What Would a Truly Integrated System of Care Look Like?

Robert Nikkel, MSW
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Imagine that you were the director of a health insurance company and you had just agreed to provide health coverage to several hundred thousand people and you will have to fund health care including mental health and alcohol/drug care too. This is called “integration.”

What it means financially is that you will lose a lot of money if you ignore the physical health needs of people with mental health problems. In the parlance of insurance folks, you’re “at risk.”

Now, someone walks into your office and tells you that about a quarter to a third of the people you’ve just signed up to serve are being poisoned but no one really knows about it or recognizes it. If it’s true, you stand to lose a lot of money unless you figure out what’s going on. And what if they also tell you that the poisoning is not some form of environmental pollution like smoky air or unclean water but is actually being caused by the very providers of health and mental health that you’re about to be supporting?

Since you’ve been in the health insurance business for a while, you recognize that in western medicine, almost everything that’s provided is some form of mutilation, i.e. surgery, or poisoning, i.e. medications. (Please note that if you’re a physician and reading this and taking some level of offense, the recognition I just pointed to was made by a physician, a well-respected one at that and he meant no offense, nor do I—just a simple way of thinking about things and the key question is whether the risks outweigh the benefits or vice versa.)

So as you might have guessed, the poisoning is not really recognized for what it is—but psychiatric medications do act as toxins in the sense that they cause many health problems, both in the short-run and also in the long-run—and you will soon be paying for it all. I won’t go into all of the medical expenses that are incurred by neuroleptics, aka antipsychotics, to use just one example, but they include metabolic syndrome which translates to the costs of diabetes, heart disease, and increased rates of cancer. The costs of end-of-life care for people with major mental health challenges have yet to be calculated as far as I know but they are likely to be considerable.

And because you’re a really thorough business expert, you also begin to study up on the effectiveness of the psychiatric medications and discover what unbiased research shows—that they’re not very effective. Most, though not all, people who take them do worse, especially after a couple of years. This adds up to more costs for psychiatric hospitalizations. Finally, you discover that these medications are really pretty expensive but the costs are likely to have been hidden in the public system because the pharmaceutical corporations have lobbied to keep their costs uncontrolled and outside the budgets of many programs.

You have a real dilemma. You’re faced with designing a system and providing funding that could end up costing you a lot more than you’re going to be receiving from employers or the state or whoever is your primary contract funder.

The purpose of this blog is to show the kind of system you would have to design. If you’re planning to be in business for more than a few years, your services would give better results and cost less.

What follows is a list of indicators that can lead to focused advocacy in order to make good on the many brave and politically popular promises to integrate care. It is admittedly an extremely ambitious set of standards

1.   The healthcare system will employ only professional and other health support staff who understand that mental health challenges are not chemical imbalances which can be managed by ongoing use of psychiatric medications.

2.  Healthcare providers will have received professional education based on well-constructed research that shows the long-term negative recovery outcomes associated with using psychiatric medications.

3.  Healthcare providers will have received professional education on the negative health impacts of short-term use of psychiatric medications.

4.  Prescribing professionals will provide this information on health risks associated with even short-term use of psychiatric medications on a consistent basis to those patients who they recommend short-term use of medications.

5.  Healthcare providers will have received professional education on the negative health impacts of long-term use of psychiatric medications.

6.  Prescribing professionals will provide this information on health risks to all patients who have been or will be prescribed psychiatric medications on a long-term basis.

7.  Healthcare providers will support patients who choose to taper and eventually withdraw from using psychiatric medications.

8.  The use of antidepressants prescribed by general practitioners and family care doctors will be reduced by at least 90% and therapy and other supports will be available from mental health staff to assist with the withdrawal process and working through trauma and other situational stressors that have led to depressive symptoms.

9.  All health care providers, including mental health and addictions staff, will be educated in the way in which nutritional factors can manifest as a range of mental health and substance use syndromes. They will be trained to educate patients on improving nutrition as a way to resolve mental health and substance use syndromes.

10.  All prescribing professionals will be prepared to manage pain without creating opioid dependence.

11.  All prescribing professionals will be prepared to assist patients with managing anxiety without use of benzodiazepines.

12.  All mental health and addictions staff will be trained in assessing the impact of psychiatric medications on physical health care status and refer patients whose physical health care has been damaged by these drugs to healthcare staff who can assist with managing and reducing the health risks involved.

13. The 20-25 year shortened life expectancy for people who have been diagnosed with schizophrenia and other mental health diagnoses will be reversed so that their life expectancy becomes equal to those who have not received these diagnoses.

14.  The 30-35 year shortened life expectancy for people who have been diagnosed with major mental health problems AND substance use disorders will be reversed so that their life expectancy becomes equal over time to those who have not received these diagnoses.

15.  The use of ADHD drugs prescribed to children and adolescents is reduced by 90% by referrals to family therapists, nutritionists, and increased enrollments in physical activities.

16.  Dental care is evaluated for all patients who have mental health and substance use problems and provided without discrimination or exception.

17.  All discrepancies in access to integrated health care for racial, ethnic, geographic location and sexual identity/preference groups are eliminated.

18.  Housing resources are prioritized for lower income patients and families so that the barriers to health created by insecure, unaffordable or unsafe living environments are eliminated.

19.  State and local leadership for mental health and addictions is restored or strengthened to ensure continued oversight and advocacy needed to achieve the other indicators in this set of standard outcomes.

20.  Funding is allocated so that resources needed to support all of the indicators in this set are preserved and increased where needed and that efficiencies gained by reducing reliance on psychiatric medications are not diverted to profits or increased administration budgets.

As I noted earlier in this blog, this is a daunting list. No integrated health care system I know of is near meeting very many of them. In fact, I would be surprised if any such system anywhere is meeting even one of them. But that highlights how far we have to go, how little the rhetoric really means, and why we need to begin posing these indicators—the sooner the better.

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34 COMMENTS

  1. How did it ever become the responsibility of the U.S. government to care for the health of its citizens?

    “In the 1950’s, when I wrote The Myth of Mental Illness,” Thomas Szasz wrote in a new preface to his book with the same title, “the notion that it is the responsibility of the federal government to provide ‘health care’ to the American people had not yet entered the national consciousness.”

    Ponder that for a moment.

    Szasz continues: “Fifty years ago, the question ‘What is mental illness?’ was of interest to the general public as well as to philosophers, sociologists, and medical professionals. This is no longer the case. The question has been answered – ‘dismissed’ would be more accurate – by the holders of political power: representing the State, they decree that ‘mental illness is a disease like any other.’ Political power and professional self-interest unite in turning a false belief into a ‘lying fact.’”

    There you have it. The lying fact of “mental illness” is now combined with political power and is so deeply engrained in our collective consciousness that we no longer question its validity. Furthermore, the notion that it is the responsibility of the federal government to provide ‘health care’ to the American people is so deeply engrained in our culture that most people don’t realize that such lying facts have outmaneuvered the truth in a relatively short amount of time.

    Therefore, as the director of the aforementioned health insurance company, I would simply pose the same questions that Szasz posed in the new preface to his book “The Myth of Mental Illness.” Then I would look for a new job.

    • How did it ever become the responsibility of the U.S. government to care for the health of its citizens?

      This is a diversionary argument. All governments should be expected to act on behalf of their citizens’ well-being or they have no legitimacy.

      The issue here is that the “health” industry does not heal, and that the “mental health” industry is actually a parallel police force.

      • Oldhead, I completely agree with you that the so-called “health” industry does not heal, and that the “mental health” industry is a police force. These industries actually thrive on making citizens sick and keeping them that way. However, the notion that it is the responsibility of the U.S. government to care for the health of its citizens is relatively new. Szasz was right about this, and it is certainly a question worth pondering. The preamble to the U.S. Constitution makes it quite clear what the aims of the government are and ought to be, namely, to form a more perfect union, to establish justice, insure domestic tranquility, provide for the common defense, promote the general welfare, and secure the blessings of liberty for ourselves and our posterity. Even in the 1950s, as Szasz points out, the notion that it is the responsibility of the federal government to provide ‘health care’ to the American people had not yet entered the national consciousness. It’s worth considering why and how this notion entered the national consciousness and whether or not it makes sense. There is a direct connection between the rise of the therapeutic state and the flourishing of psychiatry.

  2. A truly integrated system of care would mean that we have zero privacy, not even in our thoughts. We are being subject to manipulation at every turn.

    My friend, needed care for his heart condition from the County Hospital. But they wanted to send him to a psychiatrist and get him put on the neurotoxin Zoloft.

    So I wrote to him and length warning him how bad all types of psychotherapy and psychiatric drugs are. I offered to find him a lawyer. He accepted my offer, and he also terminated all contact with the psychiatrist.

    So I am very pleased. At this juncture he also has no need for a lawyer.

    But if they tried to make his heart condition care subject to seeing the psychiatrist? Is that what is meant by integrated care?

    Then he would need a lawyer.

    We must fight this idea of integrated care as though our lives depended upon it, because they do. I also suggest a good place to start is with the new building at UC Irvine, and also because of the seeming connection between that and the Saddleback Church.

  3. The list is very thorough, though incomplete in one regard: to put an end to “ADHD” diagnoses, we need to revise the oppressive nature of our educational system and take an approach that respects the individuality and internal motivations of our students. The industrial educational model is responsible for probably 90% of “ADHD” diagnoses. Consider alone the fact that 30% of the “ADHD” cases go away if kids go to school one year later. Clearly, schools (and now even preschools!) are expecting things from kids that are not appropriate, and alternative models already exist. Time to start doing what works instead of what’s politically expedient!

  4. A big one is importance of eliminating forced treatment and also knowing the role trauma plays in this system.

    We need this in an integrated system. I know I use system time and time again but am stable much of time though.

    Peer run respites are great because one can leave when feel up to it. Haha.

  5. Robert, thank you for this excellent and provocative article. What passes for “integrated care” is generally pathetic. My experience has been that integrated care means psychiatrists make decisions that “allied health professionals” (such as psychologists, social workers, peer support workers) are required to support. The latter can occasionally say a few words that offer a different perspective, but they are generally of little relevance or impact, and often only have an opportunity to be expressed after the psychiatrists’ decisions have been implemented as when “medication,” ECT, and so on have already begun. Such care is “integrated” only in the sense that multiple professionals are theoretically able to chat to each other about it. That is a superficial and fairly meaningless way of operationalizing “integrated care.” Though I imagine this version of integrated care is held in high esteem by psychiatrists who can use it as evidence of their commitment to teamwork, patient-centered care, holistic treatment, or (insert your own meaningless buzzword or phrase here).

  6. “Mental health” is an oxymoron. The whole crappy system prevents recovery from emotional pain and creates sickness where none existed. My “bipolar” was entirely iatrogenic and none of the doctors I see now realize I’m off my cocktail. They assume my mood swings are gone because my “meds are working.” Bunch of idiots!

    • Really bad reaction to the SSRI anafranil. It kept me awake; the entire 3 weeks I took it I dozed for a total of 10 or 12 hours. Psychotic mania like I never experienced before or since.

      Darned pills ruined my life. Trying to rebuild my life from scratch at 44–after 24 years–with no help from anyone. Off the “cocktail” of mind altering drugs finally. But I ache all over and am chronically unhappy. Lonely, unable to pay all my bills on $760 a month. And aching all over like I have the flu all the time! Anemic and low in vitamins but scared to see a doctor because they are liars or gullible sheeple.

      A psychiatric survivor pen pal nags me to make new friends and crap. How? No job. No social support but the Loony ghetto for decades and my (sometimes) emotionally abusive parents. Too late to start over. I’ve chosen the recluse way. 🙁 Plus there is no reliable transportation here except pricey cabs.

  8. Your article is right on the mark, Bob. And beyond my agreement with all of the markers you propose for an integrated system of health care, I particularly like your sensitivity to those who might find the use of accurate terms like “mutilation” and “poisoning” not to their liking. We all need to show this kind of sensitivity and compassion, while also maintaining an unyielding focus on the real effects of the deficits involved in mental health system failures. Psychiatry, and my own profession of psychology, have in the main become inured to perspectives other than that held by the dominant and controlling role of “expert.” This limited “expert” perspective is reinforced by the political and economic pressures to successfully meet the minimal standards for treatments covered by payers, and to not extend “treatment” beyond the reduction of “acute” symptoms. As we have seen in the past, successfully achieving these short term goals can foster an expert’s self-importance, defensiveness, and being closed to alternative viewpoints. That type of expert perspective and system orientation might even lead an “expert” professional association leader to declare a person who is voicing evidence-based contentions to accepted standards, to be “a menace to society.” So, compassion and understanding for those so caught in their self-fulfilling web of rigidity is very important. And by doing so in your article, you are living the Recovery values you preach. Your past work as an administrator was filled with many examples of compassionate visions of effective system transformation.

    I would, however, want to promote some awareness of fledgling organizations which are displaying your integrated health care organization markers. I do not know of many, but I was fortunate in November to have been provided tours of two such organizations in Tucson AZ. Assurance Health and Wellness Center (http://assurancephoenix.com/assurancewellness/index.html), particularly their original integrated health care clinic in Tucson, not only orients itself around Recovery values, but has embedded in all areas of treatment, administration, and governing authority the roles of Peer Specialists to guide and ensure reality-based program planning and evaluation. This organization was purchased by a larger integrated healthcare enterprise, but the Tucson site is still serving as the model for organizational health at the 16 additional clinics they are operating across Arizona. A smaller organization, Camp Wellness (http://medicine.arizona.edu/news/2016/ua-camp-wellness-receives-2016-recognition-excellence-award-us-substance-abuse-and-mental), is also the type of effective smaller scale organization which never loses site of self-determination and strength-based factors necessary for sustainable client hope, inspiration, and motivation. Such organizations can serve as models of the values and markers your article portrays so well.

    Thank you for your ongoing attention to the administrative realities of true system transformation toward a Recovery future.

  10. This article is all about “reform, reform, reform.” Nothing to discuss really. If you believe that a “better mental health system” is what we need, this will be music to your ears. If you see the impossibility of transforming a de facto police force into a vehicle for addressing the collective trauma of living under a corporate dictatorship, you will understand the futility of arguing and move on.

    • I almost entirely agree with your excellent sentiments, especially, ” the collective trauma of living under a corporate dictatorship,” however human distress is universal and societies need systems of care to address this. It doesn’t need to be psychiatry but I suspect most societies needs something that is organised to help address the needs of the severely distressed.

      • That’s a different issue though, isn’t it?

        The missing bit of analysis in, I daresay, most people’s anti-psychiatry critiques is the unexamined and unchallenged assumption that the purpose of psychiatry is to “help” people, and that it simply does a poor job. But that is not why the state supports psychiatry and backs it up with guns if need be. The institutional function of psychiatry (independent of any individual practitioner’s motivation) is to control people via mystification and self-blame. Once we recognize this we can detach from the often sub-conscious assumption that, if shrinks only “understood” that they are being unhelpful and had better information, they would change.

        This is why I object to the concept of “alternatives” — not because people don’t need actual means of support, but, among other things, it sets up psychiatry as the standard, and actual support as an “alternative.”

        • I think psychiatry is a mixed bag. While I realise this is rubbish as a figure it lets you know how I feel about things: I think psychiatry is 80% harmful and 20% useful. The useful things are listening, talking, understanding, encouraging, providing sanctuary and even drugging people into some semblance of peace when nothing else is available. None of that needs to be provided for by psychiatry and often isn’t.

          For myself I usually the functions of psychiatry are to be the drug delivery agent of Big Pharma and to make sure no one thinks about why people are distressed.

          If on a societal level, ie the powers that be were held to account, thought about why people were distressed then the powers that be would have to have a lot less power as poverty, racism, sexism, violence and sexual assault are at the bottom of so much mental distress. Plainly the powers that be would not welcome that, so yes I agree psychiatry on the whole is about social control.

          So I suspect our positions are not too far apart. I am saying it is politically sensible to acknowledge that a lot of people do, and will always need support.

          • To continue in the same vein, as I think people roll their eyes too often when I identify psychiatry as literally (not analogically) a branch of the “justice”/prison system, not a rogue form of medicine:

            The useful things are listening, talking, understanding, encouraging, providing sanctuary and even drugging people into some semblance of peace when nothing else is available.

            Even without commenting on the drugging reference, these things you cite as needs addressed by psychiatry are clearly not medical functions, they’re more akin to social work, personal support, and political struggle, so first off all shrinks with integrity should toss their medical “credentials.”

            Second,
            I am saying it is politically sensible to acknowledge that a lot of people do, and will always need support.

            That’s like saying a lot of people are human, or need air to survive. We are conditioned to consider such assertions as ipso facto arguments for psychiatry, but should recognize that this is a conditioned response we need to leave behind.

  11. Targeting a segment of the population, children, giving them senseless drugs just to experiment with altering them, and to feed an industry. Can anyone tell me why that would not fall within the Nuremburg definition of Crimes Against Humanity, and its Capital form?

    Via a German NGO we could investigate and get a court to bring an indictment, just like was done with Donald Rumsfeld and George W. Bush, never expiring War Crimes indictments. Won’t see either of those two guys at October Fest.