Tuesday, September 05, 2017

My Friends in High Places on the HHS's Interdepartmental Serious Mental Illness Coordinating Committee




Move over, there's a new federal mental health committee in town.  The department of Health and Human Services has formed the Interdepartmental Serious Mental Illness Coordinating Committee My friends Pete Earley and Elyn Saks are both on the committee, and Pete has been blogging about the committee for a couple of weeks now-- the good, the bad, the ranting, and the missed opportunities after the first day of meetings last week.  You'll be pleased to know that I didn't miss the opportunity to put in one of my concerns: I emailed Pete and Elyn to tell them how pre-authorization for medications is having a negative impact on the practice of medicine, and psychiatry in particular.  Nothing new, but it's a topic that every medical organization has been fighting for years and nothing ever gets done, so I thought I would ask that it be brought up again.  My thanks to Pete for including my concern on one of his blog posts

When people talk about serious mental illness (SMI), I always have the same reaction: What is it?  From what I can tell,  one gets the designation with a diagnosis: schizophrenia or bipolar disorder or severe depression.  Apparently it's not about illness chronicity or impairment, or spending time in institutions, or whether an illness responds to treatment.  I'm always at a loss: as I've said before, our diagnoses are not precise, prognoses can be wrong, and people can be very sick at one point in time and very well at others.  So while 1 in 8 adults are on SSRI's, 1 in 5 suffer from an episode of mental illness during the course of a year, and half of us will have an episode of mental illness during the course of a lifetime, these people with serious mental illness are quite few: 4.5 million Americans.  I wish these people wore signs so we knew who they were and could divide the resources appropriately. 

That said, the conversation about SMI often flows to the topic of involuntary treatment.  It goes along the lines of ...if only.  If only we could force sick people to get treatment then they wouldn't end up in jails and prisons.  If only we could force sick people to get treatment then they wouldn't be homeless, on the streets, committing violent crimes and mass murders.  If only.  If only it were that simple.  What gets missed is that addiction co-occurs with mental illness, and poverty confounds it all --so if only people were not raised in poverty, exposed to violence, and addicted to drugs and alcohol, then so many fewer people would be living on our streets, in our jails, and committing acts of violence.  If only. 

There is another problem with this kind of thinking.  It divides us into those who are FOR and those who are AGAINST forced care.  It leaves out the key factors of Access to Treatment and Engagement.  Not everyone who needs care can get it: we have a psychiatrist shortage in this country.  And not everyone who says No to treatment will continue to say No, but if they do say No and the response is to have guards brutally tackle them and inject them with sedating medications, then there is a good chance that future efforts at engagement may be met with resistance.  Sometimes, it helps to meet people on their own level, to get to know them, to let them become comfortable and trusting, and then some of these people who initially said No may become agreeable to getting care. 

The argument goes that those who refuse treatment have an inability to see they are sick, that this lack of insight it a symptom of the illness, and therefore it is a medical issue, not a civil rights issue.  I hesitate to use the term "anosognosia" because the word has become so politically loaded; those who use it believe that involuntary treatment is often the only option. I would contend that people who don't believe they are ill can often be engaged in treatment.  I'm not one for standing in someone's face and asking, "Do you know you have a mental illness?"  Instead,  people will often take medications because they feel better on them, because they are good patients who do what the doctor says, because a family member asks them to, or because while they may not think they are mentally ill, they do notice that life goes better if they swallow a pill everyday. 

Yes, I do know that there are some very sick people who are offered quality care and who just can't be engaged, and who would benefit from care that is not voluntary.  But it's not a clear pro-force/anti-force picture, and it's always better to work with a patient if you can.

So thank you to my friends in high places who are giving their time, energy, and efforts to helping our federal government figure out how to help people with serious mental disorders.  I look forward to reading more about your endeavors!

7 comments:

Anonymous said...

The whole "end the stigma of mental illness" movement encourages people to speak more openly, but also to adopt a particular language of confession: the I HAVE A MENTAL ILLNESS speech. I think it comes from AA, personally -- acknowledging you have a problem is Step One.

But do people have to acknowledge (even privately) that they have "mental illnesses" in order to recover? If recovery is what we want, then we have to allow many paths to that -- it's the recovery that counts, right?

Unknown said...

I've heard the term 'severe and persistent mental illness" used to differentiate from 'ordinary mental illness" - implicit is that ordinary mental illness is 'not as bad"

Its a brain based biological disorder that affects the patient's physical, psychological, social, emotional, and developmental processes.

So is addiction. Genes and environment both play a role, diagnosis and treatment are imprecise, and they often overlap. In both diagnostic groups the decision is made by looking at a variety of different symptoms and behaviors over time, and the degree of interference they cause is all those processes in a human life.

The huge stigma about brain diseases is where it was with epilepsy before effective dx and treatment was identified - and now some pt can have the disease eliminated completely.

Forced treatment - meds, involuntary placement in a supposedly secure and therapeutic environment...sometimes it is the last resort...sometimes it helps, sometimes not.

I think brain disorders other than malignancy are chronic, waxing and waning over time, and fully understood or predicted.

Non medical people would be shocked that there is a lack of consensus of many dz/treatments across the country, and that many meds and treatments once thought very effective/curative are not.

Better access to GOOD treatment is an idea we all should get behind....

David J. Littleboy said...

Wow. One in 8 Americans are on SSRIs. That's seriously crazy. SSRIs may or may not be a useful tool for people with severe depression (the effect size of SSRIs goes way down as the number of symptoms goes down) but the side effects are the same. Given that the whole concept of SSRIs is now considered to be completely wrong (depressed folks have too much, not too little serotonin), this is doubly insane.

Oh, well. It's not as bad as the opioid epidemic...

Mental Illness Policy Org said...

This may help you as it defines serious mental illness. https://mentalillnesspolicy.org/serious-mental-illness-not/

There is a more complete explanation of multiple efforts to define it in Appendix A, of "Insane Consequences: How the Mental Health Industry Fails the Mentally Ill"

I respectfully disagree that easier access to civil commitment before people become dangerous is the major advance that people who advocate for the seriously mentally ill want. I for one want to get people out of jails and shelters. More hospitals, easier admission, and longer stays to stabilize would help. So would community programs willing to provide services to the seriously mentally ill, rather than just providing stigma and MHFA education to the public.

Dinah said...

> No one needs to announce "I have a mental illness." People are welcome to quietly get help without being a poster child for anything. I don't routinely ask my patients "Do you believe you are mentally ill?" I would guess that most would say "no." People should live their lives fully and do what they need to do to make that happen.

>SSRI's work and are not anything like opiates. Many people take them for anxiety, or premenstrual/perimenopausal symptoms. Every patient gets to decide if they are better off taking them or not, and people who have side effects sometimes decide that the cure is worse than the problem, and that's their perogative.

>I know the 'definition' of SMI. It just doesn't mesh with my clinical experience of how many people present. There are certainly those who are chronically disabled and symptomatic and unable to function (even with treatment), and we all agree they are severely and persistently ill. But many people have episodic disorders that induce severe suffering, transient disability, and suicidal thoughts, and I don't think it makes sense to funnel resources away from anyone who feels they need help. I have been at this for a long time, including 20 years in community clinics. We all want easier access, better treatments, better community services.

R. said...

As a patient, my concern with dividing people into "seriously mentally ill" and "not seriously mentally ill" is that it can become a way of telling people that they are not bad enough or disabled enough to deserve treatment. While there certainly are people whose symptoms come on suddenly and are immediately disabling, I suspect that for many people it's a more gradual transition. I wonder whether we could actually save money and resources by making sure we effectively treat people while their symptoms are less severe, thereby keeping them from entering the population of seriously mentally ill or seriously impaired. From what I have seen (although since I am not a mental health professional, this is mostly second hand and summaries of research studies) the sooner a patient accesses treatment after symptoms emerge, the more manageable in the long term their symptoms will be.

David J. Littleboy said...

Dinah wrote:

> SSRI's work and are not anything like opiates. Many people take them for anxiety, or premenstrual/perimenopausal symptoms.

Here are two Science Daily articles that indicate that there's something seriously wrong with antidepressants.

1. https://www.sciencedaily.com/releases/2015/02/150217114119.htm

This is the by now well-known point that depressed patients have excessive amounts of serotonin and antidepressants make that worse. This means that every article ever written that uses the term "chemical imbalance" regarding serotonin and antidepressants is simply, completely, and dead wrong.

2. https://www.sciencedaily.com/releases/2017/09/170914152238.htm

This is a more recent result, showing that antidepressants are as bad for you as a reading of the side effects would indicate. Now, a 33% increase in the chance of death is nowhere near as bad as it sounds: it means that in a population of 1000 patients for whome under no treatment 3 might die of all causes over the next 6 months, now 4 will die.

The idea that 1/8 of the US population is on antidepressants now looks even more problematic to me than it did before: while a 33% increase of chance of death in the group of patients a given psychiatrist is treating is small, at the population level this is actually killing a significant number of people. Sure, it's not quite as insane as the opioid epidemic (the only similarity here is that MDs are prescribing both these medications in situations when they shouldn't be and people are dying), but getting up there.

Maybe there are cases where opioids should be used and maybe there are cases where antidepressants should be used. But 1/8 of the population? That's problematical.