The Doctor Is Out: Even If You Have Insurance, Finding A Psychiatrist Is Difficult

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(12-8-17) Every time we take a step forward, it seems we get knocked two steps back.

Getting mental health treatment remains difficult in our country despite passage of The Paul Wellstone and Pete Domenici Mental Health Parity and Addictions Equity Act of 2008 (MHPAEA) that requires parity in health insurance coverage of mental health and physical health benefits.

That’s the findings of a survey the National Alliance on Mental Illness has released based on an online survey conducted in 2016 to examine what happened when individuals with insurance sought mental health care. The study, which drew responses from 3,177 individuals, is called The Doctor Is Out.

When trying to find a provider, respondents reported the most severe problems as follows: 1. Providers were not accepting new patients (55% psychiatrist, 45% therapist); or 2. Providers were not accepting their health plan (56% psychiatrist, 11% therapist).

An earlier study had found that only a little over half of all psychiatrists will accept insurance – compared to close to 90% of physicians in other medical specialties. It’s even worse if you depend on Medicare and Medicaid because psychiatrists accept patients at “significantly lower rates than other physicians do.”

That’s especially troubling when you consider that Medicaid is the biggest payer for mental health services.

Why is finding a psychiatrist who will accept insurance so difficult?

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Lynn Nanos: A Street Social Worker Tells What It’s Really Like

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(12-04-17) I’ve always hoped someone who actually provides direct services to persons with serious mental illnesses would write a book so I was excited when I received an email from Lynn Nanos. She is putting the finishing touches on a nonfiction book about her personal experiences as a inpatient social worker. I got more excited after I read a short excerpt of BREAKDOWN: A Clinician’s Experience in a Broken System of Emergency Psychiatry due to be published in next year. Here’s a slightly edited excerpt.

Dangerously Unaware   By Lynn Nanos, LICSW

When I started working on an inpatient psychiatric unit as a social work intern for the New York state’s Office of Mental Health in 1996, my supervisor told me, “No one here is mentally ill.” She was never part of the anti-psychiatry group who believe that mental illness doesn’t exist. By stating this, she meant that many of these patients didn’t believe that they were ill.

  The Woman Who Wouldn’t Eat

I go to a psychotic woman’s apartment with an outpatient worker because she stopped eating. She stopped eating because of her belief that people are poisoning her food. Because she believes that poisonous gas is coming out of her heating vents, she covers these. Because she believes that poisonous gas is coming out of her faucets, she keeps the water running continuously. She believes that running the water blocks the gas.
As we are standing in water inches deep, she tells me that she is not mentally ill. Therefore, from her perspective there’s no need to take any medication.
The police are called and an ambulance transports her to the hospital emergency department. The emergency medical doctor calls and tells me that because she is well groomed, speaking clearly, not suicidal, and not homicidal, she is being discharged back to her home.
Everything I report to them is disregarded. I’m just a social worker.
Would she be moved on to inpatient if I am a psychiatrist or medical director of an agency? Would she be moved on to inpatient if she has a family member to advocate for her?

Weeks later, she is evicted from her apartment with nowhere to sleep except for the streets.

The Devil Told Him
A psychotic man got discharged from Bridgewater state “hospital,” really managed by the Department of Corrections, earlier that week. He was there because he was eating his feces and cutting himself to remove what he believed was the devil from his body while incarcerated. He yells out his fears of the devil when I evaluate him at the state-funded respite unit.
He tells me that he got sentenced to prison because he pointed a loaded gun toward a stranger. I inquire about what made him do this. He says that the devil told him to do it. He doesn’t believe that he is mentally ill.
Emergency medical doctors are more likely to discharge to the streets a dangerous patient who is not wanting any treatment, than a dangerous patient who is wanting treatment.
They are more likely to move on to inpatient the malingerer who doesn’t need treatment, than a psychotic patient who can “pull it together,” and cover up symptoms.
Our Current Train Wreck
 Psychiatric emergency services work can be akin to watching a train wreck without any ability to prevent the wreck from happening. When will the next tragedy involving serious injury or loss of life due to untreated serious mental illness occur? Governments are reactive.

The severe shortage of inpatient psychiatric beds along with overly restrictive inpatient commitment criteria often results in only the sickest of the sick getting admitted to inpatient units. For people with psychosis who lack awareness of being psychotic, brain deterioration often occurs long before sufficient psychiatric treatment is obtained. Early psychosis programs are completely voluntary, thus marginalize those who refuse to engage in treatment because they don’t believe that they are ill.

I know there are success stories out there. But as an inpatient social worker, I was alarmed at the extremely high rate of readmission to our units. This is what motivated me to begin writing about what I see daily.
We, or at least, I can’t close my eyes at night knowing that we could, no, we must do better.
I think of a patient on my caseload who was paranoid delusional and was refusing to accept treatment because he did not believe that he was mentally ill. He refused to sign a release of confidentiality for me to communicate with his mother, even though they resided together. She knew he was there, so I just supportively listened to her concerns. I passed these on to the rest of the team, including his psychiatrist.
Shortly after his discharge, he used a knife to stab his mother to death.
When something such as this happens, you have choices. You can pretend these events don’t happen or turn away from them. Or you can roll up your sleeves and begin advocating to improve the lives of the seriously mentally ill population who are the sickest.
I’m in my tenth year as a mobile psychiatric emergency clinician. I’ve rolled up my sleeves.

Daughter of Murdered Officer Prefers Mercy While Va. Governor Prefers Politics

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(12-1-17) Outgoing Virginia Gov. Terry McAuliffe, who apparently has hopes of running for president in 2020, should read an editorial written yesterday by the daughter of a law enforcement officer who was murdered by  William Morva, a 35 year-old man with a severe mental illness.

McAuliffe, who claims to be opposed to the death penalty on religious grounds, refused to stop Morva’s execution in July despite pleas by the National Alliance on Mental Illness, numerous elected leaders and The Washington Post.

At the time, there was speculation that McAuliffe didn’t want to appear soft on crime because he intended to make a run for the White House.  His actions mirrored how then-presidential candidate Bill Clinton hurried back to Arkansas in the midst of a presidential campaign in 1992 to approve the execution of Ricky Ray Rector, another prisoner with mental impairments. Rector left a piece of pie on the side of the tray when he was served his last meal. He told the corrections officers who came to take him to the execution chamber that he was “saving it for later.”

No solace in executing mentally ill killers

By Rachel Sutphin published in the Bristol Herald Courier newspaper in Virginia

As a family member who has suffered the death of a loved one to homicide, I support legislation in the Virginia General Assembly that would exclude people with severe mental illness from the death penalty.

I am the daughter of the late Corporal Eric Sutphin, who was killed by William Morva during a manhunt in 2006.

My dad was and is my hero.

He was so courageous, humble and light-hearted. The community loved him, and I loved being a police officer’s daughter. I have every reason to hate Mr. Morva and want revenge. Yet, when clemency was denied to Morva and he was executed this July, I felt great sorrow. It provided no solace for my loss.

Under this proposed legislation, offenders with severe mental illness at the time of the crime could be prosecuted, convicted and sentenced to life in prison without parole if found guilty — but could not be executed. For this narrow exemption to apply, defendants must have documented evidence of a mental illness that is so severe it prevented them from fully understanding reality and the consequences of their actions — making them undeserving of the ultimate punishment.

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Mom Asks HMO Psychiatrist To Help Her Distraught Daughter: Instead He Called The Cops

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(11- 27-17) I constantly receive emails from parents frustrated because they were unable to get their adult children hospitalized. Here’s one from a mother who ran into the opposite problem recently when she sought help from a psychiatrist who works for Kaiser Permanente.)

Dear Pete, 

 My adult daughter experienced a traumatic event at college. Her grades began slipping, she started losing weight, she had trouble sleeping and she was on the edge of tears or crying continuously. She told us that she had suicidal thoughts but that she did not think she would act on them.

As you can imagine, we were very concerned. We took her to see a psychiatrist at Kaiser Permanente, believing we would get help.

What happened was a nightmare!

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Street Medicine: Going Into The Woods To Help The Psychotic, Addicted & Invisible

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(11-24-17) This is one of the best stories about homelessness that I’ve read. Thank you Laurie McGinley at The Washington Post for writing it. Among the take-aways: most of these folks had been through recovery programs yet have not become engaged in treatment? Why?

Another take-away: a homeless woman who has been diagnosed with a serious mental illness agreed to see a psychiatrist when she spoke to a treatment team but disappeared when a psychiatrist came looking for her. She preferred to continue “self medication.”

And finally, the quote: “Most of our folks think they will die alone, that their future is canceled. Bringing hope is more important than any medicine.”  It’s a great reminder that it takes a personal connection to connect in a meaningful way with another person.

These are all truths that I learned personally when I spent time with homeless workers in Washington D.C.’s Georgetown neighborhood with Gunther Stern, who runs Georgetown Ministries street outreach team.

In the woods and the shadows, street medicine treats the nation’s homeless

By Laurie McGinley, published in The Washington Post on Thanksgiving Day.

Nurse Laura LaCroix was meeting with one of her many homeless patients in a downtown Dunkin’ Donuts when he mentioned that a buddy was lying in agony in the nearby woods.

“You should check on him,” said Pappy, as the older man is known. “But don’t worry, I put him on a tarp, so if he dies, you can just roll him into a hole.”

LaCroix called her boss, Brett Feldman, a physician assistant who heads the “street medicine” program at Lehigh Valley Health Network. He rushed out of a meeting, and together the two hiked into the woods. They found Jeff Gibson in a fetal position, vomiting green bile and crying out in pain from being punched in the stomach by another man days earlier.

Feldman told him he had to go to the hospital.

“Maybe tomorrow,” Gibson replied.

“Tomorrow you’ll be dead,” Feldman responded.

Months later, the 43-year-old Gibson is still in the woods, but this time showing off the six-inch scar — for a perforated intestine and peritonitis — that is evidence of surgical intervention. He greets Feldman warmly. “You’re the only person who could have gotten me to the hospital,” he says. “You’re the only person I trust.”

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Thankfully There’s A Group Helping End Homelessness That You Can Support. Please Consider It!

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(11-22-17)  Giving a meal to someone on Thanksgiving who is homeless feeds them for one day. Giving them housing puts them on a life changing path.  Patti and I make a donation each month to the Corporation for Supportive Housing  because we believe it offers communities proven solutions for ending homelessness – and homelessness in the wealthiest nation in the world should be unacceptable.

564,708 people in the U.S. are homeless.

According to a recent report, over half a million people were living on the streets, in cars, in homeless shelters, or in subsidized transitional housing during a one-night national survey last January. Of that number, 206,286 were people in families, 358,422 were individuals, and a quarter of the entire group were children.

83,170 individuals, or 15% of the homeless population, are considered “chronically homeless.”

Chronic homelessness is defined as an individual who has a disability and has experienced homelessness for a year or longer, or and individual who has a disability and has experienced at least four episodes of homelessness in the last three years (must be a cumulative of 12 months).

Families with at least one adult member who meets that description are also considered chronically homeless.  As the National Alliance to End Homelessness explains, “While people experiencing chronic homelessness make up a small number of the overall homeless population, they are among the most vulnerable. They tend to have high rates of behavioral health problems, including severe mental illness and substance use disorders; conditions that may be exacerbated by physical illness, injury, or trauma.”

47,725, or about 8% of the homeless population, are veterans.

This represents a 35% decrease since 2009. Homeless veterans have served in several different conflicts from WWII to the recent wars in Afghanistan and Iraq. Washington, D.C., has the highest rate of veteran homelessness in the nation (145.8 homeless veterans per 10,000). 45% of homeless veterans are black or Hispanic. While less than 10% of homeless veterans are women, that number is rising.

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