Earlier in this series, St. Luke’s Dr. Kathryn Beattie recounted her family’s heartbreaking and long struggle to successfully get the right care for her son, who died last fall following an overdose. Two months before 20-year-old Jack Beattie passed away, he and his family had finally been given a diagnosis — bipolar.
Jack faced his interconnected mental health and substance abuse challenges in Seattle and at care settings across the country, but hundreds of Idahoans face the same daunting problems. Access for younger people, when detection and treatment can head off a lifetime of woes and costs, is an even greater challenge.
This week, Dr. Beattie writes about some steps that are being taken in the health care community to address the unmet needs that keep many from getting the right help.
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My son Jack’s story did not play out in Idaho, but it certainly could have. The rate of any mental illness in adult Idahoans is 20.3 percent (2015), significantly higher than the U.S. average of 17.9 percent.
Roughly 59,000 Idahoans suffer from serious mental illnesses that cause an inability to function day to day, such as a psychotic or a serious mood or anxiety disorder.
The Community Health Needs Assessments published by St. Luke’s Health System in September 2016 identified improving mental health and reducing suicide and substance abuse as the top three community health needs in all communities served by our organization.
These are recommendations I wholeheartedly support — both professionally as a pediatrician and personally as a mom still recovering from the death of my son after his extended battles.
Psychiatric illness and addiction are often treated separately, but I believe an integrated approach is needed to help improve the outcomes for the many who, like Jack, experience both mental illness and substance abuse.
Today, I’ll focus on the main obstacles we need to overcome to improve mental-health care for our children. My hope is that sharing Jack’s story can contribute to lessening the stigma associated with psychiatric illness and addiction — and put us on a path to better approaches for treatment.
1. Poor access to pediatric mental-health expertise and a lack of treatment options for addiction in adolescents.
Mental illness often strikes early in life. In fact, half of all mental illness emerges by the age of 14, and three-quarters by age 24. Research shows that early identification and intervention can prevent crises and prepare children to thrive. Unfortunately, one in seven American youth lives with a mental-health condition, but less than half receive any services.
Suicide is the second-leading cause of death for Idahoans ages 10 to 44, and the overall incidence of suicide in Idaho, at 19 per 100,000 residents, is 46 percent higher than the national average.
Despite these statistics, Idaho is ranked last in the nation for availability of psychiatric care. There is one psychiatrist per 15,676 residents in Idaho; one per 10,000 residents is considered adequate for access to diagnosis and treatment of the population.
At 5.2 psychiatrists and 10.7 psychologists per 100,000 residents, Ada and Canyon counties rank as the lowest in the United States (the average is 11 psychiatrists and 30.7 psychologists per 100,000 residents).
Pediatric psychiatric expertise in Idaho is even more scarce. An extensive search of the Idaho Board of Medicine surfaced only 20 actively licensed child and adolescent psychiatrists practicing in Idaho, which equates to 4.2 child and adolescent psychiatrists per 100,000 Idaho children, or one per 22,049 children/adolescents.
Idaho recognizes the need to improve mental-health services and has increased the state budget for the Mental Health Services Department in each of the past three years, making ours one of only 12 states in the country to do so.
To address the shortage, Dr. Sam Pullen, St. Luke’s Health System’s medical director of mental and behavioral health services, has brought The REACH Institute program for patient-centered mental health in pediatric primary care to Idaho.
Conducted as an intensive, in-person, three-day interactive course, followed by a six-month, case-based, distance learning program, this “mini-fellowship” educates pediatricians, family physicians, physician assistants, nurse practitioners, neurologists and psychiatrists in the most current information regarding diagnosis of mental and behavioral health conditions. Its scope includes the use of psychiatric medications for children and adolescents, and educational materials for patients and families. The program supports primary care providers in providing mental-health care, expanding availability of diagnosis and treatment.
St. Luke’s Children’s is actively recruiting to add two child and adolescent psychiatrists to our medical staff now and planning for more next year. Three additional full-time providers would be an increase of 15 percent in the state. These providers will reserve a portion of their clinic day to provide phone consultation services to primary care providers and will develop services for a continuum of care currently unavailable in Idaho. Today, only routine outpatient counseling and inpatient psychiatry care are available, and these two extremes are often too much or too little care for many patients.
In the fall of 2017, St. Luke’s Children’s will open a partial hospitalization program to provide five to six hours of therapeutic services, five to seven days a week, for a course of two to six weeks as indicated, to stabilize patients following a new diagnosis or acute crisis. Adolescents in a partial hospitalization program will be supported academically and will have the benefit of being at home with family at night for support.
The next step will be to establish an intensive outpatient program for children who are ready to return to their regular environments. Such programs run three hours a day for two to four days per week after school or work.
2) Inadequate knowledge and understanding of the science behind mental-health diseases, as well as a universal lack of coordination treating mental-health disorders and addiction.
Research into mental-health disorders is decades behind the diagnostic and treatment advances of heart disease and cancer. Recently, though, the National Institutes of Health has put in place an updated strategic plan with increased funding for mental-health conditions — specifically directed toward early identification and suicide prevention.
With improved funding, researchers are beginning to identify some of the answers to the underlying cause of both psychiatric illness and addiction in genetics.
For example, scientists have identified gene mutations that affect the transporter function of key neurotransmitters responsible for mood.
In other words, a depressed patient’s symptoms may be predisposed by genetics and then become manifest with stressors in the environment. Ultimately, we are learning that illnesses such as depression and bipolar are biological in nature, just as are cancer and heart disease — which also result from a combination of genetic and environmental factors. It is simply a matter of identifying the relevant molecules.
But the science of mental health and addiction is much more complex than the expression of just one or two genes affecting brain function, and much more research is needed to find the causes to support earlier diagnoses and develop treatment options.
Genetic research exploring the origins of mental-health disorders is a very new science. To bring the opportunity for participation in pivotal research to Idaho, St. Luke’s research department and mental and behavioral health services teams are connected with Dr. Jon McClellan’s genetics lab at the University of Washington, which is studying the genetics of early-onset psychosis as well as sporadic schizophrenia and bipolar disorder with psychosis. This will allow our patients and their families to be part of the research that unlocks answers for early diagnosis and improved treatment.
3. The stigma of mental-health illness, which can result in delayed recognition and thus delayed diagnosis, as well as a delayed willingness of patients and families to seek treatment.
The final critical requirement for improving mental health care is elimination of the stigma associated with psychiatric illnesses and addiction. Mental-health stigma is multifaceted and encompasses social stigma, the prejudice and discrimination directed toward individuals with mental-health disorders; self-stigma (or perceived stigma), the shame and fear of rejection or failure that a patient internalizes as a result of misconceptions about their disease; and structural stigma, the stigma incorporated into social and institutional practices that presents additional large-scale barriers to mental-health care.
The misconception that mental health can be controlled consciously has persisted, but the biological basis of mental illness and addiction helps to explain why these patients need much more than good intentions or stronger willpower to overcome their illnesses.
Patients with mental-health diseases have been treated differently across societies throughout history, and the misguided view that people with mental-health issues are all dangerous, violent, unpredictable, responsible for their illness or generally incompetent is often propagated by social institutions.
In medicine, the separation of mental-health care from physical health care, and the lack of parity between coverage for mental health and other health care, also makes it more challenging for patients to access treatment and further promotes the perception that mental-health disease is not on the same level as other diagnoses.
Why does stigma matter?
Stigma makes it less likely for a disease to be of interest for funding of research or services. As highlighted above, the National Institutes of Health and the state of Idaho are now driven by data to overcome the bias of this stigma and invest in mental health.
But when was the last time you, or anyone you know, participated in a walk or fundraiser dedicated to funding depression, anxiety, suicide or addiction research or treatment? Remember that one in five Idahoans suffers from mental illness, and the number of Americans who die each year from suicide and breast cancer is nearly equal (approximately 40,000 deaths per year). Those who are impacted by either should have hope for treatment.
Stigma makes it less likely for an individual to be transparent about symptoms of the disease because of the negative social implications of having that label if diagnosed.
And once a patient is diagnosed, social stigma makes it less likely that the individual will seek appropriate treatment for fear of being ostracized for having a mental-health disease. The belief that psychiatric disease and addiction are manifestations of weakness of character increases the possibility that the patient will believe that appropriate treatment is of no value to them, either because of the lack of understanding of the science or a poor sense of self-worth.
The Behavioral Health in Primary Care (BHIP) program is one way that St. Luke’s Clinic is trying to overcome the barriers of stigma. This program places mental-health professionals in family medicine and pediatric offices so that a trip to a separate location for care is not required, and the collaboration between providers is enhanced.
St. Luke’s providers routinely screen for depression risk at every visit, and referral to an in-clinic mental-health resource is frequently a seamless first step for initial evaluation and treatment options for a patient identified at risk.
A caring patient-centered culture — enhanced understanding through well-funded scientific research, improved prevention and treatment options — and supportive social networks can help to overcome stigma and improve early diagnosis and effective treatment of mental-health disorders and addiction.
Dr. Kathryn Beattie is the executive medical director of St. Luke’s Children’s Services. These articles first appeared on Dr. David Pate’s Prescription for Change blog. Dr. Pate is the president and CEO of St. Luke’s Health System.
This story is the third of three parts. Read Jack Beattie’s story here, Dr. Beattie’s follow-up on how we can help combat the opioid epidemic here and more information from the Idaho Department of Health and Welfare about the opioid issue in Idaho here.
If someone you know is in emotional crisis
Call the Idaho Suicide Prevention Hotline at 208-398-4357.
Warning signs to watch for:
▪ Talking about wanting to die.
▪ Talking about feeling hopeless or having no reason to live.
▪ Talking about feeling trapped or in unbearable pain.
▪ Talking about being a burden to others.
▪ Increasing use of alcohol or drugs.
▪ Acting anxious, agitated or recklessly.
▪ Sleeping too little or too much.
▪ Withdrawing or isolating themselves.
▪ Showing rage or talking about seeking revenge.
▪ Extreme mood swings.
Other things you can do to help:
▪ Do not leave the person alone.
▪ Be direct. Talk openly and matter-of-factly about suicide.
▪ Listen. Allow expressions of feelings. Accept the feelings.
▪ Be nonjudgmental. Don’t debate. Don’t lecture on the value of life.
▪ Don’t act shocked. This will put distance between you.
▪ Don’t be sworn to secrecy. Seek support.
▪ Offer hope that alternatives are available but do not offer glib reassurance.
▪ Take action. Remove means, such as guns or stockpiled pills.
▪ Get help by calling the hotline or visiting.
Source: Suicide Prevention Lifeline. Learn more at the Idaho Suicide Prevention website here.
Learn more about opioid abuse
▪ The U.S. Department of Health and Human Services has developed fact sheets about the opioid crisis. Find them at hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf.
▪ To learn more about how Idaho stacks up, see the National Safety Council’s “Prescription Nation” report at nsc.org/learn/NSC-Initiatives/Pages/Prescription-Nation-White-Paper.aspx.
▪ Find more information from the Idaho Department of Health and Welfare about opioid addiction in a previous article here.