Disconnect remains between mental health issues and treatment

The Coos County Jail is staffed two days a week with a licensed mental health professional to provide services and evaluation through Correct Care Solutions, which maintains and provides the jail's medical services.

COOS BAY — Treatment for mental health issues is not a simple process.

There is no vaccine, no magic pill and no one right way to provide the right kind of treatment.

Throughout the state, police officers mainly utilize a local hospital or jail for people with mental health issues, who they suspect may either pose a danger to self or others or who have committed a crime.

But in order to enforce any form of treatment, medical providers are either having a difficult time proving danger or there are not enough resources to provide it.

Kera Hood, nurse manager for the Bay Area Hospital's acute psychiatric unit, said one of the biggest misconceptions about involuntary treatment are the requirements.

"It has to be an actual acute danger to self or others, not what they did 20 hours ago," Hood said. "You could have a person living in a rat-infested trailer with no water, but it's their right to live that way."

In past years, Hood said licensed professionals could put patients on a hold if they felt the patient couldn't provide care for themselves, but current standards now require both imminent and serious risk of danger.

With a greater impetus being put on patients' civil rights, Lisa Rojas, clinical social worker at Bay Area Hospital, said placing a hold is becoming increasingly difficult.

"Trying to prove someone is dangerous is not that easy, and it's getting harder and harder because a lot of those cases where we put people on hold are getting reversed," Rojas said. "There are a lot of people on the street who are psychotic, and they have the right to be that way and that's the choice they've made. We can't force them to take their meds because if they're not harming anybody or themselves, they're meeting their basic needs, like having enough food to eat and a place to stay, we can't just hold them."

With the narrow interpretation of the law, Rojas said many are voluntarily discharged from the hospital and the tragedy of the system is cyclical in nature as the process of evaluation and release repeats itself.

"I care for the people who come through our doors, but it's frustrating when we can't even get it to go to a hearing, and we know they need help, but they don't want to stay, and we have to let them out the door," Rojas said. "Maybe not even a week or two later, they're back, and it's sad." Overwhelming demand for services

For patients who are not held, during the daytime hours, Rojas said the hospital tries to get individuals with mental health issues connected with Coos County Health, but given the demand, getting help can often take time.

"Right now, everybody's so overwhelmed that sometimes with wait times, if they're not already established, it can be awhile," Rojas said.

With its hands tied, the hospital tries to do its best with continuing care for the individuals, but ultimately it comes back to the patient to see it through.

"We do set up follow-up appointments for all patients, but it's whether or not they keep them because we can't force them to go," Hood said.

With the Affordable Care Act providing more access to insure, it has complicated matters for health professionals as it has spread service thin.

Between July 1, 2013 and March 31, 2014, the Department of Justice reported Coos County's Medicaid-eligible severe and persistent mental illness population increased from 492 to 520.

"We've also had an increase in numbers, and this is statewide, coming to the emergency room, an increase to the outpatient and everyone is just overwhelmed," Rojas said. "We have a lack of providers because it's difficult to get people to come to rural areas, but there's also a shortage of people going into psychiatry."

Bay Area Hospital has been particularly bombarded with the need for emergency mental health services.

In 2011, 546 consults were through the ED, as well as 27 child and 159 hospital house consults.

Last year, the hospital had 743 consults through the emergency department, as well as 101 child and 271 hospital house consults.

Along with a greater need for service, Rojas said the degree of mental heath issues has changed, as well.

From July 1, 2013 to March 31, 2014, Coos County reported 176 suicide-related hospitalizations.

"I've been here 10 years, and we've seen more people coming to our ED for psychiatric reasons," Rojas said. "It seems like an increase in suicidal ideations and suicide attempts, and I don't know why it's happening, but it seems to be everywhere. We see sicker people in our unit since I started, when it used to be depressed people, but now the majority of the people we see are psychotic and used to be in the state hospital."

While the number of mental health admissions dropped from 371 to 345 at Bay Area Hospital in 2014, Hood said the number is misleading because the average length of stay has increased.

"They are staying longer, which means their conditions are becoming more intense," Hood said. "That's a huge concern on so many levels." Limitations of care in jails

Aside from the hospital, the next closest resource for officers is the Coos County Jail, where medical services are provided and maintained by Correct Care Solutions.

Jim Cheney, spokesman for Correct Care Solutions, said in the past several months, the number of patients exhibiting mental heath issues was eight, but the jail is only staffed two days a week with a licensed mental health professional to provide services and evaluation.

With the limited amount of care available at the jail, Sheriff Craig Zanni said the department is trying to rectify the problem through partnerships with outside organizations.

"I would say that's accurate, but that's not to say there aren't more people with emotional issues," Zanni said. "We're working on that right now, and we're trying to establish a program with the county."

While there are areas within the jail where patients can be isolated and observed, Cheney said the sheriff's department does not specifically maintain beds for people with mental health issues.

For patients the jail is unable to care for, the next step is transferring the patient to the state hospital, but not before a judge appoints an attorney to secure funding for a state psychiatric evaluation and the subsequent availability of a bed in a state facility. A rare, but vital resource

Bay Area Hospital, which houses 11 beds in its acute psychiatric unit and is staffed 24 hours a day with qualified mental health professionals, is one of the few hospitals remaining with in-patient crisis care.

"It's not lucrative, it's not an easy service to provide, but we do it because it's good for our community," chief development officer Barbara Bauder said.

With the cost of in-patient care so high, many hospitals within the state have closed their behavioral health units.

In the American College of Emergency Physicians' 2014 state-by-state report card, Oregon had the fourth-fewest number of psychiatric beds per 100,000 population. Since 2009, the number of beds has decreased from 28.8 to 8.7 psychiatric care beds per 100,000 people.

But while the number of beds in the state has plummeted, the Department of Justice reported in-patient mental crisis admissions rose from 13 to 14.8 per 100,000 adults between July 1, 2013 and March 31, 2014.

Limiting the number of available psychiatric beds at Oregon State Hospital, the Department of Addictions and Mental Health reported 20 percent of beds are occupied by court-ordered admissions.

ORS 161.370 allows patients to be admitted to the hospital for evaluation and restore a person's "fitness to proceed" with the legal process if a person is unable to aid or assist in his or her defense due to symptoms of mental illness.

In 2013, the average length of stay for ORS 161.370 admissions was 108 days.

Rojas said the reduction in the number of beds, including Roseburg's Mercy Hospital closing its behavioral health unit because of the budget constraints, has impacted the demand for services not only at Bay Area Hospital, but others in the state.

"It really hurt us when Mercy closed down its adolescent and adult unit because when we were full, that's where we would send the majority," Rojas said. "I'd say five years ago I never had a problem finding a bed."

With fewer in-patient psychiatric resources in the state, Coos County Mental Health director David Geels said the hospital has become more of a state resource as he estimated at one point one-third to half of the beds at the hospital were taken up by outside counties.

But with the hospital seeing an increase in the number of patients, Rojas said the hospital has its hands full caring for people in the county.

"A year or two ago when we weren't so busy, we would take patients from other counties to fill up our beds because they need treatment," Rojas said. "Right now, we're staying pretty much busy with our own county that we're not able to do that."

While other hospitals in the county, like Coquille Valley Hospital, may encounter patients with mental health issues, they do not offer mental health services and only stabilize patients for transfer.

Given that the hospital is a major resource in the area for crises, Rojas said while the facility can be overwhelmed due to the dire availability of beds, it will do what it can to help everyone in need.

"Acute psych is the last step before the state hospital," Rojas said. "If all 11 beds are full, we're supposed to call around the state to the other hospitals to see if there is a bed. Everybody is full, their EDs are backed up, nobody has beds, so we do what we have to do to treat them and don't just send them out the door."

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Comments

I don't buy that the reason we're having so many more hospital admissions is because treatment is unavailable. National stats show that more people than ever are receiving treatment for mental illness, and yet the numbers and severity of those diagnoses mentally ill continue to climb. It appears that a more fundamental problem exists: the current treatment model does not lead to recovery, but to increasing dependency and deterioration over time. 

For more science on this point, please read "Anatomy of an Epidemic" by Robert Whitaker. Whitaker highlights research showing increasing levels of disability and the scientific mechanism by which psych drugs bring this about in the long term (even if they may reduce symptoms in the short run). He also shows that mentally ill people in developing countries like Columbia, Nigeria, and India have much better long-term mental health outcomes than the US and the UK, and provides a number of alternative approaches that appear to have a much better chance of success than the current drugs-for-life model. Whitaker is not taking an anti-medication viewpoint, but arguing that we should behave in coordination with what science really tells us. The current epidemic of mental health crises supports his thesis 100%. 

The problem is not an inability to enforce treatment on people. It is that the treatment they are offered does not meet their real needs for engagement, relationships, safety, and meaningful activities, which are all essential for any of us to be mentally healthy. Drugs can be a short-term help, but they are not the ultimate treatment for mental difficulties, and until we recognize this fact, we will continue to see increasing costs and decreasing functioning in our "mentally ill" population. 

The reason why we are seeing more acute cases is because the US mental health system is not using evidence based practices and we have out of control prescribing to the point where now one out of four Americans are taking a psychiatric drug! Many psychiatric drugs are harmful in the long run, especially neuroleptics. When children who have been abused or who are in the foster care system are exposed at a very young age to powerful psychiatric medications including stimulants for manufactured 'diseases' such as ADHD, their brains become dependent. My step son started on Ritalin to help with performan enhancement at college and moved on to the harder stuff on the street when doctor shopping ceased to be an option. He then experienced a psychotic break due to meth and cocaine addiction that was all precipitated by stimulate use. ADHD medications are 'clean meth.' If you dispute this, please  declare on what scientific basis.

In the US we are also seeing a soring epidemic epidemic of bi polar disorder which many scientists are now speculating may be caused by the overuse of SSRI's (selective seratonin reuptake inhibitors) commonly known as anti depressants which in many people with unipolar depression may be triggering mania. Then, people are put on powerful antipsychotic medications, which in turn, cause even more havoc. All this for people who may be suffering from human problems such as loss or trauma!

 

 And the treatment for psychosis is abolutely barbaric in the Western industrialized nations! The reason why the W.H.O. study indicates that people living in third world countries have higher rates of full recovery from psychosis is because they are taking less drugs! While medications may have some limited value in 'stabilizing' people in the short term during an  acute crisis such as during a sleep deprived psychosis or a drug induced psychosis, that is not how they are being used in the real world.

 

Anti psychotics are misnamed. They are not 'anti' anything. They do not treat the underlying cause of psychosis. Anyone who says they do is either lying or just plain stupid. Neuroleptics, (the scientific name for anti psychotics) simply cover up the symptoms of psychosis. The myth of the chemical brain imbalance of mental illness is a myth. Next time a social worker tells your loved one that he/she has to manage their illness with meds for life like diabetes, run fast the other way. The evidence simply does not support the diabetes metaphor. Rarely, will an intelligent doctor use the misleading and unscientific diabetes metaphor with a patient but they sure are not helping to set the record straight.

When people have their first break, neuroleptics should be delayed or if patients are exposed to them, the exposure should be brief and the patient should be carefully and slowly tritrated off of them as soon as possible. Some scientists have speculated that the brain develops a structural change to 'fight back' against dopamine blocking. Furthermore, the frontal lobes of the brain shrink due to long term neurleptic use.

 

The Harrow and the Wunderlink studies, (the latter being the only double blinkd, placebo controlled logitudinal study of its kind) show strong evidence that the people who recover in far higher numbers from psychosis are those who stop taking the meds. The difference between recovered people and those cited in this article who are wandering around on the streets when they are 'off their meds' is the level of community psycho social supports that they are receiving. As long as our society continues to embrace a harmful, antiquidated model of treatment for trauma based, psychological based, sleep deprivation/drug induced psychosis by applying only a medical or disease model of mental illness, we will continue to see more and more people filling the ER's. These patients who will not take their meds, do not do well on meds because of the extreme fatique, disassociation, obesity causing metabolic disorders, seizures, incontinence, tremors, and other debilitating side effects caused by the meds. Because of disinformation from the pharmaceutical industry, the long term harm of many psychiatric drugs is being minimized, while the benefits are being exaggerated. It's time we start looking at the real cause of this crisis. A corrupted system that uses false data paid for by industries that are making a huge fortune off this mess. Let's end ghost writing, cherry picking studies for publication, direct consumer advertising of psychiatric drugs, kick backs to doctors, wining and dining of doctors. Let's bring integrity and science back to the study of mental wellness for starters by listening to the voices of those who are impacted the most, not clinicians, not family members, but those with lived experience.

The motto of the diability rights movement is 'Nothing about us without us!" People can and do recover. Start asking a person who is experiencing a complete recovery from psychosis and they will almost never say "Because I was restrained, isolated, and forced to take medication" They will say, because I was loved and cared for tenderly and listened to and I had choices and was empowered and had housing and a chance to make a meaningful productive life for myself in which my gifts could flourish"