Fort Worth Star-Telegram, Texas, Steve Jacob Column: Say You’re Fighting Mental Illness and Recovering From Substance Abuse. A Two-Week Supply of Medication is the Only Thing Keeping You From Relapsing. You’Ll Need a Refill. Good Luck Getting It.
By Steve Jacob, Fort Worth Star-Telegram, Texas
Aug. 5–Your brother is being released from a substance abuse treatment center that stabilized his bipolar condition. He is given two weeks’ worth of medication to tide him over until he can begin his outpatient treatment.
He is unemployed and uninsured and will be staying with your sister temporarily to get back on his feet after drifting between government shelters for six years.
Your assignment: Find a clinic where he can meet with a psychiatrist or mental health professional and get a prescription refill and ongoing care. After you dial the number, there is a better-than-50-percent chance that, in Texas, the following will happen:
You will encounter a rude, brusque or uninformed customer service representative (CSR) — assuming the published number was correct or you do not encounter a voice message system that will not allow you to talk to a human being.
When you ask for an appointment with a psychiatrist, you will be told that the wait is from six weeks to one year — although the CSR is almost as likely to refuse to give a time frame or even attempt to guess.
When you ask for an alternative strategy to refill the two-week prescription, you will not be offered one. Of the CSRs who suggest alternatives, the most common one is to have the patient go to the local emergency room for a refill.
That scenario is derived from a recent three-month research study by a graduate class at the University of North Texas Health Science Center, based on calls to 51 randomly chosen outpatient mental health clinics listed on the Texas Department of State Health Services’ Web site.
Vicki Nejtek, assistant professor and director of co-occurring disorders research at the UNTHSC School of Public Health, directed the project. She said callers were struck by the apathy in the CSRs’ voices and by the lack of knowledge.
“You had to pull information out of them,” she said. “It’s pretty bad everywhere.”
The UNTHSC study focused on a particularly vulnerable population: the indigent mentally ill with substance abuse addictions, also known as the dually diagnosed. The compound effect of both disorders requires more comprehensive and integrated treatment than either affliction alone.
The survey identified a significant — and crucial — gap in the Texas mental healthcare system. Patients released from a treatment facility generally get two weeks of medication and are told to secure an appointment with a psychiatrist for further treatment and more medication.
Trying to avoid a relapse
The chances of relapse are virtually certain without ongoing support, including therapy and medication. And relapse represents a huge waste of effort by patients, counselors and taxpayer dollars. As of 2003, taxes paid for 77 percent of all substance-abuse treatment.
Timely and comprehensive treatment has been proven effective. After at least 90 days of substance abuse treatment, only 23 percent return to cocaine use, for example, and there is a significant reduction in criminality.
“People are stabilized and then sent out into the community without a prescription, and told to go to the ER to get medication,” Nejtek said. “But they don’t have the cognitive wherewithal to wait for hours for service [in an emergency room], especially if they have bipolar disorder.”
Nejtek believes the prescription-writing powers of physician assistants and nurse practitioners should be broadened to buy more time for the patient between treatment and psychiatric evaluation.
The source of substance abuse
Alcoholism and drug abuse are popularly considered the result of lack of personal control or habitual partying run amok. But these are most often triggered by childhood trauma, genetic predisposition or mental illness.
An estimated 61 percent of those with bipolar disorder also have a substance abuse problem in their lifetimes, with about one-third struggling with cocaine abuse. Those with depression and schizophrenia have similar risks of substance abuse. Nejtek said her research indicates that about 50 percent of the dually diagnosed were physically or sexually abused as children.
“They are in this condition because something happened to them, and it just as easily could have happened to you or me. The substance abuse numbs their memory. This population has already been traumatized, and the system continues to make their lives miserable,” she said.
The U.S. government estimates that 22.5 million people — 9.4 percent of Americans — age 12 and older have a substance abuse disorder. An estimated 3.8 million received treatment for illegal drug or alcohol abuse in 2004, according to the National Survey of Drug Use and Health. About half of those requiring substance abuse treatment also need therapy for mental illness, according to the National Institute on Alcohol Abuse and Alcoholism.
Traditional substance abuse programs generally are not recommended for people who also have a mental illness. Most with severe mental illnesses are too fragile to handle the heavy confrontation, intense emotional jolting and discouragement of the use of medications characteristic of standard substance abuse programs. These treatments may produce levels of stress that exacerbate symptoms or cause relapse.
Local barriers to recovery
The results of the UNTHSC survey were reinforced in interviews with several local mental health officials.
Linda Ragsdale, executive director of the Mental Health Association of Tarrant County, said an estimated 60 to 70 percent of the organization’s telephone calls are from indigent patients attempting to navigate the system.
“Substance abuse is a chronic condition that has to be treated like, say, diabetes. For the dually diagnosed, the best treatment is support groups for the addiction and clinical care for the mental illness. Without medication, you won’t get to the [group] meetings, or be able to concentrate once you get there. Low coping skills are a function of the illness,” she said.
The chronic-care analogy is supported by ample research. Substance abuse requires early intervention, ongoing monitoring and treatment referrals to sustain successful results, similar to that for hypertension, depression and asthma.
In contrast, the treatment model and provider reimbursement is oriented toward assuming that a patient can be “cured,” as with a case of influenza. When the healthcare system believes that its job is done, funding and therapy stop, and free support groups pick up the slack of ongoing care.
Arlington’s Robert Miles, legislative chairman of the Texas Association of Addiction Professionals, said: “What would happen if a cancer patient couldn’t get chemotherapy? How about a diabetic who couldn’t get insulin? It’s very shortsighted.”
Trudie Hughes is case manager for co-occurring psychiatric and substance abuse disorders at the Pine Street facility in Fort Worth, which treats dually diagnosed patients from a 16-county region. She gave the Mental Health Mental Retardation of Tarrant County high marks on timely service for her local clients, but she said that those who call the organization on their own encounter much longer waiting periods.
When she attempts to get psychiatric appointments in outlying-county MHMRs, she said, “I feel like I’m hitting a brick wall.”
Susan Garnett is deputy chief executive officer of MHMR of Tarrant County, which was one of the clinics that gave a UNTHSC survey caller a time frame of up to one year for a psychiatric appointment. Garnett said the study called phone numbers off the state Web site that were administrative rather than crisis-line numbers.
She said the co-occurring disorder scenario added a layer of complexity for the receptionist to process. She is confident that the local MHMR meets its contractual duty to see qualified routine patients within two weeks.
Alan Podawiltz, director of psychiatric services at John Peter Smith Hospital, said the study’s results did not surprise him. He said JPS, which has a 24-hour psychiatric emergency room, routinely receives patients just released from treatment or prison without instructions on how to get ongoing care.
Podawiltz said that even though Dallas-Fort Worth residents have access to quality mental health services, there is a “big gap in need” in less populated areas of Texas because the system is poorly funded. He said the UNTHSC study underscores the problem’s pervasiveness.
Mental health care in Texas
Texas is 48th in the U.S. in mental health funding, similar to where it ranks nationally in most categories of healthcare finance. In 2002, per capita spending on mental health services was 44 percent of the national average — and 15 percent lower than in 1981 on an inflation-adjusted basis.
Mental health funding reflects two recurring themes in all aspects of Texas healthcare: You get what you pay for, and failing to pay for prevention ensures exponentially greater costs later on.
The Texas Drug Demand Reduction Advisory Committee estimates that the state spends less than 1 percent of its budget on prevention, treatment and enforcement of drug and alcohol use and abuse, while it spends 37 percent on problems associated with substance abuse — largely through the criminal justice system. About six in 10 Texas prisoners have been drug or alcohol abusers, and substance abuse contributes to child abuse, domestic violence, suicide, divorce, disability, homelessness, poverty and unwanted pregnancy.
Lynn Lasky Clark, chief executive officer of Austin-based Mental Health of America Texas, praised the Legislature for allocating $82 million over the next two years to bolster mental health crisis services. But she said this allocation would have little effect on the routine care identified in the UNTHSC study.
The legislative funding came on the heels of a survey of statewide mental health crisis services by the Texas Department of State Health Services. The 1,600 hospital administrators and law enforcement officials surveyed gave low marks to the state’s crisis service providers in timeliness, accessibility, competence and follow-up.
In classic bureaucratic understatement, the report concluded: “The current crisis services delivery system in Texas varies widely in how well it performs … sometimes resulting in negative outcomes for individuals, families and communities.”
sbj@star-telegram.com Steve Jacob is publisher of the Star-Telegram/Northeast and a master’s student in health policy and management at the University of North Texas Health Science Center in Fort Worth. 817-685-3955
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