Open letter to President-elect Trump: Mental Health and Addiction in the U.S.

Republican presidential candidate Donald Trump speaks to supporters as he takes the stage for a campaign event in Dallas, Monday, Sept. 14, 2015. (AP Photo/LM Otero)


President-elect Trump:

You have been elected as the outsider and someone who is expected to “drain the swamp.” You were elected because of your direct and unconventional ideas that alter the national discussion on many issues. You, along with the Senate and the House, have an opportunity to address and ultimately reform two major issues that have been swept under the rug and received little to no attention during the presidential election- mental health care in this country and the growing heroin and opioid epidemic that is ravaging our communities. As a mental health professional who works with drug addicts, I have seen the failures of the current system. Too many addicts are cut off from adequate, long term care that they need and deserve. Insurance companies are dictating treatment and not providing the necessary coverage for those in residential drug treatment programs. Low-income addicts with no or poor insurance coverage are left to fend for themselves because they cannot afford the existing treatment centers and because as a country, we do not provide sufficient care to the “have nots.” Families are mortgaging their homes, selling family heirlooms and dipping into savings just to pay for a child to go to rehab, usually on multiple occasions. While the insurance companies are deciding the length of care, our pharmaceutical companies are pumping pain pills out at an unimaginable rate, leading doctors to over-prescribe highly-addictive pills that are expensive and lead many individuals to find a cheaper source of pain relief,  heroin. While most of the heroin in this country is brought into the country from cartels south of the border, the real issue is the demand, not the supply. There will always be groups willing to step in and provide drugs.

Additionally, mental health care in this country is deplorable (to borrow a term from the election). Community mental health centers are poorly run, understaffed and driven by managed care. The services they provide are inadequate, as sessions are limited, professionals undertrained, managers underpaid and susceptible to quick burn out. The VA is a mess, as countless veterans wait for mental health care and benefits. Local hospitals are overrun with psychiatric emergencies and overdoses and are becoming overwhelmed in providing care.

As a clinician, the current state of care is sad and something needs to change. In this regard, I have outlined proposals that will address the issues listed above.

  • Reign in pharmaceutical companies ability to continue over-selling pain medications, particularly opioids, and lay out a 5-10 year plan where pain management doctors MUST find alternate measures to treat pain.
  • The department of Health and Human Services should track the amount of  pain pills doctors prescribe to a patient and ensure over-medicating patients is not happening.
  • Label fentanyl a Class A or B drug. This highly addictive pain pills is being used by heroin addicts and is 100 times stronger than heroin. If police catch someone with fentanyl, they cannot do anything. Empower police and local authorities to rid the drug from our communities.
  • Create a task force that will allow states to set up outpatient mental health and substance abuse programs at local hospitals to alleviate the emergency rooms. The outpatient care should be fully staffed with qualified mental health professionals and offer comprehensive care. These facilities will offer care to patients with Medicaid and private insurance. The care can be contracted out to private practitioners through a complete vetting process.
  • Cut the red tape at the VA and allow veterans to access private mental health clinics and providers.
  • Ensure that drug and alcohol rehabs are held to strict guidelines that ensure patients’ psychiatric and substance abuse care is treated properly. Along these lines, sober homes need very strict regulations
  • Empower school districts to hire full-time mental health professionals to provide on-site mental health care to students.

These are just some of the core suggestions that you, Mr. President-elect should consider. Your administration has a tremendous opportunity to tackle these issues. I hope you act boldly.



Patient violence in our hospitals



I was pleased to read Dr. Stephen Seager’s article this morning in The New York Times. In his article, Seager discusses the “hell” of working in a forensic psychiatric hospital where patients (upwards of 15%) are violent. It is an important read for mental health professionals, but more importantly, it should be an eye-opener for policy makers across the country. As Seager mentions, some of the most psychologically disturbed patients cause serious injury to staff and other patients. In the article, Seager writes, “In another attack, an assailant beat an elderly man with a sack of quarters and then flung him in his wheelchair onto the patio cement. At times, half the nurses in my unit are on disability from assaults or attempted rape.”

Mental health professionals in all settings can relate to and empathize with the victims of such random assaults. It is not just hospitals where staff members, clinicians and other professionals are targets of abuse by psychotic patients. Homeless shelters, clinics, outpatient psychiatric centers and even private practices can have patients who intend to and actually cause violence. But, it seems that the mental health profession is at a stand still when it comes to interacting effective policies to deal with the 15% or so of patients who become violent and out of control. As Seager argues, the legal system grants more rights to patients than to professionals. Patients can assault a clinician, and, if a clinician fights back, he or she can be fired and terminated. If you are a mental health professional working for a company or hospital, odds are one of the  employee policies includes a prohibition of defending one self. Furthermore, patients who are deemed insane can refuse treatment and medication, all in the name of “patients’ rights.”

As I have written before, this is another product of the deinstitutionalization of America’s psychiatric hospitals in the 1960s. Instead of fixing the abuse, inhumanity and cruelty that existed, the government decided to completely shut them down  and create community mental health centers. As a result, we have far too few hospitals to treat the most severely mentally ill patients on a long term basis. Our new de facto mental health care hospitals are  prisons, where abuse is all too common (see Rikers Island in New York City).

Psychiatric hospitals need more intensive care units where the most mentally disturbed patients can be treated on a long term basis. The problem is nobody wants to pay for this, and as a result, we are forced to deal with ill-equipped hospitals to house and care for the ill. Political correctness has triumphed over treatment. Maybe our policy makers should spend time in one of the nation’s psychiatric hospitals or prisons to have a better understanding of the dangers clinicians face.

Evaluating crime and mental illness

In a May 27th opinion piece in The New York Times, Dr. Richard A.  Friedman of Weill Cornell Medical College asked the million dollar question:  Why can’t doctors identify killers? His article was in response to Elliot Rodger’s shooting spree in Santa Barbara, CA on May 23rd . After a tragedy of that magnitude, where Rodgers killed six people, politicians, pundits and “mental health experts” all called for the country’s mental health system to be examined. However, even if mental health care is radically changed in the United States, it will be difficult to prevent these tragedies. As Dr. Friedman points out, “…mass killings are very rare events. In 2012, they accounted for only about 0.15 percent of all homicides in the United States. Because of their horrific nature, however, they receive lurid media attention that distorts the public’s perception about the real risk posed by the mentally ill.” What is it about the United States and mass murder that seems to be the exception rather than the rule? After all, mental illness is not limited to the United States.

While many call for stricter gun laws (me included), there are other changes that need to occur. Barriers to involuntary psychiatric treatment need to be eased. Short of threatening harm to oneself or others, it is almost impossible to be hospitalized against one’s own will. This needs to change. Second, the perception of who commits crimes needs to change. Most people with severe mental illness are not harmful. The latest statistics show that roughly 4% of  overall violence in the United States is from the mentally ill. Individuals who are under the influence of drugs and alcohol are far more likely to commit a crime. Lastly, it is about guns. Access to guns is too easy. Individuals with extensive psychiatric histories should never (yes, never) be allowed to purchase a gun. Public safety takes precedent over the second amendment.

Finally, the larger question that these tragedies pose is: What are mental health professionals and law enforcement agencies currently doing to evaluate and assess for such crimes? The simplest answer appears to be very little.  Prior to Mr. Rodger’s shooting spree, police officers met with him in April and determined there was nothing they could do. According to a May 25th New York Times article, “The officers reported that Mr. Rodger was shy and had told them that he was having difficulties in his social life.” Later on, Mr. Rodgers, writing in his soon-to-be released manifesto, wrote “If they had demanded to search my room that would have ended everything. For a few horrible seconds I thought it was all over.” There needs to be greater collaboration between psychiatrists, social workers and law enforcement agencies. Interventions for potential criminals needs to be more extensive than a brief house visit. Family members and clinicians  should have greater resources at their disposal to involuntarily commit an emotionally disturbed individual.