Reflecting on Part 1: WBUR's series on Mental Health Treatment

First, this is really well done, in depth, radio journalism. You should listen to this here, if you haven't already. It tells the story of a young man who has a story similar to many that I have seen over the years, who has had some sort of mental health problem, has accessed our system (in a manner, to be clear, that most of the country cannot) and is entering adulthood confused about his diagnosis, his need for treatment and his prognosis going forward. He (and implicitly the reporter) imply that it really shouldn't be so hard. What is it about? A few themes, that you may have heard before.

1) Behavioral/psychiatric problems are hard to diagnose, in part because diagnosis is based on clinical impression. This family had many reports; with many diagnoses and many recommendations and it made them confused.

2) Stigma lives. A youth with mental health, who develops substance abuse problems suddenly has to find a whole new treatment system. Why? Read the comments that people have left on the website. The obsession with blame and fault is impressive.

3) Primary care wasn't helpful. This family really would have benefited from a primary care doc who stayed with them throughout the journey. Kind of sad that they had to keep looking.

4) Treatment works. Sort of. Sometimes. The young man in the story was not a big fan of the many medications that he has taken over the years, although, in the end, he conceded that they may have been helpful. A long term relationship with a consistent provider may have been helpful.

More tomorrow.

WBUR Investigates Children's Mental Health in Massachusetts:

Weeklong News Series Begins Mon., Jan. 31

WHO: WBUR, 90.9 FM, WBUR.ORG, Boston's NPR News Station, examines the children's mental health system in a special series titled, "ARE THE KIDS ALL RIGHT?"

WHAT: An estimated 300,000 Massachusetts children have a diagnosable mental health disorder, but many of them don't receive care or don't receive appropriate care. That's despite the lawsuit known as "Rosie D," that mandates adequate mental health care for children on state subsidized insurance in Massachusetts. Described as a "lightning rod of change" by Children's Hospital and other child advocates, the lawsuit has had broad implications for the diagnosis and treatment of ALL Massachusetts children. WBUR Reporters Deborah Becker and Monica Brady-Myerov explore this subject in a special WBUR news series.

WHEN: "ARE THE KIDS ALL RIGHT?" airs Jan. 31 - Feb. 4 during Morning Edition from 5 a.m. - 9 a.m. and All Things Considered from 4 p.m. - 6:30 p.m., only on WBUR and wbur.org (segments scheduled to air at 6:35 a.m., 8:35 a.m. and 5:50 p.m.).

Monday, Jan. 31: ONE LOCAL FAMILY'S JOURNEY

WBUR explores the Cadogan family's struggle with son, Will, age 17, who has tried several medications, psychiatrists, therapists, hospitalizations, outpatient programs, special schools and even self-medication over the years.

Tuesday, Feb. 1: THE MEDICATE DEBATE

As psychopharmaceutical drugs become more sophisticated, and more parents demand treatment, WBUR looks at the debate over when and how to medicate children for mental health issues such as depression, ADHD and more.

Wedneday, Feb. 2: SCREENING ALL KIDS EARLY FOR MENTAL HEALTH ISSUES

Because of "Rosie D," Massachusetts has become a national model for pediatricians to regularly screen ALL kids for mental health issues during routine exams. WBUR looks at how screening has worked and whether pediatricians are equipped to do it.

Thursday, Feb. 3: ACCESS: WHERE ARE ALL THE DOCTORS?

Massachusetts has one of the best doctor-to-child mental health patient ratios in the nation, yet many families can't get the services they need. Complicating matters, a recent study estimates that half of the state's mental health providers will leave in the next five years. WBUR talks to families and doctors about the challenges around access.

Friday, Feb. 4: HOW DO WE IMPROVE?

Roundtable discussion moderated by WBUR's Bob Oakes with guests including a local parent, a doctor, the Department of Mental Health Commissioner Barbara Leadholm, and Lisa Lambert, executive director of the Parent/Professional Advocacy League.

We extend our sincere gratitude to all of the families whose personal stories will be reflected in this series and to our friends at PPAL for their work to make this series happen. This promises to be a significant milestone in our efforts to educate the public about what happens in families when a child is mentally ill.

Meeting Notice (and Free Gift Cards)

The Massachusetts Behavioral Health Partnership (MBHP)

The Partnership that Works

Please join us for an open forum about current mental health and addictions services and new directions in Massachusetts.

MBHP continues to develop and implement many innovative supports so that people with lived experience can lead lives of safety, stability, community, and accomplishment. This forum is an opportunity for us to hear from you about what is working and to hear your suggestions for improvements.

We value the lived experience and the contributions of our many stakeholder partners, including consumers, families, providers, advocacy groups, human service agencies, and legislators. MBHP would like to strengthen these partnerships by hearing from those who use services, provide services, and/or provide advocacy for our public behavioral health system.

Please let your voice be heard by attending and sharing your ideas at one of the sessions listed below.

Sessions: (Please click each location for directions.)

Tuesday, December 14, 2010: Marriott, Springfield

Wednesday, December 15, 2010: Marriott Courtyard on Tremont, Boston

Thursday, December 16, 2010: Hilton Garden Inn, Worcester

10:30 a.m. to 12:30 p.m.

Lunch will be provided. Parking is complimentary.

Gift cards will be distributed to all attendees.

To help us plan for space and lunch, please let us know which session you will be attending by e-mailing MBHPforum@valueoptions.com or leaving a message at (617) 350-1942.

If you require Spanish interpretation or American Sign Language (ASL) services, please notify us by Thursday, December 9th.

Welcome and Introductions:

Nancy Lane

Chief Executive Officer, MBHP

Facilitators:

Richard Sheola

ValueOptions® Senior Leadership Team

Clarence Jordan

Director, Recovery & Resiliency, ValueOptions® of Tennessee

Clara Carr

Director, Rehabilitation and Recovery, MBHP

Been a While: Thoughts on Children's Mental Health in the Commonwealth

One might think that I have been reluctant to post since the November elections because I was overwhelmingly depressed by the outcome. After all, the composition of the Congress has swung back toward the Right, and many of the Tea Party supported candidates have views on the role of government that would not support interventions like the Children's Behavioral Health initiative. For the record, that's not it. While the 111th Congress has accomplished much, including the passage of CHIPRA, one has to remember that it was a bipartisan effort in the 105th Congress that got us SCHIP in the first place (the same House that voted to impeach President Clinton later in the session). Congress is a wonderful and bizarre place, where much unexpected can happen. While current rhetoric calls for repeal of the Affordable Care Act, the dynamic for change triggered by the passage of CHIPRA, ARRA and PPACA is in motion, and the results of the next rounds of Congressional action are likely to surprise us all. In the end, it about building systems of care that are family-centered, evidence-based and outcomes oriented. The devilish details will provide those of us engaged in the process with lots to do. Sure, I might prefer Speaker Pelosi than Speaker Boehner, but either one will need input from those of us in the field doing the work. The recent election changes the terrain in which we work, but not the work itself. So, no, that not why I haven't written.

Truth is, I've been busy. Gave a keynote on Health reform to the Vermont Council for Quality last month that was well received, attended the annual gathering of the Physician Advocacy Fellows in New York, taught classes for medical students on health policy, saw patients in my new practice within UMass Memorial Healthcare, went to the Fall Board meeting of the Academic Pediatric Association (my last as Treasurer) and started working as faculty on the Massachusetts Patient Centered Medical Home Initiative. All of which might suggest that I haven't had time to think about children's mental health over the past month.

Wrong answer. Thought about it a lot. Three thoughts:

1) The discussions within the settlement are continuing and the system is evolving. It is instructive to read comments from both sides on the progress we have made. From the Commonwealth, there has been an enormous effort to develop wraparound services throughout the state. From the Plaintiffs come concerns about waiting lists and a paucity of resources. I am certain that both are true. In my months back in practice, I have met several families who have benefited from the the Home-Based services and the Family Partner programs that are integral to the CBHI. I have heard praise for the new level of care coordination available to families that are in the system. I have also met families churning through the system who have not found the right therapist, or who have not been comfortable with the notion of in-home services, or whose teens with mental illness are not able to engage in the system. We have lots of anecdotes of success and problems. What is clear in the discussions within the settlement is that we need better metrics for assessing progress and success in this complex endeavor.

We have some ways to make that happen. The National Quality Forum has recognized the need for the development of those metrics as has the AHRQ/CMS Quality Initiative of CHIPRA. Section 23 of the Yolanda's Law authorized the Commonwealth to designate a Children's Behavioral Health Research Center:

the primary mission of which shall be to ensure that the workforce of clinicians and direct care staff providing children’s behavioral health services are highly skilled and well trained, the services provided to children in the commonwealth are cost-effective and evidence-based, and that the commonwealth continues to develop and evaluate new models of service delivery.

Pretty clear that we need that; how can we make it happen?

2) Nationally, the system is evolving too. Much of what what we are doing in Massachusetts is of great interest to the rest of the country. One thing in particular that has generated much interest is the Massachusetts Child Psychiatry Access Program (MCPAP), highlighted in a case study by the Commonwealth Fund and a recent article in Pediatrics, led by Barry Sarvet out in Springfield. Other states are starting to work to emulate this model, such as Arkansas and Ohio. Sure, we need to work to make our system better, but shouldn't we also be highlighting our successes and "taking the system to scale" on a national level? How do we make that happen?

3) Medications are not all bad: There's a lot on the net about the overtreatment of children with psychotropic medications, and sometimes we forget that there is a risk of undertreatment as well. Lisa Lambert, in her recent post at "It's Not Over" makes that point beautifully. I recently struggled with a mother whose teen had been dropped from treatment (he didn't want to talk any more) and whose prescriber of 4 psychotropic medications had stopped prescribing because the boy wouldn't go to therapy. I tried to stick to the party line, of not prescribing multiple meds to kids disengaged from the system, but eventually wrote the scripts to restart the pharmacotherapy. It worked, at least in terms of preventing a dropout. In the course of worrying about the overuse of psychotropic drugs, it is really important to remember that, for many patients, the medications actually work. Makes building the system and making it family-centered even more complicated.

Lots of work going on. Don't always have time to write about it.

Keynoting a System for a Medical Home: Some Joy Out There in Muddville

Today, I had the privilege of keynoting the kickoff of a learning collaborative for pediatric practices that want to enhance the care that they provide for children with mental illness. The Boston Public Health Commission led a consortium that successfully got 2 grants from SAMSHA to address issues of early childhood mental health problems in the context of a community health care. It is a noble effort. One program, Boston LAUNCH, is targeting children from 0-8 with an assortment of mental health prevention approaches and the other, a Systems of Care effort that really focuses on younger children with more severe behavioral problems. What's really cool is that the BPHC convinced HRSA to allow the programs to integrate, and that they are "braiding" the funding, which be allow both programs the opportunity to work off of each other in very different circumstances. Very cool initiative. Maybe they will be able to tell us how to "fill in the blanks" in health reform.

So what did I say to them, you may ask? Really three things:

• States have much say in how health reform plays out, and they are in various degrees of understanding their role in the process. All of them will need to implement new programs that intertwine behavioral services with routine primary care.
• You can do the coolest program in the world, but if is not well evaluated, it will not change policy.
• With Massachusetts health reform, CHIPRA and the Affordable Care all mean that the system is vulnerable to change. These programs, properly evaluated, will be what informs the choices that lawmakers have to make over the next few years.

After that, we team built, talked, laughed and bonded. Overall, a good use of my time.

Save the Date: CMHC Supporters Meeting

November 23, 9:30-11am

The next CMHC Supporters Group Meeting will be on Tuesday, November 23 from 9:30-11am in the 9th Floor Conference Room at 30 Winter Street in Boston.

This will be an important meeting where we will finalize the Campaign's policy and advocacy agenda for the upcoming legislative session.

We need everyone's input and help to be successful.

Also, if you or your organization have legislative priorities or upcoming events you would like to share with the group, the November meeting is a great chance for this.

See you on November 23!

-----------------------

Show the world your support of Children's Mental Health

Cut and paste the html code below into your website for a button that will direct users to the CMHC website.

When you put it on your organization's website, let Matt know at mnoyes@hcfama.org.

Thought on Returning from Sabbatical

It is both wonderful and weird to be back.

Wonderful because I really enjoy working with patients. For those of you who don't want to go back into ancient blogging history, I left Massachusetts last September to go to Washington and work in the Federal Government as a Robert Wood Johnson Health Policy Fellow. As part of that deal, I too a year off of patient care, and left my practice, where I had worked for 18 years. One of the things that surprised me in DC was that I didn't seem to miss the day-to-day doings of seeing patients. So I was concerned that, when I got back to Massachusetts, I wouldn't either remember how or enjoy doing that anymore.

Turns out I needn't have worried. The give and take of the clinical encounter really grounds me in reality, in a way that detached policy discussions don't. Now, I am not back in my old practice in Webster- South County has continued to flourish in my absence and has recently added a third doctor to its group. I couldn't ask those patients to put their lives on hold while I was away. Since I am now working on policy stuff within UMass Medical School's Commonwealth Medicine, a great organization that lets us bring clinical and analytic expertise to the service of state government, I need to be in Worcester more. So I am working in another practice within our clinical system. And, it turns out, I really do like seeing patients.

In my new role, mental health has not been as large a part as it was in my old practice. We are screening for behavioral health issues, as one would expect from in these days of the Rosie D rollout. I am still not finding the screening terribly useful. Most of the kids I've been seeing are pretty well plugged into services, and have already been diagnosed. The system continues to work for them in its own creaky way, and I am incredibly conscious that we in Massachusetts have a lot more in our system than does any other State in the Union. Despite all that we do, it is not yet enough to calm the feeling of dread that course through a parent's heart whenever they take one step forward and two steps back. Much work to do.

What is weird about being back is that I have now travelled over the whole landscape of 90,000 foot high grand policy decisions (like mental health parity and children's mental health reform) at the Federal and State levels, seen the agencies where they are implemented (like HHS and SAMSHA and the CBHI) and been to the meetings where decisions are made that affect the lives of millions of children (no, I didn't make any of the decisions, and I don't think that I influenced them much- but I have seen the process). So now, when I am seeing a patient, and trying to figure out how to make that system work for them, I sometimes visualize it as the end of a long web of decisions that stretch from the halls of Congress to my examining room. It is an odd and vertiginous perspective, but I am getting used to it.

I did manage to attend the MCAAP Mental Health Task Force meeting a few weeks back. There is still much energy in that group, and they continue to focus on early childhood mental health. There was talk of aligning that work with the push for early childhood education, which I think is important. More on that in another post.

Not sure how often I will post in the future, but I will try to post things that are useful.