The National Alliance for the Mentally Ill (NAMI) has been sounding the alarm of a nationwide crisis in mental health services since 2011. On the other side of the Atlantic, the National Health Service in the United Kingdom is struggling to provide adequate mental health services. For us mental health professionals in Arkansas, these jeremiads ring a familiar bell.
Accepting the risk of oversimplification, let's summarize two centuries of history to provide background. The modern system of care for mental illness was inaugurated in wake of the French and American revolutions with the process of converting the old asylums into psychiatric hospitals. Over time those psychiatric hospitals deteriorated into large inhumane warehouses, and community mental health centers were hailed as the answer. That was 50 years ago. Since then we've seen a dramatic decrease in psychiatric hospital bed availability without the reciprocal creation of a community network of providers and clinics to care for the mentally ill. The result has been a transfer from the old psychiatric hospitals to prisons and the streets of a population suffering not only from severe mental disorders, but also from substance abuse, poverty and, at times, despair. So, who cares for these people?
An adequate mental health system includes a variety of professionals, from psychiatrists, social workers and psychologists to counselors, nurses and physician-assistants. These professionals need to work in clinics and hospitals with medical, psychological and social support. The data on the availability of such professionals in Arkansas speaks to our precarious situation.
According to the Dartmouth Atlas for Health Care in America, nationwide there are on average 11.4 psychiatrists per 100,000 U.S. residents, while the estimate for Arkansas is about 5.2. Furthermore, the distribution of these psychiatrists is unequal across the state, with Little Rock having 9.2 while cities like Fort Smith have 3.2 psychiatrists per 100,000 residents. Regarding the availability of public psychiatric beds, the Treatment Advocacy Center argues for 50 psychiatric beds per 100,000 residents as minimally adequate. Arkansas was listed as the state with the third fewest number of beds with 6.7 public psychiatric beds per 100,000 in 2005.
The short-term effects of our shortages are long wait times to get care, untreated conditions yielding co-occurring disorders like alcohol and drug use (sometimes used as self-medications) and use of emergency rooms as stop-gap measures. These are followed by the long-term consequences of chronic and relapsing disorders: violence — more likely as victims than perpetrators — recidivism, overcrowding of jails and prisons and a terrible burden of suffering for those patients, their families, and all of us.
The solution to a historical crisis in mental health care will require a multipronged strategy. It's clear we need more professionals trained to handle these complex issues. In order to be a psychiatrist, a physician needs several years of graduate medical education, and funding for more slots is needed in the only residency program in the state, at the University of Arkansas for Medical Sciences.
Psychologists, counselors and social workers will be required to provide psychotherapy and behavior modification strategies. We need to help nurses and PAs see the potential in specializing in mental health. These professionals will need places to work, like community mental health centers and psychiatric hospitals. Compared to nearby states such as Alabama with 39 community mental services providers, Arkansas has far fewer such providers with 15. A strong infrastructure with clinics, residential options, hospitals and crisis centers will be required to address this need. Diversion programs, from jails and shelters to families and communities, will help ease some of the overcrowded situation on the legal front. Finally, integration with the general health system will be required. Primary care clinics and family physicians will need training and education on mental health issues to prevent undue referrals to an overwhelmed system.
The needs of the mentally ill should not be hijacked by ideologies, especially since both conservative and liberal politicians can contribute ideas to build the way forward. Part of the solution will come from private enterprise, part will come from the state and many will involve public-private partnerships.
The realization of a mental health crisis tends to happen when tragedies occur. I hope we can avoid tragedies by working to move Arkansas from the bottom of the report card on mental health systems to become that shining city on the hill we all aspire to live in.
Erick Messias, M.D., Ph.D., is an associate professor in the department of psychiatry at the University of Arkansas for Medical Sciences and president of the Arkansas Psychiatric Society.