A Tale of Two Paradigms

I often wonder how to communicate more effectively with traditionally oriented colleagues who may have some beginning awareness of the shift taking place in paradigms of care in mental health and psychiatry. Some of them are closer than others to hearing the different perspective; certainly, some seem threatened by what they hear.

These are people who are not members of “the choir.” We have been pretty good at preaching to the audience already attuned to Mad in America and our continuing education project. But frankly, in my experience, we are not making enough progress in changing the way systems are working.

We need a platform for discussions and for increasing the understanding of diverging views—the tale of two paradigms. The purpose of this blog is to provide one such platform for that discussion. I will start by sharing two recent examples from Oregon and how the reports are shaped by the traditional “medical model.” Then, I will present the way in which the alternative model, the “social determinants model,” would critique them. Again, the idea here is to use this blog or parts of it in discussions with receptive colleagues.

It will be obvious that while I try to be as objective in my analysis as possible, I am an advocate for the “social determinants model” for reasons that I believe will become clear as this blog unfolds. I have included 10 talking points as an addendum to help with the discussions the blog is intended to stimulate with potential partners who are currently operating out of the “medical model.”

Before discussing the examples, I will lay out what I see as the primary characteristics of each paradigm. The “medical model” assumes mental health challenges are diseases. They are likely genetic in origin and result in chemical imbalances. They are there for the person’s entire life. Psychiatric medications restore the imbalances and reduce and keep symptoms of the disease under control. Often more than one medication at a time is necessary. Going off medications is very dangerous and usually results in relapse.  Access to care is paramount and based upon a foundation of regular medication checks appropriate to the disease diagnosis.

In the “medical model,” other services can be beneficial and include counseling and case management; ideal programs include housing, employment, educational, and family supports. Some programs are “trauma-informed” because stresses of all kinds aggravate the disease and lead to crisis services and hospitalization. Sometimes what is called “decompensation” causes threats of harm to self or others and can easily lead to severe confusion, paranoia, and even violence, which then lead to involuntary treatment. The most “chronically mentally ill” need residential treatment, often for life.

In contrast, the “social determinants model” assumes that mental health challenges are not diseases and avoids terms like “mental illness”, ”schizophrenia”, “chemical imbalances,” and “diagnoses.” People who are struggling should not be asked, “What’s wrong with you” but “What has happened?” Recovery is to be expected. Medications are used sparingly if at all and then for short duration.

In the “social determinants model,” treatment with drugs is seen as harmful, especially with mid- to long-term use. If a person has been on medications for any length of time, withdrawal is indicated but must be approached carefully and incrementally.  Peer supports like Individual Placement and Supports (IPS), Hearing Voices Network, “warmlines” staffed by “people with lived experience,” peer respite programs, Dual Diagnosis Anonymous (DDA), and complementary approaches like Soteria Houses are key elements.

In this model, the primary causes of mental health challenges are traumas of various kinds. The traditional mental health system is often a source of traumas. These often trigger reactions to earlier trauma experiences, especially psychiatric hospitalization and all forms of forced “treatment.” Professionals may be helpful in counseling and assistance in accessing safe, affordable housing but must be aware of all of the effects of subtle and not-so-subtle forms of power and control. Peers must be more than tokens in policy, program development, and evaluation. The model’s motto is “Nothing About Us Without Us.”

These two contradictory models and the assumptions behind them lead to very differing views of the two Oregon reports. The first example is a report issued in July 2020, “Better Health for Oregonians: Opportunities to Reduce Low-Value Care.”

The 50-page report was issued in July 2020 by the Oregon Health Authority on identifying “low value care” in the state’s health system. It was co-produced with the prestigious Oregon Health Leadership Council, a collaborative organization working “to develop practical solutions that reduce the rate of increase in health care costs and premiums.” The report had great potential—if it had it looked at the entire spectrum of health services through the lens of the “social determinants model.”

The overall goal of the council is to make health care and insurance more affordable to people and employers in the state. Formed in 2008, it brings together health plans, hospitals, and physicians to identify and act on cost-saving solutions that maximize efficiencies while delivering high-quality patient care. Of the 40 members of the board and council, there are no people with lived experience in mental health or addictions, nor are healthcare patients represented.

The Oregon Health Authority claims to be “at the forefront of lowering and containing costs, improving quality and increasing access to health care in order to improve the lifelong health of Oregonians.” To bolster that assertion, the OHA is overseen by the nine-member citizen Oregon Health Policy Board “working toward comprehensive health reform in our state.” Again, there are no people with lived experience or health care patients.

Those associated with the “social determinants model” would point to the absence of service users, patients, and psychiatric survivors on the major policy councils and boards. They would also challenge the system to understand the ineffectiveness and high cost of services in programs based on the “medical model.” They would point to the glaring black hole surrounding the practice of prescribing psychiatric medications. It is almost certain that the not even one member of the prestigious Council and Authority has any knowledge of the carefully researched findings regarding psychiatric medications outlined by Robert Whitaker, Joanna Moncrieff, Martin Harrow, Jo Watson, Peter Gøtzsche, David Healy, Lex Wunderink, Jaakko Seikkula, and many others. All have consistently documented the poor outcomes associated with these drugs and risks of physical harm. It is unlikely they have any knowledge about the discouraging story of withdrawal from psychiatric medications, the risks of which are still being uncovered.

The report’s Appendix 3, “Low-value measures by type,” lists 48 of these. Buried down in #40 and #48 are the only psychiatric practices that are considered “low impact.” Otherwise, all of the low-value services are physical health care in nature. The mental health services are (40) prescribing antidepressants as “monotherapy” for people diagnosed with bipolar and (49) prescribing two or more antipsychotics.

Mental health professionals and advocates coming from the “social determinants model” would point out that the first has been recognized as dangerous for 30-40 years but is apparently still used or would not have been listed. As for the second, the research and analyses listed above clearly show that using even one antipsychotic results in poor outcomes for most people even in the short-term, much less after mid- to long-term treatment. Using two or more neuroleptics is even more unacceptable, but more commonplace than would likely be acknowledged.

Those in the “medical model” would likely be reassured that there are only two psychiatric interventions needing attention for change. They can continue their practice unfettered and unaware of all of the many truly low-value psychiatric services identified by careful, unbiased research and analyses.

Those who identify with the social determinant model would read the report very differently as giving traditional mental health care a free ride. They would point to the potential savings and improved outcomes that would come by prescribing fewer of these drugs. At least in Medicaid, the budget value of psychotropic drugs is not recognized.  In most state Medicaid budgets, these expenses are deliberately separated—thanks to lobbyists for the pharmaceutical corporations. However, they are not minor budget items and well within the range of values of other interventions listed in the report.

Psychiatric drugs, many of which are prescribed by primary care doctors and/or other non-psychiatrists, have very little unbiased, well-researched evidence of effectiveness, and most of them carry risks, some of which are quite serious. This is true for adults, and is even truer for children and adolescents.

This is all illustrated in the data which came from a public records request made last year for Medicaid expenditures for all psychiatric drugs. It showed many alarming results. For example, Oregon providers were prescribing many drugs to children and adolescents. A total of $8.7 million was spent for all medication to children and youth—$3 million for antipsychotics, $1.5 million for antidepressants, and $2.7 million ADHD drugs.

Adherents of the “social determinants model” would point out the extreme risks in using these medications, especially for antidepressants, which carry the Food and Drug Administration’s “black box” warning against using them.

Adults are prescribed $82.2 million worth of psychiatric drugs. These costs do not even include the expenses of psychiatric drugs used in the state hospitals, state prisons, juvenile facilities, and local jails. Nor does it include private insurance or Medicare. To make national estimates for the costs, one should multiply the figures by 100 since Oregon has only about 1% of the country’s population.

It is especially odd that psychiatric services would receive this free ride because of the second report, Mental Health America (MHA) 2020’s report, “The State of Mental Health in America.” It is considered a devastating analysis of Oregon’s mental health system and is frequently cited in the media and elsewhere. It claims that Oregon is the second lowest-ranked state for overall mental health care.

The data upon which all states are ranked comes from the Substance Abuse and Mental Health Administration (SAMHSA), The Centers for Disease Control and Prevention (CDC), the Department of Education (DoE), and state data. The rankings are supposedly based on “outcomes,” but they are not real outcomes. Instead they are almost entirely measures of access to various levels of care and estimates of prevalence of various problems like suicidal ideas, rather than measures of functional outcomes and satisfaction with services.

This report has been eagerly employed by traditionally-oriented “medical model” advocates. They see it as a way of advocating for increasing the current types of services. However, in the absence of functional outcomes, those from a “social determinants model” would question whether access to “medical model” services is necessarily a good thing.

Critical thinkers from the “social determinants model” would ask several more questions: Who sponsored the report and how might sponsorship end up shaping the recommendations? The answer to sponsorship can be easily overlooked because the information shows up at the bottom of introduction section with the names and logos of 2 organizations, Otsuka and Alkermes. It states, “This publication was made possible by the generous support of Otsuka America Pharmaceutical Companies and Alkermes.”

However, it does not reveal that Otsuka is the maker of Abilify and that it is also “developing the ADHD drug centanafadine.” The second, Alkermes, has “more than 20 commercial drug products and candidates that address serious and chronic diseases, such as addiction, schizophrenia, diabetes and depression.” Among these products, “five are primary to the company: risperidone long-acting Injection (generic for Risperdal Consta) for schizophrenia and bipolar 1 disorder, paliperidone palmitate (generic for Invega Sustenna in the U.S., Xeplion in Europe) for schizophrenia.” There is no statement of the conflict of interest in having pharmaceutical corporations sponsor the report.

Perhaps because of this conflict of interest, the outcomes of the report reflect the interests of the pharmaceutical industry. Instead of measuring outcomes like increased functioning, recovering a full and complete life, decreased suicides, improved relationships, and affordable, safe housing, the report measures only how well people can access psychiatric drugs.

Both reports are highly flawed from the “social determinants” perspective and very reassuring to “medical model” adherents.

A major challenge for advocates will be to help the adherents of the “medical model” understand the differences between the paradigms. As system changes based on the “social determinants model” begin to pick up steam, another challenge will be to counter the inertia and resistance of providers. This resistance will be strongly supported by advocates for the existing systems of care. Certainly, as programs rely less on medications, the pharmaceutical companies will resist with all their might.

This blog should be used as diplomatically as possible with receptive providers, advocates, legislators, county mental health officials, and any other interested organizations to stimulate changes from the “medical model” to the “social determinants model.” The Addendum: Talking Points may be of assistance in organizing discussions that can be arranged by sharing this blog.

ADDENDUM: TALKING POINTS

1. There are two conflicting models for the design of mental health programs—the “medical model” and the “social determinants model.”
2. The key conceptual difference is that the “medical model” asserts that mental health problems are diseases that respond well to medications, while the “social determinants model” asserts that the problems are trauma-related and respond best to support and relationships.
3. Two recent reports from Oregon illustrate the ways in which the two models result in significantly different conclusions.
4. A problem with both reports is the absence of input from persons with lived experience.
5. The Oregon Health Authority report avoids identifying the major ‘low impact” psychiatric interventions, namely psychiatric drugs, ignoring decades of outcome research.
6. The costs of psychiatric drugs in public and private health insurance budgets are higher than is commonly understood and clearly within the range of all the other “low impact” services identified in the report.
7. The Mental Health America 2020 reports focuses on data related to access to care rather than the quality of that care and improvements in life that result from the different models.
8. This emphasis on access to care is driven by the financial sponsors of the report, two major corporations that create and sell psychiatric medications.
9. Functional outcomes, (i.e. people recovering full and rewarding lives) associated with the “social determinants model” far exceed those same kinds of outcomes associated with the “medical model.”
10. This blog should be used diplomatically with receptive mental health practitioners and program developers to assist them in reformulating their services and supports.