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Suicide and Managed Care

by Alan Lipschitz, M.D.

The history of American psychiatry will record the 1990s as the decade of managed care. Managed care is a system where health insurers closely monitor patients' treatments and restrict their insurance benefits to cover only services that the insurer judges to be "medically necessary:" This close monitoring and restriction of care has had an immense impact on mental health services: the cost savings has allowed many employers to begin providing insurance to cover mental health treatment, while the treatment restrictions have compelled treatment "providers" (psychiatrists, psychologists, and social workers) to modify their treatment techniques. These changes have had important effects on the care of suicidal patients.

Managed care treatments are designed to help people move through their current crisis and restore them to their previous level of function, and the managed care companies ask that the patient's treatment focus on the objective signs of impairment that the patient presents.

Treatments are generally not approved when they are directed at altering patients' underlying character styles or changing long-term patterns of behavior. This pragmatic approach implicitly presents the patient's characteristic long-term behaviors as the healthy, desirable, "normal" state. Focusing treatment on the currently pressing symptoms in the here-and-now help the patient and the therapy avoid digressions into lengthy, fascinating, irrelevant explorations of other areas.

Pursuing this pragmatic agenda also reassures new patients who fear that psychiatric treatment would compel them to reexamine and reevaluate their lives. While this approach was often successful with the corporate employees who were the first patients treated under managed care, managed care companies are starting to recognize that the care of patients whose impairments are more severe and persistent requires broadening the treatment beyond this acute focus.

The treatments that patients receive are also strongly swayed by managed care companies' preference for drug therapies over "talking" therapies. This preference can be explicit in rules specifying that, for example, major depression must be treated with medication, not with psychotherapy; or it can be expressed by the practice of peremptorily approving drug treatments while subjecting psychotherapies to greater scrutiny. The emphasis on providing medication treatment to most patients may mislead some therapists to expect only medication to be sufficient treatment for suicidal patients.

Fostering a positive bond between patient and therapist can be an important clement in psychotherapy, but this bond is often sundered when the managed care plan requires patients to choose a new provider from the limited "panel" of providers whom the plan has recruited. Some unfortunate patients have been forced to switch therapists as many times as their employer switched managed care plans. An important component of this bond is the patient's confidence that the therapist is dependable and the therapeutic relation will continue, but this trust is weakened by managed care's approving only a limited number of sessions, typically five to fifteen, before the therapist must again report the patient's progress. These periodic reports can also strain the patients' faith that their confidential disclosures will not be breached by the managed care company.

Another problem for suicidal patents is posed by the requirement that the managed care company approve any hospital admission. Certainly, any responsible managed care company would approve the admission of a patient presenting gross signs presaging a serious suicidal act, but for patients whom the therapist intuits to be suicidal despite a lack of objective suicidal signs, it may well prove impossible to obtain hospital admission. Patients whose admissions are not approved by the managed care company may be diverted to emergency room holding areas, or to day hospital programs, forcing these programs to restructure their procedures to service this newly-expanded responsibility.

Managed care practices radically shorten hospital stays. The psychiatric hospitals that routinely held patients for the entire thirty days that their insurance covered have had to drop their average "length-of-stay" to less than a week in order to receive patients from managed care companies. Many suicidal patients are now transferred to day hospital programs when they are discharged after brief stays on inpatient wards. This places much pressure on the hospital staff to very quickly gather data from patients, their families, and therapists, in order to quickly construct a formulation of the patient and the stresses have proven unbearable.

Most patients admitted to psychiatric hospitals initially improve under the influence of the empathic consideration, warmth, emotional support, structure, and respite from family and outside stressors that good psychiatric hospitals provide. These "nonspecific factors" in the treatment help restore the patient's morale, and counter suicidal patients' desperate sense that suicide is the only way they can find relief from their troubles. Making explicit the nonspecific factor that improve the patient is precisely the art of inpatient psychiatry.

Where formerly this understanding of the patient could slowly unfold over the course of a month-long hospital stay, the reduced stays now demand a more vigorous, active evaluation of the issues troubling a patient, so that interventions can be promptly targeted at the patient's specific problems. These problems in the patient's life must be uncovered and changed by the treatment if the patient's recovery is to be sustained outside the hospital. Suicidal patients are jeopardized when they are discharged prematurely by hospitals that are not equipped to promptly gather, organize, and use this information.

It is clear that these new treatment practices can have both doleful and salubrious effects on patients, and it is easy to imagine patients who are better off under these new procedures, or under the old ones. The effects of these changes on providers can be just as pronounced. Few providers can find work without joining managed care panels, and those treating managed care patients who may not readily confess their suicidal feelings now must become especially diligent in gathering patients' histories by contacting their family members and former therapists to uncover suicide risks that were not apparent when first meeting the patient.

Managed care demands that providers invest a great deal time and effort into explaining their treatments both in writing and "telephonically" with "'care managers," the mental health professionals who staff managed care programs. Therapists long accustomed to treating patients intuitively now find it necessary to revive their presentation skills so they can articulate a clear treatment formulation: a statement of problems addressed in therapy, the progress being made, the obstacles to continued progress, and the techniques the therapy deploys to surmount these impediments. Many therapists have not employed these presentation skills since graduating from their professional training programs. A provider whose treatment plan is not promptly approved is further taxed by the need to present the plan to senior "peer advisers," and may then have to shepherd the treatment request through appeal procedures in pursuit of the coveted authorization.

Managed care programs exercise a great deal of power over mental health treatment. Recognizing this, insurers and corporate clients have organized accrediting agencies to promulgate standards to ensure that managed care programs provide quality treatment and do not cut costs by simply denying necessary care. This is a recent development in the industry; only now are the accrediting agencies writing and field-testing these standards, which will soon be required by the industrial clients who hire managed care firms.

These accreditation standards will affect the treatments provided to millions of patients. The standards could dictate, for example, that managed care companies audit therapists' records to ensure that every depressed patient receives a thorough and comprehensive assessment that includes an evaluation of their suicide risk. Influencing these accreditation standards could make it possible to raise the quality of the care given to patients across the length and breadth of the United States.

Dr. Alan Lipschitz is a member of the ASF Scientific Executive Committee, and is Medical Director of a behavioral health managed care program.

Information provided by the American Suicide Foundation. This article originally appeared in Lifesavers, Fall 1996.