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How Yale is confronting the national mental health crisis

John Krystal, MD
Photo by Robert A. Lisak
John Krystal, MD
“The system doesn’t work for the majority of people. People have difficulty having their mental health and addiction problems recognized and diagnosed. And, once recognized, they have trouble getting access to the kind of treatments that are effective for them,” said John Krystal, MD, department chair of psychiatry at Yale School of Medicine and chief of psychiatry at Yale New Haven Hospital.

On a frigid afternoon last winter, a New Haven woman spotted her husband pacing back and forth on a bridge over the Quinnipiac River. He was shouting and waving his arms. She knew immediately that he must have stopped taking his medications for bipolar disorder, and she was terrified that he would jump off the bridge.

She called police, who rushed to the scene. When they approach her husband, he shouted “Shoot me! Shoot me!” Then he pulled a mobile phone out of his pocket and aimed it at them as if it was a gun. In police parlance, this is called “suicide by cop.” They didn’t shoot. Instead, they tackled him and prevented him from jumping.

Though this is a very rare form of suicide, the incident on the bridge puts a human face on what health care leaders call a national mental health crisis. In addition to 47,173 deaths by suicide in 2017, 72,000 people died of drug overdose. Combined, these mental-illness-related deaths amount to the fifth-leading cause of mortality in the United States.

And deaths alone don’t come close to measuring the suffering caused by mental illness. Approximately 1 in 5 Americans—or 60 million people—experience some type of mental illness in a given year. At the same time, about 3% of the adult population suffers from drug abuse disorders.

Meanwhile, there aren’t enough psychiatrists to treat the people who need their help. There are only about 45,000 psychiatrists in the United States, one for every 7,000 people, and the ratio of such physicians to the population decreased by 10% between 2003 and 2013. Many communities are psychiatrist deserts. They have none.

Leaders in the Department of Psychiatry are acutely aware of the troubling statistics. “The model of mental health care in the United States is broken,” says John Krystal, MD ’84, the Robert L. McNeill, Jr. Professor of Translational Research and professor of psychiatry and of neuroscience, as well as department chair and chief of psychiatry at Yale New Haven Hospital (YNHH). “The system doesn’t work for the majority of people. People have difficulty having their mental health and addiction problems recognized and diagnosed. And, once recognized, they have trouble getting access to the kind of treatments that are effective for them.”

Krystal is determined that Yale School of Medicine will help fix this dysfunctional system—by educating the next generation of leaders in psychiatry, performing breakthrough research, and introducing new approaches to providing care. “My hope for the department, the medical school, and the hospital is that we would over time fundamentally transform the model of care,” he says.

The psychiatry department’s 250 full-time faculty members perform research and provide care at YNHH, the Connecticut Mental Health Center (CMHC), Yale Health (services for students and faculty), and the VA Connecticut Healthcare System, and a number of them also teach in Yale’s psychiatry residency program.

Of course, medical schools and physicians can only do so much to fix problems that are incredibly complex—involving not just medicine and science but public policy, business, economics, and social inequities. (For instance, neither Medicaid nor most private insurers reimburse mental health care on an equal basis with physical health care.) Still, Krystal and his colleagues in the psychiatry department are hopeful that they can make a significant contribution to the needed changes.

Expanding Access to Mental Health Services

The transformation they’re calling for starts in clinical care. Today, people are routinely screened for a variety of medical problems, yet screenings for mental illnesses and addictions is not yet routine. There aren’t enough psychiatrists to do it, and that’s not going to change. “The bulk of the population are going to need to receive their first line of diagnoses and treatment in the context of primary care,” says Krystal. “You have to change all of medicine.”

Yale and its health care delivery partners have already shown that psychiatry and primary care can be successfully integrated. At VA Connecticut, psychiatry has been embedded into the outpatient clinics. At the same time, behavior intervention teams are providing psychiatry consultations for all of Yale New Haven Hospital’s inpatient medical services, and the model of care is now being copied elsewhere.

Department leaders say these approaches need to be spread to additional medical centers and to tens of thousands of primary care offices across the country.

One of the programs within the medical school serves as a model for reaching out into our communities to identify people with mental health problems. The Program for Specialized Treatment Early in Psychosis (STEP) engages community members and clinicians to spot young people who are beginning to experience symptoms—and get them into treatment.

STEP’s MindMap website and its social media campaigns draw in young people using quizzes and YouTube videos. Over the past four years, the program has treated more than 160 people from a 10-town area. “For people who are just developing schizophrenia, early and comprehensive treatment leads to better outcomes,” says Vinod H. Srihari, MD, the director of STEP and an associate professor of psychiatry.

Using Digital Technologies to Democratize Care

Primary care physicians are already under incredible pressure to see patients in time slivers of 15 or 20 minutes, so how can they be expected to perform mental health screenings and initial treatments? The answer: assistance from digital technologies.

The hope is that these technologies will vastly improve access to treatments, no matter where the patient lives—and at affordable prices. Benjamin S. Bunney, MD, professor emeritus of psychiatry, who co-founded one of the pioneering startups in this field, says, “These technologies are revolutionizing mental health care and the Internet makes it available to everyone.”

One approach is to ask patients to fill out digital surveys before or when they arrive at their primary care doctor’s office. The software helps interpret the answers to the questionnaire. That way, the doctor knows before the person enters the examination room if there’s a high probability that she or he has a mental illness or an addiction.

If the illness seems severe, the physician will likely refer the patient to a psychiatrist. If not, some new digital technologies are designed to help primary care physicians diagnose patients and choose the best initial treatments.

There’s also an explosion of technologies that patients can use directly via the internet—providing interactive cognitive behavior therapy sessions. These programs address a wide array of illnesses, including depression, anxiety, obsessive-compulsive disorder, and substance abuse.

Yale faculty members are developing a variety of digital technologies to improve early detection and treatment. For instance, Kathleen Carroll, PhD, the Albert E. Kent Professor of Psychiatry and director of psychosocial research, has created web-based therapy programs for people dealing with substance abuse. They’re engaging and fun, employing games, quizzes, and short story-telling videos. One of them, designed for Spanish-speaking people, takes the form of a telanovela. But the intent is serious; to teach people skills for dealing with cravings and strong emotions. “The more you do it, the better you get at it,” Carroll says.

Developing New Medicines and Therapies

If society were to shift much of the detection and initial treatment of mental illnesses to primary care settings, it would free up psychiatrists to concentrate on the most severe mental illnesses and the most treatment-resistant symptoms. They’d be able to focus on trying out new drugs and developing new behavioral therapies—often used in tandem.

Yale faculty members who staff the four-year-old Interventional Psychiatry Service (IPS) at Yale New Haven Hospital have specialized training and equipment that enables them to help patients with the most severe illnesses. They provide electroconvulsive therapy (ECT), ketamine infusion, and a handful of new brain stimulation therapies. “These treatments are for people who have failed to respond to traditional approaches—when talk and pills aren’t enough,” says Robert Ostroff, MD, the co-medical director for the Interventional Psychiatry Service.

The use of ECT for patients with severe depression has declined steadily in the United States, but technologies and techniques have improved over the past decade, making it safer and more effective, with fewer side effects. Ostroff believes it’s “underutilized, particularly in the context of the high mortality rate in depressive disorders from suicide.”

While Yale New Haven Hospital has been providing ECT for years, it’s one of the first hospitals in the country to provide ketamine infusion therapy for depression and bipolar disorder. The Food and Drug Administration in March approved ketamine delivered through a nasal spray for treatment of depression in adults who have not benefited from other antidepressant medications. Other uses of the drug remain experimental.

The newest treatments offered by IPS include electroconvulsive therapy, vagal nerve stimulation and transcranial magnetic stimulation. These brain stimulation therapies are all based on the principle that many mental illnesses are caused by dysfunctions in the brain. By targeting the precise locations where the problems reside with various kinds of electrical currents, psychiatrists can alleviate symptoms or even cure a disorder

Because these therapies are not always covered by insurers, Ostroff launched an Interventional Psychiatry Services Support Fund at YNHH to help patients pay their bills.

Expanding knowledge to deliver personalized treatments

Advances in brain science and genetics foster hopes that, just like in other realms of medicine, the treatment of mental illnesses will increasingly be personalized.

That requires significant advances in research in domains including neuroscience, genetics, brain imaging, molecular biology, and deriving neurons from stem cells. Today, most of these inquiries are taking place in isolation from one another, but Krystal foresees a melding of research in these disciplines.

Increasingly, he believes, researchers will collaborate to understand more deeply the nature of mental illness by combining knowledge of how the brain works with a deep understanding of genetics and the stresses caused by life experiences.

As researchers pass this knowledge over to clinical psychiatrists and psychologists, you can expect to see new ever-more personalized approaches to drug and behavioral therapies. And, combined with the other changes that Krystal proposes to transform the model of mental health care, perhaps we’ll see the beginning of the end of the mental health crisis.