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September 30, 2014

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J. Patrick Coolican:

Why even a little progress in addressing mental health is worth applauding

J. Patrick Coolican

J. Patrick Coolican

On Sunday, I expressed disappointment that the Legislature didn't make more progress on mental health issues.

In fairness, I want to lay out what the Sandoval administration feels it accomplished during the recently completed legislative session.

First, here's why my Sunday remarks were so dour: If there were ever a legislative session to patch up Nevada's frayed mental health safety net, it should have been this one.

Steven Brooks, one of the Legislature’s own members, seems to have suffered some sort of mental breakdown, allegedly threatening Speaker Marilyn Kirkpatrick before his removal as a member of the state Assembly. He is currently in a California jail.

Meanwhile, the Sacramento Bee revealed our practice of discharging some 1,500 patients from Rawson-Neal Psychiatric Hospital to Greyhound buses in the past five years. Patients were given one-way tickets to other cities where they had family or friends. In 10 cases, the patients were sent to places with no family or support network waiting for them.

This was an ideal time for the Legislature to hold high-profile hearings, particularly in Southern Nevada, on the state of mental health treatment. The job of a Legislature isn’t merely to pass laws. It’s to drive public policy debate, to investigate, inform and provoke. More than we realize, our failure to provide adequate mental health treatment affects all of us — especially by clogging emergency rooms and forcing Metro Police to act as a de facto mental health agency when they should be allowed to focus on preventing and solving crime.

Indeed, the Legislature did not generate the discussion for which I had hoped.

But the session was not without progress on mental health treatment.

Dr. Tracey Green, the chief medical officer of the state Division of Public and Behavioral Health, pointed to gains in a few key areas.

It seems there’s an effort to create a real system of stable care rather than stumbling from one crisis to another.

“We’re trying to look at it as a whole system and see where we can put things in place that are long-term solutions,” Green said.

About $16 million has been added to the mental health budget for the upcoming biennium, according to Green. We will still spend far less per capita than nearly every state in the union and only 57 percent of the national average, according Kaiser State Health Facts — but it’s not nothing.

A new mental health urgent care center in Las Vegas will eventually be a 24/7 clinic for emergencies. Hopefully this will take some of the strain off overtaxed emergency rooms.

Green said a new program, believed to be the first of its kind in the country, will assess the family situation of clients leaving the hospital or criminal justice system and help establish a stable home environment.

“Often the client is stable, but the home isn’t,” she said. “That’s often the missing piece of a discharge plan.”

So now, caseworkers will evaluate the home environment for potential risk factors such as guns or drugs and provide resources to stabilize it if need be.

The budget also includes a $4 million contingency fund to fix the problems at Rawson-Neal that led to the Greyhound patient dumping scandal.

The major mental health legislation of the session was Assembly Bill 287, which created a system of “outpatient civil commitment” for mentally ill patients who have a history of brushes with the law and failing to take medication.

This law is modeled after a similar one passed in many other states, including New York after a woman was pushed in front of a subway train there by a mentally ill man in 1999.

Instead of allowing the justice system to institutionalize someone, the new law gives judges the power to force mentally ill repeat offenders into outpatient treatment, specifically requiring the medication many need but do not take — leading to the revolving door among jail, emergency rooms, Rawson-Neal and the street, sometimes with tragic consequences.

In his testimony favoring the bill, Judge William Voy estimated Clark County is home to some 200 residents who fit this profile.

Judges, police and a wide range of mental health advocates favored the legislation.

Writing in The New York Times, E. Fuller Torrey, founder of the Treatment Advocacy Center, says a 2005 study of more than 2,700 people to whom the law was applied found that, after treatment, the rate of homelessness in the population fell 74 percent, the number who needed to be rehospitalized dropped 77 percent and the number arrested fell 83 percent.

The Nevada Disability Advocacy & Law Center opposed the bill on the grounds that it violated people’s constitutional rights by not allowing them to refuse treatment that often comes with harmful side effects. Moreover, Jack Mays, the executive director of the center, testified in a legislative hearing that Nevada already has a shortage of outpatient treatment. Involuntary commitment would merely worsen the shortage.

Green said implementation will be the key to the new law. “It can’t occur if we don’t have a team in place,” she said. Once 75 clients are enrolled in the program, a waiting list will be established until a client graduates from the program, she said.

The state is hiring a team that will include a psychiatrist, psychologist, nurse, social worker and others to serve clients in the new program.

Green sounded hopeful that systemic improvements are coming to our mental health system, even if incrementally.

After talking to Green, I guess I would say this: Nevada has a long way to go, but at least we are no longer moving in the wrong direction.

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  1. Medication and out-patient treatment are NOT the answers. "Patch up" on a broken building does not work well. Instead of dumping every dime into K-12 and higher ed we MUST PRIORITIZE OUR RESOURCES TO DEAL WITH ESSENTIAL SURVIVAL SERVICES. The long long-term unemployed, particularly the middle-aged, are committing suicide at record rates while we feed, house and educate illegal invaders. Go figure. Our seniors are cold and hungry because we give the "social safety net" LIHEA free utilities and EBT SNAP to illegal invaders and anchor babies. Our indigents are frequently the folks who have mental health issues and/or come from "families" who never should have had kids, "parents" who had no idea how to nurture and care for their own. So we have "adults" who don't know how to be self sufficient--whether or not they receive some form of assistance or disability. We NEED to put our resources FIRST to those who need a little training, "life skills" education and/or counseling that would enable them to get by without emergency care, without diving off the deep end, without living in pain--enable them to associate with others and to build friendships and help each other. We do NOT need to be paying teachers to retire at age 52 with a $50,000 pension when that money SHOULD BE GOING to ESSENTIAL services for CITIZens.

  2. The mental health of U.S. Government Officials should be of the highest importance...

    One day after President Obama patched up relations between Israel and Turkey... the U.S. announces that the U.S. has "proof" Syria has used chemical weapons against rebels in Syria giving a green light to both Israel and Turkey and the U.S. for military actions against Syria.

    Our leaders actions the past few months have shown and proven to be both unlawful and the worst kind of liars...

    Lock-up the president and congress they are insane!

  3. Mental Health bottomline: few care unless they are directly affected. Yes, Nevada Lawmakers and the Governor made a "token" move towards progress in identification and care, but it was and still is, not enough to affect long-term solutions, it was "kick the political can down the road" once again.

    Mental Health intervention needs to happen EARLY, while the individual is young, so that there is a chance of assisting the individual before they are a legal adult. This will be proactive in nature, and can integrate much easier treatment plans that will not disrupt the individual and will go seamlessly into their lives without making them stand out and be stigmatized. This is why it is important to also place teams in elementary education to provide mental health access to our young people who would otherwise NOT have it. Precious few parents ever follow up on referrals that school counselors provide, and this becomes a glaring disconnect, which results in children NOT being able to succeed academically and socially.

    As time goes by, such young people, uncared for, disillusioned, become discipline problems or drop outs.

    Although we can argue about the needs of the school district til the cows come home(might I posit that financial affairs are determined by administrators(whether or not they know how to deal with school needs, and not teachers).

    It would be money well spent, and resources well used, to provide early mental health intervention for our school children, proactively addressing the needs of their minds and hearts, the ONE greatest factor that affects achievement.

    An ounce of prevention/intervention,is worth a pound of cure.

    Blessings and Peace,
    Star

  4. I agree with Star that few really care about our mental health care system "unless they are directly affected." (I'd say that "directly" includes family members and friends of the "carer." I would include acquaintances, because of Bradley's story above.)

    The budget of our Nevada system had been seriously cut. It's only because of the threats of lawsuits and losing accreditation (which means subsidies) that money was found to reform it.

    I was elated to learn in Patrick's column that Assembly Bill 287 gives judges the authority to place "repeat patients" into medical care. That bypasses the expensive rigmarole of probating patients.

    This change will "catch" patients early. That makes patients happy and also makes room for the steady stream of other patients. The new mandatory treatment provision (for the patients' own good) should encourage repeat patients to stay on track with their treatment (and decrease the revolving-door syndrome).

    The 24/7 emergency/intervention care center will be an integral part of the reformed system. Add a centralized computer system to access the other components (private-care facilities, hospitals including UMC, etc.), and that does spell improvement.

  5. I have questions before my comment. How will the "mandatory treatment" (my words) new 75-patient ("repeat offenders"?) program immediately hospitalize patients? How will the judge's role be different?

    The program I'm familiar with uses an agency, such as a mental health 24/7 clinic, to screen the rationality of a patient (which could be a function of the new Nevada 24/7 clinic). If need be, the patient is placed in a mental health facility. If a doctor orders a treatment that the patient refuses, a probate hearing is set. The judge determines whether the facility has the right to force "treatment" on the patient. It sounds as if Assembly Bill 287 shortcuts this process.