Walking Out of the Darkness to Combat Mental Illness, but What about Funding?

This weekend the Out of the Darkness Walk sponsored by the American Foundation for Suicide Prevention will occur from June 1-2 to raise awareness and funds for suicide research and prevention. One June 3rd the President will convene a Mental Health Forum to follow-up on much the the initiatives for early identification and improved access to treatments proposed in his The Time Is Now gun violence prevention program. The problems of suicide and the depression that cause it are all too real. In the United States alone someone dies by suicide every 13 minutes.

Proposed Legislation

Organizations such as The American Foundation for Suicide Prevention and Mental Health America lauded the recent passage of S689 by the Senate as an important first step (it still must make its way through the House) in expanding mental health awareness and earlier diagnosis of mental illness. In particular, they cite its efforts to prevent suicide that is attained through several policies in the proposed legislation. Reauthorization of the Garret Lee Smith Memorial Act will provide youth suicide prevention programs through states and tribes. While new initiatives for training school and other personnel who regularly interact with youth in the early identification of mental illness and referral for appropriate services and treatment. It also seeks tho train this personnel in techniques for safe de-escalation of crisis situations involving individuals at risk of harming themselves. Finally, expansion of the Centers for Disease Control and Prevention’s National Violent Death Reporting System to all 50 states will create complete and accurate data that can be used to inform the design of effective (evidence-based) suicide prevention strategies.

This legislation targets children and youth. While it is important for us to improve capacity for mental health services in the schools so youth will be more resilient in facing the challenges and tragedies that every life faces, let us not lose site of the full extent of the morbidity (illness and disability) and mortality (dying) suffered by the mentally ill.  Newer thinking in neuropsychiatry is that mood disorders and schizophrenia (serious mental illness) are the result of disorders occurring during brain development. Often, the brain does not reach full maturity until age 25. For this reason, it is not until late adolescence and early adult hood that these conditions are diagnosed as symptoms become fully expressed and easily discernible from typical adolescent behavior.

Who Should Truly Be Targeted for Treatment

More than 42 million, that one of every 5 adults in this country screen positive for at least mild depressive symptoms. (NHANES 2005-2008) Unlike the situational depression that can plague many Americans, approximately 5% of the population must content with the disability and morbidity caused by serious mental illnesses. This includes recurrent major depressive disorder, bipolar disorder, and schizophrenia. These diseases cannot be cured. They are chronic illnesses that must be managed with multiple modalities of treatment from medicine, to therapy, appropriate diet and exercise.

Avoiding Suicide Alone Should Not Be The Standard of Care

Once a suicide has been successfully averted, it is not the end of the story (for the seriously mentally ill) it is only the beginning. The desire to end one’s life derives from intractable psychic pain from which the victim believes there is no method of escape but death. Preventing individuals with mental illness from committing suicide is a necessary and laudable advocacy. But there is a vast gulf between not committing suicide and attaining some quality of life. The mere act of remaining alive is not the logical progression to an acceptable quality of life. For those with serious mental illness, there is a continuous need to manage the feelings of helplessness and hopelessness that are the precursor to a suicide attempt. With that in mind, the pieces of legislation that perhaps require our greatest support are those that adequately address the one issue that continues to plague those suffering from serious mental illness the most. That issue is limited access to care. This manifest itself in a multitude of ways from long wait times to be taken on by a new psychiatrist, to the lack of coordination of care that can often occur between psycho-pharmacologist (those that prescribe and manage drugs) and psychotherapists (those who provide non-pharmaceutical based treatments), to the imperfect and ineffectual nature of those pharmaceuticals (for example, about half of those receiving anti-depressant treatment achieve remission) and finally and perhaps most importantly inadequate or completely lacking insurance coverage to pay for all the treatments mentioned. With full implementation of the Patient Protection and Affordable Care Act in 2014, new requirements with an Essential Health Benefit will hopefully ensure coverage of mental health services is indeed at parity. Medicaid expansion bills passed at the state level may prove to have the greatest impact in providing remedy to these problems related to insurance coverage. Ultimately monitoring for and enforcement of compliance will be key if the spirit of the legislation is to be achieved.

The Few and The Violent

For those with the greatest desire to keep their condition well-managed and  achieve compliance these obstacles can be insurmountable. Consider then, the minority within this 5% who are non-compliant, often psychotic patients with the greatest propensity for violence. They lack any motivation to receive treatment, manage their illness let alone stave off the psychosis which serves as the primary precursor to violence. In these times of federal budgetary austerity, there may be greater public health value in training that encourages a more accurate understanding of civil liberties and appropriately mandating violence preventing treatments. Keeping this small population of non-compliant, violent patients in treatment (even if against their will) is utilitarian. It may do the most to save lives and prevent more incidences like Sandy Hook Elementary School, an Aurora movie theater, Virginia Tech and the nameless victims like my brother Carey Hughley, III who have died at the hands of such patients. I was persuaded by  DJ Jaffe, a dedicated advocate for those with serious mental illness, Founder and diligent Editor of MentalIllness.org brings whose more critical analysis of S689 prompted me to re-examine my own views formed after reading the Time Is Now. The thesis of his argument is that none of the initiatives outlined in the Time Is Now as translated into proposed policy in the form of S689 provides violence prevention intervention to the group of individuals most at risk of committing that violence. I encourage everyone to take a look, decide for themselves than contact their local congressman, perhaps a better piece of legislation can be crafted in committee on the House side and survive reconciliation.

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