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.
To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com. Twitter: @pgionfriddo. Facebook: www.facebook.com/paul.gionfriddo. LinkedIn: www.linkedin.com/in/paulgionfriddo/
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