Friday, June 6, 2008

Some Thoughts on Spiraling Downhill: What are the system implications?

At the Mental Health forum in Webster last month, two families shared their stories, and told of how it felt to try to access the system as a teen, or the mother of a child, with mental illness.  I invited them both to blog their experience:  one, a wonderful high school senior named Bri did so earlier in the week.  You all have probably read it by now;  if not, do so before reading this.  As I read it, I wondered how the reforms for which we are advocating through Rosie D and SB 2518 might affect the outcome.  I am curious about what you all think.
What struck me most was the degree of stigma, that had attached itself to this young lady as she entered her freshman year.  Despite her early success, she "consider(ed) herself a failure";  it didn't occur to her that her sadness, her changes in eating patterns and her frustration could be part of an illness.  It was bad- she was "crazy"-"pushing [her]self to be all that [she] could be" in the face of symptoms that were unappreciated before her entry into high school.  Brianna, her family, her pediatrician didn't know there was a problem until late in the course of the illness.
Under the Rosie D. settlement and with the support SB 2518,  she would have been screened annually during middle school-  we might have been able to detect the early signs of her anxiety and depression before it rose to the level of an eating disorder, and helped her sooner.
The second thing that I noticed was that her pediatrician focused on the symptom of eating, but was not able to build  the team of mental health, nutritional support and medical services that most of us agree is needed to manage an adolescent with an eating disorder.  Why didn't he or she put together a team?  Lots of barriers:  patient confidentiality, parent confidentiality, professional traditions, off-site locations, lack of time.  It is hard to convene the teams that we need to manage these problems.
Under the Rosie D. settlement, there would have to be a team assembled to help Brianna.  Under SB 2518, it would be easier, as private insurers would have to pay for the collaboration time.  Either would be better than what we have now.
The third thing that I saw in her narrative was a school that wasn't able to "deal with these types of problems and were unsure how to help [her]".  Teaching children with mental illness is a real challenge, and many schools do not have the expertise needed to help children and families with this stuff.
SB 2518 has language expanding the scope of the Massachusetts Child Advocacy Project, allowing schools to begin to develop the expertise that they need to become full members of the treatment team.
Finally, I was impressed that, in the end, without a team and a treatment plan, the case finally ended up in courts, where the young lady and her mother were finally able to turn their lives around.  
Rosie D and SB 2518 will make it easier to keep youths like Brianna out of the courts, through intensive outpatient treatment and close monitoring and follow-up.
Brianna's story shows us that, ultimately, mental illness is a struggle for the patient and her family, and that families need help in that struggle.  No matter what system we develop in the current reform environment, the systems role has to be to support the family in their struggle. Brianna showed tremendous courage in allowing us to share in her story;  we owe her similar courage in hearing the needs that her story highlights and addressing the system issues that can fix it.   Like many of my own patients of whom I have blogged,  for Brianna and her family, it shouldn't be so hard.

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