Category Archives: Mental Health

GOP’s State of Confusion: Anti-LBGT or Anti-Muslim or Both

Confused

OK, I am officially confused. Which is it, does the GOP want to be seen as the champion of conservative religious tenets which hold homosexuality as sin and corruption; or, does the GOP want to be thanked as the protector of homosexuals from the evil-doing nasty folks of IS/Daesh?

Invisible Victims

No matter how hard some conservatives may try to avoid saying LGBT, the attack in Orlando, Florida was made on a GAY nightclub.  As noted previously Representative Dina Titus (D-NV1) was capable of observing this fact; while, on the GOP side of the aisle Representative Cresent Hardy (R-NV4) just couldn’t quite resist the temptation to generalize the victims.  Somehow, Representative Hardy’s lights couldn’t illuminated the fact that the victims were in a GAY nightclub.  He’s not alone.

The Republican National Committee’s first response mentioned “lifestyles,” but even that was edited out of their second edition – now the terror attack was made on “any American.”  Representative Pete Sessions (R-TX)  publically denied Pulse was a GAY nightclub immediately before blocking attempts to provide LGBT protections in a bill before his committee. [TP]

Senator Ted Cruz (R-TX) was blunt: “This body should not be engaged in political games,” Cruz said. “We should be focused on the threat and keeping America safe and defeating radical Islamic terrorism.” [BusIns] Against whom?  Once again, the victims of the horrendous attack were invisible.

Senator Mitch McConnell (R-KY) was just as vague in remarks made on the Senate floor yesterday — “This week in Orlando, Americans were targeted deliberately and taken  forever from their families by a terrorist ISIL has claimed is “one of  the soldiers of the caliphate.” It is clear from his behavior that this was not a random act of  violence. This was a calculated act of terror.” [LoC pdf]  Scrolling down the entirety of the  Majority Leader’s comments yields exactly Zero references to the victims of the Orlando attacks – patrons of a GAY nightclub.

Yes, it was obviously calculated, and yes, it was an act of terrorism – against the patrons of a GAY nightclub.

Squirrel Logic

But wait, after making the victims of the assault on the Pulse nightclub almost perfectly invisible in their comments about the attack, the GOP would now have us believe they champion GAY rights? Excuse my confusion – I would have thought these people were invisible to you but…

Representative Mo Brooks (R-AL) appears on the scene with this bit of baffling political analysis:  “Democrats are in a perplexing position. On the one hand, they’re trying to appeal to the gay community, but, on the other hand, they’re trying to also appeal to the Muslim community, which, if it had its way, would kill every homosexual in the United States of America,” Rep. Mo Brooks (R-AL)” [TPM]

And, far be it from Mr. Trump to pass up an opportunity to stick his oar in the muddied waters:

Donald Trump, in his first major speech after the weekend’s tragedy suggested that Hillary Clinton “can never claim to be a friend of the gay community.”  “She can’t have it both ways,” Trump said. “She can’t claim to be supportive of these communities while trying to increase the number of people coming in who want to oppress them.” Ask yourself, who really is the friend of women and the LBGT community: Donald Trump with his actions or Hillary Clinton with her words?” [TPM]

There seems to be more than a little political semantic gamesmanship here.  The message to the heretofore invisible LGBT community seems to be either you are anti-Islam or you have to be anti-LGBT, there is no middle ground.  This conflation of all practitioners of Islam as anti-gay is as inaccurate as it is distasteful divisive rhetoric.   Those unsure of this might want to consider the following comments by an Islamic scholar in the Dallas Morning News:

“As Muslims we believe there’s no compulsion in religion. That’s actually a Quranic verse. Everyone adheres to their own set of values, their own set of morals. But that should not lead to the oppression of another person or to harming another individual. The way that we talk about that is the way that we talk about anything in the Quran or in the prophetic tradition.

Yes, you’re going to find Muslims that would offer revised interpretations of the Quran. But I think one thing that’s important to stress is that conservative is not the same thing as radical. If a person has conservative views that they uphold within their own family life, so long as that does not lead to denying, belittling, or dehumanizing someone else, then I don’t think that’s particularly problematic.”

Thus much for the lack of middle ground.  Doing a quick inventory – Islam is not a compulsive religion (check), Islam has conservative followers (check), Islam teaches that one’s beliefs may not “deny, belittle, or dehumanize” someone else. (check) Conservatives are not necessarily radicals. (check) Only in the most bigoted way imaginable could a person decide that all members of the Islamic faith are radicals. Only in the most prejudicial manner could a person proclaim that all followers of Islam are necessarily so anti-gay that they could excuse or rejoice in the killing of their fellow citizens.

There may be a second message in the dog whistling coming from these Republican remarks.  It’s  message to their own base.  If the actual victims of the massacre are invisible, and if they can be generalized out of the picture, then it’s possible to believe that all Muslims are radical, and it’s acceptable to “monitor, screen, place them under surveillance, and restrict their freedom and liberty” in the name of public safety for “all Americans” (except the ones we won’t name.)

A third screech from the dog whistle may be aimed at a more general audience.  By creating an artificial “either/or” proposition the GOP can seek to associate Democrats with Muslims.  The inference is that Muslims are dangerous, Democrats support Muslims, ergo Democrats are dangerous.  Their’s is a simple but demonstrably false syllogism which depends on the acceptance of the initial false proposition that ALL Muslims are dangerous. I’m fond of calling this Squirrel Logic: Squirrels have hair on their heads. That man has hair on his head. Therefore, that man is a squirrel.

A Broader Perspective

While the GOP may wish to fixate on the terrorism facet of the attack on the GAY nightclub, what happened seems far more complex.  The horrific massacre had more than one element – it had a very disturbed radicalized young American man wielding military weaponry with a high lethality rate, in a GAY nightclub, who intended to kill GAY people.  It really isn’t hard to unpack the elements.  A marginalized person (self or otherwise?) who attached himself to a radicalized version of a religion, and who had easy access to a military weapon and enough ammunition to launch a killing spree in a GAY nightclub, the victims in which have themselves been marginalized in anti-LGBT rhetoric. 

Taking any one of the elements out of the toxic equation shouldn’t lead us to conclude that there is any single policy change that would have prevented the tragedy.  However, removing at least one certainly wouldn’t hurt and might help avoid subsequent attacks.

It would help if we could tone down the anti-LGBT rhetoric. Just as it is no longer socially acceptable to make a joke of someone’s ethnicity, wouldn’t it be nice if the mocking, demeaning, and dismissal of a person’s sexual orientation were no longer acceptable in polite society.  This isn’t “political correctness,” it’s merely fine old fashioned good manners.  It would be even more helpful if we could enact statutes protecting the rights of members of the LGBT community and being as concerned about their rights as we are our own.

It would help if we toned down the anti-Islam barrage.  Those whose image of Muslims, and especially of Muslim Americans, is composed of TV footage of Daesh outrages, or foreign cultural practices commonly abhorred, should take note of the many resources available for better understanding their Muslim neighbors.  They should consider the following statements from Muslim community leaders:

Dawud Walid the executive director of the Council on American-Islamic Relations in Michigan says Mateen doesn’t represent Muslims in the U.S. His message to the public; Muslims are American and as all other Americans, they are loyal to their country even if they disagree with certain issues.The rule of American Muslims is to abide by the laws of the land and to be peaceful and this recent extremist act that took place this morning, is the rare exception and in no way embodies our morals or our values as Americans citizens who just happen to be Muslims,” said Walid. [CBS Detroit]

Or, this:

“We condemn this monstrous attack and offer our heartfelt condolences to the families and loved ones of all those killed or injured. The Muslim community joins our fellow Americans in repudiating anyone or any group that would claim to justify or excuse such an appalling act of violence.”

CAIR is America’s largest Muslim civil liberties and advocacy organization. Its mission is to enhance the understanding of Islam, encourage dialogue, protect civil liberties, empower American Muslims, and build coalitions that promote justice and mutual understanding.” [CAIR]

A little more mutual understanding should certainly help more than vilifying the American Muslim community.

It would help if we made it less likely that a disturbed or deranged individual could  get access to a military style weapon of war, which were never designed for civilian use.   There are listings of weapons by lethality. The AK-47 style; the M-16 (AR-15) “family”; the M240 machine gun; the PK machine gun; the QBZ 95 assault rifle.  It would seem reasonable that if a gun is listed as one of the five most lethal weapons in the world that common sense implies its ownership should be restricted.  Perhaps restricting the magazine capacity would assist in diminishing the lethality of these weapons when they are misused by civilians? That, too, sounds like common sense.

It would help if we de-stigmatized those who are harboring feelings which are anti-social and the antithesis of stability.  Who missed the signals that the Orlando shooter was demonstrating troubling personal behavior? Were the signals and warnings acted upon appropriately? Who could have warned authorities that the Aurora, Colorado theater shooter was exhibiting disturbing behavior – do we need to emphasize the necessity of giving local authorities a warning about those who combine disturbed thinking with fixations on violence?  Who might have warned authorities about the intentions of the Colorado Springs PPA facility shooter?  We are fond of saying “If you see something, say something,” why not practice what we’re preaching? And, why not support the funding and increased resources of our mental health services?

If we persist in seeing only those elements of mass shootings which conform to our pre-existing ideologies then we’ll miss the opportunities available to diminish the likelihood of further mass tragedies. A broader perspective is required to reach better horizons.

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Filed under anti-terrorism, gay issues, Gun Issues, Islam, Mental Health, Nevada politics, public safety, terrorism

Murphy’s Law: H.R. 2646 and Mental Health Services

Bill Yes, the Republicans have been diverting attention from the regulation of firearms in America by switching to speaking of mental health; and yes, there’s a bill in the House (HR 2646) which seeks to address some of the issues raised by mass shootings.  However, it’s not “gone anywhere” fast; and, it’s not a particularly good bill.

The title is nice, “Helping Families in Mental Health Crisis Act of 2015” – some of the provisions are helpful, others may very well not be.  The bill does provide for more sharing of information concerning a person who has gotten treatment for mental health problems. Section 401 allows for caregivers to receive information about diagnoses, treatment plans, appointment scheduling, medications and medication related instructions, but not any personal psychotherapy notes. This sharing is intended to protect the health, safety, or welfare of the individual or the general public. Caregivers would also have access to educational records in Section 402.  There’s a fine line here. On one hand sharing information could (and possibly should) enable the caregivers involved to have a better understanding of the person’s condition and treatment plan. On the other there’s an element of concern about how much information is shared with whom – especially since mentally ill individuals are 11 times more likely to be victims of criminal acts than to perpetrate them.  [MHA]

Assisted, Involuntary, Mandatory?

Then there’s the questionable use of the English language in the term “Assisted Outpatient Treatment.”  It sounds like it would have the emphasis on “outpatient,” but the word that should be emphasized is “assisted,” as in assisted by the courts.  “Assisted outpatient treatment (AOT) is court-ordered treatment (including medication) for individuals with severe mental illness who meet strict legal criteria, e.g., they have a history of medication noncompliance. Typically, violation of the court-ordered conditions can result in the individual being hospitalized for further treatment.” [TAC]  There are studies which indicate the AOT plans in 45 states do help relieve some of the stress on caregivers, and often result in a reduction of hospitalization.  Thus, what we’re really talking about here is mandatory outpatient treatment.  Whatever we call it, “assisted,” “mandatory,” or “involuntary” before jumping to any conclusions we might want to determine if “it” works.

The efficacy depends on how we measure success.  If the criteria include  re-arrest rates, program costs, or crime rates, then the AOT plan appears successful in general societal and economic terms. [TAC] On the cautionary side, the Phelan Study (NYC 2010) included ‘184 people who were in AOT and compared them to a control group recently discharged from a psychiatric hospital and were attending the same outpatient facilities as the AOT group. Both groups experienced similar reductions in psychotic symptoms.’  “The AOT group members were four times less likely to report an incident of serious violent behavior than those in the control group,” which would be good news indeed, except that the AOT wasn’t the sole factor.  The Duke Mental Health Study (Swanson 2000) found “improved outcomes and reduced violence was associated with simply more frequent service visits over an extended period of time (6 months or more).” [PsychCen]  In short, time and treatment were the most significant factors.

And now we’re left with a question:  Is the success of the AOT programs correlated to the coercion element, or is the success of the program correlated to the extension of the treatment services over time?  If the latter, then we’d expect to be allocating more funding to the treatment services necessary.  Another question raised might well be on what basis are we justifying our political decisions concerning the implementation and funding for AOTs?  Are we successful if we reduce policing costs? Institutionalization costs? Or do we measure success in terms of the mental health of the patient?  There is, most likely, a place for AOT in our mental health care system, how much emphasis we want to place on it is a political decision.

Politicians and Policy

“On June 4, Congressman Tim Murphy introduced legislation (HR 2646) designed to dismantle the federal mental health authority – the Substance Abuse and Mental Health Services Administration (SAMHSA) – which has successfully promoted recovery and community inclusion for individuals with serious behavioral health conditions for 25 years, as called for by President Bush’s New Freedom Commission on Mental Health. The bill would replace SAMHSA with a new Office headed by a politically appointed government official, controlled by Congress ….” [MHA]

This is the point at which the two familiar bugbears of politics emerge: Congressional Control and Funding.

“Threats of sequestration in 2013 had a significant impact on people’s ability to access mental health services and programs, including children’s mental health services, suicide prevention programs, homeless outreach programs, substance abuse treatment programs, housing and employment assistance, health research, and virtually every type of public mental health support. The Substance Abuse and Mental Health Services Administration (SAMHSA) claimed it alone would be cutting $168 million from its 2013 spending, including a reduction of $83.1 million in grants for substance abuse treatment programs.” [Forbes]

What hasn’t been cut in Congressional appropriations for mental health care support for the states isn’t faring all that well in the FY 2015 budget.  Sometimes it seems that “block grant” simply means a way to pile the money together and then cut the whole stack.  For example, in FY 2013 the Community Mental Health Services Block Grant program received a total of $437 million, in FY 2014 the figure increased to $484 million, but in FY 2015 the final number is $483 million.  One provision in H.R. 2646 would allow only medical professionals with certain academic credentials to evaluate block grant requests – which sounds very “professional” except when we consider that some substance abuse and alternative programs may be very successful, but aren’t necessarily conducted with the imprimatur of currently medically credentialed individuals – critics have charged that this is a perfect way to “ossify” the field of mental health care and substance abuse treatment.

There is an alternative bill in Congress which does not eliminate SAMHSA, and which shares many of the provisions of H.R. 2646, is S. 1945.  A comparison of the two bills is available here in pdf format.  Whether the administrative situation is changed or not, unless the funding for the programs is enhanced, or at least made equal to the inflation rate, it may not matter much who is administering a smaller portion of an already diminishing pie.

It’s The Money Stupid

Enforced treatment, coerced treatment, “assisted” treatment, or whatever we may chose to call it without addressing the need for “time and treatment;” combined with Congressional micro-management, Presidential politics; and, an underfunded by a block grant system, doesn’t seem like the best approach to addressing mental health services in this country.

First, we need to get some perspective.  If SAMSHA has focused on alcohol and drug abuse it’s probably because as of 2013 we had 17.3 million Americans who were categorized as “alcohol dependent,” and some 24.6 million who had used illicit drugs in the previous month before the 2013 survey. [DAgov]  By contrast, government figures estimate approximately 10 million adult Americans with serious mental illnesses. [NIMH]  The focus issue is only important IF we’ve decided we can afford to address one problem or the other, but not both. Focus isn’t an issue if we decide that we can do two things at once and proceed to tackle both.

Secondly, there most likely is a valid social use for mandatory treatment especially for those who cannot or will not voluntarily cooperate with evidently necessary treatment plans, and whose behavior is such that the individual presents, in the hackneyed phrase, a danger to himself or others.  Further, while patient privacy is a legitimate concern, it should not infringe on the needs of caregivers and others with whom a seriously mentally ill comes in contact.   (While we’re on this topic – why not consider additional funding for local police and law enforcement agencies to allow training in dealing with the mentally ill?  If the motto is “Protect and Serve,” then might not allowing police officers to receive limited but significant information about a patient serve to improve their interaction with him or her.)

Third, it doesn’t make sense to argue for increased institutionalization, on a short or long term basis, if there are inadequate facilities available.  For example, in 2010 Nevada had 302 beds for the mentally ill, which is calculated to be approximately 25% of the total need. [TAC] [see also LVRJ 2013] If part of the solution is AOT, and the coercion element is hospitalization, then the hospital beds need to be available.

Therefore, if we are truly interested in making life safer for the general public (witness: mass shootings by mentally ill individuals) and safer for the mentally ill (who are 11 times more likely to be the victims of crimes), then it should behoove us to consider allocating some resources toward creating a system in which (1) there are adequate and easily accessible mental health care facilities and services, (2) there is adequate funding for mental health care services so that these facilities are maintained and expanded as needed, and (3) we are not overly focused on Silver Bullet Solutions, but willing to advance and develop a spectrum of mental health care services which include a wide range of treatment options.

There are some good portions of both H.R. 2646 and S. 1945, and some definite limitations and foibles exposed in each.  What neither bill manages successfully is to fully fund the mental health care needs of Americans in the 21st century.

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Filed under Health Care, Mental Health

One Great Distraction: Guns, GOP, and Mental Health

blood money The GOP response to gun violence in America is getting tiresome, and no diversion or distraction more so than when its members cite “mental health” as a topic for discussion.

The Republican Party really shouldn’t get anywhere near this distraction, not with their record on making mental health care available to American citizens. [AmerBlg]   It doesn’t do to blather on about Guns and Mental Health in one breath and then take 50+ votes to repeal the Affordable Care Act in the next.

Before the passage of the Affordable Care Act about 1/3rd of those who did have health insurance in the individual market had no coverage for substance use disorder to services, and 1/5th had no coverage for mental health services, including outpatient therapy, and inpatient crisis intervention and stabilization.  Additionally, even when a person did have coverage there was no guarantee mental health services would be covered comparably to medical and surgical care.   The situation in the small group market was a bit better, coverage for substance abuse and mental health services was more common, but many states did not have “parity” laws requiring comparable coverage with medical and surgical treatment.  Then, there were those 47.5 million Americans who didn’t have any health insurance, and the 25% of uninsured adults who have a mental health condition, a substance abuse problem, or both. [ASPE]

After the passage of the Affordable Care Act mental health and substance abuse are categories covered as part of the package of Essential Health Benefits.  With the finalization of rules as of January 1, 2014 consumers buying health insurance policies can be confident that the health plan will cover mental health services, and importantly, that there will be parity for mental health and substance abuse treatment coverage. [ASPE]

And what was the Republican reaction?  “Repeal.. Repeal.. Repeal…” at least 50+ times. [WaPo]  

January 8, 2011:  There was a mass shooting in Tucson, AZ  six were killed, eleven others wounded including a member of Congress, Rep. Gabby Giffords.   January 19, 2011: The House votes to repeal the Affordable Care Act.  On February 19, 2011 the House passed an FY 2011 continuing appropriations bill with several amendments to “severely limit” the implementation of the Affordable Care Act. The measure passed with no Democratic support.  Further votes were taken to carve up and diminish the provisions of the Affordable Care Act on March 3, 2011, April 13, 2011, and April 14, 2011.  On April 14, 2011 a House resolution advised the Senate to defund all mandatory and discretionary spending associated with the Affordable Care Act.  April 15, 2011 the Republican controlled House passed its version of the budget repealing and defunding the Affordable Care Act.  During the four months after the Tucson Shooting the Republican controlled Congress spent much of its time trying to defund, limit, or outright repeal the law requiring health insurance companies to include mental health services as an “Essential Benefit” and on par with coverage for medical and surgical treatment.  And, they weren’t finished.  Republicans tried to gut the Affordable Care Act provisions on May 3, 2011; May 4, 2011May 24, 2011; and on August 1, 2011 the Budget Control Act cut some mandatory and discretionary funding tied to the Affordable Care Act.

October 12, 2011:  Eight people were killed and another critically wounded by a shooter in Seal Beach, California.  Ironically, on October 13, 2011 the House passed the “Protect Life Act” preventing any funding from be applied to abortion procedures.  More Congressional incursions were made on the Affordable Care Act on November 16, 2011, December 13, 2011, and December 16, 2011.  On February 1, 2012 Congress voted to repeal a long term care insurance program (CLASS).  February 17, 2012 the House voted to cut funding for Louisiana’s Medicaid program by $2.5 billion, and cut $11.6 billion including $5 billion from the Public Prevention and Health Fund.  The cut to the Medicaid program was significant because Medicaid is the insurance provider for low income people, some of whom might be in need of substance abuse or mental health care treatment.  On March 29, 2012 the House version of the FY 2013 budget called for repealing and defunding the Affordable Care Act.

April 2, 2012:  A former student at Oakland’s Oikos University opened fire in a classroom, seven were killed and three wounded.  The House attacked the Affordable Care Act again on April 27, 2012, and more significantly voted on May 10, 2012 to replace the automatic budget cuts to the Defense Department by defunding and repealing portions of the Affordable Care Act. June 7, 2012 the House voted to repeal the medical device tax, and limit the reimbursements for over the counter medications.  On July 11, 2012 the House voted to repeal the Affordable Care Act.

July 20, 2012: 12 people were killed and another 58 were injured in the shooting at the Aurora, Colorado movie theater.  Yet again, opponents of gun safety regulations noted that the shooting was the result of mental illness.

August 8, 2012: A shooter gunned down six people and injured three others at a Sikh Temple in Oak Creek, WI.

September 28, 2012: Six were killed and two injured in a workplace shooting in Minneapolis, MN.

October 21, 2012:  Three died and four were injured in a shooting in Brookfield, WI.

December 14, 2012:  Newtown, CT; 27 died including 20 first grade children. On December 20, 2012 the House voted once more to replace discretionary spending cuts enacted as part of sequestration by defunding and repealing several provisions of the Affordable Care Act.  On January 1, 2013 the “fiscal cliff deal” passed the House including the repeal of the CLASS Act and cutting funds for the Consumer Operated and Oriented Plan. 

On May 16, 2013 the House voted to repeal the entire Affordable Care Act. 

June 7, 2013: Five people were killed in a shooting incident in Santa Monica, CA which ended on the campus of Santa Monica College.  On July 17, 2013 the House voted to delay the implementation of the Affordable Care Act for employers by one year.  Also on July 17, 2013, the House voted to delay the implementation of the individual mandate.  On August 2, 2013 the House voted to prevent the IRS from implementing or enforcing any portion of the Affordable Care Act.

September 16, 2013:  12 were killed and 3 injured in a shooting at the Washington, DC Naval Yard.  On September 20, 2013 the House voted to approve a short term FY 2014 continuing resolution in which the Affordable Care Act was fully defunded, including the prohibition of all discretionary and mandatory spending, and rescinding all of its unobligated balances.  On September 29, 2013 the House voted again to repeal the medical device tax, and to delay the implementation of the Affordable Care Act by another year.  September 30, 2013, the House voted to delay the individual mandate, an action which would effectively render the law inoperable.

Votes were taken in the House on October 17, 2013; November 15, 2013; January 10, 2014; January 16, 2014, March 5, 2014 to weaken the enforcement of the Affordable Care Act.  More such votes were taken on March 11, 2014; March 12, 2014; and, March 14, 2014. [LAT]

April 2, 2014: Three were killed, sixteen injured in Fort Hood, TX, scene of a previous shooting in 2009.

On January 28, 2015 Rep. Bradley Byrne (R-AL) introduced H.R 596, a bill to repeal the Affordable Care Act.  The measure passed the House on February 3, 2015. [RC 58]*

May 23, 2015: Six dead, seven wounded in Isla Vista, CA. June 18, 2015: Nine dead at the Emanuel AME Church, Charleston, SC.  October 1, 2015: Nine dead, nine injured in Roseburg, OR.   Meanwhile, the Huffington Post asked Senators what might be done about the carnage:

“If there’s one issue that these senators wanted to talk about when asked about gun violence, it was the mental health component. Nearly all of those who were interviewed said their attention is on that aspect of the problem, instead of on gun laws.

“What I’ve been focused on, and I think it very much relates to, unfortunately, too many of these mass shootings, is improving our early intervention mental health system,” said Sen. Kelly Ayotte (R-N.H.). “Hopefully we can take some immediate action and find common ground.” [HuffPo]

Improving our “early intervention mental health system?”   What appears to be more than slightly inane (if not outright insane)  is to believe that repealing the Affordable Care Act — such that we cannot assure health insurance coverage for substance abuse and mental health problems, on par with coverage for medical and surgical treatment – is going to augment our attempts at “early intervention,” – or for that matter, for intervention at any stage.

Unless, and until, the Republicans are willing to stop trying to repeal the law that requires mental health treatment coverage as part of an Essential Benefit package, and stop attempting to repeal the provisions saying that the coverage must be on par with other medical and surgical treatment benefits, the noise about “doing something about mental health” is just that – a distracting noise.

Unless, and until, the Republicans are willing to put legislation into the hopper (and bring it to the floor for a vote) increasing (1) federal support for mental health care services, and (2)  increasing the number of low income people in the Medicaid program who have access to expanded coverage, then they’ll have to pardon those who say the “mental health” rhetoric is a hollow, shallow, attempt to distract the nation from any serious and substantive discussion of gun violence as a public health issue.

References: Congressional Research Service, “Legislative Actions to Repeal, Defund, or Delay the Affordable Care Act, July 8, 2015. (pdf) Los Angeles Times, Deadliest Shooting Rampages, October 1, 2015.  Washington Post, House has voted 54 times in four years on Obamacare,” March 21, 2014.  AmericaBlog, “Republicans are using mental health as an excuse to do nothing about gun violence.” October 6, 2015.  International Business Times, “Republicans’ Mass Shooting Response Focuses Not On Gun Control But On Mental Health Reform,: October 5, 2015.  Huffington Post, “Despite Mass shootings, Republicans won’t touch gun laws,” October 6, 2015.

*Nevada Representatives Amodei, Hardy, and Heck, voted in favor of H.R. 596.  Representative Titus voted no.

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Filed under H.R. 1591, Mental Health, Nevada politics, Politics, public health

GOP Far Away Land: Solutions in Search of Problems

Alien Planet guns

It’s like they live on another planet.  Republican legislators in Carson City appear to be marching to the same off beat drum kit as their Washington, D.C. counterparts.  Have problems with infrastructure? Education? Revenue? Income inequality? Unemployment? The solution is (staccato drum roll) Pass more laws on abortion! Allow more guns everywhere!

The Single Song Sallies of the Nevada GOP are absorbed by these two.  Assemblyman Ira Hansen (R-NV backwater) proposes the following:

“AN ACT relating to abortions; revising provisions regulating an abortion performed on a pregnant woman who is a minor or a ward; requiring notification of a parent or guardian under certain circumstances before a physician performs such an abortion; providing expedited procedures for petitioning a court for judicial authorization to proceed without such notification; providing civil liabilities and criminal penalties; and providing other matters properly relating thereto.”

How this bit of anti-choice legislation addresses employment, economic diversification, educational funding, transportation, infrastructure, local government resources, provisions for mental health services, or any other major issue facing the state is pure conjecture.  The nationwide abortion rate among those under 15 years of age is negligible for the period 1990 to 2007, and abortions for those aged 15 to 18 years has declined from 21,800 in 1990 to 16,200 as of 2007. [CensusCDC]  This decline mirrors the overall decline in teen pregnancies, which in turn is linked to economic considerations, more contraceptives, and more information (read: sex education). [Pew] However, Big Daddy Government Types exemplified by Assemblyman Hansen, won’t be satisfied until every woman has to carry every man’s fetus to term.  And for this, time is being taken from taxation and budget consideration in the Assembled Wisdom.

Meanwhile, Assemblywoman Michele “Take Baking Soda for your Cancer” Fiore (R-NRA) would be happy to attach her Guns Galore amendment to any bit of legislation she can find. [LVRJ]  She lost the vote, 24-18 in the Assembly, but she’ll be back before the end of the session on June 1. [LTN]

What makes coping with single issue ideologues like Hansen and Fiore so frustrating is that Nevada does have some serious issues which need to be addressed.  Education, which was supposed to be the central feature of this legislative session, has some problems. For instance, Nevada schools ranked 50th in “overall state grades,” and 36th in K-12 achievement, 45th in standards and assessments, and 46th in school finance. [leg.state.nv]  The American Society of Civil Engineering grades Nevada a C- in infrastructure.  We “earned” a D+ in dams, and we have 36 bridges which are deemed “structurally deficient.”  The Mental Health Association reports the following in regard to Nevada’s mental health services: “The five states with the highest prevalence of mental illness and the lowest rates of access to care were Louisiana (47), Washington (48), Nevada (49), Mississippi (50) and Arizona (51).”

Speaking to the income inequality issue, Nevada’s not in a very good position in that regard either:  “The states in which all income growth between 2009 and 2012 accrued to the top 1 percent include Delaware, Florida, Missouri, South Carolina, North Carolina, Connecticut, Washington, Louisiana, California, Virginia, Pennsylvania, Idaho, Massachusetts, Colorado, New York, Rhode Island, and Nevada.”

Now, can we please talk about something other than government so small it can fit inside every vagina, and guns galore?

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Filed under abortion, Gun Issues, Mental Health, Nevada legislature, Nevada politics, Women's Issues, Womens' Rights

Nevada’s Mental Health Care Gift Basket?

Catch of the Day Catch of the Day: To Nevada Progressive for digging up the 2013 Arizona (ABC Phoenix) story about more patient dumping by Nevada mental health services, into both California and Arizona.   And, what services did Nevada mental health professionals offer?

“They had been provided a bus ticket, a small amount of cash, a print out of a Mapquest that showed them how to get to CASS. And written on it was, ‘ask for Howie,'” he said. Holleran says these cases often end in chronic homelessness. He says that stretches resources in other states, like Arizona. And it passes along the problem, instead of fixing it.” [ABC15]

Now, Nevada’s mental health services added a chaperone to the  list? So, in 2014 the mentally ill will get a bus ticket, a small amount of cash, a map, a note to find “Howie,” and a chaperone.  A regular Gift Basket?

So, by April 1014, after a year of really embarrassing news,  the Rawson-Neal facility could announce it had passed muster with the Federal authorities:

“After a year, federal officials’ ongoing probes of Rawson-Neal Psychiatric Hospital may have come to an end as the state facility was found to be largely compliant with regulations and will continue to be reimbursed by the Centers for Medicare and Medicaid Services.

The clearance and certification won’t do anything to alleviate the crisis Clark County emergency rooms face in dealing with large numbers of the mentally ill, but the accomplishment pleases at least one local hospital official.

“It makes a huge difference,” Dr. Dale Carrison, chief of staff and head of emergency services at University Medical Center said Thursday. “It’s a certified facility now. It’s good for everybody associated.” [LVRJ]

First, what on Earth does “largely compliant” mean? Does it mean there are still problems with screenings and transfers? Does it mean that the closure of the walk in clinic meant more log jams and more problems for emergency facilities?

Secondly, the administrator may have been happy back in April with a resolution which allows reimbursement from Medicare and Medicaid, but what’s happening in Clark County emergency rooms?  Yes, it’s good for everyone there’s a certified facility – it’s just not good that we don’t have enough such facilities to address the problems.

Have we solved the bed space and treatment problem described by the Las Vegas Review Journal back in February, 2014?

“At least six mental health patients have been held in the Clark County jail — some for as long as three months — when they should have been placed in mental health group homes.

Southern Nevada Adult Mental Health Services has blocked their release at least since December because it could no longer afford to pay for inpatient beds and treatment for new patients.

But state mental health officials never informed District Judge Linda Bell or the defendants’ lawyers, which left the patients lingering in jail for months where they receive little, if any, mental health treatment.”

There were two issues raised in the February report. First, was the obvious funding problem.  Could it be that the reimbursement from Medicare and Medicaid was sufficient to resolve the problem of warehousing the mentally ill in correctional facilities?  However, the second issue is almost more alarming – Why didn’t the Adult Mental Health Services inform the District Judge or the defendant’s lawyers about the problem? 

Even the funding solutions offered  in June 2014 were temporary and patchwork.  On June 19, 2014 Governor Sandoval presented a plan to the Interim Finance Committee to take $3.5 million from the tobacco settlement money to fund Mobile Outreach Safety Teams, and Mental Health Court facilities in southern Nevada. [Sandoval] {Minutes of the 6/19/14 IFC mtg are not yet available online}

Here’s a challenge for the next session of our Assembled Wisdom.  First, allocate sufficient funding for mental health care facilities and services in Nevada so that we don’t have to have another dismal year like 2013, during which we read about dumping patients off on neighboring – and other – states.  Secondly, allocate funding for implementing the current  recommendations for health care facilities for both adults and children.  We have a Governor’s Behavioral Health and Wellness Council, and it provided a report (pdf) in May 2014, and its recommendations are relatively specific.  This is as good a place to start as any.

The third leg of the stool requires some action on the part of the U.S. Congress.  The licensing issues surrounding facilities with more than 16 beds needs to be addressed.  Without diving too far down into the weeds, suffice it to say that Congress needs to review the definition of an “Institution for Mental Disease.”   Granted there were reasons back in the day to crack down on the institutionalization of too many people for periods of time which were altogether too long.  However, there are individuals suffering from conditions which periodically require intensive care.  Sixteen  bed hospitals, as the Council pointed out, aren’t logistically or financially feasible – but they can provide the kind of intensive treatment some patients need on a temporary basis.  Should the U.S. Congress be able to get beyond “Benghazi” long enough to take a serious look at the redefinition of IMD’s then we might make more progress in the treatment of mentally ill individuals in local settings.  Small facilities, staffed and equipped to meet short but intensive individual treatment, could offer care intermediate between long term hospitalization and group home treatment.

In the mean time, Nevada could do a better job of addressing the issues of mental health care – such as implementing the recommendations of the Behavioral Health and Wellness Council, and it should do so during the next Legislative session. 

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Filed under Mental Health, Nevada legislature, Nevada politics

Justified, Necessary, or Both?

The police action in Sparks, NV might be controversial, but the Washoe County District Attorney has ruled the officers were justified in shooting, and killing, an armed 45 year old woman with a blood alcohol level of 0.127 in October, 2013. [RGJ]  The wounding of the woman’s daughter may generate more controversy, but the incident illustrates some of the major issues surrounding the use of lethal force by police officers.

The woman in question was threatening suicide.  There may be no more frightening situation for law enforcement personnel than facing someone who feels there is nothing left to lose. Individuals have been reported as deliberately assaulting officers while unarmed or while brandishing a variety of lethal and non lethal weapons. Some, perhaps up to 100 per year are intent upon having the police officer assist a suicide. [PSMag] Whatever the woman’s intent, let’s avoid using the catch-phrase “suicide by cop,” because it’s an undefined, unclear, categorization into which altogether too many incidents can be inserted which may or may not resemble one another in detail. [Slate]

What is reasonably clear from the report is that the woman was pointing her gun at her own head at one point in the confrontation, and threatening to end her life.  Suicidal ideation is one symptom of mental illness, and in entirely too many cases we are asking the police to serve as mental health professionals, a task for which they aren’t trained.

The fatal shooting of a homeless, mentally ill, man by the Albuquerque, NM police generated criticism of the officers’ use of lethal force last March, but it also highlighted the growing number of instances in which mentally ill individuals – lacking adequate local mental health services – are coming into contact with police agencies. [NYT]

There are training programs available for police officers, such as the NAMI Crisis Intervention Team model.    The Las Vegas Metro PD is working with NAMI-Southern Nevada to develop a collaborative pre-arrest diversion program based on the CIT model. [NAMI-SN] The Reno Police Department also has such a program. [UMemphis]  Smaller, more rural, Nevada counties may or may not have a CIT program in place. [UMemMap]

There is research indicating that the training works.  CIT trained responders were more likely to be engaged in “referral or transport” than in an arrest, and only 12% of the encounters in the study escalated to the level of physical force, and CIT trained personnel “were significantly more likely to report verbal engagement or negotiation as the highest level of force used.” [AJP pdf]

However, it would be remiss not to ask: How much effort is being put into alleviating the necessity of having expansive CIT programs? How many resources does the community provide for the mentally ill?

We also know the unfortunate woman had a blood alcohol concentration level well above Nevada’s general 0.08% limit.  We don’t know whether in this specific case alcohol was a constant or a periodic problem, and it really doesn’t matter individually, but collectively speaking it does raise the question of how well resourced and available alcohol treatment programs  are in the area?  Are they plentiful and affordable? Are they convenient in terms of access or are there long waiting lists and limited treatment facilities?

This case in Sparks, NV also requires some reflection on several other issues. For example, is the “suicide by cop” categorization appropriate, or not?  Are we adopting and implementing consistent training programs throughout Nevada cities and counties which might reduce the escalation of incidents into lethal territory?  Are we asking police departments and law enforcement agencies to assume too much of the burden of initial interaction with mentally ill or suicidal individuals?

As with all such tragic incidents, we’re always left with more questions than answers.

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Filed under Gun Issues, Health Care, Mental Health, Nevada politics

Don’t Rush In: Limbaugh’s Unfortunate Mental Health Advice

I usually avoid Rush Limbaugh for the misogynistic racist and irrational person that he is, however when he launches one of his patented rants on mental health issues there’s a reason not to merely push the radio button and make him go away — there ought to be some push back. About 22 hours ago Mr. Limbaugh offered the following commentary on the unfortunate death of Robin Williams:

“He had everything, everything that you would think would make you happy.  But it didn’t.”  Now, what is the left’s worldview in general?  What is it? If you had to attach not a philosophy but an attitude to a leftist worldview, it’s one of pessimism and darkness, sadness.  They’re never happy, are they?  They’re always angry about something. No matter what they get, they’re always angry. ” [link]

Aside from being a mis-characterization of liberal philosophy which conveniently conforms to Mr. Limbaugh’s performance art form, this is about as bad as commentary on depression gets.

First, if Mr. Limbaugh’s advice — just be a conservative and you’ll be happy — were correct we’d not see depression clouding the lives of conservative friends and families, but unfortunately depression doesn’t respect party lines or economic boundaries.  While it may be associated with some groups more than others, the disease doesn’t leave any subset unscathed. [NHI]

Depression ChartSecondly, and perhaps most egregiously, Mr. Limbaugh gives every appearance of advising that should a person want to avoid this mental illness all that’s required is a change of political philosophy.  This is entirely too close to the “Snap Out Of It” school of really poor advice.

A person may be angry, or sad, or pessimistic, or in grief; these are simply emotions associated with everyday life on this planet.  Depression isn’t periodic sadness, or situational grief, or even temporary anger — it’s a debilitating mental disease which leaves the individual feeling helpless and hopeless…for weeks, or months, or years.

Instead of listening to Mr. Limbaugh’s misinformation, there are better sources of intelligent discussion about mental illness and depression specifically.  Why not begin with the NIMH site?  Continue on to their definitions and discussion page. There’s better information from the DBSA than you’ll find listening to a right wing radio host.  Want to find out how prevalent depression is in your area? The CDC has some answers for you.  Less interested in statistics than symptoms? The Mayo Clinic offers still more information for you, and discusses the symptoms in greater detail.

No matter what credible medical source of information a person seeks in order to advance his or her understanding of this disease, which may affect some 14 million Americans, it would have to be better than that from a radio host with a reputation for artificially categorizing all things human into a matrix of all things political.

 

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Filed under Mental Health, Politics