I am struck by the attention the news media has given the Council Bluffs' mother who committed suicide by driving her car into the Missouri River, taking her three children with her. The articles state that this woman was suffering from depression, probably a very serious and deadly illness called Major Depressive Disorder. As a psychiatrist practicing in central Iowa for about 20 years, I have seen this kind of scenario all too often, as have all of my colleagues.
Like many other illnesses, fatalities occur no matter how excellent the medical care the persons receive. Twenty per cent of people who suffer from depression die by suicide. Even though the majority of patients with major depressive disorder can be treated very effectively, about five percent of people with this disorder don't respond to any treatment including medications, psychotherapy, or electroconvulsive therapy. This does not mean that a person who has a resistant depressive illness is uncooperative, instead, it means that no matter what treatment is given, the person's brain disorder does not respond, just as there are forms of cancer that do not respond to current treatments.
The news articles suggested that the state mental health system failed the Council Bluffs' woman because of early discharges from the hospital. I have not reviewed the records and thus cannot say that this is so in her particular case, but I do know that insurance does not cover as long a hospital stay as it did a few years ago. In my practice, which is only outpatient now, I am concerned about the number of patients I refer for hospitalization, who return from their hospital stay and are not much improved, if improved at all.
Often the person's health insurance only covered a few days in the hospital. Most people can't afford to pay a hospital bill out of their own pocket, so they choose to go home without improvement if the insurance company stops payment.
Research shows that it usually takes two or three weeks for medication to help depression, so allowing only three or four days of inpatient care for severely ill patients does not seem prudent. In the past few years there have been stories of people committing suicide after being discharged under these circumstances.
I am also very concerned because the availability of mental health services in Iowa seems to be decreasing rapidly. For instance, some mental health centers have closed in the last few years because of lack of funds. In my own county in the last five years, we have seen the closing of an in-patient psychiatric unit, the closing of a hospital day treatment program, the departure of several psychiatrists including the only child psychiatrist, the closing of an intermediate care unit for the mentally ill, and just recently the closing of a care facility which housed several mentally disabled people. In surrounding counties several similar facilities have closed.
I believe that passing Senate File 69 a few years ago contributed to these closures. Senate File 69 introduced a whole new level of bureaucracy allowing counties to decide which mental health services they will support. While county administrators feel the state should shoulder the financial burden of mental health care, there is not a mechanism in the state structure that allows the state to take over these services. As a result, neither county nor state government currently is willing to underwrite the cost of mental health services, and the whole system has deteriorated.
State and county officials often say that mental health providers aren't cooperating because they won't provide free services or accept greatly reduced fees as often as they would like. However, like anyone else, there is limit to how much providers can decrease fees or provide free services before they themselves are forced out of business.
The 1990's were supposed to be the decade of the brain. In fact there have been great advances during this decade in our understanding of the brain and the illnesses that afflict it, and in treating these illnesses. However, while science has gone forward, the system for funding the distribution and application of this knowledge has gone backward. In my opinion the ability to treat illnesses that were untreatable several years ago is the greatest cause of the increased cost of medical care. It's much less expensive to send ill people home, saying they are untreatable, than giving them expensive medications, granting frequent costly psychotherapy or hospitalizing them. However, governments, employers, insurance companies, and consumers have not adequately addressed the problem of paying for the ability to treat the many more illnesses that weren't treatable just a few years ago.
How does this apply to the woman in Council Bluffs? Her case points to the tragic consequences that can result when mental illness is not successfully treated. Mental illness can be very serious, and even fatal, and isn't going to go away just because business and government authorities don't want pay for it. Unless insurance companies, governments, and the community as a whole confront the decline of mental health services and the problem of funding such services, I suspect we will see more cases like the Council Bluffs tragedy.
Jerry Lewis, MD, FAPA
Chair, Public Affairs Committee