Steve Strakowski Interview

I know that one of the greatest challenges faced by the mental health field is the massive gap between what society needs in terms of mental health providers, and the actual workforce that exists to address those needs. How do you begin to deal with that? We often talk about innovation in technology and research, but what does innovation look like at that systemic level?

I’ll give you an example of how we might approach this challenge. In Austin, I am working with a group of leaders of the major regional mental health providers to start redesigning our mental health services. This work group unites key stakeholders to integrate (and stop duplicating) efforts to optimize resource utilization. It also provides a venue to brainstorm and challenge all of our assumptions. When our work group got started, I bought everyone in the group a book on the history of psychiatry to help frame the discussion. One of the things the book talks about is how in early 1800s, the state of Wisconsin created a mental health care system that provided a continuum of care that met patients where they were and offered a severity of illness-based treatment continuum. It was wildly successful, both in terms of clinical outcomes and reduction in costs, but it failed politically and ideologically, and so it was shut down. It failed because it went against the dogma of the era regarding how we should treat people with mental illness, which was to put them in the big hospitals, often for extended periods of time.

They were good answers back in the 1800s, and in many ways it’s what we’re hoping to do now, which is create this continuum of care. It’s already what you see in most of the rest of medicine, where they’re de-emphasizing hospital stays, increasing the emphasis on outpatient care, making sure that providers are working to the top of their license, and taking other steps to optimize care, reduce costs, and improve outcomes. The historical lesson is not to let ideology and dogma block good solutions.

So the challenge is to deploy psychiatrists better, put them where they’re really needed, and integrate them into mental health care teams.

A central problem is that there will never be enough psychiatrists for everyone who thinks they need a psychiatrist. So the challenge is to deploy psychiatrists better, put them where they’re really needed, and integrate them into mental health care teams. Then refer as many people as possible to less expensive and alternative providers who are better suited to their needs, and frankly often better-trained than the physicians in those aspects of care.

Having someone with a typical case of depression see me, for example, at an elevated cost relative to other potential providers, is a poor use of resources. What makes much more sense is working as a team, providing a continuum of care through providers in much the same way that we would like to provide a continuum of facilities. That means leveraging and integrating psychiatric social workers, psychologists, primary care providers and counselors more effectively than we do now. It means relying on pharmacists to do a lot of med assessments and monitoring, and having them advise primary care physicians and psychiatric nurse practitioners. Then you bump it up to the psychiatrist — for example, me — when you need a psychiatrist, to do a medical assessment and provide complex patient care planning, but you don't have physicians doing the work of therapists and counselors and pharmacists (and the converse, of course).

We have a project right now, for instance, with CMS and the Texas Medical Foundation to see if we can train primary care doctors to do a better job managing most depression, because depression alone overwhelms every system, and in fact most of the time people can be managed with therapy and anti-depressants. If successful, this type of project design could improve access to care for many people.

That all sounds great. How close are we to that in Texas right now?

The demand for mental health care overwhelms every system, everywhere, so that is not unique to Texas. That’s the backdrop. But we do have some unique issues.

Look at our state hospitals, which were built decades ago based upon care models that are decades if not a century old. These massive and often isolated buildings and campuses, some of which are in really poor condition, were created for a very different time and often fail to incorporate modern treatment approaches. They are filled with good people who are inadequately supported working in poorly designed structures.

But there's an opportunity in that as well. There are not a lot of legacy programs in Texas in the way of reform. And everyone knows we need a change. This is a chance to do it better and different rather than just build new big buildings. We have the opportunity to ask ourselves, from the ground up, what a modern mental health care system should look like.

So what’s wrong with hospitals?

Hospitals are not healthy places. When you really need them, then use them, but they are not the optimal place to recover from any illness. It’s hard to rest, medication errors occur, other patients may present problems, and they are really designed to manage people at immediate risk of medical or psychological harm. These considerations are true of all hospitals, not psychiatric hospitals per se; mental health is no worse or better than other medical conditions in this sense. Errors happen in medicine, and you consolidate them when you put them all in an intense inpatient setting.

People often think that doctors are sending them home from the hospital because they don’t care, or don’t want them there. That’s the opposite of the truth. The doctor cares about you and because of that wants to keep you out of the hospital as much as possible. Thank them if they send you home, because you are going to be safer at home than at the hospital, and it tends to be much easier to recover at home.

So the goal is to rethink the care continuum. Again, it's not all that creative. It's to look like the rest of medicine. Let’s use each component — hospitals, outpatient care, rehab — optimally. Mental health care is not currently designed that way.

Meaning?

Take these dollars we might invest in massive infrastructure and create a different kind of infrastructure. It would be one in which we still have ICU beds, a place for really sick people to go, but we also have step-down units and long-term acute care units, and skilled nursing facilities, and other intermediate services, all of which have less overhead and are designed differently to manage a different kind of problem than treating everything like an emergency or acute episode. As a result, you get better outcomes, you get lower costs, and you get better care.

Right now, most inpatient mental health facilities are designed around that ICU level of care but are filled with people who don't really need it. At any given time, in one of these hospitals, perhaps 60-70 percent of the patients could be treated in a much less restrictive, much less expensive environment, and it would be more effective treatment. But because the rest of the continuum doesn't exist, that’s not an option.

Imagine you’re an ER doc, and you’re seeing someone who you would ideally send home to be seen tomorrow, in an outpatient or less restrictive inpatient context. But you know they won’t be seen tomorrow, because those options don’t exist, or there’s too long a wait, so instead you put them in the hospital because you're worried about them. It’s not out of malice. It’s all people trying to do their best.

Our goal, locally, is to take the Austin State Hospital campus and use that campus as a hub to create each of these pieces, with the knowledge that we are ultimately going to try to push out many of the pieces to the communities, where they belong. The current thinking is that we mirror everything, with at least one copy on the campus, in order to develop the models and test them and refine best practices and so forth.

Does that kind of set-up exist anywhere else?

There are states that have pieces of it. But to my knowledge, no one has developed the full continuum, and that is where we hope we can be the leader. That is where the most important initial innovation would lie. Not in necessarily new ideas or technology, but in a more integrated, targeted continuum of care.

That’s not a small thing. Imagine you're a 20-year-old kid who lives in a rural area who develops his first manic episode. This is a genetic brain disease, and his family doesn't have a lot of resources, and so the least bad option might be that he gets shipped three hours away to Austin to stay at the Austin State Hospital.

If your kid had pneumonia, would you be satisfied to have your kid sent three hours away for his pneumonia care? Is that good care? No, it's terrible care.

So ultimately we want to take the models we develop locally and push them out to the community. What it should look like is that this kid starts with two days at a regular general hospital with some tele-psychiatry support, perhaps from Austin. Then he can move for a period of time to a community mental health center, with some additional support from a central organization, and so on.

The goal is to use this hub we want to create as a model for the continuum and then push as much of the continuum out to the communities that would provide better care, less expensive, closer to home.

If we do it well, the research will inform our clinical practice, which in turn will feed back into the research. Everything will steadily improve.

So if you realized this vision, on the ASH campus and outside, it would be pretty new?

It would take pieces of what exists, but overall it would be pretty new. I think the really challenging part is that it would require moving policy and public perception into a different space around mental health care, and what our expectations are in terms of where and how people get treatment. It is also a challenge to providers, including psychiatrists, to think differently about their roles within the system.

The field is at a point where if we could just improve access and care delivery that would go a long, long ways toward improving mental health. Because right now less than half of the people who need care get effective treatment. That is the low bar, just to get people access to the treatments we already know are effective, but it would make an enormous difference.

But we also know that the treatments are not ideal either. And so the second step is to improve our treatments. And that can go hand in hand with the redesign. Create that continuum of care, and alongside it you build a strong research presence on the campus. We would like it become a national example of how you develop good models, how do you do science, and how do you improve clinical care. We imagine it would lead the treatment of brain diseases like MD Anderson does with cancer care or Cleveland Clinic does with heart care.

If we do it well, the research will inform our clinical practice, which in turn will feed back into the research. Everything will steadily improve.

We’ve been talking primarily about inpatient facilities, and people in acute crisis. When you talk about this continuum of care, where does everyone else fit in? Are you just focused on the acute case, on people above the threshold where they might end up in a hospital?

Not at all. The goal is also to help the less severely ill also land in a place where they can get the best treatment. Imagine you're an anxious, depressed kid. You don't need to be in a hospital. But you need to be in a type of psychotherapy that works for you, or in the right kind of group, or on the right medication, instead of randomly hitting the system and hoping you can find someone who will treat you somehow.

We have been talking about this in the context of the public sector, but in fact the biggest gap in psychiatric care, here and in most places, is if you're middle class with insurance. Then you’re never going to get in to see a psychiatrist. First of all, there aren’t enough of them. And second, few private psychiatrists take insurance. Not because they’re bad people, but they don’t need to. The demand is overwhelming, and why would they deal with the hassle of insurance bureaucracy when they can just get paid directly, and frankly see more patients more effectively.

So if you have no insurance, there are public programs, and if you're wealthy you'll pay cash, but if you need your insurance to pay for your visit, then good luck. That is true everywhere, not just in Texas.

We need to build out a continuum so there are possibilities, so you have a choice, and we need to help train people to where the evidence is strongest, and at the lowest cost, because in the end we can't afford to do it the way we've done it.

And to finish the thought, the number one of provider of mental health services in Texas right now is the Harris County Jail. There are few places more expensive than jails to deliver health care, and they are dangerous on top of that. So the goal is to expend the resources more wisely.

Why do you think we have a such a hard time doing that?

I think the bigger challenge is a conceptual one. It’s to get mental health care viewed as a branch of medicine, like any other branch. And it’s to continue to move away from ways of thinking and talking about mental health that obscure that these are brain diseases.

One example. I abhor the term “behavioral health,” which has become popular shorthand. Imagine you have schizophrenia, and you’re told you have a behavioral health condition. It suggests that if you just behaved better you’d be okay, and that is just absolutely untrue. The attempt is to make it sound friendlier, but I think it stigmatizes psychiatric conditions even further.

Part of why limited resources are spent in the worst places is the worst places are the only places that we can understand. So part of changing that distribution of resources is changing our understanding of what mental health is, and how we can best deliver care in different structures.

So what is mental health and illness? What would you say to the public, to try to reorient us?

I’d say that these are mostly genetically driven, or gene-environment, brain diseases, that impact your behavior. They can be treated effectively, but they have to be recognized and you have to have the ability to get treatment. And they are not terribly different from a migraine, or a heart attack.

The fact that we can't localize the site of the disease, as easily as we can with many other types of diseases, is because the brain is an incredibly complicated organ. But we are starting to have the evidence base to show the brain abnormalities associated with the diseases.

Just as important is for people to know that there is an evidence base of knowledge about how these brain diseases get better that we can follow, and that if you follow that evidence you will generally get better. If you don’t, you’re taking your chances.

We don't know all the details, but the truth is we don't know why people get high blood pressure either. We know high blood pressure is there. We can measure it. If you have this constellation of symptoms, then there is the typical path to treatment. You should expect that from your doctor, and if you are not getting that then you probably need a different doctor.

That’s the direction in which we are moving in mental health, and we are already further along than most people know. The treatments aren't perfect, and there is lots of room to improve them, but that is true of chemotherapy, and MS infusions, and everything else in medicine. We’ll get better, and understand more, over time, but it’s a long process.

We look back at treatment 100 years ago, and say, ‘Those people were barbarians.’ I am reasonably confident that 100 years from now, that is how people will see us. In fact, in both cases, people leading care are doing the best they can within the limits of the structure and knowledge. We believe we can move both forward to provide better care now and here in Austin.

Seems like a good place to end. Anything else you want to add?

I am excited to be in Austin,” he says. “I came here to do something big and make a difference. I wanted to try to do something new, and the leaders in the city have been nothing but supportive and progressive, thinking about mental health. So I'm cautiously optimistic that we are going to make a difference. We probably won’t end up where we think we will, but we are going to end up somewhere really cool and do something meaningful.