Serious Mental Illness in America with Dr. Zac Brooks

I am lucky today to be able to bring you an interview with Dr. Zac Brooks who is passionate about serious mental illness (SMI).  “What is serious mental illness?” you might ask.  That is one of the things we are going to discuss, and you may be surprised when Dr. Brooks explains how it was first formally defined.  We also discuss the numerous ways the US has tried to reform how SMI is treated with variable results.

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Transcript

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my future not being canceled is in your hands like a tiny baby bird[Music] right welcome to pactic today is Wednesday February 14th 2024 I'm your host Dr Ryan oir I am a fourthe Psychiatry resident in the national capital region this is a podcast about Psychiatry and Neuroscience I'm lucky today to be a to bring you an interview with one of my residency colleagues Dr Zack Brooks who is passionate about serious mental illness what is serious mental illness you might ask well that's one of the things we're going to discuss and you may be surprised when Dr Brooks explains how it was first formally defined now I'm going to shamelessly ask that if you do find this podcast helpful or interesting or a good way to fill your morning or afternoon commute could you please rate it in whatever app you're using that would help me out a lot also you can send me feedback by filling out a form atactic tocom or you can comment on episodes on YouTube search for this podcast by typing atactic into the search bar without further Ado I give you Dr Brooks welcome to the podcast Zach why don't you take a minute to introduce yourself uh to the listeners like and tell us a little bit about yourself hey Ryan thanks for having me um a little behind the scenes for everybody Ryan and I are friends in real life we're casually kind of chatting about topics that we're both interested in in Psychiatry and felt like you know what we might as well record it because Ryan has a podcast um but these are the same kind of soapbox style conversations we would have on or off the air in the um parking garage every now and then yeah that's true that's true I I have kept Ryan from leaving to vent about something oh my name is Zach I'm also I'm in The Residency with Ryan similar disclaimer you know this is all my own opinion I'm actually another behind the scenes I'm a big fan of the show it's pretty cool to come on the show for something that you are already a fan of and uh I'm particularly interested in serious mental illness that's something that I've been passionate about for a long time um there's serious mental illness in my family that's part of what got me interested in psychiatry in the first place um some people in my family got access to behavioral health services and lived fairly functional lives a lot of people did not have access to Bor health services and have not been nearly as functional in and out of psychiatric hospitals State hospitals Etc jail um prison Etc so I've seen directly firsthand the effect that access to Psychiatric Services particularly for people with serious mental illness can do and that's what made me interested in Psychiatry it's what made me interested in serious mental illness which I keep using that term what we can talk more about that later yeah I was gonna I was gonna uh interrupt you for and say so um casually if people say serious mental illness I think people kind of get this idea of okay that's that's a bad one right that's something that like affects people's lives uh a lot probably but I'm sure there are other definitions and you had mentioned getting services and things like that so I think there are specific definitions that are important when you're talking about how people get services or how get funded by the government yeah and again I think for behind the scenes for The Listener this is what I mean that this would be a conversation that we would have anytime because it's just going already but yeah so there's two terms that sometimes are used interchangeably P SMI which is persistent serious mental illness and then serious mental illness and sometimes those are used interchangeably long story short we're talking about mental health conditions that cause a significant amount of functional impairment in multiple avenues that includes occupational social personal relationships Etc so this term actually like the concepts behind this have been known for a long time right you know for Millennia people have described in various writings people who in old days they used to say maybe like cultural things such as had demons um or witches and then later on you know people would say that they were odd or you know dementia precox even right like early on set of dementia is what appeared like um Catatonia has been noted for hundreds of years and so but the term serious mental illness actually came in 1992 that's the first time it was like brought together as a concept and like a lot of things it was brought together because of funding the alcohol drug abuse and mental health administration reorganization Act of 1992 it's a big mouthful I'm a ctory nerd so I think it's kind of a cool aspect and Ted Kennedy was the person who presented that and and was kind of the main sponsor and it was almost 30 years it was 29 years after his brother introduced the Community Mental Health act which is was well intentioned but kind of is how we ended up where we are today when it comes to people with serious mental illness explain what you just meant by that yeah you know a little another behind the scenes I would say um Ryan has three podcasts from December that are related to schizophrenia um antis psychotics anti Psychiatry Etc that are related to anti psychotics and I think that I see our discussions honestly as like a continuation of your podcast already so I would highly encourage you to go listen to those um but you one of the things you mentioned is like in the early 1950s plor promazine or Thorazine was first discovered right it was discovered in France accidentally right it was they were looking for things to help with surgery anesthesia um and help to sedate people and they're like well they're not that sedated for surgery but people who are Manish seem to be calmer now it is a it's kind of sad that most of the drugs we give at least the classes were accidentally discovered especially in Psychiatry exactly yeah go ahead and when we say serious mental illness I'm going to do a more of a definition later but I I want you to think about things that are so disabling that you are likely not able to function on your own without significant support schizophrenia bipolar one disorder sto affective disorder it's not quite that narrow we'll talk a little bit more about the actual definition but just things that would cause such significant functional impairment particularly pre1 1950s medic that you were likely not able to live on your own so for hundreds of years we have people who when they became sick quite sick mentally with mental illness and suard we would become institutionalized or hospitalized and potentially for the rest of their life and for a while that was very prison-like right even until like the 17 1800s where people finally Unchained from um the walls and things like that and you know there's a lot of kind of dark history of things that they tried um you know we don't need to necessarily get into that right now we can at some point if you want but you know pouring water on people in ice bats and Insulin Comas and you know I mean pretty inhumane things at times just because they didn't know what to do um but well-intentioned does not mean that you was right exactly so we get into like the 1950s chlorpromazine thorine is developed and in America at that time there's half a million people are institutionalized and the interesting part is that like there would be people with Advanced Alzheimer's Dementia in their 70s next to a 22-year-old with bipolar one Mania but we didn't have treatments for either so we just would put anybody who the families felt like they couldn't live at home would just go there chlorpromazine and antis psychotics starting to be developed in the 50s change totally changes the game right people in France and in Europe to start with get medication and they leave they go home they haven't seen their family in a decade and they come back and the family's like oh my God you look a lot similar to what you used to look like is a revolution yeah yeah absolutely you know it got to the point that after you know over a decade since the medication came out John Kennedy and and there's a lot of books about the kennedies related to mental health conditions in their family um one of the ones that was that their sister is kind of like was hospitalized believe at St Elizabeth in DC at one point and so um but there was serious mental illness and she was pretty disabled um due to her mental health conditions and so there was in their family they were quite passionate about getting access to mental health care and the Community Mental Health Act was designed essentially to try to say hey we now have medications that can help a lot of these people no longer need to be again it was literally called institutionalized not even hospitalized because you go there and you're there you to get treated they just stay there so that you don't bother anyone else correct yeah yeah you might just roam the drowns you know or you know or anything like like no one's necessarily saying that you're like getting better or even staying the same you're just not you know your family couldn't take care of you and now you're in removed from them and the ones that cost more money probably provided more comforts you know and freedom for the uh I guess did they call them patients or did they call residents it depends on where they were depending on the institution some of them hardly even had Physicians right some of them literally were psychoanalysts or or if they were Physicians they weren't practicing with medications and so yeah I was listening to a uh story of this journalist who got herself committed in New York City to one of their asylums for women and she like she had a hard time getting out but when she finally did she did it just to get in there and see what it was like and she wrote about it afterwards and it was pretty awful yeah yeah these were frequently not well taken care of locations and also too you know now it's very common place we think of least restrictive environment but for a lot of people that seemed like at the time that was the least restrictive because there were families were concerned hey if this person is roaming around if grandpa or Grandma's roaming around they may get hit by a car or they may you know trespass or you know and we don't know what to do right and I think a lot of times again well-intentioned families just we don't know what to do and so they would go there but least restrictive environment now that there's medications the idea is that maybe people don't have to be institutionalized for the rest of their life which is well-intentioned that's great if you can go home and live in society again the problem is that the idea behind the Community Mental Health Act of 1963 was to take the funding you know 500,000 people institutionalized approximately obviously not all of them are going to be removed but even if it was 3 or 400,000 like that's a significant amount shifting to communities the idea being that that funding would then go to Community Mental Health Centers that was the premise is that you know and in fact you'd think it' be even cheaper because you're keeping people full-time 24 hours a day and so in an Ideal World now we can move people to Community Mental Health Centers we can maybe even see more people and we can get them more services and all these kind of aspects but then they can go home and live with their family and not have to be in a a did for all intents and purposes an institution depending on where you were I don't think that happened right correct essentially what happens frequently with well-intentioned cost saving while also trying to improve care it's very hard to do both at the same time Congress you know not even being partisan but just in general if you're spending M millions or hundreds of millions of federal on Mental Health Services because you have to because there's a certain amount of people that are here full-time now they go into the community well do we need the same amount of money right the premise was that the same amount of money the same pot would just be transferred into Community Mental Health and that was going to provide so many services but that pot gets cut and that pot gets cut and that pot gets cut and they say well we need the funding for this and then they start closing so many hospitals that even people who do potentially still need to be hospitalized there might not be a hospital for hundreds of miles for them anymore right and then the states have to kind of take over each state and Community has to just figure it out for themselves and also too if you think about politically what's going on in the background around this time right so that's early 60s as we progress through the 60s people are being removed from the institutions institutions are shutting down well where is a lot of funding and government attention going towards the Vietnam War right you know there's a lot of money that is going elsewhere and they say we we have $300 million I'm not sure that number we have$300 million here that's supposed to go to Community Mental Health Services that haven't even been developed yet no no no no no let's let's you know let's fund these things elsewhere we have other things to fund and some did and actually some of the ones that got good funding actually did pretty well there's some in Boston I mean again kennedies from Massachusetts so it kind of makes sense that they kind of prioritize their area but several in Massachusetts and kind of in the Northeast kind of became examples of what was intended they would have things like partial hospitalizations an inpatient unit an intensive outpatient residential uh Day program like and then just a regular Mental Health Plan you know the idea is that they have all these different levels and hopefully people can kind of slowly start to transition down um and you know maybe the day program would might be a long-term thing but the cost of people coming four hours a day versus the cost of people being there 24 hours a day is drastic yeah and I think um people being basically imprisoned is different than than getting to go home at the end of the day there's a lot there's a lot of more autonomy in the treatment as well so well-intentioned did not go how it was hoped and also too talking about you you always have to think of you know when I think of Psych history you always have to think that what ST in the background so in addition to Vietnam War in late 60s obviously the person who championed the bill JFK was no longer the President right and so you know it was his baby it was his bill he's no longer around other things are going on and so now all of a sudden it kind of becomes on the back burner but the problem is we've already shut down all the institutions we did step one without step two being done but now it's kind of irrevocably done and one thing that I think is super important and when we think about serious mental illness is that if you think about the number of people experiencing homelessness in America On Any Given night depends on the article you read you know and the study that you read it's it's all over the place but it's somewhere between 400 th and a million depending on what you read and I just find that the idea that the number of people who were removed from institutions and the number of people that are experiencing homelessness On Any Given night in America is not dissimilar as somewhat telling of what ultimately ended up happening yeah and I think it's no it's no um it's no secret that a lot of people who are living with serious mental illnesses don't have a place to live or they prefer not to be stuck in a place where there's people around trying to control them so I I can divulge a little bit of my past when I was a younger guy like I went to New Mexico and I lived um Outdoors you could call it you call that homelessness right but I was around a lot of the homeless population that that were kind of out there partly because they wanted to be um but in some cases because they couldn't hold down a job they couldn't maintain a home uh and this and they were just accepted among this community of other like people who lived Outdoors so there was there was there was a difference between the people who were there more by choice and the people who were uh there because uh they didn't really have anywhere else to be like I got very comfortable talking to people who I recognize now you probably had very serious mental illnesses but at the time I just thought that they were strange like um because I didn't know anything about uh Psychiatry or psychology really and you know that's still an ongoing issue you know I'm not from New York City but it was a big thing in 2023 that in New York city mayor Eric Adams tried to in some regards remove people experiencing homelessness essentially saying like you know if you're sleeping on park benches and things like that you need to either go to the hospital or you need to go to some kind of treatment or residential which again is quite presumptive in that one just because someone does have serious mental illness or isn't it's doesn't have a home or is it ing homelessness doesn't necessarily mean they need to be hospitalized right and that's kind of the American aspect of autonomy versus we can fix you that is just try to force them into a situation that you think that they should want instead of allowing them yeah like you said autonomy uh and uh I don't wanna I don't want to make anyone out there think that I'm saying most people who are experiencing homelessness choose it that's not what I'm saying at all we just assume things about them assume what they want or need you know we also too in America we have certain aspects of our social safety net compared to many other you know First World countries that are quite limited and so we tend to use the mental health system um to provide many social safety net services that in other countries would be provided by a h a better Urban Development Group or a better housing group and so for instance it's you know not uncommon in City hospitals and you know uh Community Hospitals for people who are experiencing homelessness to come in and you know they may report some suicidal ideation or homicidal ideation and those and you know because of that they need to be admitted or their Merit admission and they're voluntary um and that tends to spike around really bad seasonal at times right there's a huge ice freeze things like that and you know people can get I've heard Physicians say kind of like oh they're here for this is an insulting phrase but I'm I'm just kinding of saying attitudes I've heard people say oh they're just here for three Hots in a cot right you know the idea that like oh be you know there there's bad weather so that's why they're coming in and that may be true but we don't have a social safety net system that provides other Alternatives right if if you come to the ER and you don't have something that merits admission they're just going to kick you back out we don't have you know in other countries that that doesn't for instance New Zealand they they don't hospitalize people for kind of passive SI unless they want to kind of come in if you come in and say hey I need housing they're just going to help you find housing even if it's temporary and so that's the other aspect the mental health system is that you know it kind of Fosters this overall people get bitter especially in like the emergency departments and stuff too because they're like oh people are misusing this but also what alternatives are we providing people and so we kind of end up using this as a huge safety net and um that's the tough spot and it gets very very complicated very fast with the way that we provide social social services here in the US and different places because they often tie those to being doing certain things like oh if you do this you have to be in job programs or you have to show that you have uh filled out this many applications and you have to have people sign you we're going to kick you off your your social because if you don't have a job you know or if you're not trying to get a job then you don't deserve to be helped things like that which just defao disqualify a lot of people from help that probably you know we we would spend a lot less money just help in them than we spend now in the system that we have um a lot of people end up migrating I like to places like California or Florida because of the climates um I was just reading today I guess the governor of Florida uh Ronda santis is uh pushing to have it public camping be banned across the State of Florida as a way you know to get rid of people or to be able to ship them off um he likes to put people on buses and drop them off in other states so so maybe this is the way he can do that I don't know and you know when we're talking about people who are experiencing homelessness and or who have serious mental illness particularly if both if you have serious mental illness or we're saying things like schizophrenia bipolar one sto of things that are so functionally impairing that you are not able to um you know maybe even complete ADLs that at least not iadls um which is activities of daily living or independent activities of daily living such as like doing your finances um being able to grocery shop Etc pay your bills if you have both of those for the data shows that your lifespan is about 25 years less if you're experiencing homelessness and have that as compared to a peer who did not have homel did not experience homelessness and did not have serious mental illness some studies say 20 but 20 to 25 years if you have either of those just one it's about 10 to 15 years off of your life Co has kind of lowered the average age of America a little bit but for the most part the average male is upper 70s female around 80 but if you are somebody who experiences homelessness for a significant portion of your life take a decade off if you're somebody who has a serious mental illness and experience homelessness take another decade off so we're talking about you know a significant amount of Life morbidity mortality in addition to the fact of not being limited functionality throughout their life as well too so not only is there money to potentially be saved if we invested the social safety net services but also like there are literal lives to be saved getting back to the History part so we were in the the the 50s we got thorine the 60s we we got we were we were promised community health centers um and those didn't really materialize um then we're into the 70s and 80s like what happened there yeah so 70s 80s um I think an important part about the 80s is you know um like the Omnibus act Cobra right we I think a lot of the people heard Cobra for the first time and um mtala right mtala some of these terms um during the Affordable Care Act but IM tala um was actually from in the 80s during the Raiden Administration bill passed by Congress essentially saying that like if you show up to the ER you have to be able that they cannot deny you Services if they're able to provide them things like that so that's kind of going on in the background Medicare Medicaid right you know starts in the 50s and 60s and continues to pick up and as more and more people go to that and as people live longer we have more people going to Medicare so the way American Healthcare is even being delivered is changing right more Specialists less family docks right as people kind of migrate more and more to cities so so many things about the healthcare system are changing health insurance is becoming vastly more expensive so all of this is kind of in the background now we get to 1992 it's been about 30 years since Community Mental Health act for all intents and purposes it was a failure right we shut down institutions we did not provide the Community Mental Health Services and I'm not saying that that was JFK's fault but it well sometimes he wasn't around anymore exactly exactly yeah and so and you know sometimes things just don't work out and particularly as he was the champion of it like it probably needed him to kind of keep pushing through right um but his brother actually um is the person was one of the sponsors of this bill and so it's kind of a big mouthful um alcohol drug abuse and mental health administration reorganization Act of 1992 and there's tons of stuff in there I um I'm doing a presentation here in a few weeks about serious mental illness in the military um and so like read through kind of the whole thing it's like you know way too much very dense but it covers so many things and and one of the things that it talks about is essentially like state by state right if you're in a state that doesn't have a lot of money or a smaller State you're like hey we only have a certain amount of budget that we can use to provide services for people who can't necessarily pay for services themselves we're talking about Mental Health Services um the federal government says you know what we shut down all these institutions that we used to help pay for maybe we can provide a little bit of services you know to some of these people as well too we'll provide blocked grants we will give you a certain amount based on the certain percent of constituents in your state that have serious mental illness to help kind of subsidize their mental health for there you have to Define serious mental illness that's where it gets invented was to get money from the federal government okay exactly right yep and so um essentially they're like we will give you money based on a percent based on serious mental illness well all 50 states we have to have some kind of agreed upon definition so this bill kind of you know kind of comes up with this to um or around this time and it's it's the layers and layers of it I'll I'll give you what the starting definition was this is what came out with in 1992 mental illnesses listed in the DSM at this point we're in DSM 3 by the way mental illnesses listed in the DSM that resulted in functional impairment which substantially interferes with or limits one or more major activities so that's a kind of broad generic thing but the the funny part is is that we now also have to Define functional impairment and we also have to Define major life activities so their definition then required two further definitions actually the American uh Americans with Disabilities Act website Ada website actually has some pretty good information and it defines functional impairment defines major life activities we still kind of use some of those definitions today I remember learning about the Americans with Disabilities Act when I was a kid because my dad had had a traumatic brain injury and it was pretty severe he he was in the hospital for a very long time when he came out you know he had all those uh things that they talk about Phineas Gage having like it changes in personality and and um being very easily anger just flying off the handle and things like that he got involved in a head injury support group um back then because nobody really knew much about head injuries the doctors knew nothing they they would tell you nothing they didn't know anything so you had to go to the support groups to find out like what happens to people who have traumatic brain injuries and the the Americans with Disabilities Act uh was one of the things we learned about there because um the guy who started the group his name was Toby he was a police officer who had been shot in the head and was uh uh paralyzed on half of his body um plus other things right but uh he had was suing the city that we were in at the time for violations of the Americans do the Disabilities Act because they weren't updating all their infrastructure uh to be things like wheelchair accessible and stuff like that so he would he would just go around town like like taking notes of where there were no curb cuts and stuff he built up this gigantic case against the city first he just brought it to the city and said you know please do something about this but the city was like this is too expensive man we we we can't do that so he hired lawyers and it they lost the city lost in court and had to actually start uh doing the work while while you were talking I looked it up in 1990 so two years before this bill came out is when the Americans with Disabilities Act came out good know and so I think a lot of those things kind of tied into the other and honestly this bill potentially might not have existed without the Americans with Disabilities Act Right we're drawing further attention to people who need more assistance and people who um you know we as a society are deciding that maybe the federal government should potentially help subsidize some of this funding because of the amount of care that might be needed in this bill actually among a number of other things was you know the fact that they we need to figure out what the definition of SMI is well it's functional impairment in major life activities well what does that exactly mean also kind of random but also in this bill was the Sinar Amendment and that's actually what upped the age of tobacco sales to 18 at the time federally and then 2019 it became 21 so but it's actually interesting that I think it was more state byst state potentially right I think you know if you lived in a tobacco State you know you're smoking at a very young age my great grandpa started smoking when he was seven right and so um East Tennessee I would go over to friend's houses when I was in grade school and they chewed to tobacco my friends you know they'd play be playing video games shoot spitting tobacco at a can and it was disgusting because like the floor is covered in tobacco spit but so that's it's interesting just what all this bill kind of covered right that's what happens when you have you know 100 plus page document um we're doing block funding grants for constituents with serious mental illness and we're upping the age of tobacco also too kind of I like the idea of this uh this act of 1992 was like the week after I was born so I just I don't know it feels serendipitous um on my interest in SMI you're so young so that was kind of the original definition however the current like National Institute of mental health definition um is a mental Behavioral or emotional disorder resulting in serious functional impairment which substantially interferes with or limits one or more major life activities so mental Behavioral or emotional disord kind of how it classifies that okay and CDC has just a slightly word differently definition but it's Loosely about the same and so depending on the study you look at and the definition you're using currently in the United States right now the prevalence is between four to five and a half percent of the whole population of the population qualifies as having a serious mental illness correct looking at the the term like in the UK they use severe mental illness as SMI not serious mental illness so they have a different kind of definition okay and then we also like I said p SMI persistent serious mental illness which is considered similar definition and but it has to have been at least 24 months so that level of functional impairment for at least 24 months with the idea that it likely will be longer and persisting because you mentioned earlier I think to a great Point severe major depressive disorder can be debilitating people can't get out of bed but if they did ECT or they did the treatment they need potentially they're back you know at a certain point functionally um versus people with schizophrenia it is a lifelong condition that not that depression isn't but schizophrenia regardless of treatment you're still going to have some slow functional CAU up decline over time versus if you get the appropriate treatment for major depressive disorder it's very possible that you could become quite functional again and so and I I think it's very important that none of these definitions have ever used specific DSM diagnosis right mental illness is listed in the DSM yeah a mental emotional or the point is is that you don't want to either limit right like you don't want to say that like oh we didn't include that one so it can't be that level of functional you know or automatically say oh you have a bipolar disorder you must have serious mental illness now you won't be functional right you know I think I think they're trying to find that balance of you know you're not defined by your diagnosis and not all depressions are created equal right you know so there's a lot of aspects the point is more the limitations which is all DSM right the it's not a disorder if it doesn't cause functional impairment so in we got to the 1990s and then new legislation defined serious mental illness so that it could fund start to fund things that should have been maybe funded uh 30 years earlier correct okay and but then what happened how how well did that work because we are now a couple decades past that I think if you would pull a random citizen how well do you think the United States Mental Health social safety net is doing I I don't think it would be a very positive opinion I think some there's a variety of reasons for that right we talked about some of these already we're expecting mental health to be a catchall sometimes um when it doesn't need to be or can't be I cannot prescribe any medication that gives you a house I just can't do it right I can't prescribe any medication that will pay your electricity bill there's just only so much Psychiatry can do um and it needs to be kind of more of a collaborative system actually a little bit of a shout out to um there are cities and there are regions that have done good jobs using a collection of federal state private nonprofit Blends I think any state that's feeling like they're going to get a lot of their funding or most of their funding for their Mental Health Services from the federal government alone and they're not willing to spend on it is going to have problems well also I mean that's just sort of to me the closer you get to the community that you live in the more appropriate you know the the more actual knowledge the people are going to have as to what works there right and uh and so the people in those communities need to be involved in coming up with the solutions and doing things that work there because and there also will be able to be the people who see well this strategy didn't work here so they can rule things out and try something different whereas if you're just doing something that well they they said at the N imh that this is the best way to go maybe that doesn't fit your community so well I will say a couple of highlights that I think um both like an example of a couple of things that people have done well or regions have done well and examples of further legislation that has helped the Affordable Care Act people have all sorts of opinions because it became political like many things in America as far as mental health services go really changed the game as far as making things this is a incredible oversimplification but as far as mental health services go they were able to kind of Define the idea that mental health conditions can be just as debilitating and just as real as physical health conditions which we all knew but insurance companies were not reimbursing that way the Affordable Care Act said essentially if somebody has a condition that merits DSM criteria and is causing functional impairment insurance companies you need to reimburse as if that is any low back low back pain or headaches or anything else not that you're you're in to Bill at the same level of you know a cardiologist or anything like that but it totally change the game because here's part of the problem even with mental health subsid if nobody takes Medicare or Medicaid because the reimbursement rates are so low then it doesn't really help right and so and that's that can be a common problem is that reimbursement rates for insurance companies are so low that people say I'm not going to take your insurance even though you have insurance that's a definitely a problem around the area that we work in right now trying to find psychiatrists that actually take insurance at all in some cases and it's not just psychiatrist now I've read a lot of personal statements of people writing on their own blogs doctors saying I can't take Medicare or I can't take Medicaid because I can't survive in my business I don't know this is people's anecdotal experiences so I don't know how big the burden really is along the lines when I was in medical school um one of my rotations it was a part Private Practice part Hospital rotation and in their private practice you know one of the Physicians was not a psychiatrist by the way um different specialty but um they were trying to teach a little bit about the business side of medicine and in their practice they had a percentage of that we cannot take more than x per of patients with Medicare Medicaid because we are then going you know lose essentially losing money like we have to take a certain percent because we you know and same thing with hospitals right in order to get federal funds you have to take Medicare Medicaid but there's a certain percent that kind of allows for things to be reimbursed so obviously the Affordable Care did not solve everything and did not all of a sudden make a you know a magic pill magic potion but it did provide some incentive and for people who have you know your average health insurance you if you had Blue Cross Blue Shield or Etna or Humana and I don't endorse any of these I'm just naming some big ones that i' you know see commercials for if you have any of those and a decent plan you would be shocked if you were not able to find some kind of Behavioral Health Services maybe not a psychiatrist but a social worker or a therapist or something at this point right 15 years ago that was not the case you would have to have the top tier plan and even then you still might not be able to so that definitely is a big change wow yeah I was I was not quite aware of that um so yeah it's important I I I do see the change though in just the insurance as a you know basically like when I was younger I just assumed because my family didn't have much money and I and I didn't have a job that made much that I just wasn't one of those people who would wouldn't have insurance I didn't even think about it I wasn't like I deserve insurance or you know I just re didn't go to the doctor ever so um but people have a a totally different expectation now now they're they think of it more as a right or at least as something like one of those basic things you need to provide for yourself and your family and that actually ties into I was talking about the significant decree increas in life expectancy in people that have been diagnosed with serious mental illness it's very rarely the the mental illness that kills them right it's the other chronic health conditions for which they're not receiving treatment potentially because of their serious mental illness right if they're paranoid and they don't want to go to the doctor because they're paranoid or they're last time they went to the doctor because their stomach hurt they were involuntarily hospitalized because people are like oh you're talking to yourself well they're allowed to talk to themselves they're not here for that they're here because their stomach hurts and so now they avoid care or you know they have all sorts of feet injuries particularly people experiencing homelessness and things like that um and so frequently you know we see the life expectancy decrease and we think oh man this must be just such a morbid and um mortality inducing condition which it is but it's not exclusively because of that it's all the ramifications that go on by mental illness being untreated leads to these you know Downstream effects so we got to the point where now we're finally finally it seems like so finally we're funding mental health in this country like at least at a very basic level we like decided that you need to do that so we're doing that now sometimes like when I refer patients out and they go to certain places let's just call them residential treatments and they come back I kind of ask them what went on I I review their records I see what happened they like got started on five more meds and like three diagnoses but nothing in the records I got back lists a single reason why they were given those diagnoses to me it feels like these places are are like okay we now that we can charge insurance companies more we're doing for-profit mental health care where we just run people through a grinder give them a diagnosis we can bill for and a medication to match it so that you know it looked like we're treating people and then send them out have you have you ever got the same feeling before a absolutely it it's unfortunate um but like a lot of so the affordable CFT was very helpful in that it said there's some aspect of parity mental health and physical health conditions both need to be reimbursed with by insurance right however if you are a primary care doc seing somebody for bread and butter low back pain that is not the same billing as a cardiologist seeing somebody post stent that has atrial fibrillation or you know to blank some other condition right that's a level one two or three billing versus a level five billing and if people who aren't familiar the basic insurance has a one to five billon scale which over the course of a day if you're seeing 10 to 20 patients is exponentially a lot of more different amount of money generalized anxiety disorder major depressive disorder moderate the most common things that we see you would have to do a lot of documentation to be able to argue that that's a level four or level five now major depressive disorder severe with Psy cotic features major depressive disorder and with significant Catatonia you know some significant amount of functional impairment sure but the billing aspect and again I'm not saying that people are doing it just for money and for profit definitely not in fact like you mentioned especially in this area the DC area a ton of psychiatrist don't even take insurance so I think people who take insurance like I'm glad that they do but we've incentivized this fee for service program and this is not just in mental health this isn't broader American Healthcare but we're seeing it play out in mental health in order to stay seemingly financially feasible a lot of these programs feel like we need to get level four level five billing for everything so there is incentive to diagnose people with bipolar 2 disorder when it might be more of a borderline personality disorder we've seen it we've seen somebody who we feel we knew for a very long time that had X condition that as far as billing goes doesn't hit that they go somewhere else and they think oh well and and here's the thing I'm not saying that people are blatantly some people probably are blatantly doing things wrong for money probably true I I can't speak to all psychiatrists I don't think most are I think that's just it might not even be them billers and coders do the same thing for every physicians in a hospital right emrs are designed for coding they're not even designed for providers it's designed to make sure that they can get the maximum amount of coding so they can get the maximum amount of billing so they can bring in the maximum amount of Revenue it's very possible that you say rule out bipolar 2 disorder and the coders say bill for bipolar 2 disorder right and so but in order to do that they then have to slap the label of the diagnosis on it right and so you know I I I don't want to assume the worst of people but we know for a fact that certain conditions and certain levels of functional impairment associated with said conditions can make more money for services so there is an incentive were you to want to do so to add a few more diagnoses on yeah I mean I think we should all be talking about these sorts of things and uh you know I think some times we might not want to because there there is a big anti- Psychiatry movement out there and then there's a lot of people that as a baseline I think especially in the political climate now have a kind of uh conspiratorial bent on everything like if there is an incentive that the government places then there must be some giant conspiracy to do something you know like and I don't want to get the idea that we're we're we're saying that and this isn't unique to Psychiatry either I think that's the important part to say like this is the way American Healthcare System is set up for example if you do a colonoscopy in the hospital it's essentially no money for the GI dock no money for the hospital there is massive incentive to do it in andout patient or like you know urgent like urgent here kind of like Same Day Surgery Center the way billing works is essentially all of the stuff that goes into a I saw this directly that one GI doctor worked with said it could be up to four times difference in price like that's the amount that they can do save money billing Etc there's all sorts of incentive like if they can help it they're like oh someone comes in with a GI bleed on Saturday they're like can they wait till Monday and come to my office you know even though we might think diagnostically they need to be as soon as possible but there's Financial incentive and things like that it's not unique to Psychiatry I think that's the important part is that like yeah there is an anti Psychiatry movement Psychiatry is more difficult in some regards in that we don't have the as much objective lab data as compared to right it's really hard to bill for rheumat arthritis if you don't have demaras for rheumat arthritis you either do or you don't you know my hands are stiff and then get a diagnosis of rent toid arthritis exactly exactly but if you say you know my mood is low and things have been tough and sometimes I think about not wanting to be here anymore and my appetite's changed and you know I do think about things I wish I would have done differently and and you lay US list all these things it could be an adjustment disorder right like life's been tough it could be depression too right and the incentive financially is to say well let's put the one that would be more financially Fe you know feasible again not unique to Psychiatry I criticize uh the way we diagnose things a lot in the podcast and uh but I don't I know I'm a fan I listen I don't do it with the with the intention of like ah Psychiatry sucks but try just trying to figure things out better um to be a better diagnostician myself could you talk a little bit more about maybe the history of serious Al illness or can is there do you have some some kind of personal anecdotes of your own that that you think are especially I don't know either powerful or like affected you or something I think also too like the like longer aspect of like history of M I think I actually have like a presentation I've done on that at some point which I can maybe find and bring back for next time um for anybody who's listening we're planning on this being a a multi-part series as many times as Ryan will have me I'll I'll be on um well I'm starting to think that it's going to be very frequent because it's gonna be a lot less work for me just talk and then edit than it is to try to like do all this reading and like write something out and try to organize my thoughts which I'll talk about this next time but uh I'm going into I'm doing the public service Psychiatry Fellowship um with University of Pittsburgh which is focused on Community Mental Health serious mental illness and providing care in like resource limited settings how to maximize that sorry it took me so long to on here I knew I knew once the once Pandora's Box was open though that it was just going to be you know you know part part one of question mark well Dr Brooks thank you for coming on the show uh we will have you back for sure if you'll have us Dr is a pleasure um you know thank you again like I said I'm I'm a fan of the show so if it's just me listening that's fine I'm I'm happy to I'm happy to do[Music] it