Better science one key to better mental health care

'I don't think many people that you talk to would be satisfied with the treatments that we have now.'


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The future of mental health treatment in America will turn partly on breakthroughs in brain science, enhanced care options and capitalizing on the connection between mind and body, according to some of those responsible for advancing the quality of psychiatric care.

Thomas Insel, director of the National Institute of Mental Health, a research-focused federal agency, said the medical profession must better understand brain circuitry and its ties to mental illness -- and he held out hope that a new generation of psychiatrists, one trained in neuroscience, will bring improvements for patients.

"I don't think many people that you talk to would be satisfied with the treatments that we have now," said Dr. Insel, who blogs about research, treatment and related issues at nimh.nih.gov.

While heart disease and many other physical illnesses have known biological indicators, or biomarkers, many psychiatric conditions do not, he said, noting that diagnosis still relies largely on a doctor's interpretation of symptoms.

Researchers must "go back to the basics. We need to understand the diseases," Dr. Insel said. Officials and mental-health professionals also have called for:

• Casting mental illness as a major public health issue, similar to AIDS and breast cancer, so that it receives more money, attention and public support.

• Modifying emergency involuntary-commitment laws, so that it's easier to get help for a person in crisis, and privacy laws, so that doctors and colleges can talk to parents about troubled young adults.

• Expanding access to inpatient and outpatient care so that people with mental illness are less likely to end up in jails or homeless shelters. The December 2008 closing of Mayview State Hospital in South Fayette has been associated with strains on the outpatient system locally.

• Better integrating physical and mental health care, a step that would leverage the symbiosis of mind and body and enable patients to seek mental health care -- discreetly -- in a general practitioner's office.

Dr. Insel hopes that a new focus on neuroscience will help to boost medical students' interest in the field and address a chronic national shortage of psychiatrists.

"Imagine a new discipline, clinical neuroscience, that brings the best science of brain and behavior to the compassionate care of those with serious mental illnesses," he said on his blog. "Who would not want to be part of this revolution?"

U.S. Rep. Tim Murphy, R-Upper St. Clair, who is a licensed psychologist, agreed on the need for better science. "We've cracked the genome code, but we haven't cracked the brain code, which is far more complex."

But he stressed that improved treatment also depends on better understanding of environmental factors contributing to mental illness and integrated treatment of physical and mental health care. Currently, he said, Medicaid often doesn't permit a patient to incur physical and mental health care costs on the same day.

"We're going to remove that barrier," said Mr. Murphy, who in coming weeks plans to introduce a package of legislation addressing that and what he described as other gaps in care.

The century-old Mayview State Hospital served residents with serious mental illness from Allegheny, Beaver, Greene, Lawrence and Washington counties. In addition to treating patients committed under a civil process, the hospital had forensic patients sent there by police and the courts.

The closure, driven by a national push for deinstitutionalization and a desire to save money, has been criticized by some mental health professionals, law enforcement officials and hospital administrators.

They cite a continuing need for a Mayview-like setting to treat those who struggle to manage mental illness in community settings -- especially in light of the loss of other psychiatric beds, such as those at the now-closed St. Francis Hospital in Lawrenceville, and state budget cuts that exacerbated shortages of beds in housing and treatment programs.

In May, state Rep. Thomas R. Caltagirone, D-Berks County, minority chairman of the Judiciary Committee, pushed through a resolution directing the Joint State Government Commission to review all aspects of the state's treatment practices, including the possible need for inpatient beds.

"Thirty-five years have lapsed since anybody took a look at the mental health statutes, let alone situation. Thirty-five years," Mr. Caltagirone said.

Need for smaller settings

Mr. Murphy sees a broader, nationwide need for additional inpatient and outpatient beds. Echoing the concerns of the National Alliance on Mental Illness, some doctors and other advocates, Mr. Murphy said the shortages have fueled homelessness and turned jails and prisons into de facto psychiatric hospitals.

"What America has done in dealing with people with mental illness is so far short of what we should be doing, it's not surprising we are still failing," he said in a Sept. 19 speech on the House floor.

Mr. Murphy said he doesn't favor construction of big institutions but the addition of smaller settings, such as the wing of a hospital, where patients would have time to recover.

In addition to promoting increased access to care, his legislation would encourage pediatricians and emergency workers to take additional mental health training, promote research on medications and modify privacy laws that keep doctors and universities from talking to parents about their children. He said they now withhold information because they're afraid of being sued.

A new public attitude is seen as important to improving the treatment system and getting the sick into care.

Many people have misconceptions about mental illness, view it as something that afflicts other people or think about it only when hearing about homelessness or violent crime, said Pamela S. Hyde, administrator of the Substance Abuse and Mental Health Services Administration, the arm of the U.S. Department of Health and Human Services that promotes prevention and treatment.

Yet one in four American adults experiences mental illness, making it a "fairly universal issue," said Ms. Hyde, who's working to portray psychiatric disorders and addictions as a public health issue. She said she wants to foster a recognition that mental illness is widespread but often preventable and, especially in the early stages, treatable.

"We don't wait until people are sick, from a public health point of view," she said.

Many people go without care, some because they can't afford it or their insurance won't cover it, and patient care often has fallen to financially strapped nonprofit groups, Ms. Hyde said. She said she hopes the coming federal health care program will expand mental health services to people who don't have it now.

Starting with primary care

Increasingly, mental illness may be treated in the general practitioner's office, a trend that gives patients a discreet way to seek help while capitalizing on the overlap between body and brain.


After Mayview

:
A special five-part series

Sunday, Sept. 22:

Overview and portrait of former Mayview State Hospital patients.
Monday, Sept. 23:
Community hospitals struggle with mental-health caseloads.
Tuesday. Sept. 24:
Police, courts improvise to manage ill offenders
Wednesday. Sept. 25:
Housing a weak link in mental-health system
Sunday, Sept. 29:
The future of mental-health treatment


People with serious mental illness die earlier than the general population, according to research, because they have difficulty managing physical health problems. Also, researchers have found that many people with physical health problems also have a psychiatric condition, such as depression.

In May 2012, Pittsburgh Mercy Health System opened a family health center on the South Side to make sure that its clients could receive physical and mental health care in one location. So far, it's seen more than 1,000 patients.

"Due to the medical complexity of the individuals served, Pittsburgh Mercy Family Health Center's primary care center staff meets -- or 'huddles' -- each morning to discuss the patients they expect to see that day," the center said in an article it prepared for the spring edition of Health Progress, the journal of the Catholic Health Association of the United States.

The Pittsburgh Regional Health Initiative, an arm of the Jewish Healthcare Foundation, has been promoting integrated care since about 2009, program manager Robert Ferguson said. Currently, it's participating in two multi-state initiatives, one of them Partners in Integrated Care, which screens patients for depression and substance abuse at community health centers and primary-care practices.

"This is preventive medicine, basically," said Keith Kanel, the initiative's chief medical officer.

If a problem is detected, Dr. Kanel said, patients can "get exactly what they need on the spot in real time." If necessary, he said, primary-care doctors can consult with a psychiatrist.

Some patients have reported fewer emergency department visits, lessening of depression and a decrease in alcohol and drug use, among other benefits, according to information provided by the health initiative.

The health initiative also is involved in the program Care of Mental, Physical and Substance Use Syndromes, through which the staff at primary-care practices help Medicare and Medicaid patients manage depression and diabetes or diabetes and cardiovascular disease. Depression, Dr. Kanel noted, can affect a patient's ability to take multiple medications and otherwise manage his or her physical ailments.

"This is work, and you have to be up to doing the work," Dr. Kanel said.

Going forward

"Connecting the Dots." That's the theme of an Oct. 10 roundtable that Mental Health Association of Beaver County has scheduled with the county's legislative delegation.

In an era of funding cuts, consumers, providers and advocates must work hard to keep their needs before lawmakers and others who make funding decisions.

Jennifer Bentz, director of Phoenix Center, a Rochester drop-in center, said lawmakers will hear not only about the importance of affordable housing, treatment options, peer support and transportation services but how those items work together to promote a person's recovery. Residents with mental illness will share their experiences with the lawmakers.

"We want them to all know our stories, and if they're ever in a position to make decisions about the things we talk about, they will be well informed," she said.

region - health - mayviewstories

Joe Smydo: jsmydo@post-gazette.com or 412-263-1548. First Published September 29, 2013 4:00 AM


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