Addressing the Care Disparities
of Living Well with Severe
Mental Illness
Suzanne Vogel-Scibilia MD
Asst Clinical Professor: University of Pittsburgh
Boardmember: American Association of Community
Psychiatrists
THE PERFECT STORM : Crisis in
US Mental Health
WHAT IS THE PERFECT
STORM?
• 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
“We are all ignorant; just about different things.”
-- Mark Twain
What is the Mental Health
Reform History?
• 1960-1980 Liberal Era – deinstitutionalization/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
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.
NAMI Grading the States
• 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.”
A Great Social Experiment – Deinstitutionalization to Transinstitutionalization
• 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.
Deinstitutionalization
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.
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.
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.
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.
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
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
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.
Crisis in Mandarin Chinese:
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
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.
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.
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.
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
THE PERFECT STORM……
IT IS NOT JUST ABOUT
MENTAL HEALTH – IT IS
PHYSICAL TOO……
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.
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.
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…..
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.
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)
• 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.
• 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!
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.
Promising Interventions
•
•
•
•
•
•
Crisis Intervention Team training (CIT)
Mental Health Courts
Probation Officer Mental Health Specialists
Discharge Planning/Re-Entry
Assertive Community Treatment
Clubhouses