The Problem of the Treatment Resistant Chronically Mentally Ill

I have hit a dry spell recently as far as ideas/inspirations for this more personal, less professional blog. One interfering and mind clogging constant information bombardment of no help has been the daily national political uproar on “both sides of the aisle” that has been, in the current kindest of descriptors: “distracting.”

I have made a personal pledge to myself to try to avoid as much as possible political topics and I am not a political observer or analyst of any value and politics is almost indecipherable to me, as I try to understand the deal making and constant shifting alliances. The poliltical method of functioning is inimical to me and I am just not emotionall built for the world of endeavor.

But lately I have seen remarks in the press and national discourse, much of which are from state leaders and budgeteers trying to cut more monies out of mental health services for the most severely ill who need some of the most help to ensure social functioning on at least a minimally uneventful level.

The remarks I have read have still been based on the persisting and most naive of mistaken attitudes toward the “PSMI,” or persistently severely mentally ill as these patients are sometimes given their own acronym.

It has debatably been obvious that in the last 20-30 years we have mistakenly over-reduced the number of needed inpatient psychiatric acute hospital based by at least 50-75%. Decades ago we had reportedly around 550,000inpatient beds in this country before the advent of effective treatments, psychiatric drugs, many news kinds of group and individual psychotherapies well beyond the limited confines and reaches of traditional psychoanalysis. as well as the first effective psychiatric treatment at least for very severe depressions, ECT, reviled and controversial as it has been.

With the growing advent of new psychiatric treatments especially the near avalanche of new psychotropics, it became possible to discharge inpatients from years of past near incarcerations in hospitals of all genres, and the rapid expansion of outpatient psychological mental health services and methods was on, like the Oklahoma land rush.

The “de-institutionalization” ethos and ideological movement took hold just many other dominant schools of thought had done so (and have continued to do so in the last 50 decades that have also proven to be of short sighted or harmful worth such as “est,” “birthing therapy,” and the many other fads that mental health treatment is no more immune to than any other of human endeavor. The deinstitutionalisation movement held that being hospitalized for long periods of time, especially if harsh methods of frank abuse were utilized, were dehumanizing, severely destructive to the personality and emotional functioning of chronic inpatients. I have no argument with this aspect of this ideological movement as I am old enough to have seen almost unspeakable abuse in hospitals I visited and helped to review often because of scandals and tragedies.

But it had its unforeseen consequences, accelerated by the economic downtown in this country beginning in the Midwest Rustbelt manufacturing states in the 1990’s, then the several other unbelievably costly recessions we have repeatedly experienced as the result of the dark side of our free market’s system’s “dark side,” the institutional greed on a national scale that resulted in the western states’ Savings and Loan Scandal dreamed up  by Charles Keating, the “dot com bust,” the Enron scandal, and then finally the even larger nationwide housing mortgage scandal bubble that lingers with us yet.

States’ revenues did not just decrease, they decreased in the spans of several to a few years like submarines diving to the bottom to avoid depth charges. As a result state coffers shrank to levels not seen since the Great Depression. All kinds of larger and human social services with cut drastically within relatively short periods of time.

This is an old and known “truism” of the ‘mental health crisis’ in this country. What is less appreciated in my view, is that the majority of the historical numerical peak of beds in the ‘old days’ before the advent of modern psychiatric treatment, (which is what made deinstitutionalization and liberation of so many chronically ill patients possible), are now demonstrating that they need still all encompassing humane “institutions” to take care of their complex needs whether it be medical management, speech therapy, social skills building that takes long periods of time for many patients, and a host of other needs including top flight, organized readily available and accessible medical care. This is because the chronically mentally ill have been shown to have far more medical care needs than the average citizen; there are many reasons for this but that is a topic for another occasion.

The takeaway point of this post that I have been working toward is to subtly some of the deinstitutionzation over statements in the long standing set of beliefs about why so many PSMI patients ended up in large psychiatric institutions.

One of the most insoluble reasons that is with us today in even greater numbers (which why we have those unfortunately flooding the homeless enclaves of the streets in cities, the jails at all levels in this country and every ER in the country is the phenomon of the treatment refractory or more simply and in less technical psychiatric-speak, the treatment resistant patient.

Let me offer some backdrop here. Only 60% or less of persons with severe chronic or relapsing depression respond well or “fully” or in my way of looking at treatment results, satisfactorily to the old or the new expensive Prozac era antidepressants.

In the arena of recurring psychosis, which almost all psychotic illness is chronic and relapsing. A very high percentage of the psychotic patients never are completely rid of a substantial portion of their severe and difference producing symptoms and behaviors.

Only with the exception toxic, drug induced psychosis, or that induced as an unpleasant byproduct of a serious but treatable and therefore temporary medical illness, rendering the psychosis similarly short lived.

Epidemiological and long term result studies have shown consistently for generations that somewhere close to half of psychotic patients respond very well to old or new antipsychotics. Many, perhaps more than a majority are left with the symptoms of what used to be called, “chronic” or “undifferentiated” schizophrenia. Nowadays we call their very disabling residual symptoms, the negative or cognitive symptoms. They largely do not respond to anything and worsen inexorably as the patient ages. They become more and more passive socially, asocial (not antisocial, they just socialize, converse and relate in ordinary give and take talking of everyday relationship ‘commerce,’ less and less and less). Their emotional spontaneity, expressivity, ordinary use of facial expressions in conversations decreases to almost nil and is called the “flat affect,” of schizophrenia. They seem lose vocabulary though not in a manner similar to the dementias, they just use far fewer words in conversations’ their range of topics of conversations shrink with time. They usually became more and more socially isolative and isolated. For all these reasons, they are not all violent as so often portrayed in the ill-informed media. This is why they commit far fewer crimes than is attributed to them and why they are far more likely than the average person to be the victims of crimes.

All these treatment resistant factors make them poorly functional in even the most gentle and non-demanding of social settings. And this is why they still need “institutions,” of whatever size. They are almost akin to younger nursing home patients, except they can walk and talk but are also in a world of their own, yet very different.

And there are more than twice as many of them as the years before the advent of modern psychiatric treatment. And until we have true breakthroughs in the treatment of the psychiatric psychoses, that stop and reverse the neurodegenerative “secondary” symptoms of schizophrenia, that likely are still decades distant, we will need to provide for these persons far better than we do now and that means housing and care centers, in other words, modern institutions.




Millions To Lose Health Insurance Coverage

In article today, March 13yh, 2017 in The Guardian entitled, “Republican health care plan: 24 million people could lose coverage CBO reports.” the Congressional Budge Office, the nonpartisan arm of the Federal Government and Congress, announced that it projects 24 million persons now insured will lose coverage through the Republican Party’s new healthcare alternative healthcare plan, the once reviled, now widely accepted, “Obamacare,” of the Affordable Care Act of 2010.

I have been awaiting this estimate as have many other Americans and observers, and now we have it. In spite of the recent wave of promises and pledges that this health care plan would be better in all ways, it does not seem so at first and second and third readings….

I think many of us will wait to watch how the Republicans pitch and sell this to an important part of their base, the working class Americans who were without insurance fo so many years comprising the oft-quoted figure of 47 million Americans who were uninsured and prompted the move toward Obamacare. I for one am interested to see if the Republican base will react adversely and see this plan for the inadequate contrivance I at least consider it to be. Will they react with disappointment that is finally translated into lost votes in 2018? Much has been made of the white middle and lower middle class who have voted with the Republicans since President Nixon’s “Southern Strategy,” of the late 1960’s and 1970’s that in my mind really precipitated out the Culture Wars in this country.

This while working class of voters stuck with the Republicans in spite of being taken advantage of by the Republican Party and served poorly by it because the cultural issues of birth control, abortion, religious separation of church and state issues pulled them into the Republican fold in spite of losing ground economically over the past 2-3 decades.

I will be watching the elections of 2018 and 2020 to see if that bloc of voters reacts adversely to the erosion of their access to health care insurance.



Was Lyndon Johnson The First Edition of President Trump?

As usual,  I need to start by revealing my personal disclosure of perhaps bias,  my origin of interest in, and the backdrop for this somewhat offbeat, whimsical comparison and view of these two men as Presidents. And as a sop to my own ego, I must reveal/declare that I think this is an analogy that I, personally, though perhaps still mistakenly, very likely NO ONE has thought of.

The personal source of part of how this goofy metaphorical comparison came to me is indeed, “personal.” My father’s late sister was a teacher and a big cheese in American education in the 1960’s. Her name was Antoinette Miller of Houston Texas. My father and his family grew humbly in East Texas in a now ghost town that no longer exists named then, “El Mina,” Texas in the New Waverly-Conroe area and later moved during their childhoods to Huntsville. My father’s sister was the eldest and ambitious and went to college at “Texas Teachers’ College” as it was called then. One of her then classmates and somewhat close friend whom she came to know was Lyndon Baines Johnson. She rose to prominence in the NEA early in her career and was actually national President of the NEA at somewhat earlier age than most in that position. She was a national reformer and advocate and believer in the public schools as a national resource and treasure. She worked in the post-WWII years to strengthen the University of Texas state university branch system. She also in the same spirit of working to make higher education more affordable and available in this country helped in a minor but significant, persistent way, to push for the educational benefits in the FDR administration and completed by President Truman, in the GI Bill for returning veterans of World War II. my aunt’s friendship with President Johnson was deep, though largely not known nationally, but it was the basis for his appointing her his educational ambassador at large. She focused for several summers during his presidency years, visiting and studying the educational systems in India and Russia of all places! My aunt maintained her friendship and working relationship with President Johnson in her own behind the scenes style during his rough years in the Vietnam War era. I remember her stories of calling up “Lyndon,” and according to both my father and “auntie Antoinette,” she would give the President, her old college buddy, blunt Texas type unsolicited advice on his conduct of the Vietnam War. Knowing my incredibly strong-willed aunt, I can only imagine that poor LBJ had to grit his teeth and hear her out for the sake of their long-term, not well-known friendship dating back decades.

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A modest but wonderful idea for old hospital properties

Sometimes some of the best ideas do not come from state or national planners or “inside the Beltway.”

A group in western North Carolina in the out of the way mountain tourist area of Blowing Rock-Banner Elk, NC, led by a local innovative thinker has come up with a variation on a genre of an idea kicking around the country for over a decade nows. Its core idea is preservation and re-purposing of old, abandoned but still intact properties. The property of concern is typical of a growing number of such relatively new “leftovers” as medical care models in this country continue to evolve from the 50 years ago widespread model of cottage industries small private group practices of doctors and small community hospitals serving local communities and areas.

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