I was asked recently why I didn’t actively seek out a specialized
school setting many years ago in which to educate my son.
My son has a serious mental illness, one which first
manifested when he was a child. I’ve
written about this before in Health Affairs
and will write about it again in a book scheduled for publication later this
year.
The argument is this.
If you put children with a special condition – such as serious mental
illness – into a classroom with other children with the same condition, then
you can adjust your educational services to meet the needs of those children
all at the same time – and you will get better outcomes.
That’s essentially how our health care delivery system has
often been built, too. Through most of
the twentieth century, people with mental illnesses were treated in one set of
hospitals (usually state hospitals). And people with most physical conditions
were treated in a different set of hospitals.
I wrote “most” above because we even segregated regular health
care sometimes. For example, we had
specialized TB hospitals through most of the twentieth century, remnants of
which still existed in some places as we turned the page to this century.
But segregating
services like this did not lead to better outcomes.
The best data to support this conclusion come from a study
of life expectancy of people who were in state psychiatric hospitals in several
different states. The study found that,
on average, the life expectancy of people in those hospitals was reduced by up
to twenty-five years or more.
To get a sense of how significant this is, consider
this. It is greater than the overall life
expectancy reduction attributable to cancer.
The problem with segregating health care services was
this. When you segregate treatment, you often
forget about the rest of the person. The
people with mental illness who died young were not usually dying because of
their mental illness, they were dying because they had other medical problems
that were undertreated, too.
This is the argument
against segregating educational services, too.
When we did move my son into a private school for children
with emotional disturbances, it focused almost entirely on managing his
emotional disturbance, and he received few, if any, educational services. He arguably didn’t get a better health outcome,
nor did he get a better educational outcome.
This is not to say that we should educate or treat everyone “in
the mainstream.” That’s too simplistic,
because it too often implies that a “one size fits all” standard should be the
norm, when that is not what children (or adults) with serious chronic
conditions, like mental illness, need.
What people need are services tailored to their own needs that
take their “whole person” into account.
There is really only one way to do this – by integrating
care and services.
For everyone, this
means that the right thing to do is to integrate general health treatment
and services with behavioral health treatment and services.
It means screening for behavioral health in the annual check-up,
just as we screen for weight, vision, hearing, blood pressure, heart, and lung
function. It also means connecting the
work of behavioral health specialists to primary care providers in the same way
that we want obesity care, cancer care, diabetes care, treatment for hypertension,
and pain management connected to primary care.
We want good communication, and each treatment strategy considered in
the context of all the others.
This gets meaningful results, as reflected in the chart that
accompanies this column.
But it also means making
the changes necessary to integrate health and behavioral health services with non-health
services.
In the case of children, this means integrating them with
educational services, and actually making community-based care a part of the overall
instructional plan. The million dollar question
(literally) is “who should pay for this – the educational or the health care
system?”
In the case of adults, this means integrating health and behavioral
healthcare services with housing, employment, and social and peer support
services, and recognizing that recovery is only possible through integration,
and only meaningful if it can be measured by an increase in life expectancy.
Otherwise we’re just spinning our wheels and repeating our
past mistakes.
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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