excessive specialization and undermined by our payment system. Surely, there are voices advocating for "patient centered care" and bringing "value" to routine medical care, but they have barely taken hold.
Therein lies the rub for mental health care: if any area of clinical practice should engage the whole patient, in all walks of life – it's mental health. The military provides a teaching case. Sustaining the fighting force requires an all-around support package that involves much more than treating soldiers for diseases and disorders. The soldiers, and their families, need broad-based support to stick with their mission, despite the problems they are suffering. And, if they can’t stay on active duty, they need a comprehensive support package to transition to civilian life. But, the soldier leaving active service rarely gets that level of help. Suffering, with severe PTSD or post-concussion syndrome, he gets a medical retirement, a disability check, and a pat on the back to go home and try and find a job (like Osama bin Laden’s “shooter”). Too often, the families feel like they are "holding the bag" to try to get their veteran back on track. So do many families that are caregivers for the chronically mentally ill in our civilian communities.
Changing and improving the delivery of mental health services is frustrating and painstakingly slow. Four years ago, in an attempt to tackle the suicide epidemic, the Chief of Staff of the Army directed various Army agencies to coordinate their efforts, starting with having a common information system. On the face of it, the leadership recognized that effective treatment required knitting together diverse programs across risk assessment, substance abuse, IED blast effects, disability retirement, social services, education, and a host of other support services. But, most of these programs are directed by separate major agencies within the Army and DoD, and coordinating has been stymied by bureaucratic politics. If the military, that prides itself in command-and-control and conducting massive combat campaigns cannot integrate and facilitate its services on its installations, then how can we expect States and the US agencies to achieve such lofty goals on a national level?
If the tragedies such as Connecticut can be avoided, then our country needs a national campaign with the scope of a massive battlefield campaign. Frankly, the challenge may exceed our capabilities and will. Nonetheless it's worth a try. As always, the right goal has to be set. For mental health, the appropriate goal is enabling the patient, and the caregivers, to have the optimal chance for a productive and rewarding life – to focus on the quality of life, not just treatment of symptoms and signs. Such a goal requires much more than the latest medication. The indicators of a good quality of life are relationships, education, employability, recreation, and all the things than any adult expects. Accomplishing such goals requires coordination among diverse groups- mental health practitioners, educators, employers, and law-enforcement - across multiple agencies with competing funding streams. “It takes a village,” and commitment that comes from compassion and consideration. How likely is that endeavor to happen in this fiscal climate?
Serious and chronic mental illnesses go on for months and years, and often require repeated hospitalizations. Managed care has imposed such restrictions and loss of flexibility that the quality has been seriously decremented. Reimbursement plans effectively disconnect delivery of care among providers and discourage coordination. The insurers have so dramatically fractured services that patients wander from psychiatrists (prescribing medications), to psychologists (doing testing and therapy), and to a broad array of other counselors. The primary care providers managing the co-morbid medical conditions sit on the sidelines. The impediments to good care are immense.
The dominance of psychopharmacology has propagated another worrisome myth over the past 30 years – that to “cure” the problem, the doctor only needs to find the right drug. No doubt the medications have helped many and are vast improvement over the limited treatments of the past. But, mental health problems cannot be fixed with drugs. In fact, they may not be able to be "fixed" at all. The patient, or soldier, can take medications to control symptoms, but not “cure” their life problems. Learning to accommodate and adjust to symptoms and impairments requires much more than the right drug. It requires the help of a dedicated talented team that works together.
The real challenge for improving mental health care will be to apply leadership and build programs that support comprehensive care and improve quality of life. Doing so involves multiple agencies and interest groups that have huge equity in the current system and little incentive to change. There is slim likelihood that meaningful new policies can come out of today’s acrid partisan political climate. If the tragedy in Connecticut, and too many suicides, can inspire constructive action on gun control that has lagged for years, perhaps it may also inspire the White House to take the lead on transforming mental health care sooner than later.
Xenakis is a child and adolescent psychiatrist and a retired Army brigadier general. He is the Founder of the Center for Translational Medicine, a nonprofit serving soldiers and veterans.