Addressing the Care Disparities of Living Well with Severe Mental Illness

1. Addressing the Care Disparitiesof Living Well with Severe Mental Illness Suzanne Vogel-Scibilia MD Asst Clinical Professor: University of Pittsburgh Boardmember: American Association of Community Psychiatrists

2. THE PERFECT STORM : Crisis in US Mental Health

3. Service Infra-structure Deficits Access to care Lack of Parity Lack of Safe Havens for the SMI Trans-institutionalization Fragmented care Consumers without a voice. Criminalization Entitlement Cutbacks Lack of Medical Care IOC/Mental health Courts Housing cutbacks For Profit Managed Care Lack of Central Accountability in Government WHAT IS THE PERFECT STORM?

4. “We are all ignorant; just about different things.” -- Mark Twain

5. What is the Mental Health Reform History? • 1960-1980 Liberal Era – de-institutionalization/restrictive commitment/ NGBRI or diversion to treatment. • 1980 onwards; Neo-conservative Era – increased criminalization/commitments – protect the community not individual rights. • Back to the Asylum; Fond &Durham; Oxford Press 1992

6. Deinstitutionalization • Mixed conscience and convenience • Promised infrastructure never completed. • Acute care model for community mental health – not treatment of persons with chronic mental illness. Hospitals/ intense crisis services monetary black holes; resource allocation shortages; privacy concerns block data collection; inability for severely ill consumers to advocate for themselves; “civil liberties” without safety/protection; coercive control not engagement . Criminalization.

7. Providers/outpatient services expansion Funding care appropriately More Crisis Services Safety Net Resources Alternatives to Traditional Public Providers Address Medical/Psychiatry Interface/ Medical Care Mental Health Parity In North Carolina : W-S Journal 2005 – “the missing factor is money.” NAMI Grading the States

8. A Great Social Experiment – De-institutionalization to Trans-institutionalization • Three major concepts in mental health care of persons in crisis – moral treatment, mental hygiene and then the community health movement. • Trans-institutionalization as a repetitive force – first almshouses to state mental hospitals and now state mental hospitals to jails and prisons. Full circle.

9. Deinstitutionalization

10. Topeka State Hospital - 1949 • Menningers of Topeka began administrating Topeka State Hospital after reports of deplorable conditions. • Pre – chloropromazine, pre- Medicaid entitlements, and pre-community psychiatry movement - the Menningers were able to transition many people to the community – this was accomplished by concentrating expenditures on clinical personnel…. • Burnham JC Persp Biol Med 2006 Spring 49(2) page 220-237.

11. Brewster v. Dukakis – knowledge gained • 1978 consent decree affecting one section of Massachusetts produced a huge reduction in patients able to receive care at a state hospital where significant bed contraction had previously been undertaken. • Less census reduction occurred than hoped – mostly clients with MR or of geriatric age – less effective with persons with long-term CMI and new chronic patients. • Many required repeated hospitalizations despite a huge number and variety of community-based services. • Geller JL; Am J Psych 1990 Aug;147(8) p982.

12. Criminalization of Persons with Mental Illness in the US • Markowitz, F Criminology, 2006 Volume 44 (1) page 45. • As state hospital beds contract, homelessness and criminalization increases proportionally. • Extended acute care beds do not reverse this trend.

13. De-Institutionalization Difficulties • Undertaken despite marked community service needs. • Undertaken with acute shortage of providers of care in many areas. • Undertaken into the general population that has a lack of tolerance and a lack of any other types of “asylum” to harbor people in crisis. This leads to trans-institutionalization into jails, prisons and the streets.

14. Who/What Are The Culprits? Increasing Homelessness Health Coverage either inadequate or nonexistent Medicaid Reform (restricted formularies, preferred drug lists) Managed care corporations (HMOs) Negative Side Effects of Medications Selectivity of private psychiatric hospitals and care providers in treatment Anosognosia Mistakes Made by Clinicians Stigma/Lack of Safe Havens

15. No Mercy “Mercy Bookings” often put persons with mental illnesses at greater risk. As Jails are often Characterized by: - Inadequate Mental Health Treatment - Increased Potential for Victimization - Lack of Discharge Planning

16. Sequential Intercept Model • Munetz M and Griffin P Psych Serv • Elaborates a strategy for policy makers and clinicians to appreciate the points in a consumer’s interaction with the criminal justice system where interventions could occur to receive psychiatric treatment diversion and/or re-entry. Positively embraced in the US.

17. Crisis in Mandarin Chinese:

18. Crisis Intervention Teams – Memphis Model • Educational Trainings Signs and Symptoms Officer Safety De-escalation techniques Screening for medical problems Site Visits Intervention techniques Service education Presentation by consumers/FM

19. Memphis Model - CIT • Demonstrated to have less injury/death to consumers and officers when officers trained in CIT. • Multiple other CIT models exist in US. • Another model has social workers who ride with police • Another model has mobile crisis teams who show up when called by police. • CIT models exist more commonly in urban than rural areas of the US.

20. Airport Crisis Intervention : • 1980’s Help is on the way • 1990’s Help but you are charged • 2000’s You get shot – Miami Tarmac incident.

21. Outpatient Commitment – PLC or TLC? • PLC – persuade, leverage, coerce • TLC – tender loving care improved patient centered tx entitlements and service delivery assertive outreach - rather than penalties or conditions on access to services - to induce compliance.

22. Does Outpatient Commitment Work? • Catch too many Dolphins with the Tuna. • Coercive/Lack of Dialogue with consumer • Not utilized because it is time consuming/costly/providers become police • Public Relations Nightmare – for consumers and the community • Effects Voluntary Supply and Demand for services

23. IT IS NOT JUST ABOUT MENTAL HEALTH – IT IS PHYSICAL TOO…… THE PERFECT STORM……

24. CATIE Study produced a dire warning….. • Using the Framingham coronary heart disease risk data for the general population and comparing it to the same risk factors for 689 persons participating in CATIE, the ten year coronary heart disease risk was elevated in males (9.4% vs 7.0%) and females (6.3% versus 4.2%) in persons with schizophrenia.

25. THE DEPTH OF THE PROBLEM: • SMOKING - 68% versus 35% • DIABETES - 13% versus 3% • HYPERTENSION – 27% versus 17% • LOWER HDL (good) CHOLESTROL – 43.7 versus 49.3.

26. WHAT IS METABOLIC SYNDROME?????? • LIPID ABNORMALITIES – TRIGLYCERIDES AND CHOLESTEROL • ELEVATED BLOOD PRESSURE • ELEVATED BLOOD SUGAR • PRO-COAGULATION • PRO-INFLAMATION Waist circumference is an indicator of free fat mass…..

27. STRATEGIES TO ADDRESS METABOLIC SYNDROME – • ADDRESS THE PROBLEMS THAT DEVELOP See the doctor; take the treatment. • ATTACK THE “COMMON SOIL” THAT CREATES THE PROBLEM Big problems like smoking, or weight Little problems that count like dental hygiene.

28. WHAT CAN WE DO ABOUT THIS? • THE RESEARCHER, THE CARDIOLOGIST, THE VERY LARGE CANADIEN EXPERT AND MYSELF AT THE APA…. • IF YOU DON”T TAKE A TEMPERATURE - YOU CAN”T FIND A FEVER…. (the importance of monitoring)

29. Obtain a metabolic panel, complete blood cell count, and lipid panel every six months until your medication regimen is stable, and you are adhering to the testing. • Check your waist circumference – 35 inches or less for women and 40 inches or less for men. • Calculate your BMI – 25 to 30 is overweight. 30 and above puts one at metabolic risk.

30. Follow the recommendations in Hearts and Minds….. Exercise Cut down on the smoking Follow a diet that is reasonable Set small, incremental goals Remember little things and little changes make the difference. Seek treatment for BOTH types of illness!

31. Why is Self-determination Linked to Recovery? Trauma theory of mental illness (NAMI Programs) Instillation of hope and optimism (Resnick SG et al – Psych Serv 2004 May 55:5 page 540-547). Transformation of the self concept into a “more functional” sense of self. (Davidson & Straus –BJ of Med Psychology 1992 June 65-part 2; 131-145 ) Empowerment and consumer driven care helps to heal the psychological wounds of mental illness and assuage the feelings of guilt and powerlessness that is the first-person experience of these brain disorders.

32. Promising Interventions Crisis Intervention Team training (CIT) Mental Health Courts Probation Officer Mental Health Specialists Discharge Planning/Re-Entry Assertive Community Treatment Clubhouses