So, how do we improve mental healthcare in the United States?

Great Debates
1

In a thread about yet another mass shooting by a mentally ill person, I talked about the poor standard of mental healthcare in the US. Someone else in the thread asked me what I thought could be done about it, and whether other countries were doing things right. I realized, in trying to formulate an answer, that despite my long experience with the mental healthcare system (if we could call the fragmented, confused, underfunded jumble of public, private, and voluntary organizations that serve the mentally ill in this country a “system”) that I really don’t have a good plan for what could make things better.

There are some things I know that can be improved, especially residential care. As I wrote in the linked thread

It seems unthinkable that any hospital in this day and age would ward violent male offenders alongside women, or subject patients trying to get better to have to witness assault and battery in the common room, or provide less therapy in the hospital than most patients are used to out of it. But that’s how underfunded and badly-run most residential care facilities in America are. I honestly think most mental hospitals are every bit as bad as the hospitals we see in pictures from the early 20th century, just a bit cleaner.

I think part of the reason most hospitals are this way stems from the stigma surrounding mental illness. Many years ago, cancer had the same sort of stigma; people thought cancer was a communicable disease, or that it was the fault of the sufferer. Cancer wards of the time were depressing, dull places which were not nice places to visit or live in. Then as the stigma against cancer patients lifted, hospitals and caregivers realized that these patients needed to be treated with respect and optimism: many chemo wards became more inviting, friendlier places with ample sunlight and enjoyable activities. I believe the same sort of mindset change is needed in mental health.

Having said that, I’m not sure what else can be done. Throwing money at the current system won’t help; I think the money would just be lost in the confusion. Every mental patient I know relies on several different facilities for their care; how can each of these benefit equally? I honestly don’t know. How do we remove the stigma against the mentally ill? I don’t know that either. I’m too scared to talk to anyone other than my doctors about my condition because I know how they’ll react. I’ve seen too many people not get care because they’re too frightened to come forward, because they think they might be ostracized or fired for doing so. To be honest, they may be right.

As I said in the linked thread, I don’t think there is an answer for every facet of mental healthcare, an answer that will help everyone. But I want there to be a realistic answer to improve things. Is there one?

2

The police and the jails are one of the biggest parts of the system dealing with the mentally ill-and they are clearly not trained for it. So more training there.

3

One of the things that made me realize that many conservatives are not serious about this is that besides refusing to consider common sense gun restrictions they also generally oppose things like the Affordable Care Act, that does help setting better access of mental health also:

http://www.usnews.com/news/articles/2014/04/29/mental-health-now-covered-under-aca-but-not-for-everyone?page=2

Of course that helps on the access to mental care for many in the low income bracket, (and IMHO several incidents with guns are also related to mental issues at low income levels) but there is still IMHO the need to deal with what it is clear to me to be the inadequate mental health care that affluence is causing to some.

Most of the recent shooting incidents are being made by people that were overprotected, paradoxically they did get mental care but IMHO many times it was mostly geared to protect the subjects from getting into trouble with society or the authorities.

I do think that this method however hides a lot of problems that would had surfaced early and triggered more warnings to the people outside their bubble.

Eventually things like a death in the family, divorce or other factors like conspiracy theories make them fall off the control their families had before. I do think that the issue will have to be forced, just like we do see the people that leave loaded weapons around the house as irresponsible and liable to lose their rights, so we have to realize that when there is a mental condition some should never have access to guns and families must be more proactive on putting their family members on notice with the authorities and restricted gun lists.

4

I didn’t want to come back to my own thread. But I think the fate of this thread and the one I started in MPSIMS–the one that consisted of my OP and answers to a few questions, and a couple of posters who wrote variations on “this is a good thread and it shouldn’t die”, and then it did die–seem to tell me of a real problem. Especially as other threads about the same incident I referred to in mine turned into long multi-page debates filled with good discussion and bad.

The truth is, people don’t want to talk about mental health and possible solutions to it. I’ve seen this myself in real life, even amongst people who were treating me. The psychiatrist who diagnosed me with bipolar I didn’t want to explain why he’d made that diagnosis, what characterized the condition, and what I could do to treat it, other than take lithium and industrial-strength sedatives which made me largely unable to become manic if I’d wanted to summon up an incident. I spent over a year believing I had bipolar I before I saw another psychiatrist who looked at my chart and immediately identified the previous psych’s verdict as a misdiagnosis. Five minutes’ discussion with the first doctor would have probably made that clear. I recalled how when my mother was diagnosed with cancer, the oncologist talked to me for 15 minutes about her disease. For years I’d always heard about cancer as “the disease where people die from silence”. I never saw that once, not even once. But I was stuck taking drugs I didn’t need for over a year because a psychiatrist didn’t feel it was worth his time explaining things to me.

And, to be honest, if somebody who makes their living in mental health doesn’t want to talk about it, why should people on a message board want to? It’s a touchy, misshapen, sloppy, ugly subject. People who are mentally ill do bad things. Between the time this thread last got a post and now there was another shooting at a university, once again involving a suspect who “was a little bit on the crazy side” as one colleague described him–and in fact, had been involuntarily committed twice. And, just as with the previous incident, the question of why a mentally ill person was legally permitted to purchase firearms has been quickly buried in the news. Last time by the rampant misogyny of the shooter, this time by the (righteously heroic) action of the student who subdued the shooter. But the thread that connects the two incidents is unspoken, again. And even though again there is a clear-eyed 20-20 hindsight about the two suspects, nobody is standing up and saying, “Gee, I knew the shooter and knew there was a problem with him, but I never thought about getting him some help.” That, we don’t want to talk about. Maybe posting here would make people think about getting others some help. Or getting themselves some help.

Mental health awareness programs in the US are a bit of a joke. Did you know last month was Mental Health Awareness Month? If you didn’t know that you also probably didn’t know there’s a Mental Health Awareness Week in another part of the year. A few years ago the theme of the Month was “that many mental health problems could be avoided by striving toward and making positive lifestyle choices in the ways we act and think”. That’s a bit like saying you can combat alcoholism by not drinking. Being unable to make “positive lifestyle choices” is one of the defining characteristics of many mental illnesses. Yes, keeping and sustaining those choices is a step towards getting better. But it’s usually the last step. Even Mental Health Awareness Month couldn’t verbalize the first steps, or what to do with the people who couldn’t reach that last step.

We can’t improve residential mental healthcare facilities in the US before we can talk about the fact that they need improvement–or even that they exist. We can’t improve workplace conditions for the mentally ill before we admit that the mentally ill make up a decent fraction of the American workforce–or that discrimination against the mentally ill in the workplace even exists. And we can’t make headway against treating the mentally ill in America without suggesting that the mentally ill are forever tainted, and that it’s better to hide in shadows than to step out and seek help.

5

I think it useful to discuss solutions based on two different cases:

  1. The individual knows he has a problem and wants help. For example several years ago I lived in a city where such an individual knew he had a problem and asked at the Crisis Center who referred him to the police department where he asked to be driven to a state mental health institute. No one was available to drive him, no other options were available to help him. The next day he killed a 16 year old teenager. Strangely enough it turned out the state had plenty of resources to try him and lock him up in a state prison for 10 plus years (second degree murder). So clearly universal comprehensive mental health coverage would him this type of person.

  2. The person has a problem but either doesn’t believe he has a problem, doesn’t want help, or refuses to take his medication. Here you need to discuss things like civil commitment.

6

Make that effective civil commitment. Unless it can be shown that what is being proposed is much more than mere institutionalization for an indefinite period of time, too many people will oppose it.

7

1> Mental Illness is perceived as a ‘weakness’. Now, we’re both Herd Animals and Predator. Weaknesses are to be hidden, and shunned. It’s something to be ashamed of. Or so we tend to think and feel.
2> God. Combined with the above, if you’re not right in the head, it’s because you deserve it.
3> Social Darwinism = Same outcome as #2.
4> If we have such a large portion of the population, and an entire ideological party so adamantly opposed to everyone having health care, usually covered by protesting Cost, then it’s much much worse with something that falls under #'s 1,2&3.
5> Freedom. It would be incredible tyranny to legally enforce ideals of mental health and force treatment. The USSR and it’s ilk used this heavily against their critics. It is very dangerous to argue, and enforce, standards of behavior and sanity on the general public, or pre-emptively incarcerate people “for their own good”.
6> Abusive Systems. Yeah, care facilities have historically worked out so well, right? That sort of thing isn’t a thing of the past.
7> Poor education on mental illness.
8> As above, stupid assed ideas about how to treat it and combat it.

8

I can only comment from my small corner of the system, and that would be: we need to fund home visits from Psychiatric Nurses and Doctors. If we’re not going to fund residential facilities and make them actual places of treatment and healing, then home is the next best place.

I’m a home health nurse. I’m not a Psych Nurse. All nurses have some training in Psych, but I’m not certified in it. Under current Medicare Guidelines, home nurses cannot make visits for psych diagnoses alone. If a person has another medical diagnosis, then of course I will address their psych health while I’m there, but I can’t Certify someone for home visits for Bipolar Disorder like I can for Hypertension or Diabetes. There’s a place on the Medicare Assessment form where I have to mark off whether or not the person is receiving home visits by a qualified Psychiatric Nurse (why, I have no idea, since they won’t pay for it), and I’ve never yet been able to mark “yes.” There just aren’t any in my city, except for those paid and staffed by the VA.

While I’m there making weekly visits, people do better. They take their meds more often, their functional status improves, their productivity and quality of life increases. But then when I have to Discharge them, more often than not, the downward slide begins again. But the way the system is set up, I have to Discharge them when they no longer have a Skilled Need related to one of their not-Psych diagnoses. It’s stupid.

I’ve got a friend who is a VA Psych Nurse, part of a special program where they make home visits. She’s got the numbers to show that it really helps the patients. We need to expand that to the rest of the Vets, and to Medicare, Medicaid and to private insurance.

It’s not THE answer, but it’s one answer.

9

I’ve seen so many lesser versions of this, where someone is wanting help but because of lack of money, lack of public transport, or lack of friends of family able to physically get the person to the help, they aren’t helped. I still remember driving one of these people to his appointment in the next town over, because they didn’t have a treatment facility in his town. I still remember wondering what would have happened if I hadn’t been married during my last hospitalization; in the confusion I’d left my wallet at home, and the hospital had no transport service that reached to my town. And you could say, “yeah, but this happens with every disease in America.” But considering the high unemployment rate and general low income of those who are seriously affected by mental illness, lack of transport is a serious issue.

And that’s what’s hurting care systems now, I think. My experience of care facilities is that they exist to punish the patient for being ill. That belief simply hasn’t gone away. I don’t want to say that mental illness is the last disease that even health care professionals think is the fault of the patient. But it seems that way far too often.

You also mentioned God. When I was going through a spate of depression in college a “Christian” friend of mine sincerely told me if I believed in God more, my depression would go away. If this same person had told me that God would heal my broken leg or blistered feet, she would have been seen as the unbalanced one. Yet her comments were fully supported by the church leader who knew us both. They wonder now why I have left the church. It is almost medieval, honestly.

I feel that in addition to the ideas suggested above…well, it feels like I keep going back to why mental health care isn’t supported than to ideas as to how it can be. Breast cancer used to be a severely taboo subject. Then groups like the Susan Komen Foundation started raising money to support awareness. We can argue all day about whether Komen actually did anything to save any lives, but the one thing it surely did was that it was made it OK to talk about breast cancer.

Will there ever be a Komen Foundation for mental illness? I can say as someone with some experience in this subject that there never will be. It’s an uncomfortable thing to say, but the Komen Foundation wouldn’t have survived if only poor people got breast cancer. Poor people don’t “race for the cure” because they’re working 80-hour weeks to support their families, and they sure aren’t sponsoring runners with cash donations. This isn’t to say that only poor people suffer mental illness, but I can say as a fortunately comfortably middle-class sufferer that if I went around declaring my condition and trying to raise money for my cause I’d likely be on the unemployment line fast. If my company tried to do that to a breast cancer sufferer they’d find the national news on their doorstep tomorrow. Mental illness just doesn’t have the critical mass of moneyed persons to start a movement. Nobody’s going to claim a color for it or design a catchy logo. And this is not to say, “poor pitiful us,” this is just the damn truth.

10

Have any nations, states/provinces or municipalities found something that works? If so, copy them.

11

This is one thing pro- and anti-gun people have in common. They both know fuck all about mental illness. You both want to restrict “mental illness”? At least 1/4 of the population who have ever been to therapy? All people with psychotic disorders (who are generally pretty safe)? Psychopaths? who are more likely to be serial killers than spree killers, but low chance for each?

We need to define what we’re looking for, recognize signs/cries for help by individuals, but not putting someone on a blacklist because they were depressed at 16 (as most of the people I knew at 16 were).
And above all, recognize that mental illness exists, and is more common than most people care to admit, and that the rates in the population can’t be reduced and shouldn’t be ignored. Where I’m from I don’t think there is as big a stigma as elsewhere, but you still don’t tend to mention your therapy to acquaintances.
I think most countries aren’t doing it right, the US is hardly the worst, and I don’t know what the best place is. Europe ranges a lot between countries.

Jails probably need reforming first, and I don’t see that happening any time soon.

12

Aus. has, in general, a fairly good health system. Better than the USA system, and costs less. There is universal health insurance, with a mixture of public and private sector involvement.

Mental health still falls through the cracks. Care was a state responsibility, and when control of the health system was largely transfered to the Federal level, the Mental Health area just got lost between the two.

Acute care has partial coverage, and social security and jails have partial coverage, but that big area between “well enough to look after yourself” and “dangerous to other people” isn’t covered very well at all.

13

It’s not so much that there’s thing phenomenon called “mental illness” which we understand well but don’t bother offering decent services for even though we have the ability to do so.

Instead we have a phenomenon that we don’t understand worth shit and which, collectively, we’re pretty uncomfortable dealing with, which we labeled “mental illness”, pretend to understand well, pretend that what we do to people in the name of treating it is, in fact, good for them, and then, having reassured ourselves of that, turn our back on the whole matter as emphatically as we can.

14

I don’t know what we coud do to fix this, but here’s what I think keeps people from getting help (apart from them being too broke/uninsured): fear that you will lose everything (your education, your career, your family) if you press the pause button and get help.

I think this stems mainly from our poor safety net, and it’s not just the mentally ill who struggle with this. There are plenty of people with physical illness who shouldn’t be working, but bills can’t pay for themselves. It can take a long time for people to be deemed eligible for disability. If you don’t have enough savings or family support to tide you over unti then, well, you’re screwed. What else can you do but “suck it up and deal”?

And it doesn’t help that most Americans are raised to disdain government assistance and, in turn, the people who avail themselves of such services. At best, you’re seen as “weak” if you are one of them. At worse, you’re a greedy mooch. So if you’re severely depressed, adding another slew of negative adjectives–including “permanently unemployed”–is a very uncomfortable proposition.

I started availing myself of mental healthcare when I got my first “real” job in my late 20s. My job not only came with premium insurance, but I also got a ton of leave, which I could take every time I needed to make a last-minute appointment or just stay in bed, if need be. But if you’re working a McJob that doesn’t give you any time off or any flexibility in scheduling, then it’s practically impossible for you to get the help you need and keep your job at the same time. And it sucks, because someone who has a serious mental illness is more likely to have a “McJob” than a job with benefits. They’re also more likely to have poor access to good healthcare in the first place, and more likely to experience the stress that exacerbates mental illness.

So IMHO, the best thing we can do to improve mental healthcare is to shore up the safety net and encourage more employee-centered work practices. Sick leave for everyone, at the bare minimum.

15

One large problem is the trouble we have with identifying with those that have various mental illnesses. I can imagine what it would be like to be blind, deaf, mute or missing a limb. Up to a point I can imagine the pain of cancer and various other physical ailments. What I cannot do is imagine what it would be like if my mind didn’t operate the way it does now.

16

The color of mental health awareness is green, by the way…which doesn’t help the cause at all when green is also the awareness color of
Gastroparesis Awareness
Legalize Marijuana
Glaucoma Awareness
depression awareness
muscular dystrophy awareness
traumatic brain injury awareness and support
cerebral palsy awareness and support
CMV[disambiguation needed] Green and Blue CMV awareness and support
aging research awareness
celiac disease
Lyme disease
organ transplant and organ donation awareness
kidney cancer (also known as renal cell carcinoma) awareness
environmental protection
mitochondrial disease awareness
pedestrian safety
craniosynostosis awareness
bipolar disorder awareness
Close Down Green Hill / Vivisection Campaign
support our public school students and teachers
Tourette syndrome awareness
The 26 people (including 20 children) who died in the Sandy Hook Elementary School shooting in Newtown, Connecticut, on 14 December 2012 (the school’s colors are green and white).

Silver is the color for schizophrenia awareness, and brain disorders and disabilities.
Orange is for attention deficit hyperactivity disorder.
Puzzle pattern for autism awareness.
Purple for Alzheimer’s disease.
Grey for borderline personality disorder awareness.
Black for awareness for suicide, bulimia, anorexia, self-harm, etc.
Teal for post-traumatic stress disorder awareness.

So many ribbons, so many different directions, too much diffusion of effort.

17

And Four is the color of Synesthesia…

18

To me, it seems like there are a lot of hard questions and ambiguous situations involved in mental health care. Having clear answers on a lot of them might help treatment, law enforcement and legislators immensely.

These are things I see from my admittedly non-trained eye:

[ul]
[li]Some bipolar people actually enjoy the manic phase enough to put up with the depressive aftermath. Should we compel them to be medicated to even out their highs and lows, even if they’re clearly mentally ill, and clearly aware of it, but choose not to be medicated?[/li][li]Mental illness messes with people’s perceptions- they may think they’re entirely sane and don’t need help, or that they don’t need their meds. How do you convince them? Or do you forcibly medicate them?[/li][li]Where do you draw the line between merely weird and mentally ill? I can’t count the number of flat-out weirdos I’ve known who could be describe the same way as these crazy shooters.[/li][li]Where’s the threshold for “mentally ill”? I mean, I had a stretch after my wife had a miscarriage and I was very stressed at work when I was diagnosed as “moderately clinically depressed”. After a course of CBT therapy (no drugs) , I’m ok, and haven’t felt like that since. Would I count?[/li][/ul]

19

I think much of the problem is that an unpleasantly high percentage of the time, there is no good treatment for various major mental illnesses. According to the NAMI website, 20% of those with bipolar disorder, 35% of those with major depression, and 55% of schizophrenics do not respond to treatment. A better safety net isn’t going to help those folks.

Regards,
Shodan

20

From where we are today, it’s likely we will be having the same discussion 100 years from now. We really are in the infancy of dealing with mental health issues. The accepted definitions of mental health issues are in constant flux (homosexuality was a mental health issue just a short few decades ago). The treatments and success rates are all over the map. It will take years and years, and an evolution in the industry, to settle on some more consistent form of definitions, and treatments.

That said, what I would like recognized is that it will take lots of money (oh, shut up, y’all) to accelerate the pace of progress.

As a practical matter, I would first spend a lot of time, money, and effort, training law enforcement - as they are, unfortunately, often the first line of response when an individual is acting out due to having an issue. First lesson, if someone is acting up and not responding immediately to your commands, don’t just shoot them or beat them senseless.

Next I would build up the social services end - they would be tier 2 support for the law enforcement to hand off to. Obviously, there would need to be something next - care and treatment.

Lot’s to do, lot’s to do!