Insight Matters
Fall 2005

EDITORIAL

Four Degrees of Separation
by Henry A. Nasrallah, M.D., Editor

One of the greatest challenges for the psychiatric care of the seriously mentally ill is the needless and arbitrary separation of psychiatric care from other medical/surgical care. Much has been written about this in the health services arena but the chasm continues. At least four major types of separation set apart the mentally ill from the physically ill. These separations perpetuate the misperception that mental disorders are not physical or medical illnesses, and these separations frequently jeopardize the overall healthcare delivery for the millions of individuals dually affected with illnesses of the body and the mind.

The first separation is geographic. Does it make sense that community mental health centers (CMHC) are free -standing and not co-located with a general medical facility where patients can receive the full spectrum of medical care? This "separate and different" status perpetuates stigma and leads to inequality between psychiatric care and general medical care.

The second separation is financial. Psychiatric (a.k.a. mental health) care is almost universally carved out by managed care and insurance companies, with different benefits and revenue streams. The outrageous lack of parity between brain disorders that affect the mind (e.g. thoughts, emotions, behavior and cognition) versus the body (e.g. motor movements, sensations, gait) is an appalling and flagrant injustice to the 60 million Americans who suffer from a psychiatric illness.

The third separation is organizational. The medical records of CMCH patients are entirely separate from any other medical records that these patients may have. This clearly precludes optimal psychiatric and medical care and leads to misdiagnosis, medication errors, and unnecessary laboratory procedures. The millions of the chronically mentally ill who are at high risk for serious medical disorders (such as heart disease, cancer, emphysema, obesity, diabetes, hypertension, sleep apnea, stroke) are often under-served due to this lack of integration of the totality of healthcare. To its great credit, only the VA system has a combined electronic medical records system for the veterans regardless of what they suffer from, and that is a "best practice" that should be a model for all other systems of care. Even Kaiser Permanente, an HMO which is enlightened enough to co-localize psychiatry with other medical clinics under one roof, still uses separate medical records.

The fourth separation is cultural. Most CMHCs have devolved over the years from a medical model (psychiatry) to a non-medical paradigm (behavioral health). Sick individuals at the CMHC are "clients", not patients as if receiving medical care is a business transaction, not medical care. Over the years, psychiatrists have experienced a diminished role in CMHCs compared to the standard physician leadership in general medical/surgical settings. The CMHC culture accommodates "therapists" rather than "medical practitioners" yet the patients who fill the waiting rooms of these clinics suffer from brain disorders that are some of the most serious and disabling medical illnesses [e.g. schizophrenia, bipolar disorder and OCD where medical intervention, not psychotherapy, is the primary and indispensable ingredient for symptom control.

So let's do something about those separations. Let's re-medicalize the system of psychiatric health care, while preserving the importance of psychosocial care, by putting the medical aspects of psychiatric illnesses front and center so they can be seamlessly managed with other, co-occurring medical disorders. Let's do it for the sake of our patients with schizophrenia who die from various medical illnesses 16 years earlier than the average life expectancy of the general population. Let's reintegrate psychiatric practice with the rest of medicine geographically, financially, administratively, and culturally. Everyone will be better off without these separation

Back to newsletter