This leads us into discussing psychiatry per se, which managed care prioritized first. Unless you are early career psychiatrists, you are probably familiar with the anecdotal horror stories: too brief hospitalizations followed soon by suicides; the revolving door of re-hospitalizations; the escalation of the least trained psychotherapists to provide less psychotherapy; review of treatment by lesser trained clinicians or managers; denial of treatments like EMDR for PTSD that was deemed “experimental”, even if they were not; medication checks by psychiatrists being managed down to a 15 minute norm instead of the legendary 60 minute hour; and desparate polypharmacy to try to get faster results. Patients who recognized these changes sometimes called out in frustration: “Dr. X used to care about patients; now he cares about money”!
Yet, also in managed care and psychiatry, the human rights waters are muddy. If we take a step back in psychiatric time before managed care, we need to recall that in public sector mental healthcare for the poor, 15 minute med checks and inadequate hospitalizations (after deinstitutionalization) and the like were quite common in the 1960s and 70s. Managed care brought this to the social classes above the lower. Ironically, though, it is also the cost savings of managed mental healthcare that helped parity become politically acceptable, since it would not cost much extra if managed. Parity, however, may have turned out to be “Fools Gold” in terms of its treatment value.
But for managed mental healthcare, there seems to be even more than Article 3 and 25 to consider in terms of human rights. Why is that? One word may suffice: stigma.
So take Article 1: “All human beings are . . . equal in dignity”. Stigma reduces that dignity.
Article 23: “Everyone has the right to work . . .” We all know how those considered to have a mental illness get discriminated against being hired, and how they often need special help, such as that provided by Clubhouses, one of which I was most fortunate to Chair the Board. Housing has that same predicament, called “not-in-my-backyard”, which is mentioned in the previously cited Article 25.
Article 2 sets forth the various groups that need special protection, including “race, color, sex, language, religion, political or other opinion . . .” In the USA, progress was achieved in the appreciation of human rights for minorities, women, and others since the 1960s, though more progress is still necessary. But those with psychological problems were not mentioned in Article 2 as needing special protection and are lagging behind. And, if we want to make the Nazi association again, the mentally ill were the first targets. Globally, there is evidence that the majority of people with psychiatric disorders do not have access to evidence-based interventions. No wonder that the recovery movement has escalated recently, which emphasizes that we have to pay better attention and involvement as to what our consumer patients want as far as treatment goes. Yet, for all the philosophical and psychological worth of the recovery movement, it is also cheap and thereby welcomed by payers and managed care companies!
Managed care, by carving psychiatry out of medicine in terms of contracts, probably did nothing to lessen stigma, and perhaps contributed to worsening it. Then again, all is not so simple. One of the earliest rationalizations for the carve-outs of mental from general healthcare was because so-called bounty-hunters in the 1980s were rounding up adolescent and AODA patients for the for-profit hospitals for clinically unnecessary, but lucrative, hospitalizations. These Charter hospitals of the world were also profit-driven.
As my ignorance of this connection between managed care and human rights goes, I’ll plead guilty to the sin of omission, as perhaps could many, many others. Please accept my apology if this ignorance resulted in harm to patients.
(Stay tuned for the conclusion in Part 5).
Sad in Psychiatry: Affectionately called a "gadfly," and known as "da man in psychiatric ethics," Steven Moffic writes about what makes him sad about modern day psychiatry, and how to "treat" that condition so that we will become glad about what psychiatrists can do to help.