I know you may think it is old news but I just saw “Silver Linings Playbook.”  It was beautifully acted by the entire cast.  Seeing the movie also highlighted the problems with our present mental health system.  Parents frustrated, loving, scared and in the end supportive.  Their son struggling with his illness, in denial but finally realizing he needs to take his medication and see his psychiatrist.  I loved the ending. Pat had a supportive psychiatrist and family.

Mental Health Care took a dramatic turn in the 80’s when Jimmy Carter was not re-elected and Ronald Reagan won.  This article in Salon” Ronald Reagan’s shameful legacy: Violence, the homeless, mental illness “ is an enlightening piece about what happened after Reagan took office. Carter had signed the Mental Health Systems Act, which had proposed to continue the federal community mental health centers (CMHC).  When Reagan and the Republicans came into office in 1981, the bill was discarded and all the funds for the CMHC dried up. Also, we started to close down mental health hospitals.  This meant patients once hospitalized had no place to go. When I was in Maryland, many of my patients lived in the board and care facilities in the community.  These patients had been housed in the State Mental Hospital.  They each had a case manager who accompanied them to their appointments and monitored compliance with medication.  According to a report from the Treatment Advocacy Center (http://www.treatmentadvocacycenter.org/index.php), in 2005 there were 17 public psychiatric beds available per 100,000 population compared to 340 per 100,000 in 1955. This represents a 95 percent reduction of available beds from 1955 to 2005 and this explains why severely mentally ill patients have few treatment options.

My patients were part of this change in mental health care and were for me not a challenge to care for. I was responsible for treating their high blood pressure, diabetes, doing the pap smears and ordering the mammograms.  I was their primary care doctor.   I had the schizophrenic female who had her hat stuffed with aluminum foil to prevent the signals from the aliens.  She heard voices but the medications controlled them. One patient spent the day walking back and forth across the town bridge but he was picked up at nightfall.  They were never homeless.  When they had setbacks, they went back to the hospital.  They were never incarcerated except for a brief period of time and then sent back to the State Mental Hospital.  One patient caused a scene in the local bank and threatened the teller.  He did not have a gun, the local police picked him up and he was readmitted. Another patient had an altercation with her landlord; she then barricaded herself in her apartment.  The police were called because she was screaming.  The officer called me to confirm she was not a threat to herself or others.  The door was knocked in and she was off to the hospital.

For a period of time, I was the medical consultant for the adolescent inpatient mental health unit.  I managed their medical conditions which included thyroid disease, medication side effects and broken bones. These kids were placed there because their parents were unable to care for them at home.  These adolescents were diagnosed and placed in a treatment program. Treatment included medication, daily therapy and school. Education was important. They had been expelled from school because of disruptive behavior but they were smart kids. The staff became surrogate parents helping each child cope with being there. Some often stressed over having to leave what became for them a safe place.  Each child had a story but it was obvious their parents needed help.  It was difficult for me. We had a session on why hitting the wall with your hand was a bad idea after the Emergency Room doctors said I had to do something about the number of visits for “Boxer’s Fractures.” This fracture of the knuckles of the index and little finger happens when you punch a wall or a jaw.

I remember openly discussing the patients I referred to local psychologists, therapists and psychiatrists.  Now, they go into a black hole and I am told by the clinicians they cannot tell me anything and I have to ask the patient.  I do not get updates on medications or changes in status.  The patient has to tell me. So, I understand the frustration the families face.  I watched the 60 Minutes interview of Virginia State Senator Creigh Deeds.  It was heartbreaking for me to watch knowing what a shortage of providers and resource we have for those who have mental health issues.  I have had to treat my patients who parents like him stressed with high blood pressure and uncontrolled other medical conditions exacerbated by stress.

We have to agree that these patients have a chronic medical condition that needs the same intense monitoring and treatment as diabetes and hypertension to prevent complications.  We need to remove the stigma and start to provide integrative services that allow sharing of information and coordination of care between all the care providers.

The new model is Integrated Care. It integrates mental healthcare and general healthcare. This model especially includes family members who are the care givers. Mental Health providers are more concerned about privacy and are critical of this model.  I see no difference between caring for a patient with Alzheimer’s disease.  What would happen if we told the family we can’t discuss the case without the patient’s permission or we can’t force the patient to take medication that would treat high blood pressure, agitation or aggressive behavior?

We must have a serious shift in our care model. Emergency Rooms are not the place to get medications adjusted. Jails and prisons are not equipped to provide long-term care for these patients. Parents are not equipped and should not have to risk harm to prevent their loved ones from being homeless or killed because they are off their medications.  I speak as a family member with a relative with a chronic mental health condition. It is not easy for the parents who have to talk with police or monitor medications.