Statement prepared for and distributed at ICSPP meeting, Oct.2004
The insanity epidemic
-and how psychiatry aggravates it
(c) 2004, Nathaniel S. Lehrman, M.D.
Former Clinical Director, Kingsboro Psychiatric Center, Brooklyn NY
An immense increase in all forms of mental illness, especially insanity (psychosis, disabling mental disorder), has occurred in this country over the past 50 years. The percentage of Americans said to be mentally ill has nearly tripled since 1955. The total number of "patient care episodes" for disabling mental disorder (such as schizophrenia) has, on a per capita basis, quadrupled since 1955.  
Similarly, per capita outpatient admissions to ambulatory mental health programs - dealing with milder disorders rather than disability - have increased 250% since 1969.  This increase in mental symptomatology is real; only a small fraction of it is due to changes in diagnosis, such as the lowering of diagnostic thresholds.
The increase in both treatment and disability
Although one might expect that all this treatment would reduce psychiatric disability, the exact opposite has occurred: the more that psychiatric treatment has been provided, the more has disability increased.   Over the past 15 years - between 1987 and 2002 - the number of people disabled by mental illness, and therefore receiving either a social security welfare or disability benefit, has almost doubled: from 3.5 million to 5.8 million.  The expenditure on psychotropic drugs has risen from $1 billion in 1987, the year Prozac, psychiatry's first so-called "wonder drug,"  was introduced, to $23 billion fifteen years later.  These medications are the heart of treating the disabled, and important in treating the ambulatory.  During this same period, psychiatric residency programs have reduced or eliminated training in counseling/psychotherapy  - always psychiatry's key therapeutic tool -  and replaced it with education in psychopharmacology.
Harmful changes in psychiatric treatment
The simplest explanation for these figures is that psychiatric treatment increasingly harms its patients.  This was demonstrated by Dr. M.V. Pinheiro's description of the changes in treatment methods he found on returning to this country after a fifteen year absence.
Although "American psychiatry considers itself more scientific" than it had been earlier, he wrote, it has actually "changed for the worse in terms of patient care" by returning "to the unfortunate attitudes of pre-Freudian days.  A whole new generation of psychiatrists, coming from the best medical schools, ... are unable to pay attention to their patients' subjective worlds. They have been trained to look at people's outsides: behavior is what counts...  Psychosocial factors, once so popular, now seem almost forgotten."
Instead, the current "emphasis on the brain... is being used defensively by patients, families and professionals alike.  One patient recently said to me, 'I am upset today because of my brain chemistry.  Would you please adjust my medication?'  A mother recently said to me about her schizophrenic son, 'we just hope that someday you doctors will find a way to fix his brain chemistry.'"  The notion that treatment helps patients become more responsible for themselves seems to have disappeared.
Major changes imposed on psychiatric practice from above or outside have also been harmful, Pinheiro points out.  Third parties, including "government advisory groups and insurance companies, are now determining what constitutes good clinical practice although their major interest, dictated by economic concerns, is not always related to the patient's well being.   Available funds are now the main determinants of treatment...., with patients being shipped from program to program in order to comply with funding."   
The relative importance of patients and paper - the subordination of patients' needs to those of administrators - was indicated by the colleague who told Pinheiro, "in this hospital, if you lose a patient, that is bad.  But if you lose a patient's records, you must be prepared to leave town."
He wrote this in 1989. Since then, the situation has worsened markedly.

Why treatment harms the disabled/insane
As implied by Pinheiro's report, psychiatric treatment increasingly harms its most seriously ill patients by
1) its destruction of the psychiatrist-patient relationship - always the most important part of psychiatric treatment and the foundation for creating patient self-understanding and volitional change,
2) its almost total reliance on medication as the heart of treatment,
3) its deprofessionalization of patient counseling,   once carried out within the psychiatrist-patient relationship, then by social workers and psychologists, and now by relatively untrained "case managers," whose primary task is often to ensure that patients take their medications.
The doctor-patient relationship
The importance of this relationship cannot be overemphasized. Dr. Kerr S. White, former deputy director of research at the Rockefeller Foundation, maintains that the relationship itself is responsible for about half of any physician's total therapeutic impact upon his patient.
In psychiatry, the impact of this relationship is greater than in any other branch of medicine.  In the hospital, it is best established by having the psychiatrist see the newly admitted patient regularly and often in order to take a detailed history, and then continuing these regular meetings to help the patient examine, understand and change his maladaptive attitudes and behavior.
That was how treatment was once carried out. Now, however, the doctor-patient relationship in psychiatry has been more systematically and successfully destroyed than in any other medical specialty.
Continuity of care
The doctor-patient relationship is most therapeutic when continuity of care exists - having the same knowledgeable professional (formerly the psychiatrist) caring for a patient from admission to hospital as disturbed to discharge from office or clinic as recovered.  I first recognized continuity's importance in 1978, when, after retiring as Clinical Director at a large New York state Psychiatric Center, I visited Cambridge, England.  The deputy director of the state mental hospital there, a friend, showed me their remarkably successful system: the same skilled psychiatrist (aided, when necessary, by a social worker) took care of a patient both in and after hospital. This system was effective, satisfying and inexpensive; chronicity and incapacity were relatively rare, and Cambridge's costs were less than half of New York State's.
After my return, I took a part-time aftercare clinic position at another state psychiatric center where I made continuity a key aspect of my work - by visiting in hospital all my rehospitalized patients, even though I was not assigned there.  Since the ward psychiatrists did not know the patients and I did, they  were delighted with the help which my coming provided.  And when the patients were released, I resumed formal responsibility for them.   My 1982 paper, "Effective Psychotherapy of Chronic Schizophrenia," describes my successful, albeit incomplete, efforts with over a hundred such patients.  
Over-reliance on medication
The first modern, drug-company-endorsed psychotropic drug - thorazine (chlorpromazine) - was originally promoted as an aid to psychotherapy with schizophrenic patients - psychiatrically the most seriously ill.  But after this drug and its many new cousins were accepted, the notion of psychotherapy with these patients, and the significance of the doctor-patient relationship itself, were gradually eclipsed.  Drugs, especially the newer ones  - supposedly constantly improved and increasingly expensive - have become the heart of treating serious mental illness.  
When the drugs may be useful
The anti-psychotic drugs reduce explosiveness - often a desirable short-term goal for out-of-control patients - but they also impair the ability to think and feel.  Reliance on them has caused us to forget how much patients' agitation can be eased by just talking calmly and respectfully with them.  The psychiatrist's compassionate reaching out to the disturbed patient can reduce the amount of medication needed, and may even make medication unnecessary.   
After the patient's initial disturbance has subsided, his medications should therefore be reduced or eliminated as soon as possible.  Maintaining them, today's standard practice, continues their interference with his capacity to think and function.
How long should medication continue?
The indefinite continuation of psychiatric drugs for once-hospitalized patients is a major reason for the large increase in the number of psychiatrically disabled people. Efforts purporting to rehabilitate heavily drugged patients to normal living can therefore be compared to sending a boxer into the prize ring with one hand tied behind his back.
Various rationales exist for endless medication, such as  equating schizophrenia patients' alleged need for drugs to diabetics' real need for insulin, and seeing mental illness as really  "brain disease," which is never completely reversible and therefore needs medication forever.  Another reason for indefinite continuation of medication is that the fragmentation of public mental health services makes dosage reduction and discontinuation almost impossible.
Medication reduction
Since each dosage reduction may re-evoke some of the patient's original symptoms, reducing his medication, and its ultimate elimination, require close collaboration and trust between him and his psychiatrist; the latter must know the former well.  But this relationship has been greatly attenuated by psychiatry's abandonment of psychotherapy/counseling.  Psychiatrists' consequent lack of knowledge of their patients as people undermines the collaboration which dosage reduction requires.
The fragmented structure of mental health care also  interferes with the possibility of reducing medication. After having medication throughout his hospital stay, a patient is transferred to a new agency, psychiatrist, treatment team - and often medication.  Sometimes, as Pineiro says, "in order to comply with funding," additional subsequent transfers occur.   Dosage reduction cannot even be considered until psychiatrist and patient have gotten to know each other.

Orienting initial release toward recovery
A patient's first mental hospital discharge is difficult.   He will usually return to where he lived earlier, and again encounter those with whom he may have interacted negatively.  The more medication he is receiving, the more impaired he will be in facing these problems.

The transition's difficulties will be minimized if "continuity of care" exists.   If, however, as is customary nowadays, another psychiatrist and treatment team (and perhaps even another agency !!!) take over responsibility for the patient, the difficulties of establishing relationships with this new treatment team will be added to those of the transition itself, thus significantly reducing the likelihood of recovery.

One of a psychiatrist's central obligations is to provide hope and courage to her patient, especially when he seems to be losing them.  Having a familiar, respected care-taker (preferably a professional), who is available for comfort and support, can help prevent the demoralization and loss of hope patients so often experience upon release from hospital.

When should discharge occur?
The purpose of hospitalization is (1) to begin correcting the  behavior and thinking which made the patient unable to cope with his external world, and (2) significant restoration of his ability to do so.  The time needed in hospital for this varies greatly from one patient to another.  It is a totally individual matter, about which psychiatrist and patient must reach a decision together. and unrelated to formal diagnosis. Home visits before release may help determine a patient's readiness to leave, and a brief day hospital stay can ease the transition if necessary.  

Releasing the patient too soon will increase the likelihood of his failure to readjust, while over-retention can produce passivity and overdependence, which also impair his ability to function.  Both help lead to chronicity.

Orienting initial release toward chronicity
Demoralization and hopelessness are the key adversaries of improvement. If patients trust their initial care-takers, their then being transferred to other settings with new care-takers will undermine both that trust and the hopes it evokes.  After several such transfers, and especially if impaired by medication, they often give up trust and hope altogether, and try instead merely to survive, sometimes without significant human relationships.   

Reliance on medication as the primary treatment modality, exclusion of the psychiatrist as central treatment agent while retaining her as drug-prescriber, the yo-yo-ing of hope and trust (which are evoked by each new treatment relationship and destroyed by each transfer),  and the absence of a competent professional whom the patient trusts and with whom he makes important treatment decisions, all help create chronicity.

Where the path to chronicity diverges
Chronicity begins when patients lose hope after repeated failures and transfers, including hospital readmission and discharge.   While those who recover from disabling mental illness can return to previous homes, work or schools, those becoming chronic need assistance with many or all of these aspects of living.  

Places for chronic mental patients to live, and for them to spend their days, and counselors helping with lost abilities in daily living, are all costly, and large bureaucracies have been created to supply them. The danger exists that these bureauracies, in order to maintain themselves, will foster patients' dependency and consequent chronicity.  And when ensuring that patients take their psychotopic medications is defined as a counselor's main or primary task, chronicity becomes increasingly irreversible. And that's why the number of psychiatrically disabled individuals keeps rising.

The vast increase in the number of mentally disabled - insane - Americans  during the past fifteen years represents a veritable epidemic.   While the comparably huge increase in psychiatric services during this period would be expected to reduce these numbers, it has not.  Unlike the more effective psychiatric services of years past, those provided today often harm patients and impede recovery.   

This new harm is caused by (1) psychiatry's almost total reliance on medication as the heart of treatment, (2) the resultant destruction of the doctor-patient relationship - always a central part of medical practice in general and of psychiatry in particular, (3) the deprofessionalization of patient counseling, once carried out within the psychiatrist-patient relationship in order to evoke patient self-undestanding and volitional change, but now often limited to ensuring that patients take their medications.


Some new programs

Two new programs for the mentally disabled warrant examination in the light of the creation of chronicity by overmedicating and under-counseling. Both see medication as the core of treatment - presumably endless because of the difficulties of dosage reduction.

The Texas Medication Algorithm Project, a creation of the drug companies, placed large numbers of mentally disabled patients on the newest, and therefore most expensive, drugs.  Apparently in response to the high costs, the state dissolved its existing mental health department, transferred mental health centers to the state health department, and directed them to focus on "disease management" - "a managed care concept that helps to care more effectively for people with chronic diseases like major mental illness."   


Although the new system offers several levels of benefit package based on patient functioning, the first item on the lowest level - and therefore involving all patients - is medication:  perhaps "five hours of medication management per year," which includes "20 minutes with a psychiatrist every 90 days," according to the chief operating officer of a local public mental health center.

While claiming that "mental illness is finally being treated as a brain disease," the C.O.O. maintains that "the emphasis is on treating the whole person," and that "the client will [therefore] be more involved in their own treatment, giving them a better opportunity for recovery."

The brain disease concept of mental illness, and the "disease management" model of its treatment, represent a self-fulfilling prophecy - that mental illness is necessarily chronic and irreversible. Definng the new system's sole role as providing permanent, long-term care ignores how treatment creates chronicity, and ignores or abandons those efforts toward full recovery which are most likely to succeed: those made before chronicity develops

In New York, the primary purpose of its new "Personalized Recovery Oriented Services" (PROS) is to get Medicaid (i.e. 50% federal) funding for existing rehabilitation programs, such as day hospitals and drop-in clubs.  A very complicated reporting system has therefore been set up - evoking memory of Pinheiro's comment about losing a patient's records being worse than losing the patient himself.

Like the Texas program, New York's has different "service components" "to assist individuals in managing their illness and restoring the skills and supports necessary for living successfully in the community," and to assist "in attaining specific goals such as a higher level of education, secure housing and employment."  Despite its recovery rhetoric, however, it is also based on the indefinite continuation of drug treatment.  

To train the people relating directly to patients in this and similar programs, a nationwide Certified Psychiatric Rehabilitation Practitioner (CPRP) program has been set up. Admission to the certification examination requires a minimum of high school or equivalent; psychosocial rehabilitation (PSR) experience of 6 months to 2 years, depending on education level; and additional approved training in PSR (60 hours for most applicants).  Whether called CPRP's or case managers, these are relatively untrained people taking primary responsibility for chronic patients. To what extent they will serve primarily as state-paid baby-sitters, whose first task is ensuring that patients continue taking their medications, remains to be seen.