Monday, March 22, 2010

The death of Mental Health care

The House passed the health care bill - you know the one: everyone agrees that it's massively flawed and "needs to be fixed" in the future. It's the one that raises taxes for ten years, while only providing benefits for six, so one of the things that will have to be "fixed" is the huge gaping hole in the budget. A bunch of the budget fixes are wildly unpopular, so Congress is unlikely to do any of them, so the financial hole will be deep.

So let's think about what the Fed.Gov will have to do. If it can't raise revenue, it will have to cut costs - indeed, all the talk about "Death Panels" (if you're on the right) or "bending the curve" (if you're on the left) amount to the same thing: costs will be cut, probably in a crisis atmosphere, because there won't be any alternatives.

As a thought experiment, pretend that you're a CEO at a troubled company. Your balance sheet is an exciting shade of crimson, and the Board of Directors and shareholders are insisting that you turn things around. Looking at the annual budgets of your six departments, you see this. Which departments get the most of your attention?
Departments A, B, and C make up almost 85% of your cost. Any turnaround has to begin (and maybe end) there. As Willie Sutton answered when asked why he robbed banks, that's where the money is.

Do the new Department of Health will have a massive - maybe $200B a year - fiscal hole, and it will have to fix it. Bending the curve won't just be a good idea, it will be unavoidable. They'll start with the areas where there's the biggest expense and the smallest number of people served. And that area is Mental Health.

Consider Depression:
The total cost per patient was estimated at € 5,500 (95%CI € 5,000—6,100) over six months in 2005 prices. Direct costs were estimated at € 1,900 (€ 1,700–2,200), 35% of total costs, and indirect costs at € 3,600 (€ 3,100–4,100), 65% of total costs. The cost for antidepressants represented only 4% of the total costs. [emphasis mine]
You can't blame Prozac - it's just not a big part of the cost, which is almost $15,000/year per patient (conversion rate €1 = $1.30). Or Schizophrenia:
After 2 years, the rate of patients treated successfully is 82,7% for LA risperidone, 74,8% for olanzapine and 57,3% for haloperidol depot. The 2 year-cost per patient treated by LA risperidone is 14,055 Euro. [emphasis mine]
That article is interesting, because there were several other treatments in the study, some of which were twice as expensive. That's a lot of money. And so it will be cut, because it will have to be cut. What happens then?

David over at Fighting For Liberty had a post regarding mental health in his town:

This morning, I received this news:

Teenager’s killer released from psychiatric hospital

The parents of a 14-year old girl who was shot and killed want to know why their daughter’s killer is free to walk the streets.

…But just 5-years after he killed the steele’s daughter Jasmine, and seriously wounded a woman, James Mann was released to a halfway house not far from where the Steele’s live.

He’s now somewhere in my quaint little hometown.

Understand, this town isn’t big. Most everyone lives within two square miles or so. This … creature … is now my neighbor.

David, that's not a creature. That's someone's son: [See Update at end]
I've seen real demons, in someone's eyes, the window to their soul. Something is strange, and then there's a realization that something's there. Literally, the hair stood up on the back of my neck, and time slowed down as adrenaline flooded my system. My dog growled, and then fled. I don't blame him; I would have fled myself if I could have.


Today, we have ... what can only be described as wonder drugs. I remember ancient times, back around 1970. A man described how Lithium changed his life. But Lithium was delivered as a salt, because that was the only way the body could absorb it. I wonder how his life went, with the Lithium salts slowly poisoning his system. Now that I've seen a demon myself, I guess it beat the alternative. The drugs are a lot better now, but nobody quite seems to really understand what goes on with brain chemistry.

I remember how people talked about the "weird kid". It's better now, but not a lot.

All that's fixin' to end, because it's going to have to end. There just won't be the money to pay for all this. Sure, there will be money for the meds (some of them, anyway - remember, Prosac was only 4% of the cost). There won't be money for the doctors to monitor the patients and make sure that the patients take their meds. And so a ticking time bomb will be sent out to live with society. Some parts of society - like David - will think about the "Old Yeller" cure:
He should have fried in the chair. And I don’t want to hear this righteousness about no capital punishment for mentally unstable. This creature murdered a 14-year-old girl. You don’t give murderers a bottle of pills and let ‘em roam free.
David's a friend, and what he writes isn't wrong. But there's another side to the story. I've witnessed the "switch going off". I've seen for myself how the new meds keep the switch from going off - I'm not joking that these are Wonder Drugs, because they help balance the brain chemistry, and keep the Demon at bay. But it's not cheap, or easy, to keep that Demon chained:

Harry, three, and his sister Elise Donnison, two, were found [dead] in holdalls [carseats] in the car in Heathfield on Wednesday.

Their father Paul Donnison said: "Their lives have been taken away in the most cruel way. I am unable to understand."

Their mother Fiona Donnison, 43, of Lightwater, Surrey, was arrested on suspicion of murder. She remains in hospital [after an apparent suicide attempt] and is yet to be questioned.

Medical innovation will go out the window, which means no new Wonder Drugs. Listen to the talk about "savings" from eliminating "me-too" drugs. Well one of those "me-too" drugs had different side effects from the first one, side effects that didn't cause convulsions. It costs more, though, so there will be less of it, because there will have to be less of it.

Stephany writes about the many failings of the current mental health care system. To read her archives is to see just how vulnerable these people are - to themselves, to others, and to the government. Soon there will be many more of these people. What happens to them?

I'm told that despair is one of the deadly sins, but it's moments like this that bring it bubbling right up to just beneath the surface. I do think that many - maybe even most - of the people who have passed this bill have good intentions, but they've parked their car on a steep hill, with the wheels straight and without the parking brake set. They think that they can run to stop the car if it slips out of gear. I don't think that they can.

I also hear that taking the Lord's name in vain is a sin, and so I will not say more about those who have just paved a super highway to Hell with their good intentions.

UPDATE 22 March 2010 10:36: It's important to point out that David's a friend, and a good man. It's unlikely in the extreme that he's the only one in his town worried for his family. He's probably rational to be worried.

Thre's been a great advance in the public's perception of mental health over the last 30 years, for which I'm profoundly grateful. This sort of situation jeopardizes that advance, and is likely to become all too common in the years ahead. The "Old Yeller" solution is particularly horrifying to me, because there is no retribution associated with it; it's purely a safety measure. It's depressing beyond words to think that this sort of thing may become popular, because it's the only option left to the people.


David said...

Perhaps too harsh a choice of words on my part, BP. But knowing that someone who murdered a young girl moves into your neighborhood is not easy to take when you've got young kids.

I'm not looking for forgiveness for speaking with my heart here, but I'm angered. When I think about who the victim is, I think about that dead girl and her dad and because of that I have a hard time putting myself in the shoes of a killer's father.

David said...

... and for the record - I updated that post with further thoughts and an apology for the name-calling.

roaming_gnome said...

In the 80's when health care funding was cut, a mental health hospital was closed in the town I went to college in. All of the mentally ill people (mostly schizophrenics) were released onto the street with a months supply of medication and the clothes on their back. Most of them are still there, sleeping in street corners and talking to themselves. I don't see it getting any better now.

Stan said...

I have to ask this simple question:

Would it make difference if the person that committed a murder was paroled from prison instead of having a mental health label.

Because the facts and real data speak volumes in these highly publicized scare mongering campaigns.

It is far more likely you will have a paroled murderer from prison moving into your nieghborhood with you never even knowing their background or the crime they have committed.

Now, let us add that those deemed/labeled with serious mental illness are far more likely to be the victims of violence, than to perpetrate a violent crime. (In both cases when violence is a prevalent feature of a particular crime, it usually or most often has associations with drug and alcohol abuse coupled together with these rare and tragic events)

I personally don't excuse violent crimes (especially murder) whether or not there is a mental health diagnosis attached or not. I happen to believe when someone takes a life, there must be a some related value and punishment given to the individual found guilty by our society.

Our mental health system is in total disarray and does not have the modality or tools set in place to treat those with mental health issues humanely or effectively today.

Unfortunately I do not see any positive changes coming our way anytime soon. This Health Care Reform sure isn't going to address the failed core issues involved.

So in the end the fear mongering lives on, the denial or curtailing of human/constitutional rights campaigns continue, and the targeting of vulnerable populations of citizens will go forth unabated by a society and media that is looking for easy scapegoats as solutions far to often for their self made/reflected social ills.

soulful sepulcher said...

Here is another side of life in the mental health system, where anyone can read about the day a mental health judge deemed my daughter a vulnerable citizen from society, a person who can suffer harm from the public and the only answer the court gave was to lock her up in the state institution; now months have passed and we have advocated sternly for simple life basics and dignity...such as fresh air breaks and outings outside of the hospital with us. It took months and months just to get her name spelled correctly. Imagine when we have meetings that discuss housing. There isn't any. Facilities ARE closing, funding IS being cut further.

The stigma that follows a person with a mental health label is atrocious, for it is the ignorant of facts society that only reads the horror forensic stories, and assumes ALL of "them" are forensic patients, when in most patients with these labels are at high risk for being a victim of crime themselves.

Borepatch said...

Stan, the system is - as an engineer would say - hopelessly wedged. It looks to me that it's going to get more wedged, since there is such as crisis of governmental legitimacy developing in this country right now. Since this new plan is promulgated by the government, it will inherit this added crisis on top of the ones it already has.

Stephany, thanks for the link. It's the one I was thinking of, but couldn't find.

My biggest concern is that, even with all the problems we have today, we've made big strides in people's attitudes in the last 30 years. I fear that all that will be at risk now.

Thanks to everyone for their comments on this.

soulful sepulcher said...

As long as we all keep speaking out, we can somehow keep knowledge moving forward. This is a very complex subject, for sure, and one that will never go away as far as need goes. Until the system corrects itself with outpatient care and choices for care, not always based on medications....this will not stop.

My daughter ending up in the system from a wrong diagnosis should alarm anyone who enters the psychiatric medication based paradigm of care. (a cautionary tale at best, but with DSM-5 expanding labels and approval of meds by the FDA with renewed and remarketed drugs (such as Seroquel)it becomes a murky muddy watered trench when discussing "mental health".

Everyone is at risk for wrong things to happen to them.

ASM826 said...

Laws, rules, and gov't agencies are a crude tool to try to help people. They just don't work very well, and often they work in unintended ways.

I have one time seen what I believed to be real evil possess a person. It is a long story, but I do not think the modern words of mental health care described the events.

M. Scott Peck (author of The Road Less Traveled) wrote a book called People of the Lie based on his experiences as a mental health professional. I recommend to anyone who thinks there are easy answers.

soulful sepulcher said...

I have witnessed the modern medical modality based on pharmaceuticals induce an eye as the one depicted in this post, drug induced psychosis from prescribed drugs such as Zyprexa, Zoloft, Seroquel et al; you may have been looking at the limbic section of the brain in an active brain scan.

Chemically induced psychosis via doctor prescriptions, paid by private insurance, tax payers, medicaid and now OBAMA's nightmare.

Welcome, to 1984, and the end of the world as you ever imagined it.