Mental Health Care in Kansas: Roy W. Menninger, M.D.
Roy W. Menninger, M.D., Topeka Kan.
June 4, 2010
Media articles about mental illness too often portray it in the context of violence - as if they were synonymous. Not a good thing. This conflation is both evidence of and a cause of stigma
MY PRESENTATION to cover:
● Brief story of psychiatry
● Mentally ill in jails & prisons
● Tale of MH reform in Kansas
● Issues in rural MH
ORIGINS of PSYCHIATRY
Psychiatry has had no linear course of development from its earliest forms as have other disciplines (e.g., alchemy to chemistry; astrology to astronomy). Our origins are scattered: in primitive medicine, mythology, hypnotism, theology, philosophy, law, anthropology, literature, & popular lay healing.
No stable & consensual theoretical vantage point has developed. Rather: competing, bitterly opposing schools the rule. The primary contemporary example: the bitter debate between somatic & mentalist philosophies of mind.
EVOLUTION OF PSYCHIATRY & PSYCHIATRIC TREATMENT
Asylums have existed since the Middle Ages but were solely custodial. Oldest: Bethlem ("bedlam") in 13th century as the Priory of St. Mary of Bethlehem but by 1815 had only 122 patients. On Sundays patients were exhibited to the public as entertainment. Mentally ill usually confined at home, often in dreadful conditions.
Presumed causes of illness: devils à treatment by exorcism, witches à treated by burning; disturbance of bodily humors (black bile, yellow bile, phlegm & blood) à treatment by bleeding, purging, emetics, restraints
First state hospital: State Lunatic Asylum at Worcester (1833), created by Rev. Louis Dwight to deal with the mentally ill in jails
The asylums movement is a story of good intentions gone bad. Asylums initially begun by volunteers (not gov't.) and were based on a moral philosophy of healthy, caring environment. Began with high hopes for cure and initially saw high discharge rates. With markedly increased numbers of patients (1840s), enthusiasm waned & hospitals deteriorated into human warehouses.
Intended to fulfill a dual purpose: rehabilitate the inmates and then, by virtue of its success, set an example of right action for the larger society. A Utopian flavor.
Social reformer Dorothea Lynde Dix (1841-47) focused on sad plight on the mentally ill in jails & prisons and was directly responsible for the opening of at least 30 more state hospitals. Total of 75 public hospitals by 1880. First census of "insane persons": à 91,959 "insane" - ½ at home, ½ in hospital, 0.7% (397) in jails.
MENTALLY ILL IN JAILS & PRISONS
In 1992, by contrast, jail population of schizophrenics increased 10x to 7-10% and in some places, 25%.There were 283,800 people with mental illness in the nation's prisons and jails. Approximately 15-20% of individuals in prison and in jails reported a mental illness. As many as 40% of those who come in contact with the corrections system have a mental illness.
In the US, the number of mentally ill in jails now surpass numbers of patients in psychiatric hospitals in New York, Austin TX, Dallas Country, Seattle, and San Diego. In the Los Angeles County Jail, 3,300 of 21,000 inmates "require MH services on a daily basis..." - it is the largest mental institution in the country.
In Kansas: currently 2/3rds of prison population (9,000) have Axis I (clinical disorders) or Axis II (personality disorders & MR) diagnoses. The increase of persons with mental illness in jails & prisons is clearly a direct result of deinstitutionalization.
Notable: society has only 2 ways of handling deviants: labeling them either sick or criminal. Depending on the label, individuals are shifted from one to the other, illustrating the "Balloon Phenomenon" - reducing mental hospital census produces an increased jail census & vice versa.
America's jails and prisons have become our new mental hospitals.
(a) There are now more than three times more seriously mentally ill persons in jails and prisons than in hospitals ranging from North Dakota (approx equal numbers) to Arizona and Nevada which have almost ten times more mentally ill persons in jails and prisons than in hospitals. It is thus fact, not hyperbole, that jails & prisons are the new mental hospitals-ill-equipped or motivated to care for them.
(b) At least 16 percent of inmates in jails and prisons have a serious mental illness. In 1983 a similar study reported that the percentage was 6.4 percent.
(c) 40 percent of individuals with serious mental illnesses have been in jail or prison at some time in their lives.
(d) It is now extremely difficult to find a bed for a seriously mentally ill person who needs to be hospitalized. In 1955 there was one psychiatric bed for every 300 Americans. In 2005 there was one psychiatric bed for every 3,000 Americans. Even worse, the majority of the existing beds were filled with court-ordered (forensic) cases and thus not really available.
(e) We have now returned to the conditions of the 1840s by putting large numbers of mentally ill persons back into jails and prisons.
20th Century - Diagnosis and treatment pursued parallel (but separate) tracks: biological ("nerves") & psychological theories & treatment; intensely competitive & often mutually exclusive and divisive
New hope for cure came with accidental discovery that fever cured neurosyphilis (1917), tried w/ other psychoses using malaria; unsuccessful
Other biological treatments tried and (usually) abandoned:
- Total tooth extraction (to eliminate "bacterial poisons"
- Convulsions à improvement in severe depression leading to use of metrazol and later, electric shock
- Insulin therapy
- Early drugs:
- Opium à morphine
- Sedatives (chloral hydrate, paraldehyde, barbiturates)
Other physical treatments for "nerves" (some of which are still used):
- Rest cure
- Cold wet packs
- Sleep therapy
1920-30s - Center of gravity of American psychiatry was in the mental hospitals, but they were totally custodial - virtually without treatment of any kind. Population by 1933: 366,000, w/ some hospitals >8,000 patients (Milledgeville GA)
WORLD WAR II
Successful treatment of psychiatric casualties à new atmosphere of enthusiasm & hope for successful treatment
Lessons (many of which had been discovered during WW I, forgotten, and re-learned in WW II)
- community and outpatient treatment of disturbed persons was possible and effective
- early intervention essential for rapid improvement and preventing subsequent hospitalization
- new psychological and biological therapies (including but not limited to psychotropic drugs) introduced, offering fresh hope for normal existence outside of mental hospitals
Post-war public reaction: an upsurge of interest in mental health; increased number of applicants for training. In 1946, some 108 physicians started psychiatric residency at the Menninger School of Psychiatry (ultimately responsible for training 7% of nation's psychiatrists).
1963, 1965, 1967 - Community MH Centers Acts, proposed by JFK, were products of "Action for Mental Health." They initiated the community mental health movement and the creation of CMHCs but decreed federal & local county funding for them without state involvement.
a - Public outrage over the appalling conditions in state hospitals
Albert Deutsch published Shame of the States (1948), reflecting the horrors of state hospitals, primarily Byberry in Philadelphia: patients flung into misery and seemingly forgotten. But it was intended as a call for reform, not censure or closure. Further exposure of state hospital conditions in movie of MJ Ward's novel, "The Snake Pit," (1949) starring Olivia de Havilland; on the cover of Time magazine
b - Parallel trends
- Antipsychiatry movement: preached that mental hospitals were wicked and repressive, and that there was no such thing as mental illness, just social rejection, labeling and ostracism.
- Rise of civil rights movements, extended to psychiatric patients. Civil rights were seriously truncated by the then-employed commitment & institutionalization proceedings. (RWM's experience as a 1st yr. resident: incarceration with a single signature)
c - Introduction of the antisychotic drugs (1954) - initially chlorpromazine [Thorazine] & reserpine [Serpasil] followed by many other psychotropic meds; this facilitated planning for extra-hospital treatment
d - Emergence of the community mental health concept and "social treatment" - belief that persons would receive better and more humanitarian treatment in their community rather than in state hospitals far from home-in any case, cheaper
e - Financial considerations: state government wished to shift the cost burden to the federal & local governments: to federal Supplemental Security Income (SSI) and Medicaid, and local law enforcement agencies, emergency health and mental health services.
BUT - the community mental health center system was totally unprepared to deal with such severely ill pts, i.e., they could not provide basic care (food, clothing, shelter) or the support mechanisms to enable severely ill persons to cope with their environment.
CMHCs initially primarily provided psychotherapy for the walking (worried) well with virtually no provision for services to the actively ill persons pushed out of the state hospitals. Closing state hospital beds eliminated major services for severely ill-still true today.
Deinstitutionalization reduced state hospital population from 559,000 in 1955 to 338,000 in 1970, to 107,000 in 1988, to 71,619 in 1994 - a decrease of 88% in nearly 40 years.
Deinstitutionalization was the true "shame of the states". One-third became homeless; many transferred to other institutions lacking treatment capabilities: nursing homes, boarding houses, etc. and especially jails. In short, it was transinstitutionalization, not deinstitutionalization
Continuing neuroscience advances: progressively better understanding of neurochemistry & brain localization à development of increasingly effective medications ("2nd generation meds") & precision neurosurgery (Parkinson's, brain tumors)
Increased awareness of mental illness and its treatability, though stigma still rampant; development of psychiatric units in general hospitals & increased numbers of private psychiatric hospitals (from 150 in 1970 to 444 in 1988)
But this trend produced steadily increasing costs (esp. psych hospital), leading to cost-containment methods (managed care, HMOs, restricted benefits, policy exclusions of mental illness) à
· diminished role of in-patient treatment, with shorter lengths-of-stay, and major change in role of hospital (from treatment to diagnosis and stabilization)
· and increasing emphasis on out-patient treatment and community treatment services
KANSAS MENTAL HEALTH SYSTEM HISTORY
1949 - death of a legislator's wife à mobilized determination to change things; Gov. Carlson invited Dr. Karl Menninger to assist; KAM agreed, asking (and receiving) $21 million for staff & training. Result: marked improvement of state hospital care with transformation of Topeka State from a custodial into a teaching institution. Continued until its closure in 1997. At its peak, KS state hospitals had approximately 5,000 beds.
1987 (38 years later) - Rapp (KU) report: "Toward an Agenda for MH in Kansas" à major finding: extreme incongruence between MH program policy and financing policy. Kansas was ranked #42 & moving backwards.
Funding differences: CMHCs funded by federal money & county levies; hospitals by state General Fund. Two separate systems. Absolutely no coordination or collaboration.
1990 - MH Reform legislation introduced major changes: all patients referred for hospitalization were first screened by CMHCs, either admitted or assigned a case manager and diverted to community programs. SH bed utilization was sharply limited to reduce SH costs. Result: the beginning of coordination between CHMCs and SHs.
Over 6 yr period (1990-96), KS General Fund expenditures for community services increased from 18% to 51% of the MH budget; state hospital expenditures declined from 82% to 49%. Avg. daily state hospital census in Kansas declined by 50%; community caseloads increased by 222%.
Kansas state hospital beds decreased from 1,003 in 1990 to 340 in FY2004 [275 adults, 35 adolescents & 30 children]
CMHC system: majority of persons are indigent or low income: adults with severe persistent mental illness (SPMI) and children with serious emotional disturbance (SED). Virtually no private pay patients
1997 - Topeka State Hospital closed. Heavily impacted Topeka & Shawnee County because of considerable previous in-migration of psychiatric patients seeking treatment from the substantial supply of psychiatric services-but there were Insufficient alternative community services available
1998-2003 - decreasing 3rd party reimbursement for psychiatric patients since psychiatry briefly viewed as the most expensive medical service, à increased restrictions on utilization & reimbursement (chiefly decr. LOS). Other psychiatric hospitals (private) closed or moved (e.g., Menninger); number of in-patient beds for acute services decreased dramatically: from 488 to 324 (-164) by 2008 for private hospital beds & 480 NFMH beds. Reduction 53% nationwide, 89% in Kansas.
Recent trends: SH admissions are increasing (Osa - 994 in FY00 to 1,176 in FY08; Larned - 870 in FY00 to 2,181 in FY08), LOS are decreasing, readmission rates are higher than the national average. (LSH - 9%, OSH - 13%, Rainbow 12% higher. More than 50% of 1st admissions to KS hospitals are persons connecting with the mental health system for the first time.
State hospitals increasingly used their beds for acute, short-term stabilization rather than treatment per se. Emphasis on "efficiency" measured by short lengths-of-stay and rapid return to the community and the CMHC. "Efficiency" is not equivalent to good treatment: pts cannot remain long enough to become stabilized or allow for discharge planning. KS has next to lowest hospital beds / 10,000 popln: 1.3 (MO has 0.9; CO - 1.6, OK - 2.0, NE - 3.0)
State hospitals are the safety net to accommodate indigent pts. too sick or too disturbed to be able to utilize the extensive community resources developed to avert hospitalization. It is seriously overstrained. It is in crisis.
Target population numbers using CMHCs are increasing: from 17K in 1994 to 36K now (paid by Medicaid), and the non-target population is increasing: >70K today (not covered).
Result: increased burden on supplemental community services without increased funding made much worse but recent budget cuts - >$20 million in the past 2 years alone-a 65% reduction.
CURRENT TREATMENT CONCEPTS -
Good treatment now means both psychopharmacology and psychosocial treatment (psychotherapy environmental support of groups, case managers, family, social agencies, wrap-around services, work), based on thorough assessment & diagnosis. Community-based treatment.
Public system more developed and more comprehensive than private ones.
BUT in-patient hospital treatment essential for severely ill patients who cannot be treated in the community
Emphasis of care has shifted from symptom suppression and cure to recovery, resilience & successful management of illness
Major service issues:
· services are still seriously deficient in many places for many persons,
· the absence of a mechanism to prevent patients from drifting out of the system.
· ready access to information about quality medical/psychiatric or social psychological services, and the services themselves, especially for children and their families, plus
· accessing many other resources and services such as housing, transportation, education, vocational training, & job opportunities
If effective integration of these various disciplines of knowledge and service from separate departments of government with the mental health system were possible, that would indeed be a true transformation of the MH System in Kansas.
In sum, Kansas has a better-than-average mental health system that needs significant improvement, especially in regard to greater patient and family involvement and more broadly available services with easier access.
● 31 frontier counties (less than 6 persons / sq mi),
● 39 rural counties (from 6 to 19.9 persons / sq mi),
● 21 densely settled rural counties (20 - 39.9 persons / sq mi),
● 9 semi-urban counties ( 40 - 149.9 persons / sq mi), and
● 5 urban counties (with 150 or more persons / sq mi).[i]
KS MH Providers:
● 74% of masters' level qualified MH professionals have mailing addresses in the 5 urban counties
● 1.2% live in Frontier Counties.
99 of Kansas' 105 counties are designated by the Federal Government as "Health Professional Shortage Areas", e.g., there is a population-to-psychiatrist ratio 30,000:1 in those designate counties.[ii]
Providing MH services in rural areas is a huge problem -
● major depression rates in some areas significantly exceed those in urban areas.[iii]
● Teens and older adults in rural areas have significantly higher suicide rates than their urban counterparts.[iv]
● Stress with cyclical farm crises, natural disasters and social isolation.
● In many rural communities, mental health services are simply not available. More than 85 percent of the 1,669 federally designated mental health professional shortage areas are rural.
● Distance to mental health providers and a lack of public transportation to reach care prevent rural people from accessing needed mental health services. Result is that those in rural Kansas may experience a delay in care, inconsistent care, or no care
● Social stigma attached to mental health problems. This stigma in combination with a general lack of anonymity in many small communities leads some people to forego treatment.
● Culture of self-reliance pride à refusal to ask for help
In summary, 3 major hindrances to good treatment in rural & frontier counties (see Appendix B):
- the lack of mental health care professionals, psychiatrists or specialists for children,
- very long distances that consumers and families must drive to gain access to treatment, and
- stigma and cultural resistance
SUMMARY - THINGS TO THINK ABOUT:
- Behavioral health & mental illness are low on the public priority totem pole
- Most people think they won't be affected-therefore, not to worry
- Yet 20-25% of population has a diagnosable mental illness
- Depression: "the common cold of psychiatry"
- Resistance to providing adequate funding for current public MH services is unrelenting; therefore efforts to achieve it must be unending. Alleviation of some of the barriers to treatment in rural areas requires even more $:
- e.g., regionalized clinics and hospital beds
- e.g., sufficient salaries to attract and hold qualified MH professionals
- to combat stigma
- to overcome cultural reluctance to seek treatment
- to emphasize the fact that mental illness is treatable-and is not a sign of character weakness or masturbation
- to continue to remind the public & their legislators of the need to provide adequate funding
- to identify new services, programs, treatments
- Resist the temptation to sensationalize examples of the depredations and occasional tragedies of mental illness
- Look for opportunities to connect mental illness with success:
- impact of Consumer-Run Organizations (CROs)
- Examples of the positive outcome of good treatment
- Strategies for managing stress and other "how to..." articles
Other results of Kansas Mental Health Reform (See page 7):
· Specialized community services to target populations increased
· Majority of adult consumers of community service programs are living independently; over half involved in work or educational activity
· [Some] specialized children's services have been developed in many areas of the state
· Consumer-Run Organizations (CROs) increased in size and number (to 20 by 2005).
· Address inadequate capacity of community service programs to deliver appropriate levels of service to more consumers. What is needed: aggressive outreach.
· Address statewide gaps & make services & opportunities for consumers more equitable across catchment areas, esp. for children
· Nursing Facilities for Mental Health (NFMH) should be covered by a gatekeeping system to prevent costly & unnecessary institutionalization
· Develop standards to address consumer empowerment issues, such as representation on governing boards
BARRIERS TO MENTAL HEALTH TREATMENT IN RURAL AREAS. The barriers to mental and behavioral health services in rural and frontier America have changed little over the past three decades. Several studies and projects have reported that resources have historically been concentrated in urban areas of the United States, and the limited availability, accessibility and acceptability of rural mental and behavioral health services have created serious consequences for individuals, families and State mental health authorities.
The following issues have been identified by a survey of the National Association of Rural Mental Health on barriers to and concerns regarding service delivery in rural America:
Stigma and Cultural Issues
● Social stigma of mental illness
● Lack of rural-specific technical assistance
● Mistrust of health professionals in some rural and frontier communities
● Focus on illness care rather than on adequate early intervention and prevention
● Lack of cultural competence in spite of increasing diversity
Financing and Reimbursement
● Uncertainty of public funding streams
● Lack of flexible funding streams
● Lack of funding for prescription medication
● Complicated and cumbersome funding arrangements
● Restrictive reimbursement requirements, such as the need to have licensed professionals on staff to seek Medicaid/Medicare reimbursement, when private insurers will pay for services provided by case managers, etc.
● Lack of funding for evidenced based practices specifically for rural areas
● Reimbursement problems with telehealth services
● Funding systems are complex and fragmented leading to increased costs for providers
● Higher cost of service delivery in rural areas due to low volume of patients
● Managed care organizations place restrictions on providers
Structural and Organizational Issues
● Insufficient communication among primary care providers and community mental health centers
● Incompatible software or hardware and inadequate infrastructure for telehealth connections
● Limited availability of clinicians with prescriptive authority
● Lack of specialists, especially those with child/adolescent expertise
● Lack of public transportation
● Distances and difficulties accessing care even when transportation (private) is available
● Professional specialization interferes with adequate "life management" needs
● Lack of integration of mental health and primary care in many areas
● Lack of integration of mental health and substance abuse services
● Difficulties faced by rural providers when competing for funding, such as a lack of organizational capacity/ expertise, the use of urban criteria for contracts (i.e. levels of required credentialed professional staff) by government agencies, etc.
● Lack of support for care givers, professionals and families (i.e. affordable housing, comprehensive rehabilitation programs)
● Lack of peer support services and consumer led groups
● Lack of comprehensive needs assessment data specific to rural and frontier areas
● Unintended impact of Federal regulations (HIPPA)
● Unaddressed behavioral health care needs of rural women
Access and Workforce
● Lack of trained staff members/providers/clinicians
● Lack of availability of dual-diagnosis treatment
● Lack of telehealth services
● Lack of continuing educational opportunities (i.e. for RN's to become Nurse Clinicians with a psychiatric specialty and an ability to prescribe medications)
● Significant distances to service providers
● Excessive wait times before services are available
● Lack of financial incentives for professionals to work in rural areas
● Lack of scholarships and grants for training
● Inadequate prescription drug benefits, especially for the self employed
 Micale MS, Porter R (1994): Discovering the History of Psychiatry. New York: Oxford University Press, p. 2
 Rothman DJ (1971): The Discovery of the Asylum. Social Order and Disorder in the New Republic. New York-Toronto: Little, Brown and Company
 Torrey EF (1997): Out of the Shadows: Confronting America's Mental Illness Crisis. New York: John Wiley & sons, Chapter 3
 Huss L, Grinage B, et al (2003): Forensic Subcommittee Report of the Kansas Governor's Mental Health Services Planning Council (mss)
 Torrey EF (1997): op.cit.
 Huss & Grinage, op. cit
 Torrey EF, Kennard AD, Eslinger D, Lamb R, Pavle J (2010): More Mentally Ill Are in Jails and Prisons Than Hospitals: A Survey of the States. Online report: Treatment Advocacy Center, Arlington VA 22203. www.treatmentadvocacycenter.org
 Menninger RW, Nemiah JC (2000): American Psychiatry After World War II. Washington DC: American Psychiatric Press Inc., P. 1-2
 Grob GN (2000): Mental Health Policy in Late Twentieth-Century America. In: American Psychiatry After World War II. RW Menninger & JC Nemiah, eds. Washington DC: American Psychiatric Press Inc. Pp. 232-258
 Lamb HR (2000): Deinstitutionalization and public policy. In: American Psychiatry After World War II. RW Menninger & JC Nemiah, eds. Washington DC: American Psychiatric Press Inc., pp. 259-276
 Torrey 1997, op cit
 Deutsch A (1948): The Shame of the States. Manchester NH: Ayer Company
 Torrey 1997, op. cit.
 Rapp CA, Moore TD (1995): The first 18 months of mental health reform in Kansas. Washington DC: Psychiatric Services 46:580-585
 Chamberlin R, Boezio C, Brown A (1995): Kansas Mental Health Reform - Progress as Promised. Office of Social Policy Analysis, Univ. Kansas (mss)
 Chamberlin R, Zebley L, Marty D, Pewewardy N (1998): Topeka State Hospital Closure Evaluation: Final Report (Revised). Lawrence KS: School of Social Welfare, University of Kansas (mss), p. 1
 Hammond M (2005): personal communication
 But, since these critical services are not medical,
- they are not reimbursed by medical payment insurance systems
- they are not regularly supported with tax dollars
- they are not readily accessed by persons with mental illness
- there are no mental health funds available to pay for these services
- they are located in other parts of government, and
- there is no super-ordinate authority to enable even minimal coordination with mental health services.
 Sweeney S (2010): Personal email communication: Mental Health Treatment for Seniors in Rural Kansas (May 21, 2010)
 Chamberlin R, Boezio C, Brown A (1995): Kansas Mental Health Reform - Progress as Promised. Office of Social Policy Analysis, Univ. Kansas (mss)
[ii] Primary Care: Health Professionals Underserved Areas Report, 2010, Kansas Department of Health and Environment.
[iii] Probst, J.C., Laditka, S., Moore, C.G., Harun, N. and Powell, M.P. (2005). Depression in rural populations: Prevalence, effects on life quality and treatment-seeking behavior. Office of Rural Health Policy, US Department of Health and Human Services, Rockville, MD.
[iv] Institute of Medicine (2002). Reducing suicide: A national imperative. Goldsmith, S.K., Pellmer, T.C., Kleinman, A.M. and Bunney, W.E. (eds). Washington, D.C. National Academy Press.