Broken Minds, Broken System

DSHS Tries to Improve Texas Mental Health Care

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Public Health Feature - November 2007

By  Crystal Conde
Associate Editor

Mental health care in Texas is ailing and getting worse. The number of people needing treatment is huge and expected to grow, yet finding and access to care is lagging. And even though Texas has more than 23 million residents, it has only 2,350 psychiatrists and 10 state mental health hospitals. This increasingly forces hospitals, emergency medical services, and police to deal with people in crisis.

Only three other states do a poorer job than Texas caring for people with mental health problems, says the National Association of State Mental Health Program Directors Research Institute Inc. It ranks Texas 47th, ahead of only Florida, Idaho, and Arkansas, in per capita mental health spending.

The Texas Department of State Health Services (DSHS) is painfully aware of the problem. It predicts a depressing future for mental health in the state. DSHS projects a 6-percent increase by 2009 in the number of adults who already get mental health care from a Local Mental Health Authority (LMHA) but who will need additional crisis services. The projection for children is shocking - a 74-percent increase. Even worse, DSHS expects 47 percent more adults and 195 percent more children will need crisis intervention by 2009. Projections are based on higher treatment demand resulting from expected population increases. 

DSHS contracts with 39 LMHAs to deliver mental health services in communities across Texas. Local residents and community Mental Health and Mental Retardation center executive directors within each LMHA are responsible for using public money to assemble a network of service providers and propose the most suitable treatment alternatives for people needing mental health services. To locate the LMHA in your area, visit  www.dshs.state.tx.us/mhservices.

Emergency medicine physician Diana Fite, MD, of Houston, knows the problem of mental health patients needing crisis help from a hospital all too well. She's seen many patients in a hospital emergency room because they either used up or stopped taking their medication.

"The biggest frustration is the patients in mental health crisis taking up our rooms for so long. These patients aren't in and out. These patients are in there for hours and hours and even a day or two," Dr. Fite said. "If they could be reached before crisis stage, our emergency departments would be a little less crowded."

The problem is not unique to Texas. An American Heart Association report indicates about 18 million Americans use the general medical sector for mental health care in a year. And, the number of people requiring care for mental illness in emergency departments is rising. (See " Mental Health-Related ED Visits, 1998-2004.") 

All Not Lost

Although the situation looks hopeless, efforts to improve are under way. DSHS will make the first move to improve the state's mental health care system this month when it starts to redesign crisis services. The main priority will be taking pressure off local law enforcement, state hospitals, and emergency departments while providing appropriate settings for care.

Revamping the mental health system will begin with attention to four areas: crisis hotlines, mobile crisis units, crisis stabilization units (CSUs), and in-home psychiatric services for children.

Crisis hotlines staffed by trained mental health counselors and mobile crisis units that operate in conjunction with the hotlines and provide emergency and urgent care would give every county basic crisis response resources. As a result, communities would be able to identify, screen, and stabilize patients safely. In addition, the crisis hotlines will seek accreditation from the American Association of Suicidology.

Enhanced local crisis services in the forms of CSUs and children's outpatient care would allow communities to establish or expand assistance programs. CSUs provide short-term, supervised residential treatment and may hold a person without a commitment for up to 48 hours for observation.

Joe Vesowate, assistant DSHS commissioner for mental health and substance abuse services, says six CSUs will be operating or starting up by late next year. In-home psychiatric services for children will address children's needs in a comfortable, family-focused environment.

DSHS realized the need to revamp crisis services in 2005 when it convened a Crisis Redesign Committee of mental health, law enforcement, emergency health, and hospital professionals, as well as representatives of the courts, community services, advocacy groups, and consumer, professionals, and health care organizations. The charge of the committee was to study the mental health system, examine emerging standards of practice, and recommend improvements.

Following an exhaustive review of biomedical and social services literature, crisis services quality management, and input gathered from statewide hearings, the committee released its report in September 2006. (It is available at  www.dshs.state.tx.us/mhsacsr. You can download PDFs of the report and implementation overview.)

Equipped with a plan for enhancing the state's mental health crisis services, DSHS received $82 million from the Texas Legislature this year for 2008-09. The Texas Medical Association supported the appropriations, made under Senate Bill 867.

The money for crisis services will fund those initiatives and priorities recommended by the Crisis Redesign Committee. About 66 percent of the funds will be added to existing LMHA contracts. About 30 percent will be distributed as investment incentives among communities. DSHS will provide, on a competitive basis, funding to communities that identify gaps in their mental health services, create plans to address their needs, and are willing to contribute at least 25 percent in matching resources.

Mr. Vesowate, who cochaired the redesign committee, called the legislature's appropriation "historical," and said legislators saw "that mental health is an important part of the health care system" needing attention. 

Dr. Fite says delivering mental health care at the community level would help curtail the use of emergency rooms by mentally ill patients and hopes the $82 million will result in services being directly delivered to those in need. 

Mental Health Report Card

In its report, the Crisis Redesign Committee noted significant variances in mobile outreach, CSUs, and crisis hotlines across the state. Also of concern were drastic differences in the ability of urban and rural areas to deliver timely services.

Bill Race, MD, the DSHS medical director for behavioral health, says Texans in mental health crisis in some areas of the state may live more than 100 miles from the nearest state hospital. Access to mental health services at the community level, such as short-term intervention or stabilization, would help patients and their doctors.

The committee found that mental health care systems were most effective in areas with strong collaboration among organizations and stakeholders, such as mental health centers, hospital districts, physicians, health departments, law enforcement officials, judicial systems, and advocacy groups.

"What we had been hearing was emergency rooms are clogged; jails are clogged; state hospitals are full. One of the goals was to look at how we can main-stream these activities into the broader health care arena," Mr. Vesowate said.

Funding for enhanced crisis services will benefit Texas physicians, too. Dr. Race says physicians in Texas will have more resources to deal with crises.

"With uniformly trained hotline and mobile response systems, physicians can intervene and in severe situations hopefully provide more observation of these patients and refer our [DSHS] help to get residential treatment or hospital treatments. Thus, physicians feel more supported in helping in these situations," he said. 

Integrated Health Care

Studies show a close connection between mental health and physical health. The American Hospital Association's (AHA's) February 2007 TrendWatch shows a link between mental and physical illnesses. (To read the report, log on to www.aha.org/aha/trendwatch/2007/twfeb2007behavhealth.pdf ). 

For example, patients suffering from depression are twice as likely to have diabetes and are at increased risk of developing heart disease. The report also touts the benefits of addressing behavioral health. Hospital stays fell by 78 percent among patients who took part in psychotherapeutic interventions. Hospitalization frequency decreased by two-thirds for these patients, and emergency department visits dropped by almost 50 percent.

Because many chronic ailments accompany mental health issues, physicians recognize a need to integrate mental and physical health care. Priscilla Ray, MD, a Houston psychiatrist, advocates training medical professionals in attending to patients' physical and mental needs.

The crisis services redesign won't instantaneously blend physical and mental health, but both Mr. Vesowate and Dr. Race look forward to the eventual integration of the two types of care under the new system.

Addressing mental health among children is more and more a task falling to primary care physicians and pediatricians. The Texas Medical Board (TMB) reported in May that only 326 child and adolescent psychiatrists were practicing in the state.

To help fill the gap, DSHS child psychiatrist Emilie Becker, MD, suggests psychiatrists mentor pediatricians and family practitioners, further strengthening physicians' abilities to provide care in one setting. TMA has a resource to help primary care physicians recognize and treat children's mental health conditions. (See " TMA Primary Care Physician's Guide to Child Mental Health.")

The Children's Hospital Association of Texas May 2006 Children's Mental Health in Texas: A State of the State Report asserts that inadequate funding has resulted in "a decline in the number of children served by state and local agencies and increased reliance on de facto providers such as public schools and the juvenile justice system." (The report is available at www.childhealthtx.org. It is posted under "Bentsen Project.")

The report indicates a need for increased outpatient and community-based treatment programs to relieve the burden faced by inpatient facilities for children and adolescents. According to Dr. Becker, funding for crisis redesign implementation will increase access to health care workers who can assess children in a secure and comfortable location.

"Whether someone's calling the hotline, using the mobile crisis outreach team, or staying in a community respite service, we want to make sure that access to someone with training in children's mental health is available at each of those levels," she said.

Crystal Conde can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email atCrystal Conde.  

PH.Chart Nov. 7

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SIDEBAR

TMA Primary Care Physician's Guide to Child Mental Health

In 2002, the TMA Committee on Child and Adolescent Health developed Integrating Child & Adolescent Mental Health Into Primary Care: A Resource Guide for Physicians to assist primary care physicians recognize and treat children's mental health conditions.

A revised version is now available that contains:

  • Updated medication information,
  • A more streamlined discussion of clinical problems,
  • Examples of common problems that can be managed in the primary care office,
  • Specific office implementation strategies,
  • New community team development and implementation plans,
  • Updated billing and coding recommendations,
  • Tips on how primary care physicians can coordinate mental health services among schools, state agencies, the juvenile justice system, and other entities in their communities.

To request a hard copy of the guide, email  Susan Griffin  or call (800) 880-1300, ext. 1462, or (512) 370-1462. A PDF can be downloaded on the  TMA Web site.

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