When Does An Illness Become A Serious Mental Illness? And Does Our Definition Divide Us?

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 (9-7-17) My friend, psychiatrist, author and blogger, Dr. Dinah Miller, posted a blog at Shrink Rap yesterday that asks what is and isn’t a serious mental illness? She is the co-author of  COMMITTED: The Battle Over Involuntary Psychiatric Care.)

Friends in High Places: thoughts about SMIs

By Dinah Miller

Move over, there’s a new federal mental health committee in town.  The department of Health and Human Services has formed the Interdepartmental Serious Mental Illness Coordinating Committee.  My friends Pete Earley and Elyn Saks are both on the committee, and Pete has been blogging about the committee for a couple of weeks now– the good, the bad, the ranting, and the missed opportunities after the first day of meetings last week.

You’ll be pleased to know that I didn’t miss the opportunity to put in one of my concerns: I emailed Pete and Elyn to tell them how pre-authorization for medications is having a negative impact on the practice of   medicine, and psychiatry in particular.  Nothing new, but it’s a topic that every medical organization has been fighting for years and nothing ever gets done, so I thought I would ask that it be brought up again.  My thanks to Pete for including my concern on one of his blog posts.

When people talk about serious mental illness (SMI), I always have the same reaction: What is it? 

From what I can tell,  one gets the designation with a diagnosis: schizophrenia or bipolar disorder or severe depression.  Apparently it’s not about illness chronicity or impairment, or spending time in institutions, or whether an illness responds to treatment.
I’m always at a loss: as  I’ve said before, our diagnoses are not precise, prognoses can be wrong, and people can be very sick at one point in time and very well at others.  So while 1 in 8 adults are on SSRI’s, 1 in 5 suffer from an episode of mental illness during the course of a year, and half of us will have an episode of mental illness during the course of a lifetime, these people with serious mental illness are quite few: 4.5 million Americans.  I wish these people wore signs so we knew who they were and could divide the resources appropriately.

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Co-Founder of This Is My Brave Passes. “HOPE” – Hang On, Pain Ends.

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Anne Marie Ames and Jennifer Marshall

(9-6-17) My good friend and fellow mental health advocate, Jennifer Marshall, best-known for launching This Is My Brave, lost the organization’s co-founder last week. Here is the tribute that she wrote about Anne Marie Ames.)

A Tribute to our Co-Founder, Anne Marie Ames

By Jennifer Marshall, reprinted from THIS IS MY BRAVE webpage

My heart is shattered into a million pieces.

How could I have let this happen?

I wish I would have loved her better.

I wasn’t ready to say goodbye.

Those were the first thoughts and feelings that rushed over me like a wildfire after it happened. I found out about Anne Marie’s passing through a call from Michelle, one of her closest friends and neighbors.

How we all wish we could have said goodbye.

Within minutes, Michelle was at my doorstep where Ben and I had been holding each other in shock.

Anne Marie was one of my best friends for the past four years. As some of you know, we met at a jewelry party hosted by Kiran, where the running joke after that night was that Anne Marie and I had fallen in love talking for two hours in a corner where no one could interrupt us.

It was the truth.

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Top Federal Officials Missed An Opportunity To Send A Powerful Message About Mental Illnesses

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(9-4-17) Health and Human Services Secretary Thomas Price called serious mental illness a “silent epidemic” that touches nearly all Americans. Housing and Urban Development Secretary Ben Carson agreed. But where were their peers when the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC), created by Congress, held its first meeting last week?

The 21st Century Cures Act stated that these top federal officials would be members of the committee.

Attorney General Jeff Sessions.

Secretary of Veterans Affairs David J. Shulkin.

Secretary of Defense James Mattis.

Secretary of Education Betsy DeVos.

Secretary of Labor R. Alexander Acosta.

Commissioner of Social Security Nancy A. Berryhill.

I know I am nitpicking. All of these leaders work grueling hours and simply can’t be everywhere the public would like them to be. Plus, they sent senior officials from their agencies to represent them, many of them mental health experts.

But the Trump Administration missed a opportunity by not having its elite leadership team appear at the inaugural meeting, even if it were only long enough for a photo. (See photo at end of this blog showing those who did attend.) Each agency also should have issued a press release on the day of the meeting issued by its top executive addressing how their agency is working on improving mental health services and is reducing stigma within its own ranks.

Consider the powerful, positive message their appearances would have sent to the public and to the federal employees who work in their agencies.

Last week, I posted Secretary Price’s impressive opening statement and in this blog, I will share Dr. Elinore McCance-Katz’s important remarks to the committee.

But first a personal observation. When Secretary Price arrived at the meeting, he spoke to everyone in the room, asked their names, and shook their hands. Unfortunately, Secretary Ben Carson arrived at the last minute and left immediately after he spoke so he was unable to greet everyone.

When I worked at The Washington Post, I spent several weeks traveling with Archbishop Desmond Tutu. He made a point of introducing himself to every doorman, every food server, and the housekeeping staff when we traveled, at times, he did this before greeting dignitaries. I never forgot the visual statement it made: you are important regardless of whether you are the head of a great university or a janitor. You matter.

You might not agree with Secretary Price’s politics, but he showed tremendous class when he arrived at the meeting and took time to introduce himself and shake hands.

As for the others, they missed an important moment when they could have done tremendous good simply by showing up for a picture.

Remarks by Assistant Secretary Dr. Eleanor McCance-Katz

Thank you Secretary Price.

  • In my role as Assistant Secretary for Mental Health and Substance Use, I am pleased to pledge the support of SAMHSA to the Secretary’s priority issue related to Serious Mental Illness. As many of you know, SAMHSA is the agency within HHS that is charged with leading the efforts to address behavioral health issues, such as SMI and SED in our country and I look forward to the work of this committee in helping SAMHSA to address this mission.

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Sec. Price Calls Serious Mental Illnesses A “Silent Epidemic”: Phone Call About Violence Sparks Debate

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(I was surprised and flattered when Sec. Price mentioned yesterday how my book had influenced his thinking. His comment came 6 minutes into his opening remarks.)

(9-1-17) Serious mental illnesses remain a “silent epidemic” in our nation, Health and Human Services Secretary Tom Price said yesterday in his opening remarks at the inaugural meeting of the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC). Regardless of your political leanings, Dr. Price’s passionate commitment to improving our federal mental health care system was inspiring.

I was equally impressed with how Assistant Secretary Dr. Elinore McCance-Katz chaired the first session. (I intend to post her comments next week if I can secure a copy.)

Dr. McCance-Katz made it clear that there will be a shift in priorities at SAMHSA under her leadership in keeping with the marching orders that were given to her by the 21st Century Cures Act, which contained a modified version of Rep. Tim Murphy’s (R.-Pa.) Helping Families in Mental Health Crisis Act.

While there was much discussion at yesterday’s meeting, it was too early for the group to reach any specific recommendations. The most lively debate came after D. J. Jaffe , author of Insane Consequences, called in by telephone during the public comment period to complain about a lack of mention at the meeting about violence. This happened during the last hour of the day long session. (If you will recall, Rep. Murphy decided to write his bill after the Newtown shootings.)

Dr. McCance-Katz and the Treatment Advocacy Center’s Executive Director John Snook both said that while the vast majority of individuals with mental illnesses are not dangerous and much more likely to harm themselves than others, a percentage of those with SMI’s that go untreated are, in fact, more violent. Dr. McCance-Katz added that to brush over that fact is “disingenuous.”

Those statements clearly made some committee members uncomfortable.

The only member of the public, who attended the meeting, was Amanda Woodward, who asked the committee to focus on persons with mental illnesses who are being inappropriately incarcerated. Her comments prompted TAC’s Snook to warn that our nation is at a tipping point. Money that could be spent on mental health is being diverted into building bigger jails with psych units, in effect, making jails the main providers for treatment of those with SMIs.

That spending on more and more jails is wrong.

In addition to speaking, Ms. Woodward, a Virginia nurse who has worked in jails, signed a letter presented to the committee by Families for Treatment of Serious Mental Illness, in response to committee member  Elyn Saks’ recent article in Politico about giving patients more say about whether or not they will accept treatment. Saks argues in her thought provoking piece that offering a choice might, in fact, result in more individuals electing to undergo treatment while forced treatment drives them away.

I have reprinted the letter below. 

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Suggestions Sent To Me About Advisory Committee: How About Ending Taxpayer Funded Hotline For Snow Anxiety?

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(8-30-17) The debate about patient consent that I’ve highlighted this week has spurred additional interest in the first meeting of the congressional mental health advisory committee scheduled for August 31, Thursday, here in Washington D.C.

I’ve received emails from readers who have asked if involuntary commitment laws will be discussed. That’s highly unlikely because involuntary commitment standards are set by each state – not the federal government – based on a “dangerous” criteria established by a U.S. Supreme Court ruling.

This first meeting will be about introductions of commission members and potential topics to be discussed in the future.

In preparation, I’ve been asking for suggestions about steps that can be taken to improve the federal system. Here are some of the ideas that have been shared with me.

Medication pre-authorization: a suggestion from Dr. Dinah Miller, c0-author of Committed: The Battle over Involuntary Psychiatric Care.

 As you probably know, when a patient is prescribed a medication, they may go to the drug store to fill it, only to be told that it requires “pre-authorization.”  The pharmacy may then contact the prescriber by sending a form that needs to be filled out, or the prescriber may need to call the insurance company’s pharmacy benefits manager (PBM) to negotiate for the patient to be approved for the medication, a process that often takes 20-30 minutes of uncompensated doctor time.  Sometimes it’s just a hoop to jump through, often the PBM wants to know that the patient has failed other, cheaper, medications or that there is a specific diagnosis that requires this specific medications without any leeway to use medications “Off label” as we sometimes resort to.  Usually the process is instituted for expensive medications, but not always: one psychiatrist recently mentioned that she spent 30 minutes getting authorization for a sleeping pill — she was not aware that a 90 day supply of the medication could be obtained at WalMart for $10, much less than the cost of her time. 

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Supporters of Forced Treatment Take Issue With Expanding Patient Consent To Refuse Care

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(8-29-17) Elyn Saks’ thought provoking article in Politico about forced treatment (that I posted yesterday) sparked a lively discussion on my Facebook page. This never ending debate about civil rights comes before the first meeting this Thursday of a federal mental health advisory committee. One of the quickest to argue with Dr. Saks was D. J. Jaffe, who wasn’t appointed to the Interdepartmental Serious Mental Illness Coordinating Committee, but was a key proponent in helping Rep. Tim Murphy (R. Pa.) get his Helping Families in Mental Health Crisis Act, signed into law. It was that act which created the new advisory committee. Feel free to join the discussion on my facebook page.

Heal Thyself?

A federal panel on serious mental illness gets bad advice.

 By D. J. Jaffe, first posted in City Journal. 

In a recent op-ed in Politico, law professor Elyn Saks argued for “expand[ing] the definition of competence” of seriously mentally ill people so more can refuse to consent to treatment. “Instead of designing new ways to force medication on patients,” she writes, “we need to put our efforts into finding new ways to help people want treatment so we don’t have to use force.” Those are not mutually exclusive choices. Both are needed. This proposal—to make it harder to designate incompetence—is dangerous both to society and to the mentally ill themselves.

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