If you look at the map, our hospital in WV is about 2300 miles from Tucson Arizona where 1 year ago today we shared our prayers along with feelings of sadness and loss with six families who lost a loved one as a result of the actions of a young man with mental illness. With 13 other individuals wounded in the same event, it is difficult to avoid taking a long hard stare at the way mental illnesses have affected our lives, our state and our nation.
At our hospital, we see patients with mental illnesses frequently. Is this surprising? – No. The National Alliance on Mental Illness (NAMI) website reports that “we’ve all been hit by the worst economic times and highest unemployment in more than 25 years. Those unemployed workers are reporting symptoms of severe mental illness four times more than people who still have jobs. Four times as many report thoughts of suicide.” Additionally, NAMI reports, “returning combat veterans are experiencing very high rates of serious mental illness, suicide, addiction, homelessness, and incarceration related to posttraumatic stress disorder.”
“How are you?” I frequently ask the patients and families in our Emergency Department who have presented with symptoms of mental illnesses. The responses usually consist of a wide range of issues and situations that are not easily solved within the few hours they are with us: “I’m about to lose my house”, I’ve been out of work for the last year and a half and can’t find anything”, “ I just found out I had cancer”, - or – what I think of as the ‘perfect storm’ of emotions and stress: “my wife and I aren’t getting along – ever since I lost my job, we’ve had financial arguments which are affecting our relationship and the children, the house is about to get foreclosed...we have no where to go”.
Each story seems more heart wrenching then the one that came before it. But what is even more difficult is looking into the eyes of the patients across from me and seeing their ‘heart’; their emotional pain, vulnerability, frustration, fear, anger, hurt, abandonment, disappointment - you name it, the emotions are there. Emotions that sometimes lie buried under situations or dynamics of fighting to keep your family together or pounding the pavement looking for a job only to face rejection over and over and over again.
And yet, as heart-wrenching as these stories are, I’m glad to be having a conversation with each patient as opposed to helping families with locating a funeral home and additional support after the successful suicide of a loved one.
In 2009, the National Alliance on Mental Illness published their report “Grading the States” which listed West Virginia having a grade of “F” (the national average was a “D” – which was the grade given to West Virginia in NAMI’s 2006 report). Arizona – where the shootings in Tucson took place, received a grade of a “C” in 2009. Just under ten miles from the east of us, Maryland received a “B” – one of the highest grades in the country as there were no states that were worthy of an “A”.
But what do these grades mean?
In short, they mean that we (those of us providing care for our patients and families) need to be better then we are. We need to have the open discussions about the provision of care for patients and families who present to Emergency Departments with suicidal ideation, depression, anxiety, bipolar, schizophrenia and addictions and understand that all of these are real, treatable illnesses and not major character flaws. We need to understand that the face of mental illness is not some stranger off the street – it’s the patients and families in our care, our co-workers, our neighbors, our friends, our families and sometimes ourselves.
We need to protect and strengthen out state’s mental health care system and understand that doing so is an investment that will provide real benefits for patients and families in providing them with the care, support and resources necessary to address the illnesses they have.
As providers and as a community, we should also ask ourselves how we can apply the lessons learned from the events in Tucson to our own communities. In his Statement on The Arizona Tragedy and Mental Health Care, Michael Fitzpatrick, the Executive Director of the National Alliance on Mental Illness stressed the importance to “objectively determine every factor that may have contributed to this tragedy so we can act on lessons learned”.
He specifically listed ten questions to begin this process which included asking:
1. Was there a diagnosis?
2. What is the full medical history?
3. When were the symptoms first noticed?
4. Did family members receive education about mental illness and support?
5. Did the person or family ever seek treatment only to have it delayed or denied?
6. Was the person seen by mental health professionals? By whom? How often?
7. Was treatment coordinated among different professionals?
8. Was the person prescribed medication? Was it being taken? If not, why not?
9. Was substance abuse involved?
10. What may have triggered this psychiatric crisis?
Here are my questions:
What would the care provided for patients and families in West Virginia look like if we asked these 10 questions on every patient in our care? Would West Virginia still have an “F”? What if we implemented similar processes to those of our “B” grade Maryland colleagues. What if we looked at the vast difference in the commitment process for patients in Maryland vs those in West Virginia and made adjustments as needed to insure safe and expeditious access to care?
I wonder if it is a coincidence that two of the states with the highest grades: New York and Maryland are also referred to as “2PC” states; states which require two physicians to commit a patient where as states with lower grades (including West Virginia) do not have that process in place? I wonder if implementing the 2PC process in West Virginia would be more cost effective then the presently established treatment process?
While I like to think this is an easily attainable goal, sometimes the more important task is just to provide good care for the patients we see instead of letting them (and their families) "slip through the cracks" again and again by not acknowledging the presence of their symptoms or their need for care.
We have to look back at the intricate needs of each state's NAMI report card and the symptoms and goals of the patients and families in our care and ask ourselves:
Are we providing good care or fostering the "F"?
