Quality Mental Health Care Possible?
it right the first time" has become a mantra for business,
although it is often easier said than done. The right way,
of course, is the way that leads to the desired business outcomes,
and without excessive cost. Mental health care also has a
right way to do things the first time, but the principles
that underlie quality are not always obvious to a casual observer.
Much of what passes for quality care these days is not, and
even experts can sometimes have trouble determining where
superior care can be found. So, is quality mental health care
possible? Of course it is, as long as attention is paid to
some basic principles.
For a start, you have to know
where you want to end up. From an employer perspective, that
means effective and cost effective care for employee problems.
Ideally, quality mental health care outlays will be more than
offset by savings in such employer costs as absenteeism, recruitment
and training, reduced productivity, and other health care
expenses. From the employee's perspective, the desired outcome
is accurate identification of the problem, appropriate treatment,
and resolution of problems.
Next, quality mental health
care requires ready access for employees in need. Multiple
referral routes improve the odds of appropriate help seeking.
Internists, EAPs, and self-referral can be supplemented by
worksite self-assessment programs. Actual or perceived lack
of confidentiality can be major barriers to access, along
with paperwork and authorization requirements. Prompt access
to initial care is essential.
Perhaps most important is the
initial clinical evaluation. Significant emotional distress
often has multiple causes, and the central factor is usually
not obvious. The initial evaluation should be broad and thorough,
with careful attention to personal life, workplace factors,
commonplace anxiety and depressive disorders, drug and alcohol
use, concurrent and causal medical illness, and much more.
Although many current clinical systems use evaluators with
narrower training and experience, this is where highly skilled
clinicians with broad and advanced training are most essential.
Evaluators with narrower skills are not aware of what they
don't see. It is too easy to ease a divorce, rather than treat
an underlying anxiety disorder and thus repair a marriage.
Dissatisfaction at work is often caused by unpleasant changes
at home. Poor job performance attributed to work stress can
be due to a hidden conflict with a supervisor, an unrecognized
depression, or even an undiagnosed medical illness. And, a
small percentage of the time, emotional distress can be the
presenting symptom of such problems like thyroid disease,
cancer, or other medical illnesses. Just as in medical care,
doing it right the first time starts with the right initial
Treatment can then focus where
it well help best, and fastest. Psychotherapy does this when
it focuses not only on the apparent issues, but also on less
obvious core issues. For most people, good psychotherapy is
both more useful and shorter than supportive ("hand holding")
treatment. Medication helps treatment work effectively and
quickly when it is used accurately for treatment of the anxiety
and depressive disorders that are so common in distressed
employees. Used properly, medication and psychotherapy make
each other more effective. Only rarely are they equally effective
alternatives for the same problem, and rarer still are the
times when medication alone is fully sufficient. Treatment
providers should have experience and skill in their treatment
areas, but broad training in all of psychotherapy, medication
and also medicine is not always needed.
Even if you know what to do,
quality mental health care is not easy to bring about. To
get there, start by setting basic standards and guidelines,
and perhaps your own clinical oversight group. Standards in
mental health care should resemble those in medical care.
Existing professional diagnostic (DSM-IV) and treatment (American
Psychiatric Association, and others) guidelines are a good
place to start, along with basic principles of the good psychiatric
care that senior managers might seek for themselves. Finding
the right psychiatrists, psychologists and social workers
is vital, as is understanding the important differences in
training, skills and expertise of these three mental health
disciplines. Talk to managed care, insurance, consulting and
other companies about your new guidelines for quality mental
Unfortunately, it has been
too easy in mental health to pass off lesser levels of care
as optimal. Employees may recognize friendly care, but will
rarely know when something important has been missed, or when
an evaluator's skills are too narrow. While much of mental
health care is not what it could be, not all treatment is
the same. Quality mental health care requires both forethought,
and ongoing attention to effectiveness. Existing measurement
tools tend to focus on patient satisfaction more than on the
triad of accurate diagnosis, appropriate treatment, and patient
recovery. While care must be taken to protect confidentiality,
there are appropriate ways to assess and encourage quality
diagnosis and treatment. Overall mental health treatment costs
should also be weighed against measurements of workforce effectiveness
and other cost offsets. Understanding the basic principles
of quality mental health care makes it a very possible goal.
Jeffrey P. Kahn, M.D. is President
of WorkPsych Associates, a NYBGH member. WorkPsych (WorkPsych@aol.com)
provides a range of executive assessment, development and
treatment services, as well as corporate benefits and management
consultation. He is also editor of Mental Health in the Workplace:
A Practical Psychiatric Guide, active in the business relations
efforts of the American Psychiatric Association, and Past
President of the Academy of Organizational and Occupational