Too many mental health challenges and not enough psychiatrists (with Jacob Appel)
Spencer Greenberg speaks with Jacob M. Appel, Professor of Psychiatry and Medical Education at Icahn School of Medicine at Mount Sinai, about the mental health crisis, psychiatrist shortages, and the revolutionary potential of genetic testing.
Deep Dive Analysis
19 Topic Outline
Introduction to Jacob Appel's Diverse Expertise
The Current State of the Mental Health Crisis
Causes of Increased Sickness and Reduced Access to Care
Challenges in Psychiatric Care Access and Funding
Repeat Hospitalizations and the Broken System
Proposed Ideal Mental Health System
Effectiveness of Substance Use Disorder Treatments
The Problem with Suicide Liability and Prevention Programs
Mental Disorders Associated with High Suicide Risk
Psychiatrist vs. Psychologist: When to See Which
Revolutionary Potential and Ethical Challenges of Genetic Medicine
Making Resource Allocation Decisions in Healthcare
Understanding and Addressing Invisible Victims in Healthcare
Impact and Effectiveness of the Affordable Care Act
Rethinking End-of-Life Care and Preventative Medicine
Bioethics Lightning Round: Body Integrity Disorder
Bioethics Lightning Round: Prejudice Against Ugliness
Bioethics Lightning Round: Polygamy and Assisted Suicide
Bioethics Lightning Round: Resuscitation and Patient Autonomy
4 Key Concepts
Bowling Alone
This concept refers to the breakdown of social structures and disconnection from other people, which is identified as a major factor contributing to the current mental health crisis. It suggests a decline in community engagement and social capital, leading to increased isolation.
Invisible Victims
These are individuals who suffer harm (e.g., death from preventable diseases) due to a lack of healthcare funding or access, but their suffering is not directly visible or attributable to a specific denial of care. Society tends to prioritize care for 'visible victims' (those actively denied a specific treatment) at the expense of invisible ones, leading to irrational healthcare allocation.
Body Integrity Disorder (BID)
BID is a condition where individuals believe certain healthy body parts are not integral to their body, similar to how transgender individuals feel they are in the wrong body. Some data suggests that allowing people to remove these non-organic limbs can reduce self-harm attempts and improve their functioning.
Medically Aid in Dying (MAID)
This refers to the practice where a person with capacity, who understands their situation, can end their life with the help of a doctor. It is argued that individuals should have the autonomy to determine their life's end, with appropriate safeguards to ensure informed consent and prevent coercion.
12 Questions Answered
Yes, there is a definite mental health crisis, evidenced by a significant increase in young adults seeking psychiatric emergency care (from one per week to two per night) and a simultaneous decrease in access to care.
The crisis is driven by people getting sicker due to factors like social media, disconnection, and the breakdown of social structures, combined with reduced access to care due to a shortage of providers.
Psychiatrists often don't accept major insurance because the reimbursement rates for time-based services like psychiatry do not adequately compensate for the work, unlike procedure-based medical specialties.
An ideal system would involve 'scatter-aside housing' (integrating patients into regular community housing) and comprehensive 'day treatment programs' (structured daily programs offering psychiatric care, therapy, recreation, education, and training).
Detox programs are not perfectly effective, but they are generally more effective than most other options, especially when combined with rehab, communal programs like AA, and certain medications.
Overly cautious hospitalization due to psychiatrist liability for suicide can deter patients who are not high-risk from seeking help when they truly need it, as they fear losing their rights and freedom.
Disorders with high suicide risk include obsessive-compulsive disorder, body dysmorphic disorder, psychotic disorders (especially when compounded with substance use), bipolar disorder, and borderline personality disorder.
Psychiatrists are medical doctors who can prescribe medication, while psychologists primarily offer psychotherapy. For mild to moderate issues, a psychologist may suffice; for severe impairment, medication (from a psychiatrist) is often needed, and for many conditions, a combination of both is ideal, though it's not always clear which approach is best for an individual.
The primary challenge is the extremely high cost of targeted genetic treatments (millions per dose), which will force society to make difficult decisions about which of the thousands of treatable diseases to fund, potentially leaving no resources for other societal needs.
Society needs to decide in advance, rationally and equitably, how these decisions will be made, involving a wide range of stakeholders to incorporate diverse values and prevent groupthink, rather than making haphazard choices based on immediate demands.
The Affordable Care Act made an enormous positive difference by allowing more people, especially the working poor who were previously uninsured, to obtain health insurance, thereby improving patient outcomes and preventing more severe conditions that would require inpatient care.
The default in healthcare is often to keep patients alive at all costs, even when there's no clear indication it aligns with the patient's wishes or provides quality of life. There should be limits on resuscitation when patient wishes are unknown and prognosis is very poor, defaulting to what the majority would want.
19 Actionable Insights
1. Eliminate Suicide Liability
Remove legal liability for psychiatrists for patient suicides (when no medical error occurred) to enable authentic clinical judgments and prevent over-hospitalization that deters future care-seeking.
2. Implement Comprehensive Mental Health Support
Establish scattered-site housing in diverse communities and structured, full-day treatment programs (8 AM-5 PM) offering psychiatric care, therapy, recreation, education, and training for severely mentally ill patients to improve long-term outcomes.
3. Allocate Genetic Treatment Ethically
Society must decide in advance, using a rational and equitable framework, which expensive genetic diseases to treat, involving diverse stakeholders to prevent haphazard, politically driven choices and ensure fair resource allocation.
4. Prioritize Invisible Victims
Reallocate healthcare funding from high-cost, visible victim care to preventative measures and less immediate needs, which can save more lives long-term, even if politically unpopular, to address systemic biases.
5. Boost Psychiatric Residency Funding
Increase government funding for psychiatric residency programs to address the critical shortage of mental health providers, which is currently exacerbated by artificial limitations supported by the profession.
6. Reform Psychiatric Insurance Reimbursement
Adjust insurance reimbursement rates to adequately compensate psychiatrists for time-based care, rather than procedure-based metrics, to incentivize private practitioners to accept major insurance and improve patient access.
7. Integrate Community Preventative Care
Embed preventative care into communities by addressing structural barriers to health, such as providing fresh produce at hospitals for patients advised to eat healthier, rather than solely relying on individual compliance.
8. Legalize Medical Aid in Dying
Allow medically assisted dying for individuals with capacity, incorporating safeguards like waiting periods for impulsive decisions and accurate education on palliative care, as the option itself can provide comfort and autonomy.
9. Complete Advance Directives
Fill out an advance directive (living will or healthcare proxy) and discuss end-of-life wishes with family to ensure patient autonomy, as the default in healthcare often prolongs life at all costs without clear patient wishes.
10. Involve Diverse Stakeholders
Ensure a wide range of stakeholders and perspectives are involved in major medical ethics decisions (e.g., resource allocation) to prevent groupthink, identify blind spots, and avoid tragic outcomes.
11. Routine Mental Health Screening
Implement routine screening for suicidality and depression at every well-patient visit, as this low-cost practice offers significant benefits in early identification and intervention without inducing suicidal thoughts.
12. Empower Patient Agency in Care
Give more credibility to patients’ subjective feelings about their safety to leave the hospital, as over-restriction can deter them from seeking help when truly suicidal, fostering trust and engagement.
13. Consider Limb Removal for BID
For Body Integrity Disorder (BID), if a limb causes extreme distress and evidence suggests removal improves function and reduces self-harm, physicians should consider it as a harm reduction strategy.
14. Medication for Severe Mental Illness
For conditions like bipolar disorder and schizophrenia, medication is an essential part of the treatment program, complementing psychotherapy and social services.
15. Strategic Choice of Mental Health Pro
Choose a mental health professional based on primary need: a psychologist for therapy for mild-to-moderate issues, or a psychiatrist for medication for severe impairment or medication preference, noting good providers will refer.
16. Utilize AA for Addiction Recovery
Explore Alcoholics Anonymous (AA) or similar secular communal programs for addiction recovery, as they can be highly beneficial for individuals who connect with their spiritual or communal aspects, complementing other treatments.
17. Support Consensual Polygamy
Morally support consensual polygamous relationships between adults based on genuine affection, provided logistical and legal challenges can be resolved without economic fraud.
18. Reframe Work as Enjoyment
Cultivate a mindset where work is viewed as enjoyable and fun, rather than a chore, to increase productivity and reduce misery.
19. Prioritize Social Connection
Actively foster social connections and address societal disconnections, as isolation and lack of social support contribute significantly to mental health decline across all age groups.
6 Key Quotes
I mean, I think I really don't see the distinction between working and relaxing, because I think maybe things other people might think are work, I actually think are fun, like writing bioethics papers.
Jacob Appel
I always like to say there are more child psychiatrists in my office suite than there are in all of Wyoming.
Jacob Appel
What I don't like is being brought to the hospital every month because somebody sees me on the street talking to myself. You have me spend a day here, tune me up a bit, and then send me right back out where I came from. And I don't blame them.
Jacob Appel
I wrapped the light around my bed sheet around my fist and I punched the light out as hard as I could. And it worked. And I had lots of meetings and disciplinary consequences as a result, but it was still the right thing to do.
Jacob Appel
I think the larger question you're driving at is do we spend too much money on clinical care as a whole versus preventive care? And there's a much stronger argument for that.
Jacob Appel
I mean, the last thing I need to do is I know people I know are on the documentary and they talk about me. The last thing you want to know is what people you know socially and care about think about you. I want to know what they tell me and not what they told the world.
Jacob Appel
1 Protocols
Ideal Mental Health System for Severely Ill Patients
Jacob Appel- Provide 'scatter-aside housing': Place patients with severe mental illness in middle-class apartment buildings and houses around the community, rather than clustered together.
- Enroll in 'day treatment programs': Patients attend standardized programs from 8 AM to 5 PM daily, offering a combination of psychiatric care, therapy, recreation, education, and training.