BRATTLEBORO — Louis Josephson, president and chief executive officer of the Brattleboro Retreat, has stated that “there is no mental health system” in Vermont. In his response, Frank Reed, the state's commissioner of mental health, claimed that there is.
Of course, both are right.
On paper, there is a system - hospital and residential care, community mental health, randomly scattered private practitioners and, of course, prison - but try in practice to consistently access this system.
Examples of troubles include unreasonable waits in emergency rooms for crisis screening, extended community mental-health waiting lists, frequent turnover of community mental-health clinicians, lack of integration of state agencies, and appalling rates of incarceration of people who are mentally ill.
And this list is not exhaustive.
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Based on my experiences, I have the following suggestions for upgrading the services currently provided to Vermont's mentally ill clientele.
• Deinstitutionalize community mental health. These processes need simplifying, with decreases in paperwork, lighter administration, and more rapid intake of patients.
Master's level reimbursable clinicians need to be placed permanently at Vermont Department of Children and Families and public defender's offices and in every primary care and pediatrician's office.
The focus of their collaborative interventions must be symptom evaluation, brief intervention, and triage. Limit the community mental health agency buildings to providing care for the seriously mentally ill and developmentally disabled patients.
• Decriminalize psychiatric patients. In Vermont, commitment of patients requires a psychiatric diagnosis plus evidence of dangerousness to self or others - and then a court appearance. There has to be a better way for patients to receive care for their mental illness without having to go through the legal system.
Of course, this system was put in place to protect the rights of the individual, but frequently this system interferes with the individual's right to get care. This is a particularly pernicious problem with outpatient commitment.
• Decriminalize illicit drugs. Society has to decide whether drug use and abuse of all sorts is a crime or an illness. We know from prior experience that prohibition does not work, and I doubt anybody claims that the war on drugs that we have had in place for 25 years has been effective.
The logical next step is to stop treating substance use and abuse of all sorts as crimes and make health care a primary focus.
We should allow Suboxone to be prescribed in all primary-care offices and move methadone programs onto hospital grounds. This would provide an overt statement that substance abuse is a treatable health-care problem and help integrate this high-risk population into other health-care services.
• Have the Department of Mental Health explicitly support mental health. For the past 20 years or so, the Department of Mental Health has underwritten an advocacy newspaper, Counterpoint. Unfortunately, much of the advocacy provided through this publication is in fact anti-psychiatry.
Surely, it is time for the Department of Mental Health to at the very least support an equally funded pro-psychiatry publication outlining the benefits of psychiatric treatment.
• Train primary care providers and pediatricians in mental health. An estimated 30 percent of all health care has a significant behavioral/mental health component.
We should build into the relicensure of at least the primary-care family practice doctors and pediatricians six hours of behavioral-health education focused on symptom identification, treatment intervention, and triage.
Physicians applying for licensure in Vermont are already mandated to receive explicit education about narcotics prescribing and Hospice care. It would be a simple step to expand these directives.
• Increase pay for psychiatric providers. Currently, there is no difference in reimbursement between child and adolescent psychiatrists and adult psychiatrists. Overall reimbursement to psychiatrists and other mental-health providers is at the low end of the salary scales in health care.
No wonder there is a significant shortage of these practitioners. An increase in pay and providing loan forgiveness for psychiatrists and nurse practitioners could only help.
• Addressing the problem of guns. Annually in Vermont, more people suicide by guns than accidentally die in motor-vehicle accidents.
Surely, as a society, we can spend as much on decreasing these unnecessary deaths as we have spent on decreasing the motor vehicle fatality rates.
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There is, I believe, ample evidence that we as health-care providers are holding up a broken system.
We can only hope that Vermont's health-care leaders can step up to the plate and make the necessary adjustments to enhance quality for patients and their families - and the providers who serve them.