Plan to restrict SSRI access could have negative impact

FINDLAY — At a mental-health and overmedicalization summit in early May, U.S. Health and Human Services Secretary Robert F. Kennedy Jr. announced a plan to limit selective serotonin reuptake inhibitors (SSRIs), the most widely prescribed class of psychiatric medication. The proposal has already raised concerns among clinicians, law enforcement officials and mental health experts about the potential ripple effects on public safety and community health. SSRIs work by increasing the availability of serotonin, a neurotransmitter that helps regulate mood, according to the Mayo Clinic. By stabilizing serotonin levels in the brain, these medications provide millions of people with a greater sense of emotional steadiness and relief from symptoms of depression and anxiety. The summit, hosted in Washington D.C. by Make America Healthy Again and the Inner Compass Initiative, focused on what organizers described as the nation's "overmedicalization" of mental health. He believes there is an "overreliance" of psychiatric medication in the U.S. Kennedy argued that patients often begin treatment "without a clear understanding of the risks and how long they will stay on these drugs or how to come off of them," calling the system a failure of informed consent. Kennedy has said withdrawal from SSRIs is more difficult than withdrawing from heroin. As a former heroin addict, he said he tried many times to get clean and each time, struggled. Heroin is known to be incredibly addictive, while SSRIs are not. He has also made claims that this class of medication causes people to become school shooters without evidence. Reporting from Ellen Barry, a journalist with the New York Times, about the announcement said that SSRIs have been well-established in treatment and that clinical trials have found them to be both safe and effective. Psychiatrists are already urging patients to try therapy both as an alternative and in tandem with medication, but that often this is impossible because insurance will not pay for it. The solution to the current reliance on medication, Kennedy posits, is to incentivize providers to taper patients off of SSRIs and in many cases, deprescribe all together. A federal "Dear Colleague" letter, penned by representatives of the Center for Medicare and Medicaid Services, Administration for Children and Families, Health Resources and Services Administration and Substance Abuse and Mental Health Services Administration, released the same day as the summit, encouraging non-pharmaceutical interventions such as therapy, social connection, focused sleep interventions and nutrition-related strategies. It also emphasized that deprescribing is "not synonymous with abrupt discontinuation." But experts say the proposal oversimplifies the realities of mental-health care. Many providers would agree that better diet, sleep and exercise are immensely beneficial to both physical and mental health. However, they are things that are simply not sustainable for some, because of the constant willpower to continue to make healthy choices, are easily derailed by environmental or biological stressors and are more difficult to maintain for someone suffering from a chronic illness. Dr. Christian Steiner, a psychiatrist with Blanchard Valley Hospital, argues that psychiatric medication is a valuable tool in creating treatment plans for his patients. "We have to have our tools," he said. Steiner said that he supports further research into both the efficacy and the risks of the medication, but said that stopping "a major mode of treatment" for a large portion of Americans is dangerous. He said a common criticism of mental healthcare is that providers are "just throwing drugs at the wall to see what sticks." This is simply not the case, he said. In his own practice, Steiner does his best to take a holistic approach. He already recommends healthy changes to diet, sleep and exercise before prescribing medication, but sometimes lifestyle changes are not enough and sometimes someone is unable to change and maintain a healthy lifestyle due to life circumstances. The "Dear Colleague" letter also noted concern for overprescribing to children. Steiner said he doesn't believe this happens often. He understands the risks of prescribing to developing brains and said he is hesitant to do so because of the permanent effects it can have. The concern is not just that Kennedy's announcement is going to shake people's faith in the healthcare system as a whole, perpetuating a stigma surrounding mental health and the usage of mental health medication, but is also going to have implications for law enforcement as they respond to mental health crisis calls. Steiner believes these crisis calls are likely to multiply exponentially. Difficulties for law enforcement Both the Findlay police and the Hancock County Sheriff's Office have emphasized that mental health-related calls are some of the most difficult calls their officers respond to, because they can be unpredictable and can spiral out of control very quickly. "If we lose a major mode of treatment, for any disease, that disease is going to worsen," Steiner said. "Reduced access to this medication will increase the number of individuals experiencing these psychiatric crises that then law enforcement could be called to." An increase in mental health crisis calls would increase officer workload and officer stress. Hancock County Sheriff's Chief Deputy Tom Walker agrees that an increase in crisis calls would take its toll on his deputies. "Most officers genuinely want to help people," he said. But he believes the cumulative impact of "high-volatility" incidents, like crisis calls, would lead to increased burnout, stress, compassion fatigue and repeated exposure to trauma and violence sometimes involving children and families in crisis. Law enforcement has made progress in the way of officer wellbeing, but believes there is still room for expansion of wellness resources to ensure first responders remain both resilient and effective in their roles. Walker theorizes the decision to restrict access to medication would also make de-escalation efforts from law enforcement more difficult during crisis calls. These calls could become more dangerous to first responders because of an increased volatility of the situation. Emotional dysregulation can make law enforcement encounters more unpredictable and more dangerous to everyone involved. He later voiced concern at the seemingly rapid increase in dynamism surrounding children in crisis. He said that these calls have always been a part of the law enforcement profession, but that they are no longer isolated geographically or socioeconomically. He said he's noticed these calls becoming more serious and often involving assaults, threats of violence and access to weapons, which significantly elevates danger for the children, their families, educators, first responders and the community as a whole. "From a law enforcement perspective, any circumstance that negatively impacts emotional regulation or stability can make de-escalation efforts more difficult and unpredictable," he said. "That, in turn, could increase the likelihood of volatile encounters or uses of force, which is something no one wants for the individual involved, their family or responding officers. Ultimately, these situations reinforce the importance of careful clinical guidance, continuity of care and strong community-based mental health support systems." Walker said he's anxious Kennedy's announcement is an oversimplification of a much larger issue and said broad, sweeping policy decisions without considering the complexities of the situation would have detrimental effects on American mental healthcare and would perpetuate stigma surrounding "legitimate" treatment options. "If enacted without careful medical guidance and support systems in place, abrupt changes to treatment access could unintentionally increase crises, instability or untreated mental health conditions within our communities," he said. The goal, he said, is never for law enforcement to use force, but because crisis calls are so "dynamic and rapidly evolving," there are situations where it may become unavoidable. Local law enforcement agencies provide every officer with crisis intervention training to give them an understanding of de-escalation tactics that Walker says is focused on communication, patience and resolving situations without force, but volatility can be difficult. "Deputies must also balance de-escalation efforts with the immediate safety of the individual involved, responding personnel and the public," he said. Law enforcement officers must often make split-second decisions during ever-evolving situations, decisions that could, in some cases, be the difference between life or death. Walker is keenly aware of the optics and expectations of the community when officers must use force to contain a situation, but believes it is unrealistic to expect every situation to be resolved peacefully. "The reality is that even with extensive crisis-intervention and de-escalation training, people experiencing severe emotional, mental health or behavioral crises can be unpredictable, irrational or desperate," he said. "In some cases, those individuals may act violently or make dangerous decisions that place themselves or others at risk. Our responsibility as law enforcement officers is to use our training, judgement and available resources to pursue the safest possible outcome for everyone involved, while recognizing these situations are often highly-dynamic and evolving in real time." Dr. Carole Lieberman, University of California — Los Angeles psychiatry professor, forensic psychiatrist, award-winning author and expert witness in several high-profile court cases, agrees that should access to life-saving mental health medication be restricted, crisis calls to law enforcement would increase exponentially. She said use of force encounters would also increase in tandem and without viable treatment alternatives, jails across the country could feel the brunt of the impact. While local law enforcement places an emphasis on training for these calls, Lieberman believes it to be impossible to train for every scenario. As exemplified by a recent local case involving a Findlay man experiencing a mental health crisis, any resistance or violent reaction to being taken into protective custody, known legally as a "pink-slip," could result in jail time because it is the safest place with both doors that lock and staff. Local officials say this trend is driven by a collapse in psychiatric infrastructure, a shortage of treatment beds and a lack of community-based services, but scholars argue it reflects a pattern in which confinement replaces care. Captain Jesse Sterrett, Hancock County jail administrator, reports that approximately 50%-75% of county inmates are treated for mental health issues while incarcerated. Lieberman said that while jails are acting as de facto mental health facilities, they are not doing it well, mainly because jails are not being staffed with the mental health professionals to provide care. Lieberman said the only solution is to bring back the state hospitals to truly effect change. "Activists called for the 'least restrictive environment' for the chronically mentally ill," she said. This meant that this population was essentially dumped back into the community without adequate resources for help. The goal was to create community-based resources, but Lieberman notes this quickly became a fool's errand, because with the onset of psychosis, getting back to a care clinic to refill medications can be difficult and that adequate community services were not properly funded. "So these people are now either in jail or on the streets," she said. She believes jails are already struggling to stabilize people with serious mental health issues and that "if more people arrive (to the jail) in crisis because they have not been tapered from their medication and provided with psychotherapy, then jails would become even more dangerous for the staff and the other inmates," she said. Jail time can make it more difficult for someone to get a job, which can mean increased poverty and difficulty getting insurance to pay for treatment, which could mean an increase in self-medication habits as well as law-enforcement encounters, perpetuating a never ending recidivism cycle. Lieberman concludes it would be dangerous to have a "federal one-size-fits-all" policy and that every case needs to be properly managed by a physician to ensure patients' treatments are safe. She adds that the narrative framing the policy shift doesn't take into account scientific evidence, mental health professionals already full workload or professional expertise. Though no one knows the true implications of this announcement until policy changes have been made, experts are concerned. Without viable alternative treatment options that have been proven to be effective, broad policy decisions made by someone who is not a healthcare provider, Kennedy's attempt to restrict the most widely prescribed mental health medication could have ripple effects for the law enforcement, jails and the community as a whole. In recent times, law enforcement officers are being asked to do more with less. If enacted, a restriction to mental health medications could leave first-responders in the gulch. Officers, already stretched thin, are shouldering responsibilities that the healthcare system is unable to meet, responding not because they are the most appropriate resource but because they are the only ones left. For many in the field, the concern is not abstract: without sustained investment in clinical care, crisis stabilization and long-term treatment options, experts fear the nation may find itself relying on police and jails to manage mental illness by default, repeating a cycle that communities have spent decades trying to break.