Vivek Chellappa ’09: U.S. public mental health care under-funded, not malicious

Thursday, March 6, 2008

I found the recent column by Renata Sago ’10 (“U.S. public mental health care system as unstable as its patients,” Feb. 28) troubling for its broad generalizations and lack of research. Sago describes public mental health care (PMH) in harsh terms, criticizing it as “antiquated” and “ineffective,” and deriding it for “its crippling incompetence.” Although this is a defensible position, Sago fails to offer a single piece of evidence to support her conclusions.

At a basic level, Sago groups PMH, which is independently run by each state, as a “system,” without appreciating the differences and problems individual states may have in addressing the challenges of PMH.

Sago offers incredibly biased views of public mental health care, suggesting that public mental health patients are “subjects of experimentation instead of individuals.” Her description of the system as being “paralyzed by apathy” further vilifies PMH and its goals without an ounce of support for the reasons behind her condemnation. Sago seems to suggest that public mental health is somehow designed to pry on its patients, which is a gross exaggeration of a $29.5 billion system that serves 6.1 million people, and an affront to the hard work that understaffed nurses and social workers face amid funding shortages, particularly in inner cities.

Sago mentions that the system discredits war trauma for soldiers, but post-traumatic stress disorder is diagnosable as an Axis I disorder. Unfortunately, military funding in mental health services has been lacking and resources are strained, leading to rushed evaluations and errors, but that is separate from suggesting a systemic discrediting of soldiers’ welfare. On the issues of poverty and race, research has documented that ethnic minorities are less likely to seek mental health care and that the incidence of psychopathology is increased among the poorest in our country, but briefly mentioning that the system discredits those populations is an oversimplification of complicated issues.

Furthermore, Sago demonstrates a misunderstanding of the purpose of the Diagnostic and Statistical Manual of Mental Disorders (DSM), a set of diagnostic criteria used by mental health professionals. The DSM was first published in 1952, and has been revised five times, most recently in 1994, with a slight revision published in 2000. Even a perusal of the 800-page DSM should reject Sago’s notion that “every personality trait is a ‘disorder.'” The DSM-IV groups diagnoses into five different axes, which, when combined, help mental health professionals in a wide range of purposes, including clinical, research, administrative and educational, according to the American Psychiatric Association.

One of these axes represents personality disorders and mental retardation, which are considered separate from most psychopathology, partially because these are chronic long-term conditions that have practically no effective treatments. These diagnoses are rightfully separated from Axis I diagnoses, which include schizophrenia, depression, anxiety disorders and bipolar disorder because treatments for these patients tend to be much more successful. Even a normal person with the flu would have a DSM-IV diagnosis, on Axis III, which assesses acute medical conditions and physical disorders.

The idea that every personality trait represents a disorder indicates a misunderstanding of a complicated classification system, meant to be used by trained professionals who assess a broad range of criteria before assigning diagnoses. Normal personality traits will not bring about a diagnosis of psychopathology, and a series of abnormal traits are required for personality disorder diagnosis. The key point is that DSM classification is only meant to be used by trained professionals. It’s very likely that there are professionals who are inadequately trained, but again, that problem points towards funding shortages, rather than a systemic failure of PMH.

Sago’s comparison of asylums to jail is unfair. Due to the severity of some patient’s psychopathologies, there will always be a need to institutionalize a percentage of patients because they present a risk to the safety of themselves and others. Recently, practitioners have recognized that institutionalization is not required for most patients. In the 1950s, institutionalization was far more widespread, with 600,000 patients confined in mental health institutions, whereas the confined patient population by 2001 had dropped to 60,000. The balance of patients is usually treated with community mental health programs, a proven treatment strategy, but funding shortages prevent adequate care from reaching many patients, leaving them in the dark.

Sago also writes that “the mentality of the system is that these individuals do not have the potential to attain stability.” It’s not clear how Sago would have insight into the mentality of all state-run PMH services. Regardless of what Tom Cruise may say, PMH has helped millions of patients improve the quality of their lives, and most states pay most, if not all, treatment costs for lower income patients. Mental healthcare may never be able to treat everyone with psychopathology, but until funding for proven modern treatment programs is drastically increased, hundreds of thousands of veterans, low-income residents, and homeless patients will be left behind.

We are fortunate to live in an age where science has significantly increased our understanding of mental illness. Modern advances in all aspects of treatment strategies have increased our ability to help more patients improve their lives than ever before. The DSM-IV has its flaws (until 1974, homosexuality was listed as a disorder), but the DSM system is constantly being revised to account for new research, with a new edition to be published in 2012. Failures in PMH should not be attributed to some generic “system” that provides “little assistance to patients” and creates “the illusion of deinstitutionalization” as Sago suggests, but rather to inadequate funding, as well as the stigma toward asking for mental care.

Vivek Chellappa ’09 meant this to be a letter to the editor.