Mental Health

Three Years Later, Mental Health
Remains Burning Cape Cod Issue

Just over three years ago, this newsletter dedicated most of one issue to the topic "Mental Illness: Bringing Our Silent Problem Out Of The Shadows."

Today, we revisit that subject in depth with a variety of articles.

As the Advisory Board of To Your Good Health, A Health Care Newsletter, pointed out at its recent meeting at the Sheraton Four Points Hyannis Resort, much is happening, but much more remains to be done.

Carol Plotkin is Executive Director for Behavioral Health Services, the mental health arm of Cape Cod Healthcare (CCHC). Although there are some bright spots, she painted a generally dark-hued picture of the current situation, mainly as it affects the demographic bookends of Cape society, the young and the old.

"One of the first issues of primary importance involves geriatric mental health," she declared. "It's an under-served area and many, many seniors go off-Cape for in-patient treatment care because it's more appropriate in a geriatric unit than in a mixed unit as we have now."

The good news, however, was her disclosure that plans are underway to create a geriatric unit at Cape Cod Hospital in some of the space that's opening with the movement of beds to the new tower.

"At the other end of the life cycle spectrum," Ms. Plotkin continued, "the only in-patient beds for children on the Cape went away when Beacon Point closed in mid-May." [See related story.]

Ms. Plotkin said CCHC will take 16-year-olds in exceptional cases, but the normal admittance age for the mentally ill is 18.

The good news, she added, is that several groups are actively seeking some organization that will come in to meet that need and the number of school-based health centers that can provide some screening is increasing.

Finally, she said, "there is a general lack of community resources."

The length of stay of mentally ill patients is increasing, she said, often because of a shortage of "robust services, particularly housing." In other words, there's nowhere for them to go...and that includes, most poignantly, placement for those children relying on foster care.

Going into specifics, she continued, "We have very acute psychiatric illness here on the Cape, including many folks who have ended up here from elsewhere. Our psychiatrists say our patients are sicker and sicker...and younger and younger."

Addiction problems, often to pain medications, fuel this trend, she said. And she quoted the Department of Public Health as reporting the Cape has the highest rate of opioid admissions to Emergency Rooms in the state.

Another "sobering statistic" she cited was the Cape's suicide rate-the highest in the state, particularly among men over 65 who are recently widowed or living alone.

Denise Dever, President of Home Instead, a non-medical care service, noted that her office often gets calls from children off-Cape concerned about the mental state of parents here living alone who "maybe haven't been diagnosed with dementia, but they're lonely and our people do provide a degree of companionship that enables them to remain at home."

Dr. Arthur F. Bickford, founder of the Duffy-O'Neill Clinics and currently affiliated with the addiction-oriented High Point Treatment Centers in Plymouth and elsewhere off-Cape, said a new drug, Suboxone, was offering hope for dealing with addiction withdrawal problems, mostly involving pain medications, but that it was expensive and requires up to six months of intensive use.

But one continuing problem, he added, was treating patients from locked mental health facilities who also have physical problems. "Most hospitals want 'clean' psychiatry, whatever that is," he said.

Jim Lyons, retired head of CCHC, pointed out that hospital economics also play a part. He recalled that years ago Cape Cod Hospital tried to operate a children's psychiatric unit on a small scale, but, because of low reimbursements "it turned out to be an economic disaster" and had to be abandoned.

Dr. Bickford offered that "I think Cape Cod today is big enough for a single psychiatric hospital."

And Susan Miller, Academic Dean at Cape Cod Community College who holds a Masters degree in Community Mental Health Nursing, summed up, "We've known what to do for 30 years, but we still have this fragmentary approach. The Cape is a living laboratory and we should be testing things here as a model for the rest of the country."

New Youth Assessment Center May Plug
Gap In Cape’s Mental Health Coverage

Given the demographics of Cape Cod, it’s easy to understand why treatment of the emotionally fragile in our younger population has been a sometimes thing as parents too often struggle as care-givers in frustrating isolation.

Examples:

• A minus: some 10 years ago, Cape Cod Hospital closed down the adolescent in-patient wing in its Psych Center;
• A plus: five years later, a private non-profit facility, Beacon Point opened a six-bed in-patient facility for young people (six to 18) in Hyannis;
• Another minus: just this past May, Beacon Point was forced to close as the “non” in “non-profit” became an unsustainable “negative.”

Where’s a frustrated parent to go?

Well, time for another “plus.” Coincidentally with Beacon Point’s closing, Cape Cod Human Services cut the ribbon on a new satellite facility in Hyannis called the Kids and Teens Assessment Center.

Billed as “A One Stop Resource For Families,” it doesn’t provide actual treatment. But it does help with “…assessments, treatment plans and connections to appropriate services.”

This includes psychological and neuropsychological testing, medication evaluation, and recommendations for services. They’ll also assist in obtaining insurance and community agency support.

“A clearinghouse,” in the words of Director Peggy Meenan, LILCSW, to help family care-givers cope.

The Center will assist children from age four through their teens.

Some services are billable to insurance companies, some technical assistance will be provided by Cape Cod Healthcare, but the bulk of the financing will be in the form of $245,000 in grants from local charitable organizations.

“I can’t remember anything coming together so fast,” Rich Brothers of the Cape and Islands United Way said at the May 24 dedication, referring to the fund-raising effort.

“There are gaps in the current mental health system state-wide as well as here on the Cape and Islands,” Ms. Meenan added. “The Assessment Center will close some of those gaps.”

The Assessment Center, which as of this writing already had reached more than 50 young clients, can be reached at 508-790-5903.

Specialized Help Just A Call Away
For PTSD, The Bloodless Wound

Tony Dingman responds to two titles, wears two suits and deals with two diverse specialties in the practice of psychiatry. He had a chance to demonstrate both sides on the same day in Hyannis recently.

Shortly past noon, Doctor Dingman wore his civilian garb as a child psychiatrist—Center Medical Director of the Department of Mental Health Cape Cod & Islands and Child-Adolescent Psychiatrist for the new Kids & Teens Behavioral Health Assessment Center, which was just opening its doors (see related story).

Later that afternoon, Lieutenant Colonel Tony Dingman of the Massachusetts Army National Guard—preparing to leave on his second tour of duty in Iraq—donned his uniform for a presentation at Barnstable High School on “The Effects of Post Traumatic Stress Disorder (PTSD) on Soldiers and Families.”

As more and more of our service people rotate back from Iraq, this has become an increasing concern.

Dr. Dingman pointed out that this is a particularly serious problem among reservists and National Guardsmen who rotate in and out of a civilian environment where “nobody understands!”

Dr. Dingman says the best way to deal with PTSD is to talk to someone who has been through it.

Irritability, loss of concentration and “false beliefs about the world around you,” are some of the symptoms, but it’s still very difficult to assess who needs help, Dr. Dingman explained.

However, specialized help is available through an organization called Military OneSource. It has a 24/7 toll free hot line—1-800-342-9647—where “all calls are answered by a professional who can help” and a web site— www.millitaryonesource.com —where phone consultations can be scheduled and links to other military resources are provided.

PTSD can lead to a host of other difficulties, including substance abuse, a road some people mistakenly take as a way to silence the demons.

But the best solution, Dr. Dingman says, is to find someone who has been there “who can look into their eyes and tell what’s going on there, because if they don’t get treatment, they’ll just stay in that sorrowful place.”

Mental Health Treatment Available
For Bottom Half Of '2 Cape Cods'

There are two Cape Cods. One is the sandy summer playground with its palatial ocean view homes owned by some of the nation's wealthiest families. And then there is the often invisible hard-scrabble, seasonal existence of the working poor, where uninsured single parents and many immigrants often work more than one job just to survive.

This frustrating dichotomy can lead to depression, anxiety and addictions. Yet these Cape Codders with the highest need enjoy the least access to services.

To deal with this disparity, the Cape and Vineyard Community Health Center Network has established The Community Care for Depression (CCD) to create a comprehensive "no wrong door" system providing an array of behavioral health services at each health center for all Cape Cod adults and adolescents without regard to their socioeconomic or insurance status.

The project is funded by the Robert Wood Johnson Foundation-Local Initiative Funding Partners. The foundation's matching grant of $460,000 has been supported by Barnstable County, Cape Cod Healthcare and the Cape Cod Grant Makers Collaborative.

Service providers include the four Cape Cod Community Health Centers, Cape Cod Free Clinic and Community Health Center, Duffy Health Center, Mid-Upper Cape Community Health Center and Outer Cape Health Services.

Achievements thus far include more than 16,000 screenings of over 12,000 unduplicated patients, most of whom would not have otherwise received services; direct assessment, counseling, psychiatric services and medication assistance to over 1,800; referral of over 2,000 patients to a range of needed mental health and addiction services; facilitation of the use of shared psychiatrists among health centers and enlistment of pro-bono and reduced fee therapists; plus a pilot program for depression screening and suicide prevention at a local high school.

Future goals include mental health screenings at all health centers beyond the funding cycle and increased capacity for Portuguese-speaking patients.

For further information contact Tim Lineaweaver LMHC, LADC-1 Project Director at 508-540-7146 or tnt410@aol.com.

Some Practical Pathways
To Dealing With Stress

Stress is an unavoidable part of life. The demands of jobs and family, along with financial, health and time pressures can at times become overwhelming.

Fortunately, we all have within us natural ways of reducing stress and recharging ourselves. Exploring the sources of stress and transforming our reactions are important steps on the path to well-being.

Following are some initial actions one might take toward a less stressful, healthier life, although professional assistance may be helpful:

1. Identify your main sources of stress. Is your stress internal or are you dealing with external situations beyond your control? Prioritize what you might be able to avoid, alter or accept.

2. Learn effective relaxation technique such as meditation and proper breathing.

3. Plan a strategy for reducing the stress in your life. Begin slowly with one or two of the easiest changes.

Here are some useful techniques for calming and renewing your body and mind:

• Attitude: This important asset can be learned and cultivated. Most stress is not about the outside world, it is about your relationship with the outside world…and with yourself;
• Breathing: Adapt the old life-saving mantra—Out with the tension, in with the calm;
• Support: Cultivate companions who exude a positive attitude. If you can’t get this from family or friends, seek professional assistance. Nix the neggies;
• Simplify: Know your limits. Turn down requests that are not a priority in your life;
• Exercise: Movement and gentle stretching are a powerful way to reduce muscle tension. Yoga, walking, swimming, dancing or Tai Chi can be beneficial, but check first with your physician;
• Food: Choose easily digestible whole and natural foods. Avoid caffeine, tobacco and excessive alcohol.
• Mindfulness: Don’t dwell on the past or future. Enjoy the now.

(Ms. Kovanda provides individual stress-reducing counseling. She can be reached at 508-428-8635 or Kovanda@comcast.net.)

Rehabilitating Aging Or Broken Body
Often Requires Psychologist’s Support

As the health psychologist at the Rehabilitation Hospital of the Cape and Islands, John Allen, Ph.D., helps patients deal with the psychological effects of illness and aging.

“You don’t need to suffer from clinical depression or have a mental illness to benefit from psychological support,” says Dr. Allen. “Many of our patients have lived very successful lives but nevertheless have real problems when confronting illness, aging and the losses associated with them.”

At RHCI, Dr. Allen and his psychologist and social worker colleagues specialize in helping patients—and their families—adjust to health-related life changes. Whether it’s helping an inpatient deal with a devastating stroke or accident, or supporting an outpatient who’s making lifestyle changes to reduce the risk of a heart attack, the goal of psychology is to help patients develop the skills to deal more effectively with their situation.

“Many of our patients’ lives have been altered permanently by what brought them to us,” says Dr. Allen. “Our role is to help them use what they do very well to compensate for what they have lost.”

The principles can also be applied to helping people manage the losses that come with aging. Dr. Allen references Positive Aging, by Robert Hill, Ph.D., in which the author describes four key characteristics of people who are age positively. “They are able to mobilize their own resources, whether that’s inner faith or a social network. They have flexible personalities that enable them to adapt and change. They have a positive outlook. And they also follow a healthy lifestyle that includes exercise, good nutrition, and decreased stress.”

Dr. Allen points out that his focus is “to shift the focus from pathology to possibility because the traditional model of treating depression and major mental illness with psychotherapy and medication doesn’t necessarily apply to people facing losses due to aging or illness.

“Aging is a challenging time,” he concludes, “but people don’t have to suffer in silence.”

Some Medications Produce Weight Gain
So Mentally Ill Must Watch Their Diets

We are a growing nation but not always in a good way. The incidence of overweight or obesity has been spiraling up and, unfortunately, the prevalence is even higher in people with mental illness.

Many factors affect a person's weight status, one being medication. Weight gain is a frequent side effect of some of the antipsychotic medication and can affect compliance. One should keep in mind that although there may be some initial weight gain, that in the long term if the medication is effective the patients should start to feel more positive and be motivated to improve their eating habits and start exercising. The medication compliance is essential to help people take better care of themselves. People should be made aware of the possibility of weight gain at the beginning of treatment and their weight should be monitored.

Some studies have shown that with schizophrenics there is an increased consumption of high-caffeine, high-calorie beverages, which, when accompanied by a lack of motivation to exercise, contribute to a rising weight.

Or perhaps their medication makes them feel tired or thirsty and, to relieve this condition, they increase their intake of caffeine with beverages that also contain sugar.

Low calorie options are available such as water, whether plain, flavored or carbonated, or diet caffeine-free soda.

Start cutting back by alternating regular beverages with sugar-free-caffeine free soda and continue to replace beverages with sugar-free choices that are better for hydration.

A person can be overweight and follow a poor diet because they may not be motivated to cook or plan meals and consequently rely on the high-fat, high-calorie food choices in fast food restaurants or convenience foods from the supermarket. Making changes to decrease high-calorie foods should be accompanied by an increase in fruits, and vegetables and fiber.

Weight loss is difficult but not impossible and ongoing support and education from the beginning of treatment has been effective in improving eating habits and physical activity.

Start learning what a healthy serving size is, how to plan a meal that includes most food groups, that snacks do not mean chips, candy, and cookies but rather fruit, cereal and milk or a yogurt…all quick, and easy.

Ongoing support from family, friends and healthcare providers is necessary to promote changes and maintain these healthy habits.

Eating well and exercising will help improve compliance of medications, reduce medical complications and improve one’s physical and mental health.

(Ms. Gibbons, a Registered Dietician and Certified Diabetes Educator, provides outpatient nutrition medical therapy at Cape Cod Hospital.)

Post-Stress Problems Can Affect Us
--With Or Without Traumatic Event

Since September 11, 2001, PTSD, or Post-Traumatic Stress Disorder, has become a common term to describe the mental health condition that affects those who have experienced a traumatic life event. Not all trauma, however, leads to PTSD, just as we don’t necessarily need dramatic trauma for stress to affect any of us, for better and for worse.

All life events include some degree of stress. A hurtful and undesirable life event, as well as trauma, can generate stress. Traumas come in all shapes and sizes. Some are small and barely noticed, like a sprained ankle; others are catastrophic, like the death of a loved one by suicide.

We interpret and experience trauma differently. What is traumatic for one person may not be traumatic for another. A trip to the dentist may generate tremendous anxiety for one person and relief for another. We experience trauma in our own way. Think of some life events and rate them as to how stressful or traumatic they were for you.

We always seek to adapt after a traumatic life event. It’s our survival instinct. The challenge is to learn to adapt in a healthy manner.

Drug or alcohol abuse is one common example of unhealthy adjustment. Viewing life with heightened appreciation, such as after a near-death experience, is a healthy way to adapt. What happens after a traumatic life event? Stress or “post-traumatic stress” manifests itself physically, psychologically, socially, and sometimes also spiritually.

Let’s take one example that hits close to home: a Cape Cod hurricane. Before the storm arrives, we go about our routine business. As we receive word of the storm’s approach, we become attentive and anticipate its arrival. Our body mobilizes for action. Our mind generates thoughts and feelings. Our actions prepare us with provisions and defenses.

When the storm arrives, preparation is ended and all is out of our hands. We are at the mercy of the storm, riding it out until it ends.

Then, after the storm, there is the onset of shock, disbelief or numbness as we survey the damage. Finally, we assess what’s needed to recover.

We know we will never be exactly the same, but we seek a new routine that works for us. We calm down and think about what the trauma has done to us. For the future, this storm teaches us to become cautious and better prepared. Spiritually, we may realize how precious life is, how fragile and vulnerable we and our surroundings are measured against the forces of nature. At the same time, we may recognize how resilient and loving human beings may be; how we help each other recover, often in a surprisingly quick and healthy manner.

What’s important to realize about trauma is that, with or without help, we may not only recover successfully, but also learn to improve our life from the event—those clouds really can have a silver lining. We can all relate to that.

(“Dr. Bob” is a mental health practitioner in Osterville, specializing in Post-Traumatic stress, anxiety, depression, and issues related to suicide and suicide bereavement, 508-477-1676.)

We All Pay Dearly In The End
For ‘Savings’ On Mental Health

Our nation is still reeling from the tragedy at Virginia Tech. As the shock wears off, the natural inclination is to find fault. We search for the “black box” – the evidence of what went wrong. While there are undoubtedly many factors that might have changed the outcome of April 16, there is an underlying issue that can’t be ignored.

Mental illness affects almost 60 million Americans. That’s an estimated one in every four adults and one in every five children. Mental illness is more common than cancer, diabetes or heart disease, making it the leading cause of disability in the United States.

As Americans, we are so frightened by mental illness, or the stigma associated with it, that we do a fairly good job of ignoring it. So does our government.

Despite advances in medicine and therapy that make it possible to treat and prevent lifelong disability from mental illnesses with increasingly greater success, the systems that do so are woefully under-funded at all levels. Even Medicare discriminates against mental health treatment, as do private health insurance companies. Almost 90 percent of private health plans place limits on mental health care that they don’t place on medical/surgical care.

The cost to all of us is horrific. Senseless tragedies. Wasted lives. Broken families. Increased crime. Lost productivity.

How many more tragedies must occur before our national and state leaders get serious about making mental health care a priority?

There are more than 2,000 community mental health organizations across the country, which have brought quality treatment to millions in need of mental healthcare—including those with serious mental illnesses, the uninsured, the homeless and children in foster care.

Chronically under-funded, most of these organizations have, in recent years, wrestled with managed care, diminishing resources, and growing needs. Some have been forced to merge or go away entirely, leaving large geographic areas without accessible care. For the most seriously mentally ill, case management services and community supports are being cut back. And services to adults and children with depression, anxiety or disruptive behaviors, who with treatment could lead highly productive lives, have been all but eliminated. There are too few dollars to support experienced professional staff capable of doing so much more.

We know now that Seung Hui Cho, the gunman at Virginia Tech, was diagnosed with a mental illness and ordered to get treatment. He spent some time at a psychiatric hospital. But it wasn’t enough. He fell through the cracks. Our nation’s funding priorities did not allow for a comprehensive system of early intervention, assessment, monitoring, treatment and authority to keep him from being a danger to himself or others.

There are solutions, but the problem is of such magnitude that it will take a dramatic shift in our thinking and it will take government action, recognizing the prevalence of mental illness and recognizing that treatment is indeed worth our time and money.

Perhaps the tragedy at Virginia Tech will help focus our national, state and local leaders on the need for seamless, ongoing care for those with mental illness. We can continue our patchwork approach to public mental health services and suffer the consequences. Or we can move toward a more cohesive national mental health system that better meets the needs of those with mental illness and their families and communities.

(Mr. Shulman is President/CEO of South Shore Mental Health, 1- 617- 847-1903.)

SHINE ON…

Medicare Mental Health Coverage
Is Available…With a Few Twists

In case you were wondering…or possibly hesitating to seek treatment…yes, Medicare does have a mental health component.

This government program covers inpatient and outpatient mental health care which includes services to help find, diagnose and treat mental health problems. Part A will help cover care given in a hospital and Part B will help pay for doctors’ services, outpatient therapy, laboratory tests and partial hospitalization.

These services can be given in a clinic, doctor or therapist offices or outpatient hospital department. They can include individual and group therapy, family counseling, testing, occupational therapy, prescription medicine that cannot be self-administered and individual patient training and education.

Medicare, however, only pays for services provided by a health care professional who is part of the program. Always ask if your health professional accepts Medicare payment before scheduling treatment.

Some outpatient mental health care may require more intensive treatment than can be delivered through simple office visits. Your doctor or therapist may recommend what’s called a partial hospitalization program, a more intensely structured program. But, for partial hospitalization program to qualify for Medicare payment, your doctor must testify that the only alternative would be admission for inpatient treatment.

These partial programs are given through hospital outpatient departments and local community mental health centers.

Medicare does limit its coverage in an inpatient psychiatric hospital to a total of 190 days lifetime. After that, it will only pay for more inpatient psychiatric care in a general hospital where there is no lifetime limit for covered care. Because of this, most people receive treatment in the psychiatric ward of a general hospital.

Generally, you will have to pay 50 percent of the doctor and professional charges for mental health benefits after your yearly Medicare Part B deductible. If one has a supplemental Medigap or secondary insurance, it may cover the Part B deductible and the co-insurance. It’s always best to review your policy before you begin treatment so you are clear on what you may have to pay out of your own pocket. Don’t hesitate to discuss these issues with your provider.

Finally, individuals must understand the difference between traditional Medicare and a Medicare Advantage plan (HMO/ PPO) in order to decide which type of Medicare delivery system best meets their needs. All Medicare Advantage plans must provide the same benefits and services that are offered under traditional Medicare, but may not offer the same selection of doctors. Co-payments and deductibles also may differ.

For more information on Medicare or the Medicare Advantage plans you are encouraged to call SHINE (Serving the Health Information Needs of Elders) at 1-800-334-9999.

(Ms. Curtis is Regional Director of SHINE, a division of the Massachusetts Executive Office of Elder Affairs.)