The New Asylums: Complete System Failure

I have been meaning to write about this issue for a very long while, but have left it on the burner for so long I forgot about it. Then today in psych class I had it thrust into the forefront rather brutally. Before I go on, I want to share this episode of Frontline from 2005, one that I hadn't actually seen before. I should expect that it won't take long to get the gist of a truly magnificent breakdown of how we manage mental illness in the U.S.



It didn't take very long to provide you with a pretty good idea as to just how truly screwed up this is. Keep in mind Frontline filmed that episode in a prison that is still considered a model for psychiatric care in the prison setting. This is no way to treat people with mental illness, even people who really do need to be locked away from society.

What really makes me angry about our new model for dealing with serious mental illness, is that all the excuses made for closing state institutions are exacerbated by this method of dealing with the seriously mentally disturbed. It is far more expensive to deal with the mentally ill either in prison, or on the streets coasting in and out of jail. The biggest reasoning was expense - but the expense has dramatically increased. It is a huge expense for local communities and ultimately still costs the state more.

On top of this, it is extremely hard for the seriously mentally ill to actually get the help they need and even qualify for. There are "homeless" mentally ill persons who aren't actually homeless. They have a place in a group home and access to care. But then they wander off from home and end up living on the streets - off their meds, hungry and exposed. And there are truly homeless mentally ill persons who aren't getting any help - not because they don't qualify, but because they are not together enough to go out seeking it. And even if they try, the system is not set up to be managed by a paranoid schizophrenic who believes there are people trying to kill her, or someone with bipolar who walked nearly a hundred miles from people who knew him while in a manic phase. That is not the "freedom" that wellmeaning, but ultimately ignorant lobbyists/policy makers were trying to provide with the idea of mainstreaming.

And the local communities - the communities in which people who know and love a particular mentally ill individual lives, are not set up to deal with them. We have had forty plus years to get it together and help these folks and still we are flailing about, failing too many. Even here in MI, where the quality of care provided by county Community Mental Health (CMH) services is generally quite exceptional, we are allowing too many to slip through the cracks. In many places, there is virtually no organization to provide services to the mentally ill. In others, southern California in particular, the services provided are truly abysmal.

And again, the states are still fitting a huge portion of the bill - in many cases a much larger bill than the state hospital system cost.

Michigan is particularly hard hit right now, as we have closed some of our mental health facil...Excuse me, prisons at the same time we have also eviscerated the budgets of the county CMHs. We are dumping these folks onto their local communities and pulling the funding that might have provided services for them. The clinics that manage paroles and people on probation are getting overwhelmed - in many cases with clients who should not be outside of a lockdown facility. Meanwhile, people with less serious mental problems, but who do not have insurance and do not qualify for medicaid are screwed.

Myself for example. I finished with my last therapist about a year ago. I was told that I would see another intern therapist last summer - then that was bumped to the fall...I haven't bothered trying to call again - I know what is happening and know that I am not going to get help. At least I am on meds and not left completely screwed. For more people are worse off than I am. No therapy, no psychiatric services - they won't get help until their mental illness becomes acute and they either commit a crime and end up in prison, or at least get picked up by the cops and pushed through the medicaid requirements.

Please don't think that things are much better elsewhere. For the past several years MI has managed to provide mental health services on a shoestring, that far outstrip the quality of care offered in many other states that have substantially larger budgets per public mental health consumer. It is not like those services have improved as budgets get hit across the U.S. Indeed the quality of care here has not actually suffered that much, we just can't provide that care to the people who desperately need it.

I have some hope that the new healthcare plan is going to help with some of this. The APA has managed to push for some provisions that should improve access to mental health services and they went through. But it is only going to help with people in temporary crisis. People who are dealing with situational mental problems or who exhibit mild symptoms. It is not going to do a damned thing to change our prison and "homeless we can ignore" based system of care for the seriously mentally ill.

Just so we are perfectly clear about this, those scenes where they showed these yellow cages in a half circle - their "group therapy" session - that is not a reasonable way to provide group therapy. Not an effective means for any sort of functional therapy. Punishing inmates for breaking rules they don't understand is not effective therapy. Pretending that there is anything valid about an admission of guilt for rules violation, coming from a guy who is incapable of understanding what he is pleading guilty to is a fucking atrocity.

And remember, the system we got a glimpse of in that video - that is a model system for prison based mental health care. That is worlds apart from what one gets in county lockup or most prisons in the U.S. It gets far, far worse than what we see in that episode of Frontline.

My Experience With Universal Healthcare

I have been without health insurance for most of my adult life. The time I actually had insurance, it was the really shitty, rather expensive kind that blue collar workers tend to get - high deductibles, high premiums that are hard to manage and a hell of a lot of exclusions.

Without insurance, I have been relegated to having the stoned hippie who lived with me at one point, stitch the hole in my arm left by an ex-lover (who it turned out was married) and my 22 pistol. Without insurance, I have learned to give myself stitches and (as the lovely Juniper discovered) have become a very good hand with butterfly insta-sutures - even one handed, because the wound is on my other arm. Without insurance, I once bought cocaine on the street as a numbing agent, so a friend could drill a cavity that I packed myself - thankfully another friend is a solid hand with a needle in the gums. Without insurance, I have a small chunk of my left elbow bone floating about under the skin - thankfully it only hurts when I bang it just right. Without insurance, I have learned to manage sprains and minor fractures - I learned from the best as a rather "active" child, to manage splints and immobilizing bandages. Without insurance, I became pretty adept with herbal medicine - I can make tinctures, extracts and even a few isolates, all day long. Lets hear it for medicine as it was practiced 150 years ago.

But there have been plenty of times when I was afflicted with something or another, that simply couldn't be left to home healthcare. For those, I had to turn to the U.S. version of universal health care - the emergency room. Let me just take this moment to thank those of you who have been paying for or who have expensive insurance paying for the programs that cut thousands off of the hospital bills - not because I asked them to, but because they wouldn't treat me if I didn't sign the papers that allow them to cover the cost out of special funds that many hospitals have for people who can't pay. They have to pay the staff somehow - and that is the how. It comes out of funds that everyone who can pay, is paying into. The best you can do, is make donations later, to that fund - because you don't even get the bill. Which is to say that you get billed, but that is for the actual bed cost and sometimes for tests they have to run.

I have been in ERs a lot. I have been there when I was injured or seriously ill on my own. I have been there when I have been injured on the job. I have been there when my eldest had a temp of 104.3 and rising when he managed to get the damned thermometer out of his mouth (at eleven thirty pm - almost two am). I have been there when he gashed his head - I wasn't home when he gashed his leg. Something I have noted - the ER is pretty much always crowded - though thankfully, when we were there in the middle of the night with a high fever, we were in a children's ER waiting area that was quiet. And they aren't full with people who have serious emergencies, few enough with even urgent care needs. They are full with people who are sick or injured, who if they had a doctor, if they had insurance, could see their primary care provider. But they don't have those things and are thus relegated to the only provider they can get - the ER.

And most of them are in one of two positions - they make little enough, that they qualify for one of those programs I was talking about, or they make a little too much and just won't be able to pay for any of it. I have been in both categories and I have sometimes been able to pay some - mostly I have come to accept that for the time being, I am going to have horrible credit. But that is besides the point - the bottom line is that those who can afford to pay, are paying for those visits. Taxpayers are also paying for those visits. And to make this a really big "what the fuck?!?!" Many of those people have fucking health insurance - they just don't have enough - don't have enough to cover five hundred dollar annual deductibles. Don't have enough to cover half the cost of the primary care physician visit. Don't have enough to cover the cost of the script the doc will write them and know the hospital pharmacy will fill it for free.

I am that strange sort of introvert - the kind who is capable of sitting down and having a conversation with a whole lot of different sorts of people - as long as the conversation is only with one or two other people...I have talked to a lot of people in ERs and there are all sorts there. Including people like Beatrix, from a couple of posts ago - people with preexisting conditions, who simply can't buy insurance, can't, because no one will sell them any, at any cost. Some of them can pay their bills - at least over time, many of them can't - many of them are just giving up and going on disability, because that is the only way they can actually get healthcare. It's not that they flat out can't work - it's that if they do, they lose their medicaid. So they end up living in poverty, at taxpayer expense - when they could actually work, if someone would let them and not take away their healthcare.

Our current government is about as disgusting as can be. Unlike the other republicrats, they were hired in part, because Americans want publicly funded healthcare options. 60% of republicans polled, want UHC. Substantially more democrats want UHC. And we have a democrat majority - virtually a supermajority. So what the fuck is going on? As Stephanie mentions, the only motherfuckers who don't want public options, are the insurance lobby, the corporate media and the fucking assholes we hired to bring us fucking healthcare...

I am not fond of asking for help - but I am not afraid to...Or to give something back for it.

Thanks to a very lovely commenter and dear friend, things are looking much better. If you really would like to help out, please call your local "sliding scale" clinic and ask about donating the funds for helping someone in your community get the prescriptions they need. Because I am far from alone with this problem and I can almost guarantee someone in your community could use the help...

We have run into a rather bad snag in my corner of the world. Overall things are rather sunshine and roses - at least as sunshine and rosy as they can be. But a somewhat nasty - scratch that - a very nasty problem has arisen. There is a need for medication, coupled with a very frightening lack of resources for meds for this month as possibly next. I think that next month is looking more promising and after that it is totally smooth sailing. But this month is most definitely fucked.

I really fucking hate asking for help, but I also dread the idea of school and honestly, life in general, moving backwards instead of forwards. I also want to be very clear that I absolutely do not want to impose on anyone who is in dire straights themselves. I am just hoping that some of you might have something to spare and would be willing to help out. It needn't be much, because I have come to gain a great many friends here on the intertubes and the need isn't that huge - though in relative terms, the cost of a months worth of wellbutrin - even the fucking generic, is rather high (for example, the combined cost of everything I take - sans my wellbutrin, is 1/5th the cost of my monthly scripts).

I also thought it would be fun to turn this into a something of a challenge - I will donate an hour of time, for every ten dollar increment towards the meds. I will grant that I was already intending to do some community volunteering, but I have simply been unable to form a solid plan for that. So if I actually get to my goal, I will commit to *52 hours over the next year, of **maintenance and repair to my local YWCA - who I understand can particularly use the help...

I am trying to figure out the whole fucking paypal thing and will probably leave the damned thing up, once I figure out how to actually get into my existing paypal account and how to post an icon. Until then, please email me if you can and want to help. And as an added bonus, I will be happy to hear what you might want me to write about and try to comply with requests as quickly as possible - which isn't to say it would necessarily happen quickly. I have a semester to finish up and boys coming hard on it's heels and......You get the picture...I am hopeful however, that the next semester will not be quite so brutal. It's a little heavier load, but in a regular, sixteen week semester, rather than this really short one I'm in now...

*above and beyond any other volunteering I am planning for - which admittedly is uncertain right now...

**Or whatever else they need done - as I understand that they also need donation pick-up help as well...

Help Vaccinate a Child...

Times are really tough - I know that about as well as one can. Though there are those who have been suffering worse financial woes than I have, having lost my family's home in Portland, I know all too well how bad things are. But there are those here in the U.S., who could really use your help - and if it helps to shame anyone into donating, I made a donation myself, even though I am a student without income.

I was shocked this afternoon, when I read over at Respectful Insolence, that Nevada has abysmal vaccination rates. Not because of the anti-vax loon brigade, but because the economy is bad there and apparently the state doesn't have enough funding to ensure that all kids get vaccines. The state recently managed to put together the funding for the actual vaccines, but not enough that they don't have to charge for the actual administration of the shots. They must charge $16 for a single vaccine or $25 for more than one.

I have been where a lot of those families are. While $25 may not seem like a hell of a lot to most people, when you are to the point where you have to ration your eating to five or six meals a week, to ensure your children get enough to eat, that works out to being a lot of meals you will miss that month. And I can also attest, trying to functionally work when you're only eating one meal, ever day or so is not easy and certainly not healthy. These are folks who cannot afford to lose a single damned dime. And so there are a lot of kids not getting the vaccines that will not only keep them safe - they keep their communities safe too.

And so as bad as things are right now, I managed to throw down $25 dollars and will sleep somewhat more soundly tonight, knowing that I just ensured that a child in Nevada who wouldn't have been vaccinated will be now. And dammit, if I can manage that, what can you manage?

Here is a link to the page where one can register for a James Randi Education Foundation event. If you scroll down the page, you will see a line that allows you to donate $16 or $25 to help vaccinate a child. I would ask you to ignore that $16 bullshit and help a child get the whole shebang. Further, I would ask that you give until it fucking hurts, because this is not just for them, it's for all of us. Here is a direct link to the $25 donation slot. Please vaccinate as many kids as you can....

CAM, Anti-Vax loons and the Morons at Merck

I am more than a little pissed after reading this post, which I found through Greg Laden. I am pissed because I have become increasingly involved with fighting non-evidence based medicine, mostly with people around me. I don't really write about it much, though I have begun thinking that I should. I haven't really felt the need to, because there are a lot of great medical bloggers out there who do such a fantastic job of it - several of whom are linked in my sidebar. In particular, Orac, PalMD, Mark Hoofnagle and the great people at Science Based Medicine do one hell of a job tearing down the veneer of crap and exposing it for what it is.

Here's the issue I have. I'm a reasonably intelligent person, a bit above average even. Yet I am also what I like to call, pathologically credulous. I have fallen into remarkable amounts of magical thinking over the years and not because I'm dumb. In fact part of it is because I tend not to assume that something is true, just because everyone else says it is. And my relationship with non-evidence based "medicine" was largely grounded in the idea that evidence based medicine is largely profit based and therefore largely corrupt. What wasn't so apparent to me at the time, was that a lot of the bullshit that I was falling into was just as profit based and much of it was even more corrupt - though much of the corruption was a very different sort. I also fell into a lot of the bullshit because many of the claims were made by people who also made claims that were easily verifiable - they fostered my trust and I believed what they had to say about things that weren't so easily verifiable.

And that is the key to sucking people into so called alternative medicine. Efficacy by association. Throwing plant medicines that actually have some degree of efficacy (largely because many pharmaceuticals are derived from plant sources) into the mix, even though this can actually be quite dangerous in some cases (a whole post of its own sometime). Throwing legitimate medical treatments in, but using them for things they simply aren't called for - such as chelation therapy. It makes it easier to sell people on flat out bullshit. Things like osteopathy, homeopathy and energy medicine - things that are not only not supported by evidence, but which are flat out absurd on their face. Things that are based on nothing more than magical thinking.

It's bad enough that some of these "medicines" can be dangerous in and of themselves - either because the actual treatment is harmful, or more often, because the treatment is used in place of evidence based medicine. But it doesn't stop there. There is a very dark side to this, with insane and deadly notions like HIV/AIDS denialism, denial of the germ theory of disease, the anti-vaccine movement and anti-chemotherapy proponents. People actually die because of this complete and utter bullshit.

Another reason it is easy for some people to fall into magical thinking in regards to medicine, is because of the perception that evidence based medicine is mostly based on therapies developed by corrupt pharmaceutical companies. Most people don't start out believing that, but I think that most people do recognize that pharmaceutical companies and for that matter, medical science in general, is not immune to corruption. And I think that most people recognize that sometimes that corruption includes maliciously covering evidence that companies wish to avoid becoming public. This makes it rather easy for some people to buy the CAM line that critics of CAM and even fringe CAM ideas, are simply shills for Big Pharma - an evil bogyman that's out to addict people to their medicines and cast them aside when they've been poisoned by them. From there it isn't much of a trek to believing that all evidence based medicine is evile and that doctors are merely merchants of death, the death manufactured by Big Pharma.

This is why I am so very angry at Merck and the doctors that contributed to their advertising rag, disguised as a legitimate science journal*. The doctor involved should should face sanctions. And Merck should be fined heavily by the FDA. Things that would happen, if we lived in a reasonable world, in a reasonable country with reasonable oversight. There is something very wrong with a system where this can happen and the people involved don't even understand that they did something wrong. This is absolutely and categorically disgusting and unconscionable.

But the idea that this somehow validates the proponents of woo, the peddlers of magical thinking in the guise of medicine, is a logical fallacy and a rather obvious one - if not also one that is easy to accept. Just because another pharmaceutical company and some doctors were really damned stupid and highly unethical, does not mean that all of science based medicine is. And there are several doctors and scientists out there who would like to make sure you know that this is not the mainstream of science based medicine. Some of them have even written about this....


Respectful Insolence

Adventures in Ethics and Science


Dr. Isis

Stranger Fruit

Greg Laden

*I would also note that I am more disappointed in Elsevier for publishing this bullshit, than I am with Merck and the people involved from their end. That they would choose to put out this kind of garbage reflects poorly on them and while it may be a while yet before I am publishing papers, this will certainly reflect on my decisions about where to publish.

The US: a nice place to live, but don't get sick

I would like to thank Revere, of Effect Measure, for his open willingness to share his posts per the creative commons licensing, share and share alike. I have chosen to add this license to the writing here as well, the tag can be found in the side bar.

I really appreciate Revere's writings on public health issues. As such, I thought it would be very appropriate to use a post he wrote about the state of health care in the U.S. to get the conversation about universal health care started. I will be adding posts from others on this topic, both pro and con, in the future, along (of course) with my own thoughts. This post was originally posted to Effect Measure, June 19th 2007. . .

From Effect Measure;
The Editors of Effect Measure are senior public health scientists and practitioners. Paul Revere was a member of the first local Board of Health in the United States (Boston, 1799). The Editors sign their posts "Revere" to recognize the public service of a professional forerunner better known for other things.

It's a myth that's hard to bust. The one that says the United States, the country that spends more on health care than any other, has the best medical care in the world to go with it. It hasn't been true for a long time. It doesn't. But it is part of the core belief of most Americans. I wonder who benefits most from that falsehood? But to the facts:

As early as 2000, the World Health Organization made the first attempt at ranking all the world's healthcare systems. The U.S. came in 37th out of 190 nations in the provision of healthcare. (France, according to the June 2000 report, was first.) The report was criticized for using inconsistent comparison measures and for failing to note that some countries deny expensive care to very sick patients. Americans could still reasonably cling to their long-held pride.

But in 2006, the Organization for Economic Cooperation and Development, an international organization that aims to lift living standards by promoting economic development, compared health spending and health statistics in its 30 member nations. Its report was more detailed than the WHO rankings, and had more controlled and consistent measures. The data, taken more seriously than the WHO rankings, left Americans with little to brag about.

And [NIH's Dr. Ezekial Emanuel's] recent commentary [in the Journal of the American Medical Association] was published the day after another report released by the Commonwealth Fund, which supports independent research into healthcare issues, found the United States at the bottom among six industrialized nations on measures of safe and coordinated care.

If all of that doesn't seem damning enough, insurance provider UnitedHealthcare Group took out a full-page ad in the Wall Street Journal on March 19 declaring: "The health care system isn't healthy.... A system that was designed to make you feel better often just makes things worse." One of the very industry giants that critics point to as a cause of the problem was defensively pointing back.

Amid stacks of reports, all with wonky measures of access, equity, efficiency and medical outcomes, two statistics stand out. The U.S. spends more on medical care than any other nation, and gets far less for it than many countries. According to the 2006 analysis by the Organization for Economic Cooperation and Development, the U.S. spends an annual $6,102 per person -- more than any other country and more than twice the average of $2,571. Yet Americans have the 22nd highest life expectancy among those nations at 77.2 years compared with the analysis' average of 77.8 years. People in Japan, the world leader in longevity, live an average of 81.8 years.

The report also found that the United States had about 2.5 times the average years of potential life lost due to diabetes: 101 years per 1,000 people compared with the average of 39 years per 1,000 people. Americans had fewer practicing physicians, or 2.4 per 1,000 people, than the average of 3 per 1,000 people. Infant mortality rates have been falling in the U.S., but are still higher, at 6.9 deaths per 1,000 live births, compared with less than 3.5 deaths per 1,000 live births in Japan, Iceland, Sweden, Norway and Finland. (LA Times)

When Andrew Speaker used subterfuge to fly back to the US for treatment of his XDR-TB an Denver's National Jewish Hospital it was not only to get home to his family but because he believed the care in the US was better than anywhere else. In fact, Italy has the second best health care system by the international comparison rankings and some of the best TB experts in the world. You probably didn't know that. Number 1? France. I'll bet you didn't know that either. You can quibble about the ranking method (if you can claim some expertise), but the only thing everyone agrees the US comes out on top for is cost. Cadillac prices for a high mileage junk car.

When I was in medical school the prestige specialties were internal medicine and psychiatry. That's what the brainy students chose. Not any more. Why? Because you don't get to do "procedures" in those specialties. Doctors get paid for "procedures." Handsomely paid, I might add. Managing chronic disease? Sorry. No procedures.

For starters, the American system doesn't measure up worldwide in controlling chronic diseases, such as diabetes or hypertension. Payment systems reward doctors for doing procedures, not for managing those chronic conditions, so a world-class center -- like Boston's Joslin Diabetes Center, which is supported by philanthropy -- stands in stark contrast to results seen by regular doctors treating the disease in average patients.

Kidney disease patients on dialysis have a higher risk of death in the United States. By an act of Congress in 1972, all end-stage renal disease is covered by Medicare, even for patients younger than 65. But because of Medicare funding cuts, patients on dialysis receive less time on dialysis than patients in Europe and Japan. That helps explain why Americans on kidney dialysis have a mortality rate of 23% compared with 15% in Europe and 9% in Japan, according to a May 2002 report in JAMA.

The US, alone among the industrialized nations, has no universal health care. Let me correct this. The average US citizen doesn't. Members of Congress already have their health plan. Even the CongressThings so adamantly opposed to "socialized medicine" are not giving up their government health plans. They'd rather hold the average American hostage to their ideological pecadillos.

Meanwhile, those of us who can afford to, pay. And pay. And pay. But we don't get our money's worth.

And those who can't afford it? You supply the answer.