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February 6, 2018 by Bob Nikkel, MSW

What Would a Truly Integrated System of Care Look Like?

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.


bnikkel_miaceRobert Nikkel, MSW, is a Clinical Assistant Professor in the Public Psychiatry Training Program at Oregon Health and Science University. He was the State of Oregon’s commissioner for both mental health and addictions from 2003-2008. He is the director of the Mad in America Continuing Education project and a member of the Board of Directors of the Foundation for Excellence in Mental Health Care.

One thought on “What Would a Truly Integrated System of Care Look Like?

  1. Ed Childe BSc MD says:

    Thank you for this.
    I was lucky enough to begin medicine and psychiatry in 1952 before there were any supposedly effective psychiatric drugs. I’d studied science, and Freud’s efforts to help people to open up safely to find the cause of their psychological distress seemed an excellent scientific way to go.
    In psychiatric residency I found that getting to know my patients and their life stories provided an answer to why they had debilitating symptoms. Since we’d done this together it gave them the knowledge to do this themselves, and they began to recover.
    With this wonderful beginning its not surprising that I refused to drug people, even if it meant fleeing McGill and Canada for therapy for myself, and to try to earn a living in the drug era.
    Helping people with psychoses was more challenging because the inciting traumata usually dated back to infancy, and so therapy was much more protracted, but modified psychoanalysis frequently produced extremely gratifying results.
    Sometimes I think that we forget that we are mammals and that a great deal of our development happens before our rational left brain gets going.

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