American Psychological Association
Inappropriate Prescribing
The drug industry
Health insurance reimbursements are higher and easier to obtain for drug treatment than therapy, which has contributed to the increase in psychotropic drug sales and a shifting of psychiatry toward psychopharmacology, says Daniel Carlat, MD, associate clinical professor of psychiatry at Tufts University and author of the 2010 book "Unhinged: The Trouble with Psychiatry."
"There is a huge financial incentive for psychiatrists to prescribe instead of doing psychotherapy," he says. "You can make two, three, four times as much money being a prescriber than a therapist. The vicious cycle here is that as psychiatrists limit their practices primarily to prescribing, they lose their therapy skills by attrition and do even less therapy."
http://www.apa.org/monitor/2012/06/prescribing.aspx
Imo- This is an equally touchy subject but I have long worried about the effect of some of the very powerful psychotropic drugs prescribed to the developing brain. And these drugs are new (last 40-50 years). When they match the diagnosis they are brilliant.
--But what happens to a child prescribed the wrong meds, or not followed up on properly, or misdiagnosed? What happens when the trend is to prescribe drugs first?
I have long worried about about our seniors who are often prescribed ten or so different drugs at the same time. My dad's doc is one who has changed course and reduced his meds to two.
Imo- Is our insanely overpriced HC system driven by Big Pharma? (The other giant political lobby in Washington DC)
When we talk about the mentally ill and guns, what are some of the correlations, I wonder?
Our LE is overwhelmed by an opioid crisis. There might be as many drugs as guns out there in America. --A very deadly combination...
Your concerns about psych meds, the role of psychiatrists, and the state of our mental health care are spot on.
The difficult and harsh truth to accept is that for the vast majority of seriously mentally ill people, there is no "cure". Those who have a
brief situational mental health crisis, such as grief following the death of a loved one, a relationship break up, situational depression, even maternal post partum depression-- these kind of mental health conditions often resolve without life long impairment.
But for many, many people, the approach to their mental health needs is lifelong. Often a combination of meds with intensive and/ or regular, perpetual therapy is needed for them to be maximally functional, and appropriately supervised and monitored.
Lots of people being treated for mental illness, and/ or their families, are
resistant to this kind of plan.
Lots of people being treated for serious mental illness and/ or behavioral conditions arising from organic brain problems, and their families,
WANT this kind of plan. They want them to be closely monitored, with regular therapy, respite/ overnight care available for families, and the option of short term AND long term residential care.
The harsh issue is that no one wants to pay for the HUMAN component of care and supervision, which is astoundingly costly, relative to even expensive psychotherapeutic drugs. Educating, training, hiring, retaining, and paying for all of the levels of providers is HUGELY expensive. This encompasses all levels from aides, to psychiatrists.
With outcome evidence so depressing and dismal, and relapses and deterioration so common, it's my opinion that the entire industry from payers (insurance sources) and providers has HAD to shift to a crisis-oriented outpatient approach for intensive mental health care, and relies on meds to "control and supervise" seriously ill patients. Meds are still, IMO, vastly cheaper than HUMAN resources to nurture, care, comfort, and supervise. Supervision and regimen compliance (meds and appointments) has been outsourced to families.
When families reach their breaking points, need respite, or need to have their loved one removed into residential long term or short term care, the bar is VERY high to get those services, except for brief hospitalizations. The plan is ALWAYS to return the patient into the care of their family members, until the family abandons the patient, AND the patient FINALLY demonstrates they are "enough" of a "danger to themselves and others."
Civil outpatient commitment, IMO, is a management strategy that is underutilized to mandate compliance to a treatment regimen.
To get to the point where someone CAN be put into a civil committment status, or guardianship status, there has to be a LONG paper trail of a lot of contact with the mental health system, social services involvement, school involvement (for minors), and yes, the justice system when they display violent or criminal behaviors, threats, and tendencies.
So it's easy to see the leap to how the criminal justice system has become the de-facto network of residential care for a lot of mentally ill people.
And when we shield mentally ill kids, young adults, and adults from developing that needed HISTORY within the criminal justice system AND mental health system, it is virtually impossible to keep them from doing things like buying weapons. Until they have ENOUGH history officially in the background system, and they have not had their rights removed by a court, or put in guardianship status, then they CAN pass background checks and buy weapons.
And we can't seem to "fix" the problems with adequate supervision, mandatory compliance to treatment regimens, adequate ACCESS to competent mental health treatment regimens, enough mental health workers at all levels of care, and willingness to pay for the millions of people who need lifelong care and supervision.
So what you have is a system that preserves the "rights" of seriously mentally ill people to refuse or avoid care, above the "rights" of the rest of the public not to be hurt or injured by them.
Coupled with a liberal/ progressive ideology that abhors the involvement of any level of police or criminal justice consequences with violent behavior by mentally ill people.
Coupled with the relatively easy access and affordability of psychotropic drugs that blunt and control violent behavior, and frequently improve the societal functioning of the mentally ill.
So that's where the money has gone. We pay for psych drugs fairly readily, and are thrilled when patients and their families are in compliance with the process of outpatient medical psych appointments, because we have done "something" that can be demonstrated with actual outcome data, that works, to improve the lives of the ill person, and everyone around them.
Psych drugs DO work to control violent behavior and impulses in the correctly identified and diagnosed population of the mentally ill.
I think we clearly know what "doesn't work" at this point.
The trick is determining how, as a society, we are going to compel treatment from those that are unwilling. The challenge is deciding who is "mentally ill enough" to compel them to have a care regimen, and consequences/ interventions when they don't comply. The challenge is deciding from which people we will restrict their rights.
Currently, it seems (IMO) that a lot of anti-gun ideologists would prefer to work on these "people problems" by creating more restrictions on the rights of the many (law abiding gun owners to have), in order that "the few" criminally impulsive/ criminally insane "might" have less access to guns.
The sheer raw emotion of these mass killings by very troubled people has shifted the focus of attention to "gun control", rather than "controlling bad people". Why? Because guns are inanimate objects that are far easier to control than people. And passing more laws to control law abiding people is far easier than actually tackling the issues of deciding how we are going to structure a process to remove rights from some people who are seriously ill and/ or permanently impaired.
There is also an unrealistic/ childish "wish" by a lot of people that "if only" someone like NC had had just a little more "talk therapy", he would have been "cured" of his "mental illness". I've heard and read a lot of people lamenting that "If only" he had continued to take his prescribed meds, he wouldn't have shot and killed 17 people. Neither is correct.
Someone like NC was seriously, permanently, and organically impaired, and IMO, should have been in multidisciplinary mandated treatment, coupled with legal restrictions on his "rights". He needed lifelong supervision and treatment; now he will get it.
NC avoided treatment, or was only sporadically compliant, and the rest of the adults in the mental health, school, and law enforcement systems avoided doing ANYTHING legal and official that would have restricted his rights to buy a gun. They
enabled him,
at every level, to become the killer he now is, IMO.
Nobody, but nobody, wanted to stick their neck out to start the process of civil commitment for this massively disturbed youth. Nobody wanted to bring criminal charges against him. Lots of people begged LE for help, and "said something". Those who could have *done* something, didn't do the
RIGHT thing.
Timothy McVeigh bought fertilizer and rented a truck. He killed 168 people without a gun. But IIRC, he was a veteran, and had knowledge of, access to, and interest in guns. He chose to use a bomb to carry out his murderous intent. The Columbine killers didn't need AR-15s. The Virginia tech shooter used handguns. Numerous school shootings have been carried out with handguns. Terrorists have used knives to slash, and trucks to run over groups of vulnerable pedestrians.
Guns aren't the problem. People are the problem-- people with bad intentions.
But guns are an easy villain. Guns are inanimate and don't talk back. They don't vote. They are scary looking, and can kill. Gun control activists who have never handled, or shot a gun, are regarded as "experts" by the anti-gun media and activists. The media won't publish very many occurrences where a "good guy" with a gun prevented, or stopped, a "bad person with a gun" from more mayhem. That is simply too controversial for the anti-gun agenda.
The serious issues we cannot seem to get a handle on is how to identify and control the PEOPLE who have murderous intentions.
But yes, it is easy to medicate those that are willing to be medicated to control their serious manifestations of mental illness. So I don't see that stopping any time soon. Other than incarceration in the criminal justice system, it's pretty much the only effective thing we have for the mentally ill with criminal and violent behaviors.
God, it's so depressing.
