It’s been a busy month for mental health in the media. First there was another university shooting; this time five were killed. This was followed rather quickly by the bloody stabbing and murder of a private psychotherapist in her Manhattan office. In between were two front-page articles in the New York Times, one that reported depression spiking worldwide across all cultures in the forties and fifties; and the second that reported an alarming and rapid rise in the rate of suicides among forty- and fifty-year-old Americans.
I believe there is a thread that runs through these stories; the thread is the ongoing failure of modern American psychiatry to meet the outpatient mental health needs of our population. People who suffer from complex conditions that combine brain biochemistry and neurophysiology with psychology need to be treated by practitioners who are trained in both medication and psychotherapy. Anyone who has a biochemical mental illness also had emotional disturbances about that condition, and they require a practitioner who can teach them about their illness and create a relationship at the same time. Unfortunately insurance companies and medical institutions have been consistently devaluing and disincentivizing the physician/therapist for several decades now and the result is that it almost impossible for patients to find and connect with practitioners who can meet the breadth of their needs.
For example, the student in Illinois. There are reports that he had been taking Prozac in recent months but that he had stopped a few weeks prior to the incident; that he had had an extended period of treatment as an adolescent, but had functioned very well as both an undergraduate and a graduate student. There are only a few conditions that cause someone to change abruptly in the manner described in this incident; the most likely is bipolar illness. In any case what is clear is that here was someone on medicine, with a history of considerable emotional problems, who started acting oddly, and there is no mention of the prescriber being involved in any way. This is because, most of the time, prescribers barely know their patients, see them infrequently, are not their therapists, and will not be called if things are not going well. As they were not called here.
The Manhattan slasher was quite different, not high-functioning at all, a chronically psychiatrically ill young man who was in and out and in and out of various public hands;but as is often the case with the chronically mentally ill, he has never had any real continuity of care, shuffled from one clinic to another, one hospital to another, known but unknown, never settled into the kind of care that might have actually been able to monitor his compliance with treatment.
It does not and should not surprise us that depression is common in the forties and fifties when responsibilities are many and the limitations of life loom ever larger. The rising rate of suicide among this group however is perhaps another testament to the large unmet need for effective mental health care.
What makes all of this ironic is that we are better than ever able to provide the kind of care that is needed; we have more and better medicines, more accurate diagnoses and more specific well-tested therapies than ever before. Unfortunately we have constructed a fragmented mental health system that produces nowhere enough Prescriber-Therapists to meet the need.