Suicide and Obamacare

In 2009, there were 36,891 suicides in the United States, according to the CDC.  This translates to a rate of 11.9 for every 100,000 people.

And rates among certain groups were even higher.  For example, the suicide rate among veterans, according to the Veterans Administration, was three times higher – or 35.9 per 100,000 veterans.

Suicide is a problem that ought to command our attention.

And it does.  For many years we have used suicide data as surrogates for documenting the consequences of serious mental illness.  We all know that the “danger to self” standard we use for determining when people with mental illness qualify for emergency care is, in effect, a “suicide may be imminent” standard.

As a result, for many years community mental health organizations have also been asked to track suicides as a measure of the effectiveness of their programming. 

But there are reasons why focusing on suicide rates too closely leads to inadequate public policy.

Suicides are just the tip of the iceberg.

Many more people consider or attempt suicide than die from it.  If you really want to be staggered by a national statistic, CDC reported that in 2011 7.8 percent of the teenage population had attempted suicide.  That is one thousand times as many as had died from it.

Also, the overwhelming majority of people with serious mental illness who die early do so not because of suicide, but because they are undertreated for other chronic conditions (such nicotine addiction, diabetes, and cardiovascular problems).  Some of these are linked to treatments they receive for their mental illnesses.

Finally, at the community level the number of suicides is usually so small that it is nearly impossible for any single organization to affect the rate more than anecdotally.  The agency may be able to point to individual cases where its intervention made a difference, but it will probably never be able to move the rate on its own.

And when the suicide rates don’t move, policy makers use this to justify decisions to reduce or eliminate program funding. 

So what does Obamacare have to do with suicide?

Many other provisions of the law have been lost in the din surrounding the most visible parts of the Affordable Care Act.

One of these was a mandate that the Department of Health and Human Services focus on the quality of our health care.  Since 2012, it has been doing this, along with a number of agencies in the Department, including the Substance Abuse and Mental Health Services Administration (SAMHSA). 

SAMHSA has just invested over two years in developing a National Behavioral Health Quality Framework (NBHQF). 

When the NBHQF is finalized, it will open the door to the use of new standard outcome indicators in determining the effectiveness of health and behavioral healthcare in our communities. 

We will be able to add these indicators to suicide rates, giving state and local officials much more powerful tools in judging the effectiveness of community mental health programs.

For example, suicide risk assessments (NQF #0104) will become a standard diagnostic tool in provider settings.  Providers will also be expected to use depression screening tools such as the PHQ-9 at six and twelve month intervals to monitor patients consistently over time (NQF #0710-0712).  And risky behavior assessment and counseling for children under the age of 13 will become a standard of practice (NQF #1406), as will diagnostic evaluation of children with major depressive disorder (NQF #1364-1365).

These all focus our attention on the 999 in every 1000 who consider and attempt suicide in addition to the one who tragically commits it.

We can also expect the integration of health and behavioral healthcare to become more systematic. 

Cardiovascular and diabetes monitoring of people who are prescribed antipsychotics (NQF #1933-1934) will become a standard of practice, as will management of ADHD in children in primary care settings (NQF #0107-0108). 

These indicators focus our attention on some of the other reasons people with mental illness die so young.

We all have an opportunity to say how we feel about these indicators. 

SAMHSA has released the NBHQFin draft form, and is accepting public comments on it until September 17, 2013.  Comments can be submitted using an online form, and don’t have to be formal or comprehensive.

The NBHQF will be finalized after the public comment period.  Then it will begin to guide the funding and delivery of mental health services. 

But for the next week, we all can say how we think the government should measure the quality of our behavioral healthcare services.

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

Why Are We Afraid of Mental Health Screening?

Should all school children be screened for mental health?

The evidence suggests that if we do not screen them, then we will be continuing a persistent and historical pattern of neglecting the mental health needs of our children.  But why let evidence get in the way of fear?

Over the past several months, legislators in a number of states have considering mandating – or at least offering – mental health screening for all children, either in the schools or in pediatricians’ offices. 

But when the Connecticut Legislature had a public hearing on a mental health screening bill recently, opponents came out in force. 

One parent called mandatory screening an “unnecessary invasion.”  The Connecticut Civil Liberties Union argued that mental health screenings should be optional.  A treatment provider asserted that the problem wasn’t with a lack of assessment, but the lack of treatment options.

And in recent days, a Palm Beach Post writer in Florida joined the chorus when he claimed that mental health screening is less “straightforward” than vision and hearing screening in an editorial entitled “Florida Should Not Require Mental Health Screenings in Schools.”

The truth is that if we don’t at least screen, then we don’t know what it is we’re supposed to treat.  And this “head in the sand” approach is what has gotten us into trouble in the first place.

The extent of our neglect of our children’s mental health needs is staggering.  

In 1999, the U.S. Surgeon General estimated that 10 percent of children had mental illnesses serious enough to disrupt their home life or schooling.  That percentage is still cited today, but we have more recent data, too.

For example, the Substance Abuse and Mental Health Services Administration noted that in 2009 two million children between the ages of 12 and 17, or 8.1 percent of the population, had a major depressive episode.

In the same report, SAMHSA also disclosed that 2.9 million children that year, or 12.1 percent of the population, received at least some mental health services in a school setting.

But here’s where the neglect comes in.  Only 407,000 children in 2009 received special education services because of their mental illness – just a fraction of those who needed them.

And this neglect is getting worse.  According to the most recent data from the U.S. Department of Education, only 389,000 children were offered special education services in 2011 as a result of their mental illness.  To put this number in context, this was:

• The smallest number in 20 years;
• A drop of over 20 percent in just six years; and
• Only 8 tenths of one percent of the entire school-age population.

In other words, less than one in every ten children with a serious mental illness is even identified as emotionally disturbed by our special education system.

As for the other nine in ten, their time bombs just tick silently.

Perhaps this could be justified if the stakes were low.  But they are not.  We all know the results of neglect.  We see them every day in our homes and neighborhoods, and, most tragically, on the news.

And what is most frustrating is that the “controversial” screening that could save lives is both simple and non-invasive – and straightforward. 

More often than not, mental health screening consists of a few questions that can be answered and scored in minutes. 

Here is a link to a commonly-used tool, called the PHQ-9.

It asks nine questions about how a person has felt in the last two weeks, with one follow-up question at the end.  Has the person been having trouble falling asleep or staying asleep, or sleeping too much? Been feeling tired? Experienced a poor appetite or overeating? Had trouble concentrating?

These are hardly the kinds of questions that probe so deeply into the psyche of the individual as to scar or stigmatize them for life. 

But, ironically, when we refuse to ask these questions we do end up stigmatizing people for life – if not costing them their lives.

It may seem hard to believe that there could be any fuss about using such screening tools universally when you consider the alternative.  Or that the tools can reasonably accurately identify an emerging mental illness.  But they can, and do.  And the more we use them, the better off we will be.

So what are our schools afraid of?  And, more importantly, what are we all afraid of? 

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

The War on Health

Policymakers across the country have declared war on health.  You may have missed the headline, but this is a war with many casualties.

Its objective is to topple health care as we know it.  When health care falls, our health will be the victim.

Battles are raging in many states to cut the legs out from under health care financing.

The Arizona Senate Appropriations Committee recently voted to eliminate the Medicaid program.  This would make 1.3 million people uninsured and cost the state $7.5 billion in federal funding. 

A Florida Senate leader has threatened to eliminate Medicaid unless the federal government agrees to massive changes.  This would cost Florida over $10 billion, and make 3 million people uninsured.

Wisconsin’s Governor has proposed dropping over 60,000 people from Medicaid because they are too rich.  “Too rich” means a two-person household income of less than $29,100.     

Medicaid isn’t the only target. 

Pennsylvania just cancelled its state-funded health insurance plan for low income residents.  As a result, 42,000 people lost their insurance.  A half million more on the waiting list have to fend for themselves.

New Jersey’s Governor proposed a 15% reduction in state health appropriations this year, six times greater than the overall reduction in his budget in his recent speech to the Legislature.

Florida’s Governor proposed eliminating state-run health department clinics, even when they generate revenue.  In Palm Beach County alone, this would cost 60,000 people their regular source of care.    

This war began quietly while the eyes of the public were focused on federal health reform.  The Center on Budget and Policy Priorities has detailed a number of battles we have already lost:

• New Jersey lowered income limits and reduced eligibility for the state’s Children’s Health Insurance Program.  50,000 more people are uninsured as a result.  
• Mississippi reduced its mental health budget by 22% in the last two years. 
• Illinois and Ohio cut community mental health services for children and reduced or eliminated community mental health services for adults who are not on Medicaid.

Elected officials declared this war on health by suggesting that health care was the weapon of mass destruction of our state economies.  It wasn’t.  The real weapons were the war in Iraq and Afghanistan at a total cost of over $1 trillion (and counting), for which the federal government did not have the courage to pay, and the greed of a financial industry which fattened our burst housing bubble. 

Health care is not a foe of the state, and people who need it should not be treated as enemy combatants.

However, people with mental illness are this war’s prisoners, often jailed instead of given the care they need.  This is not an exaggeration. The three largest mental health institutions in the country are Riker’s Island, the Cook County Jail, and the Los Angeles County Jail.  The largest mental health institution in Texas is the Harris County Jail.  It has 2,400 “patients” on any given day. 

In 2011, Texas is considering cutting $1.1 billion from state mental health services.  

According to the US Bureau of Justice Statistics, in 2005, more than half of over 2 million prison and jail inmates had mental health problems.    Over 1.25 million Americans are being “treated” for mental illness in our prisons and jails.

Elderly women and children are this war’s hostages. 

The Medicaid program funds 68% of the 1.8 million nursing home beds in the U.S.  Almost a million people live their lives in these beds.

650,000 of them are women, the vast majority over 75 years old and widowed.  In his recent speech, New Jersey Governor Christie articulated a fearful future for them.  Others share his vision “to move our aged, blind, and disabled [Medicaid] recipients into modern managed care.” 

These sick, elderly women suffer the indignity of being blamed for the state budget crisis they had nothing to do with creating.  If the Governor’s vision becomes reality, they won’t just have to cope with incredible health challenges.  They will be put at the mercy of the discredited “modern managed care” denial system.

Mostly under the radar, 31 states have already implemented cuts in children’s health programs.  As representatives of the Iowa Child and Family Policy Center and Voices for America’s Children note in their recent publication, The Healthy Child Story Book, for the first time in our history children may live shorter and less healthy lives than their parents.

Meanwhile, legislative bodies in Ohio, Louisiana, and Arizona have found the time to pass laws banning animal-human hybrids.  This is no joke.  The Louisiana bill’s sponsor, State Senator Danny Martiny, said the Louisiana Conference of Catholic Bishops asked him to introduce it.    

Louisiana ranks 49^th among the states in health, ahead of only Mississippi.  While imaginary beings occupy the attention of political and religious leaders, this war will produce millions of all-too-real casualties.