The following ‘backstory’ will inform the reader of the main intent of this blog, which is to educate about what has happened to mental health care in this country, why we cannot even find enough mental health professionals in this country to meet the service needs, whether it be in the communities anywhere, the military VA system which is flooded with the mental health needs of the troops of the last three wars/conflicts in the Middle East, and my view why we now have the previously unimaginable now constant regular near monthly occurrence of senseless mass shootings in this country.
I am a veteran psychiatrist, formerly in years past a part time instructor and clinical faculty trainee supervisor for almost 18 years at Duke University Medical Center, where I trained in adult, child and geriatric psychiatry. Those training and early practice years were in some of the “golden clinical years” mental health practice in this country. That era was marked by a national working system of county by county mental health centers staffed and functioning well. Resources in general were of course better in urban areas and in short supply in sparsely populated areas. I “grew up” psychiatrically in one of the most well resourced areas in the entire country in my field, the Research Triangle Area of Raleigh-Durham-Chapel Hill. It was comparable to other such resource rich areas in this country, San Francisco, Cambridge-Boston, New York City, Ann Arbor. These kinds of urban areas were marked by the common elements of multiple well respected medical schools with strong departments of psychiatry, progressive populations and local and state governments that supported mental health services routinely, a better educated population, routine support of education and human services, and many ancillary mental health services, such as residential treatment centers for youth, very good mental health consulting services in juvenile justice facilities, and state hospitals that were closely affiliated and often actually extensions of nearby medical school psychiatry departments. I myself after completing my training years at Duke, followed a path of working for several years in the Duke affiliated state mental hospital outside Durham NC, helping to start a new acute adolescent inpatient unit, a new service at that time for that part of the state. It was typical in North Carolina that many if not most, of the state hospital psychiatrists were former or current medical school faculty psychiatrists who worked in both worlds. At Duke and the UNC School of Medicine Departments of Psychiatry, faculty were actively encouraged to take part of their weekly or monthly practice time and travel out to area wide mental health centers and to help to staff them. As a result the mental health centers in outlying areas often had outstanding psychiatric staffing and coverage. I also did this staffing for several years one day a week, four very rural counties’ mental health centers that existed far from Durham and Duke and were extremely rural and poor along the northern tier of the border with Virginia nearly a hundred miles north of Durham. I greatly enjoyed this work.
However, since those ‘golden years’ as I have briefly described them above, in the 1970’s and 1980’s, mental health funding came under heavy fire and suffered grievously progressive more and more restrictive and prejudicial loss of funding from the federal levels. A bit of background. Under the Nixon Administration, “block grant” funding came into being which effectively greatly limited funding for many human services at the states’ levels, by funding such services through capped or limited chunks of money. In the Reagan Administration years, this intentional method of limiting “social programs” by decreasing funding through artful means was extended by forbidding the transfer of hospitals’ earnings from federally funded healthcare reimbursements from such programs as Medicare and Medicaid to other funding needs. Mental health programs were particularly hard hit and experts in those years felt then certain penalizing funding restrictions were intentionally directed at mental health services which have long been viewed with less than charitable understanding by the less politically and socially elements of our political system. Hospitals which funded training programs by openly utilizing “public funds,” i.e., reimbursement monies from Federal programs such as Medicare and Medicaid had to drastically cut back by the end of the Reagan era. I recall when my own training program which had for instance, usually 16 first year psychiatry ‘residents,’ psychiatrists-in-training, shrank within several years from that number to just six a year. Our child psychiatry program shrank from two to four child fellows to two every other year or so. If a wealthy an institution as Duke with its $6B endowment cannot afford to sustain its training costs, in such programs, imagine what has happened at programs across the country. This occurred all over the country, as psychiatry programs downsized by up to 2/3 to 3/4 to survive economically. The highly respected Tufts School of Medicine in Boston almost two decades ago had to be ‘bought out’ by the Harvard Medical School to survive and continue functioning. In child psychiatry we produce so few child psychiatrist nationally we are in a crisis that has been documented for years in national media, even the Wall Street Journal, that several years ago ran an article documenting the months’ long wait for families in many parts of the country to have their children seen by a child mental health professional. In child psychiatry nationally it is so bad, we are at the point of being in danger of not even repairing the number of child psychiatrists each year who die or retire.
So this blog/forum will strive to document what has happened over the last 30 years in the general field of mental health and educate how and why we as a nation, evolved into the nationwide mess we are in.
A few telling examples:
1. Currently in this country the largest psychiatric hospital in this entire country is supposedly according to several years of media reporting, the Harris County Jail, of Houston Texas, where approximately 2,400 of the 10,000 inmates are chronically mentally ill patients who have ended up in that justice system. Harris County a few years ago was forced to increase its county jail cohort of full time psychiatrists from 3 to 15 to cope with the treatment needs. The average citizen who pays the slightest bit of attention to any news in the last few years is now aware that a huge nationwide shift of mental patients from hospitals (many of which no longer exist) to the jails of this country.
2. The homeless population of this country has grown by huge numbers that we still do not know the full extend of. Certainly this increase has been unfortunately greatly fueled the Great Recession since 2008 with Wall Street and Housing Bubbles bursting and nearly plunging this country into a second Great Depression. But it is also well known now that at least 50% or more of the homeless are also the chronically mentally ill for whom past treatment resources have also disappeared, displacing or moving them to the streets.
3. Just this past week of August 11th, national statistics have been released that the national suicide rate has started to go up again with acceleration in many age groups.
4. And finally even the most ill informed are all too well aware that substance abuse is now truly epidemic in this country at far greater rates and penetration into previously drug abuse naïve population groups. The prescription drug abuse related death rate has skyrocketed to a national epidemic health problem from a state of being much less, unrecognized, almost restricted to wealthy entertainment class in past decades.
Lastly I will exercise my wacky wit, wife ranging interests to intersperse this main orientation and concern of this blog with book reviews, and commentary on social trends in this country that I think are interesting and worthwhile and give them what I would hope will be a somewhat unique viewpoint, that of developmental, old fashioned psychiatrist who still believes in many ideals that all could be subsumed under the general now nearly forgotten ethic of the “common weal,” the “common good,” this missing too much in our present societal direction with the loss or erosion of many values of prior generations that I think concerned citizens of this country and of the world can all agree upon, are still worthwhile and very much needed now more than ever.