Healthcare Reforms for the Mentally Ill

Catalyst VOlume 10

Neuropsychiatric illnesses are some of the most devastating conditions in the world. Despite being non-communicable, mental and neurological conditions are estimated to contribute to approximately 30.8% of all of the years lived in disability1. Furthermore, in developed nations like the United States, mental disorders have been reported to erode around 2.5% of the yearly gross national product, which fails to account for the opportunity cost of families who have to take care of patients long-term.¹ If left untreated, many patients with neuropsychiatric illnesses cannot find gainful employment; their aberrant behavior is stigmatized and prevents forward professional and personal advancement. In fact, about three times as many individuals living with mental illnesses who are in state/local prisons rather than rehabilitative psychiatric institutions.²

Though the Affordable Care Act has substantially decreased the amount of uninsured individuals in the U.S., there are still millions of people who fall into something called the Medicaid gap.³ People in this group make too much money for Medicaid, but too little money to be able to qualify for government tax credits in purchasing an insurance plan. In an attempt to fix this ‘hole,’ the federal government offers aid to states in order to expand their Medicaid programs as needed.⁴ States that have accepted the Medicaid expansion sponsored by the federal government, have seen sudden reductions in their populations of uninsured people, which has directly improved quality of life for the least fortunate people in society. However, in the many states that continue to reject federal aid, the situation is considerably worse--especially for the mentally ill.

Mental health patients are especially vulnerable to falling into the Medicare gap. Many patients suffering from psychiatric conditions often are unable to find serious employment. According to a report by the Department of Health and Human Services in March 2016, there are 1.9 million low-income, uninsured individuals with mental health disorders who cannot access proper healthcare resources.⁵ These impoverished psychiatric patients are originally eligible for Medicare. However, once their treatment takes and they become employed, they might pass the Medicare income threshold. If their private health insurance does not cover the cost of their psychiatric treatments, patients will relapse, creating a vicious cycle that is exceptionally difficult to break out of.⁶

Furthermore, many psychiatric illnesses often initially present during adolescence or early adulthood, which is right around the time students leave home to go to college. So, during initial presentation, many students lack the proper support system necessary to deal with their condition, causing many to drop out of college or receive poor grades. Families often chalk up these conditions to poor adjustments to a brand new college environment at home, preventing psychiatric patients from properly receiving treatment.⁶ Alone, many students with psychiatric conditions delay seeking treatment, fearing being labeled as “crazy” or “insane” by their peers.

Under the status quo, psychiatric patients face significant barriers to care. As the Medicaid gap is unfortunately subject to political maneuverings, it probably will not be fixed immediately. However, the United States could fund the expansion of Assertive Community Treatment programs, which provide medication, therapy, and social support in an outpatient setting.⁸ Such programs dramatically reduce hospitalization times for psychiatric patients, alleviating the costs of medical treatment. Funding these programs would help insurance issues from being a deterrent to treatment.

In the current system, psychiatric patients face numerous deterrents to receiving treatment, from lack of family support to significant social stigma. Having access to health insurance be a further barrier to care is a significant oversight of the current system and ought to be corrected.

References

1. World Health Organization. Chapter 2: Burden of Mental and Behavioural Disorders. 2001. 20 3 2016 <http://www.who.int/whr/2001/chapter2/en/index3.html>.
2. Torrey, E. F.; Kennard, A. D.; Elsinger, D.; Lamb, R.; Pavle, J. More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States .
3. Kaiser Family Foundation. Key Facts about the Uninsured Population. 5 8 2015. 25 3 2016 <http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/>.
4. Ross, Janell. Obamacare mandated better mental health-care coverage. It hasn't happened. 7 8 2015. 24 3 2016 <https://www.washingtonpost.com/news/the-fix/wp/2015/10/07/obamacare-mandated-better-mental-health-care-coverage-it-hasnt-happened/>.
5. Dey, J.; Rosenoff, E.; West, K. Benefits of Medicaid Expansion for Behavioral Health. 28 3 2016 <https://aspe.hhs.gov/sites/default/files/pdf/190506/BHMedicaidExpansion.pdf>
6. Taskiran, Sarper. Interview. Rishi Suresh. Istanbul, 3 3 2016.
7. Gonen, Oner Gurkan. Interview. Rishi Suresh. Houston, 1 4 2016.
8. Assertive Community Treatment https://www.centerforebp.case.edu/practices/act (accessed Jan 2017).

The Health of Healthcare Providers

Catalyst Volume 10

A car crash. A heart attack. A drug overdose. No matter what time of day, where you are, or what your problem is, emergency medical technicians (EMTs) will be on call and ready to come to your aid. These health care providers are charged with providing quality care to maintain or improve patient health in the field, and their efforts have saved the lives of many who could not otherwise find care on their own. While these EMTs deserve praise and respect for their line of work, what they deserve even more is consideration for the health issues that they themselves face. Emergency medical technicians suffer from a host of long-term health issues, including weight gain, burnout, and psychological changes.

The daily "schedule" of an EMT is probably most characterized by its variability and unpredictability. The entirety of their day is a summation of what everyone in their area is doing, those people's health issues, and the uncertainty of life itself. While there are start and end times to their shifts, even these are not hard and fast--shifts have the potential to start early or end late based on when people call 911. An EMT can spend their entire shift on the ambulance, without time to eat a proper meal or to get any sleep. These healthcare providers learn to catch a few minutes of sleep here and there when possible. Their yearly schedules are also unpredictable, with lottery systems in place to ensure that someone is working every day, at all hours of the day, while maintaining some fairness. Most services will have either 12 or 24 hour shifts, and this lottery system can result in EMTs having stacked shifts that are either back to back or at least within close proximity to one another. This only enhances the possibility of sleep disorders, with 70 percent of EMTs reporting having at least one sleep problem.¹ While many people have experienced the effects of exhaustion and burnout due to a lack of sleep, few can say that their entire professional career has been characterized by these feelings. EMTs have been shown to be more than twice as likely than control groups to have moderate to high scores on the Epworth Sleepiness Scale (ESS), which is correlated with a greater likelihood of falling asleep during daily activities such as conversing, sitting in public places, and driving.¹ The restriction and outright deprivation of sleep in EMTs has been shown to cause a large variety of health problems, and seems to be the main factor in the decline of both physical and mental health for EMTs.

A regular amount of sleep is essential in maintaining a healthy body. Reduced sleep has been associated with an increase in weight gain, cardiovascular disease, and weakened immune system functions. Studies have shown that, at least in men, short sleep durations are linked to weight gain and obesity, which is potentially due to alterations in hormones that regulate appetite.^2,3 Due to this trend, it is no surprise that a 2009 study found that sleep durations that deviated from an ideal 7-8 hours, as well as frequent insomnia, increased the risk of cardiovascular disease. The fact that EMTs often have poor diets compounds that risk. An EMT needs to be ready around the clock to respond, which means there really isn’t any time to sit down and have a proper meal. Fast food becomes the meal of choice due to its convenience, both in availability and speed. Some hospitals have attempted to improve upon this shortcoming in the emergency medical service (EMS) world by providing some snacks and drinks at the hospital. This, however, creates a different issue due to the high calorie nature of these snacks. The body generally knows when it is full by detecting stretch in the stomach, and signaling the brain that enough food has been consumed. In a balanced diet, a lot of this space should be filled with fruits, vegetables, and overall low calorie items unless you are an athlete who uses a lot more energy. By eating smaller, high calorie items, an EMT will need to eat more in order to feel full, but this will result in the person exceeding their recommended daily calories. The extra energy will often get stored as fat, compounding the weight gain due to sleep deprivation. Studies involving the effects of restricted sleep on the immune system are less common, but one experiment demonstrated markers of systemic inflammation which could, again, lead to cardiovascular disease and obesity.²

Mental health is not spared from complications due to long waking periods with minimal sleep. A study was conducted to test the cognitive abilities of subjects experiencing varying amounts of sleep restriction;the results showed that less sleep led to cognitive deficits, and being awake for more than 16 hours led to deficits regardless of how much sleep the subject had gotten.⁴ This finding affects both the EMTs, who can injure themselves, and the patients, who may suffer due to more errors being made in the field. First year physicians, who similarly can work over 24 hour shifts, are subject to an increased risk of automobile crashes and percutaneous (skin) injuries when sleep deprived.⁵ These injuries often happen when leaving a shift. A typical EMT shift lasts from one morning to the next, and the EMT will leave his or her shift during rush hour on little to no sleep, increasing the dangerous possibility of falling asleep or dozing at the wheel. A similar study to the one on first year physicians mentioned prior studied extended duration work at critical-care units, and found that long shifts increased the risk of medical errors and lapses in attention.⁶ In addition to the more direct mental health problems posed by the continuous strain, EMTs and others in the healthcare field also face more personal issues, including burnout and changes in behavior. A study on pediatric residents, who face similar amounts of stress and workloads, established that 20% of participants were suffering from depression, and 75% met the criteria for burnout, both of which led to medical errors made during work.⁷ A separate study found that emergency physicians suffering from burnout also faced high emotional exhaustion, depersonalization, and a low sense of accomplishment.⁸ While many go into the healthcare field to help others, exhaustion and desensitization create a sort of cynicism in order to defend against the enormous emotional burden that comes with treating patients day in and day out.

Sleep deprivation, long work duration, and the stress that comes with the job contribute to a poor environment for the physical and mental health of emergency medical technicians and other healthcare providers. However, a recent study has shown that downtime, especially after dealing with critical patients, led to lower rates of depression and acute stress in EMTs.⁹ While this does not necessarily ameliorate post-traumatic stress or burnout, it is a start to addressing the situation. Other possible interventions would include providing more balanced meals at hospitals that are readily available to EMTs, as well as an improved scheduling system that prevents or limits back to back shifts. These concepts can apply to others facing high workloads with abnormal sleeping schedules as well, including college students, who are also at risk for mood disorders and a poorer quality of life due to the rigors of college life.¹⁰

References

1. Pirrallo, R. G. et al. International Journal of the Science and Practice of Sleep Medicine. 2012, 16, 149-162.
2. Banks, S. et al. J. Clin. Sleep Med. 2007, 3(5), 519-528.
3. Watanabe, M. et al. Sleep  2010, 33(2), 161-167.
4. Van Dongen, H. P. et al. Sleep 2004, 27(4), 117-126.
5. Najib, T. A. et al. JAMA 2006, 296(9), 1055-1062.
6. Barger, L. K. et al. PLoS Med. [Online] 2006, 3(12), e487. https://dx.doi.org/10.1371%2Fjournal.pmed.0030487 (accessed Oct. 3, 2016)
7. Fahrenkopf, A. M. et al. BMJ [Online] 2008, 336, 488. http://dx.doi.org/10.1136/bmj.39469.763218.BE (accessed Oct. 3, 2016)
8. Ben-Itzhak, S. et al. Clin. Exp. Emerg. Med. 2015, 2(4), 217-225.
9. Halpern, J. et al. Biomed. Res. Int. [Online] 2014, 2014. http://dx.doi.org/10.1155/2014/483140 (accessed Oct. 3, 2016)
10. Singh, R. et al. J. Clin. Diagn. Res. [Online] 2016, 10(5), JC01-JC05. https://dx.doi.org/10.7860%2FJCDR%2F2016%2F19140.7878 (accessed Oct 3, 2016)

Visualizing the Future of Medicine

Catalyst Volume 10

What do you do when you get sick? Most likely you schedule a doctor’s appointment, show up, and spend ten to fifteen minutes with the doctor. The physician quickly scans your chart, combines your narrative of your illness with your medical history and his or her observations so that you can leave with diagnosis and prescription in hand. While few give the seemingly routine process a second thought, the very way in which healthcare providers approach the doctor-patient experience is evolving. There is a growing interest in the medical humanities, a more interdisciplinary study of illness. According to Baylor College of Medicine, the aim of the medical humanities is “understanding the profound effects of illness and disease on patients, health professionals, and the social worlds in which they live and work.”¹ Yet medical humanities is somewhat of a catch all term. It encompasses disciplines including literature, anthropology, sociology, philosophy, the fine arts and even “science and technology studies.”¹ This nuanced approach to medicine is exactly what Dr. Kirsten Ostherr, one of the developers of Rice University’s medical humanities program, promotes.

Dr. Ostherr uses this interdisciplinary approach to study the intersection of technology and medicine. She has conducted research on historical medical visualizations through media such as art and film and its application to medicine today. Originally a PhD recipient of American Studies and Media Studies at Brown University, Dr. Ostherr’s interest in medicine and media was sparked while working at the Department of Public Health at Oregon Health Sciences University, where researchers were using the humanities as a lens through which they could analyze health data. “I noticed that the epidemiologists there used narrative to make sense of data, and that intrigued me,” she said. This inspired Dr. Ostherr to use her background in media and public health to explore how film and media in general have affected medicine and to predict where the future of medical media lies.

While the integration of medicine and media may seem revolutionary, it is not a new concept. In her book, Medical Visions, Dr. Ostherr says that “We know we have become a patient when we are subjected to a doctor’s clinical gaze,” a gaze that is powerfully humanizing and can “transform subjects into patients.”² With the integration of technology and medicine, this “gaze” has extended to include the visualizations vital to understanding the patient and decoding disease. Visualizations have been a part of the doctor-patient experience for longer than one might think, from X-rays in 1912 to the electronic medical records used by physicians today.³

In her book, Dr. Ostherr traces and analyzes a series of different types of medical visualizations throughout history. Her research begins with the study of scientific films of the early twentieth century, and their attempt to bridge the gap between scientific knowledge and the general public.² The use of film in medical education was also significant in the 20th century. These technical films helped facilitate the globalization of health and media in the postwar era. Another form of medical visualizations that emerged with the advent of medicine on television. At the intersection of entertainment and education, medical documentary evolved into “health information programming” in the 1980’s which in turn transitioned into the rise of medical reality television.² The history of this diverse and expanding media, she says, proves that the use of visualizations in healthcare and our daily lives has made medicine “a visual science.”

One of the main takeaways from Dr. Ostherr’s historical analysis of medical visualizations was the deep-rooted relationship between visualizations and their role in spreading medical knowledge to the average person. While skeptics may argue against this characterization, “this is a broad social change that is taking place,” Dr. Ostherr said, citing new scientific research emerging on human centered design and the use of visual arts in medical training. “It’s the future of medicine,” she said. There is already evidence that such a change is taking place: the method of recording patient information using health records has begun to change. In recent years there has been a movement to adopt electronic health records due to their potential to save the healthcare industry millions of dollars and improve efficiency.⁴ Yet recent studies show that the current systems in place are not as effective as predicted.⁵ Online patient portals allow patients to keep up with their health information, view test results and even communicate with their health care providers, but while these portals can involve patients as active participants in their care, they can also be quite technical.⁶ As a result, there is a push to develop electronic health records with more readily understandable language.

In order to conduct further research in the field including projects such as the development of better, easier to understand electronic health records, Dr. Ostherr co-founded and is the director of the Medical Futures Lab. The lab draws resources from Baylor College of Medicine, University of Texas Health Science Center, and Rice University and its diverse team ranges from humanist scholars to doctors to computer scientists.⁷ The use of technology in medicine has continued to develop rapidly alongside the increasing demand for personalized, humanizing care. While it seems like there is an inherent conflict between the two, Dr. Ostherr believes medicine needs the “right balance of high tech and high touch” which is what her team at the Medical Futures Lab (MFL) works to find. The MFL team works on projects heavily focused on deconstructing and reconstructing the role of the patient in education and diagnosis.⁷

The increasingly integrated humanistic and scientific approach to medicine is revolutionizing healthcare. As the Medical Futures Lab explores the relationship between personal care and technology, the world of healthcare is undergoing a broad cultural shift. Early on in their medical education, physicians are being taught the value of incorporating the humanities and social sciences into their training, and that science can only teach one so much about the doctor-patient relationship. For Dr. Ostherr, the question moving forward will be “what is it that is uniquely human about healing?” What are the limitations of technology in healing and what about healing process can be done exclusively by the human body? According to Dr. Ostherr, the histories of visualizations in medicine can serve as a roadmap and an inspiration for the evolution and implementation of new media and technology in transforming the medical subject into the patient.

References

1. Baylor University Medical Humanities. http://www.baylor.edu/medical_humanities/ (accessed Nov. 27, 2017).
2. Ostherr, K. Medical visions: producing the patient through film, television, and imaging technologies; Oxford University Press: Oxford, 2013.
3. History of Radiography. https://www.nde-ed.org/EducationResources/CommunityCollege/Radiography/Introduction/history.htm (accessed Jan. 2017).
4. Abelson, R.; Creswell, J. In Second Look, Few Savings From Digital Health Records. New York Times [Online], January 11, 2013. http://www.nytimes.com/2013/01/11/business/electronic-records-systems-have-not-reduced-health-costs-report-says.html (accessed Jan 2017).
5. Abrams, L. The Future of Medical Records. The Atlantic [Online], January 17, 2013 http://www.theatlantic.com/health/archive/2013/01/the-future-of-medical-records/267202/ (accessed Jan. 25, 2017).
6. Rosen, M. D. L. High Tech, High Touch: Why Technology Enhances Patient-Centered Care. Huffington Post [Online], December 13, 2012. http://www.huffingtonpost.com/lawrence-rosen-md/health-care-technology_b_2285712.html (accessed Jan 2017).
7. Medical Futures Lab. http://www.medicalfutureslab.org/ (accessed Dec 2017).