Mental Health Articles - 5/4/09

As mental health support wanes, many doomed to homelessness
01:25 PM CDT on Sunday, May 3, 2009
By KIM HORNER / The Dallas Morning Newskhorner@dallasnews.com
Richard Antwine's last home was the county jail.
The 47-year-old ended up there, again, after another round of homeless shelters, boarding homes and psychiatric hospitals. This time, it was because he failed to report to his parole officer. He said he missed the appointment because he was hospitalized. He has severe depression and was hearing voices telling him to hurt himself. His court-appointed lawyer said he doesn't belong in jail. "Somebody dropped the ball somewhere," she said.
Antwine's situation is all too common among the chronically homeless, those with disabilities such as mental illnesses who have been on the streets long-term. But it's not new.
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Chronic homelessness resulted from a shift away from the institutions that once housed more than half a million mentally ill people. Get people out of the state hospitals, experts thought in the 1960s, and they can live on their own, thanks to medications that were new at the time.
But the mental health services that were supposed to help those people adjust came up short. And many of the people, including growing numbers of Vietnam veterans, were left homeless. In the 1980s, cities looking to revitalize their downtowns tore down the cheap rooming houses where the very poor lived. Finally, in the 1990s, the political climate made it difficult to get more government money for housing and mental health treatment.
The result is today's disjointed system of psychiatric hospitals, substance-abuse treatment centers and homeless shelters. It's a system that comes at a huge expense to taxpayers and doesn't come close to solving the problem.
"We've just come to accept the fact we have homeless people roaming the streets like we have rats roaming the alleyways," said Michael Stoops, executive director of the National Coalition for the Homeless. "We have grown accustomed to having human beings living on the streets. It's kind of a sad commentary."
Shortage of services
On any given night, there are at least 1,000 chronically homeless people in Dallas and more than 124,000 nationwide. At the heart of the problem is a lack of mental health services, a deficiency that's especially acute in Texas.
The state ranks 48th nationwide in spending on mental health care for its poorest residents. And this lack of commitment goes back more than a century, if you believe Dr. J.A. Corley, the superintendent of Texas' first state hospital, the State Lunatic Asylum. He complained that the 9-year-old facility was overcrowded and underfunded after it had filled to capacity with 352 patients.
"Our sister state of California, though younger than Texas, has provided accommodations for over one thousand of her insane," Corley wrote to try to shame the Legislature. That was in 1870.
Such institutions were being de-emphasized by the 1960s, the first of a series of factors that have conspired against the chronically homeless. Among them:
•A shortage of affordable housing. Revitalization efforts in the 1980s led to the tearing down of cheap housing even as federal housing assistance programs were being cut. About 18,000 people are on a waiting list for housing assistance from the Dallas Housing Authority, and the wait is three to five years long.
"The bottom line is we have a housing affordability crisis, and it most negatively affects people on very low incomes," said Dennis Culhane, a University of Pennsylvania professor who has done extensive research on homelessness.
•Low disability benefits. Many of the chronically homeless receive disability checks of about $675 a month, hardly enough to rent an apartment and pay other living expenses.
•Disenfranchisement. People on the streets with mental illness have had little voice among lawmakers. This year, the mayors of Texas' largest cities asked for $50 million over two years to help the homeless. The measure is pending.
•Fiscal conservatism. Advocates for more housing and mental health treatment face a tough political climate.
"Over the last six years, there's no doubt that there has been a tone of fiscal conservatism that has perpetuated the reputation of Texas being stingy with mental health dollars," said state Rep. David Farabee, D-Wichita Falls, a longtime mental health advocate. Farabee said he's hopeful that federal stimulus money also will allow the Legislature to provide more mental health dollars.
•A fragmented system. Many homeless people fall through cracks because of a lack of coordination among social service agencies. A person leaving one psychiatric hospital, for example, may be told to follow up at an outpatient clinic. But if the person doesn't show up, the clinic is not likely to track him or her down because it has no funding to do so.
•Stigma. There's a lack of understanding that the chronically homeless are extremely vulnerable and need significant help putting their lives back together. Instead, they are blamed for their situation.
"Generally, mental illness is something you can't cure by yourself," said John Castañeda, executive director of Turtle Creek Manor, a Dallas center that serves people with mental illnesses who also face addictions. "To say 'pull yourself up by your own bootstraps' won't work. It's impossible."
Many challenges
Richard Antwine wants to get off the streets. He wants his own apartment. And he wants to work.
Some days, he walks several miles asking business owners if he can sweep their parking lots. He talks about making a little money clipping other homeless guys' hair, saying he once attended a barber college.
But he's up against a lot. His severe depression has left him suicidal at times. He hears those voices. He has abused cocaine and alcohol, a common escape from mental illnesses.
He has a criminal record that includes drug possession, theft and unauthorized use of a motor vehicle. The divorced father of three grown daughters does not have the kind of family support that keeps some others from spiraling into homelessness.
Antwine's sister, JoAnn Williams of Garland, has watched him through psychiatric institutions, shelters and jail for years. She cooks for him and gives him cash here and there, but she has a family to take care of and said her brother needs more help than she can provide.
"I don't know where he is from one day to the next," she said. "If I don't hear from him, I don't have no way of calling him. He don't have a phone, and I don't know if he's dead. I watch the news all the time. Sometimes I am scared to watch the news."
'Good intentions'
Across the nation, thousands of people like Antwine have ricocheted through institutions for years despite the many programs designed to help them.
"We've had a quarter-century of good intentions, well-meaning programs and human gestures, but to be honest, they have not worked," said Philip Mangano, executive director of the United States Interagency Council on Homelessness. "The antidote to homelessness is, shockingly, a place to live."
Many programs to help the homeless traditionally have not placed enough emphasis on housing, Culhane, the professor, said.
"We have a lot of homeless people who get social services, shelters, mental health services, all of which does nothing to solve their housing problem," he said. "It's not a good use of resources to spend all this money and they're still in a cardboard box on Main Street."
Mangano, who will leave his post this month, led efforts to encourage cities including Dallas to adopt 10-year plans to end chronic homelessness. This has led to increased funding for special housing and support for the chronically homeless, and that's gotten a number off the streets.
But there's still not nearly enough housing, leaving many chronically homeless people like Antwine to fend for themselves.
Passed around
Antwine's dizzying ordeal through psychiatric hospitals, emergency rooms, boarding homes and shelters in just the last four months shows how the lack of care can doom someone to the streets.
In January, he spent about two weeks at Terrell State Hospital, a psychiatric hospital with about 300 beds and several aging empty buildings that once housed nearly three times that number of patients. From there, he was taken to a clinic, but he left before seeing the doctor.
Instead of going to a boarding house as planned, he ended up at The Bridge, Dallas' homeless-assistance center. Soon after, he said, he was robbed and stabbed as he searched for an East Dallas rooming house. He recovered at a Pleasant Grove boarding house but soon left over a rent dispute. From there, he went to the Salvation Army's shelter and finally to another boarding home.
In March, Antwine was placed under the care of a special team of caseworkers who stay in close contact with patients to make sure they take medications, show up for appointments and remain stable. It's an intensive service that few receive because of strained budgets. Antwine started feeling better and made plans to move into an apartment on April 1. But even the caseworkers had no control over what happened next.
Police arrested Antwine as he walked downtown on a warrant for not reporting to his parole officer. Instead of moving into a new home, Antwine was in jail, wearing a striped uniform, eating skimpy bologna sandwiches and staring at the wall because he could not afford anything to read.
"I don't know what's going on," Antwine said last month. "I'm just sitting here doing nothing when I shouldn't be here."
'It's a travesty'
At an April 17 parole hearing, Antwine's lawyer, Raquel D. Brown, argued that her client tried to do everything right.
"That's why I think it's a travesty," she said.
On Thursday night, after a month in jail, Antwine was released.
His whereabouts were unknown.
ABOUT THE SERIES: CHRONICALLY HOMELESS
The Dallas Morning News is taking a closer look this year at the struggles of helping the chronically homeless. This article is the second in a series examining the costs of inadequate treatment and exploring possible solutions. The project received support from the Carter Center, which offers fellowships in mental health journalism.








Editorial
Pull the plug on health care holdup in Texas
Editorial board
Thursday, April 23, 2009
In Texas, access to health care is rationed by ZIP code. If you live on the border or in the state's vast rural areas, you'll have trouble getting to a family doctor.
Even if you live in a city, you might have trouble finding a family physician if you live in the wrong ZIP code.
Doctors know that, and legislators know that. There are solutions offered to fix it, but as is often the case, politics and influence can wallop good public policy.
Though Texas legislators can't make doctors, they can make it attractive for young physicians, dentists and other medical professionals to open up practices along the border, in the state's rural communities and in the inner cities where they are needed.
A bill sponsored by state Reps. Warren Chisum, R-Pampa, and Richard Peña Raymond, D-Laredo, would encourage doctors and dentists to locate in the state's underserved areas by offering to help repay their student loans. State Sen. Judith Zaffirini, D-Laredo, is sponsoring another version of the student loan repayment bill aimed solely at doctors and paid for by increasing licensing fees.
The money for the Raymond-Chisum bill would come from closing a tobacco tax loophole. Every pack of cigarettes is taxed. Smokeless tobacco — you know, "chaw," snuff, dip, even rolling tobacco — is taxed on price. That tax advantage can be widened if manufacturers cut the tax in half by offering two for one specials on a product that is a known health hazard.
Business is good enough for the "people's tobacco" — as some refer to it with a straight face — that the industry can afford high-powered lobbyists to maintain the loophole. The lobbyists are earning their money. The House version is bottled up in committee. Zaffirini hasn't rounded up the 21 votes needed to bring her bill to the Senate floor. Time is running out.
Don't expect anyone to jump up and crow about killing those bills. Instead, what opposition that does surface will focus on problems with the bills. The truth is, whatever problems there are could be fixed if the bills get an honest debate. But that cannot happen as long as the bills languish in committee or beg for support.
While the bills languish, the problem grows.
Of the state's 254 counties, 114 do not meet the national standard for one physician for every 3,500 people, according to the Texas Academy of Family Physicians. As the state's population increases, front-line doctors and other medical professionals will be in even shorter supply along the border, in rural areas and in the inner cities.
The average medical school graduate walks off the stage with a diploma and a $130,000 debt. A medical practice in a rural area won't generate enough to repay that debt promptly, so newly minted doctors opt for urban and suburban practices or gravitate toward lucrative specialty practices.
Zaffirini, Chisum and Raymond are offering help, but their bills are dying. Not from neglect, though. Quite the contrary. Somebody is paying close attention to keep them where they are.
I May Be Mentally Ill, But I Still Have Sex
Inadequate sex ed has put people with psychiatric disorders at a needlessly high risk of diseasePublished April 23, 2009 by Josey Vogels in My Messy Bedroom SEE Magazine
Most of us have had the opportunity, at least once in our lives, to tee-hee or snicker as someone demonstrated how to use a condom by deftly rolling it over a banana or some other phallic-shaped fruit or vegetable. But imagine if you saw this and it led you to believe a banana with a condom on it must be present during sex to prevent infection.
It sounds ridiculous, I know, but it’s a conclusion you have to account for when you’re teaching safe sex practices to someone who is delusional, for example. But an even bigger roadblock to providing sex education to the mentally ill is the general assumption that mentally ill people don’t have sex.Which is just simply not the case.
In fact, studies in the U.S. and Canada have shown that patients in long-term psychiatric facilities are as sexually active as outpatients, whether they’re having sex with other patients or with partners who visit them. Yet, in most cases, institutions don’t even bother doing regular Pap smears or STI (sexually transmitted infection) testing on patients — and never mind trying to understand the unique problems that put the mentally ill at greater risk for sexual health problems and HIV infection. As a result, an estimated 19 per cent of people who are mentally ill are HIV-positive.
Someone with schizophrenia may be more at risk because they have a strong “command force”; that is, their brain makes them to do things most of us would think better of. If someone suffers from bipolar disorder, their extreme mood swings can put them at greater risk as well. “The manic are often grandiose, and impervious to potential danger and the results of their actions,” says Jane Reiha, a nurse in London, Ont., who works with the mentally ill. “The depression phase can also put them at risk, she adds, as sex is often the only pleasure left to them. “Often, people with mental illness seek sex with just anyone for a source of warmth, or because sex is cathartic, and a reassurance that you’re still alive — it may be one final attachment to reality.”
Thanks to funding cutbacks, the trend toward de-institutionalization means more mental health patients are being released into the community, increasing their exposure to risk.
“On the ‘outside,’ there may be increased opportunity for sexual encounters,” says Reiha. “And their limited capacity to deal with additional threats to well-being, and their disadvantaged economic and social status — like cohabitating with others in rest homes — can bring them into contact with high-risk groups like drug users.”
Unfortunately, says Reiha, there is a persistent belief that talking to the mentally ill about sexual issues will simply encourage promiscuity. Most health professionals would rather hang on to the belief that this group is asexual. The line they usually get from the staff when they ask to come and speak at their homes is: “Our clients do not have sex.”
But as far as Reiha is concerned, the human need for intimacy, warmth, and sexual expression is universal and people are sexual beings all the time, regardless of health, illness, or disability. The mentally ill have a tremendous need to express their feelings, to have their concerns and needs validated, and to be given the information necessary to manage life, she adds. They also have specific needs and considerations when it comes to sexual health.
According to Reiha, women with schizophrenia often have a history of abuse and usually have chaotic and unsatisfying sex lives as adults. “This is compounded,” she says, “by the fact that they can get pregnant.” In fact, birth control, is another hot topic. “Permanent birth control takes power away from the patient, but we have to think about whether or not the patient is even able to make those decisions.”
Which is why she tends to focus on condom use, especially because condoms also help prevent STI. But this can be tough when you’re dealing with people who may suffer from delusional thinking, have bizarre ways of communicating and a short attention span. (Doesn’t sound all that different from trying to teach teenagers, if you ask me, but I think I see her point.)
To overcome these obstacles, Reiha uses a lot of interactivity, role-playing, and visual aids when teaching the mentally ill about sexuality. “There may be a finger dexterity problem, for example,” Reiha says, “so the key is to practice opening the condom package and rolling it on, repeating often.”And no, they don’t use bananas.
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Clue to lithium benefits in bipolar patients
By Mark Cowen
24 April 2009
Dis Model Mech 2009: Not yet available online
MedWire News: Researchers have identified a possible mechanism for how lithium stabilizes the mood of patients with bipolar disorder, a finding that may lead to the development of more effective drugs to treat the condition.
Lithium has been use to treat bipolar disorder patients for more than 50 years and is one of the most effective treatments for the condition. However, researchers are unsure how lithium works in the human brain.
In laboratory cell tests, Adrian Harwood, from Cardiff University in the UK, and team found that lithium affects the molecule phosphatidyl inositol triphosphate (PIP3), which is important for controlling brain cell signaling.
Specifically, lithium inhibits inositol monophosphatase (IMPase), which is required for making the simple sugar inositol, from which PIP3 is made.
Importantly, this research shows that increasing the amount of IMPase causes higher levels of PIP3, but that PIP3 levels can be reduced with lithium treatment.
The gene IMPA2 – which produces a variant form of IMPase – has previously been linked to bipolar disorder. The current research suggests that lithium could counteract the effects of the altered IMPA2 protein. Harwood commented: "We still cannot say definitively how lithium can help stabilize bipolar disorder. However, our research does suggest a possible pathway for its operation.
“By better understanding lithium, we can learn about the genetics of bipolar disorder and develop more potent and selective drugs.”
He added: "Altered PIP3 signaling is linked to other disorders, including epilepsy and autism, so this well established drug could be used to treat other conditions. Research into lithium could become very important over the next few years."
The research will be published in a forthcoming issue of the journal Disease Models and Mechanisms.
MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a part of Springer Science+Business Media. © Current Medicine Group Ltd; 2009













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Friday conference aims to help the exonerated cope with life after prison
5:01 PM Mon, Apr 27, 2009 Jennifer Emily/Reporter DALLAS MORNING NEWS

When the wrongly convicted are released from prison, there is little help provided as they try to adjust their new lives
A conference Friday at the Christian Chapel CME Temple of Faith, 14120 Noel in Dallas, is trying to remedy that. It's held from 8 a.m. to 3 p.m.
It's called "A Day for Social Justice: The 2009 Dallas Interfaith Exoneree Conference."
Tickets range from $15 to $25, depending on whether you want lunch. Attendence is free for exonerees and their family members.
The deadline for advance registration is Thursday. Contact jlpage@uta.edu for more information. You can also register from 8 to 8:30 a.m. Friday at the conference.
Dallas County - with 19 DNA exonerations - has cleared more inmates through genetic testing than any county in the nation since 2001 when Texas began allowing post-conviction DNA tests.
According to the press release:
The University of Texas at Arlington School of Social Work is sponsoring the conference with Central Dallas Ministries and the Christian Methodist Episcopal Church. The Hogg Foundation, a UT Austin organization that helps raise awareness of mental health issues, also is supporting the event..
Dallas County District Attorney Craig Watkins is the special guest and a conference speaker. Watkins founded his office's Conviction Integrity Unit in July 2007. It oversees the review of hundreds of DNA cases in conjunction with the Innocence Project of Texas. More than 20 people who were wrongly convicted in Dallas County have been exonerated.
Dr. Jaimie Page, director of the Exoneree Project at the UT Arlington School of Social Work, is organizing the event along with Social Work graduate students Crystal Joshua and Chasity Alexander. They hope to educate the faith-based community about the service gaps that exonerees experience and aim to raise money to close those gaps.
Dr. John Stickels, assistant professor in criminology and criminal justice, started a chapter of The Innocence Project of Texas at UT Arlington in 2003. Some of his students are working to exonerate inmates believed to have been wrongly convicted. Dr. Stickels also serves on the board of the Innocence Project of Texas.Some clients have served almost 27 years behind bars, the professors say.
"Exonerees aren't given a dime when they leave prison. Many don't have a place to lay their heads that night," Dr. Page said. "If they have no family - and many do not - they are essentially homeless."
Exonerees are not eligible for benefits that actual parolees can receive because they are, in fact, innocent, Dr. Page noted. She said the Exoneree Project hopes to fill a six- to eight-month gap in services. Proceeds could be used for medication, identification, toiletries and clothing, but also counseling and immediate housing upon release.
During the conference, several exonerees are scheduled to talk about their experience. Several panel discussions also are planned. The topics are: UT Arlington School of Social Work's Exoneree Project: An Overview of Texas Exonerations and Exoneree Issues; Legal and Legislative Experts: Wrongful Convictions, Dallas County Efforts and Legislative Update; and Faith Leaders: Spirituality, Social Justice and Roles of Interfaith Leaders.


HEALTH & SCIENCE
"Mental health home" proposed to boost care for psychiatric illnesses
The idea builds on the patient-centered medical home concept endorsed by the AMA and other medical societies.
By Victoria Stagg Elliott, AMNews staff. Posted April 27, 2009.

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Jim Dearing, DO, a family physician in Phoenix, often refers patients with significant mental health issues to a psychiatrist. But he rarely hears back from the specialist. In addition, his patients sometimes come to him with a prescription in hand, but are unable to name the doctors they saw or articulate the care plan.
"Psychiatrists treat them to the left, I treat them to the right, and patients get lost in the middle," said Dr. Dearing, who is on the American Osteopathic Assn. board of trustees.
To increase the coordination of care between physical and mental health and make this situation less likely, two psychiatrists published a paper in the April Psychiatric Services. They suggest creating a "mental health home" for patients with serious mental ills.
Their goal is to increase the access to behavioral, social and medical services that these patients require and to reduce the risk of repeated hospitalizations, incarcerations and homelessness. Access to primary care, in particular, is important because many of the newer medications used to treat mental illnesses put patients at increased risks for diabetes and other metabolic problems.
"We work primarily with a population of seriously mentally ill people, and they have the most disability and the most difficulty, not only with mental illness, but with all sorts of comorbidities. We're struggling with this population to coordinate services and integrate primary and specialty care," said Thomas E. Smith, MD, lead author and associate professor of clinical psychiatry at Columbia University's College of Physicians & Surgeons in New York. This proposal "is taking the same principles and overall approach of the medical home but tailoring it to individuals with serious mental illness."
Drugs used to treat mental illnesses can increase a patient's risk for diabetes.
The idea of a medical home for those with serious mental illnesses or other health problems is not new, and the details in the Psychiatric Services paper have much in common with community mental health centers, a concept first established in the 1960s. These organizations still exist, although many now operate much differently.
"It's old wine in new bottles, and it's absolutely the exact right thing to do," said Carl Bell, MD, director of the Institute for Juvenile Research in the Dept. of Psychiatry at the University of Illinois in Chicago. He also is chair of the American Psychiatric Assn.'s Council on Social Issues and Public Psychiatry.
The APA is working to understand the implications of the medical home concept on the specialty because the care model has been put forward for a broader base of patients by the AAP and AOA as well as the American College of Physicians and the American Academy of Family Physicians. These organizations issued "Joint Principles of the Patient-Centered Medical Home" in March 2007. Their principles defined the comprehensive primary care approach as one involving an ongoing relationship with a physician who leads a team and coordinates care across all areas of the health care system, all stages of life and all aspects of a person's well-being. It includes patients' active participation in decision-making. It also involves enhanced access through open scheduling or other options.
The American Medical Association signed on to the concept in November 2008, although the organization is continuing to study funding issues for the medical home model. A report on the topic is due from the AMA Council on Medical Service at the Annual Meeting in June.
Generating a buzz
So far, the response to the mental health home proposal has been enthusiastic.
"The article is absolutely right on," said Kim Griswold, MD, MPH, associate professor of family medicine and psychiatry at the University at Buffalo in New York. "If anyone needs a medical home, it's a person with serious mental illness. We have neglected this population." She researches primary care access for this population.
The model has been promoted mostly as a way to improve primary care, and proponents were happy to see specialists express interest.
"There's a longstanding problem integrating mental health and physical health. The fact that the mental health community is interested in the medical home is a very good sign," said Robert Phillips, MD, MSPH, director of the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care.
But concern stems over the possibility of creating multiple medical homes. In addition, care in the proposed mental health home will tend to be coordinated by a behavioral health clinician who is unlikely to be a physician.
"The family is at the center of the medical home, and they are not well-served by the fragmentation of having two homes. We have got to collaborate in such a way to provide for the needs in one home," said Jane M. Foy, MD, professor of pediatrics at Wake Forest University School of Medicine in North Carolina. She also is chair of the AAP Task Force on Mental Health.
Creating a mental health home faces similar barriers to the medical home, including finding funding streams and educating physicians on how it should work, and reimbursement for mental health services can be more challenging. In addition, mental illness tends to be more stigmatized than physical health issues, and many experts believe this will prove to be a significant stumbling block to improving coordination of care.
This content was published online only.