From Cell to Cell: Failures in Mental Health

Sep 05 2012 Published by under General Health

Paul Gionfriddo, a former legislator, helped shaped Connecticut's mental health programs:

I was twenty-five years old in 1978 when I entered the Connecticut House—two years younger than Tim is today. I had a seat on the Appropriations Committee and, as the person with the least seniority, was assigned last to my subcommittees. “You’re going to be on the Health Subcommittee,” the committee chairs informed me. “But I don’t want to be on Health,” I complained. “Neither does anyone else,” they said. So that’s where I went. Six weeks into my legislative career, I was the legislature’s reluctant new expert on mental health.

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The 1980s was the decade when many of the state’s large psychiatric hospitals were emptied. We had the right idea. After years of neglect, the hospitals’ programs and buildings were in decay. But we didn’t always understand what we were doing. In my new legislative role, I jumped at the opportunity to move people out of “those places.” Through my subcommittee, I initiated funding for community mental health and substance abuse treatment programs for adults, returned young people from institution-based “special school districts” to schools in their hometowns, and provided for care coordinators to help manage the transition of people back into the community.

Unfortunately, he now realizes that his efforts included many mistakes, documented in the saga of his schizophrenic son, Tim, who now lives on the streets of San Francisco when he can stay out of jail:

First, we didn’t understand how poorly prepared the public school systems were to educate children with serious mental illnesses in regular schools and classrooms. Second, we didn’t adequately fund community agencies to meet the new demand for community mental health services—ultimately forcing our county jails to fill the void. And third, we didn’t realize how important it would be to create collaborations among educators, primary care clinicians, mental health professionals, social services providers, and even members of the criminal justice system, if people with serious mental illnesses were to have a reasonable chance of living successfully in the community.

He discusses in detail the travails of having a child with mental health problems, including misdiagnosis and the lack of coordination of care and support. When his insurer finally approved "enhanced services," it also informed them that their son had exhausted his lifetime benefits.

What has the representative learned during his 25-year journey with a schizophrenic child? And how would it change his approach to these problems?

We can do better. And this is how I’d do it if I were a legislator today.

I’d mandate—and provide funding to ensure—that every teacher receive training in recognizing symptoms of mental illness in students and in how to handle students with a mental illness effectively. I’d require that all pediatricians be trained to make early and periodic screening for mental health concerns a regular part of well-child exams. I’d require school administrators to incorporate recommendations from pediatricians and mental health professionals into students’ IEPs.

I’d implement the Affordable Care Act’s Medicaid expansion for single adults without delay in 2014 and put much more money into community mental health services. States must stop cutting mental health funding, as they did from 2009 to 2012 when they cut funding by $3.4 billion, and start recognizing the importance of preventing and treating mental illnesses. Mental illnesses won’t disappear by pretending they’re a failure of personal will any more than congestive heart disease will disappear by pretending people diagnosed with the disease could run a marathon if they’d only try.

I’d integrate how services are delivered by funding collaborative community mental health programs and have them run by mental health professionals. I’d include services for chronically homeless people under this collaborative umbrella.

At the same time, to clear our county jails of people with mental illnesses, I’d get rid of laws targeting homeless people, such as those against loitering or sitting on a sidewalk. And I’d make sure that there was supportive short-term and long-term community housing and treatment for everyone needing them. Both were promised almost fifty years ago in the federal Community Mental Health Centers Act of 1964—promises that were broken when it was repealed in 1981 and replaced by a block grant to states.

Finally, I’d insist that the spirit and mandates of the federal Mental Health Parity Act of 2008 be enforced uniformly across the states. Not only should every state insurance regulator require insurers to cover mental health services without high deductibles and copays or arbitrary limits on counseling sessions or hospital days—as the act mandates—but they also shouldn’t allow an insurer to single out mental health professionals to receive lower reimbursements, as happened here in Florida in late 2011. People like Tim have waited far too long for fairness; all payers in every state—including Medicare, Medicaid, and all private insurers—should pay equitably for preventing, evaluating, and treating mental illness.

We would never treat any other chronic, prevalent disease the way we treat mental illness. Mental illnesses cost as much as cancers to treat each year, and the National Institute of Mental Health notes that serious mental illnesses can reduce life expectancy by more than twenty-five years. That reduction in life expectancy is almost twice the fifteen years of life lost, on average, to all cancers combined. When Tim needed hospitalization, an insurer sent him to drug rehab. Imagine the outcry if the insurer had tried to send a smoker with lung cancer who needed hospitalization to drug rehab.

Perhaps even if Tim had gotten earlier, more effective, and better integrated care, he still would have become homeless. But I don’t believe that, not even for a minute.

Like many other adults, Tim is where he is today because of a host of public policy decisions we’ve made in this country. It took a nation to get Tim there. And it will take a national commitment to get him back.

The full story appears in the current issue of Health Affairs; you can listen to it as a free podcast here.

 

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