Talking Mental Health Reform

I’ve been struggling with this post for several days now. As an idealistic nursing student who just came off of her psych rotation and a person who counts beloved family members and friends among those with mental illnesses the whole mental health issue is an important one to me. What I didn’t want was to add to the ranting, the all-American throwing around of opinion and feelings on the issue. Those have their places, but as I read over the growing online dialogue and listened in on conversations taking place in gyms and grocery stores, I felt something was missing. Something important.

We’ve spent a lot of time, in the past few days, talking about what we think. Postulation about what should be done (gun control, better mental health care – both of which I support – censor news and media, etc, etc.) is certainly therapeutic and I support that need (outside of the trend towards demonizing mental illness). But as hard as it is to keep my opinion to myself, that’s not what I felt needs to be talked about. I think we need to talk about what actual mental health reform means.

As I said before, I just finished my psychiatric nursing rotation (I’m a student, in case you missed it). Nurses aren’t doctors. We don’t diagnose. Despite that, I’ve studied the DSM’s for the major psychiatric illnesses and – possibly more importantly – attended group therapies and spent time in a local psychiatric center. I’ve watched people cry as they shared their struggle to ‘be normal’ because they don’t want this illness that is BiPolar disorder.  I’ve watched as a doctor scribbled hasty notes concerning a client’s neologism (the making up of words, a diagnostic in certain mental illnesses) because that same doctor had never heard anyone say Redonkulous before. I’ve learned that the ‘mentally ill’ are people, first and foremost, and they are sadly, almost criminally, under-represented and overlooked.

Some key points[1] I learned in my studies this last semester include:

1. There is no specific cause of mental illness. All current research points to varying, random mixes of any of the following factors: social and cultural norms, stress and anxiety, drugs – including alcohol, genetics, nature, neurological issues (eg: decreased or increased serotonin, etc.), physical illness, and nurture. 
2. No-one is ‘safe’ from the possibility of developing mental illness. Given the right circumstances it can be you.
3. All people (even you & me) have one or more indicators for any given mental illness. Many indicators, displayed over specific periods of time and within defined circumstances, are required for diagnosis. This means we really shouldn’t be labeling people because they’re different.
4. Occurrence of mental illness increases in the face of poverty. This could be due to poor nutrition, added stressors, or inadequate health care. Or it could be the other way around. No one is sure.

I think these points are particularly important to understand before we can, as a country, intelligently discuss ‘what is to be done about mental health care.’ I’ve listed my source – the theory textbook I spent a semester studying – at the bottom of this post. Feel free to find and read it, or take my word on it. Either way, don’t go in un-informed.

Before you read on, please, put aside your prejudices,  paranoia,  religion, social ideals, fears, or political party, and try to read with an open mind. I am going to be brutally honest about health care from a nursing student’s perspective. And the first thing a nurse is trained to do is examine his or her feelings and then put them aside. Get the data first, then make up your mind.

Now that the housekeeping is out of the way – what is to be done about Mental Health Care?

This is a really big question. So big that I’m not sure that people throwing it around know what they’re holding. For instance, it would be a quicker and easier answer to outright outlaw guns (including putting down insurrection and forceful taking of arms from those who refused to relinquish them) than to correct the ‘problem’ with health care.

Why?

1. There’s no one cause of mental illness. That means screening for it is really hard. For example, we can’t say “Oh, watch out for people who talk to themselves — ok, we can, but then you’ll be watching my Great Aunt as she putters around trying to remember what the hell she was doing and ignoring Johnny, who just lost his job and has a kid dying from cancer. So, ten seconds later, when he takes out his gun and kills his whole family, you’ll be shocked.
2. Poverty is a factor. Any way you slice it, poverty and mental illness go hand in hand. A while ago, Occupy Wall Street and the 1% movement was a big thing. And that bothered me because this ‘impoverished’ group of people were complaining about making less than several hundred thousand. Meanwhile, my family – along with 46.2 million [2] others – live on budgets far under the federal poverty guidelines which range from an annual income of $11,000 for a family of 1, to just shy of 50,000 for a family of 8 [3]. This means a whopping 42.6 million people are at increased risk of having or developing mental illness.
3. Yet, these impoverished people (who have to pay taxes, rent, and feed families on less than sustainable incomes are not covered by any kind of free health care. In fact 13.8% of impoverished children have no access to health care of any kind, and as much as a quarter of those 42.6 million impoverished Americans have no health care access[2]. That means: poor nutrition, higher risk of a physical illness which might increase risk of mental illness, and more stress.
4. Stress is a factor. I’m pretty sure I can make the statement that our culture is a culture of stress (just ask any soccer mom or retail manager) and not get too much argument. Changing social norms is a vast undertaking. Just ask Elizabeth Cady Stanton, who helped organize the 1848 Women’s Rights Convention. The 19th Amendment, which gave women the right they’d fought for so long, was ratified in 1920. That’s 72 years, folks, for something as simple as “I want to walk into a polling place and have my say.” Could you imagine the kind of personal and social commitment that reducing our stress culture would take? For instance, as a woman, my stressors include bills, work/grades, family health, food, fear of rape/mugging/theft (yes, that’s happened in my apartment complex), traffic/commute/defensive driving, scheduling (OMG, scheduling!), and generally trying to make sure my family is happy.
5. Drug culture. Now, I grew up in back country Virginia. People smoked pot, they drank. It was pretty much all there was to do outside of playing with cowpies, so I get that. But the fact remains that research shows drugs – including alcohol – is a major factor in mental illness [1]. It may only hide the illness, or it may exacerbate the illness. Meanwhile, our culture promotes the past-time of drinking. Did you know that, for women 1-2 drinks a week is all they can have before there are negative effects on their body and mind. Men get as much as 3-4. And none of that should be in the same day. Meanwhile, marijuana and other drugs effects on physical health may be inconclusive, but the one thing we can probably all agree on is that it changes one’s mental state. For some people, that’s all their brain needs to stop working the way we think it ‘should.’ This won’t set well with the “Legalize It” factions, who have won some major ground in recent years with the legalization of marijuana.
6. Stigma. This has been addressed elsewhere. But it needs said. Mental illness worsens over time [1]. In nursing terms, this means a person’s “baseline” (what’s normal for them) becomes less and less the social ideal of normal the longer they go untreated. But people fear seeking treatment. Because discrimination against mental illness is the one thing not covered by EOE (equal opportunity employment) laws in most states. How can I say that? You have to pass a mental wellness assessment to become a registered nurse, or a postal worker. You even have to pass a “test” of your mental and emotional health when applying for positions with companies like Blockbuster and Books  A Million. They call them employee surveys, but if you answer questions like “Everyone has blue days” positively, you won’t be employed. How do I know this? My husband used to have to grade the applications when he worked in management at these companies. And they aren’t the only ones.

And those are just the tip of the ice burg. The big one? Inadequate health care. That’s a whole list of its own. You may not want to read on. These facts are not pretty, and I’ve seen them in action.

1. Inadequate mental health facilities. The 1980’s saw a large-scale cut to mental health[1]. A lot of mental health facilities closed. People now must rely on hospitals, which are poorly equipped to handle mental illness, or the penal system. Most of the people in my psych rotation had been in and out of mental institutions or the penal system for years, which leads us to:
2. HMO’s. Because of our current ‘for pay’ medical services, people are forced out of treatment centers before they may be fully ready to take on the stressors of everyday life again. The need to stay is not a crutch or a weakness on the part of the ill (if you’ve ever spent time in a mental health facility, let me tell you, you’ll WANT to leave). Shoving them out the door is a cost-containment move on the part of healthcare HMO’s – the insurance providers those same people are paying for their access to health care. The clients leave, but they can’t cope or don’t have access to the meds/support they need and they come right on back. We call it ‘the revolving door.’ [1]
3. The Nursing Shortage. As if not having enough facilities for people who need services isn’t enough, we’re in a nursing shortage. When you go into mental health, you’ll see doctors who spend under 5 minutes asking random questions to their patients, 15 minutes taking report on the patient’s mental condition from the nurse, and then you won’t see them again. It’s largely the job of the nursing staff – from unlicensed care providers (often burly armed men who are good for a ‘show of force’) to the registered nurse herself – to monitor the patient and move them forward on their treatment plan. Imagine spending 8-12 hours trying to help one person cope with something they don’t understand and can’t control. Now, imagine that you’ve got to do that times 8-10 people (or more) and give medication and log everything into the computer. In one day. And it’s just you and one other nurse. Fun, huh? No big surprise that the retention rate for staffing is god awful and the schools can’t churn out enough fresh meat fast enough. And let me tell you, nursing school is a kind of hell I’m not sure I’d wish on my enemies. If you pass you’re 90% likely to be sued by the very people you’re just trying to help. The nursing shortage may eventually become a surplus but I doubt that’s likely during my career. That being said – you know how many of my class of 50 want to go into mental health nursing? 2.
4. There’s a real lag in neuroscience. The most difficult thing, I think, about psych medicine is: we don’t know. We don’t know why any of this stuff happens, so we don’t know what medication will work. Not to mention, it can all have different effects on different people depending on unknown chemical balances. Hell, there’s several medications I’ve read about that work, but the reason or method it works is yet unknown  And others which will help with one illness, and turn another into something very dangerous. We simply don’t know enough to be effective in the limited time frame we have to help people. And people get really sick of hoping that this next drug or therapy is going to be the ‘right one.’ There’s nothing worse than going through treatment after treatment hoping the next time will be the last, while you struggle against the odds to maintain ‘normal.’ If you doubt that just ask any terminal cancer patient what it feels like to hope without hope.

The last barrier to better mental health care is you. To make the kind of changes needed to actually make a difference in mental health care, each and every American is going to have to stop being the selfish little shits we are and give a crap about people we don’t know.

What will you sacrifice for the sake of your neighbor, or some kid in some town you don’t even know?

Will you give up aggressive driving? Nights at the bar? Your dislike for ObamaCare? How about your tax money? Your fear? Your career plans?

Can you? Or is the discussion about mental health just another way to help you deal with your feelings of social responsibility and your fear that last week’s tragedy could have been yours?

I, for one, hope it’s more than that. And I hope that I’ve been able to help make it a more intelligent conversation.

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References

[1] Townsend, Mary C. (2010). Essentials of Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice, 5 edition.

[2] http://www.census.gov/prod/2012pubs/p60-243.pdf

[3] http://aspe.hhs.gov/poverty/12poverty.shtml

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This blog post is dedicated to Dorothea Dix, who cared enough about mental illness to change their wold for the better.