Colorado, like many states, is experiencing a mental health crisis.
This crisis did not happen overnight. Our culture has long separated mind and body, disconnecting mental health from physical health. Disconnection kills. We are dying sooner and more often; more of us died last year from drug, alcohol and suicide than ever before, 150,000 Americans, and more than 3,000 Coloradans.
Their deaths are medical and social failures — despair, hopelessness and loneliness fuel our current crisis.
The human costs of the crisis can be seen in the care of Lawrence.
Lawrence suffered because his physicians were disconnected. His nephrologists thought he was too mentally ill for a nursing home. His psychiatrists thought he was too medically ill for a group home; so, he lived on a locked psychiatric unit for months.
Lawrence became disconnected over time.
His kidney function deteriorated over years. When he saw internists, they offered lifestyle changes which he could not make. His schizophrenia progressed over decades.
When he saw psychiatrists, they trialed medications that reduced his symptoms while dulling his mood. As his friends advanced careers and formed families, Lawrence went on disability.
For years, physicians discussed dialysis with him. He declined. One day, he was found face down, transported to the hospital, and the choice was no longer his. During his initial emergent dialysis, he struck a healthcare worker and Lawrence finished his first dialysis session in restraints.
When he would begin his next dialysis session was the question. After the assault on a health care worker, even an assault while delirious, no dialysis center would agree to treat him as an outpatient. He needed dialysis to live, so Lawrence stayed on a psychiatric unit for months.
He was treated with medications and therapy so that his mood settled, and his mind cleared. Three times a week, he went downstairs with a member of the nursing staff to watch Turner Classic Movies while receiving dialysis.
His clinicians sought outpatient treatment, telling dialysis centers that he loved Ava Gardner, major league baseball and his sister. They never reciprocated Lawrence’s love, because they could never look past his assaultive action.
As time stretched out, Lawrence grew eager to see a game under stadium lights instead of the hospital’s flickering fluorescent lights. His care team held meetings between the nephrologists and psychiatrists but could never build more than a fragment of a treatment plan.
Lawrence insisted that he had survived on fragmented care for decades. He was discharged on a Friday with plans for him to return to the emergency department when he experienced symptoms of worsening renal failure.
He died within the week. The coroner called it cardiac arrest; we call it a predictable outcome of the disconnections between the medical and mental health systems.
While it’s easy to be distracted by current events — politics and our drama — the issues that are having the most impact on people are those absent from cable news and our news feeds.
Let’s not be distracted by calls for walls but begin tearing down the walls people see every day and building bridges to unite facets of our health that should have never been disconnected.
Recently Gov. Jared Polis called for the creation of a behavioral health task force to address Colorado’s mental health system.
While we applaud these attempts, there have been many commissions both in Colorado and nationally that have attempted to address mental health. We think that in 2019, this latest call for a commission can be different.
We call on all our leaders, both local and national, to address the crisis of our time. Let’s bring forward thoughtful and comprehensive solutions to mental health care in Colorado and the nation. Let’s, at a minimum, ensure the commission creates the following connections:
Make every door the right door for mental health.
Despite the best intentions, we have created a specialty system for mental health disconnected from other health services. With health conditions as prevalent as mental illnesses and substance use disorders, we must consider how our financing and policy of mental health often limits where and when a person can get access to mental health services. Diagnosed with depression or anxiety in primary care? Here is a referral for this month. Identified as having a mental health need in school? Here is an evaluation this week.
To open doors, the commission can consider the amazing work of the State Innovation Model’s efforts to integrate mental health and primary care.
We need to embed mental health professionals in the places and spaces people present with need. We do not need to simply wait until they show up (if they show up) to the mental health system for care. No one would accept this if this were another health condition, but yet we expect and accept this in our mental healthcare.
Create a universal mental health and addiction benefit.
Fragmentation in health benefits fails to support mental health. A recent review of states finds that most are not enforcing the federal law requiring mental health benefits to be treated at the same level as medical benefits. This begs the question — why do we have two separate benefits if mental health is as inextricably linked to our health as it is? We call on lawmakers to consider creating a universal mental health benefit that applies to all — one that is not predicated on your coverage or socioeconomic status, but one that is guaranteed no matter what.
Support payment models which reinforce team-based care.
Just as our benefits are fragmented, so too are payment structures. We pay for mental health differently and often out of a different pot of money from physical health. These fractured payment paradigms undermine the ability for mental health to be treated in multiple settings and reinforce the fallacy that mental health is different from all other aspects of health.
Current payment models encourage individual care, but the evidence base shows team-based care is more cost-effective. We need payment models which allow for flexibility and encourage team-based care.
This crisis will not be solved overnight, but Colorado is poised to do so because it has experience in innovative payment mechanisms for mental health in places like Grand Junction.
It’s time for us to build more bridges, to reconnect more disconnected people, and to address a health issue that we all will feel even if we haven’t felt it yet. Colorado, let’s embrace your frontier spirit and take lead on radical reform for a mental health that reconnects all of us.
Can we make 2019 the year for a new vision for health — one that has mental health at the center?
Abraham Nussbaum is a psychiatrist and writer. Benjamin F. Miller is a clinical psychologist and Chief Strategy Officer for Well Being Trust, a national health foundation focused on advancing the mental, social and spiritual health of the nation.
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