Social stigma core cause for fewer mental hospitals

Austin American-Statesman, February 7, 2001

The Jan. 29 front-page Austin American-Statesman article, “Is a single psychiatric hospital enough to serve Austin patients?” discusses what’s available for Austinites needing inpatient mental health care. The article correctly notes that despite explosive growth both in population and the need for mental health care, the number of private psychiatric hospitals has dwindled from four to two since 1996 and that the remaining two may merge into one this year.

The article points out that the merger would limit consumer choice. That’s true, but the merger is a good solution for the community.

While I appreciate sensitivity to consumer concerns, it’s helpful to explore the fundamental cultural and economic phenomena behind the situation we’re in today.

The core cultural problem is stigma. Disorders of the brain carry a frightening and mystical aura that separates them from other ailments. The end result: lack of insurance parity with other physical medical conditions. This is utterly irrational. Treatment success for serious mental illnesses ranges from 60 percent to 80 percent, whereas that of heart disease, for example, ranges from 40 percent to 50 percent.

People who have a mental illness fail to seek early treatment for mental disorders for fear of social and job discrimination. Not only is the opportunity lost to treat the medical condition early on, but often the first psychiatric encounter will occur only after horrific tragedy.

At the core of the economic problem is the cutthroat environment facing health-care institutions today.

The remaining two private psychiatric hospitals in Austin — Seton Shoal Creek and St. David’s Pavilion — do not stand alone. Operating the past few years either in the red or barely breaking even, they are part of larger health-care networks — Seton Healthcare Network and St. David’s HealthCare Partnership.

Both health-care networks are struggling financially because of low managed-care reimbursements, inadequate mental health benefits on insurance plans and crushing reductions in hospital Medicare payments brought about by the 1997 Congress, which ruthlessly balanced the budget on the backs of health care. And if that’s not enough, Seton, which serves as the de facto hospital district for Central Texas, has a mission to care for all comers regardless of ability to pay. With the uninsured in Central Texas reaching an alarmingly high rate of 25 percent, that’s a hefty number of people.

The American-Statesman article pointed out that the lengths of stay for psychiatric hospitals have decreased from 19 to six days in the decade beginning in 1990. This is not necessarily a bad thing. One reason is advances in psychiatric pharmacology producing drugs that target the exact brain chemical imbalance and leave the rest of the brain alone, resulting in far fewer side effects. A second reason is the massive shift in the past decade from inpatient to outpatient care.

An unfortunate reason for decreased lengths of stay is managed care limiting inpatient days to the bare minimum, as if it were reasonable to use a predetermined recipe per mental diagnosis for everyone. Under ideal circumstances, within six days a child or adolescent or adult may be admitted, obtain an accurate diagnostic profile, receive effective psychotherapeutic intervention including stabilizing medications. Meanwhile, the patient and family become oriented to healthy coping skills. Psychiatric hospital admissions tend to be devastating and frightening events for patients and families.

Six days for a psychiatric length of stay is indeed ambitious.

On the bright side, Austin is blessed with an exceptional cadre of dedicated and skilled mental-health caregivers — nurses, doctors and mental health aides. And the fact that two normally competing health-care networks have come together to collectively arrive at an innovative community solution to meet the private psychiatric hospital needs is extremely encouraging.

Austin is fortunate to have the public 312-bed Austin State Hospital, which typically operates at near full capacity, to meet the needs of the indigent and those committed by the courts. Austin is lucky to have the option of even one private psychiatric hospital given the cultural stigma of mental illness and the resulting parsimonious funding within the current harsh health-care financial environment.

If the state attorney general’s office approves a proposed merger of the Seton and St. David’s mental health-care facilities, the public will be better served in the short- and long-term with one high-quality, financially viable private psychiatric hospital than with two competing facilities operating on shoestring budgets, in the red.

Toni Inglis, MSN, RN CNS (retired), FAAN, a lifelong Austin resident and retired neonatal intensive care nurse and editor of NursingNews, writes a monthly opinion column for the Austin American-Statesman editorial page.