MHARRV Web Log

Suicide prevention, if there is to be prevention in the form of reduced rate of suicide, must involve much more than screening tests and mobilizing providers. Experience indicates that the effort must bring in those many elements of a community that have PROXIMITY to those who feel suicidal.

But proximity is not nearly the point of emphasis in all of the activity and energy so far. Formation of the American Association of Suicidology, The American Foundation for Suicide Prevention and the work being done reducing public STIGMA about mental illness have all failed to reduce National or local rates of suicide. New and less toxic medication, better diagnostic expertise for Mood Disorders (Bipolar) and better management of Major Depression (in some places) still has not done it.

The U. S. Air Force devised and implemented the only successful plan that did in fact reduce suicides and their rate. What was the hallmark of the Air Force plan? Before they reorganized provider access, they worked hard to create involvement of the people in CLOSEST PROXIMITY to persons thinking of suicide; that is their hallmark. While the same idea appears in the suicide prevention planning documents of the State of Illinois for example, it is the item least emphasised and remains un-implemented.

Who are the ones in closest proximity? Well it is not their Psychiatrist, nor is it their mental health counselor or therapist and is not their Primary Care Doctor. Proximity and easy access is the last thing those providers could deliver. Of course it is family, friends, neighbors, and people in workplaces or churches. Connection to normal elements of life saves people. That defeats isolation. But suicidal people draw away from family and normal elements. Who could educate those elements to stay in proximity and protect suicidal people? It’s hard work. Well the people in the Air Force did it; they did the work.

Why does this education of and development of proximal helpers come last if at all? We do know of the long-time mental health practise of limited contacts with families of patients. But why not the other proximal people?What priorities stand in the way? The many answers to that occupy so many aspects of the entire subject of mental illness, we might not get far without attempting to focus discussion. I hope to illuminate the issue by highlighting mistaken priorities. If we admit that nearly all other medical conditions are given priority over suicide and the Mood Disorders that cause suicide. Acknowledge that; develop deep disapproval of it and determine not to accommodate to it.

The Story of Medical Prioritizing

The incidence of death from heart attacks was steady for many years. It was not known how to get at the causes. Knowledge and inventions changed that. It became a priority. Cancer became a priority after discoveries and expectations rose. Science fueled the sequence. Childhood infectious disease became a priority. AIDS became a priority. We value life and we value the potential of each person. Because of that we work hard to reduce death rates and losses of health,income, productivity and so on. Look at the enormous change in standards of Nurse and Physician in Cardiac care. Their training and re-training must be rigorous in order to manage the astonishing precision equipment and principles. Thats a priority behavior.

Groups of people decided to see to it that great numbers of people are protected from death. The same efforts developed in Cancer care. Virus and Bacterial vaccines came about because people were determined; priorities were high. In these examples of physical disease, the protection had to come through efforts and training of experts. Families could not have done it. Clergy couldn’t. but they could and did supply inspiration and some funding.

In the Twenty First Century, why is there not yet inspiration for mental health funding? Is it that the public and the Medical Profession do not consider mental illnesses dangerous? Such mental diseases cannot kill like cancer or coronary disease? Are the citizens not valuable enough for priority? Could it be that mental health services fail to inspire public and professional people? Certainly we know now that mentally ill people can recover (70% to 80%) Plenty of progress is there. Certainly we know of the high achieving capacity of many people with Mood Disorders. Those with Schizophrenia can be productive as well. The tools for these results are before us.

In my opinion, There remains no excuse for not placing priority on those lives. People suffering suicidal danger deserve every bit as much protection as any with chest pain, cancer or infection. Their age is likely young adult ages 15 to 35. They are apt to be in colleges or graduates holding responsible jobs. If young or old, so what? How is that different from the aggregate of people with cancer or coronary disease?

So why not a priority for funding, training, new standards etc. One reason: Mental Health Provides lack the community “pull” of Cardiologists. Also, Hospitals (medical people) never did put a determined priority on protecting life threatening mental illness. Has suicide danger and death been merely accepted as inevitable? Maybe suicide death rate is considered part of life. Maybe we cannot influence the steady rate any more than we could the operative death rate for Gallbladder surgery. That’s a small rate. Well even that has been reduced by the less intrusive Laparoscopic Gallbladder surgery. There again, experts made it their business to protect people.

Modern information about the Genetic and Biologic nature of Mood Disorders put them clearly in to the SCIENTIFIC CATEGORY OF DISEASE. There is not any disease that does not create emotional manifestations. Sickness of any kind can screw up our thinking; every disease. The public and the entire Medical and Mental Health Profession must come to grips and wake up about this. There is no excuse for sinking back to a century ago. The findings are exciting enough, promising enough, inspiring enough to expect leaders and the public to bring a determined priority to all of the skills and practices of Mental Health.

We began this discussion by highlighting people in proximity to suicidal patients. We said they are not the providers but are the neighbors, friends, family, workplace and church connections. They can be trained to reduce isolation. They can be helped to bring re-connection and can learn validation. Suicidal people need persons who know how to accept the reality of those painful feelings. So far, the work of recruiting and preparing these proximal people has not begun. Where is priority?

Mental Health Providers are likely the most able to prepare the public for its role as proximal protectors. Surely the old time pattern of limited family contact must stop! But what priority stands in the way? Is it the finances of clinical practise? How much of it is the routine of counseling/psychotherapy? How much of it is the privacy demands of that routine and the old-time mental health code?

As in the new training demands for Cardiac Nurse and Physicians, what could be required for counselors? Must the Mental health providers make it their business to hone the training; select those most accomplished in the hard work of managing major Depression and suicidal patients? What new standards, medicines and tools are needed for inpatient care?

Are new licensing standards needed to reward efforts and efficiencies in recruiting proximal protectors? Does anyone imagine that the insurance industry is waiting for Mental healthcare to show innovations? Would insurance programs develop that reward reconnection efforts and new standards of training and performance?

Dr. Charles Smith

Severe Clinical Depression recovery is best when the dis-connected life of persons with severe mood disorders is re-connected in terms of family, friends and important supporters. Recovery is best when providers use medications vigorously by changing if one drug fails and keep trying changes, if necessary, to include more than one drug. Recovery is best when counseling therapy is active and continuous. Better than all of this is when all three of these aspects are included vigorously and enthusiastically.

The reconnection to family and other supporters appears to be the work of mental health providers and not to be left to others. Peer support groups or mutual help support groups should be prescribed as enthusiastically as medicines for the reconnection benefit, for the suicide protection and the hope that comes from others who understand.

Primary Care Physicians can be trained to do this vigorous and enthusiastic prescribing just as mental health providers would do. If the combination of these three disciplines works for 80% then lets see to it that all of the patients/clients get the full works.

Dr. Charles Smith

Something to Think about: So many barriers against effective depression recovery and recovery from many mental ilnesses, such as access problems and fragmentation, yet one not mentioned usually is the privacy habits of mental health system. The habits of providers in compliance with HIPPA and the mental health code may be blocking some of the benefits said to come from efforts to defeat isolation and reconnect family and friends. Trouble is family especially gets put into the category of causing depression. Providers don’t avidly seek to prepare family to come alongside

Neither do providers work very hard at peer support. Over the years, providers had not created these peer support groups; they came mostly from private efforts such as DBSA, Grow, Emotions anonymous and locally the Group Hope support meetings. Providers had not until recently been refering to peer groups.

One wonders if providers, who certainly care about clients, become overly wedded to benefits of counseling and therapeutic methods and skipped past their role in helping people reduce isolation and recruit family and friends back into the life of clients. So-called privacy concerns may be way off base if used inadvertantly to hinder recovery.

Literature these days keeps pounding on the point of bringing personal supports to bear for persons suffering Clinical Depression. The latest comprehensive report comes from The Depression and Bipolar Support Alliance…the DBSA. See it at www.dbsalliance.org.

As a person not steeped in the history of the Mental Health Code, nor experienced in the mystiques of counseling and therapeutic sessions, it may seem inappropriate for me, a Primary Care Physician (Ret.) to imply any inadequacy in the care of mood disorders. I do challenge on the privacy issue.

If the mental health system in Winnebago County or any other community is to restructure and retool, part of it will require reconnecting with the public and the rest of the health community. One step, I believe, will be for mental health providers to rethink themselves thoroughly on the subject of privacy. Elements of the public already perceive mental health care as oddly and persistently “none of our business.” Wait until the public finds out about recent literature that wants mental health providers to recruit family and friends into the scene for better recovery. Then whose business is it?

If privacy and the Mental Health Code are thought of as UNCHANGEABLE, then maybe we would add another category to the list of barriers. We know of discontinuity, fragmentation, imparity of insurance etc, and now we have “stuck in the squat.” Something to think about.

Dr. Charles Smith

Meds Alone Couldn’t Bring Robert Back
Experts like to debate the effectiveness of new drugs, but they overlook a key element of recovery.

By Jay Neugeboren

Newsweek

Feb. 6, 2006 issue - When my brother Robert arrived at Bronx Psychiatric Center in 1998, Dr. Alvin Pam, chief of psychology, told me it was the consensus of the staff that Robert would never be able to live without supervision, and if discharged, was destined to be repeatedly rehospitalized. By this point in time, my brother had been a patient in the New York state mental-health system for nearly 40 years, and had been given nearly every antipsychotic medication known to humankind.

But he had not yet been given any of the new medications—the so-called atypical antipsychotics a National Institute of Mental Health study recently found were not significantly better than the old ones, a discovery that has caused intense debate in the mental-health community. Robert’s reaction to the drug was seemingly dramatic. Several months after Robert started taking it, Dr. Pam called to say his recovery was nothing short of miraculous—he was clear thinking, free of delusions, and the hospital was planning his discharge.

A few weeks after that, Robert telephoned. “Alan’s leaving—Alan’s leaving!” he kept screaming. Alan was my brother’s social worker—a man to whom he was very attached and whom he had known for many years, from his long-term stay at another hospital. I called and discovered that, without warning, Alan had been transferred to another state hospital.

Robert began having tantrums, hallucinations, bodily tremors, irrational fears, panic attacks, and he became both dangerously manic and depressed. It would be more than a year before the hospital would again prepare him for discharge. The question, then: why did the medication that worked so well—so miraculously—on Monday stop working on Tuesday? The answer: because Robert was deprived of a relationship that had been a crucial element in his recovery.

At about this time I was interviewing hundreds of former mental patients for a book I was writing. They were people who had been institutionalized, often for periods of 10 or more years, and who had recovered into full lives: doctors, lawyers, teachers, custodians, social workers. What had made the difference?

Some pointed to new medications, some to old; some said they had found God; some attributed their transformation to a particular program, but no matter what else they named, they all—every last one—said that a key element was a relationship with a human being. Most of the time, this human being was a professional—a social worker, a nurse, a doctor. Sometimes it was a clergyman or family member. In every instance, though, it was the presence in their lives of an individual who said, in effect, “I believe in your ability to recover, and I am going to stay with you until you do” that brought them back. So it was with my brother, who, through his daily collaboration with Alan and the dedication of Dr. Pam (who refused to go along with the staff consensus that Robert would never live on his own) has not had a single recurrence for more than six years, the longest stretch in his adult life.

At Robert’s new home at Project Renewal in Hell’s Kitchen, the staff is equally dedicated to the 60 or so residents. Rehospitalization rates are below 3 percent each year, and director Jim Mutton says, “Most individuals remain compliant with their medications for years at a time.”

Like Jim, I too have witnessed hundreds of formerly homeless, mentally ill adults renew their lives not only through access to a wide range of medications, but through access to individuals like Jim and Dr. Pam, who believe that pills, while useful, are only a small part of the story, and that the more we emphasize medications as key to recovery, the more we overlook what is at least as important: people working with people, on a sustained long-term basis.

In New York state, there are more than 60,000 individuals living with psychiatric disabilities. What does it matter if one medication is superior to another if 34,500 of these people have no safe place to live, and therefore no opportunity to work, no choice of treatments and no access to dedicated individuals who are being paid decent wages to work with them?

Let’s provide a range of medications, and let’s study their effectiveness, but let’s remember that the pill is the ultimate downsizing. Let’s find resources to give people afflicted with mental illness what all of us need: fellow human beings upon whom we can depend to help us through our dark times and, once through, to emerge into gloriously imperfect lives.

Neugeboren lives in New York City.

© 2006 Newsweek, Inc.

Tuesday Gov. Blagojevich came to Rockford to deliver money to the Eiger Lab. I am sure that the Eiger Lab is worthy of attention by the Governor for what Eiger Lab has accomplished as a Rockford business. Whether Eiger needs the money is something I can’t answer. Let me share my difficulty with the Governor’s behavior.

Since coming to power the”reformer” governor has steadfastly ignored member initiatives. Without arguing the merits of member initiatives, these are local projects which met the criteria of the initiatives. These projects are grass-roots and represent what local groups, in concert with local legislators, determined to be important. The governor has steadfastly ignored this and created his own process and decided that he alone will benefit from distributing our money.

Since Gov. Blagojevich is governing a state with serious financial problems, he is employing a methodology that has been used by politicians for years, “shift and shaft”. Shift the money from old project priorities, i.e. member initiative projects, to his priorities for maximum personal political benefit. Therefore the “shift’ takes place for the new priority, Eiger Labs, and those holding the old priorities get the “shaft”.

In addition to member initiative priorities another group which has lost funding is those Illinois residents suffering from mental illness. The Governor has effectively destroyed the community service system which been under construction for almost 40 years. The Governor has made an effort to have the Federal Government fund our state mental health system through Medicaid. Fewer citizens will receive service and the range of services is narrow and therefore will not provide for recovery.

In essence, since the state is broke, pork projects come at a cost of pitting one group against another. Those groups with the least political support suffer the most. They are the shaftees. These groups tend to be those who need the most support to maintain programs needed for their recovery.

Please, Governor, we need integrity not game playing to solve problems that confront the “have nots” in our state.

Richard Kunnert, President
Mental Health Assn. of the Rock River Valley