Another Failure in Mental Health

By: BG (Ret) Stephen N. Xenakis, M.D.

Tragically, the country has witnessed another senseless killing. Great credit to the school officials and law enforcement in California that conducted the training and preparation to protect the children and staff.

Some months ago, USA Today published my commentary after the tragedy in Charlottesville that we have systematically failed to act and mitigate heinous violence. Sadly, the latest carnage in California and Texas brings the issues back into the spotlight. All of these men demonstrated serious mental health problems, were known to governmental agencies, but their care was not coordinated among agencies that could help or were the right authorities alerted to the possible dangers they presented.

Good mental health is a public health concern. It is fundamental to the safety, security, and productivity of our communities and nation at large. Mental health issues and concerns show up in many sectors of American society. Mental health problems impact prisons and criminal conduct, education, employment and productivity, veterans, national defense, social concerns (bias and prejudice), and many more. No other specialty has such a wide and diverse impact, and begs for coordination and collaboration. Unlike any serious public health problem, disturbed men and women with a history of violence and aggression are not tracked and enrolled in community-based mental health programs. Instead, we have filled our prisons with emotionally disturbed men and women and have made the jails de facto psychiatric hospitals. Wrong place for many of them, and little chance of their getting the right treatment.

Why don't we tackle serious mental illness like other major health problems across our society? In the interests of public health, we immunize our children against fatal illnesses, track down cases of tuberculosis, and have world-class safeguards for clean water and sanitation. Violence, especially perpetrated by guns, is a public health problem. Violence, linked to mental health, should not be handled like surgery, medicine, pediatrics, etc. Like Public Health, this brand of violence has a broad impact. The data are compelling that the incidence of gun violence

correlates with the availability of guns, and explains the high number of gun deaths in the US, most definitely in the hands of men and women with a track record of aggression and violence.

Effective mental health services in our communities, including the military and Veterans Affairs, are woefully lacking. Devin Kelly was incarcerated for a year at the Navy brig after conviction for domestic violence. The U.S. Air Force admitted that it did not report him to the national data bank and mistakenly dropped the gun charges. There is no indication that he was ever referred to mental health services or received any treatment. I fundamentally disagree with the NRA’s tactics on diverting attention from gun control to mental health problems, but cannot ignore that mental health services across the country are inadequate and fail to serve the most seriously disturbed and disturbing individuals in our society.

In part, the failure to provide effective mental health services falls to the professions themselves. For years, standard psychiatric care has defaulted to the prescription of powerful psychotropic medications. Many advocacy groups have pushed back on behalf of seriously mentally disturbed patients. They oppose forcing prescription of drugs against the will of the patients over worrisome adverse side effects. There is a valid basis to their concerns, but the campaign against these drugs has contributed to unintended consequences. Too many seriously disturbed men and women wander the streets, are homeless, and vulnerable to victims of abuse, violence, and neglect. Moreover, any number of other disturbed men and women, including perpetrators of domestic violence, have exploited loopholes to assert their rights to avoid treatment and monitoring.

Too often, psychological treatments and therapy are protocol-driven and routine. The practitioners justify their approaches and claim they are providing evidence-based remedies grounded in published research. There are serious flaws to the evidence-based framework that dominates healthcare. The approaches and the associated clinical practice guidelines (CPGs) have major shortfalls in diagnosing and treating many patients. The most effective treatments help 60% of patients at best, not much better than a coin toss, and many patients receive only marginal benefit. A number of patients fail to improve at all and are often labeled “treatment-

resistant” as if blamed for not getting better. The payers, including the federal and state governments, impose limitations and restrictions on mental health services, because, in part, the efficacy and durability of such treatments have not been demonstrated. The cumulative effects of these policies and practices have weakened the breadth and depth of appropriate and needed mental health services.

Our country needs and deserves robust and progressive mental healthcare. It is time to develop and implement policies and practices that keep our communities safe and secure. The growing movement on value-based healthcare can help. It focuses on outcomes and measurable impact of treatment and therapy. Effective mental health programs should optimize the potential for the seriously mentally ill to have productive and gratifying lives and mitigate the harm to our families and communities.

Stephen N. Xenakis is a child and adolescent psychiatrist, a retired Army brigadier general, and the author of “We failed Heather Heyer.”

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