As a nation, we have a long and shameful history of failing to provide mental health services for vulnerable populations. The need is particularly acute in rural areas, where mental health service providers at all levels are scarce to nonexistent.
“Jennifer,” a 19-year-old nurses’ aide, walked in during a busy afternoon at one of my group’s satellite offices in a small frontier community, where I was the only provider on duty that day. There was blood running down her leg, and she asked to see the doctor. When I entered the room, I saw that Jennifer had a 1 1/2 inch gash on the front of her left thigh. It was deep, penetrating through the fatty tissue underneath the skin. I did not need to ask her how it happened: Jennifer was my patient and I had already spent hours with her, and on the phone coordinating with her psychiatrist, trying to adjust the medications that would control her mood disorder and prevent her compulsions to do this kind of damage to herself. I wearily reflected that at least this time it hadn’t been a suicide attempt.
As I worked to repair Jennifer’s leg, we talked about how she’d been doing and what had led up to this event. She said she was barely hanging on, that the new medication doses weren’t working, and that she could not say with any kind of certainty that she would not do something like this again if I sent her home. All patched up, Jennifer sat with one of our clinic staff while I went to get on the phone with her psychiatrist – a three hours’ drive away in Denver, our nearest metropolitan area. I got through the receptionist and the nurse and several minutes on hold, and finally had the doctor’s ear. I explained that Jennifer had cut herself again, that she was medically very stable, and that she would require inpatient psychiatric care. The psychiatrist told me that she didn’t have any hospital privileges to admit, and advised me to “send Jennifer to the nearest ER – they’ll take it from there.”
I had to hold back a gasp of dismayed amazement: this was the best care Jennifer’s specialist could offer her in a time of crisis? To present anonymously to any old emergency department? “You don’t understand,” I told the Denver psychiatrist. “I am the nearest ER.” (It was true. The closest hospital was ours, 30 miles away, and I was on call that day). Eventually I did put Jennifer in my hospital for observation and safety purposes. It took me two days and about three hours on the telephone, but I finally found a doctor and a facility, about 200 miles away, willing to take her. In my region, the only providers we have, whether it is psychiatrists, psychologists, social workers, or even therapists, are through the publicly-funded Area Mental Health Centers, which serve geographically large portions of the state and are constantly overbooked. The event with Jennifer’s leg was years ago. Because of her mental health needs, she was eventually forced to move away from her family and the community she grew up in, to live closer to these types of services.
Jennifer lived on the western edge of Region 1. The nearest AMHC is in Ellis County.
There are no quick or easy solutions, but the Patient Protection and Affordable Care Act (PPACA) will provide a framework for some important first steps. Thirty-five million dollars are designated for mental and behavioral health education grants, with priority to professionals serving areas of high need like mine. It will take years to train these professionals, so there is no time like the present to begin. Like other medical providers, mental health providers will be incentivized to use evidence-based treatments and report their quality data, improving outcomes for patients like Jennifer. The National Prevention, Promotion and Public Health Council is to give the government annual reports on best practices related to, among other things, mental health, behavioral health, and substance use disorders.
Besides these federal-level programs, there are opportunities within the PPACA to help communities to take charge of their citizens’ mental health. The Primary Care Extension Program provides Health Extension Agents to assist primary care providers like myself in locating and utilizing mental health resources. Community Transformation Grants and Healthy Aging, Living Well Grants will be available to local governmental agencies with ideas for improving their citizens’ wellness, including mental well-being. A great many other beneficial provisions are listed here.
Perhaps most importantly, the PPACA stipulates mental health parity in reimbursements from insurance companies, so that if a patient is covered at 80% for her medical expenses, the same will be true of her mental health expenses. This is a long-overdue acknowledgment of the fact that mental health needs are no different from physical health needs. To those of us who care for people like Jennifer, mental-health parity is, pardon the expression, a no-brainer. But payment parity, along with all the aforementioned programs to empower communities in this important work, will be on the chopping block if Congress votes to repeal the PPACA. We have already waited too long for progress on this issue; let’s not take any more steps backward.