The Top Health Policy Stories of 2013

It has been a busy health policy year.  Here are my choices for the top health policy stories.  They all may not have made big headlines, but all will reverberate for some time. 

The Slowing of Healthcare Inflation

This was on my watch list coming into this year, and I’ll lead with it today because it was the best health policy news of the year.  When healthcare inflation came in low this year, it did all sorts of good things.  It helped balance state budgets, extended the life of the Medicare Trust Fund, and dropped the price tag of the Affordable Care Act.  Inflation is supposed to jump up this year as millions more become insured, but we can at least hope that a more modest trendline continues.

Mental Health Parity

And for some more good news… It took five years and incessant lobbying from heroes like Patrick Kennedy, but the final rule implementing the Mental Health Parity Act of 2008 was finally released this year, coinciding roughly with the 50^th anniversary of President Kennedy’s signing of the Community Mental Health Centers Act of 1963.  This isn’t the end of the fight for fairness and equity for people with mental illnesses. It is just a new beginning. One that will test a new generation of policy leaders. Let us hope – and pray – that these leaders will rise to the occasion and make policy with justice for all.

And now for the not-so-good news….

The Lack of Action in the Aftermath of Sandy Hook

Didn’t you just assume that policymakers would give us much stronger gun laws and much more robust mental health screening and services in the aftermath of the Sandy Hook massacre?  But for most, once the wailing quieted down, so did their commitment to act – just as it did after Tucson, Aurora, Blacksburg, and D.C.  It is a year later now.  What has really changed to prevent such a tragedy from happening again in the future?

The Death of Itzcoatl Ocampo

Itzcoatl Ocampo may not be a household name, but when he died last month in a jail cell while awaiting trial for murder, it was a depressing denouement to the story which probably demonstrated most effectively how our social welfare policies have failed.  Ocampo was accused of killing four homeless men two years ago.  I wrote about this in a column entitled California Screaming. But those victims’ lives had value – to their families and society. And Ocampo was a decorated veteran.  His death was reported to be a suicide; his mental health needs may have been neglected.  I’ve known policymakers who would argue that this was one person gone bad, and no one could have foreseen the outcome.  But they are wrong.  This story is way too familiar, and ties together the way we too often neglect homeless people with chronic mental illness, veterans, and veterans who are both homeless and chronically mentally ill.

Magic Johnson Speaks Out – Again – about AIDS

It was twenty-two years ago when Magic Johnson announced that he was infected with HIV.  At the time, most people saw HIV infection as a death sentence.  But as he and others lived on with the AIDS virus because of advances in pharmaceutical medicine, two things happened.  We grew to understand that people could live with HIV infection.  And we became more complacent about preventing it.  As Johnson and others point out year after year, a quarter million U.S. residents are infected and don’t even know it.

The Tragedy of Allen Daniel Hicks, Sr.

When Allen Daniel Hicks died of a stroke in 2012, he died of an often-silent chronic disease that attacks African American men more frequently than other men and women.  And we know this.  What made Mr. Hick’s death so tragic, and what made it a story in 2013, were the circumstances under which he died.  After suffering his stroke while driving his car in Florida, he was initially brought to jail, instead of a hospital, for resisting an officer – apparently while incapacitated. A settlement was announced this year, making news headlines in Tampa. But the whole story reminded us that race does matter, in the ways diseases attack us, and sometimes in the way we respond to them.

The Obamacare Rollout

If it hadn’t been for the government shutdown and Duck Dynasty, the problems with the Obamacare rollout might have been the only news story of the last three months of the year. In fact, this was such a pervasive story (and, I think, a political winner for the Republicans), that it probably even prevented another budget crisis from happening.  (I bet you didn’t even remember that Congress had originally scheduled one for this month.) Thank goodness for small favors, but with over a million people already insured because of Obamacare the real story of the rollout will not be written until next year.

And so in the meantime, in the words of St. Nick, Happy Christmas to all!

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

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/

Veterans and Mental Illness: A 2013 Update

Fifty-four percent of Iraq and Afghanistan war veterans who have sought treatment in the VA system since 2001 have been treated for mental disorders.

This is the second most-frequent diagnosis among these veterans.  It is an indicator of the profound effect recent war service is having on the mental health and well-being of our veterans.

The data come from a March, 2013, report entitled Analysis of VA Healthcare Utilization Among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) Veterans.  

Here are some numbers that reflect how extensive the use of VA services has been during the last decade.

As of the end of 2012, 2.5 million troops had served since the beginning of the Iraq and Afghanistan wars.  Just over 1.6 million had become eligible for VA healthcare.  Of that group, almost 900,000 had used VA healthcare services by the end of 2012.

These 900,000 veterans most often sought treatment in VA centers in the south or in the west.  More than 85,000 sought treatment in the VA South Central Healthcare Network, while more than 80,000 sought treatment in the VA Desert Pacific Healthcare Network.  By contrast, less than 39,000 sought treatment in the VA New England Healthcare System.

Of those seeking treatment, 88 percent were male, and 12 percent were female.  93 percent had been seen on an outpatient basis only, while 7 percent had been hospitalized in a VA hospital on at least one occasion. 

Almost half were under the age of 30.

And the 550,000 who accessed care during 2012 alone represented 9 percent of the total number of veterans receiving VA care during the 2012 fiscal year.

And while – as might be expected – musculoskeletal system conditions were the most frequent diagnosis (58 percent) over the entire decade, nearly as many veterans (54 percent, or over 486,000) were diagnosed with mental disorders.

Many had two or more disorders.

Post-traumatic Stress Disorder, or PTSD, was the most frequent mental disorder treated in VA settings.  Over a quarter million OEF/OIF/OND veterans were treated for PTSD by the end of 2012.  But depressive disorders were nearly as prevalent, with more than 200,000 veterans being diagnosed with those.  Also, nearly 200,000 veterans were treated for neurotic disorders.

Together, these numbers provide strong statistical evidence that repeated exposure to environmental risk factors, including violence, are factors in multiple mental health conditions.

On the other hand, only 59,000 were diagnosed with alcohol dependence and only 32,000 with drug dependence.  These numbers suggest just as strongly that the mental disorders among returning veterans were not caused by risk factors within the control of the veterans themselves.

On Memorial Day, all of these data should give us pause to think about the inadequate federal and services and systems to which our OEF/OIF/OND veterans are returning. 

While the VA has taken steps in recent years to extend additional services to returning veterans, including allowing veterans to enroll in VA health services for up to five years after service and waiving co-pays for health problems related to military service, a significant number of veterans have not yet entered – or will never enter – the VA system.  

In addition, as a number of news outlets, including the Daily Beast, reported in March 2013, 245,000 veterans had been waiting for more than a year for disability benefits as of December 2012.  The average wait time for Iraq and Afghanistan veterans was between 316 and 327 days.

The federal government could be doing more for these men and women, but so could our states.

Funding for mental health services were cut by $4.6 billion by states between 2009 and 2012, and the unwillingness of many states to expand Medicaid benefits this year is certain to take a toll on many of our returning veterans and their families.   

We all know that this is no way to treat our returning veterans.

So as we raise our flags on another Memorial Day, we should never forget that our responsibility to those who serve our country extends over 365 days. 

Now is the time to pay back those for the sacrifices they have made.  Or are we so cold as to expect these mostly young veterans to have made this sacrifice – along with the toll it took on their health and mental health – all by themselves?   

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

Pushing for Mental Health Parity

Former U.S. Congressman Patrick Kennedy was in South Florida last week pushing the radical idea that all people, including those with mental illness, are created equal.

What makes this idea radical in 2012 is that we continue to discriminate against the 6% of Americans who have serious mental illnesses.  Patrick Kennedy understands this, and is devoting his life after Congress to fighting on their behalf.

It is a fight that affects him personally, as it does the one-fifth of all children and the one-fourth of all adults with a diagnosable mental illness each year.

Discrimination against people with mental illness takes on many forms – arrests for loitering, incarceration instead of treatment, and perhaps most commonly in the unequal coverage by insurers for mental health conditions.

This last form of discrimination was supposed to have ended with the passage of the Mental Health Parity and Addiction Equity Act of 2008.  But the federal “rule” implementing this law has never been finalized.

At a field hearing hosted by Rep. Kennedy on October 9^th, a speaker from the American Psychiatric Association talked about the effect this has had.  In late 2011 Florida Blue (formerly Blue Cross Blue Shield of Florida) terminated its contracts with nearly every behavioral health provider in the state.  Providers had to sign new contracts for significantly less reimbursement.

Before that action, a psychologist was receiving just under $52 for a full counseling session, already far less than the average hourly rates paid to carpenters, plumbers, and electricians. 

After the action, the same psychologist received just $46 per hour.

The Florida insurance commissioner said that he had no jurisdiction over this. 

This isn’t just Florida’s problem.  I point out in testimony being presented today (October 17^th) at a public hearing on behavioral health parity hosted by the Connecticut Office of the Healthcare Advocate that actions like this affect every state.  Because there is no federal rule, a Connecticut insurer covering mental health care given in Florida also pays that pitiful amount – because the Florida insurer sets the reimbursement for others.

Insurance discrimination affects everyone.  But people with serious, chronic mental illnesses face worse today. 

As low income, single adults, they were all supposed to become eligible for Medicaid benefits in 2014 to cover mental health services.  But the U.S. Supreme Court said earlier this year that states could opt out of that Medicaid provision.  As homeless people, they often end up in jails and prisons because there are not enough places of care.  And as returning veterans – or “returning heroes,” as Rep. Kennedy prefers to call them – they often wait months to receive treatment through the VA.

There is still another way we deny people with mental illness fair treatment for their disease – ironically, by hiding behind their “civil rights.”  Local police officers and sheriffs known as mental health officers have become gatekeepers to emergency mental health services, and judges often make decisions about treatment.  A mental health officer once denied my son emergency care at a time of severe crisis because he didn’t think the crisis was severe enough to “deny his civil rights” by bringing him to a hospital for 24 hours.  So he didn’t get care that day. 

But he was jailed six times over the next three years. 

People with chronic mental illness, Kennedy noted at a reception my wife and I hosted at our home, don’t have a big political constituency. 

That’s why states have been able to cut $4.6 billion in mental health funding since 2009.

We can change this nightmarish reality if we want to. 

Here are just two examples of how.

In recent months my son has been involved with a behavioral health court in San Francisco.  Behavioral health courts take into account a person’s mental illness in devising treatment strategies to reduce recidivism.  There’s evidence that they work.

And instead of just playing catch-up long after a disease has ruined lives, we can begin with equal treatment – including parity in insurance coverage – for a set of chronic diseases that take as big a health toll each year as cancers.

Rep. Kennedy is optimistic that the tide will turn soon.  He believes that this time we will not repay war heroes with neglect, and that what we do for them will lift up everyone with mental illness.

I sure hope he’s right.

Because there are elections around the corner, and something has got to change. 

Mental Disorders in the Armed Forces

“In 2011, mental disorders accounted for more hospitalizations of U.S. service members than any other diagnostic category.” – Armed Forces Health Surveillance Center Medical Surveillance Monthly Report, June 2012

Recently, my daughter Elizabeth told me about a friend who stopped in to see her at the mall where she works while attending college.  Like her, he’s in his early twenties.  They worked together at a toy store a few years ago, and she hadn’t seen him since then.

He had enlisted in the army.  He was deployed overseas twice, and served a tour in a war zone.  He sustained a minor physical injury, now healed, while serving.

She said that he seemed a little down in the dumps when she saw him.  He told her that he is having trouble with his relationships since his return, but doesn’t think there’s anything wrong with him.  He’s pretty sure he doesn’t have PTSD, and sees no reason to seek counseling or other mental health supports.

Instead, he mostly keeps to himself and drinks a little more than he thinks he should.

Elizabeth is concerned about him, and should be.

Nearly one million (936,283 to be exact) active duty service members were diagnosed with at least one mental disorder from 2000 to 2011.

And, according to the most recent Armed Forces Health Surveillance Center Medical Surveillance Monthly Report, both the numbers and rates of service members diagnosed with mental disorders increased by 65% during the same period.

These just count active duty military personnel who are diagnosed with a mental disorder.  They don’t include either veterans or the young people who – like Elizabeth’s friend – have no formal diagnosis.

Mental disorders now account for more hospitalizations among U.S. service members than any other diagnostic category.  Suicide is the second leading cause of death among active service members (behind combat injuries), and mental disorders are the third most common reason for ambulatory care visits, behind musculoskeletal disorders and routine health care.  

Between 2003 and 2011, the rates of certain mental disorders with a significant environmental component soared as our involvement in Iraq and Afghanistan deepened.

• The rates of depression and adjustment disorders doubled.
• The anxiety rate tripled.
• The PTSD rate went up six-fold.

On the other hand, the combined rate of alcohol and substance abuse and dependence remained nearly the same (alcohol dependence was lower; other substance dependence was higher), as did the rates of schizophrenia and other psychoses. 

Just as worrisome is that the rates of the more environmentally-influenced mental disorders have not gone down as we’ve wound down our combat roles.  Between 2009 and 2011:

• The depression rate was about the same.
• The rate of adjustment disorders was 10% greater.
• The PTSD rate was 12% greater.
• The anxiety rate was 23% greater.

The surveillance report noted that all these numbers should be viewed in a broader context – that one in two adults will meet the criteria for a mental disorder at some point in their lifetimes.

Here’s the problem with that comparison.  There are only about 3 million total OEF/OIF (Iraq and Afghanistan) veterans and active duty personnel combined.  So the “lifetime” prevalence of mental disorders among the still mostly young people in these groups is already at least 30% - and could already be much higher.

As Elizabeth pointed out, “If they don’t get help today, where will they be ten years from now?”

Good question. 

So what should we do?

For one thing, we need to beef up mental health services to both active duty personnel and veterans, including planning the transition to from military to civilian life much more carefully than we have done in the past. 

We might also consider a couple of prevention strategies.  Adjustment disorders are twice as common in active duty teenagers as in any other military age group.  If we were to increase the age of recruitment by a year or two, we could prevent a lot of these.  In addition, anxiety and depression both peak when active duty personnel are in their late twenties.  If we restricted multiple deployments and limited separation from growing families, we might curtail these, too.

We also need to improve adult mental health services in general.  There are still too many policy leaders who avoid tackling this problem by pretending that mental disorders are personality weaknesses. 

But when they effectively paint at least 30% of brave, young active duty military personnel and veterans with this sloppy old brush, the real weaknesses are the policymakers’—most notably their own denial of reality.  

You can read more about service gaps in meeting the needs of veterans by clicking on the names of each of the following columns: Answering the Call, Veterans and Mental Illness, Veterans Dazed Not Dazzled by Mental Health Care, and Iraq and Back.

Answering the Call

It is worth noting on this “traditional” Memorial Day of May 30^th that over 6,400 service people have lost their lives so far while fighting our two most recent wars.

Unless we put more money into health and mental health care, many thousands more will eventually lose their lives fighting the physical and mental effects of these wars.

This past weekend, we learned that 45% of returning Iraq and Afghanistan War veterans are seeking compensation for service-related injuries. 

The challenge of finding the billions of dollars needed to treat these men and women will test us as a nation. 

It will likely stoke the fires of yet another protracted battle about “public option” health care in America.

This fight is about to take place because of two reasons.

The first is that the percentage of veterans seeking compensation is twice what it was in past wars.  “Invisible” injuries with behavioral manifestations, like PTSD and traumatic brain injury, account for much of the difference.

The second is that the VA system has too little capacity to meet the needs of even the lower percentages of those who have survived past wars and made similar claims for assistance.

This usually means that we begin by denying the existence of injuries we don’t easily see. 

I remember a Memorial Day parade I attended when I was a youngster in Middletown, Connecticut.  Then, as it still does today, Middletown closed its mile-long Main Street to traffic as a collection of high school and middle school bands, children’s sports teams, public safety officers, public officials, and groups escorted war veterans past cheering crowds.

The particular parade I recall featured two of Middletown’s earliest returning Vietnam veterans.  I remember standing on the roof of a two-story building watching them as they rode in a convertible down the parade route.  They were impressive in their dress uniforms, waving to the crowd.  One, as I recall, had lost a leg in battle.  The other, an arm and an eye.

Their injuries were undeniable.

The thing about parades, though, is that once one float passes by, we always turn our heads to see what comes next. 

And with Vietnam veterans, what injuries came next weren’t always so easy to see.  Agent Orange affected thousands, addiction affected tens of thousands, and PTSD affected hundreds of thousands.  As a matter of public policy, we ignored all of these for years as the Vietnam War’s real death toll mounted. 

The ongoing lack of capacity to serve the health and mental health needs of veterans is an even bigger threat to the well-being of veterans today.

A March 2012 Gulf War Veterans’ Illnesses Task Force Report provided some recent, statistical insight into this.  It noted that of the over 500,000 service members who served in Operation Desert Shield, 152,126 filed successful service-connected disability claims.  But only half – 79,415 – received VA healthcare.  The same was true of the almost 600,000 Desert Storm service members.  165,596 filed successful service-connected disability claims, but only 87,612 received VA healthcare.

There are three times as many Iraq and Afghanistan veterans as there were Desert Shield or Desert Storm veterans.  By percentage, twice as many returning Iraq and Afghanistan service veterans are filing claims as did Gulf War-era veterans. 

Based on the current numbers of claims being filed, over 750,000 may ultimately file successful claims, and at least 400,000 already need treatment for mental illnesses.  The VA system has the capacity to provide health and mental health care to only a fraction of them.

These are wars for which most of the rest of us have been called on to make no sacrifice by public officials who dishonor the sacrifices of brave veterans when they cower in fear at the word “taxes.” 

This may seem harsh, but we were asked to pay no new taxes for these wars, in spite of the billions of dollars we spent on them and the thousands of lives we sacrificed.  Does that seem right?

We would say that we meant it when we honored the sacrifices of veterans – especially those who have died fighting our wars – when we flew our flags, visited our cemeteries, and attended our parades this week.

So here’s our choice.  Will we answer the call when asked to sacrifice more tax dollars for health and mental health care for all? 

Or will we turn our backs on our veterans once the parades have passed us by?

Iraq and Back: Veterans Experience Tragic Delays in Obtaining Mental Health Care

A newly released report found that hundreds of thousands of veterans experience excessive delays in trying to obtain mental health services from the Veterans Administration (VA).  This is especially sad to consider today, both because May is Mental Health Month and the President has just renewed our troop commitment to Afghanistan.

William Hamilton was a 26 year old Iraq veteran when he died in May 2010.

One of five siblings, he joined the army when he was nineteen.

He experienced his first symptoms of mental illness while serving a tour in Iraq in 2005. He was diagnosed with PTSD and an anxiety disorder. 

He was discharged honorably later that year and sought treatment at a VA Center.

For four years, as his condition worsened, Hamilton bounced from one VA treatment setting to another. 

In 2006, he was diagnosed with major depressive disorder.  Chemical dependency complicated his treatment.  He was hospitalized at the VA on several occasions over the next two years, and had several unsuccessful VA transitional housing placements.

In 2009, he was diagnosed with schizoaffective disorder.  He had two extended stays at the VA hospital and another at a rehabilitation center. 

In 2010, he was also diagnosed with psychosis, and by then it seemed to his parents that the VA didn’t want to see him anymore. 

Three times in 2010, his parents contended, Hamilton was denied admission to a VA medical center. 

The first was early in the year after he was found running in and out of traffic and hospitalized in a community hospital.   The second was after he was hospitalized a month later after being found walking the streets naked.  

In both instances, hospital personnel documented that the VA center reported that there were no beds available those days. 

The third was a few days before he died in May.  Community hospital personnel said that when they spoke by phone with the VA center at 4:20 p.m. they were told that the VA did not accept transfers that late in the day.  So they found a Department of Defense hospital to admit him.  His parents expected him to be transferred to the VA center from there, but instead he was released three days later. 

His parents said that he was unstable.  He died four hours later when he stepped in front of a train.

Did the VA center’s failure to accept and treat William Hamilton contribute to his death that day?

His parents thought so, and the Office of the Inspector General of the Department of Veterans Affairs agreed to investigate.  It released the report of its findings a little over a month ago.

It determined that the VA center did have beds available on the first two dates in question, and should have admitted him.  However, it could not determine whether he had been denied admission in May, too. 

That’s because when it tried to verify the 4:20 pm phone call, the VA center records showed that “no outgoing calls were recorded from any VAMC extension to anywhere on the subject day.” No one could say why, but the OIG suggested that “it would not be plausible” that no outgoing calls were made during that entire day.

This tragic case is an exclamation point on a bigger story.

According to a new reportissued by the OIG just last week, hundreds of thousands of veterans experience delays in obtaining mental health evaluations and care from the VA.

The VA mandates that all initial mental health evaluations for veterans seeking mental health care from the VA for the first time be completed within fourteen days.

Over 373,000 veterans sought such care in FY2011.  Only 49% had their mental health evaluations completed within 14 days.   An estimated 28,000 evaluations were never completed at all.

The VA also mandates that patients new to a specific mental health clinic be granted appointments within fourteen days of when the veteran wants to be seen.

Out of 262,000 appointments, only 64% met this deadline.  94,000 veterans waited longer.

In Denver CO, the average wait was 19 days.  In Milwaukee WI, it was 28 days.  In Spokane WA, it was 80 days, and in Salisbury NC, it was 86. 

One of the things that jumps out at me about William Hamilton’s tragedy is that as his symptoms of mental illness became more and more serious, his treatment never seemed to catch up with his disease.

And what jumps out at me about the VA data is that where veterans’ mental health is concerned, playing catch-up seems to be the norm.

Comments are welcome on this and other columns.  If you have questions about this column or would like to receive an email notifying you when new OHPM columns are published, please email gionfriddopaul@gmail.com.

California Screaming

I first heard about James McGillivray, Lloyd “Jim” Middaugh, and Paulus “Dutch” Smit about a month ago, though not by name.

A tiny news crawler reported that three men were victims of a serial killer in southern California.

James McGillivray’s body was found near a Placentia, CA, shopping mall on December 21^st.  53 year-old McGillivray hung out almost every day at the mall.  Regulars there called him humble, unobtrusive, and a “nice guy.”  A 17 year-old commented “I don’t know why someone would kill him.”  McGillivray was sleeping when he was attacked and stabbed to death.

Jim Middaugh’s body was found along a riverbed trail in Anaheim on December 28^th.  He was also stabbed to death as he slept.  After his death, his mother – to whom Middaugh was exceptionally close – described her six foot, four inch son as a “gentle giant.”

Dutch Smit was 57 years old when his body was found outside a Yorba Linda public library on December 30^th.  He left three children and 10 grandchildren.  He was described by his daughter as “an honest and sincere soul.”  He enjoyed the library, often sitting and reading quietly for hours on end. 

McGillivray, Middaugh, and Smit had one thing in common.  

They were targeted for death because they were homeless.

The police considered McGillivray a “loiterer,” but his homelessness may have been tied to his drinking.  According to the National Coalition for the Homeless (NCH), a 2008 survey identified substance use as the leading cause of homelessness among single adults.

Smit, who called himself a wanderer, not a transient, was a hoarder who left his home when it became too unsafe to live in.  Hoarding is a symptom of mental illness.  Mental illness is the third leading cause of homelessness among single adults.

Middaugh lost his transitional living apartment for sex offenders after he had lunch with a friend at a Chinese restaurant that was too close to a public park where children might be playing.  He had been convicted for “lewd and lascivious acts on a minor under the age of 14.”  But the crime for which the 42 year old was still being punished had occurred more than twenty years in the past.

80% of crimes of violence against homeless people are committed by people under the age of 30. 

The suspect in the executions of McGillivray, Middaugh, and Smit is 23 years old.  Itzcoatl Ocampo, of Yorba Linda, CA, is a former Marine who served in Iraq.  As a Marine, Ocampo was reported to have earned at least four medals and commendations.

Ocampo was caught with blood on his hands on January 13^th, while executing a fourth homeless man, John Berry, a 64 year-old Vietnam Veteran.  Ocampo targeted the others simply because they were homeless, but apparently attacked Berry as retaliation after Berry spoke out in the media about the murders.  During the assault, a Good Samaritan intervened and chased Ocampo down. 

Police and prosecutors seem certain that Ocampo does not suffer from PTSD or other mental illness, but his attorney is not so sure.

There is no doubt that the Good Samaritan, 32 year old Donald Hopkins, now does.  He is receiving counseling after witnessing the violence because the scene keeps playing over and over again in his head.

This story – and the relative lack of national news attention it has received – bothers me a lot. 

Perhaps it is because of the way we treat homeless adults.  Of 235 cities surveyed by NCH, 33% prohibit “camping,” 30% prohibit “sitting or lying,” and 47% prohibit “loitering,” all of which are often selectively enforced against homeless people.  Of the ten "meanest cities" toward people who are homeless, three are in California, but my home state of Florida is home to four – St. Petersburg, Orlando, Bradenton, and Gainesville. 

Or maybe it is because we ostracize even children with behavioral health conditions, setting many of them on their path toward isolation and homelessness as adults.  The school district in my old Connecticut home town of Middletown made news last week for forcing such children into cell-like “scream rooms.” The federal government is now investigating.

Or maybe it is because my son also happens to live in California, and is homeless, has mental illness, and self-medicates.  He has been beaten up, cited for “sitting or lying” on a sidewalk, and been in jail, but he also loves reading in libraries, has an honest and sincere soul, and has been described as a gentle giant.

But I think what screams out most to me is that these executions call attention to our deeply flawed views about homelessness, behavioral health diseases, and the victims of violence in America.  

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Veterans Dazed, Not Dazzled, By Mental Health Care

Nearly 2.1 million veterans received mental health care from the Veterans Administration between 2006 and 2010.  According to a Government Accountability Office report released in October, 1.2 million veterans received mental health treatment in 2010 alone.

Almost 30% of the 7.2 million veterans who received treatment from the VA received mental health treatment.  So did 38% of Iraq and Afghanistan (“OEF/OIF”) veterans.  Many more probably needed it. 

The GAO report shows how pervasive mental illness is among veterans, and how co-occurring mental illnesses overwhelm both veterans and their service delivery system.

Younger veterans and reservists are especially affected.

We now have over 22 million living American veterans, but only 4 million served during World War II or the Korean War.  Seven million served during the Vietnam War, and almost 6 million are OEF/OIF veterans. 

OEF/OIF veterans accounted for 12% of all those receiving VA mental health services in 2010, a three-fold increase in just five years.  The GAO said this was expected “because of the nature of OEF/OIF veterans’ military service – veterans of this era typically had intense and frequent deployments.” 

Another October 2011 report entitled Losing the Battle: The Challenge of Military Suicide quantifies the tragic effect of this.  We lost 33 active and reserve duty Army personnel to suicide in July 2011 alone, and veterans – less than 10% of our population – account for 20% of all suicides in America.

There are three reasons why we lose so many veterans to suicide.  They are

• Traumatic brain injury, resulting in disability;
• Chronic pain from bodily injury; and
• Post Traumatic Stress Disorder (PTSD).

PTSD is far and away the most significant of these reasons.  I wrote about this in an earlier column.  As both the GAO report and the chart accompanying this column show, nearly half of the veterans receiving VA mental health care in 2010 had PTSD.  Most had at least one other mental health diagnosis, too.

It is a national failure that we don’t do a better job of identifying suicide risk factors and intervening earlier.

VA screening protocols may be part of the reason.  The authors of Losing the Battle report that returning veterans have historically been discouraged from admitting to mental health problems as they fill out their post-deployment screening forms.  As a result, the GAO reports the VA now “requires veterans treated in primary care settings to be screened for mental health conditions such as PTSD, depression, substance abuse disorders, as well as a history of military sexual trauma.”

And it turns out that veterans are more dazed than dazzled by the mental health care they are offered.

They avoid it, the VA told the GAO, because of stigma, lack of understanding about available services, logistical challenges accessing health services, and concerns about the quality of VA care.

• Mental illnesses are stigmatizing largely because many people still believe that they are “behavioral” weaknesses, not serious and life-threatening diseases that can shorten life expectancy by 25 years.
• Many also believe that services are only for people who are severely mentally ill.  They avoid seeking care for fear they will be labeled “whiners” and “psychosomatics.”
• Veterans, reservists, and non-veterans have logistical challenges in accessing services.  The VA does not have a full complement of mental health providers.  At least those they have get paid.  Major insurance companies are cutting reimbursements to community mental health providers, so patients who find providers outside of the VA often can no longer afford the out-of-pocket cost.
• It is impossible to have a quality mental health care system unless non-mental health professionals don’t just screen for – but are trained in managing – mental illnesses.

A 2009 SAMSHA reportfound similar reasons given by the 5.1 million civilians who also reported unmet mental health needs.

We can begin to fix this if we do four things:

1. Commit a fraction of the resources we committed to the wars to fight the mental illnesses they have caused – in the VA and in the community, wherever veterans, reservists, and non-veterans receive services.
2. Increase training of primary and specialty care providers so they recognize, diagnose, manage, and refer patients with mental illnesses.
3. Make periodic mental health screening a part of wellness exams for everyone, starting with young children.
4. Insist that insurers honor the mental health parity mandate.

We remember the sacrifices of our veterans when we fly our flag.  We honor those sacrifices when we take care of the men and women who made them.

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Veterans and Mental Illness

On a sultry June morning in our national’s capital last Friday, I visited the Vietnam Veterans Memorial. 

Scores of people moved silently along the Wall, viewing the names of the men and women who died in that war.  Some stopped and took pictures.  One group of men about my age surrounded one name for a photo.  Two young women posed in front of another, perhaps a grandfather or great uncle they never got to meet.

It is always an incredibly moving experience to visit the Wall.  It treats each of the people it memorializes with respect. There is no rank among those honored.  Officer or enlisted, rich or poor, each is given equal space and weight.

It is a form of acknowledgement and respect for which many veterans still fight.

Brave Vietnam veterans returned from Southeast Asia to educate our nation about the effects of war and violence.

I didn’t know anything about Post Traumatic Stress Disorder when I entered the Connecticut Legislature in the late 1970s.  I had only vaguely heard of “shell shock” from which some World War I and II veterans suffered.  At that time, the condition, like the way we thought of other mental illnesses, suggested some sort of stigmatizing weakness inherent in the individual.
Vietnam veterans changed our thinking.

They knew that PTSD was a real mental illness caused by violence. 

It took courage and strength to deliver this message to a nation not ready to hear it.  We didn’t know then that the violence of war, the violence of neighborhoods and families, and the trauma of natural disasters cause this illness.

As a result of their advocacy, the National Vietnam Veterans’ Readjustment Study (NVVRS) was conducted in 1983.

It found that a startling 830,000 Vietnam Veterans (26%) reported symptoms of PTSD, and many thousands more had other mental illnesses, such as Depression.  As the National Center for PTSD summarizes, a re-analysis of the data twenty years later suggested that up to a staggering 80% of Vietnam veterans reported at least some symptoms related to PTSD.

The Persian Gulf War introduced a new illness, Gulf War Syndrome, to our lexicon.  It is characterized by both physical and mental health problems. Only 8% of Gulf War veterans have been diagnosed with PTSD, possibly because their exposure to violence was of shorter duration.  But nearly 38%, or 263,000, Gulf War veterans sought treatment from the VA alone for illnesses and chronic conditions, many related to Gulf War Syndrome.

According to the U.S. Department of Veterans Affairs, an estimated 10% to 18% of returning Iraq and Afghanistan War veterans have PTSD, and up to 25% will have Depression.

Mental illness is as devastating in veterans as it is in any population.  According to the National Coalition on Homeless Veterans, on any given night 107,000 veterans are homeless.  76% of these men and women have behavioral health illnesses.  140,000 are imprisoned.  Half of these have mental health problems.

While I was in Washington, I attended a dinner with my wife Pam and her colleagues at Mental Health America and its affiliates around the country, at the completion of their annual conference and before the ringing of their symbolic freedom bell, forged from the chains once worn by people locked in mental institutions.  The 2011 Clifford Beers Award winner, Dr. Patricia Deegan, a survivor of schizophrenia, spoke of the courage of those who refuse to give in to the diagnosis of serious mental illness and to let it define them.

The Vietnam veterans who lobbied me had such courage, and refused to let PTSD define them.

We have fought three seemingly endless ten-year-plus wars in the last fifty years, and another one which caused significant physical and mental damage to its participants.  Millions of veterans and their families have been affected by PTSD.

Thousands of others who have been exposed to violence, terrorism, and natural disasters also share this experience.  

This should teach us an important lesson.

Mental illness doesn’t cause violence, but exposure to violence causes mental illness.

One of the things I love most about America is that although we are so diverse, we share a common purpose.   

The people whose names are on our national monuments - Washington, Lincoln, and the 58,272 on the Wall – remind us that this common purpose involves an entitlement to life, liberty, and the pursuit of happiness.

June 27 is PTSD Awareness Day.  It is a good day to remind ourselves why the bells of freedom mean so much to us all, especially the 7% of all adult Americans with PTSD.

The people whose names are on that Wall are remembered for sacrificing to give the rest of us a safer, more secure life.  They would not have forgotten those who came home with mental illness.

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