He has heard from patients who are concerned about being “labeled” based on their diagnosis. The question has been raised as to whether that increased stigma—already a huge issue with mental illness—will deter patients from seeking help. Another area of concern is how clinicians would respond: Will they avoid diagnosing patients because they don’t want the responsibility? Or will they be ultraconservative and write “paranoia” in the chart, when the patient may only have some mild anxiety?
“The problem is that when you start writing laws, [politicians] don’t have the understanding that we in medicine have about the difference between someone who’s at risk and someone who isn’t,” St. John says. “So some of it is going to be the definition—who is going to define it? And then how are they going to follow up on that?”
How information might be gleaned is another concern, and one that can be misleading. If medical charts or pharmacy records are mined, say, for specific diagnoses or medications, there is room for error.
“I have a patient with multiple sclerosis who takes an antidepressant for urinary incontinence,” St. John says. “She’s not taking it for depression. But, you know, she’s on an antidepressant—so, therefore, she must have a ‘mental illness.’”
What You Can Do
The mainstream media would have us believe that the individuals who represent the greatest threat to public safety walk into a clinic foaming at the mouth and with their eyes rolling back in their head—in other words, they should be identifiable at first glance. But identification of mental illness can be both more subtle and more complex, even for those with a psych/mental health background.
The key sign that someone has a mental impairment is disordered thinking. They may seem as if they can’t quite get their lives together; maybe they have difficulty following what a clinician considers a fairly straightforward regimen. They may appear disheveled or exhibit poor hygiene. Their responses to questions may seem “odd,” or they may convey a sense of fearfulness or paranoia.
With treatment, many people with mental illnesses do quite well. The difficulty is getting them adequate treatment, as well as monitoring to ensure they comply with it. Unlike other patients, who may be “willfully” noncompliant, those with mental illness are often incapable of keeping appointments or figuring out how to refill their prescription or follow the prescribed regimen without assistance.
Where does that assistance come from? That is precisely the problem the US has faced since deinstitutionalization occurred in the 1980s. Yes, there were asylums in which mentally ill patients were abused or neglected or otherwise treated as less than human. But for some patients, the facilities lived up to their names.
“There are a lot of people who actually did well in the institutions, because they needed that regimen—they got sleep, food, and shelter,” says St. John. “There are people who the best thing for them, and for society, is to put them in a place where they have protection. They call them asylums for a reason. And then we just kind of threw them out in the street and didn’t provide the services. That’s where we went wrong.”
The community-based services that were promised when the institutions closed have not materialized in a sufficient way. What is needed, advocates say, is adequate housing for the mentally ill—places where trained professionals can keep an eye on them and assist them with matters of daily living, including treatment plans.
“If you have that case management integrated into the housing component,” Parsons says, “if you have assigned and supportive housing for the chronically mentally ill, you’re going to do a better job getting them into treatment.”
That would rescue many of them from homelessness and perhaps cut down on some of the minor criminal offenses for which many mentally ill individuals find themselves incarcerated. It would also provide a layer of safety, as someone would be monitoring the patient for signs of deterioration.
“When symptoms worsen, what patients do is socially withdraw—they don’t want to be around people because they tend to be paranoid, their thoughts are more disordered,” St. John observes. “So then there aren’t people around to see them, and then you don’t hear anything until something bad happens.”
Equally important, and slowly starting to occur, is the integration of behavioral health services into primary care. Parsons is hopeful that the emergence of accountable care organizations and the expansion of the medical home concept will lead to better communication and coordination between providers, and ultimately better care for mentally ill individuals.