Mental health courts are growing, even though they have no guide

The number of mental health courts in the United States has steadily grown from a mere four in 1997 to over 175, according to Council of State Government Justice Center estimates.

Yet, because of the diversity of program models and their relative newness, there have not been any nationally accepted criteria for effective mental health courts, mental health advocates say.

The Justice Center, a watchdog group, addresses that issue in an updated edition of its paper "Improving Responses to People with Mental Illnesses: The Essential Elements of a Mental Health Court."

The report can be viewed by clicking here.

The publication is the result of many rounds of rigorous review and describes the 10 important program elements that jurisdictions should consider when planning, implementing or enhancing a mental health court.

This latest edition of details the aspects of mental health court design and implementation that can be consistently found in successful courts.

“As communities across the country start mental health courts, they must have resources to help focus their efforts and ensure that their programs are based on collaboration among the criminal justice, mental health, substance abuse and related systems,” said Assemblywoman Sheila Leslie, the specialty courts coordinator of Nevada’s Second Judicial District and Justice Center board member.

Right: A mental health court in Alaska, where the convicted get cheered, not scorned.

“The essential elements, which reflect the consensus of researchers and practitioners, should be of great use to jurisdictions as they work to improve outcomes for people with mental illnesses in the criminal justice system," she added.

Personal note: I've written extensively about mental health courts throughout the country. Alaska has one of the leading justice programs that deals with this very issue. For more information, view my website at Tom-Davis.net.

As Democrats and Republicans Convene, Let's Hope They Think of Government's History of Purpose and Courage

As the Democrats gather in Denver to nominate a presidential candidate, let's hope they don't lose sight of government's appeal to the disadvantaged.

I often think of Paul Wellstone, the late senator from Minnesota, set out to achieve before dying in a plane crash in 2002. He was, perhaps, one of the first prominent members of Congress to push for insurance reform for mental health coverage.

And it's the message that gets lost when the petty little disputes take center stage.

Wellstone was a apolitical rarity, but a gem. He was also the first - and perhaps the only - leading member of Congress to push for mental health parity in health insurance coverage. He was a rare commodity in a political world that values accommodation and "triangulation."

When Wellstone died, his attempts to bring recognition and, no pun intended, sanity to mental health coverage died with him.

I think of Wellstone at a time when a certain population group - young people - is at its most desperate and vulnerable.

In 2005, the most recent report from the National Center for Health Statistics showed that 4,212 youth, or 10 percent of those who are between 15 and 24 years old, took their own lives.

Suicide is the third leading cause of death among this age group. In the same year, 272 children aged 5 to 14 years old committed suicide; this equates to 0.7 percent of this population, according to the New Jersey Association of Mental Health Agencies Inc.

Parents and teachers must be vigilant in recognizing signs of anxiety and depression -- both of which could be due to drug abuse or could indicate a risk of suicide, according to the NJAMHA.

For many students, a certain level of anxiety when starting school is normal. The changing school environment, the pressure to succeed, as well as concern about possible bullying, could be significant causes of anxiety.

However, for some younger people, anxiety could be a sign of a mental disorder, a biologically based illness that is just as real as any physical disease.

In either case, parents and teachers must be supportive by listening and comforting youth to help them work through their anxiety, and by remaining alert to a potentially more serious condition that needs professional help, according to the NJAMHA.

"With the appropriate treatment and services, most individuals can lead healthy, productive and fulfilling lives. By contrast, without treatment, students are more likely to experience worsened health symptoms, both mental and physical, which could interfere with their relationships and academic performance," said Debra Wentz, chief executive officer of the NJAMHA.

This story originally appeared in The Huffington Post on Aug. 27, 2008.

In defense of John Cusack

Some movies I can watch over and over again, and I never get sick of them. In fact, I'll like them even more - even after seven or eight views.

The list of movies is short - Star Wars, The Shawshank Redemption. But, for me, the one flick that probably tops the list is High Fidelity.

It's not necessarily better than the movies I mentioned (though, over time, it may earn that kind of second-look classic status that elevated It's a Wonderful Life from box-office-bomb status to a masterpiece). It's just that some movies you can relate to better than others - especially when you've lived with a mental illness, but never really understood what it was or how it affects you.

No, this is not a movie about mental illness. In fact, John Cusack's character, Rob Gordon, makes an off-the-cuff remark about "woman-schizo stuff" issues that some might find offensive, but others might describe as an authentic piece of movie language used by a character who repeatedly fails in his relationships with the opposite sex but is in denial about what's tripping him up.

But the setting, the people and the lives they lead remind me much of the life I led before I was married in 1996 - a single, cynical, paycheck-to-paycheck life that was always more desperate than dreamy. And Cusack's character clearly has obsessive-compulsive issues (his obsessions with music and women, each encapsulated in top-five lists, for instance) that make me reflect back to the days when the neatest place in my house was the cabinet where my 300 or so cassette-tape albums - each expertly cleaned and dusted - were kept.

And with each new viewing, I pick up dialogue, foreshadowing events and plot conventions that somehow escaped me (and probably many people, because the dialogue is fast and complex) when I first saw it and endeared the movie to me even more (and, yes, perhaps this repeated viewing is also a function of my own obsessive compulsiveness).

And no actor connects with me more than John Cusack - and not so much for his good looks (ha ha). There's something appealing about his earthy, well-grounded pragmatism that embodies the personalities of educated, under-employed Generation X working stiffs who have lived anything but a "Leave-it-to-Beaver" lifestyle.

I owe a debt of gratitude to John Cusack, actually. His portrayal of an obsessive compulsive record-store owner in High Fidelity kind of validated the kind of existence I had in the early 1990s, when I was suffering through eating disorders and I'd bum a couple of bucks from a friend so I could buy a 79-cent taco at Taco Bell (and call it dinner).

He continues to put out movies - however flawed, like War Inc. - that employ a high-level complex form of dialogue and plot conventions that put them a notch above the average movie - or even the best movies. The characters are human who suffer from the everyday diagnosed and undiagnosed maladies that connect with a movie viewer more than a privileged political pundit who makes his or her living off a Fox News appearance would.

This was on display in High Fidelity, which will most likely be on some critics' top-movie lists for this decade and was an underrated love story when it was released in 2000. It introduced Jack Black - or, what he's all about - to the movie world and contained some of the most intelligent dialogue exchanges I've ever heard in any film.

Most importantly, it humanized the flawed - and, perhaps, obsessive compulsive - individual who had to come to grips with his own personal issues and shortcomings and learn to live with them and move on. Indeed, Cuscak's Rob Gordon offered one of the most authentic and humanistic apologies I've ever heard in any film (or even in real life) when he looked at his ex-girlfriend - the one he cheated on, reneged on a debt to and generally treated rather poorly - and uttered two simple words.

"I'm sorry."

This story originally appeared in The Huffington Post on Aug. 25, 2008.

One flew over the Morning News

By PAUL RAEBURN

Last Sunday, The Dallas Morning News ran what it called “an investigation” of the use of psychiatric drugs to treat foster children in Texas. The story started off with a bang, or several of them:

• One in three foster children in Texas has been diagnosed with a mental illness. Wham!

• Those kids have been prescribed “mind-altering” drugs — including some not approved by the federal government! Bam!

• The drugs are being prescribed by doctors with a financial stake in pharmaceutical companies’ success! Socko!

All three of these revelations occurred in the first two sentences. That’s taut writing, sure to grab a reader’s attention. Unfortunately, the overheated language and the lack of context in this story gives readers a distorted view of mental illness in children—and the way it’s treated (or mis-treated).

The article supports the widely held view that children are being over-diagnosed with mental illness, over-treated with dangerous drugs, and that this is happening because of financial collusion between doctors and drug companies. All of those things might be true—but the Morning News investigation does not make the case.

To her credit, the story’s author, Emily Ramshaw, does qualify her slam-bang lede. Accepting drug-company money is not illegal, she points out in paragraph three, and much of it has funded “groundbreaking scientific advances.” And she notes that financial ties between doctors and drug companies are often disclosed on Web sites, and in conference programs and journal articles.

But then she resumes her investigative zeal with a fourth charge. “Multiple drugs” were “being prescribed by doctors who weren’t psychiatrists or pediatricians,” she writes, some of whom “spent less than 10 minutes examining their young patients.”

I’ll raise some questions about these charges in a moment, and suggest what Ramshaw might have done differently to make this a first-rate story. But first, a word about one of Ramshaw’s anecdotes, guaranteed to reinforce the notion of wrongdoing, even though she herself reports that no wrongdoing was found.

The story, told in seven paragraphs, is of a twelve-year-old boy who died while being restrained in foster care. At the time of his death, he had four psychiatric drugs in his bloodstream. Ramshaw tells us that an autopsy found that his death was accidental—not related to the drugs. So why juxtapose these two observations? Are we to conclude that the autopsy was faulty? Ramshaw doesn’t say. And here’s the quote with which Ramshaw ends the anecdote: “He didn’t need any meds. He was the kind of kid who if someone had just threatened to call his mother, he probably would’ve stopped what he was doing…I know Mikie and I didn’t need emotional stabilizers to save our lives.” The authority being quoted? Mikie’s teenage older sister.

Now back to Ramshaw’s powerfully delivered assertions.

1. One-in-three foster children in Texas has been diagnosed with a mental illness.

The implication is that this is very high; that healthy foster kids are being wrongly diagnosed with mental illness, and wrongly prescribed psychiatric drugs. But how high is it? Ramshaw acknowledges that foster children “have far higher rates of mental illness than the average child,” but she doesn’t clarify—or back up—the implication that the kids are being over-diagnosed. She should have said how common psychiatric diagnoses are among American children generally, and interviewed experts about whether they think Texas foster kids are being over-diagnosed.

2. The kids are being prescribed “mind-altering” drugs not approved by the federal government.

Note the hyperbolic language—“mind-altering” drugs, not the more neutral “psychiatric drugs.” And here’s an important contextual point Ramshaw leaves out: only a few psychiatric drugs have been approved for use in children. The federal government has little money for studies with kids, and drug companies don’t want to invest in that. If they can already sell unapproved drugs to kids, why should they risk a study that might find problems and eliminate that lucrative market? The use of unapproved drugs in kids is a serious problem; but the alternative for many kids, Ramshaw should have said, is no drugs, even for kids who clearly are suffering.

3. The drugs are being prescribed by doctors with a financial stake in pharmaceutical companies’ success.

Again, note the strong language. Does a doctor who is paid for a talk have a stake in a company’s financial success? That’s going a little too far. Ramshaw reports that drug company money has funded breakthrough research, but she doesn’t make clear that in the absence of that money, the research wouldn’t be done. It’s right to question research supported by drug companies—but she should have noted that in many cases there is no alternative.

4. Drugs are sometimes being prescribed by doctors who aren’t psychiatrists or pediatricians.

First, let’s dispense with pediatricians. Their training includes only the briefest exposure to psychiatry, if they have any exposure to it at all. Ramshaw is right—drugs should be prescribed by child psychiatrists, who are the experts. She fails to note that there are about 7,000 child psychiatrists in the United States—one for every 750 American children with severe mental illness. If other doctors didn’t prescribe psychiatric drugs to children, then most mentally ill children who need them wouldn’t get them. And we could have used more information—perhaps in a sidebar—about what doctors are prescribing medicine to foster kids. She is right about one thing: no doctor should prescribe these drugs after only ten minutes with the patient.

Ramshaw clearly did extensive reporting for this piece, and it had the makings of a first-rate investigation. It failed, I think, because she tried to tackle too many things—the poor treatment of foster children in Texas, questions about the misuse of psychiatric drugs by unskilled doctors, a suspect financial relationship between doctors and drug companies, and questions about the FDA’s drug-approval process for kids.

As my colleague Curtis Brainard here at The Observatory suggests, she might have done better turning her investigative skills on whether Texas foster kids are being over-medicated—a tough-enough story in itself. And if she discovered that was true, she could have reported on what might be done to correct the problem.

Or she might have confined herself to investigating the doctors treating these kids and their connections to drug companies. That, indeed, was the headline on the story: “Some Texas foster kids’ doctors have ties to drug firms.” Again, if she nailed that story, she could have followed up with reporting on what the state might do to confront that issue.

Ramshaw’s story, I fear, will leave most readers thinking that the vast majority of kids are being over-diagnosed and over-medicated by a greedy alliance of doctors and drug companies. There is no doubt that that happens. Drug companies are often far too aggressive in pushing their medications, to the detriment of patients, and doctors should not have such strong financial ties to drug companies.

Most mental health professionals, and the parents of mentally ill children, however, think that the problem is exactly the opposite: too many mentally ill kids are not getting the treatment they desperately need.

Reporters who venture into this territory cannot let heart-tugging anecdotes lead readers to faulty conclusions. We need to be acutely aware of the political and public policy debates into which our stories fall. Whether she intended to or not, Ramshaw has given lots of ammunition to critics who say we’re vastly over-medicating our kids. Fair enough, if the reporting backs it up. But in this case, the reporting falls short.


Paul Raeburn is a journalist and broadcaster, and the author, most recently, of Acquainted with the Night, a memoir about raising children with depression and bipolar disorder. His stories appear in The Huffington Post, The New York Times Magazine, Scientific American, Technology Review, Psychology Today, and on his blogs, Fathers and Families and Psychology Today's About Fathers. Raeburn has been senior editor for science and technology at BusinessWeek, science editor at The Associated Press, and is a past president of the National Association of Science Writers.

Quick fixes for dealing with people with mental illness before they face a judge and jury

Some interesting headlines - all courtesy of the National GAINS Co-Occurring Disorders and Justice Center, which provides practical assistance to help communities design, implement and operate integrated mental health services.

Mentally Ill in Jail Too Long, Lawsuit Charges (Austin American Statesman, 2/15/07)...

Officials Clash Over Mentally Ill in Florida Jails (New York Times, 11/15/06)...

State Standoff on Mentally Ill (Denver Post, 12/5/06)...

Competency to stand trial is a constitutionally required mandate, the GAINS center says. But many people with mental illness who find themselves on death row - or something short of that - find themselves without the kind of legal protection that could give them any chance of getting the right treatment, whether they are found incompetent or not.

In many jurisdictions, however, solutions for these competing issues have been found that are relatively easy and inexpensive to institute, the GAINS center says.

At the competency examination stage, the priority is promptly providing competency examinations to minimize any delay in the criminal proceedings, avoiding extended incarceration for persons awaiting examination and avoiding unnecessary hospitalization for competency examinations, according to the center.

Virginia increased fees for community-based examinations to attract more qualified evaluators.
Jurisdictions in Illinois, Washington State, and Massachusetts provide court-based examiners.

In Seattle's Municipal Mental Health Court, initial competency assessments are made by a public defender, a defense social worker and a court- employed mental health professional.

These assessments, which precede the formal competency evaluation request, provide for a more accurate referral process.

"Clearly, much can be done to streamline competency examinations and restorations without major statutory revisions that can take years," according to the center. "With strategic convening of local stakeholders, major change is possible through creative alterations of local procedures and improved communications. There are quick fixes that work."

When all else fails, carry on

A friend recently sent me this picture from September 1988.....I'm sitting in my college newspaper office, dealing with what was perhaps the most impossible job of my life.

The managing editor shoved our newsroom into a small closet-like space, and moved the business office into the more spacious, main office area. He erected Berlin Wall-sized cubicles supposedly to help protect our privacy.

(Editor's note: Now that I'm a member of the newspaper's board of trustees, I recently helped lead the effort to knock down the cubicles and move the newsroom out of there).

Anyway, during that time, various things helped pull me through....but what served as a spiritual springboard for me - more than anything else - were songs. If it's true that songs serve as the soundtracks of our lives, than none served me better than this one:

Carry On/Crosby, Stills, Nash and Young

One morning I woke up and I knew
You were really gone
A new day, a new way, and new eyes
To see the dawn.
Go your way, I'll go mine and
Carry on

The sky is clearing and the night
Has cried enough
The sun, he come, the world
to soften up
Rejoice, rejoice, we have no choice but
To carry on

The fortunes of fables are able
To see the dawn
Now witness the quickness with which
We get along
To sing the blues you've got to live the tunes and
Carry on

Carry on
Love is coming
Love is coming to us all

Pain can be felt in many different ways

By SUSAN DOWD STONE
Featured Blogger

In trying to present analogies which illuminate the pain of mental illness and the anguish these sufferers bear, I witnessed the following scene.

While standing outside of Macy's, I noticed a man who had obviously suffered with polio, or an illness which brought extensive limitations to his limbs. His arms were disfigured and he propelled himself with two crutches that barely stabilized his forward movements.

Each step held the possibility of catastrophe as he flailed to maintain balance. These exhausting motions required constant rest against a light pole, a store window, a mailbox.

It took nearly fifteen minutes for him to move down a single block.

While deeply touched by the courage of his hard won independent mobility, I thought... this is what it is like for a person with mental illness to try to negotiate his day. The simplest task, the most benign interpersonal exchange presents challenge of exhausting proportions.