I found Stephen Eide and Carolyn D. Gorman’s report at Manhattan Contrarian simultaneously encouraging and frustrating. Here’s the nub:
The concept of a Continuum of Care system can guide discussions of accountability in mental health policy. In recent years, mental health has been a leading focus of news coverage, with policymakers at all levels of government regularly questioned as to their plans for reform, though the direction of mental health policy reform is often vague, if defined at all.
To function as a tool for accountability, Continuum of Care must be a term of distinction. Not all public mental health programs serve the seriously mentally ill, and not all programs that provide some benefit to the seriously mentally ill should be considered part of the Continuum of Care.
A significant number of major problems facing us could be ameliorated with better mental health care including homelessnesss, crime, mass killings, and drug abuse. I’m afraid it would require more than Continuum of Care but a sea change in how we think about mental health.
We’ve got to remove the stigma and take it more seriously at the same time. Families and those troubled themselves are reluctant to seek care. And the cases in which care is not a choice should be considered more critically than at present.
Families may be reluctant to seek care but when they do and something goes wrong they are not reluctant to file civil suits against the state.
Quality caregivers don’t come cheap and most institutions are reimbursed at Medicaid rates.
End result, something will go wrong and then the state will wash their hands of the problem.
Are we really ready to pay to care for the mentally ill and homeless?
I didn’t think so.
Where to start? First, I would recommend thinking long and hard about being labeled mentally ill or any of its euphemisms.
Eventually, anybody deemed mentally unfit will lose any Constitutional Rights.
While your medical records are protected by HIPPA, your company can require you to sign a waiver allowing them to rifle through them, and when you refuse, they can fire you. (Luckily, I am with the VA, and now, my ex-employer is paying for my disability income.)
The New Orleans VA Medical Center has a really good Mental Health Department, but they are overworked. My psychiatrist has a caseload of about 3,000 patients. Since she got my “cocktail” worked out, I only require a short checkup once a year, but I have a psychologist I see, as needed. They have classes for various issues.
Private healthcare seems to be a mess. I have family members who have been prescribed various medications by General Practitioners, Gynecologists, etc. These are powerful drugs that alter the chemical mixture in your brain, and giving them out like candy is a really bad idea.
Since all my medical care is through the VA, I have every doctor send a message to my physiatrist for approval. I have been with her for over 15 years, and she is one of the few people I trust without question. One upside to a large caseload is that she has firsthand knowledge about various combinations.
In my opinion, the biggest problem is that the patient is rarely told that these medications are for life. If you have a chronic condition, the medications are what make you feel better. It is like diabetes. You do not stop taking insulin as soon as your blood sugars are normal.
We have managed to decrease the stigma for some social acceptable mental illnesses, like depression (at least partially) but certainly not for the really debilitating versions, especially schizophrenia. On the provider side I think one of the big issues is how to pay for the care. Networks are getting better at figuring out how to make the financials work and insurers are paying a bit better which has resulted in some networks greatly expanding behavioral care. Net works that had zero addiction specialists are adding them now. Still a ways to go and I dont know if the insurers will ever be willing to pay for everything.
On the medication side they are better now than in the past but still leave a lot to be desired I think. Even when nominally effective they can leave people feeling dysphoric or just wiped out. Makes compliance tough and when they stop because they dont like the drug side effects they get in trouble.
I also dont think that we have a good plan for those patients for whom nothing works very well. We have pretty much gotten rid of the state hospitals and there is that small fraction that probably should have had stayed and had chronic inpatient care.
Steve
For privacy reasons I don’t want to be to specific but as a parent I found that when you look for help it’s almost nonexistent (so overcoming stigma isn’t the real issue IMO.) Can’t tell you how clueless some of the providers are, how inadequate the treatments are, and how little help you get in how to parent a child with mental health challenges (mostly you get blamed by the schools and feel completely isolated socially.) And we live in a large metro area and had abundant financial resources. I basically ended up diagnosing my own child and finding a psychiatrist who agreed and put him on the appropriate medication (well, at least after several trials and errors we found the right regimen- and here I’ll put in a plug for genetic testing which finally helped determine which drugs he could metabolize well.)
Even with all of that there’s now all the long term concerns with the side effects of the meds. We are just still soooo far from understanding this stuff, let alone having good treatment options.
Plus, many illnesses are heritable and so in many cases the afflicted lack a good family support system because parents and other family members may have related disorders or milder forms which have led to dysfunctional behaviors and substance abuse. I’ll never forget when my husband and I tried attending a support group and realized that the other parents all either had a significant mental illness or their spouse did. No offense intended but these folks were in no way in a position to offer support.
The wait time to see a child psychiatrist in our area is well over 6 months if you are in our network. Outside of our network it is over 9 months. There just arent that many of them and everyone wants them. Pediatricians and family practice docs try to take up the slack but it often doesnt work very well.
On a personal note our son was an Aspie with other issues. We certainly know what it feels like to be blamed by the schools and become socially isolated. However, we did get lucky and at our public school there was one dean/counselor who was very clued in and helped make it bearable even when individual teachers were still clueless. We went through the same thing with meds. It takes tinkering to find the right combo.*Good luck. Its a lifetime commitment. Our son is doing OK but there are still lots of little crises but at least he is able to hold a job.
*Then you send them off to college and they listen to their friends and decide they should try stopping their meds. Abrupt withdrawal is definitely not good for some of those meds.
Steve
BTW when I say “reduce the stigma” I don’t mean normalize. Right now I see pressure to normalize which I think is an error.
My reactions to the summary:
1. I don’t share the desire to institutionalize the mentally ill that seems popular, and I’m not sure money is the primary limitation. Perhaps its second, but I don’t think mental health professionals would find institutional setting appropriate if medical solutions exist. OTOH, the Illinois Governor is refusing to provide psychiatric evaluations of jail inmates required by law pursuant to pandemic-era emergency orders. I’m sure it’s a way to save a buck.
2. Data-sharing mental health records runs into the problem that in most (all?) states mental health records are protected at a level above HIPAA. What they desire is standardization of waivers and a loss of at least some privacy that is considered constructive to the therapist-client relationship.
3. It appears that increasing appreciation for mental health treatment is increasing the use of mental health professionals in a variety of new areas, some of which are probably not as important as others. I’m intrigued by the notion that some mental health care is not part of the continuum, but this will be controversial.