Issue 1, Number 3 - Fall/Winter 2011

Expanding Preventative Care to Mental Health

By Jason Merrick, EMT-P

This past year, a prominent figure in Sonoma County, Peter Kingston, who was a loving father, friend, and the husband of Sonoma County Supervisor Shirlee Zane, took his own life suddenly and seemingly without warning. He was the type of person other people relied upon, a community leader and a man anyone would hope to call a friend and colleague.

When I first learned the news, a sobering thought jetted into my mind: “If someone like this could take his life, then all of us are susceptible.” The weight of that thought was immediate, definite, and forced me to pull over as I was driving. Thoughts churned in my head violently. In my limited interaction with this man, I quickly came to see him as capable, respected, kind, warm, and engaging. The inevitable questions came: Why? Could I have helped prevent this?

Regarding this particular individual, let me state clearly and unequivocally that I recognize that no one—family or friend—could have prevented this tragedy. Yet out of this devastating act, I am compelled to advocate for a relatively new primary care model from my background as a paramedic in California and from personal experience.

For the last five years, I have practiced advanced life support in the San Francisco Bay Area. I have encountered suicide in many forms ranging from people having suicidal ideations (thoughts about suicide with or without a plan and without actually committing the act[1]), to survivors of unsuccessful attempts, to the deceased who unfortunately did succeed. Sadly, I come across these calls quite often. Sheriff departments throughout California report that 9 percent of emergency calls are related to a mental illness crisis[2]—nearly one in ten. These individuals are difficult to deal with most of the time, altered by medications, violent, or extremely emotional. The scenes are often chaotic, with distraught families or lonely and tragic deaths.

More than 80 field protocols guide my care as a paramedic for everything from cardiac emergencies to poisonings, yet not one deals directly with psychological issues. Paramedics and Emergency Medical Services (EMS) professionals do have protocols to help deal with psychological symptoms, such as to chemically sedate a person who is violent and acting out. My point is not about changing the EMS system but rather that, in an acute mental illness situation, there is little paramedics and first responders can do except transport a patient safely to a hospital and hope for the best. We cannot treat a mental emergency in the same way we can treat a diabetic episode, for example, where the simple administration of dextrose will help the patient immediately. Clearly, the real care for mental health emergencies must begin long before the person reaches that climatic point necessitating emergency medical services.

My personal experience is that mental health issues need time and professional care to heal or at least to be better managed. I myself have seen a therapist in the past and most likely will continue to do so because this changed my life for the better. After college, I went through a rough patch with feelings of doubt and despair I had never experienced before. I had major questions about the direction of my life and decisions I needed to make. Talking with my supportive parents and friends brought temporary relief yet I felt as though I was burdening them with the weight of my problems. Then, after experiencing bouts of anxiety with increased heart and breathing rates and strong, unsettling feelings, I knew something needed to change. I sought out therapy and after meeting with several therapists, continued to see the one I felt most comfortable with and could confide in. We talked about my immediate mental anguish, how to control my despairing thoughts, and past issues that had surfaced.

From the moment I stepped into that office, my mental outlook began to improve. I started to see possibilities and to realize that other people experience the same feelings. One mistake I made was to completely discontinue therapy after just a few months. However, I was able to control new doubts using mental exercises I had learned and then return to therapy to confront my new fears. As someone who was extremely pessimistic about therapy at first, I am now certain there is great power and healing in words and discussion, confiding in someone and receiving compassionate and professional, yet emotionally objective, guidance in return.

Prior to 2008, our health care system enabled employers to avoid offering mental health benefits and charge higher co-pays and deductibles for employees who sought mental-health services.[3] During this time, many primary care specialists began advocating for primary care to include behavioral health as part of an integrated, whole patient approach. Since 2008, the federal Mental Health Parity and Addiction Equity Act, which helps equalize mental health and addiction coverage with medical coverage, and the Patient Protection and Affordable Care Act, which will require behavioral health coverage for all who are insured by 2014, together are greatly increasing access to mental health and addiction services.[4]

Furthermore, the Affordable Care Act includes a provision that allows states to integrate primary care, dental services, and behavioral health under one roof, a “Health Home” for beneficiaries of public healthcare (Medicare/Medicaid). The idea is to provide states the opportunity “to build a person-centered care system that results in improved outcomes for beneficiaries and better services and value for state Medicaid and other programs.”[5] The concept is an evolution from the earlier comprehensive primary care model that will allow our health system to become more proactive in the discovery of mental illness.

The conventional model of health care delivery is designed to treat mental health conditions after they surface. Instead, a whole patient approach or holistic approach regards individuals through a multi-faceted prism that employs a Comprehensive Health Evaluation to evaluate everything from age-related conditions to chronic ailments so that potential problems can be identified as early as possible. Many community health centers have already incorporated this approach into their primary care visits, including using a Patient Health Questionnaire to assess a patient’s mental well being and tests for mental or behavioral disorders such as depression and substance abuse.[6] Depending on the scoring, a Primary Care Specialist (PCS) or the primary care physician may inquire further or recommend an in-house Behavioral Specialist (BS) to speak with the patient. The presence of an in-house Behavioral Specialist has several benefits: if the case is severe enough, treatment can be initiated immediately. Otherwise, the patient can schedule an appointment during the assessment, which they are more likely to keep. This approach also allows for better coordination between specialties and for including behavioral health in the patient’s entire care and case management, from chronic conditions to treatment for anxiety.

Through the integrated model, the PCS and/or BS are able to identify and diagnose problems more readily, develop a baseline, and perhaps recommend relaxation techniques and tools to enable a person to self-manage sudden anxieties or destructive thoughts. This would also enable earlier treatment and interventionist measures, preventing acute mental health emergencies down the line and the associated costs in emergency care, hospital care, incarceration, intense in-patient treatment, medication, and crisis therapy.

From a societal standpoint, the cost savings and quality of life improvements of preventative mental health care are potentially huge. An estimated 25 percent of the U.S. population suffers from a mental illness with an associated cost of about $300 billion.[7] Mental health disorders and illnesses cut across all age, racial, and economic barriers and are associated with chronic medical diseases such as diabetes, cardiovascular conditions, and obesity. At least one in five children and adolescents between the ages of 9 and 17 has a diagnosable mental disorder in any given year.[8] And not only are mental disorders such as depression and anxiety debilitating, these often lead to alcoholism and dependence on other drugs. According to the World Health Organization, mental illnesses account for more disability in developed countries than any other group of illnesses, including cancer and heart disease.[9]

The costs associated with these disorders are extremely high, especially when sudden intervention is needed. A single emergency response for a psychological condition includes an advanced life support ambulance at $1,400, two police officers at $100 each, and a dispatcher at $25.[10] Add to that the emergency room visit, psychological evaluation, court, and treatment, a single acute mental health incident can run tens of thousands of dollars.

Unfortunately, only 25 percent of people with mental health disorders successfully get help for their illness in our current health care system. But this is changing.[11] Public health departments and many forward thinking private advocacy groups[12] are moving in the right direction with the “Health Home” model.

At the moment, the Affordable Care Act provides for integrated Health Home care that includes behavioral health but this provision applies to public insurance programs such as Medicare/Medicaid. Private insurance payers and employers are finally realizing the benefits of prevention in terms of cost savings and improving overall physical health, such as encouraging people at risk to eat healthier and to exercise regularly to prevent a heart attack down the line. Approaching mental health care the same way could pave the way to greater societal acceptance of therapy and further de-stigmatize the need to get help. For all of our social advances and increased knowledge of the human condition, the need for mental health services still tends to be regarded as something of a red flag, a deficiency. Sadly, this continues to engender shame and concealment. Imagine if everyone had the freedom and support to access mental health services—similar to screening for breast and colon cancer or high blood pressure. Mental health therapy may one day come to be valued as physical therapy is now: a necessary part of healing and sustained good health.

1. emedicinehealth.com, Roxanne Dryden-Edwards, MD, http://www.emedicinehealth.com/suicidal_thoughts/article_em.htm
2. Walsh, Joseph and Dana Holt. Jail diversion for people with psychiatric disabilities: The sheriffs’ perspective. Psychiatric Rehabilitation Journal 23: 153 (1999)
3. Nancy Shute, 10/25/2007, “Paltry insurance coverage could soon get a boost”
4. Colleen L. Barry, Ph.D., and Haiden A. Huskamp, Ph.D, Moving beyond Parity – Mental Health and Addiction Care under the ACA
5. Substance Abuse and Mental Health Services Administration, http://www.samhsa.gov/healthreform/healthhomes/
6. Patient Health Questionnaires (PHQ-2, PHQ-9)Bo Greaves, M.D. Medical Director, Vista Family Health Center, Santa Rosa, CA
7. Center for Disease Control and Prevention, U.S. Adult Mental Illness Surveillance Report, http://www.cdc.gov/Features/MentalHealthSurveillance/
8. U.S. Department of Health and Human Services, Healthy People 2010, Chapter 18: Mental Health and Mental Disorders
9. Center for Disease Control and Prevention, U.S. Adult Mental Illness Surveillance Report, http://www.cdc.gov/Features/MentalHealthSurveillance/
10. Cloverdale Health Care District, Cloverdale, CA
11. U.S. Department of Health and Human Services, Healthy People 2010, Chapter 18:
12. Patient-Centered Primary Care Collaborative, “Patient Centered Medical Home: Building Evidence and Momentum”, page 2

About the author: Jason Merrick grew up in Sonoma County and now resides with his fiancée outside of Petaluma on a small ranch. He has worked as a paramedic, firefighter, and emergency room technician throughout the San Francisco Bay Area for the last five years. Comments may be addressed to jgmerrick76@lycos.com.