More trained clinicians, research urged for mentally ill

At a Capitol Hill forum, physicians and parents of mentally ill children discuss disparities between mental health treatment and other medical care.

By — Posted April 1, 2013

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Mental health professionals and other participants at a recent congressional forum said a dearth of trained physicians and the presence of too many regulatory barriers are some of the main factors preventing severely mentally ill children from getting the medical help they need.

The March 5 bipartisan forum was convened by Rep. Tim Murphy (R, Pa.), who chairs the House Energy and Commerce oversight and investigations subcommittee, to discuss what federal resources might be needed to prevent another incident such as the mass killings at Sandy Hook Elementary School in Newtown, Conn. The forum focused on severely mentally ill individuals who could be prone to violence but who often don’t receive the timely treatments available to those with other medical emergencies.

“Why do we treat the head differently from the rest of the body?” asked Pete Earley, an author and the parent of a son with mental illness, during the forum. These disparities often mean that mentally ill patients can wait weeks, months or sometimes even years to get needed care and social services. In his son’s case, “it took nine years to get meaningful treatment,” he said.

The Affordable Care Act has taken some necessary steps to expand coverage for mental health patients, said Rep. Henry Waxman (D, Calif.), the top Democrat on the Energy and Commerce panel, during the forum.

A final federal rule setting minimum coverage requirements for qualified health plans starting in 2014 bolsters essential benefits for mental health services, and it specifies that a federal mental health parity law will apply to qualified health plans on and off the ACA’s health insurance exchanges. After the Newtown incident, the American Medical Association and other medical organizations called for improved access to mental health services in letters to President Obama and lawmakers on Capitol Hill.

But the ACA won’t solve all the problems related to mental health treatment, Waxman said. “There is an unwarranted stigma attached to seeking help for mental illnesses. There are shortages of facilities, beds and caregivers to provide treatment.”

Primary care’s training shortfall

Only 7,500 child psychiatrists are available in the U.S. to care for 15 million children who have mental disorders, said Harold Koplewicz, MD, president of the Child Mind Institute. “The math doesn’t work. The only way it’s going to work is if pediatricians and primary care physicians, the primary people who take care of these kids,” are better trained.

There’s never been a better time to bolster this training under the auspices of health system reform, Dr. Koplewicz said. For example, he said, pediatricians who become certified or better educated on these disorders could in turn get paid at higher rates for treating these patients.

The country is never going to produce enough child psychiatrists, Dr. Koplewicz said. He suggested that the solution is to find social workers and others who want to be trained in evidence-based treatments who can work under the supervision of psychologists or psychiatrists.

Another area seen as lacking is research on these disorders. “Big Pharma has stopped investigating treatments for the central nervous system, and, frankly, the National Institute of Mental Health needs more funds to really look at child mental illness or pediatric neuroscience,” Dr. Koplewicz said. The fact that 75% of serious psychiatric illnesses occur before the age of 24, and 50% before age 14, points to a need to identify these children early and treat these diseases effectively as soon as they show up, he said.

Police, not caregivers, handle patients

Participants at the Capitol Hill forum stressed how the severely mentally ill often are dealt with through the criminal justice system instead of receiving treatment at hospitals or by mental health care professionals.

75% of serious psychiatric illnesses occur before age 24; 50% occur before age 14.

Earley described how he was told he couldn’t get help for his son at a Virginia hospital because his son didn’t meet state “imminent danger” criteria. Earley said that medical staff told him, “Bring your son back if he tries to kill you or someone else.”

Handling mentally ill patients this way isn’t just costly, it’s also ineffective, said Thomas Insel, MD, director of the National Institute of Mental Health. “What you end up with is a series of precipitous visits. It’s just not the way to manage any serious medical problem.” Several of the forum participants emphasized that the police don’t always know how to respond to these situations.

Pat Milam, whose son Matthew took his own life after a long bout with mental illness and previous suicide attempts, said he tried to alert law enforcement officials about gasoline cans and propane tanks he had found in his son’s room. The response he received was that Matthew could not be charged because he’d done nothing illegal. Milam told the forum that the 24-year-old eventually took his life using a homemade explosive device.

Milam said physicians wouldn’t discuss his son’s care with him because of privacy restrictions imposed by the Health Insurance Portability and Accountability Act. The family is an essential informant of a mentally ill child’s condition, “but the HIPAA law says that you can’t talk,” said Michael Welner, MD, a forensic psychiatrist who’s the founder and chair of the Forensic Panel. The result is the family takes home a patient who is severely ill without having access to the patient’s doctor, and with no interim manual for mental health training, Dr. Welner said.

Liza Long, the parent of a son with a mental disorder, who wrote the widely read blog “I Am Adam Lanza’s Mother” after the Newtown shootings, called at the forum for a national commitment to end the stigma that surrounds mental illness. “As long as we keep treating mentally ill children and adults in prisons, it will be difficult if not impossible to achieve true parity between physical and mental health,” she said.

Long said her son Michael, who takes a variety of prescription drugs to manage his conditions, had a message for the forum’s participants: “Tell them that I’m not a bad kid. Tell them I want to be well.”

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How society perceives psychiatric issues

A Capitol Hill forum on violence and the severely mentally ill drew testimony about the stigma that surrounds the diseases, as well as the lack of parity in access to care between those seeking mental health care and those who need medical treatment for physical problems. A recent Kaiser Family Foundation poll of more than 1,200 adults concluded that:

  • 76% thought the seriously mentally ill experience discrimination. People with serious mental illness were second only to immigrants as the group perceived to be experiencing the most discrimination.
  • 45% of those living in households where someone received mental health care said they observe a significant amount of prejudice against the seriously mentally ill. Among those who have not dealt with mental illness in their households, only 35% felt this way.
  • 66% said they would be uncomfortable if a person with a serious mental illness worked in their children’s school.
  • 47% said they would feel uncomfortable living next door to such an individual.
  • 41% said they would feel uncomfortable working with someone who had a serious mental illness.

Source: Kaiser Health Tracking Poll, Kaiser Family Foundation, Feb. 27 (link)

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