BRATTLEBORO — As the keynote speaker at an early October conference in New Hampshire, the Brattleboro Retreat's top administrator delivered a stark summation of mental health treatment.
“There is no mental health system,” said Louis Josephson, Retreat president and chief executive officer. “I defy anyone here ... tell me what our mental health system is and what it looks like.”
Josephson went on to detail a litany of issues including a “patchwork” of underfunded services, chronic workforce and bed shortages, and dramatically shorter life spans for those with serious, persistent mental illness.
But Josephson also - in his speech and in a later interview - pointed to potential bright spots such as integration of mental and physical care; experimentation with new insurance models; and expansion of crisis services.
He said he's speaking out to draw more attention to problems and solutions in mental health treatment, both in Vermont and nationwide.
“If we do things right - if we do the right things for our patients - then I think we'll see the financial benefits as well as the community benefits,” Josephson said. “So I'm optimistic.”
A gathering storm
Josephson has been working at the Retreat for less than a year, but he brings an extensive background in the field. He has worked in mental and behavioral health in New Hampshire, New York City, and Los Angeles.
In his Oct. 7 speech at the University of New Hampshire, Josephson said he has seen the same problems everywhere - and the situation has been worsening.
“This issue has been bubbling up to the surface,” he said. “It's an issue hospital systems and communities are grappling with all over the [country].”
As Josephson sees it, the major issues plaguing mental health treatment include:
• The quantity of treatment for mental illness that happens behind bars. “People always ask me, what's the biggest mental health provider system in the country? It's our jails,” Josephson said.
He pointed out that the general public wouldn't accept mass incarceration of those who suffer from Alzheimer's disease, though such patients sometimes can pose behavioral problems. “But somehow, when it comes to psychiatric illness, we're OK with people being served in jails,” Josephson said.
• If psychiatric patients aren't being treated in prisons, they're sometimes stuck in emergency rooms for extended periods, waiting for a bed at an inpatient mental-health facility.
Josephson pointed to a nationwide decline in the number of psychiatric beds and facilities, despite the fact that the need for such treatment isn't decreasing. Citing statistics from the Centers for Disease Control and Prevention, Josephson said about half of U.S. adults develop some sort of mental illness.
With fewer treatment facilities available, “we see more homelessness, we see more repeat people in emergency rooms,” he said. “We're not having a continuum of care we need to treat people.”
• For many, there is no care at all: Josephson said almost 40 percent of those with mental health and substance-abuse problems never get treatment.
He believes the continuing stigma associated with mental illness is one reason for that. “This is something that's in the mix that's different from other medical conditions,” Josephson said.
• Mental-health facilities also are struggling to find enough staff, a problem that Josephson labels “chronic and worsening.”
“We are losing psychiatrists at a greater pace than we're replacing them in the workforce,” he said.
Lessons from the field
While Josephson often cited national statistics for his arguments, he also was speaking from firsthand experience as a Vermont mental health administrator.
For instance, the emergency room problem was highlighted this year when Brattleboro Memorial Hospital was cited by the state for issues involving two patients who had been unable to leave the hospital due to a lack of available psychiatric beds elsewhere.
Psychiatric care in prisons also has been controversial: The state earlier this year settled a discrimination lawsuit filed by a prisoner, and officials agreed to give some severely ill patients access to more psychiatric treatment.
Staffing and bed shortages also have hindered the system, especially after Tropical Storm Irene forced the closure of the Vermont State Hospital in 2011.
A different perspective
But Frank Reed, commissioner of the state Department of Mental Health, doesn't agree with Josephson's central thesis - that there is “no mental health system” in this state or elsewhere. “Vermont does have a well-developed system of care that we've had for a number of years,” Reed said.
On the inpatient front, Reed acknowledged issues with emergency room waits, but he contends Vermont's problem is not nearly as serious it is nationally.
Reed also conceded that there are health care staffing shortages in Vermont. He objected, however, to the suggestion that there isn't enough staff at the Vermont Psychiatric Care Hospital in Berlin. The hospital currently is operating at full capacity, he said, though it is still relying on temporary help to fill some needs.
Overall, Reed said, the state has rebuilt inpatient psychiatric care capacity to a level “slightly above” what it was before Irene struck a debilitating blow. The 25-bed Berlin facility opened in 2014, for instance, and the Retreat opened a new, 14-bed, adult intensive unit the year prior.
“The investments that have been made by the Legislature and the administration have been pretty significant to try and get the mental health system back on track,” Reed said.
Josephson acknowledges such investment in the state's mental-health services, and he'd like to see more - whether or not it is at the Retreat. He argues that mental health funding is “one of those investments that saves money elsewhere.”
Practical proposals
At the same time, Josephson understands that governmental budgets are tight. So he's highlighting several other ways in which he sees the potential for improvement:
• Integrating physical and mental health care.
There is too often a dividing line between the two, resulting in psychiatric patients not receiving prompt or proper care, Josephson said.
Solutions could involve “mental health counselors and clinicians in a primary care office, working and seeing the same patients,” Josephson said. “It could be telepsychiatry to an emergency room or into a primary care office. There are a lot of solutions out there - a lot of research and experiments going on.”
State officials say they've been working toward more integration of primary care and psychiatric care to “reduce redundancy and increase points of access” for those in need of mental health treatment. But Reed cautioned that such change takes time.
State Rep. Mike Mrowicki, D-Putney and a member of the House Human Services Committee, said integrated care “recognizes the reality that physical health issues and mental issues are co-occurring.” He'd like to see more of it.
“It is the integrating of treatment that lends itself best to having 'a system,'” Mrowicki said.
• Josephson also sees promise in new insurance models.
In 2013, the Retreat and Blue Cross Blue Shield of Vermont established the “Vermont Collaborative Care” program. The idea is to invest more heavily in up-front, immediate mental health treatment, with the goal of saving money later by decreasing long inpatient stays or emergency room visits.
While there's been only a small impact on the quantity of inpatient care, Josephson said the program “immediately started driving down the emergency room visits related to mental health and substance abuse issues. That saves real money.”
He believes the program could expand, noting that there has been interest in Massachusetts.
• Josephson has begun pitching another form of investment: He wonders whether Vermont's 14 hospitals could pool their resources to establish additional mental health crisis centers.
Such centers would be “staffed by psychiatrists. We can start treatment. Have the right, safe physical setting that you need,” Josephson said. “There are so many dangers with people waiting in emergency rooms. They're not set up for people with mental health issues.”
More crisis centers could improve care and possibly save money in the long run: Josephson points out that hospitals already are spending large sums to house such patients in emergency rooms.
Josephson's argument for crisis center investment mirrors his argument for other kinds of mental health care reform.
“The alternative is just the current state of affairs,” he said, “which is bad care and losing money.”