s/o Improving Mental Health Care

[TechWife]

In a few other threads, people have mentioned the need to improve the mental health care system in the US. I thought it might be an interesting discussion to have separate from the other discussions going on.

 

Here is some food for thought.

 

"While the federal government dedicates $130 billion towards mental health each year, the so-called 'mental health system' is best described by its deficits. To name just a few:  There is a nationwide shortage of nearly 100,000 needed psychiatric beds.  Three of the largest mental health “hospitals†are in fact criminal incarceration facilities (LA County, Cook County, and Rikers Island jails).  Privacy rules that frustrate both physicians and family members generate nearly 8,000 official complaints yearly.  For every 2,000 children with a mental health disorder, only one child psychiatrist is available.  The leading federal mental health agency does not employ a psychiatrist."

 

 

 

 

[SKL]

We definitely have room for improvement.

 

I support an organization that is not run by the government, which provides mental health services to thousands of individuals and families in my state.  These include services for parents to improve their parenting, respite, foster care and fostering support, daycare, counseling, mentoring, residential treatment, self-contained school, group homes, support for newly independent college students, and more.  The services are provided in a positive, respectful, and loving atmosphere which might not be attainable in a government-funded operation.  I don't know how common this type of organization is across the country.

[Joker]

We've been dealing with bad mental health care for the past year. It's ridiculous how long it takes to get into a psychiatrist or a psychologist. We recently moved and have had to take appointments with a not yet licensed therapist because that is all available at the moment. My teen wants help, has asked for help, and yet it is extremely difficult to get her that help. We finally have her a therapist but a psychiatrist is a long ways out even though her current medication isn't helping. Her pediatrician can try to change and work on the medications but it's not what dd needs. This has been the most frustrating and difficult thing I have ever been through, so I can only imagine what it's like for her and others in need.

 

 

ETA: We have offered to pay cash, not use insurance, use those not on our insurance, etc. but it changes nothing. There are just not enough psychiatrists to go around.

[goldberry]

I am deeply concerned about adults who are seriously mentally ill being allowed to refuse treatment until they either hurt themselves or others.  "We can't do anything until they actually DO something!"  I know it got to this point because supposedly there was abuse where people tried to get others committed, etc without real grounds.  But now it has gone the opposite direction where people know someone is dangerous but no one can do anything about it.

 

I don't know what the answer is.

[TechWife]

We definitely have room for improvement.

 

I support an organization that is not run by the government, which provides mental health services to thousands of individuals and families in my state.  These include services for parents to improve their parenting, respite, foster care and fostering support, daycare, counseling, mentoring, residential treatment, self-contained school, group homes, support for newly independent college students, and more.  The services are provided in a positive, respectful, and loving atmosphere which might not be attainable in a government-funded operation.  I don't know how common this type of organization is across the country.

 

How do they go about funding a system like this? 

 

A few years ago our state delegated mental health care to regional management organizations. They received a set amount of funds and if they didn't spend it all, they were allowed to put the money towards research or adding services at their discretion.  They did this to purposefully decentralize the decision making so each area could provide the type of services needed by their population. This was supposed to encourage them to be cost effective. Some regions banked the money for future expansion (saving towards buildings, major upgrades). This year, the state cut the funding to the regional groups. They are not budgeting enough for them to meet operating expenses. The reason? They saved too much money. They are expected to take the shortfall out of their savings. Therefore, there will now be no money for expansion or future improvements in those regions. Regions that don't have savings to draw from will likely have to cut services. There's no telling what will happen next year. 

 

I'm also curious to know how the services are accredited and evaluated. Are they held accountable by a board of directors? Who is on the board of directors? How can you tell that the service is provided in a "positive, respectful and loving atmosphere?"

 

What is the population they draw from? Do they accept insurance? Are these services available to indigent patients or is it a private organization? 

 

Info would be greatly appreciated. 

[TechWife]

There are just not enough psychiatrists to go around.

 

I wonder what could be done to remedy this. Do you live in an urban area or a rural area? I wonder if it would be in any way effective for someone (hospitals, states, who?) to start an education loan forgiveness program for psychiatrist if they will work in an underserved area for a certain length of time. The longer they serve in an area, the higher % of their educational loans are paid off, maybe? 

 

How would hospitals go about encouraging more physicians to enter psychiatric practice? 

 

What about therapists - there are many different types of therapists and different training programs. Is there a way to recruit people to those fields as well? 

[Joker]

I wonder what could be done to remedy this. Do you live in an urban area or a rural area? I wonder if it would be in any way effective for someone (hospitals, states, who?) to start an education loan forgiveness program for psychiatrist if they will work in an underserved area for a certain length of time. The longer they serve in an area, the higher % of their educational loans are paid off, maybe? 

 

How would hospitals go about encouraging more physicians to enter psychiatric practice? 

 

What about therapists - there are many different types of therapists and different training programs. Is there a way to recruit people to those fields as well? 

 

We live in a suburb of a very large city. There are several other large cities we would drive to if care was offered. They aren't super close but not too far for the care either. My understanding has been many do not want to see pediatric patients anymore due to liability. They try to help and if/when a patient does something wrong they are blamed. I also have been led to believe the requirements necessary to see minors may be unsavory (length and debt) to many.

 

The ones we can get in to see the soonest we would pay OOP and it is high but they are still months away. The ones that will take our insurance are scheduling very far out.

[TechWife]

I am deeply concerned about adults who are seriously mentally ill being allowed to refuse treatment until they either hurt themselves or others.  "We can't do anything until they actually DO something!"  I know it got to this point because supposedly there was abuse where people tried to get others committed, etc without real grounds.  But now it has gone the opposite direction where people know someone is dangerous but no one can do anything about it.

 

I don't know what the answer is.

 

Actually, it has a lot to do with treating people with dignity and honoring their personal autonomy. We can't go around putting people into hospitals and drugging them without giving them a say in the matter. People should be treated in the least restrictive environment possible as well. 

 

States handle involuntary commitments differently as well. It is harder in some places than in others to prove that the person in question should be held for evaluation. 

 

I think another problem is availability of services. Where, exactly would folks who need assistance live? Often there is no availability for anything past an emergency 72 hour hold and many hospitals struggle to do that. Many times patients spend the entire 72 hours in the emergency room and therefore don't have access to a therapeutic environment during that stay. 

[SKL]

How do they go about funding a system like this? 

 

A few years ago our state delegated mental health care to regional management organizations. They received a set amount of funds and if they didn't spend it all, they were allowed to put the money towards research or adding services at their discretion.  They did this to purposefully decentralize the decision making so each area could provide the type of services needed by their population. This was supposed to encourage them to be cost effective. Some regions banked the money for future expansion (saving towards buildings, major upgrades). This year, the state cut the funding to the regional groups. They are not budgeting enough for them to meet operating expenses. The reason? They saved too much money. They are expected to take the shortfall out of their savings. Therefore, there will now be no money for expansion or future improvements in those regions. Regions that don't have savings to draw from will likely have to cut services. There's no telling what will happen next year. 

 

I'm also curious to know how the services are accredited and evaluated. Are they held accountable by a board of directors? Who is on the board of directors? How can you tell that the service is provided in a "positive, respectful and loving atmosphere?"

 

What is the population they draw from? Do they accept insurance? Are these services available to indigent patients or is it a private organization? 

 

Info would be greatly appreciated. 

 

The organization is old, but it has transformed a lot in recent years.  I don't know the details, but it seems about 10% of its costs are currently covered by charitable donations, plus they get some grants, and a lot is covered by operational revenues.  They are hired by some government-run agencies to assist certain people.  They also charge [subsidized] fees for some services.  Other things wouldn't make sense to charge for - helping young people transition from group homes to college etc.  Plus, the majority of families served are low-income.  Medicaid pays for some of the services.  I found an article that says they have a new operation set up to provide counseling services to people who aren't eligible for Medicaid, and that accepts insurance.

 

The organization is kind of a favorite in the local donor community, perhaps because of their openness including volunteer opportunities.  I have personally worked with them hands-on (as a volunteer and donor) over several years, and I've seen how the staff speak about and perform their work, how the clients are treated, and how they respond.  Also, when I've worn their t-shirt or mentioned them in the community, people have come up to me and told me of positive encounters they've had as a client, parent, or whatever.  I've never heard a negative word spoken about them so far.

 

They are licensed, accredited, audited, governed by a board of directors, and accountable to whoever has provided funding with strings attached (that would be any government-funded grant).

[Joker]

I also want to point out that our pediatricians and psychologists/therapists feel confident in regards to what medication dd should be taking but they aren't the ones who are supposed to be doing it. Is there maybe something that could be done to consolidate the job of a psychiatrist? Her therapist and doctor know her better than her psychiatrist but the psychiatrist is the most trusted and listened to in regards to medication. Maybe we need to change that. The psychiatrist is prescribing the medication but truly talks and sees her less than other professionals. The other professionals don't seem to want to take the responsibility, though. There are children that need help and aren't getting it and that should be most important.

[AimeeM]

I can't express how much I disagree with those who feel the mentally ill need to be forced into treatment. 

There is a REASON nobody can forcibly interfere until someone is hurt - nobody has the right to interfere, unless that person's choices, or actions, are interfering with the rights of others. 

Most "seriously mentally ill" people do not hurt others. 

If we assert that the government should be able to mandate mental health services, the line isn't even fine or gray - it's bold and unmistakable; there is nothing, at that point, preventing the government from interfering in the medical decisions of any citizen, if they decide that citizen can't, for whatever reason, make a reasonable decision. Want to stop chemo? Nope - you're obviously depressed over your condition and in no shape to make that decision.

 

My BIL is mentally ill. Paranoid schizophrenic I believe was the eventual dx. He's in jail currently for attempting to kill my sister, in front of their children. This happened during his "mandated treatment". 

If he had been kept locked up for the treatment, the same thing would have happened when he was released.

When medicated he felt fine - so "fine" that he didn't understand why he needed medication. So he'd stop the medication and stop going to therapy and the same thing always happened - he would slip back into paranoia. Back into the delusions. 

 

I have an uncle with the same dx as my BIL. Both are considered severely mentally ill, but only one was ever violent. My uncle, despite his dx, was NEVER violent. Seriously mentally ill, as qualified, but not a threat to anyone. 

 

ETA: I want to qualify that I love my BIL. Still. What he tried to do is horrible. No doubt about it. I knew him "lucid," though, and I love him. I knew him before his "trigger" happened, before it all started to decline, and I worry for him, even after what he tried to do. I wouldn't tell my sister that, but there it is. 

I want to say that I don't think there is a way to "fix" this system. I'm never going to agree that taking away a person's individual rights, just because they "might" be a risk to others, is okay. Never. I know too many people who are mentally ill and aren't violent and have never been violent, that despite my other experience (with a violent mentally ill person), I simply can't say that I wish he had been locked away before he got the chance to be violent. 

 

 

[SKL]

nm

[Joanne]

Some thoughts from a professional in the trenches with this population.

 

One BIG issue is that insurance companies have reduced the payments to Master's level clinicians to an absurd low. At this point, I am probably not going to pursue getting on insurance panels because they do not pay enough. Some are as low as $30 per session. In my private practice, I have to cover CEU, rent, license renewals, liability insurance, marketing (directory listings, website, other stuff), an online/cloud health record system. That is just the business cost - not shelter, food, clothing..... And let's not mention student loans. ;)

 

Not taking insurance means many people who HAVE insurance have less available choice. My specialty (substance abuse related clients) NEED the support, guidance and encouragement in order to build a healthy recovery or respond healthfully to a diseased family member. But they can't afford my pay-per-service and they can't afford to NOT use their insurance.

 

I "civil commit" people all weekend long at my psychiatric emergency room job. A "case" needs to be built by law enforcement, the psychiatrist AND the psychotherapist/social worker (me). It has to be backed by specifics, many many pieces of paperwork that support the need to take away the rights of the individuals. Many of our patients are uninsured, which leaves the county mental health hospital. That hospital often "doesn't have beds" which means people stay with us for hours. We are not a therapeutic environment. We are crisis care; stabilize, medicate, move them on. When we can't move them on, the acuity on the unit goes up. No one benefits.

 

Related to that is that HIPAA and confidentiality laws forbid me from talking to family members (for more information, for support, for discharge planning) unless the patient signs. This remains true even if the person is under an emergency detention order. The patient needs to sign "consent" for each individual who wants to talk to me. Ever try to get consent from a paranoid schizophrenic? :lol:

 

Law Enforcement is a crap shoot in terms of how trained and aware they are of mental health issues. Many, many Officers still believe that an adversarial relationship is the only way to "get through to them." They do not understand the medical model of mental illness. The younger the patient, the more likely "they" are to believe that the parents just need to {fill in the blank with some kind of punishment, often physical."

 

The Psychiatrists, the RNs, and even many of the therapists are absurdly and woefully under-informed regarding substance abuse. Since substance abuse (or process addiction) is co-morbid with many mental illness, it is imperative that they have evidence based, actual information in order to treat. They don't.

 

(As I have mentioned) - One industry that has grown since deinstitutionalization are group homes/personal care homes. They are unregulated, the people who own/run them often not licensed or trained. They are awful places, even the best of them. (Not unlike nursing homes). Only worse.

 

General stigma, misinformation, fear, myth - these impact the health of the population and the family and community members. The impact of this is not really quantifiable but clearly massive.

 

It's a mess.

 

Oh, and education level is a factor as well in terms of statistics and outcome.

 

 

[beaners]

We have been trying to find a therapy option for one of our teenagers. Because of his limited English, special needs, and likely mental illness in addition to a history of severe trauma, it has been extremely difficult to find an appropriate option. We aren't even discussing cost. There are just so few places that are able to say "yes" to more than one of the angles complicating treating him.

[TechWife]

I wouldn't want the government to be able to force treatment either, without some evidence that it was needed to protect others.  How that evidence might get to the authorities, without creating a slippery slope, would need to be explored.  Apparently right now there is no way to intervene and prevent a crime until after a crime has been committed, and then it becomes a prison service I guess.  That doesn't seem right either.

 

Well, there's one big problem with this - no one can read minds. The vast majority of people with mental illness are not violent, nor are they criminals. The purpose of mental health treatment isn't to prevent crime, it's to help people become healthy. I seriously cannot stress that enough. Mental health care isn't about crime prevention and it isn't about controlling people. It is mental health care. I think too often people look at the word as a noun and not a verb. Providing care (noun) must be administered with great caring (verb). 

[SKL]

nm

[SKL]

nm

 

[TechWife]

When I read "mental health" I was thinking of a much more broad thing including much less serious matters than those mentioned above. Not disregarding the issues mentioned up thread I would say it's annoying that so many therapists have such restrictive business hours. And insurance companies don't cover certain types of therapy sessions in some cases.

 

I do intend for this to be broad in scope - it is a broad issue. 

 

You have a great point about hours - it's hard for someone to work full time to get to appointments during regular business hours. Chronic health conditions, like depression or anxiety, can necessitate frequent appointments, especially at the start of treatment. It's not realistic for many people to get a couple of hours off of work on a weekly, bi-weekly or even monthly basis. Employers need people to work - that's why they hired them. Employees need to work - that's how they get money to live. 

 

Insurance is another issue - strangers deciding what appropriate health care is has long been an issue. The providers have to be willing to work with the patients' insurance companies and appeal everything in an attempt to get it covered. It takes a lot of time and money to do this - driving cost up. The cost must be passed on to the patient in the fee structure, as providers can't afford to do this for free. But, insurance companies limit what they will pay, so the provider is still out of funds. It doesn't encourage them to accept insurance payments at all (many don't), which perpetuates the problems of access and affordability. 

[TechWife]

Right, but since this was a spin-off to the other threads concerning crimes, I think it is relevant that sometimes people see signs of danger before a reportable crime is actually committed.  And it might be a good idea for those people to have some way to report what they think is a danger, before a crime is committed.

 

Yes, and it was spun off, by me, to intentionally address this issue apart from crime. If you would like to address the issue in that context, please do so in the other thread. 

[TechWife]

I read that the Virginia Tech shooter had a number of documented complaints against him before he committed his crime.  Is there anything to be learned from that situation?

 

Please take this discussion elsewhere. We are discussing improving mental health care, not mass shootings. There is a different thread you can go to if you'd like to discuss mental health care within the context of crime. 

[TechWife]

 Her therapist and doctor know her better than her psychiatrist but the psychiatrist is the most trusted and listened to in regards to medication. Maybe we need to change that. The psychiatrist is prescribing the medication but truly talks and sees her less than other professionals. The other professionals don't seem to want to take the responsibility, though. There are children that need help and aren't getting it and that should be most important.

 

I think this is an excellent point. Expanding the role of the psychiatrist (which would probably involve more and/or different training for psychiatrists), more case management that includes all care providers might both be options. 

 

Sadly, too much in health care comes down to money. 

 

Psychiatrists can't afford to take more time with their patients because of the way they are reimbursed. No one gets paid to do case management, except for those who work for the insurance company. I have a hard time believing that the case managers who work for insurance companies really have the best interest of the patient in mind because their role is primarily that of cost containment for the insurance company. 

[TechWife]

Some thoughts from a professional in the trenches with this population.

 

 

Will any of this help the issues you have laid out? I offer this not to turn towards politics, but to point out some proposed solutions and discuss their validity. I tried to find a summary, but it looks like it hasn't been written, so this is the full text. 

[TechWife]

 

 

Related to that is that HIPAA and confidentiality laws forbid me from talking to family members (for more information, for support, for discharge planning) unless the patient signs. This remains true even if the person is under an emergency detention order. The patient needs to sign "consent" for each individual who wants to talk to me. Ever try to get consent from a paranoid schizophrenic? :lol:

 

 

I've seen this play out in a few different scenarios. It is truly sad that the people who want to help are prevented from doing so by law. I can't imagine living with someone, wanting to help them, yet being prevented by law, from being an active part of the discussion. 

 

Edited to ask: How does one even begin discharge planning without involving a support system in many cases? It's a bit of a rhetorical question, I know. 

[wapiti]

I would like to see much, much more cross-specialty research into the biological causes of mental illness, particularly with regard to the connections between the immune system (gut) and the nervous system.  There is a lot of research going on, but from the standpoint of current clinical application, I think too much focus is misplaced on the brain as separate from the body.  The concepts are very complicated on a molecular level (e.g. hexosamine biosynthesis pathway, methylation; not even getting into the mysteries of the micro biome, the role of infections in a malfunctioning immune system, and specific genes that affect thousands of cellular processes) and I imagine it's not easy to be an expert in the chemistry and immunology but see the big picture at the same time.  We have a lot of puzzle pieces and yet what we don't know is a lot.

[itsheresomewhere]

One thing besides what has been mentioned I would like to see is no limits on insurance for help.  Limiting how many sessions that are covered is wrong.  Things can not be fixed magically in so many sessions.  A DF has been fighting the insurance company for a while now for their DD.  The insurance company feels that her disorder can be fixed in 20 sessions a year.  They are racking up quite a bit of medical debt to get the help she needs.  

[TechWife]

One thing besides what has been mentioned I would like to see is no limits on insurance for help.  Limiting how many sessions that are covered is wrong.  Things can not be fixed magically in so many sessions.  

 

I think that's a great idea. 

[Liz CA]

I am deeply concerned about adults who are seriously mentally ill being allowed to refuse treatment until they either hurt themselves or others.  "We can't do anything until they actually DO something!"  I know it got to this point because supposedly there was abuse where people tried to get others committed, etc without real grounds.  But now it has gone the opposite direction where people know someone is dangerous but no one can do anything about it.

 

I don't know what the answer is.

 

Not sure how this plays out in other settings but where I work, if someone voices suicidal or homicidal ideation, they can be sent for a psych eval and kept for 72 hours on a 5150 code.

 

[Katy]

HIPAA could be amended to include a clear exception for cases when someone is not capable of making decisions for themselves based on psychiatric or neurological status.

 

 

I also want to point out that our pediatricians and psychologists/therapists feel confident in regards to what medication dd should be taking but they aren't the ones who are supposed to be doing it. Is there maybe something that could be done to consolidate the job of a psychiatrist? Her therapist and doctor know her better than her psychiatrist but the psychiatrist is the most trusted and listened to in regards to medication. Maybe we need to change that. The psychiatrist is prescribing the medication but truly talks and sees her less than other professionals. The other professionals don't seem to want to take the responsibility, though. There are children that need help and aren't getting it and that should be most important.

There is currently a movement to give the ability for pharmacists to give prescriptions for minor conditions that would typically be treated in a walk in clinic.. I don't see why a therapist couldn't take an additional year of training and get a license to prescribe a narrow range of medications specific to their field.  As it stands if you happen to be in a state where there is a postbac RN program a therapist could probably get a nurse practitioner license in a few years.

 

Alternatively we could expand existing medical schools and open new ones.

 

I can't express how much I disagree with those who feel the mentally ill need to be forced into treatment. 

There is a REASON nobody can forcibly interfere until someone is hurt - nobody has the right to interfere, unless that person's choices, or actions, are interfering with the rights of others. 

Most "seriously mentally ill" people do not hurt others. 

If we assert that the government should be able to mandate mental health services, the line isn't even fine or gray - it's bold and unmistakable; there is nothing, at that point, preventing the government from interfering in the medical decisions of any citizen, if they decide that citizen can't, for whatever reason, make a reasonable decision. Want to stop chemo? Nope - you're obviously depressed over your condition and in no shape to make that decision.

 

My BIL is mentally ill. Paranoid schizophrenic I believe was the eventual dx. He's in jail currently for attempting to kill my sister, in front of their children. This happened during his "mandated treatment". 

If he had been kept locked up for the treatment, the same thing would have happened when he was released.

When medicated he felt fine - so "fine" that he didn't understand why he needed medication. So he'd stop the medication and stop going to therapy and the same thing always happened - he would slip back into paranoia. Back into the delusions. 

 

I have an uncle with the same dx as my BIL. Both are considered severely mentally ill, but only one was ever violent. My uncle, despite his dx, was NEVER violent. Seriously mentally ill, as qualified, but not a threat to anyone. 

 

ETA: I want to qualify that I love my BIL. Still. What he tried to do is horrible. No doubt about it. I knew him "lucid," though, and I love him. I knew him before his "trigger" happened, before it all started to decline, and I worry for him, even after what he tried to do. I wouldn't tell my sister that, but there it is. 

I want to say that I don't think there is a way to "fix" this system. I'm never going to agree that taking away a person's individual rights, just because they "might" be a risk to others, is okay. Never. I know too many people who are mentally ill and aren't violent and have never been violent, that despite my other experience (with a violent mentally ill person), I simply can't say that I wish he had been locked away before he got the chance to be violent. 

 

What if instead of being locked away he was simply required to take medication?  If he is completely lucid and nonviolent when treated, what if instead of jail he was required to go to a county health clinic each day to be supervised taking his medication, periodic blood tests for medication serum levels, and had a GPS anklet to ensure he could be found if he was not compliant?

 

Not every condition can be treated with medication, but I'm not arguing for those that can to be locked away.  There are ways of requiring someone to be medicated without hospitals.

[Liz CA]

One thing besides what has been mentioned I would like to see is no limits on insurance for help.  Limiting how many sessions that are covered is wrong.  Things can not be fixed magically in so many sessions.  A DF has been fighting the insurance company for a while now for their DD.  The insurance company feels that her disorder can be fixed in 20 sessions a year.  They are racking up quite a bit of medical debt to get the help she needs.  

 

Good point!

It is very frustrating for the providers as well to see someone make progress and then the insurance cuts off and they are left dangling.

[TechWife]

Not sure how this plays out in other settings but where I work, if someone voices suicidal or homicidal ideation, they can be sent for a psych eval and kept for 72 hours on a 5150 code.

 

 

That is the case in many (most?) places. The problem is that there is a shortage of beds and those holds often take place in an emergency room that has limited access to mental health treatment. A 72 hour hold is often simply a band aid. Many patients are released after their holds, but without continued access to treatment, they will not be able to get the help they need. 

 

I had been told that in a state where one of my relatives resides that it is very difficult to get even a 72 hour hold, so I went looking this morning and found this detail of what is required in different states to place someone on a hold for an evaluation. They do have some things in common, but there are slight differences. 

 

I'm defining access as availability and affordability. Does anyone have another definition they use? 

[Valley Girl]

 

 

What if instead of being locked away he was simply required to take medication?  If he is completely lucid and nonviolent when treated, what if instead of jail he was required to go to a county health clinic each day to be supervised taking his medication, periodic blood tests for medication serum levels, and had a GPS anklet to ensure he could be found if he was not compliant?

 

Not every condition can be treated with medication, but I'm not arguing for those that can to be locked away.  There are ways of requiring someone to be medicated without hospitals.

 

Am I understanding correctly that you're talking strictly about people who have a demonstrated history of violence when unmedicated?

 

Otherwise, there are a whole host of issues to consider, including whether it is legal or right to force someone to take medications which, like all meds, have risks and side effects. And where do you draw the line?

[Katy]

Am I understanding correctly that you're talking strictly about people who have a demonstrated history of violence when unmedicated?

 

Otherwise, there are a whole host of issues to consider, including whether it is legal or right to force someone to take medications which, like all meds, have risks and side effects. And where do you draw the line?

 

Violence or threats of violence or self harm when a condition has been demonstrated to be responsive to medication seems like a reasonable criteria for requiring treatment.  Not all such conditions can be treated so effectively that taking medication can stop violent tendencies and restore a person to lucidity and leave them completely functional, but for those that can it seems a reasonable standard that would serve not only them but public safety.

 

This is something that should probably be determined by a judge and an independent psychiatric and occupational therapy evaluations, not by families or the patient's individual practitioners, either of which could be rife with motivation for abuse.

 

Honestly this doesn't seem to be more of an overstep than the states that require those convicted of substance issues to wear ankle monitors to alert the court of continued substance abuse.  Cheaper and less disruptive to lives than jail for sure, and arguably much more compassionate.

[TechWife]

 

What if instead of being locked away he was simply required to take medication?  If he is completely lucid and nonviolent when treated, what if instead of jail he was required to go to a county health clinic each day to be supervised taking his medication, periodic blood tests for medication serum levels, and had a GPS anklet to ensure he could be found if he was not compliant?

 

 

With current laws, this won't work. It is well established that people have the right to refuse treatment. 

 

 

Requiring that someone be present at a health clinic everyday restricts their movement. 

Requiring someone to take mind altering medications is invasive. 

Requiring a blood draw is invasive and an invasion of privacy. 

Tracking a persons' movements with a GPS is an invasion of privacy. 

 

Is what you are proposing better than having people go without treatment? Very likely. I just don't know how to make that happen. Is it ethical to require this? Also, what would happen to the person if they were noncompliant? Would they then have to live in a facility because they couldn't be trusted to take their medications? That strikes me as inappropriate and unnecessary. 

 

I don't like your proposal, but I'm having a hard time articulating just why. I tend to try to put myself in the other person's place, so I approach it like this: 

Am I comfortable with someone restricting my movement? 

Am I willing to take mind altering medications because someone else decided it was best for others?

Am I willing to have someone invade my body on a regular basis and have personal information about me?

Am I willing to have someone virtually follow me around?

 

What safeguards can we put in place to keep abuses from happening? Use of chemical restraints is a big deal in nursing homes and it is very difficult to prevent abuses in that closed environment. How could we possibly prevent abuses in an open environment? Would abuse be less likely in an open environment. 

 

How does court ordered psychiatric treatment work? Can the courts order someone to get continuous psychiatric treatment beyond the emergency hold period? Or is that something they made up for tv shows? I assume that would require a crime to be committed, though, which puts us right back where we started, using mental health treatment as crime prevention, which, it seems to me, is inappropriate because we cannot predict who will and who will not commit crimes. 

 

There are no easy answers. 

[TechWife]

Violence or threats of violence or self harm when a condition has been demonstrated to be responsive to medication seems like a reasonable criteria for requiring treatment.  Not all such conditions can be treated so effectively that taking medication can stop violent tendencies and restore a person to lucidity and leave them completely functional, but for those that can it seems a reasonable standard that would serve not only them but public safety.

 

This is something that should probably be determined by a judge and an independent psychiatric and occupational therapy evaluations, not by families or the patient's individual practitioners, either of which could be rife with motivation for abuse.

 

Honestly this doesn't seem to be more of an overstep than the states that require those convicted of substance issues to wear ankle monitors to alert the court of continued substance abuse.  Cheaper and less disruptive to lives than jail for sure, and arguably much more compassionate.

 

Thanks for the clarifications. 

 

I'm curious, though, as to why you would not want the opinions of the patient's own physician to be included in the determination. I think there is definitely need for an independent evaluation, but the opinion of someone who has known the patient long term can be invaluable. Especially considering if this person were to be treated on an outpatient basis, they would likely be continuing to provide care. Or is it just that you don't want the individual's own psychiatrist to be the sole decision maker? That I can get behind. 

[AimeeM]

If he's proven to be violent and cannot (separate from "will not") understand that taking his medication is necessary for the well-being of others, I have no problem with him being locked away - in an appropriate setting (a non-abusive, locked down, health-centered institution).

 

If someone has no history of being a danger to others, though, I do not agree with any aspect of forced medical care. How slippery a slope would that be? Butter-slippery on a hardwood slope is my guess.

HIPAA could be amended to include a clear exception for cases when someone is not capable of making decisions for themselves based on psychiatric or neurological status.

 

 

There is currently a movement to give the ability for pharmacists to give prescriptions for minor conditions that would typically be treated in a walk in clinic.. I don't see why a therapist couldn't take an additional year of training and get a license to prescribe a narrow range of medications specific to their field.  As it stands if you happen to be in a state where there is a postbac RN program a therapist could probably get a nurse practitioner license in a few years.

 

Alternatively we could expand existing medical schools and open new ones.

 

 

What if instead of being locked away he was simply required to take medication?  If he is completely lucid and nonviolent when treated, what if instead of jail he was required to go to a county health clinic each day to be supervised taking his medication, periodic blood tests for medication serum levels, and had a GPS anklet to ensure he could be found if he was not compliant?

 

Not every condition can be treated with medication, but I'm not arguing for those that can to be locked away.  There are ways of requiring someone to be medicated without hospitals.

 

[AimeeM]

With current laws, this won't work. It is well established that people have the right to refuse treatment. 

 

 

Requiring that someone be present at a health clinic everyday restricts their movement. 

Requiring someone to take mind altering medications is invasive. 

Requiring a blood draw is invasive and an invasion of privacy. 

Tracking a persons' movements with a GPS is an invasion of privacy. 

And all of the above would make it almost impossible for somebody to hold down a job, to make matters worse.

 

Is what you are proposing better than having people go without treatment? Very likely. I just don't know how to make that happen. Is it ethical to require this? Also, what would happen to the person if they were noncompliant? Would they then have to live in a facility because they couldn't be trusted to take their medications? That strikes me as inappropriate and unnecessary. 

 

I don't like your proposal, but I'm having a hard time articulating just why. I tend to try to put myself in the other person's place, so I approach it like this: 

Am I comfortable with someone restricting my movement? 

Am I willing to take mind altering medications because someone else decided it was best for others?

Am I willing to have someone invade my body on a regular basis and have personal information about me?

Am I willing to have someone virtually follow me around?

 

What safeguards can we put in place to keep abuses from happening? Use of chemical restraints is a big deal in nursing homes and it is very difficult to prevent abuses in that closed environment. How could we possibly prevent abuses in an open environment? Would abuse be less likely in an open environment. 

 

How does court ordered psychiatric treatment work? Can the courts order someone to get continuous psychiatric treatment beyond the emergency hold period? Or is that something they made up for tv shows? I assume that would require a crime to be committed, though, which puts us right back where we started, using mental health treatment as crime prevention, which, it seems to me, is inappropriate because we cannot predict who will and who will not commit crimes. 

Bingo. 

First, yes if there is a crime that has been committed, the court CAN order psychiatric care after the emergency hold period. My BIL was, for the first violent offense, placed in an extended emergency hold. He broke "outta the joint" (a locked down hospital ward); he was then placed back in and "did his time" in emergency hold; then he was released and required to take his medication AND see his psychiatrist. The problem is that he didn't feel like the medication and psych care was necessary (because he was medicated and feeling fine and thought he could handle this on his own).

So he didn't go to treatment and another, much more serious, violent crime was committed. Now he's in prison for 15 or so years. Special unit. 

 

However (as I've said before, lol), prior to his actual violent crimes, I wouldn't have advocated for forced treatment - because he is the only one of several similarly seriously mentally ill people I know who is violent... literally, the only one. I know others with his exact condition, just as serious, who are completely harmless... which speaks to your fourth sentence above. It IS inappropriate because we cannot predict who will and will not commit crimes - even amongst those with EXACTLY the same condition. 

 

There are no easy answers. 

 

[Anne in CA]

The mental health care where I live is abysmal. I had a cook try to commit suicide last summer after his car wouldn't start and he couldn't come to work. His wife told me he had been on a wait list to see someone since his depression got overwhelming since NOVEMBER. He tried to kill himself in JULY and still had not seen anyone. When he did try to kill himself he was taken to the local hospital to get his stomach pumped. He had swollowed a large amount of Norco. After two days when he woke up he got upset when they told him he was going to have to go to San Diego to an in patient treatment facility so the hospital sent him to county jail and he got no help at all. We could no longer employ him, because he lost his driver's liscense and could no longer drive to work. Also, he was in a pit of depression and he had said several rude things to me the week before so I was about to let him go anyway. Glad I wasn't the straw to break the camel's back.

 

Every day at my restaurant in town I see homeless people with real mental health problems. In Portland a lot of the homeless were definately employable, some were mentally ill, yes, but lots of the homeless in Portland were what you would call urban campers or they were gay kids who had been thrown out of their homes for being gay. The homeless people here are not capable of holding employment for sure. There are a couple of large churches that provide them with medical care and food, but that is not enough.

 

I don't know what it would take to help the people I see around me, and part of the problem is that when we do help them, San Francisco just sends up more. It is a never ending flood.

[Katy]

To answer the questions above, I believe threatening to harm someone when there is also a psychiatric diagnosis is sufficient threat, and there are frequently multiple threats before there is action.  Plenty of clinics have extended hours and such visits would only require a nurse to supervise and any visiting nurse agency or walk in clinic could arrange to give meds off hours and not interfere with working hours, as long as someone licensed would sign the form.  This would be no more disruptive than a judge requiring an addict to go to daily meetings, and perhaps less so.

 

Certainly all the things I mentioned are invasive, but much less so than hospitalizing or jailing someone.  When you get arrested for harming or threatening to harm someone it is public record anyway and so is no longer an invasion of privacy.

 

Judges can order anything they want unless it is so severe as to be unconstitutional.  Frequently with things like addiction judges give someone two choices: submit to rehab, testing, and ankle monitors or go to jail.  This is not much different IMO, and if you have a wife and kids who you tried to murder but after 72 hours of being medicated you are lucid again I'm willing to bet that most people would choose being medicated to going to prison for years.  Whether your wife would or should take you back after such an incident is another discussion entirely.

 

A patient's own physician and family should not be the sole people making decisions because the physician would gain financial benefits and if the person has means, the family could too.  Independent evaluations, while considering statements from family, physicians, hospital staff and law enforcement, would have nothing to gain from telling a judge a patient is worse than they actually are.

 

Think about Michael Jackson's doctor.  He did unethical things to soothe Michael to keep the job and relationship.  It can be difficult to be emotionally objective as a practitioner over a longer period of time.  A few months ago there was a case of a dental office doing a lot of unnecessary procedures to poor children because state coverage would cover it. That office had no oversight and had been running an insurance fraud scheme for years.  It was a parent who started to question and turned in a report of fraud after her instincts told her to get a second opinion. I wouldn't want a similar scenario, where a physician was charging  fees to hundreds or thousands of patients who didn't actually need such supervision solely because it would be an easy way to increase their income.  In some small towns there is only one doctor with maybe a couple PA's.  Making it up to a physician alone without a judge would invite too much abuse IMO.

[AimeeM]

To answer the questions above, I believe threatening to harm someone when there is also a psychiatric diagnosis is sufficient threat, and there are frequently multiple threats before there is action.  Plenty of clinics have extended hours and such visits would only require a nurse to supervise and any visiting nurse agency or walk in clinic could arrange to give meds off hours and not interfere with working hours, as long as someone licensed would sign the form.  This would be no more disruptive than a judge requiring an addict to go to daily meetings, and perhaps less so. My brother-in-law takes medication several times daily. Most of the mentally ill I know, who are medicated, take medication throughout the day at different times. 

 

Certainly all the things I mentioned are invasive, but much less so than hospitalizing or jailing someone.  When you get arrested for harming or threatening to harm someone it is public record anyway and so is no longer an invasion of privacy. I've never heard of someone going to jail for threatening to harm someone, unless there is a RO and a history between the threatened and the person threatening. 

 

Judges can order anything they want unless it is so severe as to be unconstitutional.  Frequently with things like addiction judges give someone two choices: submit to rehab, testing, and ankle monitors or go to jail.  This is not much different IMO, and if you have a wife and kids who you tried to murder but after 72 hours of being medicated you are lucid again I'm willing to bet that most people would choose being medicated to going to prison for years.  Whether your wife would or should take you back after such an incident is another discussion entirely. Missing the point. He wasn't lucid enough, even medicated, to understand that his condition required medication to remain stable. My uncle, who was a non-violent mentally ill man with the same disorder as my BIL, and every bit as severe, only took his medication (when he DID take it) to humor his family - he believed pretty firmly that everyone else had the disorder, not him. 

If someone is so mentally ill that that they cannot be trusted to recognize the need for the treatment in the first place, how on earth can you (general "you") assert that they are ever lucid enough to make a decision between "take your meds" and "go to jail"?

 

A patient's own physician and family should not be the sole people making decisions because the physician would gain financial benefits and if the person has means, the family could too.  Independent evaluations, while considering statements from family, physicians, hospital staff and law enforcement, would have nothing to gain from telling a judge a patient is worse than they actually are. I pretty firmly believe that my uncle died a seriously mentally ill, but happy, well cared-for man not because of anything any institution ever did for him - but because of what his local family and his private physicians did for him.

How many seriously mentally ill people do you really know with significant means? I mean, my uncle had means, due to two inheritances, but those involved in his care gained nothing monetarily from the care they gave him. 

There are very few Michael Jacksons in the world. 

 

 

Think about Michael Jackson's doctor.  He did unethical things to soothe Michael to keep the job and relationship.  It can be difficult to be emotionally objective as a practitioner over a longer period of time.  A few months ago there was a case of a dental office doing a lot of unnecessary procedures to poor children because state coverage would cover it. That office had no oversight and had been running an insurance fraud scheme for years.  It was a parent who started to question and turned in a report of fraud after her instincts told her to get a second opinion. I wouldn't want a similar scenario, where a physician was charging  fees to hundreds or thousands of patients who didn't actually need such supervision solely because it would be an easy way to increase their income.  In some small towns there is only one doctor with maybe a couple PA's.  Making it up to a physician alone without a judge would invite too much abuse IMO.

 

[TechWife]

To answer the questions above, I believe threatening to harm someone when there is also a psychiatric diagnosis is sufficient threat, and there are frequently multiple threats before there is action. 

 

How do you define threat? A lot of people threaten a lot of things. Who has to identify that a threat is made? What would keep a family member from saying that they were threatened as a way to try to manipulate the treatment of the patient? 

 

Plenty of clinics have extended hours and such visits would only require a nurse to supervise and any visiting nurse agency or walk in clinic could arrange to give meds off hours and not interfere with working hours, as long as someone licensed would sign the form.  This would be no more disruptive than a judge requiring an addict to go to daily meetings, and perhaps less so.

 

I think you might be over simplifying this a bit - medication has to be taken on a schedule, sometimes several times a day. 

Also, where are these clinics with extended hours that you are talking about? I've never heard of such a thing.  Are you proposing that any clinic, such as a free standing urgent care, could be where someone is designated to take their medications? That's certainly an interesting idea. The reimbursement structure would have to be in place, though. Not insurmountable. 

 

Certainly all the things I mentioned are invasive, but much less so than hospitalizing or jailing someone.  When you get arrested for harming or threatening to harm someone it is public record anyway and so is no longer an invasion of privacy.

 

I am using the word invasive in the medical sense - a procedure that requires entry into someone's body is invasive. Every invasive procedure has risks and benefits to both the patient and the provider. 

 

I would consider blood test results and the fact that a patient is under medical treatment to be information that should remain confidential. People should not give up their medical privacy. I don't think court orders for mental health treatment should be publicly available to the general public. Someone should have to prove they have a legitimate "need to know" and the person should also have to consent to their medical information being given out. Judges should seal the court proceedings. Likewise, there would need to be safeguards in place to make sure the movements of anyone tracked by a GPS device remain confidential, and there would need to be stipulations as to the uses of the information gained through the tracking device. 

 

 

 

Judges can order anything they want unless it is so severe as to be unconstitutional.  Frequently with things like addiction judges give someone two choices: submit to rehab, testing, and ankle monitors or go to jail.  This is not much different IMO, and if you have a wife and kids who you tried to murder but after 72 hours of being medicated you are lucid again I'm willing to bet that most people would choose being medicated to going to prison for years.  Whether your wife would or should take you back after such an incident is another discussion entirely.

 

Assuming someone would be properly medicated within 72 hours and be lucid enough to make that determination (between treatment and jail) is actually a big assumption. We would have to have more psychiatric beds available, but that is doable. Also, is it realistic to expect someone to have found the right medication combination within 72 hours? In many cases it may not be possible. This is probably where the additional 14 day period that is possible in some areas (California is one, I think) would come into the picture, but not all areas have this.  

 

A patient's own physician and family should not be the sole people making decisions because the physician would gain financial benefits and if the person has means, the family could too.  Independent evaluations, while considering statements from family, physicians, hospital staff and law enforcement, would have nothing to gain from telling a judge a patient is worse than they actually are.

 

I agree that the physician shouldn't be the sole person to make the recommendation, but I think this independent evaluator should consider the physician's opinion. Why? Because if the personal physician disagrees with the independent evaluator, the personal physician doesn't have to agree to see the patient. For example, what if a personal physician recommends a residential treatment facility for someone because he believes the person needs that type of intensive treatment and it isn't available on an outpatient basis. Here comes the independent evaluator, who disagrees, therefore throwing the case back to the personal physician, who has already said he can't provide the treatment needed. He is not ethically bound to provide the treatment, either. Then, here we have someone who needs treatment but now has to find a different provider. We would have to eliminate the shortage of psychiatrists in order to do this. 

 

 

Edited to correct highlighting.

[TechWife]

So, here is some more food for thought. 

 

What community resources and supports would be helpful for those undergoing mental health treatment? These could be supports for a full range of mental illnesses, not just the most severe and not just those who are at risk for harming themselves or others. These would be services that are generally available. 

 

I would like to see a mental health advocate position similar to that of a guardian ad litem that would personally represent the interests of the patient in court. 

 

What about assistance with activities of daily living? Someone to help the patient suffering with depression develop a daily routine, encourage them to stick with it and help them troubleshoot when things aren't going well, for example.

 

Access (again, think availability and affordability) to a  fitness center and someone to teach safe use of equipment - This would help so many people with mental illnesses! Maybe fitness centers owned by hospitals could apply for grants to make this service available. Could this be done with private providers and still be affordable? 

 

Access to prescription medication would be needed. 

 

What else? 

 

 

 

[TechWife]

 

Otherwise, there are a whole host of issues to consider, including whether it is legal or right to force someone to take medications which, like all meds, have risks and side effects. And where do you draw the line?

 

Thanks for bringing this issue up - we haven't fleshed this out.  Some side effects are permanent as well. 

[Liz CA]

That is the case in many (most?) places. The problem is that there is a shortage of beds and those holds often take place in an emergency room that has limited access to mental health treatment. A 72 hour hold is often simply a band aid. Many patients are released after their holds, but without continued access to treatment, they will not be able to get the help they need. 

 

I had been told that in a state where one of my relatives resides that it is very difficult to get even a 72 hour hold, so I went looking this morning and found this detail of what is required in different states to place someone on a hold for an evaluation. They do have some things in common, but there are slight differences. 

 

I'm defining access as availability and affordability. Does anyone have another definition they use? 

 

I do agree that the hold alone accomplishes little if not followed up by psychiatric care and this is where several factors, i.e. the shortage of providers, the insurance companies and HIPAA seem to conspire against adequate care.

 

[Katy]

My brother-in-law takes medication several times daily. Most of the mentally ill I know, who are medicated, take medication throughout the day at different times.

 

I've never heard of someone going to jail for threatening to harm someone, unless there is a RO and a history between the threatened and the person threatening. 

 

Missing the point. He wasn't lucid enough, even medicated, to understand that his condition required medication to remain stable. My uncle, who was a non-violent mentally ill man with the same disorder as my BIL, and every bit as severe, only took his medication (when he DID take it) to humor his family - he believed pretty firmly that everyone else had the disorder, not him. 

If someone is so mentally ill that that they cannot be trusted to recognize the need for the treatment in the first place, how on earth can you (general "you") assert that they are ever lucid enough to make a decision between "take your meds" and "go to jail"?

 

There are visiting nurse services that could bring an RN to him for medication several times a day.  There are walk in clinics that are available from 7am-9pm that could make an arrangement. Obviously this would be a bigger issue in more rural areas, but we're talking about someone walking into a clinic, stepping into a private area, swallowing a pill, and signing a paper.  Any RN could do this for someone in less than 5 minutes, just the same as someone going frequently for allergy shots given only by an RN. We could probably even have an LPN or a med-tech (a CNA certified for medication) do it. Not more complicated than jail.

 

People are arrested for threatening people every day, especially if they threaten with murder or acts of terrorism. Basically a threat has to be substantial, but if there is evidence that you intend to carry it out you can and will be arrested.  In some areas "assault" is only verbal and "battery" is only physical, but this varies greatly around the world.  Wikipedia on assault clarifies this issue.

 

If he's not lucid enough medicated to remember if he doesn't take his medications he's going to jail then you are correct, this might not work for him.  It definitely wouldn't work for everyone.

 

I think you might be over simplifying this a bit - medication has to be taken on a schedule, sometimes several times a day. 

Also, where are these clinics with extended hours that you are talking about? I've never heard of such a thing.  Are you proposing that any clinic, such as a free standing urgent care, could be where someone is designated to take their medications? That's certainly an interesting idea. The reimbursement structure would have to be in place, though. Not insurmountable. 

 

Assuming someone would be properly medicated within 72 hours and be lucid enough to make that determination (between treatment and jail) is actually a big assumption. We would have to have more psychiatric beds available, but that is doable. Also, is it realistic to expect someone to have found the right medication combination within 72 hours? In many cases it may not be possible. This is probably where the additional 14 day period that is possible in some areas (California is one, I think) would come into the picture, but not all areas have this.  

 

I agree that the physician shouldn't be the sole person to make the recommendation, but I think this independent evaluator should consider the physician's opinion. Why? Because if the personal physician disagrees with the independent evaluator, the personal physician doesn't have to agree to see the patient. For example, what if a personal physician recommends a residential treatment facility for someone because he believes the person needs that type of intensive treatment and it isn't available on an outpatient basis. Here comes the independent evaluator, who disagrees, therefore throwing the case back to the personal physician, who has already said he can't provide the treatment needed. He is not ethically bound to provide the treatment, either. Then, here we have someone who needs treatment but now has to find a different provider. We would have to eliminate the shortage of psychiatrists in order to do this.

 

Yes, any urgent care or visiting nurse service.  Urgent care would be cheaper.  There are already reimbursement schedules for nurse only or tech only visits.

 

Yes, 14 or 21 day inpatient periods are much more realistic.  Many drugs might take 6 weeks or more to taper to the proper levels.

 

You're correct about the independent evaluate vs physician unable to provide that level of care.  There already exist rules that someone cannot be discharged from a hospital unless they are going to a safe place that will provide necessary care.  These are complex situations that are unfortunately common and are why hospitals have a social workers.  I'm certain Joanne could provide better information about what those laws are already than I could. 

 

 

So, here is some more food for thought. 

 

What community resources and supports would be helpful for those undergoing mental health treatment? These could be supports for a full range of mental illnesses, not just the most severe and not just those who are at risk for harming themselves or others. These would be services that are generally available. 

 

I would like to see a mental health advocate position similar to that of a guardian ad litem that would personally represent the interests of the patient in court. 

 

What about assistance with activities of daily living? Someone to help the patient suffering with depression develop a daily routine, encourage them to stick with it and help them troubleshoot when things aren't going well, for example.

 

Access (again, think availability and affordability) to a  fitness center and someone to teach safe use of equipment - This would help so many people with mental illnesses! Maybe fitness centers owned by hospitals could apply for grants to make this service available. Could this be done with private providers and still be affordable? 

 

Access to prescription medication would be needed. 

 

What else? 

 

There are already group homes that provide some people with assistance with ADL. I'm not sure how they are structured but I know a few people who have worked at them.  Joanne probably knows more.

[Joker]

Requiring someone to take mind altering medications is invasive. 

 

This is something I don't think all really get. Drugs, especially those for mental health, work differently on everyone. I can't imagine my dd being forced to take medication she is not comfortable taking. Thankfully, health providers have mostly listened to her/us when she says a drug makes her feel worse/bad/funny/etc. Maybe all aren't really listening and trying to force meds on some of these people instead of working with them to find the right medication and dosage. I have had to advocate for her sometimes in this regard but my end goal is to find something that helps her. Sometimes the professionals get caught up in thinking they know more than the patient and society definitely thinks they often know more. It is really difficult to find the right medication, dosage, and therapy to help someone. It's not a quick fix.

[TechWife]

There are visiting nurse services that could bring an RN to him for medication several times a day.  There are walk in clinics that are available from 7am-9pm that could make an arrangement. Obviously this would be a bigger issue in more rural areas, but we're talking about someone walking into a clinic, stepping into a private area, swallowing a pill, and signing a paper.  Any RN could do this for someone in less than 5 minutes, just the same as someone going frequently for allergy shots given only by an RN. We could probably even have an LPN or a med-tech (a CNA certified for medication) do it. Not more complicated than jail.

 

Again, you are over simplifying this. You speak as if these resources are already in place, and they simply are not. This is a really good idea worth exploring, but your insistence that these services are in place is uninformed and misguided. 

 

One potential barrier to this I see is transportation. Perhaps we should add that to the list of community support services. 

 

People are arrested for threatening people every day, especially if they threaten with murder or acts of terrorism. Basically a threat has to be substantial, but if there is evidence that you intend to carry it out you can and will be arrested.  In some areas "assault" is only verbal and "battery" is only physical, but this varies greatly around the world.  Wikipedia on assault clarifies this issue.

 

Substantial is the key word, here. One you hadn't previously brought up. So how substantial would it have to be to justify forced medical treatment? What type of proof would be required? 

 

Yes, any urgent care or visiting nurse service.  Urgent care would be cheaper.  There are already reimbursement schedules for nurse only or tech only visits.

 

There is a reimbursement schedule for home health care. It is very low reimbursement, especially when Medicaid is involved. There is no reimbursement for in office care by an RN, LPN or med tech. Their services are included in the doctor's fees. They are not reimbursable separately. 

 

Yes, 14 or 21 day inpatient periods are much more realistic.  Many drugs might take 6 weeks or more to taper to the proper levels.

 

Or longer - it can take years to find the right combination of medication and dosages. 

 

You're correct about the independent evaluate vs physician unable to provide that level of care.  There already exist rules that someone cannot be discharged from a hospital unless they are going to a safe place that will provide necessary care.  These are complex situations that are unfortunately common and are why hospitals have a social workers.  I'm certain Joanne could provide better information about what those laws are already than I could. 

 

I'm sorry, but hospitals discharge homeless people to the street all the time. They aren't shelters or hotels. People are also free to leave the hospital at any time (except for involuntary holds) and can therefore leave without a discharge plan in place. 

 

There are already group homes that provide some people with assistance with ADL. I'm not sure how they are structured but I know a few people who have worked at them.  Joanne probably knows more.

 

Yes, and as she has already said in this thread, they aren't good. Additionally, the goal of mental health care is to care for people in the least restrictive environment, therefore we should do what we can to promote independent living. 

 

Sorry, all. For some reason I've had to edit this post several times for highlighting. I wish the quote function were easier to use! 

 

[TechWife]

 Sometimes the professionals get caught up in thinking they know more than the patient and society definitely thinks they often know more. It is really difficult to find the right medication, dosage, and therapy to help someone. It's not a quick fix.

 

I liked your post because I agree with what you said, not because I like what you said, KWIM? 

 

There's an inclination in our culture at large to want to solve problems. What many don't understand is that mental illness is very complex. It's sad that people understand that cancer is complicated and that it takes time to treat cancer, that diabetes is a chronic illness, etc., but they don't think about those same facts applying to mental illness. Treating mental illness well is complex, time intensive and ongoing for many people. 

[TechWife]

If we're really looking at a list of things that could improve someone's life and exercise is on the list then food might as well be. I would have no idea how that would work, though.

 

I think that's a good idea. Nutritional counseling of some sort included in a fitness package along with exercise? Of course, we would need to make sure people have money to purchase healthy foods as well. Mental health care really requires a huge and varied safety net and I just don't see that safety net. A case manager of some sort that would help people access services would be good. 

[Carrie12345]

I think that's a good idea. Nutritional counseling of some sort included in a fitness package along with exercise? Of course, we would need to make sure people have money to purchase healthy foods as well. Mental health care really requires a huge and varied safety net and I just don't see that safety net. A case manager of some sort that would help people access services would be good. 

 

As a person who loves the exercise and nutrition field, I think this is a fabulous idea.

As a person who can't afford advanced degrees in exercise science and dietetics, I'm pessimistic. It costs a LOT of money to become qualified to help the neediest people with little compensation.

[TechWife]

As a person who loves the exercise and nutrition field, I think this is a fabulous idea.

As a person who can't afford advanced degrees in exercise science and dietetics, I'm pessimistic. It costs a LOT of money to become qualified to help the neediest people with little compensation.

 

Yes - a lot of what we've been talking about is in the "pipe dream" category, sadly. Funding is a real issue in mental health care, but it's difficult to talk about that without entering the political arena. I'll just say that if priorities were rearranged, a lot of things could happen, KWIM? 

 

I'm thinking this particular position would perhaps be a county employee of some kind. Or, alternately, an employee of a hospital who contracts with the county. That way, it isn't a fee for service arrangement.

 

There is a hospital in our area that owns three free standing fitness centers. They employ both exercise physiologists and registered dietitians. The fitness centers host their outpatient cardiac rehab program and  are open to the public on a membership basis. They could, conceivably, add a program for those with mental health problems, or they could just provide the services without having a formal program. Now, places like this aren't widely available around the country, though, so the problem of access would have to be solved. The YMCA's are another potential route for delivering services.