As UHS Scrimps, Student Care Suffers

Elizabeth A. Whitman ’05-’06, who suffers from an eating disorder and depression, refilled her University Health Services (UHS) Zoloft prescription over the phone for eight months.

She never saw any mental health professional during that time.

After the eating disorder she battled throughout high school recurred during her freshman year, Whitman made an appointment at UHS Mental Health Services.

She was referred to a nurse practitioner with prescribing ability and began taking Zoloft, an anti-depressant. She also began seeing a UHS psychologist every other week.

After a semester of appointments, Whitman told her psychologist that she wanted to stop therapy.

Whitman then continued taking Zoloft for eight months, getting refills from UHS without ever seeing the nurse practitioner—or any other clinician.

“Then I started getting depressed again, worse than before,” says Whitman, whose family has a history of depression.

That fall, she returned to UHS, where another nurse practitioner switched her to the anti-depressant Lexapro, telling her “everything will be fine.”

Whitman said she wanted to restart therapy with her old psychologist, who no longer worked at UHS.

“I had to see someone else, the drug wasn’t working, and I started to have suicidal thoughts,” she says. She started cutting herself and bought a bottle of sleeping pills. Her roommates told her to return to UHS and she did. She informed her UHS psychologist that she was thinking about suicide.

But Whitman says her new psychologist told her she didn’t think Whitman was a danger to herself—and that she should “just try and focus on other things.”

Finally, after a year of start-and-stop care with four different UHS clinicians, she decided to take a semester off and try to get more consistent, professional help at home.

Like other students who have sought help at UHS, Whitman faced a treatment system that patients and medical experts say focuses more on the bottom line than on the mental well-being of its students.

The Crimson’s six-month investigation into mental health at Harvard has found that UHS is coping with rising costs and increased demand for treatment by shuffling students through a confusing system of multiple clinicians and then nudging them out to stay under budget.

Under UHS’s “split care” system, students are usually assigned to two care providers—one for medication and one for therapy—rather than to one psychiatrist.

The practice is used by many managed care organizations and minimizes payrolls, but some students say they have felt neglected and alone as they try to coordinate their own care between clinicians.

Additionally, Harvard has implemented a new policy allowing for only two to four months of therapy, which students say amounts to no more than a conveyor belt of treatment aimed at making the best use of a limited number of therapists.

But administrators say it’s financially impossible for the University to keep tabs on every student who walks through UHS’s doors.

“I feel this tension,” says University Provost Steven E. Hyman, who is former director of the National Institute of Mental Health. “What do I want? I want every person here who is in distress to identify themselves and get the best possible individualized care to help them. I also want to be able to afford this.”

Cracks in Split Care

In a letter to administrators last year, Elizabeth J. Quinn ’04 described a friend who, after being placed in a psychiatric hospital following a manic episode, got medication from a UHS psychiatrist weekly for three months without getting any therapy.

“That UHS psychiatrists could, one week, determine that this student was dangerously incapable of caring for herself and, the next week, think she was capable of independently organizing her own elaborate treatment program while adjusting dosages of sometimes-debilitating psycho-pharmaceuticals and taking four classes is simply absurd,” Quinn wrote.

The experiences of students like Quinn’s friend and Whitman reveal the cracks that pervade UHS’s “split care” treatment system.

In “split care,” some psychiatrists and nurse practitioners provide medication, while other nurse practitioners, psychologists and social workers provide therapy. Traditionally, psychiatrists provided talk therapy and medication to patients who required both.

Some students with serious mental health problems say navigating a system of clinicians with subtly varying purposes is too daunting.

While seeing only one clinician for care may be easier for students with severe mental health problems to manage, it is also expensive.

Psychiatrists earn a mean annual salary of $135,220, and psychologists earn $56,540, according to Department of Labor statistics.

UHS Mental Health Services Director Dr. Richard D. Kadison simply says that split care is the system that best allows UHS to meet the needs of students. But other mental health experts say its roots are economic.

“Split care is driven by financing. Health insurers—and the Harvard system is in effect an insurance company—restrict psychiatrists to prescribing and only the very highest care, and therapists, who are cheaper, are dedicated to therapy,” says Meredith Rosenthal, assistant professor of health economics and policy at the School of Public Health. “It’s a very typical pattern.”

Richard Hermann, an assistant professor of psychiatry at Harvard Medical School, says that there’s nothing wrong with the split care model, as long as communication is kept open between the two clinicians.

“It’s not a problem if they talk to each other,” Hermann says.

But students who have sought help at UHS say coordination is often left up to patients, leaving students struggling with weighty problems to carry yet another burden.

Whitman says that seeing both a psychologist and a nurse practitioner created confusion when she wanted to discuss how her antidepressant was impacting her mental health.

She says her psychologist always referred her to the nurse practitioner when she wanted to speak about the medication, but the nurse practitioner referred her back to the psychologist.

“You can’t separate how you’re feeling from medication which alters brain chemicals and moods,” Whitman says. “There’s really no way to separate how you’re feeling from the medicine.”

Kadison says this year clinicians have started to have weekly team meetings to discuss student care.

But Mental Health Advocacy and Awareness Group Co-Chair Caitlin E. Stork ’04 calls the split care system a “quick fix.” Even the best communication between two clinicians cannot equal the benefits of seeing just she says, one person.

“Private, traditional psychiatry where they provide both medication and therapy—that’s the best way it works,” says Stork, who was diagnosed with bipolar disorder when she was 15 and now takes medication to control it.

Kadison says that UHS sometimes has the prescriber also perform therapy if there are “clinical reasons” to warrant that.

In interviews with 24 students who had visited UHS for mental health problems, only one student received both medication and therapy from the same clinician—a nurse practitioner.

Nursing the Problem

Some students and mental health experts say that this system—which sometimes leaves sole care for a student’s mental health in the hands of a nurse practitioner—is short-changing patients to reduce costs.

On top of their bachelors or associates degree, nurse practitioners must spend one to two years in graduate school for a masters.

An adolescent psychiatrist has nine to ten years of training—four years of medical school, one year of general residency training, two to three years of residency training in general psychiatry and two years of training in psychiatric work with adolescents.

Whitman says she felt the nurse practitioners she saw did not have enough training to make decisions about medication.

Rosenthal, the public health professor, says that using nurse practitioners is a good way to cut costs—so long as they work in conjunction with doctors.

“Nurse practitioners don’t stand alone. They are part of a medical group where the doctor is effectively behind them,” Rosenthal says. “They are really cost effective, and they listen better than anyone.”

But some students say few UHS prescribing psychiatrists and nurse practitioners are listening—they’re just doling out medication.

After a year of agonizing over concentrations and work, one female 2003 graduate saw a UHS clinician to deal with her anxiety disorder.

“I saw a guy whose whole job was to prescribe drugs to children. He wasn’t a therapist, but he was the only guy I could see within three days,” she says. “His immediate response was to put me on medication.”

Kadison says UHS prescribes medication to around a third of the students it sees. Students should not go longer than two months on medication without seeing a clinician, he says.

This may be the general guideline, but Quinn says the practice of it is far from perfect.

“Drugs are prescribed [at UHS] without patients being in talk therapy or a suggestion of restructuring the way they live life,” Quinn says. “No matter how great a drug is, if you go home to a place with no one to talk to, you’re not going to be better.”

Triage

When students initially call UHS for an appointment, they are given a triage interview by phone, in which clinicians determine who the student should first see—a prescribing clinician or one focused on therapy, Kadison says.

Kadison says UHS began this system one and half years ago in order to get students on a fast track to care as soon as they express interest in getting help. While previously a student would have to wait for an hour-long appointment slot before their first contact with a UHS clinician, now a student receives this 20-minute triage appointment usually within a day of making their original call.

Kadison says that the “most experienced clinicians” do triage. But it is luck of the draw whether a student has that first triage appointment with a psychologist, psychiatrist or nurse practitioner.

Dr. Clarice J. Kestenbaum, a professor of clinical psychiatry at Columbia and a former president of the American Academy of Child and Adolescent Psychiatry, says that the decreased wait time is not worth it if the student sees the wrong person.

Kestenbaum says that only clinicians with expertise in both therapy and medication should be able to do the first evaluation—which she says is critical to getting a student on the right recovery path.

“The person is getting short-changed,” she says. “The question is, is the patient seeing the doctor they need?”

Katherine T. Kleindienst ’05 says she was diagnosed with depression after 20 minutes of triage, then spoke to a nurse practitioner for about an hour and walked out of UHS with a prescription for the anti-depressant Lexapro.

“It’s really short for someone who you’ve never met to get an idea of what is going on with you,” Kleindienst says.

Hyman, who chairs the UHS executive committee says that prescribing medication to a student after an hour’s evaluation is a legitimate medical practice.

“This is more complicated than strep throat by far, but this is a serious illness and you don’t want to have to schedule three appointments to get a prescription for an SSRI,” Hyman says, referring to a common class of anti-depressants. “A skilled clinician can certainly in an evaluation tell whether someone warrants treatment.”

Episodic Care

While UHS’s triage system allows students to get care more quickly, another new system attempts to get them out of therapy more quickly too.

Under a policy begun this fall known as the “episode of care,” UHS decided to conserve resources by roughly limiting student therapy to two- to four-month treatment courses.

Kadison says the “episode” is more a guideline than a limit, but that seeing a student weekly for up to four months is roughly what UHS can offer within its budget.

“We realize that we cannot offer open-ended weekly therapy to the whole community because we wouldn’t have the resources,” Kadison wrote in an e-mail.

He says that UHS has always informally followed this guideline and recently formalized it.

Experts say that therapy can be effective in a short period of time, but some students say they feel abandoned when faced with the possibility that they might have to end their therapy before they’re ready.

Hilary C. Robinson ’03 says she was “shocked” when a UHS therapist told her about the episode of care policy this fall.

“He said there’s been a new policy, and that it’s very much a ‘how long will it be to fix this’ type of thing,” says Robinson, who is now a first-year law student. “It seems like they really want to set an end date, to get people working towards an end date…the thought is to expedite care. It might be appealing to students to just get it over with, but…it’s just not that easy.” A female junior, who has suffered from an eating disorder since high school, says she had been seeing a UHS therapist for almost a year when the therapist told her about the policy last spring.

“She asked me some questions to gauge whether I should continue seeing her, what progress had been made and what my goals were,” she says. “I sort of expected that we might evaluate where I was, but it was a little scary because I really didn’t want to stop seeing her.”

Now, she sees the therapist once every three weeks as opposed to the weekly appointments she had last year.

Kadison says that UHS does not force students out of therapy, and that the policy has cut down on overuse of services, not prevented students from getting reasonable amounts of treatment.

Previously, some students had up to 150 visits per year—at least three per week, according to Kadison.

“We want to do everything we can for students, but we can’t be a hospital,” he says.

But Robinson says even if UHS does not cut off treatment, the policy might be off-putting to patients with serious mental illnesses.

“I really feel that it is a completely devoid and cheap view of what the obligations of Harvard mental health really are,” Robinson says. “If the system is so overburdened that patients must now fit their therapy into an administrative timeframe, then we must admit as a University that we have a problem—a problem only exacerbated by restricting patient access to the only solution currently available.”

Managing to Care

Kadison estimates that the number of therapy visits to UHS climbed by 1,000 last year.

Few deny that UHS Mental Health Services is overwhelmed.

Located on the fourth floor of Holyoke Center, UHS Mental Health Services sees 1,800 to 1,900 students per year, with a staff of 12 psychiatrists, nine psychologists, six nurse practitioners and 13 social workers.

In its busiest periods, November and December, and March and April, Mental Health Services provides care for around 850 people per week, 80 percent of whom are students and graduate students, Kadison says.

UHS has also increased its mental health staff from 14 full time employees to 20 since 1999, although Kadison says there has been a corresponding increase in visits accompanying every increase in staffing. They have also extended staffing for after-hours urgent care, Kadison says.

The greater cost of providing healthcare is evident in the jumps in Harvard’s student healthcare fee over the past four years. This fee was $745 for the 2000-2001 academic year. This year healthcare cost $1,142.

A 1999 Office of the Provost report pointed to long student wait times and general difficulty in scheduling appointments as major deficiencies of UHS therapy. The report cited the use of UHS services by non-students as one significant factor in the inflexibility students encountered in scheduling appointments.

The report recommended that UHS focus primarily on providing care to students and refer all non-students, including faculty, staff and retirees, out to affiliated clinicians.

Since that report, Kadison says UHS has operated under a policy of referring out faculty and staff and treating students in house “when possible.”

In 1999, 32 percent of UHS mental health appointments were logged by non-students, according to the Provost’s Committee report. This year, Kadison estimates 25 to 30 percent of appointments were taken up by non-students, but says exact statistics are not available.

The new policy was intended to decrease the time between requests for first appointments and first appointments from five to seven days—the 1999 standard—to three to five days.

Kadison says that UHS has met this goal.

But according to a poll conducted by The Crimson, almost 30 percent of students who had been to UHS said they had to wait from one to two weeks for a first appointment. Thirty-nine percent of students who had been to UHS received their first appointment within two days of placing their first call and around 26 percent got an appointment within one week.

Regardless of the changes UHS has made to accommodate more students, Hyman says a dramatic increase in the number of students seeking therapy since 1999 has necessitated yet another look at how the system can be improved, or expanded, to meet the demand.

He and Dean of the College Benedict H. Gross ’71 formed a committee charged with that task this fall.

While UHS has implemented some of the recommendations of the 1999 committee, the use of split care and episode of care demonstrates continued emphasis on keeping costs down—an emphasis that was a primary criticism in the 1999 report.

“Perhaps the most widely expressed complaint about UHS in general and [Mental Health Services] in particular is that managed care is imposing constraints...the perception among many administrators across the Harvard community that student care is governed by the bottom line rather than quality standards is cause for concern,” the report concluded.

Four years later, Undergraduate Council President Rohit Chopra ’04, who has focused on improving mental health resources this semester, echoes the report. He says he would not call UHS “cheap,” but adds that he does think they compromise student care to be cost effective.

“UHS is an HMO,” Chopra says. “I’m sure they could [provide better care] but I assume that they want the HMO to be self-sufficient even though that might be unrealistic in a college setting.”

— Anne K. Kofol contributed to the reporting of this story. —Staff writer Katharine A. Kaplan can be reached at kkaplan@fas.harvard.edu.