Monday, February 7, 2011

Comments on the WBUR series.

I promised comments, but, like most of America, I watched the Super Bowl and ate chilli last night (good vegetarian chilli with a nice sourdough bread and cheddar cheese atop, Moosewood recipe). This morning, I woke up to WBUR's comments and though that I might start by reflecting on those, which you can read here.
A few thoughts:
1) Stigma really does exist. Lots and lots of people do not seem to believe that mental illness is as common as it seems to be, and that there is value in blaming parents, Ben Spock, liberals, modern society, the internet, vaccines, toxins and all manner of things for its existence. Their conclusion is that, if we just took those things away, it would get better. Much more likely is that mental illness does exist (the brain is the most complicated organ we've got; why should that work better than our heart or liver?) and that we are seeing more problems now because people are surviving childhood diseases that may have been harder on those with mental illness in the past, and that we are asking the brain to function in a way that we have not asked it to do in the past. In any event, how a brain gets messed up is useful in prevention work; what to do after the fact is actually a separate issue. People should be kind to those trying to cope with the aftermath, many of them are, but a lot of the ones that aren't wrote into WBUR last week (and perhaps went back to their Scientology meetings afterwards). The fight is not over, just because we have mental health parity now.
2) There is a disparity between care for the poor and the middle class (and the rich): But it is not what you think. The rich can pay cash for a child psychiatrist like Dr. Edna in Mad Men, who will talk with there child, develop a plan for treatment that involves therapy with the judicious use of medication, and sometimes treatment in ranches in New Mexico. The poor are locked into Medicaid, which is held to an EPSDT standard for children: If we find it, it must be treated. This allows the poor in States with good advocates to do things like the Rosie D. lawsuit, and to get Medicaid to cover a variety of what are called "wraparound" services, things that do more for kids than give them medications with reckless abandon. Granted, they still do: there are several studies showing that rates of medication in Medicaid patients are high. But it is usually the case that meds in Medicaid, at least in Massachusetts, are tied to some sort of therapy and the CBHI is working hard to get the children with serious emotional disturbances into some sort of coordinated care. The vast majority of us, however, are in commercial plans, which are not held to the EPSDT standard. Those kids often find it easier to get medications than to get therapy, and may actually be getting care that is less comprehensive than either the rich or the poor, a problem that is augmented because the parents are working, and don't that the time or resources to advocate for their child that are available to those who are either rich or poor.
3) What to do about this is a political decision. So, do you upgrade the middle class to at least the level of support given through Medicaid? Or to do take down the poor to the level of the middle class? That is a classic politic dilemma, and fits well into the current discussions about the appropriate role of government. I would argue that to cut services to the poor guarantees increase cost in unemployment, disability and incarceration in the future, and is a "penny-wise, pound-foolish" strategy, but others would certainly disagree.
4) Treatment of mental health problems in childhood is complicated. While the new services offered by the CBHI are great, they reflect that complexity, and will require much care coordination if they are to be used effectively.

Good series. You should listen to it.
Good chilli. You should eat it.

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