Daniel D. Sewell, MD, Director, Senior Behavioral Health, UC San Diego Medical Center
Care For Your Mind acknowledges and appreciates the collaboration of the National Network of Depression Centers and the American Association for Geriatric Psychiatry in developing this post.
Chemical restraint is a serious problem in nursing homes. History has shown that psychotropic medications tend to be overused in order to keep residents with problem behaviors such as wandering or combativeness subdued or “under control.”
In other words, there are documented instances when serious psychiatric drugs are given to people who might not have needed them.
To address this and other nursing home quality issues, the Centers for Medicare & Medicaid Services (CMS) created a Five-Star Quality Rating System. One of the rating criteria is the number of residents at the facility who are receiving antipsychotic medications: the larger the number, the lower the score the facility receives.
Although this system was created with good intentions, as a geriatric psychiatrist I see the negative consequences firsthand.
To keep their ratings high, nursing homes in my community are turning away patients who require medications to manage their mental health conditions. Even patients with long-standing, well-documented chronic mental illnesses like recurrent major depression are being rejected. Sadly, this leaves many older adults in need with nowhere to go.
My question for colleagues and patients: Is this happening nationwide? If so, what can we do to fix the system and ensure better mental health care for our older citizens?
Hurting the people they’re trying to help
In San Diego, a metropolis of over three million people, there are hundreds of nursing homes, yet I can currently count on only a few to accept people with chronic psychiatric illness. So when older patients with chronic mental illnesses leave my inpatient unit, where are they supposed to go?
The problem lies with the regulations and policies behind the ratings system. It’s far too black and white, without room for nuance or exception. Here’s why: to calculate the rating, the system counts the number of patients taking psychiatric medications without considering individual circumstances. The system doesn’t recognize a difference between people who actually need the drugs and those who are given the drugs unnecessarily. In the system’s assessment, all psychiatric medications are essentially labeled as bad.
In practice, this process is discriminatory and puts the people who need these medications in harm’s way.
The current system is also economically short-sighted. Many patients who don’t get their psychiatric medications will end up back in the hospital, which is not only an extremely costly process, but also cruel to patients and their families. The price of continuous use of antidepressants or other psychiatric drugs is far, far less. In the long run, the rating system does not save money because it does not keep people out of the hospital and stabilized.
In my day-to-day work as a psychiatrist, I’ve seen the real-world implications of this system. Unfortunately, policymakers and bureaucrats don’t seem to understand how a well-meaning concept can translate into serious problems with actual patients.
Here’s an example. There’s a woman who’s been admitted to my hospital’s inpatient geriatric psychiatry inpatient unit a total of three times. The first time was understandable: she suffered from treatment-resistant depression. We treated her successfully with medication and ECT. She was then discharged to a nursing home with instructions for them to continue her medications for depression. After a certain length of time, however, the nursing home significantly reduced her antidepressant dose. She was then discharged to the home of a family member but her family members were not informed about the dose reduction. As a result, she relapsed and was re-admitted to the inpatient unit.
When she was once again well enough for discharge from our inpatient unit, at the request of her family we arranged for her discharge to the same nursing home where the patient had been before because it was so close the where family members live. This time, however, we spoke directly with a clinician at the nursing home and explained that there was a high probability of another relapse if she didn’t remain on this medication at the dose we had established as optimal. Because of her history of recurrent episodes, we explained that she needed to take an antidepressant for the rest of her life. We thought we’d established a trusting relationship with the facility, so we sent her back.
Sadly, she ended up being admitted to our inpatient psychiatric unit yet again with symptoms of depression. Despite our warning, as well as monitoring by family members, the nursing home physician had stopped her antidepressant because of concerns over the Five-Star rating being lowered.
This is an all-too common scenario, and one that has devastating human — and system-level consequences.
Moving forward and making improvements
Although I know the ratings system has caused an issue in my community, I can’t speak about what’s happening elsewhere.
So, I pose the question to colleagues, patients, family members, and caregivers in other regions: is this a problem nationwide? If so, what we can do? How can we improve the ratings system in a way that allows for the legitimate use of psychotropic medications?
Here’s one idea: allow a way for nursing homes to submit more information about each patient’s mental health history. That way, the use of medications can be evaluated on a case-by-case basis, without negatively affecting the facility’s overall rating. For instance, if a person has a long history of depression and needs medications to stay stabilized, that information can be submitted as part of the ratings process and the facility won’t lose any points.
Overall, the ratings system is a noble idea, but it needs fine-tuning. We have a duty to serve our older population as best we can. For many, that includes taking psychiatric medications. No facility or physician should be punished for providing prescriptions to people who need them.
- What problems have you found in nursing home adjustments of psychiatric medications for their residents?
- How should the CMS account for nursing-home residents who take psychiatric medications for legitimate mental health reasons?
Daniel D. Sewell, MD, is a Professor of Clinical Psychiatry in the Department of Psychiatry UC San Diego. Dr. Sewell currently fills a number of roles at UC San Diego which include: Medical Director of the Senior Behavioral Health Program, Director Emeritus of the Geropsychiatry Fellowship Program, Co-director of the Memory Aging and Resilience Clinic, and Course Director for the fourth-year medical student geropsychiatry elective. Dr. Sewell’s honors, awards and contributions to the field include: being named a “Top Doc” in San Diego County for the past 5 years in a row, receiving the UC San Diego Leonard Tow 2005 Humanism in Medicine Award; being recognized as a Distinguished Fellow of the American Psychiatric Association; serving as the ACROSS Representative for the American Association for Geriatric Psychiatry in the American Psychiatric Association’s Assembly, serving as a member of the Board of Directors of the American Association for Geriatric Psychiatry, 2010-2013; receiving the 2014 American Association for Geriatric Psychiatry Educator of the Year Award and being voted the Recipient, of the UC San Diego School of Medicine’s Third Year Class 2016 Kaiser Excellence in Teaching Award. In addition, Dr. Sewell is currently serving as the president of the American Association for Geriatric Psychiatry and has authored over four dozen peer-reviewed scientific publications.