Personal Accounts: An Open Letter to Utilization Review Workers

I am a 31-year-old student pursuing a master's degree in a distinguished social work program, and I have a strong interest in the policies and practices of managed mental health care. I am entering the profession at a time when it is extremely important to understand the language of those like you who control the delivery of health care services: the language of managed care. By doing so, I can respond better and more ethically to the needs of persons seeking treatment, and I can more successfully negotiate obstacles to reimbursement for treatment.

You are a utilization review worker with the heavy responsibility of determining length and course of treatment for mild to severe mental illnesses. This task is complex for the most highly trained professionals and is certainly a challenge for those with far less training in clinical diagnosis and assessment for treatment. I recently read the Act to Protect Consumers in Managed Health Care Plans in the Commonwealth of Massachusetts. A summary of the major provisions indicates that utilization review staff must be qualified and trained and that only qualified health care professionals shall be directly involved in the review of all decisions about coverage.

Question: As a utilization review worker, do you feel qualified and trained to make decisions determining treatment for mild to severe mental illness? Do you defer decisions about cases in which you do not feel qualified to make treatment decisions?

I pose these questions because of concerns about the moral, ethical, and legal conflicts that may arise when cost drives access to treatment, and I pose them as a professional in training interested in working toward responsible and ethical management of care. I also pose them as a past consumer of mental health services for whom access to services became a matter of life and death.

I would like to share part of my personal struggle with manic-depressive illness to illustrate the risk and inadequacy of trying to measure mental illness and mood disorders in corporate managed care terms. Surviving the depths of depression and the heights of tumultuous and uncharted manic episodes was a three-part endeavor that included my own efforts, the support of my family and friends, and access to care that involved considerably more than writing my discharge plan at the time of admission. Until my illness was under control, after a three- or four-year period, I was able to gain access with insurance to psychiatric hospitals for as long as four months.

Managed health care was part of the system; however, it did not have such a strong role in limiting care and determining course of treatment as it does now. My psychiatrist, whom I often think of as my lifeline, kept me safe and alive, secured my stays, and managed my illness, with the help of psychiatric nurses, social workers, and other hospital support staff.

I have been through hell and returned, wearing few scars as I reconstruct my life. Due to the complete and adequate health care, including reasonable and respectable lengths of hospital stays, that I received, I can manage my own illness. A mild dose of lithium, infrequent consultations, and a strong desire to live and learn is how I do so.

When I began getting sick several years ago, depression and mania set in in different ways, with different degrees of intensity. I dropped out of college twice, losing all tuition. The beginning of one episode was the late autumn day I put on green army pants and a green army sweater and didn't change for weeks. (I must have somehow been aware I was preparing for a battle.) My college friends first reacted with chiding and laughter until other symptoms joined my green uniform, and they became concerned. I stopped going to class. I slept all day.

My thoughts were dark and slow, and soon nothing and no one mattered. Feeling nothing for those closest to me intensified my feeling of pain and self-loathing. If I feel nothing, how can I live in this world? If I tell people that I feel nothing and that I am consumed with thoughts of death, they will prolong the pain by taking away my opportunity to escape. I left school and went to my parent's house for a short time, where I attempted to end the nothingness with suicide. The emotional pain was excruciating and at the same time was part of that nothingness. The suicide attempt led to my first trip into a hospital, where I would eventually regain my feeling.

What protected me was mental health professionals who were wise and concerned enough to stay close to the course of my illness, throwing me lifelines along the way. These lines came in the way of psychopharmacology trials and resulting appropriate medications, psychotherapy, electroconvulsive therapy, and a safe shelter by way of inpatient hospitalization.

Question: As a utilization review worker, do you feel qualified to determine length and course of treatment? What will it take for me to regain my feeling?

I was released from the hospital with a restored feeling that soon swelled into a life force that would eventually be diagnosed as mania. I returned to school feeling confident and convinced that this episode was the only one that would occur. Influenced by a growing mania, I decided I did not need to take lithium, or any pill for that matter. I went from a bright, level-headed, modest-enough 23-year-old woman to a fearless, reckless, hyperconfident, 23-year-old woman on a manic path of exhilaration and destruction.

Sleep seemed optional, an interruption of my manic activities, and I rarely took time out for it. I went to class during the day, went to work waitressing most evenings, and then went to the diner in town all night to write all my important thoughts, poems, and daily reflections. I moved out of my shared apartment into the country, with no bus or other transportation. I rented a car on my sister's credit card, unbeknownst to her, and simply drove it as my own. I bought a dog for a companion, for I had managed to alienate my circle of human companions. I didn't care. From my manic point of view, they were all inhibited and restrained.

Rural central Pennsylvania could not contain my unbridled, manic energy, and so I bought a pair of red leather pants and flew to Manhattan. I went for three days without rest, oblivious to my condition or to the danger I was courting as a young woman on the nighttime streets of New York City, befriending strangers, smoking crack, and sleeping on benches. After 72 hours I collapsed with exhaustion, spiraling down into total darkness. I found my way back to the hospital with the help of family members. A psychiatrist, in coordination with social workers, psychiatric nurses, and other hospital support staff, eventually managed all these developments and more.

Question: As a utilization review worker, do you feel qualified to determine length and course of treatment? What will it take for me to restore and rebuild my health?

In the present models of managed mental health care, you as a utilization review representative are a central figure in determining length and course of treatment. Please be aware of the enormous responsibility that goes along with this position at a time of intense cost containment. Be informed and respectful of the nature and complexity of mental illness as you become a key part of the management team. Be aware, when approving or denying certain services, including inpatient hospitalization, that timing is an important factor.

You are making quality-of-life as well as actual life-and-death decisions on a daily basis. Perhaps we can all work together toward high-quality and cost-efficient management of care by honestly examining what gatekeeping practices fit and what practices need to be shaped up or thrown out. Gatekeepers and those involved in gatekeeping practices must strive to take care of, rather than take advantage of, persons in need of fair guidance and assistance with treatment. Without such care, I would have been dead years before my 31st birthday.

Have a Question? Ask Journal Staff at the APA Annual Meeting

Authors and potential Authors are welcome at the Psychiatric Services booth during the American Psychiatric Association's annual meeting beginning May 30 in Toronto, Ontario. Visitors can take home an early copy of the June issue, ask staff about publishing in Psychiatric Services, and pick up a set of writing tips. Authors may also submit papers(six copies for review for publication.

Alos at the booth, individual subscriptions to the journal will be sold at a substantial on site discount. Information about group subscriptions and other benefits offered through the Psychiatric Services Resource Center (PSRC) will be available, along with the new PSRC video rental catalog.

The journal's is part of the APA Periodicals Exhibit located in the APA Resource Center, next to meeting registration in the Toronto Convention Center, next to meeting registration in the Toronto Convention Centre. The APA Resource Center will be open from 11 a.m. Saturday, May 30, until 3 p.m., June 3.

Ms. Pemberton is studying for a master's degree in clinical social work at the Smith College School for Social Work in Northhampton, Massachusetts. Send correspondence to her at 25 Ballard Street, Apartment 2, Jamaica Plain, Massachusetts 02130. Jeffrey L. Geller, M.D., M.P.H., is editor of this column. It is one of several articles in this issue focused on women and chronic mental illness.