Mental health cuts increase emergencies

It is now accepted social truth in this country that the last 20 years or more of funding cuts, so unwisely effected for ALL the wrong reasons, have resulted in longer waiting times in community hospital ERs and the huge shifting by the hundreds of thousands of mentally ill patients to the local and state correctional systems, that it is almost trite to write about this. But as the saying goes, “the beat goes on,” due to the still misguided policies underlying mental health funding policies in this country.

It is so bad that this writer cannot refrain from penning a bastardization (sorry for the language momma…), “destroy them [inpatient psychiatric beds] and they will come…to the ERs and jails.”

Continue reading “Mental health cuts increase emergencies”

More States Paying the Price of Cuts

One of the sadly recurring, and enduring themes of so-called “mental health reform” in this country,  is the inevitability of a number of problems as state hospital beds are foolishly cut in this country and staff positions are cut as well.

Continue reading “More States Paying the Price of Cuts”

Re-Admissions: The Big Problem in Psychiatric Hospitals

For once I am going to refer to a very recently published psychiatric literature article. It is published in the Efficacy and Safety of the 3-Month Formulation of Paliperidone Palmitate vs Placebo for Relapse Prevention of SchizophreniaA Randomized Clinical Trial,” by Joris Berwaerts MD, et.al. and “Long-Acting Injectable Risperidone for Relapse Prevention and control of Breakthrough Symptoms After a Recent First Episode of Schizophrenia: A Randomized Clinical Trial,” by Kenneth L. Subotnik, PhD, et.al.  However the editorial piece for that issue is what I will link the interested reader to as it has the “meat” of this topic and its lessons, written by William T. Carpenter MD, and, Robert W. Buchanan MD, titled, “Expanding Therapy with Long-Acting Antipsychotic Medications in Patients with Schizophrenia.”

First, the problem that these articles and editorial address. A huge percentage of psychotic patients, in this context, those with schizophrenia stop taking their oral medications that mostly prevent recurrent relapses of their illness. At the hospital level where i work, we call this “recidivism,” a term a I do not especially like as it comes from the correctional system [read jail/prison] but we are stuck with it. It means that a patient has again become ill and has to be readmitted and restarted on his/her medication and stabilized once again. This is a HUGE problem in psychiatry and costs untold tens if not hundreds of millions of dollars for each state hospital psychiatric system. Without an old fasshioned public health system as in the “old days,” where public health nurses went out to TB patients homes and saw to it that they took their anti-tubercular medicines daily in person, we do poorly with ensuring “compliance,” with chronically mentally ill (CMI) patients to ensure they take their oral medications everyday, and they relapse. Estimates from studies range all over the place but are often near or over 50%!

For more than three decades we have had older generation antipsychotic medications, that come in “depot” form, in which the medication can be administered in an injection in the arm or buttock and last from 2 to 4 weeks at a time. Administration and the right dosage are asssured; we know the patient receives the medication and relapses are much less common. These medications are Haldol, and Prolixin. But they are in the generation of antipsychotics that can cause muscle cramps and motoric restlessness (akathisia), both of which are unpleasant side effects. Medications can be given that largely prevent these but patients often do not like to stay on these two medicines long term though they work very well.

We have had  for several years recently two of the newer, “second generation,” antipsychotic medications, Abilify and Risperdol that come in long acting depot injectable forms. And while they have far less of the above side effects, they have other kinds of “metabolic,” side effects, but the big problem with them is that they are incredibly expensive. A dose of the Ability deopt from can cost up to $1700 a dose!

 

Bring Back the Asylums! Really?

This article will discuss the surprising but necessary and growing realization in this country that in order to adequate repair our broken national mental health care delivery system, we have to “bring back the asylums.” Instead of continuing to downsize and abolish inpatient beds, and close more and more state hospitals, we need more beds, more specialized units and more new, modern replacement state hospitals to replace our ageing physical plants of state hospitals that are on average, almost all over 100 years old!

I must also apprise/warn the reader that I have violated the big rule of blogging that I have read in every tutorial on blogging in the last three years, to keep your piece to say, 300-500 words maximum. I have ten-tupled that out of necessity to cover this complex and controversial subject fairly and adequately. I do not believe the batted about insulting Internet based concept that suddenly all American Internet readers have suddenly developed incredibly short attention spans. The blogging books and authorities all would hold me up, I am sure, as the Greatest Violator of Blogging Rules Ever. I would answer that if you are not interested in the crisis of mental health care, and/or mental health reform in this country, quit now, stop reading this piece, save yourself time and do something that fits and pleases you better. I will not mind. But if you are, I would hope you will find this piece informative, motivating and encouraging. I do not write from a pessimist’s heart, and am not the old character from the cartoon strip of Al Capp’s, Little Abner, now long out of print and unknown to anyone under 40 years old or so; this character was called “Joe #@?!” or something like that. He was a total gloom and doom guy, worse than Eyore of Winnie the Pooh. He was illustrated so well pictorially by Al Capp to give any reader of the comic strip an immediate recognition of this character’s constant and unfailing pessimism and even constant expectation that misfortune was waiting for him at any second, by drawing with a little black cloud just above his head that was already raining on him and no one else wherever he went. I am hoping to write and promote change in the opposite, optimistic, we can gradually make things better mode. And fortunately in my state of practice in North Carolina, no matter our present hurdles, we are working diligently on them, I think in the last few years we have turned a number of big policy and implementation corners, and I am proud of this state’s efforts under very very adverse circumstances. I also hope that by writing from that perspective, and by picking up and publicizing in my own small way, successes, victories and advances I find through my professional collegial grapevine of four decades of colleagues from my training years, different places I have practiced, and the wonders of my cool little Google Internet keyword army of helpful search bots, I can spread some good news of mental health reform efforts in other locales that are also fostering improvement and progress against the daunting odds and difficulties we face commonly all over this country. So get your favorite beverage, get you thinking and pondering cap on, and undertake to read [in as many sittings as it takes] this massive blog “missal” on “bringing back the state hospitals,” not exactly a popular or politically correct concept perhaps these days.

Continue reading “Bring Back the Asylums! Really?”

More on Milwaukee County mental health services facility crisis

On June 18, 20 the able reporter Ms. Meg Kissinger for the Milwaukee Journal Sentinel newspaper that has been superbly documenting this now 15 year old story, wrote of the latest repair efforts by the County to fashion a feasible plan to resurrect and restructure this facility and its services to its clients. She documents the new effort in her article, “County considers closing Mental Health Complex, privatizing care.” In my distant uninformed opinion they do deserve a lot of credit for toiling under years of stress, failed plans, recurrent crises and scandals. If anything they are to be commended for long term public service efforts, through I am sure, multiple sets of officials.

As it is reported currently, there are a number of short and long term plans to try to create better services. Ms. Kissinger details this in her latest article, “County considers closing Mental Health Complex, privatizing care.”

The major elements of the plan appear to be to get the county government out of the operation of the center and the judgment appears to be that this level of system change is needed to have a chance of success and improvement when the newspaper’s own series, “Chronic Crisis: A System That Doesn’t Heal,” referred to in recent posts has failed in part because of poor political leadership, division and poor follow through as well it appears just poor paltry efforts at reorganization inadequate to the task.

The main elements appear to be: 1) “turning over direct patient care to a private organization as is done in most other counties across the country;” 2) delivering psychiatric services at two separate locations at two different and hopefully dispersing and easing access to services; 3) including multiple services at each “access hub,” including a mental health clinic, peer-run services (where patients having achieved high levels of recovery and stability can help give on the spot support and guidance to new and continuing patients–a very effective mode of service and means of helping sustain compliance and continuing attendance and contact; 4) intensive  outpatient services, 5) a crisis line, 6) care coordination with I expect designated staff specialized in obtaining, scheduling and referring to diversified services, long known as case managers, essential parts of any such outpatient mental health organization that did not exist decades ago; 7) and a medication management clinic. Additionally, and very significantly, the long nationally neglected truly essential component of local inpatient crisis psychiatric care, a 60 bed inpatient unit “for patients that need around-the-clock care will be included. On the face of it, this sounds like a very well thought out plan.

Further the article notes that apparently the plan was put together with extensive consultation with all the needed stakeholders essential to the enterprise, patients, families, advocated, clinicians. Workers and current clinicians are to be afforded apparently every opportunity to retain their jobs and continue to work. In past efforts I have witnessed in a number of states, the private organizations would come in and ape Frank Lorenzo’s original model with bankrupting and reorganizing Continental Airlines in the 1980’s of essentially firing everyone, then making them re-apply for their jobs, and then paying them if they consented to be rehired–at far lower salaries wages, taking cruel advantage of their needs like everyone else not inherently wealthy like big Cheeses like Mr. Lorenzo, to go back to work at any cost to themselves, establishing the model of screwing the working class (I now disavow being a radical, Commie, or goof ball Socialist or any of the other epithets used to discredit anyone who notes the consequences to now depleted “middle working class).”

What I have seen happen over and over in now TWO different states who reorganized their “mental health center” based systems with this costs at any cost rehiring approach and vile treatment of committed clinical staffs, is that many of the staff who face losing up to say 40% of their pay, in many instances, much of their retirement and vestments, is that they quit and move on….Then the private corporate re-organizers happily, as this HAS seemingly been their intended plan, hire new clinicians, like Mr. Lorenzo did, desperate to get jobs in a recession economy, willing to settle for lower pay, but also altering job descriptions and required clinical qualifications to a lower level, from  Master’s levels counselors, social workers and psychologists, to those with 2 or 4 year Associates’ or Bachelors’ degrees, far far less actual patient centered exposure and clinical experience and “rotations,” as those are very expensive for these lower level training programs to provide, and the privatized “behavioral centers,” end up with often very less qualified staff who nonetheless work hard and are happy to be fulfilling their own mental health worker aspirations. Later many of them find they have been locked into near permanent lower pay servitude with not much of a ladder of career and earning power advancement, a cruel but now pervasive employment practice in so many industries. Quality of care suffers.

Other cost cutting measures usually follow. Less well trained “prescribers,” and experienced therapists with less experience than Masters’ level, and PhDs and MDs manage acute and chronically mentally ill patients’ psychotherapeutic and psychopharmcological treatment needs. Patients are seen in medication groups instead of individual as much as possible to further save money, are seen often only on walk in basis in crisis. Patients are smart, and they migrate to the ERs where they can see more skilled practitioners, and get better care and we end up with mess we have now, patients flooding local hospitals’ ERs.

One cautionary note and quote in Ms. Kissinger’s June article is by the County Executive Mr. Chris ABele, who was quoted as stating: “Uncontrollable expenses significantly influence the cost of doing business as a county entity.” This kind of mantra used to be heralded as justifiable and ethical as it was long repeated all over the county in this now overwhelmingly utilized of mental health local system of care delivery, would save costs by ‘getting the meddlesome government out of it.’ What has evolved instead is that clinical services are cut in every manner conceivable in addition to the honest expense saving approach of consulidating administrative services, and unifying the management components into a central cost effective entity. That was done and almost always promotes honest savings, more unified management, better oversight, etc. But the other hack and slash approaches are just too tempting for most organizations to resist and almost universally quality of care has declined in the last two decades dramatically. Just ask patients older than 40 or parents of adult mentally ill, or patients trying to seek more than piecemeal, silo’ed services in which the client/family has to apply separtely for every service they need and processes of delivery take far longer than they did before in the organizations that have followed this kind of recipe. It is repairable and correction and refinement of service delivery organization is finally beginning to evolve in enlightened centers.

But when privatization evolves to equal profits over service expenditures and funding sources, i.e., the local and state government start the Nixon approach of decreasing funding annually, then quality declines in synchrony with those cuts as governemnts handily and happily get out of the “mental health business.” Recently Obamacare has taken the aporach that an interim solution is to expand Medicaid. Right now that is the only visible solution but it should be temporary. And it has rightly generated enormous controversy as it shifts costs to the federal level, WILL result in cuts elsewhere in the Federal budget at time when we need to be rebuilding everywhere, infrastructure and God knows what else, or means the dreaded rabies inducing reaction to “higher revenue streams,” the euphemism for higher taxes. The reality is that the public mental health client cannot fully pay for their mental health services they need and few in the world of economic governmental reality are paying responsible attention to that undeniable reality. And again the powers that be seem to still be forgetting the old American ideal of the “common weal,’ the good of the majority, the ‘help thy neighbor ethos.’

Let us hope the folks, all concerned in Milwaukee learn from the mistakes of the rest of the country’s floundering experiment with “mental health reform,” and do it better and differently. They certainly sound as if they have a sound plan, if only they make it work RIGHT.

Mental Health Reform–The Beginnings of It All

A State Hospital Dome
A Typical State Hospital Skyline

 

 

 

 

 

 

 

Since this is the very first entry into this site devoted to the contemporary history of one of the states’ efforts at “mental health reform’ since the late 1990’s, I should preview what will the be the ongoing thrust and intent of this effort.

  • This author will endeavor to focus primarily on my state’s mental health reform efforts since the late 1990’s
  • I will also in these early posts draw upon my knowledge of some of the first efforts in the United States to begin to grapple with the long dormant tasks, needs and dilemmas of the public mental health services sectors, long neglected and unchanged since the 1963 ‘Comprehensive Mental Health Center Act’
  • I will trace the many steps and changes that the effort in North Carolina has undergone, from incremental changes, improvements and commendable efforts at correction, the fits and starts, the usual “unintended consequences,” tough lessons learned since 1999-2001 when this started
  • I intend to also give credit where credit is due to the state of North Carolina, its leaders, political structure and veteran Department of Health and Human Services, to reach recently now consolidating improvements, and recent commendable achievements wrought under difficult circumstances when many were harsh and vocal critics of this uncertain reform effort, myself included in past years
  • And finally, I will try to observe a personal tenet of mine, to give credit and ‘compliments, as the positive fruits begin to take unmistakable and firm footing, that were long doubted by many especially the sector of mental health professionals [again including this humble observer; I believe that in our currently polarized and argumentative public climate, we have just about lost the sense of fairness in complimenting each other, looking past philosophical differences and vilify or deny the worth of others’ ideas; and a fitting compliment goes a long way to forging partnerships needed for fashioning corrective steps and improvements, when taking on such complex and overwhelming social problems that this blog attempts to describe, educate and promote a better grasp of where we have been and where we are hopefully headed in our efforts of promoting the common weal and good for all our citizens in need.
  • Along the way I hope to show how North Carolina, in my view is one of the nation’s leaders in devoting impressively large and comprehensive resources in addressing the effort of mental health reform even in these times of a lasting and lingering economic slowdown, where the temptation could be understable to stint on budgeting sufficient resources, and end up repeating the decades or even centuries old practice of giving short shrift to the mentally ill and cutting their budgets since they by and large, do not have powerful lobbying groups on a level with labor unions, huge corporations, nationally based special interest groups, with a few exceptions that serve special groups among the mentally ill populations.
  • Finally I pledge to the readers of this commentary observational effort, to present as even handed a presentation and historical accounting as this practitioner can, given I am not a trained historian, reporter or writer; similarly I must make “full disclosure” particular to this effort and my position: I am a psychiatrist and subject to the views and educational, clinical ethos or bias that goes along with and arises out of my four decades of practice and experiences, that I have practiced in many settings from private, academic, public state hospital and local mental health centers, HMO clinics, Native American populations, correctional facilities for adults and adolescents, outpatient and inpatient settings of all stripes from acute to residential. Mostly, I must respect the ethical expectations of my current employer, a state hospital of the state of North Carolina, and will not abuse this position and knowledge I have of this institution, its staff, leadership and especially its clients, all of whom I owe a debt of gratitude for permitting to practice and do what I love best, treat and help patients, and teach trainees and participate in a care organization that puts its efforts where its mission statements vows, to be an aid to all, operate with respect and be honestly transparent, and to constantly self-monitor and improve. I am in the twilight of my career in some ways, and realized when I came to work here, that I had come full circle, from my first years out of residency at Duke when I took a state hospital staff psychiatrist position at the then but no longer existing John Umstead Hospital north of Durham, to help start an acute inpatient adolescent unit and a comprehensive multidisciplinary family therapy training program. I was green, inexperienced, eager and did not know my own limits but always itching to contribute. Now I work with, in many ways, the most challenging clients of my career, and think in a karma kind of way, that venue I have worked in heretofore, no matter how different, has prepared me for what I do now, and I am ever grateful to be here, at a time of great change and challenge. I hope the reader will enjoy the story I will attempt to tell.

Respectfully yours,

 

Frank Black Miller MD DFAPA

 

We Need the “Asylums” Again Believe It Or Not

On January 16, 2015 the American Medical Association issued a press release giving notice of an article that asserted the current model fo treating the mentally ill as “ethically unacceptable and financially costly.” It was walking about the decades old failure of “de-institutionalization” that in in its second or third cycle of failure, being re-enacted in states all over the country once again, with similar and predictably disastrous results. I have the feeling that its title and byline in the press release was a little bit intentionally inflammatory to call attention to the importance of this issue.

This article was startlingly timely in that this author had just this week launched this blog on the broad topic of “mental health reform” and the state by state and national debacle it has become since the 19990’s in Michigan and since 1999-2000 since the same dishonest cruel blueprint was foisted upon the naive and desperate legislators in those states to save monies. Michigan by the 1990’s was in accelerating economic swandive mode because of the near bankruptcy of the Big Three American auto makers at the end of the second George W. Bush Presidency, forcing the surprisingly opposition to the bail out first of the two USA life saving bailouts that were left to the the new Obama administration. One would think that the Republicans would remember the satirical but emblematic motto of the character of “General Bullmoose,” in the old “Lil’ Abner” cartoon series by the great satirist Al Capp, “What’s Good for General Bullmoose is Good for the USA!” General Bullmoose was a character who represented the auto (GM–get it?) and military interests that dominated the country in those decades from the 1950’s onward. Business was supreme and has always been the organizing ideological center of the Republican Party. Michigan was one of the Rust Belt States losing population by the thousands yearly as families fled the loss of jobs in the auto and allied industries foretelling a trend that continues to this day.

Meanwhile North Carolina in the late 19990’s suffered enormously from the precipitous “Dot .com” bust of overvalued darling companies of stock hucksters on Wall Street that were innovative but made no money and somehow a free Internet based serviced equalled or guaranteed riches in the future. Conservative economists and stock experts who warned in ever darker tones in those years about that folly were lampooned unwisely by the upstarts of the New Economy that no one could define as old fuddy duddies with their economic heads in the sands of progress. North Carolina was perhaps the third most important “Dot .com” economic engine in the country after Silicon Valley and the Boston Corridor because of North Carolina State University’s technical powers and the graduation of the RTP (Research Triangle Park”) into the tech Big Leagues with dozens of start up tech companies who went bust as funding vaporized when results never appeared and tight money clamped down. Then North Carolina got hit with Hurricane Floyd which devastated an Eastern part of the state and cost the state in short order between one and two Billion dollars to helps its citizens rebuild. Then North Carolina lost a very important legal economic case in the early 1990’s that went all the way to the Supreme Court and cost the state over $900B in one year. North Carolina lost its contention that it could, as it had been for 9 or 10 year years, taxing the federal retirement pensions and benefits of retired federal workers living in the state. The loss meant the state had to refund almost a billion dollars swiftly as NC is a state that requires by its own Constitution that its annual state budget always be balanced, no matter what, no funky borrowing or issuing junk bonds as a way out. So the General Assembly was desperately looking for a way to save approximately two billion dollars quickly and fell sucker to the pitchmen from Michigan and before that Massachusetts in the 1980’s who had saved those states huge amounts of monies but slashing the budgets and costs of the mental health systems with a new plan that was called euphemistically “Mental Health Reform.”

Its basic tenet was to close ‘expensive’ out dated state hospitals and their beds, since everyone knew by that time that being in the state hospital environment was bad for your because of the three decade long promulgation of the modern fallacy of “institutionalization.”

The four state hospitals in Nor Carolina, Dorothea Dix Hospital in Raleigh, Cherry Hospital in Goldsboro, John Umstead Hospital in Butner outside of Durham, and Brougthon Hospital in Morganton in the western third of the state and the largest, had their beds reduced by roughly two-thirds each. The bogus reform plan, a several hundred spreadsheet program utilized in other states notably Michigan, promised the building of comprehensive outpatient services as it dismantled and destrroyed the well functioning local county by county mentalh health services. It was also suppposed to build for a start, sixteen smaller, more regionalized (read local and closer to families) less “isntitutional” smaller “mni” state hospitals. None were built for years by the state except one which was placed in the outskirts of the western town of Sylva without a large enough supportive psychiatric cohort staff of practtioners in an old, converted, rennovated nursing home and one unit housed in a small community hospital in Linville NC.

And the results were predictable, patients lost their long trusted psychiatrists and clinicians by the droves and it took years to replace those. Crises with patient ended up in the ERs of small hospitals all over the state, many with any psychiatrists on their staffs OR any inpatient psychiatric units. Patients also ended up in even greater numbers in the jails, at the country and state levels. Counties suddenly had to find staff, resources and medication budgets to care for at least 10-20 times more mental patients than they had ever had, Jail suicides dramatically increased. And the mental health reform took years to try to catch up.  A prominent then Duke faculty psychiatrist in the mid 2000’s stated publicly for the media in an interview that it would “take 10 years for the state to replace what we had [in state mental health capabilities] ten years ago. A more damning indictment of the the state’s mental health reform effort could not have been verbalized except the description by a Dr. Steve Crane MD a teaching physician for the family practice residency program in Hendersonville and Asheville as “the disaster that just keeps on giving,” which was a satirical take-off on the then current circulating satirical description of Hurricane Katrina and the failure of the Bush Administration to respond to it in a timely fashion which is now a classical study in government and business schools on how NOT to handle a crisis.

To quote the article in the Journal of the American Medical Association published January 20, 2015, “As the United States population has doubled since 1955, the number of inpatient psychiatric beds the United States has been cut by nearly 95 percent to just 45,000, a wholly inadequate equation when considering that there are currently 10 million U.S. resident with serious mental illness.

Continuing, the authors of the article, Dominic Sisti Ph.D., Andreas Segal MS, and Exekiel Emanuel MD Ph.D, wrote “For the past 60 years or more, social political and economic forces coalescent to ove severely mentally patients out of psychiatric hospitals.” They went on to say that the psychological civil rights movement propelled deinstitutionalization and resulted in “transinstitutionalization” which meant the severely mentally ill hit the ERs, jails and homeless shelters and streets around the country in huge numbers.  To further quote, “…most disturbingly, U.S. jails and prisons have become the nation’s largest mental health facilities. Half of all in mates have a mental illness or substance abuse disorder; 15 per cent of state inmates are diagnosed with a psychotic disorder.”

Instead, to quote the press release itself, “the authors suggest that a better option for the severely and chronically mentally ill, and the most ‘financially sensible and morally appropriate way forward includes a return to psychiatric asylum that are safe, modern and humane. They argue the term ‘asylum’ should be understood in its original sense–a place of safety, sanctuary and healing,” and I would add long term care, and long term rehabilitation to permit development of the current mantra ideal goal of “recovery.”