Shaping the Future of Mental Health Care

Robert Michels, M.D.

National Coalition of Mental Health Professionals
and Consumers Symposium

New York University Medical Center

June 22, 2001

Physicians going back to Hippocrates have had an ethical responsibility which has two components. One is to take good care of their patients, maintain their professional competence, know what is known about the diseases their patients might have, provide good treatment and monitor that treatment. They have to be good caretakers. That's usually what people think about when they think about medical ethics. But there is a second component as well. They have to help create a system in which patients will have access to that good care. They have to make sure that there are enough physicians, that they are appropriately educated, that future ones are trained and that we learn to provide even better treatment through research. We have become strikingly aware in the last decade that the health care system in which physicians work can not only facilitate taking good care of patients, it can also interfere with taking good care of patients. Thus physicians have two responsibilities-taking care of their own patients and making sure that every one in the community is going to have the best possible care available to them.

In mental health care, this is the best of times. It is also coming dangerously close to being the worst of times. It's the best of times in terms of what we know and what we can do to help people. Our knowledge about psychiatric disorders, their diagnosis and their treatment has grown extraordinarily in the last few decades. Somebody with manic depressive disorder or schizophrenia or obsessive compulsive disorder or panic disorder or attention deficit hyperactivity disorder, is disadvantaged by those disorders. But they are infinitely better off in 2001 than they were in 1991 or 1981 because of the knowledge that we have and the treatments that are available. If they get those treatments it's the best of times. However, unfortunately, the limiting factor for most of our patients isn't what we know or what we might be able to do for them, but what actually happens to them in the community and in our current health care system. The limit to the quality of treatment that sick people get today is not based on knowledge but rather on structural aspects of the health care system, access to care, funding and other resources.

This has been a problem for decades and a problem which is worse in mental health care than in general health care. Within the last 10 years a new system has emerged and grown immensely, one that was advertised as at least a partial solution to these systemic problems. It was to offer a means of increasing efficiency, of controlling excess costs, of improving access and of monitoring quality. In most of these respects it has failed. Furthermore, its unintended side effects have been strikingly negative. I am referring to the managed care system. Its negative effects have included intrusions upon the doctor-patient relationship so that privacy and the autonomy of the physician caretaker has been seriously impaired. At the same time the problems it was supposed to solve-the problems of access, of cost control, of quality control- have not gotten better, and in the case of access have actually gotten worse.

What can we learn from this? One important thing is that we cannot focus simply on scientific knowledge and professional skills, on new treatments and new methods of treating; we have to make sure that the health care system allows that knowledge and those treatments to make a difference. It is the responsibility of the health professions to make sure that patients can get the best possible health care we have as well as insuring that the quality of that care improves over the coming years. We have to pay attention to the system. In many ways we are partly responsible for our problems. We were sleeping at the switch in the old health care system and failed to deal with some of the problems that it created, and for the most part slow to respond to the new problems created by the emerging health care system.

However, things are changing. We have raised the consciousness of the public, of our patients, of our political leaders, and effective action is beginning. We have to make sure that our patients have access to the best that we can offer them and that our community supports that access. What are the limits? One set of limits includes the problems of the general health care system. Another is the longstanding social stigma and prejudice against our patients, against the mentally ill and the diseases from which they suffer. Prejudice is to a great extent based on ignorance, based on assumptions that might have been valid two or three hundred years ago, but are not valid today.

It's always striking to me in teaching medical students how they assume that a psychiatric diagnosis assures chronicity and the failure to respond to treatment, and how startled they are when they learn that you are far better off in 2001 receiving the diagnosis of many major psychiatric disorders with the treatment currently available for those disorders, than you are with the diagnosis of comparably disabling physical disorders.

The public doesn't know this yet, and because it doesn't know it, it has not demanded that political leaders provide parity and access to diagnosis and treatment. We have to educate the public. We have to educate the leaders. And we have to monitor their performance. We as a profession have an ethical responsibility to assure that the emerging health care system provides treatments for those who need them. We have an ethical responsibility to care for our patients, but we also have an ethical responsibility to make sure that our society makes it possible for other patients to receive the care they need. Any health care system is tested by how well it cares for those who need help. Fifty percent of the burden of illness in this country is the result of psychiatric and behavioral disorders. Those individuals should not be disadvantaged because of a social stigma based on false beliefs. We have a responsibility to make sure that they aren't.

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