Needed: A biopsychosocial ‘therapeutic placenta’ for people with schizophrenia

Consider stroke. Guidelines for acute treatment, access, intervention, pre­vention of post-hospitalization relapse, and rehabilitation are extensively spelled out and implemented.¹ (The Box outlines Mayo Clinic guidelines for stroke management, as a demonstration of the comprehensive­ness of the approach.)

Schizophrenia and related severe mental illnesses (SMI) need a similar all-inclusive system that seamlessly provides the myriad components of care needed for this vulnerable population. I propose the term “therapeutic placenta” to describe what people with a dis­abling SMI brain disorder deserve, just as stroke patients do.

Closing asylums: Psychosocial abruptio placentae
In a past Editorial,² I described the appalling consequences of eliminat­ing the asylum, an entity that I believe must be a key component of the SMI therapeutic placenta. The asylum is to schizophrenia as the skilled nurs­ing home is to stroke. SMI patients suffered extensively when asylums were shut down; they lost a medical refuge with psychiatric and primary care, nursing and social work sup­port, occupational and recreational therapies, and work therapy (farming, carpentry shop, cafeteria, laundry, etc.). For SMI, these services are the psychosocial counterpart of various physical rehabilitation therapies for stroke patients that no one would ever dare to eliminate.

Persons with schizophrenia and other SMI have suffered tragically with rupture of the main compo­nents of the therapeutic placenta that existed for decades before the advent of medications. The massive home­lessness, widespread incarceration, persistent poverty, rampant access to alcohol and drugs of abuse, early death due to lack of primary care, and absence of meaningful opportu­nities for vocational rehabilitation are all consequences of a neglectful soci­ety that refuses to fund a therapeutic placenta for the SMI population.

The public mental health system in charge of SMI patients is broken, disconnected, and failing to provide the necessary components of a therapeutic placenta. It should not be surprising to witness the terribly stressful life and premature mortality of SMI patients, who are modern-day les misérables.

The Table lists what I consider to be the necessary spectrum of health care services through the life of an SMI patient that an optimal therapeutic pla­centa must provide until an effective pre­vention or a cure for SMI is discovered.

Reasons to be hopeful
Admittedly, encouraging steps are being made toward establishing a therapeutic placenta for SMI:

The RAISE Study³and Navigate Program⁴ demonstrate that implement­ing a comprehensive program of acute treatment and psychosocial interven­tions and rehabilitation yields better outcomes in SMI.

The Institute of Medicine released a landmark report on psychosocial interventions for mental illness and substance abuse disorders. It outlines a new model for establishing the effec­tiveness of intervention and the imple­mentation of psychosocial strategies in clinical practice.⁵

The 21st Century Cures Act, if passed by Congress and signed by the President, will increase funding for the National Institutes of Health, which in turn will bolster the budgets of the National Institute of Mental Health, National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism and enhance the chances of discovering better treatments and prevention of SMI.

The Helping Families in Mental Health Crisis Act, more directly relevant to men­tal health and psychiatry, proposes, if passed, to:
• enhance evidence-based and sci­entifically validated interventions in the public sector
• raise the profile of mental health within the federal government by creat­ing a position of Assistant Secretary for Mental Health in the U.S. Department of Health and Human Services, who will have oversight of both research and mental health care within the fed­eral government.

Unacceptable disparity must be remedied
Planning an effective therapeutic pla­centa is imperative if health care for SMI patients is to approach the comprehen­sive spectrum of treatment, rehabilita­tion, and prevention available to stroke patients. Although stroke is regarded as a sensory-motor brain disorder, it is also associated with mental symp­toms, just as schizophrenia is associ­ated with sensory-motor symptoms. Both are disabling brain disorders: one, physically and cognitively; the other, mentally and socially. Both require a therapeutic placenta: Stroke is sup­ported by one; schizophrenia is not. This is an unacceptable disparity that must be addressed—soon.