Why is mental illness the only chronic disease we don't begin to treat until Stage 4?
I posed that question in a presentation for over 400 attendees at last week’s winter meeting of the North Carolina Hospital Association. For an audience that witnesses first-hand the crowding of patients with mental illnesses into general hospital beds and emergency rooms, the question resonated.
Stage 4 of a chronic disease is associated with the imminent threat of death – a widely metastasized cancer, for example, or kidney disease so advanced that only dialysis or a transplant keeps the person alive.
The odds of recovery are long.
It is the same with mental illness. Either the patient's life or someone else's needs to be at stake before we guarantee access to treatment. That's Stage 4.
Diagnosing and treating a disease at Stage 1, 2, or 3, always improves the odds of survival and recovery.
Why not apply that standard to mental illness, too? In Stage 1, people show early signs of the disease – sleeplessness, anxiety, and fatigue, for example. These are signs that can be readily identified using common mental health screening tools, and symptoms that can be managed through the use of medications, counseling, or even healthy living.
In Stage 2, the disease is more advanced and the symptoms more pronounced. Depression may affect performance at school or work for example, or “command voices” (sometimes known as auditory hallucinations) may become louder and more pronounced. This is a stage at which – if we act aggressively and provide the proper supports – we can help patients maintain an independent life, even though they may require an occasional hospitalization.
People in Stage 3 are in need of ongoing treatment and support, which is often expensive – like chemotherapy in the case of cancer. But with mental illness, people in Stage 3 are far more likely to be in jails than in treatment beds, and among the homeless population instead of the general population.
While 6 percent of the general population has serious mental illness, that description applies to an estimated 15 percent of male prisoners, 31 percent of female prisoners, and one-quarter of all people who are homeless.
Intervening effectively during Stage 1, 2, or 3 can save lives and change the trajectories of those lives for literally millions of people.
But that isn’t what we usually do. According to the National Institute of Mental Health, just over half of adults with serious mental illness receive any treatment at all.
That finally may be about to change.
Last week, Florida’s Governor Rick Scott and the Federal Department of Health and Human Services came to a compromise. HHS is going to permit Florida to transition nearly all Medicaid patients into private managed care plans, including for those needing long term care. In return, the Governor dropped his opposition to Medicaid expansion. If the Legislature agrees, Medicaid will be available for many more adults with chronic diseases – especially for people with mental illnesses.
And this will make a huge difference.
If Florida implements Medicaid expansion, other states - like North Carolina - that are still on the fence are more likely to follow suit. And its managed care program may also offer cost-saving lessons to states that have already braced expansion.
Policymakers will have a new source of revenue to intervene more effectively to treat mental illness at every stage.
This means more screening and early intervention at Stage 1, more integration of behavioral health, education, and primary care services at Stage 2, and more emphasis on treatment as opposed to incarceration or neglect at Stage 3.
The best part is that states can pick and choose from a long menu those strategies that suit them the best.
And this means that patients in general hospitals throughout the country – where mood disorders are the 5th most common diagnosis – will finally get some relief.
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