Our Broken Mental Health Care System


“We’re protecting civil liberties at the expense of health and safety,” – Doris A. Fuller, Executive Director of the Treatment Advocacy Center,




As those of you who have read my column over the almost three years I have been writing my weekly feature are aware, I have rarely ever, actually never, ventured into the political arena, as it has always been my goal to educate and enlighten when it comes to the field of mental health, and specifically various forms of mental illness.  Sadly, I can refrain no longer.  Our country’s mental health system (both civilian and military), and our local mental health system as a reflective microcosm, is BROKEN!  It is now, has been for decades, and will continue to be so unless the powers that be wake up and realize their denial and ignorance of the problem is leading our country into a very dark and unforgiving place.


The recent tragedy at Fort Hood, the second there in just a few short years, underscores just how poorly treated, under treated, and untreated mental illness can lead to horrendous violence with staggering results.  Just a few short weeks ago Ivan Lopez, a serviceman being treated for psychiatric illness(es), ended up taking the lives of three innocent people, wounding almost a score of others, all before taking his own life.  The word tragedy really does not even begin to accurately describe the events.  Before that there was James Holmes who showed up at his first court hearing following his Aurora theater rampage with orange hair and an absolutely wildly psychotic look in his eyes; Virginia Tech’s Seung-Hui Cho who was delusional; Jared Lee Loughner who had frightened classmates at his Tucson community college before his psychotic storm; and, of course, Sandy Hook Elementary School’s mass murderer Adam Lanza whose signs of mental illness prior to his murderous acts are undeniable.  Tragically the list over the past three decades can go on and on, and, if significant steps to fix our broken mental health care system are not taken soon, will most certainly continue into the future.


Let’s begin with a brief overview of mental illness that can lead to such horrific events.  Fortunately, the vast majority of psychiatric disorders never lead to violence, and even the most severely disturbed psychiatric patients rarely threaten, let alone take, the lives of others.  Nonetheless, when random acts of senseless violence are perpetrated by the mentally ill it is important to try and understand how such brutality can spew forth in the world of the mentally ill.  It is vitally important to realize that serious mental disorders have the ability to make it so that a person believes things that are not true, are not grounded in reality, and therefore these delusions (fixed false beliefs) can direct their behaviors in seemly senseless and random ways.


Psychosis, or psychotic behaviors, is the most serious and tangible change in the person’s perception of reality.  Psychosis can lead to frank paranoia, auditory and/or visual hallucinations, thought control, and thought insertion.  Hallucination and thought insertion can actually “command” a patient to act in ways they are unable to refrain from.  Yes, even to maim and kill.  It is not only schizophrenia that can lead to psychosis.  Severe depression, post-traumatic stress disorder (PTSD), and other psychiatric conditions can cause an alteration in an individual’s perception of reality.  In fact, because there are so many varied psychiatric conditions that can lead to a distortion of reality, whether transient or more sustained, I am careful to query any of my patients I think may be at risk to be certain they are still firmly in touch with reality.  If/when someone has demonstrated the presence of potential psychiatric issues, or recent aggressive and/or irritable behavior, it is critical to determine the presence of paranoia, suicidal ideations, hallucinations, and whether or not the patient feels the need to challenge his enemy no matter how fantasy based this adversary might be.


This alteration in reality, along with irritability and marked impulsivity, are the ingredients for a recipe of violence.  In this state even the most insignificant of slights can be perceived as a huge insult leading to totally unexpected and unpredictable responses.  Suicide, as part of a severe depressive disorder, is by definition a loss of being firmly tied to reality.  Severe depression can make a person’s future seem so incredibly hopeless, and without the availability of effective treatment and support make them feel so extremely helpless as well, that remaining alive becomes unsustainable.  Although the true reality is that the future always holds hope tightly within its arms.


Make no mistake about it.  In my opinion, and that of many other mental health care professionals, the provision of high quality wide-ranging psychiatric care would go an extremely long way in eradicating the type of events we have seen all too often in our country, especially the past few years, where someone takes the lives, often of many people, while struggling in the throe of severe mental illness.  There is little doubt that if our society were to provide the necessary resources, and accept the need, for enforced hospitalization along with the judicious use of modern anti-psychotic medication, a huge percentage of these nonsensical acts of violence could be eliminated.


The current system of provision of psychiatric services in this country is just not working.  Not only in the civilian world, but, as recently demonstrated yet again, within the military model as well.  It is all too easy to point the finger at ineffective gun control as the cause, the problem, but in fact it is a broken mental health system that accounts for the fact that each and every day between six and twenty-six veterans take their own lives.  That’s right, each and every day some of those that have sacrificed so much so that we can live in a free America commit suicide.  Among active service members the rate of suicide is also shooting through the roof, now estimated to be, on average, almost one a day.


It is not just the stress of combat in such arenas of war as Afghanistan and Iraq that account for the dramatic surge in suicide amongst active and veteran military personnel over the past decade.  An absolutely huge study was recently completed by the National Institute of Mental Health (NIMH) which included observations on 1.6 million active duty and retired military.  According to epidemiologist Michael Schoenbaum, in The Wall Street Journal, “The story is not so simple as ‘war is hell’ and you send people to war and bad things happen to those people.”  Researchers found that individuals, both men and women, who enlist in our various branches of the military are significantly more likely to have a history of impulsive anger and depression which predisposes them to act upon suicidal thoughts.  These same researchers found that a full one-third of soldiers who attempted suicide had an identifiable mental illness prior to enlisting, and that as many as one-quarter of active-duty soldiers who have never even been deployed to combat have some type of diagnosable psychiatric disorder.  These facts make it all the more necessary for drastic improvements to be made in the provision of timely and effective diagnosis and treatment interventions.


The provision of mental health services in the military is mired in the same dysfunctional forces which have devastated the application of psychological and psychiatric services in the civilian population.  When it comes to the treatment of severe psychiatric illness there is a concerted withholding of professional inpatient services that would never ever be tolerated in any other realm of medicine.  Think about it.  If you showed up to the Emergency Room with uncontrollable hypertension (high blood pressure), chest pain of unclear origin, a skyrocketing body temperature, or uncontrolled bleeding, you would very likely be hospitalized immediately.  Yet, people suffering from frank psychosis (auditory and/or visual hallucinations, delusions, etc.) or severe anxiety and/or depression will likely be walking out of that very same ER.


According to a report from the Bureau of Labor Statistics access to mental health care is worse than any other types of medical services.  The Bureau reported that in 2010, 89.3 million Americans were living in federally-designated Mental Health Professional Shortage Areas, compared to just 55.3 million Americans living in similarly designated primary care shortage areas, and 44.6 million living in dental health shortage areas.


Sadly, this is the sum-total result of the de-institutionalization movement begun decades ago as well as today’s third-party insurers, including our own government, spreading the falsehood, in order to lower their costs and thereby boost their profits, that even the most critical of psychiatric disorders can be effectively treated on an outpatient basis.  Yet, none of the outpatient services have any sort of reliable system in place to check for impending violence, or to check in on those who have acknowledged considering it.


Many years ago the thinking was that by treating the mentally ill in the least-restrictive environment we, as a society, would be protecting the civil liberties of the mentally ill, and thereby, somehow, speed up their recoveries.  The thinking went that it was certainly better for the mental health of these individuals to be living in the community rather than what was perceived, rightly or wrongly, as the cold, unfeeling institution environment.  However, in the decades since, the most critically suffering mental health patients have been ending up in homeless shelters and jails with an occurrence rate similar to that not seen since the late 1800’s.  In fact, the number of inpatient psychiatric beds has declined to a per capita level not seen since 1850.  These lost beds have not been replaced with nearly enough community based programs to reach even a modicum of those who really need treatment.


To bring the point closer to home, let’s look at the availability of inpatient psychiatric beds for children and adolescence here in Santa Barbara County.  For the past twenty-eight years in which I have been practicing psychiatry here in Santa Barbara, except for a one-year period back in the early 1990’s, there have been a total of ZERO such inpatient beds available anywhere within our County.  Not a single inpatient psychiatric bed for a minor anywhere.  This has, and I know of this from direct personal experience with a patient of mine, resulted in minors with significant psychiatric illness being housed in our local Emergency Room not for hours, but for days.  And I don’t just mean one or two, I mean for over a week.  That’s right, teenagers having their acute psychiatric illness being “managed” in an Emergency Room for over a week while trying to find an inpatient bed somewhere, anywhere, within a 100 mile radius.  This is an absolute travesty, and is sadly not a rare occurrence.


We still do not know all the details which led Ivan Lopez to carry out such a horrific massacre at Fort Hood, but what we do know is the he is likely just the latest instance of what happens when inadequate psychiatric services are provided, all too often in the service and direction of organizations and insurance companies looking to boost their profits. Let alone the U.S. Government doing virtually the exact same thing in order to reduce their costs.  There is now a clear and present danger facing our society when it comes to the woeful lack of effective mental health services, and in particular inpatient care for the critically effected psychiatric patients.  As Dr. Keith Ablow, a nationally renowned psychiatrist stated shortly after the tragedy, “anyone who wants to frame the Fort Hood tragedy as a gun control problem is an enemy of the truth and the good, and an impediment to doing what is right for all our people.”






Glenn E. Miller, M.D. is a Board Certified Psychiatrist.  Educated as a pharmacist, physician and psychiatrist Dr. Miller has been in private practice in Santa Barbara for more than twenty years.  Dr. Miller is co-author of Ancient Herbs, Modern Medicine: Improving Your Health by Combining Chinese Herbal Medicine and Western Medicine.  Opinions in the column are Dr. Miller’s and not necessarily those of this newspaper.  Send questions or topics you would like covered to glenn@healthymindhealthyfuture.com