Mental health care in Michigan has room for improvement, but will it?

I stared at the Excel sheet and looked at the first person on the list. She was in her mid-40s, single, white and had been to the emergency room over 38 times in one year.

As the medical director for quality at a community hospital in Metro Detroit, I and several members of our staff met with our local community mental health agency to figure out how many of our Medicaid patients were both high utilizers of our emergency room and had a behavioral health diagnosis.

I reviewed the medical record of Ms. X, the woman at the top of the list. Her chief complaints varied from headaches to back pain to abdominal pain. She was never admitted to the hospital, but her ER visits always consisted of expensive imaging studies (CT scans, MRIs, etc.), lab work and her demand that her pain would require narcotics. Behind the medical complaints, the patient’s past medical history included a diagnosis of anxiety and substance abuse.

We concluded that her persistent visits were most likely due to an underlying narcotic addiction combined with an anxiety disorder: she would present with a physical problem in order to gain access to the narcotics to which she was addicted. Several of the patients on the list had similar stories, but others were “frequent flyers,” due to repeated suicidal attempts or exacerbations of an underlying psychotic condition.

We adjourned our meeting with an agreement to develop a process to have these patients identified in the emergency room and then evaluated by a mental health social worker, in hopes of diverting them to a behavioral health setting where their problems could be appropriately addressed.

Working on this project revealed how greatly we need reform of Michigan’s mental health system. I am not a psychiatrist, but as the person responsible for quality healthcare in my hospital, I feel that, if I am being held to providing the best possible care for our patients, the current policy dynamics that need to be understood and addressed.

Cases like Ms. X’s forced me to study Michigan’s public mental health system and what I found is an underfunded and decentralized system that cannot hope to achieve the goal of providing services to the most vulnerable members of our society.

A decentralized system

The project I worked on at my hospital is based on the collaboration of one community hospital in one county to identify and appropriately treat this subgroup of patients.

What about the patients from other counties that make it to our emergency department? What about the same county patients who are seen at neighboring hospitals not involved in our integrated process? Pilot projects can be educational before committing to a major initiative, but, why isn’t the state developing a similar project that involves all counties and all major health systems in Michigan?

Prior to my work on this project, I had little to no understanding of how Michigan’s public mental health system was administered. I had assumed there was a central state office that had authority over several smaller local branches.

Instead, Michigan’s public mental health is administered through over 46 community mental health service agencies (CMHSP). While some of the smaller county agencies have coordinated together to provide services, they remain independent organizations, structurally and philosophically.

One could argue that more local control can allow the individual CMHSPs to tailor programs and resources to the varied demographics they serve. The counterpoint is that each CMHSP is forced to go it alone with limited resources. My concern is that our system is far too fragmented without a strong central state entity to monitor the local CMHSPs, share best practices and set standards. A patient should receive the same high-level of care whether they live in Detroit or Tawas.

The need for integration

More than 10 years ago, then-Gov. Jennifer Granholm convened the Michigan Mental Health Commission to fix a “broken” system. I took particular notice of one part of its recommendations:

  • Provide wide access to patient treatment information while maintaining confidentiality
  • Provide medical integration with primary care providers
  • Provide continuity of care tracking

I applaud the Commission’s foresight in that non-behavioral health medicine has continued to accomplish these same goals. With most health systems adopting electronic medical records, the time is right for our public mental health system to fully integrate with their physical medicine partners to assure appropriate and efficient care.

In 2013, Gov. Rick Snyder’s Mental Health and Wellness Commission issued a recommendation to “endorse the Michigan Health Information Network efforts to support care-coordination across the boundaries of physical and behavioral health settings.” As reported in Crain’s, there has been progress made in this recommendation.

My concern is that we are not doing enough. Simply having the ability to link a patient’s mental and physical health history may not allow health professionals to make timely interventions. Because of the stigma associated with mental illness and substance abuse, patients are not likely to share this in emergency rooms. One more reason to have a stronger central state entity to help guide this process with the multiple health systems and hospitals in Michigan.

Rethinking long-term inpatient care

Closing psychiatric hospitals in favor of treating more patients in the community (deinstitutionalization) has been the practice for several decades in Michigan and in the rest of the country. The reasons are manifold: the history of abuse of patients in several institutions, the potential for civil rights violations, and the development of new drugs which have given hope that patients could be treated in a community setting.

The number of Michigan’s public health hospitals designed for mental illness and developmental disabilities has decreased to five, with the argument made that we can continue to serve this vulnerable population without a larger number of long-term, inpatient beds. A recent opinion piece in the Journal of the American Medical Association has countered this well-established notion by proposing that we “bring back asylums”. The authors of this article point to the fact that several of the most chronically ill patients are ill-suited to be taken care of in an ambulatory setting and, instead, fill emergency rooms. From my own review at the hospital I work at, I believe the authors are accurate in their claims.

The recommendations I have outlined – creating a stronger state authority, developing better integration between behavioral medicine and physical medicine, and investing in additional inpatient facilities for the chronically ill – will come at a cost, at a time when our locally elected officials appear obsessed with cutting spending. I would argue that without reform and investment, our system will remain inefficient and, thereby, wasteful.

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Comments

Steve S.
Sun, 06/28/2015 - 9:54am
I am suffering from GAD and Depression. When I say suffering I mean I have it and it is far from managed. For decades I made periodic attempts to get to the cause of my chest pain. Every time I got a battery of cardiac test and was told everything thing is fine. It never once circled back to the initial complaint with a then what. Finally just a couple years ago while I was finally diagnosed with severe depression, I guess I made it obvious when I attempted suicide, I was once again at the emergency room for chest pain I asked if they had something like a margarita in a shot. Finally I found relief and ended up with a script for Xanax after that. My point that goes with your point is, the problem is greater than routing known mental health patients to the proper route but considering a mental health issue after the physical route finds nothing. I saw many different doctors and several hospitals and none even broached the subject with me. My current thing I am now working on is mood enhancement. I feel strongly that being stuck in a depressive state is a cyclical perpetuity of the state. I feel strongly I need something that makes me feel happy, a happy pill, even a silly pill. Something that will break my current cycle. I have been told every time, ya I wish there there was something too. To me that is not really funny. The obvious path for the happy pill is not a pill, it is marijuana. Specifically strains that attack anxiety and boost energy and there are plenty of choices.
DLB
Mon, 06/29/2015 - 10:45am
The mental Heath system in the state was one of the best in the country in the late 70's early 80's. Then Engler came in and destroyed the state system with promises of sending the money saved from closure of the state institutions to local CMH's. Surprise, surprise republicans lied and the money was used for tax cuts instead. We need to fix it now! Of course with the current party in charge not even being able to even fix our roads, I don't have much hope.
Joe
Mon, 06/29/2015 - 1:58pm
30 to 40 years ago we had effective, efficient champions in the Michigan Legislature who cared about and protected the delivery of mental health services to those members of society for whom there was no voice. We no longer have politicians who will take on the thankless task of advocating for the mentally ill. That is why a high percentage of mentally ill patients are first seen in County jails, and in law enforcement venues. The Commission convened by then-Governor Granholm came up with a report, and, as usual for committees and reports, nothing transpired or happened to implement the recommendations. This issue begs for resolution, but it will take strong and committed individuals with power and money to fix these problems.
Leon L. Hulett, PE
Mon, 06/29/2015 - 5:21pm
What was the cost to treat Ms. X for one year?
Leon L. Hulett, PE
Wed, 07/01/2015 - 10:59am
Vikram, I don't agree with you. I don't agree with Joe or DLB either about how great our mental health system in Michigan was back then. It is not good and never was. I knew a woman in the 50's whose husband didn't want her. He wanted to run around. She was put in a state mental institution and he had a housekeeper that washed no dishes and cleaned no floors into the house within the week. The institutionalized wife was raped, electroshocked and given 250 mg injections of Thorazine to keep her quite. When the husband found she had been raped he brought her home and kept her for the rest of his life. She was ruined and he was the unhappiest of men. A young man, a college graduate, in 1957 was put in a state institution for "Kissing a Girl" under the Criminal Psychopath law (1950) of that time. I have the case file from the court. That law was rescinded in 1967 (I have a copy of the law) and the institution, the Ionia State Mental Hospital, was closed in 1972 amidst broad claims of violating people civil rights. The doctor in charge of the hospital told the young man (in 1960) that 70 percent of the people there did not deserve to be there (in such an institution). I told him none of them "deserved to be there." He said, "But one man raped the wife of the man in charge and had tied him up and forced him to watch." "These were dangerous people." I told the man, from 1957, there are places for people that do crimes like that and in this rapist's case he would not have raped the guy's wife if he had been in the correct place, prison. Also, the institution had obviously done him no good as he was repeating the crime. He did not "deserve" to be there either, he deserved to be in the right place. When the young man who kissed the girl, the college graduate, left the institution in 1960 he got a minimum wage job in another country and was, in my opinion "ruinied" by the mental health system in Michigan. [The rest of the story is: that the Sheriff who arrested this man from 1957, had a son from the same high-school, that had "depants" a young man, came up behind him and pulled his pants down to his ankles in a public place. The second time he did it, that young man, turned and knocked the Sheriff's son unconscious and a sprawl on the floor. The Sheriff did not recuse himself and no mention was made in the case record, only my interviews. The judge had been personally keeping an eye on a local "trouble spot" where sexual predators were known to frequent. Sure enough, the young man from 1957 was seen near that area once, and the judge recognized him in court. The judge did not recuse himself. No mention was made in court. No mention was made by the girl who had been kissed. No mention was made in a letter from three psychiatrists.] My sister sent me a link to recent meta-study in mental health. This study looked at 100,000 people, cases, from FDA approved drug studies. They found the placebo groups in all the FDA studies, had been falsified by the drug companies, using high risk people to load the placebo groups. Then they, the drug companies, were able show that the drug was "no worse than Placebo." The FDA then approved the worthless drug. The authors felt that all FDA drug approvals, all drug company studies submitted for psychiatric drug approvals, using placebo studies, were suspect. They felt all such psychoactive drugs actually have no proven validity. In my opinion, if politicians, are given only false information regarding mental health, like the FDA officials, they will make the same wrong decisions. I pray they have the wisdom to see through the lies. Scientific lies based on a preponderance of carefully placed and staged opinion, and vast amounts of money being spent to preserve them, can be daunting. I don't envy them their task if they wish to be honest. I encourage people to look to simple mental treatments like; "take a walk", "shake it off", "toughen up", "stop and smell the roses", "have the courage of your own convictions." They will serve you much better. For people suffering from addictions, there are groups out there, that do provide services where 70% or better do not return to drug use or abuse, in two years. I encourage you to find them and use them.
Kathleen
Tue, 06/30/2015 - 9:35pm
Interesting to read this assessment of the mental health system from a medical professional who is from the outside looking in. The outside often provides a valuable perspective and this one is echoed from those who work inside as well. Something to add to the litany of costs associated with poor access to mental health services are the costs of the many who end up incarcerated as a result of mental illness. This population is costly and their incarceration is unjust and inhuman.
Carol
Wed, 07/01/2015 - 2:49pm
To correct one of the comments above, the Mental Health System in MI was top notch until the powers that be looked at the mental health system in California and their deinstitutionalization. At that point i.e. 1970, the State of MI started to deinstitutionalize it's "stable" patients. I know because as a young new college graduate, I was hired by the Kalamazoo State Hospital to assessed patients along with the nursing and recreation staff and determine if they could live in a group home or nursing home. Many of the patients had been institutionalized so long that they had never seen a highway or super market!! And the "line" I was to use when asked was that it was "cheaper to have the patient in their community than in a state hospital". Thus deinstitutionalization began in 1969 and by the mid to late 1970s, mobile vans were driving around the low income areas of my city looking for people/patients who had left the group homes, were living on the streets and needed their medication in order to stay stable. And then what is more interesting is that in 1990, i returned to college for my Master of Social Work degree. One of my class was Groups and Organizations and we were blessed with a speaker for the Organizations part of the class i.e. the Director of the Calhoun County Mental Health System. He shared all about the financial issues involved in deinstitutionalization and at the end of his lecture, I asked about the people, the human being that were sent out from the hospitals. I asked three times and three times he shared about the financial savings. Finally on the fourth time, he admitted that it was a Catch 22 as the State of MI could not give more funds to the counties to care for the people that were sent until the state hospitals were downsized. And today we house the people who should be in an institution, in our prison!!
Wed, 07/01/2015 - 6:37pm
Dear Dr. Reddy: I am a veteran psychiatrist of now 40 years' practice in North Carolina, former Duke Univ faculty for 19 years, and med school graduate of UofMich undergrad and medical school. I very much appraciated your articles which were hut upon by my Google searchbots I have had out trolling the Net for a number of years now since NC embarked on its ill fated "mental health reform" effort in 1999-2000. I had been interested in these matters since a medical school classmate of mine of UofMich Med Sch sent me (in those early days of the pre Net, 1992) newspaper clippings from the Free Press on the then Gov Engler's dismantling of the public mental health system in Michigan. After that I started following it and was appalled when the same group from Michigan that engineered those efforts were brought in as 'consultatnts' to NC in 200 to do the same thing here, among them Richard Visingardi PhD from Michigan and Carmen Hooker. If you are not already aware, the Detroit Free Press years ago did a many article award winning series on the mental health destruction wrought by the Engler initiatives and the damage they wrought by the late 1990'. Unfortunately that series is no longer hosted on the digital online edition of the Detrroit Free Press, the "FREEP." It would be instructive reading if you could find someone who has archived it as it presaged what is going on in many states since that type of plan has been exported to many other states. I very much enjoyed your article in the Bridge Magazine etc and followed up on the links and curated/downloaded the Michigan Governor's reports on mental health plans etc. I would submit for your reading my own recent effort at blogging on mental health reform as I have now gotten to the point in my career where I have time wrtie and read more and more though I still work full time in NC's western most state psychiatric hospital, "Broughton Hospital" in Morganton NC which is 50 miles east of Asheville in the "foothills" region and just south of some of the Tenn Smoky Mtn range. My wife is Cherokkee so years ago we moved our family after our first batch of girls were out of the home, to WNC so she could be closer to her massive extended family on the Cherokee Reservation, the "Qualla Boundary." In any case, my official 'mental health reform' blog can be found at: https://mentalhealthreformblog.wordpress.com/ if you would wish to read my thoughts and see if we have any common grounds for correspondence, etc. Again thank you for your well thought out and timely article. We are seeing all the same issues everywhere in NC and everyone in mental health seems to be thinking the same thoughts, having the same frustrations and challenges and asking the same questions. Yours, Frank Black Miller MD DFAPA
Noreen
Fri, 07/03/2015 - 9:21am
I am the parent of a child who is severely disabled by Fetal Alcohol Spectrum Disorder (FASD). Although this is caused by physical brain changes, it is not covered by medical insurance. Since it causes cognitive and behavioral symptoms, it is considered a mental health disorder. Since my husband and I both work 2 jobs, we have private insurance. This covers 10 hours of mental health services per year for the family. There is no other help available. We live in a rural county, and Community Mental Health can only provide services to Medicaid and Medicate recipients. We have nearly bankrupted ourselves trying to give our daughter hope of being as functional as possible. I was once told by a CMH worker that if I divorced my husband and quit both jobs, my daughter would receive all the services she needed. So instead of helping someone who is contributing to the "system" with taxes, and trying to be a responsible parent, we would have had to become totally dependent on the already overburdened system for everything. In addition, it takes me a minimum of 10-15 hours per week to navigate the services my daughter needs. How likely is it that those who most need these services are able to follow through and get them?! And now that she is an adult, what will happen to this adult child when I cannot care for her at home any longer? Where will she go? Who will be her advocate then? Who will have that many hours a week to spend just navigating the system on her behalf? The mental health system is so very broken that I despair of it ever being functional in my lifetime, and probably not in my daughter's, either. As she becomes more stable, I have a bit more time to advocate for these issues. Please use your voices to keep this before our representatives in government!
Leon L. Hulett, PE
Sun, 07/05/2015 - 8:31pm
Noreen July 3, 2015 at 9:21 am Noreen I must confess I have no real knowledge of this disorder nor the kind of life you and your daughter must have. At this point I can only sympathize with you and your family and your financial difficulties. Could you please tell me what services you are getting, and what services you feel would be best to handle this situation? Also, can you say what symptoms you have observed in kids with this disorder? Love, Leon
Thu, 07/16/2015 - 12:23pm
I am attempting to write this as articulately as I can. I still suffer great cognitive brain damage following 35 yrs of suffering severe side effects, adverse reactions, and continual withdrawals on psychiatric drugs while they were attempting to fix my 'chemically imbalanced' mind. When that no longer worked, ECT was provided. Finally, I was handed my final addiction through my community mental healthcare agency on a silver platter. Never informed of it's addictive properties. However, it didn't end there. My mental healthcare workers also informed me that it was 'just fine' to stop taking my Klonopin if I wanted to after 10 + years on it (I'd overdosed on it repeatedly to escape the crippling depressions and extreme anxiety they induced with Mental Health not being very concerned at all, so I took matters into my own hands - enough was enough.) I informed my drug and alcohol counselor, my DBT teacher, and my therapist of my intentions. I was provided no support what so ever. I was never informed of not ONE symptom I may experience with this 'cold turkey' withdrawal. And I was not allowed to talk about it with my therapist after I had barely lived through it. They left me to endure the most extensive physical, emotional, but mostly mental torture of that withdrawal at my home, completely alone. I immediately began having paranoid experiences, hallucinations, pounding heart palpitations, my head felt like it was being tightened in a vise every single day for weeks. I experience almost 50 almost fatal symptoms while mental health neglected to inform me of any of it. My brain overcompensated with the sudden loss of the drug by producing anxiety at levels I didn't know the brain could survive from and abject fear. I literally felt like I was dying every moment for weeks. I experienced every symptom of schizophrenia, anxiety disorder with agoraphobia (I lost touch with reality so severely, I could no longer leave my home), bi-polar disorder, and obsessive-compulsive disorder, to name a few. I was forced to go 6 days with no sleep while filtering in and out of psychosis when I have never experienced these or been diagnosed with these severe disorders before. I had continual seizures and prayed every single minute of every single day for this torture to end. Only, it wouldn't. I then began praying for a gun. If Mental Health is really in the business of helping people while dolling out between 5-7 or more toxic drugs to treat us then I highly recommend they learn about the drugs they are prescribing and especially their deadly withdrawals. When I began noticing something was going terribly wrong with me I begged my therapist to get me in to see my psychiatrist. That request was denied. I was told I had to wait until my scheduled appointment well over 3 weeks from then. I told her I wasn't going to make it that long, and I didn't. I would end up in the psyche ward, and then the Emergency Room where they prescribed the very same drug that was causing all this. I cried knowing that if my mental healthcare workers refused to listen, or believe me, the ER doctors were no help, and my family physician refused to treat me (she said I was Dr. shopping when more Klonopin was the last drug on earth I wanted at that time - that's what was killing me.) I now had nowhere to turn to for help. If my mental health workers were not going to inform me of the dangers of coming off benzo's, then I knew they were going to refuse the next person going through the same thing from taking or withdrawing the drug that their psychiatrist prescribed. Psychiatry is the only branch of medicine where the patient is NOT listened too - after what, what do we know? we are supposedly mentally ill. If you are able to help reform our mental healthcare in Michigan, please, and I beg, please do so - so that more people don't have to suffer so horrendously at the hands of their psychiatrists and mental healthcare workers. No, I'll never, ever set foot again in a psychiatrist or a mental health care agency no matter how much I'm suffering. The last ten years of disabling adverse reactions from Klonopin, and it's withdrawal almost killed me. I can't take anymore.....
Kathryn Lynnes
Thu, 08/06/2015 - 4:21pm
I was one of two "consumer" representatives on Governor Granholm's Mental Health Commission (Commission). One of the key issues raised by the Commission that Dr. Reddy did not mention was how stigma against persons with mental illness is a key factor in the failure of both the public and private mental health sector in Michigan. Stigma affects public funding for research, treatment, supported housing, and job assistance. Although mental health insurance parity is supposed to be the law of the land, private insurance companies are still discriminating against persons with mental illness. A recent story on NPR (http://www.npr.org/2015/07/29/427464632/health-insurers-flout-federal-pa...) detailed how many insurers are failing to comply with the federal parity law and are facing no enforcement actions from the Department of Labor. Psychiatrists are also impacted by stigma due to low reimbursement rates. This, in turn, leads to a shortage of psychiatrists. Primary care and ER doctors are just as likely to view a patient with mental illness through the "stigma lens" as a lay person. For example, many of the medications for bipolar disorder and schizophrenia lead to significant weight gain and metabolic syndrome. Instead of working with the patient and their psychiatrist, primary care doctors frequently blame the patient for their lack of will power. Many ER doctors do not see a person who just attempted suicide as someone with a medical condition who is in crisis; they see them as an obstacle that is keeping them from helping someone that is more deserving. Until stigma is addressed in the media, public, medical community, the insurance industry and the legislature no real progress is possible. Primary care and ER doctors typically do not want to deal with persons with a serious mental health diagnosis (e.g. schizophrenia or bipolar disorder). They tend to disregard anything the patient says because they are "crazy".