It’s the black sheep of the medical world.
The issues it causes are talked about in hushed words and hidden from neighbors, friends and family. Psychiatric care and mental health issues often only are pushed into the limelight in times of tragedy as an easy explanation – and just as quickly forgotten.
Understanding the need
Depression and anxiety are two of the most common mental health issues, according to Dr. Ujjwal Ramtekkar, child psychiatrist for Mercy Child Psychiatry. And, as with any disease, recognizing these ailments early is critical for successful treatment.
In children, Ramtekkar said, a physical health issue can often be a symptom of a mental health issue.
“If a child is acting out and going to the nurse’s station multiple times during the day or throughout the week, one must consider what exactly is going on,” Ramtekkar said. “In pediatrics, many times the somatic symptoms – for example stomachaches, headaches, dizziness, nausea – are the presenting issues for underlying anxiety, depression or some other psychosocial issues going on at home that might be making kids stressed out.”
Ramtekkar said that with further medical investigation and by talking with children exhibiting these symptoms, sometimes healthcare professionals can uncover the underlying issue, preferably before the condition becomes worse.
“If you do not identify anxious temperament, anxiety or inability to handle stress early on, and help them with educational and psychological tools, it will eventually develop into a full-blown anxiety disorder that might need medications and some other higher level of treatment,” Ramtekkar said.
He noted, that in psychiatry, working with children is like playing with wet cement.
Their brains are much more flexible and easier to work with than a fully matured adult’s.
“There’s not much room for molding it and reshaping it,” Ramtekkar said of adult brains and mental health treatment. “In pediatrics, initially it’s the skills part which is important, before we get to the pills part, whereas in adults more often than not because they are presenting related serious symptoms, the pills part becomes primary in addition to the skills part.”
According to Dr. Azfar Malik, chief executive officer for CenterPointe Hospital in St. Charles County, there are two main types of adult patients in the realm of mental health. One group consists of patients who are chronically mentally ill and non-functioning. The second group is composed of people who are functioning, but with conditions such as depression, substance abuse and mood disorders.
Oftentimes it’s the second group of patients who are left out in the cold.
“Community mental health centers have been put in the unfortunate position of (only) having the resources to serve individuals who really rise to the level of serious and persistent mental illness,” explained Wendy Orson, chief executive officer of the Behavioral Health Network.
Removing barriers to access
The St. Louis region has many major medical facilities providing psychiatric care, but Orson and Ramtekkar say “barriers to access” still block people from receiving appropriate mental health care.
Orson said there is a large group of people who may be referred to a psychiatrist by their primary care physicians or another source, but may have trouble overcoming the challenges in the way.
“The issue is that – despite having three big healthcare organizations in the St. Louis area being very active in mental health in this community – the wait times still are too long. There are very limited providers that are present here and many times even when the referrals are made from the primary care, only a third of them are actually completed because of all these barriers to the access (of care),” Ramtekkar said.
Barriers range from the number of healthcare providers to the stigmas still attached to psychiatric care. Long wait times, problems worsening due to a lack of timely treatment and potential crisis are all potential pitfalls in the modern healthcare system.
“The issue is that, in order to appropriately and accurately diagnose and treat, we have to intervene fairly early,” Ramtekkar said. “The problem in the West County area and St. Charles County area is no different from the rest of the nation as well. We don’t really have enough mental health clinicians to provide those services.”
A lack of providers for mental healthcare is not a new problem, according to Orson.
“Right now I think we are at a workforce shortage as it pertains to psychiatric care, so I know that there are pretty long waiting lists even for people who have resources and funds to access those services,” Orson said. “It’s been ongoing for a while, (but) I think it’s just been exacerbated in more recent years.”
She added that changes to Medicaid may be critical for Missouri to retain its psychiatrists and to give patients a way to pay for required services.
“If other states around Missouri are expanding Medicaid, there are better opportunities for psychiatrists to work in those areas,” Orson said.
Other steps may need to be taken as well, according to Orson, such as connecting schools and education resources with community health resources and properly compensating mental health specialists who are trained in the state to remain in Missouri when their education is complete. For the patients, a different approach to treatment may be needed.
Providing a continuum of care
Proper treatment of a mental illness is much more than simply catching or diagnosing it early.
“A lot of times patients are hospitalized, then they are thrown out of the hospital and there’s no continuum of care,” Malik said.
But follow-through is critical in treating a patient. Tools like outpatient programs used as follow-up to treatment are critical in order to fully and effectively treat those in need, according to Malik. Properly monitoring medications, therapy and additional treatments are all critical to helping a patient heal.
“Somebody who is dependent on alcohol or drugs is usually admitted for a brief period of detoxification,” Malik said. “Then they go back to the same society where they (are) hanging around with the same friends, and they are doing the same drugs and alcohol, so the relapse rate is very high in that population.”
CenterPointe features a variety of outpatient programs, Malik said. And many healthcare providers in the area are working to establish and uphold a stable continuity of care for patients.
Innovative approaches to services and funding also are being tested.
The Mercy Medical Group has begun a new donation-driven program, called Mercy Kids in Schools, which will be used in three St. Louis schools to help identify kids at risk for behavioral disorders, and help treat those ailments early before they manifest into illnesses that are harder to treat.
The program also will help to remove any barriers in the way of kids accessing psychiatrists, and Mercy will provide a psychiatrist who can talk to the students at any time in school via telemedicine. Mercy also will employ a social worker to spend time at each school during the week to get to know the kids better and become a friendly face they can come to with their problems.
“When it comes to behaviorally acting-out kids, when it comes to bullies and when it comes to kids who get bullied, they all have a mental health issue at the background,” Ramtekkar said. “It’s never just for the fun, it’s always to satisfy or to accommodate some mental health issues.”
Ramtekkar said having a social worker consistently present in these schools will provide a natural estimation of the kids’ behavior, as opposed to 30 minutes spent in an isolated psychiatrist’s office.
Likewise, the Behavioral Health Network has a program in place called the Hospital-Community Linkage Program, which connects hospitals to mental health centers in the community in order to expedite a patient’s access to psychiatric care.
Orson said that since mental and physical ailments often go hand-in-hand, treating them together is key.
“It’s a warm hand-off between the two programs in order to improve outcomes for individuals,” she said.
Time for a difficult discussion
For a good chunk of history, the standard practice for treating those with severe behavioral disorders was institutionalization. In the United States, it wasn’t until the middle of the 20th century that major reforms to psychiatric care changed the status quo.
However, despite the medical advances in the field over the last century, Malik said a taboo still hangs over the field.
If mental healthcare is to be improved, experts agree that the conversation around the topic must change.
The discussion about mental healthcare has to be one that is ongoing, Orson said. She said it doesn’t help that many times, the media will portray people with mental illnesses as violent, while the majority of people with a mental illness are not violent.
Part of this depiction is because of the way the healthcare system operates at the state and national level, said Malik, but the attitude toward mental healthcare also continues to play a role.
“Mental health has always been in the background, in the back room,” Malik said.
Tragedies like the mass shooting in Aurora, Colorado, shine a fleeting spotlight on mental health issues, but the attention and subsequent discussion of it quickly fade away.
“They just bring it (mental health) up every time an incident happens, and then it’s forgotten, unfortunately, until the next incident happens,” Malik said. “Then it comes up again, and it’s forgotten again.”
Orson said there is still a long way to go in terms of eliminating the stigma attached to mental illness, and that treating a behavioral disorder is no different from treating any other disease.
While changes in the delivery of care may not be immediately forthcoming, experts agree that removing the stigma and breaking down the barriers at an individual level is a good place to start in motivating mental healthcare reform. Recognizing that health is a combination of mental and physical and that no one thing defines a person is an important point for individuals and their physicians to remember when it comes to a continuum of care.
“In the past people really looked at mental health as something that needed to be treated in a separate way, in a separate place, but as we are moving forward we are really learning that we have to treat the whole person,” Orson said. “Too many times physical ailments are really a result of mental health issues and vise versa, so without treating the whole patient we are really missing the boat.”