Our Mental Health System is Broken

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The WHO announces the first death to bird flu in Mexico. Dr. Anthony Fauci faces down his critics in Congress. An FDA advisory panel strongly rejects use of MDMA for treatment of PTSD. This is America Dissected, I'm your host, Dr.

Abdul El-Sayed.

I vividly remember my first day on my inpatient psychiatry rotation in medical school. While we'd had a three-week block on mental health, covering various diagnoses and treatments, it's one thing to hear about serious mental illness and its various symptoms and pathways, but it's another to take care of people suffering them. You realize how very deeply these illnesses can destabilize a life. You learn to see the people behind the illness. As we've discussed in our previous episode about post-traumatic growth with Professor Richard Tedeschi, our conversation about mental health has progressed by leaps and bounds.

We talk openly about mental illness in our culture, and words like depression and anxiety and trauma are casually intermixed into our conversation without the open gawking and private scorn they'd have earned just a few decades ago. And that's a really good thing. It's opened up a discussion that has served to destigmatize mental illness and empower people to seek the care they need. But there's something missing in our discussion. See, mental health, and therefore mental illness, it's a spectrum.

While our social acceptance of milder mental illness is really important, and it's created space for people to get the care they need when and where they need it, that hasn't necessarily penetrated the conversations we have about more serious mental illness. While we have language to talk about things like mental health days and trauma, we lack the language we need to talk about schizophrenia, or severe bipolar disorder, or debilitating depression, the kinds of mental illnesses that so profoundly disrupt a person's functioning as to require intensive, persistent care, often in an inpatient hospital setting. Consider the conversation we have about the unhoused. Too often, our politics veer toward a frustrated nonchalance to the causes of homelessness. to begin with.

The tendency toward nimbyism, that is, not-in-my-backyardism, is driven by an indifference to the experiences of the unhoused. While homelessness is, at its core, a problem of too little housing, the folks who tend to be unhoused are not a random sample of society. Rather, nearly a third of the chronically unhoused in our society have untreated serious mental illness. And that failure is also a problem of too few resources. According to a 2022 report from the American Psychiatric Association, the number of inpatient mental health beds in this country dropped nearly tenfold between 1970 and 2014,, from 340,000 nationwide to just 40,000..

You heard that right. We lost 300,000 mental health beds in the U.S. in a span of 45 years. That drop was fueled by two main policy changes, Medicare policies that dramatically reduced funding for mental health care and a society-wide turn against inpatient mental health care, largely reacting to the worst vignettes from a bygone era that convinced Americans that mental hospitals were brutal places. Back then, medications were far less effective than the treatments available today.

Just as these new treatments, particularly for psychotic disorders, were coming online, the inpatient facilities needed to administer them were being decommissioned. Meanwhile, the Reaganism of the 1980s saw mental health care budgets that could have gone to providing outpatient treatment alternatives slashed. So what happened to folks needing care? Too many wound up, either unhoused and living on the streets or housed in America's burgeoning prison systems, where up to a third of the population suffers a serious mental illness. While we thought we were quote, deinstitutionalizing people with serious mental illness, the more appropriate way to talk about this would have been re-institutionalization, trading out one institution designed around providing health care for another designed to mete out punishment.

And that's the thesis of our guest's most recent book, called American Madness, which breaks down our country's utter failure to provide the resources necessary to care for people with severe mental illness. A practicing psychiatrist and professor, Dr. Alice Feller, has been thinking about the challenges of caring for people with severe mental illness for decades, both as a practitioner and a researcher. She joined me to break down the public policy that led to this terrible state of affairs, how it's impacted, care for this community, and what we can do to change it. Here's my conversation with Dr.

Alice Feller. All right, let's jump right in. Can you introduce yourself with the tape?

And so when you've built a system where there are huge odd workarounds, you know it doesn't work. And that is probably nowhere more true than it is when it comes to mental health. But I want to step back for a minute and ask, when did you decide to become a psychiatrist and why?

I had a flash of insight when I was watching this patient, who was a like 18-year-old gay guy who was really flamboyant, and this is in the 70s, so it's really a long time ago. And he had a stack of 45s out on the floor, and his record player, and he was just dancing, rocking out. And I thought, you know, if he can do it, I can do it. So I decided, no, I'm going to go into psychiatry, do what I like.

when a psychiatrist talks about something like psychosis, or bipolar disorder, and mania, what are you talking about in particular? And how does that differ from, you know, the kind of, I hate to say run-of-the-mill, but more common types of mental illness, or lack of mental health, we'll call it, that we tend to talk about in popular culture?

So psychosis means that it's a loss of reality testing. You can't tell what's real and what's not real. So very commonly, almost universally, people with schizophrenia will have auditory hallucinations. So they'll hear voices, and they sound as real as our voices. right now.

It's very hard to understand that this is not a real person speaking. So people believe, understandably, that someone on the other side of the wall, or someone hiding behind something, is saying these things, and the things that they say are cruel. Because unfortunately, the way this works is people have thoughts that if they're not psychotic, they could brush aside and say, well, you know, that's not really me. But if they are psychotic, their voices will put it into words and accuse them, like, you're a pedophile.

Ordinarily, they could say, you know, I like playing with my nephews, but that doesn't make me a pedophile. So it's incredibly hurtful. And you can see people yelling at the air. I know they're yelling at their voices. So that's one thing that happens.

Another thing is that people sometimes imagine that their parents or their children even sometimes have been replaced by an imposter or an alien. And sometimes they'll launch attacks, physical attacks, on those people in the belief that they've been replaced, you know, when the real one is somewhere else.

There's a book called The Best Minds, written by Jonathan Rosen, I think. And it's about his childhood best friend, who was a brilliant guy and very charismatic and graduated from Yale Law School, sort of improbably. But he was schizophrenic, and he killed his girlfriend in the belief that she was a wind-up doll. And then he realized something was very wrong. So that's one delusion.

Another thing is that the voices will tell people to commit suicide. And sometimes they do.

There's a very high suicide rate in the first year of schizophrenic illness, 20 times the normal rate for that age group. So people just suffer enormously.

Bipolar disorder, we call it.

. So schizophrenia is a thought disorder. It's hard for you to think normally.

Bipolar disorder is a mood disorder. So people get either very, very happy and into a manic state, or very, very depressed, into a severe depression.

And so being very, very happy is kind of nice. Sometimes people are intrusive and their judgment goes wrong. But when they sort of tip over the line into a severe episode of mania, they feel so irritable, and they have no sleep at all. And they're just so hair-triggered with their rage, really. People are enraged often.

So they get dangerous to other people and dangerous to themselves. Severe depression, people sometimes commit suicide, so they're dangerous to themselves if they're sick enough.

And I can also understand. one of the worst things about schizophrenia is it tends to, you tend to have a first break in your early 20s, right? Maybe a little bit later in some folks, but you know, this is the prime of life and you're just starting out in your life. And then all of a sudden this hits, there was a young man at my medical school, several years before I started, who had a first break of psychosis and knew, understood when he understood what happened, you know, he'd been committed, and when he left the hospital, he committed suicide. And you can imagine the way that he had, he was processing this life that he had had, you know, just a couple of weeks before and then what this meant for him and the overwhelm of that.

And you, you know, you start to appreciate just how important it is for folks to have the kind of care that they need. And you know, one of the points that you brought out, whether you were talking about severe depression or schizophrenia, schizoaffective disorder, or bipolar, is that we talk about a danger to oneself or others. And that, that danger, I think people tend to think of themselves as the object of that, of that danger, and that people should be kept away. But it's really a lot more about how do you create a space where somebody can be safely treated and stabilized. And when those spaces go away, it sort of sets up a lot of the challenges of maintaining treatment.

You know, you write beautifully about trying to help your patients navigate the system. And one patient that you talked about is a patient named Robby. And I want to invite you to share a little bit about Robby and what you learned from him. And then we'll use his experience as a jumping off point to talk about some of the systematic issues.

And the unfortunate thing was that we thought, he was in the hospital, we thought that if we could just keep him for a few more days or maybe a week, we could really help him. But that's when I realized, that's when the bed shortage became evident. They just couldn't keep people long enough, not even for a week or two weeks.

So it's very, very common.

Can you speak to what IMD is, why that exclusion was put in place, and the implications it has today?

So basically, hospitals started closing their doors and sending patients out who weren't at all ready and who couldn't be handled in the community, and often ended up homeless or in jail, unfortunately.

And one of the odd things in this country is we don't think of ourselves as having a publicly funded health care system. But when you take Medicare and Medicaid, they pay for the majority of health care in this country, right, the majority of health care dollars. So now, when you say a hospital is exed out of getting Medicare funding as a function of having more than 16 mental health beds, what you're basically saying is we are going to exclude mental health entirely. And here's the irony of it, right? You think about Medicare, it was intended to fund people with certain disabilities.

We could have, Congress could have made a decision to empower and invest in mental health care, and they made the decision to do exactly the opposite. Can you walk us through specifically what the argument for doing this was? I get that they thought that, you know, mental health was going to swallow Medicare up, which, if you look at it now, it sounds insane. But that's what they thought. Can you walk us through the conversation that was had at the time?

Also, there was a, that was sort of from the right, from the left, there was a lot of noise about how there wasn't such a thing as mental illness. And it was just labeling and confining people for no reason. And, or, you know, people wanted to get rid of their family members, so they'd stick them in a mental institution.

So, and a lot of the public has no experience with severe mental illness. They have never really spent time with someone who suffers from schizophrenia or a severe bipolar disorder, and they don't realize what psychosis looks like and how impaired people are when they're really fully psychotic. So it was hard for a lot of the public to actually see the need for these hospitals. So it was a combination of the right wing and the left wing getting together.

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You speak to the role that the stigma around mental illness had in shaping this decision. And you can see it play out. Also, you know, I just used the term insane, which is, you know, is a term that we started out using around people with serious mental illness, that now has taken on a new meaning. Negative connotation. And as I think about that, that's probably a word I should stop using.

But, you know, that stigma is alive and well, continues to be alive and well today. And, as you said, a lot of the public doesn't have an experience with somebody with serious mental illness. the way that somebody can develop a delusion, like you talked about with Robbie, and truly and deeply believe that his parents, people who, you know, sensibly want the best for him, are really trying to poison him. And this is a fixed belief that is a function of nothing but a disease, a true chemical imbalance that exists in his mind, and that can be treated. And when we decide to undercut space to treat, what we are basically saying is we're going to moralize these diseases out of our sight and then rob the people who need them of the treatment that they need to be able to function and engage in the way that we want for all of our loved ones.

One of the things that didn't happen, though, which you could have imagined happening, would have been, you know, the development of either smaller psychiatric hospitals, right, less than 16 beds that would have popped up, or even outpatient centers. And I'll talk a little bit more about outpatient treatment in a bit. But that didn't happen. Can you explain why?

And so people had the choice, the public had the choice, policymakers had the choice of whether to spend money on mental health care or something else, you know, roads, buildings, schools. There's a lot of things that people want to spend money on. So it was just a low priority. I mean, I think you're right. You know, stigma certainly plays a lot of, plays a big part in it.

And I think that that helped to shape this idea that people who are being treated in these facilities would be better off without them. Can you speak to the way that these facilities have been?

stigmatized in popular culture and the impact that that's had on the way that we think about them and also how that's changed?

But it's, you know, that movie was powerful. It was so powerful. And the scenes, you know, the scenes of torture, you know, this is what shock treatment, shock therapy, quote, unquote, looks like, which it doesn't look like. It's done under general anesthesia. So it's no worse than a surgical operation, probably a lot less painful.

But people don't know that.

with psychosis. They do almost, you know, they don't work for everybody, but they work for a lot of people. And you can sort through the different drugs and find ones, you know, for a particular patient. that's the most effective one for that patient and has the least side effects. You want to look for that, and also in the lowest dose.

So if you have your patient in the hospital, you can do all that because you can see them every day. You sit down with them every day. The nurses talk to you, other doctors and other staff, and you see your patient, you ask them and you get to know them. And you say, you know, is it helping with the voices or do you feel drugged? or, you know, and then you can adjust it day by day.

And it's really incredibly helpful. It's really too bad that people can't get that kind of treatment.

So, once you equate somebody who's got mental illness with criminal, right, which is, in effect, what we've done here, then it just itself justifies the action that you took, which, you know, if you think about it, is just even more cruel and unusual than making sure that somebody gets the treatment that they need. How, you know, as you think about this approach and being able to build the kind of system where we don't do this, can you talk to us about some of the ways that policymakers are starting to think potentially more positively about trying to address this issue?

We need more nurses. We need more MSWs, family therapists, the whole gamut, but especially people that work with serious mental illness. They don't really teach about it, and you can take a PhD program and be a clinical psychologist and hang out your shingle and never learn anything about serious mental illness or not anything, you know, that really counts.

So that's a terrible shame. It's like going through med school and not learning about bones.

And look, connective tissue is great. It's interesting. A lot of terrible diseases happen to connective tissue. But, like everybody, right, has a mental health state. And the amount of time that we spent actually learning about it was so limited as to like justify the stigma for it.

I mean, it was interesting because all of the other physical health doctors would be like, oh, y'all just came out of psych. OK, so you had a break. Let's talk about the real stuff. And you're like, y'all, this is pretty real stuff. And it just, it sort of speaks to this way that we've like, decapitated the body in all of the ways that we practice, right, and all of these different specialties.

It's like you have head doctors and then you have body doctors. And the body doctors you take seriously, but the head doctors you don't. And I think that's starting to change. One of the things that, you know, that what you talked about in California in Prop 1 raised for me, is that another place that people with serious mental illness end up, if they don't end up in jail, is unhoused and on the street. And of course, California is sort of the tip of the iceberg when it comes to the challenge of housing.

How important is it that we think comprehensively about the long term here? You know, I find that the lack of mental health beds is a real challenge. But at the same time, oftentimes when people get discharged, there's not always a place for them to go, which means that they may not have the stability they need to continue the treatment that they need to be able to live an organized life. And I want to ask you, how often does that go hand in hand, this sort of failure to invest in the mental health system and then also a failure to invest in basic things like housing in certain communities?

So that's actually more the reality than people being tied down and shot with medicine. But I think of it, like, you know, suppose there's someone who has a head-on crash and they end up unconscious with a head injury and they may be bleeding into their skull. You know, the ambulance crew doesn't wait until they come to so they can sign a consent for treatment. Likewise, we put our demented elders in memory care. We don't ask them if they want that.

We think that it's what they need, so they don't wander out and, you know, get run over by a car or something like that. I think that it's really, I think that the kindest thing we can do for someone who is really psychotic is to treat them. And I don't, if you saw the inside of these hospitals, you would realize that it's not the terrible, terrible thing that we envision. You know, I would tell people when I was an intern and working in psych emergency, I'd tell people, well, you know, I'm really worried about you. after I talked with them for a while and said, I think you may kill yourself.

You know, I think that's a possibility or you may, you know, ruin your life or hurt someone else. And so I'm going to hospitalize you. And nobody ever turned and ran. Nobody ever attacked me, certainly not. It just seems that it's cracked up to be so much more evil than it is.

You sort of think about it like a seizure disorder. Over time, the more seizures that somebody has, the bigger the impact it's going to have on the health of their brain over time, and the higher the probability that they're going to have subsequent seizures. And so early intervention, like many diseases, is really important. And at the same time, it is something that we should always think about, right? And we should have some level, I think, of discomfort, of saying, okay, we are, as a community, making a decision for an individual.

And I think, in a functioning society, all of us should be thinking always about what are the ethical constraints of being able to do that. And I think, as you all articulated, if you're doing something for that person's best interest and you understand that the disease itself, part of what it does, is, takes away the ability to make those decisions, that framing, I think, is a much more ethically rigorous way to be thinking about this. I want to ask you, one of the things that has happened, we talked about improvements in treatment for severe mental illness. And one of the pieces that's come up with the conversation is how important it is to be building institutions, not just inpatient institutions, but outpatient institutions. And there are new models that have come up.

You have a clubhouse model. There's an organization I used to work with, called Fountainhouse, that does really great work in New York City.

You stop the loss of gray matter, and people can return to maybe their full functioning before or at least some version of that. And compared with just going down, down, down into irreversible psychosis, it is so much better. And absolutely, that needs to happen, mostly as an outpatient. Early treatment, early intervention programs for schizophrenia are outpatient programs with maybe hospital backup. But basically, they're outpatient programs.

I would educate every mental health professional about serious mental illness and give them hands-on experience as much as possible. I would require the nonprofit hospitals to provide inpatient psychiatric care on pain of losing their nonprofit status. And I'd require the for-profit hospitals to do the same on pain of losing their licenses. I would tell everybody forever that families are not responsible for the serious mental illness of their children. It's so, so painful.

Yeah.

Dr. Feller, we appreciate your insight and your perspective and just really appreciate you educating us here today.

It's not quite clear how the man was infected, but the risk to the public is low, considering that none of the individual's contacts tested positive for the virus. But what this case does highlight is that, as viruses capable of mutation, like influenza viruses, continue to spread, they take on new mutations that open new avenues for animal to human transmission. While we still don't know enough about this case to come to any conclusions, it should remind us that cow to human isn't the only risk for transmission, and that we need to continue to watch the full swath of this virus' evolution and to stop it from spreading in birds. to prevent that evolution in the first place. Dr.

Anthony Fauci found himself back on Capitol Hill last week. Here's a supercut of his time there. Why was it so important that the virus not have started in a lab?

Profane versus serious. Lies versus honesty. Corruption for fame and power versus steadfastness for the public good. And the trap. all of us who desperately wish for a government staffed by good, honest, brilliant people like Fauci is that we think that by confronting them, we can convince folks.

But that's not what happened. Instead, the opportunity to question Dr. Fauci, the one man that the far right has fixated on as a punching bag for all things COVID, precisely because he is so unimpeachable, turned into an opportunity for folks on the fringe to create yet another round of viral clips that they can share with their base. In some respect, it's emblematic of all the lessons we in public health seem to have failed to learn about how to communicate to the public in this internet era. Don't give liars platforms.

Don't debunk pre-bunk. Don't attribute good faith to people who've shown that they have not a good faith bone in their body. And look, I understand the impulse, the notion that this is finally the opportunity to clear the record and restore his good name, but it's just not. I was sad to see a man I really respected and admire be turned into fodder for right wing clickbait. Finally, in today's installment of science being about methods.

A major blow to psychedelic treatment advocates.

See, the gold standard of clinical studies is a randomized, controlled trial. Ideally, you want to quote blind participants to whether or not they're receiving the study medication or a placebo. But how do you do that when people, well, can tell if they're getting super high on the course of treatment? And, ideally, to really understand the impact of the drug, you'd want people who are naive to it. But in one study, 40% of participants had used MDMA in the past.

All this exacerbates the potential adverse effects, which, for MDMA, include misuse and possible overdose. That's all to say that while I do believe that there are likely important medicinal qualities to these substances, the research on this has flaws. And given the misuse potential of these substances, it's important to be cautious. I'd like to see more research on this, and I do hope that it yields some bulletproof evidence. That's it for today.

Thank you so much to Alice Feller for joining us. And if you have guest recommendations for the show, share them with us at info at incisionmedia.co. On our way out, don't forget to rate and review the show. It really goes a long way, like really goes a long way. So please, we're independent now.

We need you. American Dissected is also on YouTube. Follow us on YouTube at Abdul El-Sayed. That's where you can follow me on Instagram, TikTok, and Twitter. Finally, to check out more of my content and subscribe to our newsletter, head on over to incisionmedia.co.

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