Monday, April 23, 2007

Mental health care delivery in US

After I finished writing my last post, I did what I needed to do, which was to stop watching and reading the news for a while. I went out of town (already scheduled outing) and didn't even bring my laptop. Quite a feat for me. I've only started catching up on the news this morning.....

As some students go back to class at Virginia Tech this morning, many questions still remain. In catching up with the news, I was pleased to see that college campuses are now starting to analyze how they deal with mental health issues. (Seattle Times)
Awareness is especially heightened at the UW [University of Washington], given a murder-suicide earlier this month, when a campus employee was killed in her office by an ex-boyfriend who then shot himself.

The UW's president and the provost on Friday formed an advisory committee on violence prevention to take a look at safety protocols across campus.

Already, a UW counselor works part time assisting resident housing advisers with student mental-health issues. In addition to its regular clinical services, the campus counseling center also operates a consultation line five days a week to handle questions from faculty, staff or students.

When the UW identifies a student who has talked about or attempted suicide, the student must see a campus psychologist. The student is then given the option of undergoing four assessments with a mental-health provider.

If the student declines to participate in those assessments, the UW can start proceedings to remove the student from school, said Eric Godfrey, vice provost for student life at the UW.
What I really hope happens is a careful look at how all mental health care is delivered in the entire country - not just on college campuses? I know, but a doc can dream can't he?

As I've talked about on this blog before, the mental health services in my little county are sparse at best. We have about 100,000 people in the entire county and about 500 square miles to cover. The number of psychiatrists I can count on one hand (and it's even less than five).

A lot of people have barked to me that only psychiatrists should be prescribing mental illness medicines and the primary care doc should be left out of it. The reason PCPs prescribe is because there is no one else to diagnose and treat these patients. It can take months to get an appointment with a psych.

Other supportive services are overloaded as well. We do not have the number of counselors that are needed to adequately services the patients of this community. So, what happens, these patients end up in the ER.

Since there is no inpatient psychiatric hospital in the county, we have to transfer out everything. And, the ER docs out there know how difficult it is to transfer out a psych patient to a different county. This patient can sit in the ER for 8-10 hours (delaying treatment) while the doc tries to get a hospital to accept them.

Or, some patients end up in jail, dealing in the legal system, and maybe dumped back into the outpatient follow-up system which I have described above. There's no good solution here. But, maybe, just maybe, some good can come out of the VT tragedy with this look at mental health care delivery in the US.

Update 4/24/07: Here is a letter to the editor from the Chicago Tribune who states as far as her state is concerned, when it comes to grading mental health care delivery, "Illinois received an F."


SOUL said...

i'm totally with you on this. so much more needs to be done for these patients. but the sad thing is... it's the silent ones that do things ... like massive shootings , or murder suicides. everybody just says... i had no idea... he/she seemed fine...he/she just "snapped".
i don't think people just "snap" .... there's a lot of weight on that branch, before it actually falls to the ground!

Dr. Gwenn said...

This entire situation drove two points home for me - very similar to Dr. A's positions:

1. We need places for people who can't function safely in society that are not jails. We have to stop trying to force people into society who are clearly needing a step or two of separation. This is not being mean or judgemental but realistic. If treatment and outpatient care are not possible for some patients, we owe those people a safe and reasonable place to be cared for. We haven't done a great job of that at all.

2. There has to be a stipulation in the law for family to be notified when adults have become incapable of caring for themselves. Hiding behind the "over 18" legality when a person is not in sound mind does not make sense to me. Never has, in fact. It disturbs me to my core that young adults can be in trouble with out their family being notified.

If something like this ever happens again, we have ourselves to blame as a society - this IS the wake up call that our current mental health system is not working.

Great posts, Dr. A.

BTW, I similarly didn't bring my laptop on vacation - tough to do but worth it!

Mother Jones RN said...

You bring up many valid points, Doc, and I couldn't agree with you more. Our mental health system is in shambles, and I hope that this latest tragic episode with serve as a wake up call for your nation.


Anonymous said...

I've been blogging about this as well. I would like to see the determination for the use of substituted judgment become universal. In other words, use the same criteria to determine cognitive/judgment impairment and the use of a guardian to make healthcare decisions until the person is able to independently care for himself or herself.

Just as I wouldn't allow a person with dementia to refuse bathing, eating and toileting, I shouldn't allow someone who refuses due to impaired cognition/judgment as a result of mental illness.

What gets lost is that comprehensive community-based mental health services were supposed to be in place and fully take up the neds of the people who were involuntarily confined to state psychiatric hospitals and then were deinstitutionalized en mass during the late 1970's. Well, NIMBY, failure to fund services, failure to provide shletered jobs and supervised housing, etc. failed a huge patient population. It's simply inhumane to allow people to founder, and to incarcerate hundreds of thousands of people with untreated or under-treated mental illness.

Jessica said...

For me when going to college this fall I went ahead to make sure I had everything set up, spoke to the school therapist, got an off campus therapist and psychiatrist lined up as well. Once at school I spoke with my RA letting her know what happened to me this summer so that if I needed her help later on I wouldn't have to start from the beginning. This was all good and I was being proactive... most importantly I was doing this all for myself and because I WANTED to not because some said I had too.

Then I had a bad night and asked my RA to hold on to my meds for me (I myself felt confident that I would not do any thing drastic, and told her so. the only reason I wanted her to hold on to them was because it would just make me feel so much more at ease.) She of course, had to tell her supervisor. Then they were all involved in this. While meeting with the on-campus therapist she said that we would be heading down to the residence life office at the end of out appt. (This was sprund on me w/o any warning.) Once there I was told I had to sign a contract saying I would see an off-campus therapist and a psychiatrist and that I would send release of info. papers for the school therapist to be able to talk with them all. Also that I call one or the other if I was feeling suicidal. And that if any appts were missed and not rescheduled or I stopped seeing either one w/o consent of the campus therapist it would result in my removal from the dorms.

This whole contract was horrible! It was like being in the hospital the first time all over again! I was faking being better (although I did truly get better, later) so I could get myself out of my contract. Now the stuff that I was doing to stay safe and healthy was suddenly something I wanted nothing to do with. When I was having problems with my psychiatrist and we weren't getting along I was scared that if I left her in search of another I would be kicked out of the dorms. It wasn't until the contract was lifted (after 1st semester) that I finally left that psychiatrist.

Anyways... sorry for this to be so long yes, we do need better care for this sort of thing but I strongly feel that requiring something like this is not the way to go. There has got to be a better way... only I don't know what.

Congrats to anyone who made it through all of that rambling! :)

coaster1robert said...

The ACLU took the federal government to court in the 1980's,and the ACLU won their case. the states were forced the let the mental ill out state hospitals,that why mental health basically failed.You have to blame the liberal ACLU for that. that's why S- Fransisco has a homeless problem,they are all mental ill,look how their being treated by there liberal gov. Robert

ERnursey said...

8-10 hours? Oh my. We have had patients stuck in the ER for 3 days until their 72 hour hold expired and they had to be let go. Seen every 24 hours by a psych crisis worker who would uphold the hold and leave to continue working on elusive placement which never happens. Are they getting any sort of psychiatric care? Of course not.