Saturday, December 31, 2011

There should be NO rush to close Lakeshore

Letter to the Editor, Knoxville News Sentinel  - December 31, 2011
Stephanie Matheny, Citizens for the Ten Year Plan, Knoxville
No rush to close Lakeshore facility
Citizens for the Ten Year Plan calls for the state of Tennessee to pause its apparent headlong rush to close the Lakeshore Mental Health Institute so we can ensure that whatever action is taken there will protect some of our most vulnerable neighbors: the indigent mentally ill.
We have a horrible track record of deinstitutionalizing the mentally ill but then failing to live up to promises of community-based mental health care. One result of this failure has been an increase in homelessness and incarceration among the mentally ill since the 1960s. Lakeshore has served as a critical safety net for those most in need, caring for people that other providers turn away, including poor people without health insurance.
It may be true, as Department of Mental Health Commissioner Douglas Varney argues, that closing Lakeshore will free up state resources to better fund community-based mental health care. We might even be able to serve more people with the resources we have now. But the public has yet to see a concrete plan to accomplish this.
Because there is no emergency — no sudden, unforeseen crisis — that mandates the closure of Lakeshore in just six months, we should take the time to develop a plan through a transparent, inclusive process that engages diverse stakeholders. This plan must address the indigent mentally ill in northeast Tennessee. While current Lakeshore residents must have first priority, any remaining resources that are freed up if Lakeshore closes must be directed to serve those with the fewest resources.

Saturday, December 24, 2011

In North Carolina, the state has cut its inpatient psychiatric capacity by half since 2005, says Dr. Bret Nicks, an emergency physician at Wake Forest Baptist Medical Center in Winston-Salem and a spokesman for the American College of Emergency Physicians. Nicks points to a report from the Institute of Medicine released in 2006 that found U.S. emergency departments were already overtaxed and overcrowded. "Now you are adding in patients who are unsafe to leave but yet have nowhere to go," he said. "I consider patients with acute psychiatric needs as really the forgotten patient population in the U.S. right now."

MENTALLY ILL FLOOD E.R. AS STATES CUT SERVICES

CHICAGO/NEW YORK (Reuters) - On a recent shift at a Chicagoemergency department, Dr. William Sullivan treated a newly homeless patient who was threatening to kill himself.
"He had been homeless for about two weeks. He hadn't showered or eaten a lot. He asked if we had a meal tray," said Sullivan, a physician at the University of Illinois Medical Center at Chicago and a past president of the Illinois College of Emergency Physicians.
Sullivan said the man kept repeating that he wanted to kill himself. "It seemed almost as if he was interested in being admitted."
Across the country, doctors like Sullivan are facing a spike in psychiatric emergencies - attempted suicide, severe depression, psychosis - as states slash mental health services and the country's worst economic crisis since the Great Depression takes its toll.
This trend is taxing emergency rooms already overburdened by uninsured patients who wait until ailments become acute before seeking treatment.
"These are people without a previous psychiatric history who are coming in and telling us they've lost their jobs, they've lost sometimes their homes, they can't provide for their families, and they are becoming severely depressed," said Dr. Felicia Smith, director of the acute psychiatric service at Massachusetts General Hospital in Boston.
Increased demand in mental health services
http://link.reuters.com/sud75s
State mental health budget cuts
http://link.reuters.com/tud75s
Visits to the hospital's psychiatric emergency department have climbed 20 percent in the past three years.
"We've seen actually more very serious suicide attempts in that population than we had in the past as well," she said.
Compounding the problem are patients with chronic mental illness who have been hurt by a squeeze on mental health services and find themselves with nowhere to go.
On top of that, doctors are seeing some cases where the patient's most critical need is a warm bed.
"The more I see these patients, the more I realize that if it's sleeting and raining outside, the emergency room is the only place they have," said Dr. R. Corey Waller, director of the Spectrum Health Medical Group Center for Integrative Medicine in Grand Rapids, Michigan.
Government agencies such as the National Institutes of Mental Health, the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration could not provide fresh data on use of psychiatric services in recent years.
But doctors from more than a dozen hospitals nationwide, mental health advocacy groups and state-funded agencies told Reuters they are all seeing a marked increase in psychiatric emergencies.
A WORSENING PROBLEM
The National Association of State Mental Health Program Directors (NASMHPD), an organization of state mental health directors, estimates that in the last three years states have cut $3.4 billion in mental health services, while an additional 400,000 people sought help at public mental health facilities.
In that same time frame, demand for community-based services climbed 56 percent, and demand for emergency room, state hospital and emergency psychiatric care climbed 18 percent, the organization said.
"This wasn't one round of cuts," says Ted Lutterman, director of research analysis at NASMHPD Research Institute. "It was three or four for many states, and multiple cuts during the year."
If the economy doesn't improve, next year could be worse because many community mental health agencies are cutting programs and using up reserve funds, says Linda Rosenberg, president of the National Council for Community Behavioral Healthcare.
"It's been horrible," she said. "Those that need it the most - the unemployed, those with tremendous family stress - have no insurance."
In the emergency room, this increased demand has meant doctors and social workers are spending hours and sometimes days trying to arrange care for psychiatric patients languishing in theemergency department, taking up beds that could be used for traditional types of trauma.
More than 70 percent of emergency department administrators said they have kept patients waiting in the emergency department for 24 hours, according to a 2010 survey of 600 hospital emergency department administrators by the Schumacher Group, which manages emergency departments across the country.
Ten percent said they had "boarded" patients for a week or more.
And many hospitals are not prepared for the increased caseload of psychiatric patients, says Randall Hagar, director of government affairs for the California Psychiatric Association.
California cut $587 million in state-funded mental health services in the past two years, the most of any state, according to the National Alliance on Mental Illness, a patient advocacy group.
"They don't have secure holding rooms. They don't have quiet spaces. They don't have a lot of things you need to help calm down a person in an acute psychiatric crisis," Hagar said.
"Often you have a patient strapped to a gurney in a hallway outside of the emergency department where social workers are desperately trying to find an inpatient bed," he said.
FROM CITIES TO SMALL TOWNS
In North Carolina, the state has cut its inpatient psychiatric capacity by half since 2005, says Dr. Bret Nicks, an emergency physician at Wake Forest Baptist Medical Center in Winston-Salem and a spokesman for the American College of Emergency Physicians.
Nicks points to a report from the Institute of Medicine released in 2006 that found U.S. emergency departments were already overtaxed and overcrowded.
"Now you are adding in patients who are unsafe to leave but yet have nowhere to go," he said. "I consider patients with acute psychiatric needs as really the forgotten patient population in the U.S. right now."
Dr. Stephen Anderson is an emergency department doctor at Auburn Regional Medical Center, a mid-size suburban hospital outside of Seattle.
"When the economy is hurt they are some of the first to drop off the healthcare rolls," he said of local residents in the largely blue-collar community.
Anderson, who heads the Washington Chapter of the American College of Emergency Physicians, said the state has lost a third of its inpatient psychiatric beds in the past decade.
Lately he is seeing a marked escalation in patients with psychiatric problems turning up in the emergency department. In early December, a third of its beds were occupied with people in a psychiatric crisis who were not safe to return to the community.
The problem extends out to small towns.
Sullivan splits his time between the big emergency department at the University of Illinois Medical Center at Chicago and St. Margaret's Hospital, a tiny facility in Spring Valley, Illinois, about 100 miles southwest of the city.
On a recent shift, a young woman with schizophrenia arrived at the hospital. She had just lost her job and apartment and was living with relatives. She could not afford the medications that were keeping her illness in check.
The woman asked Sullivan to switch her prescriptions to drugs that could be found on the $4 discount list at Wal-Mart and other discount stores.
"I didn't feel comfortable doing that," Sullivan said, noting that emergency physicians are being asked to deliver specialized care that should be handled by a psychiatrist.
He found a healthcare facility about 25 miles away with a psychiatrist who could help, but even that presented a problem for the woman, who had no way of getting to the appointment.
"It's almost akin to having a cardiac patient come in and say, 'I need someone to adjust my defibrillator.' In the emergency department, we can do a lot, but there are some things we have to leave with the specialists," he said.

Thursday, December 22, 2011

Identifying, protecting people with mental illness

There is no medical or scientific test to determine who is dangerous. A look at mental health programs around the country that work.

The Spoerls Story

Pat Spoerl has tried for years to get help for her son, John, who has schizophrenia. But he does not want to be confined for treatment. A look at the struggle of families.

The Lesson of Alberta Lessard


In 1971, this school teacher was placed in the Milwaukee Co Mental Health Complex. She fought back. And her case set new standards for commitment laws.

Wednesday, December 21, 2011

State to reform prisoner treatment | WWLP.com

With treatment, would we even need to be discussing reforming prisoner treatment of the mentally ill?

I, for one, think not.

State to reform prisoner treatment WWLP.com

Monday, December 19, 2011

Laura’s Law – Forced Treatment, Saved Lives

Laura’s Law – Forced Treatment, Saved Lives

How to Reform the Mental Health System

"The moral of this story is that just throwing money at the mental illness problem will not by itself necessarily lead to any improvement."

Read on:  How to Reform the Mental Health System

We need to establish a legal right to treatment

From the blog of Mr. Pete Earley

Last week, I explained why I believe the “dangerousness” criteria is an impediment to getting people the help that they need. One reason why civil rights activists pushed hard in the 1970s to get “dangerousness” established was because forcing someone into a state mental hospital was a draconion move.  Being committed was often a de facto life prison sentence. Barbaric treatments, such as forced lobotomies, destroyed lives.

What happens today if someone is forcibly committed?
 In Virginia, on average, you will spend five days or less in a locked mental ward. Your “treatment” will be medication and, if you are willing, therapy in groups where the topic will center almost exclusively on the importance of taking medication. After your five days end, you will be discharged. If you are fortunate, you will be linked to community services. But there’s a good chance that you will be released without any serious follow up.
In short, your life will have been disrupted — not only by your illness – but by the state. Yet, little will be done to actually help you recover from your disorder or help you better handle your symptoms.
This is not meaningful treatment. It explains why some critics are so adamant about clinging to the “dangerousness” criteria. Deep down, they do not believe involuntary commitments benefit anyone. 
In 1959, Dr. Morton Birnbaum was studying public policy and mental illness at Harvard University in a post-doctorate program when he hit upon an idea. His proposal later became known as the “right to treatment” argument. Put simply, Dr. Birnbaum argued that if the state decided to deprive a citizen of his liberty, the state was then obligated by the U.S. Constitution to provide that individual with real and effective treatment. 
I interviewed Dr. Birnbaum for my book, CRAZY: A Father’s Search Through America’s Mental Health Madness, and he told me that his goal had been to force state legislatures to provide meaningful services to patients in mental hospitals. Unfortunately, the civil rights lawyers – who initially teamed-up with Birnbaum and then took over the legal cases that Birnbaum [who was both an attorney and medical doctor] had filed — had a different agenda. They wanted to close down all state hospitals.
Dr. Birnbaum eventually broke away from these legal activists who went on to play a key role in the deinstitutionalization movement.
I believe that the best way to rid ourselves of the ill-conceived “dangerousness” criteria, is by actually offering meaningful help to people who need it. If we accomplished that in our communities, the number of forced commitments would drop and the commitment process would be seen more as a gateway to recovery than a punishment. 
What we need is a national, legal standard that would define meaningful treatment.
Let me give you an illustration. Before I wrote CRAZY, I spent a  considerable amount of my career writing about jails and prisons. I was a reporter in Tulsa, Oklahoma, in the 1970s when a federal judge took control of the state’s poorly funded prisons and forced the state legislature to spend tax dollars to improve living conditions in them. I also wrote about class actions lawsuits that activists filed on behalf of inmates. Over time, a national standard was adopted. Prisoners won the right to attend religious services, live in a minimum amount of square feet, have access to medical and dental care, eat well balanced meals and regularly shower and exercise.
The civil rights movement in mental health that happened in the 1970s and 1980s  was geared — not at winning patients the right to better treatment — but in protecting them from being forced to accept  any treatment.  At that  time, that may have seemed sensible. Is it now?
Why, I wonder, can’t Dr. Birnbaum’s “right to treatment” theory be used to guarantee specific rights to anyone who is involuntarily committed?  Why is there no national standard that spells out what services an ill person MUST be provided?
I’m not only talking about access to medications. I’m talking about requiring states to provide evidence based practices, such as excellent case management, access to assertive community treatment teams, Housing First opportunities, peer-to-peer support, transportation and other wrap-around services.
Since writing CRAZY, I have seen dozens of successful recovery programs and I have come to believe that most people who show the symptoms of a serious mental disorder can get better — especially when they get meaningful treatment.  Is there a way that we can use Dr. Birnbaum’s “right to treatment” claim to force states to provide the best — not minimal – services to persons who are committed? Can’t we argue that to do anything less is to deny that patient’s legal right to treatment?
What I am proposing it not a new idea. In fact, it is what Dr. Birnbaum’s hoped would happen decades ago when he first coined the term. It’s about time we listened to him.
What do you think? What sort of national standard would you envision?

Sunday, December 18, 2011

"We know you are safer if you have tools that allow you to avoid violence"

Model approach to mentally ill under scrutiny
Seattle Times Newspaper

Local News | Model approach to mentally ill under scrutiny | Seattle Times Newspaper

Recovery is Ideally Person-Driven But Not Always

I am a consumer who has successfully lived both medicated and not medicated during different points ....

By Amanda LaPera

NOTE: Amanda LaPera posted the following comment as both a consumer and family member in SAMHSA’s recent “Guiding Principles of Recovery” forum.  It is reprinted here from the website www.treatmentadvocacycenter.com

While I think the idea behind most of the listed guiding principles is sound, I do take issue when it states that “Recovery is Person-Centered.” Instead I think it would be more appropriate to state that “ideally, recovery is person-centered” since that is not always possible. I apologize for the long response, but many people on this site have called people’s statements into question based on lack of evidence. There is a small but very important population being ignored throughout these various threads: those who are the most severely ill and lack the insight that they are indeed ill. This is not a made-up disease, or something cured by simple nutrition. Anosognosia is real.

Most of the comments I've read from "consumers" who have bipolar or schizophrenia and have lead normal lives or from those who equate assisted outpatient treatment (AOT) to torture don't understand that AOT does not apply to most people. Not all those who have a severe mental illness have anosognosia or a need for intervention. I am not here to represent any organization or to try to use propaganda to sway this discussion. I am trying to provide a more thorough understanding of the real issue. Please hear me out on this.

I am consumer who has successfully lived both medicated and not medicated during different points in my life. My mother has bipolar and has decided that she can't function without medication. (I completely agree with her - medication along with appropriate care from competent mental health care professionals is how she is able to take care of herself). My father has late-onset paranoid schizophrenia and tried to commit suicide three times, had three involuntary hospitalizations, has anosognosia, and has been homeless for the last 10 years where he's been taken advantage of, had his nose broken after being attacked, and was treated for frostbite from sleeping on the cold streets. My sister has severe anxiety/depression and, without her medication, I would worry for the safety of her and her children. My friend has bipolar and, without medication, was completely unable to work, leave her house, or function. And my son, who has something that nobody can correctly label yet, has been misdiagnosed over a dozen times by nearly 20 different mental healthcare doctors, mistreated with medications that caused ulcers, stunted growth, and then weight gain, and is currently doing much better without any medications.

Not everyone needs nor responds to medication. In fact, the medications of the 1970s and 1980s did my mom more harm than good. Finally, science has advanced enough to provide her with appropriate and effective medication. I can see all sides of this issue. The issue of anosognosia and the recognition that some of the most vulnerable people need others to help them to get treatment does not apply to all individuals who have bipolar or schizophrenia, only the most severe, like my father. It seems to be easy for many here to dismiss this idea as a family's desperation (yes, many families don't have enough information to help their loved ones effectively, and it is a very painful position to be in when you have to watch your loved one deteriorate), or an overzealous pharmaceutical industry (yes, there are definitely abuses there), or incorrect diagnosis (yes, we need more research dollars to be spent on understanding and "mapping" the human brain's chemical functions to eventually be able to provide reliable evidence of all mental illnesses), or even torture (yes, the psychiatric hospitals have committed many deplorable abuses in the name of medicine). But do these same individuals here not recognize that all human beings deserve the decency to be able to live healthy, productive lives, free from a severe disabling condition?

What about Andrew Goldstein and Kendra Webdale? What about Scottt Harlan Thorpe and Laura Wilcox? What about Jared Loughner and Rep. Gabrielle Giffords and the six who died? What about Seung-Hui Cho and the 32 people at Virginia Tech? What about Kelly Thomas and the police department? The list goes on and on. What do all of these tragedies have in common? A person who was severely mentally ill who was not being adequately treated and whose family knew there was a mental illness that needed to be treated.

I am not saying all violence is attributed to mental illness, nor am I claiming that all those with severe mental illness will become violent. Neither could be further from the truth. However, definition of recovery aside, how in good conscience could SAMHSA ignore these people in this discussion? While they make up a very small minority, we are still talking about human life and mental illnesses that must be addressed. Money will always be an issue, but it’s far less costly to provide sufficient care—be it inpatient or outpatient—than to sit by, pretend there isn’t a problem, and allow things to continue as they have been, with people being incarcerated or left to fend for themselves on the streets, which only results in more money being spent and more preventable tragedies.

Let’s look at the facts. According to SAMHSA, homelessness is frequently a mental health issue. Their National Mental Health Information Center lists the following statistics: over the course of 1996, 2.1 million adults were homeless; 39% of the homeless population in America report having a mental illness, and 20-25% meet the criteria for a severe mental illness. There are also several individual factors that may increase a person's risk for becoming homeless and remaining homeless for a longer period of time, one of which is an untreated mental illness that can cause individuals to become paranoid, anxious, or depressed, making it difficult or impossible to maintain employment, pay bills, or keep supportive social relationships. Homeless individuals with severe mental illness are twice as likely as other homeless people to be arrested or jailed. SAMHSA also reports: “Homelessness among people with serious mental illnesses can be prevented. Discharge planning that helps people who are leaving institutions to access housing, mental health, and other necessary community services can prevent homelessness during such transitions. Ideally, such planning begins upon entry into an institution, is ready to be implemented upon discharge, and involves consumer input. Providing short-term intensive support services immediately after discharge from hospitals, shelters, or jails has proven effective in further preventing recurrent homelessness during the transition back into the community.” And, according to the U.S. Department of Justice, Bureau of Justice Statistics’s study “Mental Health and Treatment of Inmates and Probationers” by Paula M. Ditton, BJS Statistician: “At midyear 1998 an estimated 283,800 offenders with mental illness were incarcerated in the Nation's prisons and jails.”

I don’t pretend to have the answer to everything, but I do know that we must recognize this subset of the population before they are incarcerated or homeless, and include them in this discussion.

Ramsey, Faulk Oppose Cut to Program for Disabled | Humphrey on the Hill | knoxnews.com

Kudos to Lt. Gov. Ron Ramsey & Sen. Mike Faulk for opposing cuts to the Family Support program!

Ramsey, Faulk Oppose Cut to Program for Disabled | Humphrey on the Hill | knoxnews.com

"They contend the success in Nevada County could never be exported to a big city. But what of New York, which has tougher law that has been in place for 11 years? Judges there have ordered treatment for 9,700 people. The concept works in Manhattan and in Nevada County. Surely, it's worth a try in Los Angeles, Fort Bragg and Fullerton."

It's worth a try in Tennessee as well.

http://www.sacbee.com/2011/12/18/4128614/a-law-a-success-a-lesson-ignored.html

AOT: It's a tough issue. But legislators who tackle it would leave their mark by helping people who, through no fault of their own, cannot help themselves.

http://www.sacbee.com/2011/12/18/4128632/lauras-law-needs-help-from-prop.html

Saturday, December 17, 2011

"Stopping the Revolving Door - A Civil Approach to Treating Severe Menta...

Parkwest shooting points to need for a new law

We are getting closer to an AOT law in Tennessee. With the proposed closure of Lakeshore, AOT would be a necessary tool to ensure treatment compliance of folks who are released into our communities. AOT would help protect the safety of everyone concerned by utilizing the community resources who will directly benefit from increased funding due to Lakeshore's closure. Research has shown that AOT will also reduce the workload for our law enforcement, jails, court system and homeless shelters. I urge you to contact your legislator in support of Senate Bill 608!

Guest Column
Reprinted from Knoxville News Sentinel, Spring 2010

Abdo Ibssa was not a monster. But the man who shot three staff members at Parkwest Hospital last month, killing one before taking his own life, lived in the grip of a monstrous disease. Severe mental illness made Mr. Ibssa believe that a doctor at Parkwest had implanted a tracking chip in his body, and propelled him to the hospital on a violent rampage.
How did we as a community allow this to happen? One might assume that Mr. Ibssa somehow slipped under the radar of an overburdened mental health care system. But the truth is even sadder.
Far from being under the radar, Mr. Ibssa was known to local authorities. According to news reports, Ibssa was accused of violently attacking aman last year, and earlier in 2010 was committed by his family to a Knoxville mental hospital. When he was deemed stable, he was released with a prescription for medication and (tragically) nothing more. After the shooting, police found the pills in his home, apparently un-utilized.
It is a pattern all too familiar to people like me, who struggle endlessly to keep a mentally ill family member out of harm’s way. Our loved ones reject outpatient care, and the system does nothing to stop them until they do something to prove they are “dangerous to self and others,” the standard for involuntary hospitalization.
Eventually they are released to repeat the heartbreaking cycle, unless of course their dangerous behavior included a violent crime. Then they get years of free mental health care in a prison cell.
The root of the problem is that many people with severe mental illness are incapable of recognizing that they are sick and in need of treatment. The clinical term is anosognosia, or lack of insight. In the minds of those who suffer from it, there is nothing wrong with them. When left on their own in the community, they stop taking medication.
While people with mental illness on the whole are no more violent than the general population, untreated severely mentally ill individuals are a different story. Studies show that untreated severe mental illness is among the most reliable predictors of future violence. And yet when an outpatient goes “off meds” in Tennessee, families and caregivers must stand by helplessly, knowing with certainty that dangerous behavior is around the corner, but legally powerless to prevent it.
In most states, a legal tool known as “assisted outpatient treatment” (AOT) is a potential solution. Under an AOT law, a mental health official or family member can seek a court order, requiring a severely mentally ill person to comply with treatment as a condition of remaining in the community. The purpose of the court order is not to punish the person if they should happen to stray off treatment. Quite the contrary. It is to ensure that the person’s condition is constantly monitored, and to give authorities the legal right to help as soon as treatment non-compliance is detected.
These laws have been found to dramatically improve outcomes for patients. In New York, researchers have documented steep declines in rates of homelessness, hospitalization and incarceration.
Tennessee is one of only six states without some form of AOT on the books. In recent years, attempts by legislators to pass an AOT law have been stymied by the state Department of Mental Health, which has cited concern for the civil liberties of the mentally ill and the cost of comprehensive outpatient care.
The civil liberties objection is absurd to me, as it should be to anyone who has spent time in the company of an actively psychotic person. This condition is a living hell that no one would ever rationally choose for himself. These individuals are crying out for our help, even if their words and actions say the opposite.
The cost objection is incredibly short-sighted. Want to talk high cost? Look at what the state spends to hospitalize, prosecute and incarcerate people who we currently permit to become dangerous. The opportunity to spend a little up front to avoid these bills down the line should be seized by even the most hard-hearted fiscal conservative.
The time has come for Tennessee to leave the Dark Ages of mental health care and enact an AOT law. Some of us on the front lines of this issue have been saying so for years. But if the Parkwest tragedy doesn’t wake up our legislators and mental health officials to this urgent need, I can’t imagine what will.


Karen Easter

Parkwest shooting points to need for a new law

Wednesday, December 14, 2011

One Knoxville Mom's Story

Susan Vanacore, a retired licensed clinical social worker, knows what it’s like to not just work with the mentally ill but to live with them as well.

During the Knox County Commission’s Dec. 12 work session, Vanacore told the commissioners about her 27-year-old son who stabbed her husband a little over a year ago after suffering what was called a ‘psychotic breakdown.’

Her son is currently in prison, awaiting trial, but Vanacore feels that he belongs in a place such as the Lakeshore Mental Health Institute, which is in danger of shutting down by the middle of next year.

Vanacore and others addressed the commission to encourage them to help keep Lakeshore open.

“I found difficulty in finding care for him,” Vanacore said. “No doctor would accept him. We need places for people to get treatment who need more long-term treatment, and we need to remove the mentally ill from the jails so they can also get treatment.”

“They deserve to have a life where they are respected and treated in their communities,” Vanacore continued. “I don’t want to see anyone else go through this. I was a consumer for my son, and the road is paved with very good intentions.”

Closing Lakeshore is part of a plan to outsource mental-health care to private inpatient facilities and community-based programs.

State Department of Mental Health Commissioner Douglas Varney announced the plan last month, but commissioners were taken by surprise with the plan. They tried to reach Varney to reason with him, but to no avail.

Led by Commissioner Jeff Ownby, commissioners are in agreement to ask a number of state leaders, including Gov. Bill Haslam, to delay closing the facility for at least two years.

“The question I’ve asked is ‘What’s the plan?’ and no one seems to know,” said Commission Chairman Mike Hammond. “This isn’t meant to be criticism of anyone, but if Lakeshore closes, we don’t know the plan. We will be responsible for picking up the pieces, organizations will be responsible at how they’re going to operate with the closure of Lakeshore.”

“This body has had extensive public hearing, we’ve heard numerous output, I do not see that as having occurred with this situation,” Hammond continued. “This is a significant move, and I know the state has the opportunity to do it, but I endorse this resolution to have the state move a lot more slowly.”

There was major concern among officials that there are not enough programs to serve many of the Lakeshore patients, not to mention an increase of the homeless and mentally ill in prison should the facility close.

State Rep. Joe Armstrong commended the commission for their efforts and would lend his support in keeping Lakeshore open.

“This is a sensitive issue because we follow what goes on at Lakeshore,” Armstrong said. “If you look at the census of the campus, there were more than 3,000 patients. We developed a master plan in 2007, and there is a way to reduce the census. It will come down to additional costs.”

The commissioners unanimously backed the proposal during its work session, and will vote on it during next week’s meeting.

“We need to make sure we direct this where it needs to go,” said Knox County Mayor Tim Burchett, addressing the commission “We need to make sure the governor knows this is an area of concern. I’ve received a lot of resolutions and the level of frustration I’ve come to find is the greatest with you all. You need to make sure (State Finance) Chairman (Randy) McNally hears your concern about this.”

Meanwhile, Burchett’s office announced it has scheduled a meeting with Varney, slated for Dec. 14 in the City-County building’s sixth-floor conference room. The Knoxville Journal will follow up on the story.

J.J. KINDRED

J.Kindred@theknoxvillejournal.com

Haslam on Lakeshore Closing: 'I think this is the right approach' | Humphrey on the Hill | knoxnews.com

From the News Sentinel:
Gov. Bill Haslam indicated Tuesday he is inclined to push ahead with a proposal to close Lakeshore Mental Health Institute -- a day after Knox County commissioners said they would ask state officials to step in and keep the facility's doors open.

Haslam told the News Sentinel the proposal made by state Department of Mental Health Commissioner Douglas Varney in mid-November was part of a "top-to-bottom review" of his department, which the governor ordered all commissioners to conduct.

Haslam said the final decision to proceed with closing the Lyons View Pike center will be made "in four weeks or so," and he left the impression he would follow Varney's recommendation.

"From everything I understand, I think this is the right approach to take," he said. "The question is: Can we help more people more effectively? It seems to me that we can."

The state could close the aging institute, which is surrounded by a popular community park, by the end of the fiscal year, as part of a plan to outsource mental-health care to private inpatient facilities and community-based programs. If approved, Lakeshore would stop admitting patients next month.

Many local officials are concerned the community lacks enough programs to serve a majority of the patients who end up at Lakeshore.

And, they're predicting a rise of mentally ill in the homeless and jailed populations if the operation shutters.

During Monday's County Commission work session, officials said they were blindsided by the state proposal and wanted answers. A number of them said they tried to reach Varney and he did not call back.

They agreed to ask the local legislative delegation to get involved. They also wanted state officials to delay closing the facility at least two years. County Mayor Tim Burchett on Tuesday secured a meeting with Varney for this afternoon. A number of commissioners are expected to attend.

"The commissioners have a lot of questions, and the sooner we can get him in, the quicker we can find solutions," the mayor said.

He added that they'll ask Varney "to give us the plan on how the closure will take place as they see it."

Haslam said he agreed that "more explanation for people in the community" is in order.

When asked, however, whether a two-year delay is appropriate, the governor said: "I'm not sure what the purpose of a delay is. If it's right now, why put it off?"

County Commissioner Jeff Ownby, who spearheaded the move to seek help from state officials, said he was upset that the governor appears disinclined to reconsider proposed plans for Lakeshore's future.

"I guess the governor doesn't care about an unfunded mandate in the city and county where he lived," said Ownby, adding that today's meeting is "a waste of time if it won't change anything."

"I think it's disappointing that (Haslam) would already make that observation without even talking to the public here and the local officials here to see if we couldn't work out some situation other than leaving the third largest city in the state without a mental hospital," he added.

Commission Chairman Mike Hammond said "the governor is going to do what the governor is going to do," but he was less critical.

Hammond said he just wants to hear the state's plans, and it's even possible he could support the measure.

"The fact that there is a plan and it hasn't been shared with the local elected officials obviously is a concern because this is a great asset to our community -- both Lakeshore and also the property," he said. "How are these people going to be taken care of? Are there other services that are going to be provided at the local level? Those are some of the questions we need answered."

Haslam on Lakeshore Closing: 'I think this is the right approach' | Humphrey on the Hill | knoxnews.com

Detroit News Editorial: Make it easier for the mentally ill to get help

Proposed reform of state's mental health code allows for earlier treatment to keep patients off streets, out of jail.
On any given night in Detroit, there are about 8,000 homeless people seeking shelter, says Cheryl P. Johnson, head of the Coalition on Temporary Shelter. About 80 percent of them, she adds, have mental health problems. Various studies on jail and prison inmates in this state indicate that from 1-in-6 to 1-in-4 have mental health issues. Clearly, the system designed to deliver mental health services to Michigan residents isn't working.

Efforts at legal reform of the system have been met with setbacks in recent years as state lawmakers have been distracted by budget problems and other economic issues. But the problem remains.

The Michigan Probate Judges Association and the Mental Health Association in Michigan are proposing a significant revision of the state's mental health code to make it easier for residents — or their families or guardians — to receive the help they need.

One goal of the proposal is to update the code so it recognizes most mental health treatment now is delivered on an outpatient basis rather than in mental hospitals. Michigan, like most other states, has long since shuttered its public, long-term residential treatment facilities for the mentally ill. Elaborate safeguards in the mental health code to prevent people from being shut away in mental hospitals often get in the way of allowing them to obtain the immediate treatment they need.

Another part of the proposed reform is to change one of the definitions of those who need court intervention to obtain treatment so that they are described, in part, as people who because of their illness do not understand their need for treatment and in the opinion of an appropriate mental health professional might harm themselves or others in the near future. This allows a probate judge to require treatment earlier in a victim's progression of mental illness rather than waiting until afterhe or she has done something physically destructive.

The proposed revision also requires mental health authorities — usually a community mental health board — to use all of the criteria for determining whether someone needs involuntary treatment, not merely the most restrictive criterion. And it gives families or guardians the ability to seek and obtain a second opinion if their request for treatment has been turned down by a mental health board.

The screening process through which county mental health boards determine whether someone should be treated and to seek court approval for that treatment isn't systematic across county lines. Oakland County has about two-thirds of the residents of Wayne County, yet in 2010, there were more applications for court approved mental health treatment in Oakland County than in Wayne County.

The proposed revision of the code would also allow court-appointed guardians to seek mental illness treatment for a ward. Currently, says Chief Wayne Probate Judge Milton L. Mack, guardians can seek surgery for their charges but not medical intervention to deal with a mental problem.

The current code has a confusing array of avenues for seeking involuntary mental treatment. The reform streamlines the code and allows judges a wider range of options in ordering differing kinds of treatment.

Too many of the mentally ill remain on the streets or in jail or prison cells. This is inhumane and should be an embarrassment to policymakers. Sensible revision of the state mental code is a good place to start in remedying the situation.

If the safety net can be "a tangle of unconnected strings", then AOT can help connect them.

In the past 40 years, scientists have developed ways to immunize against more than a dozen life-threatening diseases.

We've improved sanitation, food safety and water purification.

Yet we are no closer to identifying those with mental illness who are dangerous than in 1971, when schoolteacher Alberta Lessard won a groundbreaking legal case that prohibited states from forcing people into care.

That decision required a judge to find a person to be an imminent physical danger in order to compel treatment. It took the decision making away from families and doctors and put it in the hands of police officers and judges.

Without a precise way to measure dangerousness, people who need care may slip through the system with tragic results like those at Virginia Tech in 2007 and Tucson this year.

If we can look at studies of how beta blockers help reduce heart attacks, "why can't we apply general knowledge to save the next Virginia Tech from the next Cho?" asked Jeffrey Swanson, a Duke University professor who has studied the correlation between mental illness and violence for more than 20 years.

The answer is there is not enough data.

Shrouded in stigma and secrecy, illnesses that affect the brain long have been regarded as distinct from other health issues such as cancer and heart disease. Psychiatric hospitals are separate from other health facilities. Until recently, insurance rarely covered many mental health claims.

It's been only 30 years since the Diagnostic and Statistical Manual -- a benchmark used by doctors to identify diseases and conditions -- defined objective criteria for what constitutes a mental illness.

Without data to develop sound social policy, lawmakers have had to guess at where to draw the line between protecting the public and safeguarding individual rights. That has created a fragmented system with a patchwork of approaches.

Even within a state, the way cases are handled can be determined by where a person lives.

When incidents such as Virginia Tech or Tucson happen, it reignites an entrenched debate about how best to approach the issue.

On one side is E. Fuller Torrey and the Virginia-based Treatment Advocacy Center, which works to make it easier to force people into care when they are not of sound enough mind to make the decision for themselves. On the other is Bob Bernstein and the Washington, D.C.,-based Bazelon Law Center, which calls for fewer restrictions and expanded care in the community.

In the middle are people such as Ryan Spellecy, a medical ethicist at the Medical College of Wisconsin.

"Not all people with mental illness are dangerous, of course," Spellecy said. "So, we can't compel someone to be treated just because he has mental illness."

The problem comes at the point at which that person becomes dangerous.

"There is a gap between when a person gets sick and when we get him into care," he said. "All kinds of horrible, horrible things happen."

Experts point to programs that work, from crisis intervention training to assertive community treatment and mental health courts. But they are not applied in a coordinated way. Even officials in communities that do certain things well say more is needed.

The safety net can be a tangle of unconnected strings.

Crisis Intervention Training

In Wisconsin, only police officers can bring a patient into a hospital to be held on an emergency detention. That puts them on the front line of a medical issue -- and gives them authority to render decisions they may not be equipped to make.

Jon Lehrmann, a Milwaukee psychiatrist, once tried to have a woman committed who suffered from chronic schizophrenia and had delusions that she should not eat. He filed a petition with police to have her brought to the county Mental Health Complex for care. But the officers refused, saying they found evidence she recently had eaten some cheese.

Lehrmann persisted, telling a supervisor the officers would be responsible if the woman died. When they brought her to the hospital, doctors found that she had life-threatening dehydration and had lost 42 pounds in 17 days -- more than a quarter of her weight.

Of the more than 5,200 people listed in the past 25 years as a "preventable tragedy" on Torrey's website, nearly half were incidents involving people with mental illness and the police.

In 1988, Memphis police shot and killed a man with schizophrenia. In the aftermath, police worked with university researchers and the local chapter of the National Alliance on Mental Illness to develop a 40-hour training program that educates officers on ways to identify people who are in psychiatric crisis and get them into care with minimal force.

"People assume that people with mental illness are dangerous," said Lyn Malofsky who conducts training in Milwaukee. "We have to teach people how to deal with people with mental illness."

Malofsky, who struggles with depression, has helped train Milwaukee area police officers for the past seven years on signs to look for, how to actively listen to people in psychiatric crisis and how to act more gently to minimize violence. More than 300 Milwaukee officers have volunteered for CIT and there are plans for more sessions in 2012.


Since the Memphis program began, crisis intervention training has been held in more than 1,000 cities worldwide. It has been expanded to include teachers, librarians, bus drivers and health care workers.

Studies have shown a reduction in the incidents of officers being injured in cases that involve suspects with mental illness. Police officers who receive the training have more confidence and are better at diverting people from jail, studies show.

But if a case reaches the point where police are involved, experts say, it means many opportunities were missed along the way.

"We are the last ones that should be involved," said West Allis Police Chief Mike Jungbluth, who began his career as a psychiatric nurse. "A cop shows up at your door with a badge and a gun. That doesn't exactly facilitate sharing."

The number of people brought to Milwaukee County's mental hospital on emergency detentions rose 33% in the past 10 years. In West Allis, police brought one man in 57 times from 2006 through 2010, including 14 suicide attempts.

"Something's not right when we're doing it like that," said Jungbluth.

Mobile Urgent Treatment Teams

Under this approach, groups of psychiatric social workers and nurses respond to calls from people in distress and try to calm them down before they need to go the hospital.

A review this year by the U.S. Department of Health and Human Services gave high praise to Milwaukee County's team for adolescents in psychiatric crisis.

The report found that the annual costs of hospitalization for adolescents fell by more than 50%, from $10.5 million to $5 million from the team's inception in 1994 to 2010. In the third quarter of 2007, nearly four in five cases were diverted from hospitalization. In addition, those who were hospitalized through the crisis team had significantly lower lengths of stay than adolescents not seen by the team.

Milwaukee County is expanding its teams for adult patients with additional funds from the 2012 budget. Last year, the team fielded 30,000 phone calls and made 1,265 visits.

Assertive Community Treatment

With this model, patients live in their community under supervision of a team of social workers, doctors, nurses and occupational therapists. The teams meet daily to discuss the patients in their care.

Developed in the late 1960s at Mendota State Hospital in Madison, the approach is now used by mental health authorities and centers that deliver care around the world, including the U.S. Veteran's Administration.

The team works with each patient on a range of issues, from monitoring medication to help in shopping, cooking, cleaning and social activities.

A team member might notice that the person isn't eating well or looks more disheveled than normal.

"They can be there when a patient starts to ruminate about wanting to hurt themselves or someone else and get help before things get out of hand," said Thomas Zander, a retired lawyer and psychologist who has fought to expand civil rights for mental patients.

Milwaukee does not have a true assertive community treatment program. But there is a growing emphasis on out-patient services.

It costs substantially less in the long run than institutional care. One day at Milwaukee County's Mental Health Complex costs $1,364, or $497,860 a year. The cost of out-patient care in Milwaukee's community support programs is $17.66 a day, or roughly $6,446 a year.

Assisted Outpatient Commitment

Under this arrangement, patients live at home but are under a legal order that compels them to follow a treatment plan -- including taking medication. If they fail to comply, they can be brought back to the hospital on an involuntary commitment.

Forty-four states have variations of this law, designed as leverage to get more people to accept treatment.

Wisconsin led the way with passage in 1995 of the "Fifth Standard," which allows the commitment of people who are so "substantially incapacitated by mental illness" that they cannot make an informed decision about whether to accept medication and treatment. The person has to have a history of treatment to qualify.

But the Fifth Standard is rarely invoked, and its use varies greatly from county to county.

In Waukesha County, court records show, it was used an average of 10 times a year over the past five years. In Milwaukee County, Probate Court Commissioner Patrice Baker can't recall the last time it was used.

If the standard is followed, and the patient gets care in the community, the approach can be effective, said Darold Treffert, a psychiatrist who served as superintendent of the Winnebago Mental Health Institute for 15 years and lobbied for the law's passage.

Torrey, a psychiatrist whose late sister suffered from schizophrenia, founded the Treatment Advocacy Center in 1998 to push for expanded outpatient commitment standards nationwide.

"It cuts down on homelessness, criminalization -- all the bad stuff that comes with being chronically mentally ill," Torrey said.

Civil libertarians, like Zander, argue that these arrangements do not work.

"If a patient-doctor relationship is going to be successful, you have to have trust," he said. "You can't have trust if the patient knows that any time the doctor can turn in to a police man and put him behind a locked door."

Swanson, the Duke professor, studied the success of outpatient commitments and found that they work if combined with extensive community services, such as help with housing and getting the patients on disability insurance.

Mental Health Courts

Modeled after drug courts, mental health courts deal with people whose crimes are directly related to their mental illness. Typically, defendants charged with nonviolent crimes such as shoplifting or panhandling are able to avoid prosecution in exchange for adhering to their treatment plan.

Already, a large number of prisoners are seriously ill. A 2009 study published in the journal Psychiatric Services found 2 million people in prisons and jails with severe mental illness.

There are more than 250 mental health courts in the United States.

Wisconsin has only one, in Eau Claire, founded in 2008. Outagamie County is setting one up in Appleton with a federal grant from the Office of Justice Programs.

Mary VanRoy, the Eau Claire court's clinical coordinator, said getting the program established proved to be more complicated than she envisioned because most of the defendants also have drug and alcohol addiction. They don't have homes or jobs and do not receive Social Security disability payments. So, case managers have had to spend more time working out those details.

"I was not prepared for the intensive case management that was needed," VanRoy said.

E. Michael McCann, who served for 38 years as Milwaukee County district attorney, tried unsuccessfully to establish a mental health court before he retired in 2006. Milwaukee County has a program to help people accused of crimes who have mental illness. Justice 2000 provides assistance in navigating the criminal justice system, but the cases are handled as part of the regular court docket .

San Antonio, where mental health courts started in 2007, is considered a model in this area.

"It used to be that we would make the order for a defendant to get mental health care and we wouldn't hear from them again unless they killed someone or killed themselves," said Oscar Kazan, a court commissioner who hears 3,500 cases a year, about 15 a day.

Now, he is able to issue an order with a sentence holding the defendant and case worker responsible. If the defendant does not comply, both he or she and the caseworker can be found in contempt -- though Kazan hasn't had to take that step yet.

Case managers balked at first, afraid of the responsibility, Kazan said. But time has shown that this approach works, he said.

"You'd be amazed how responsive people are when you listen to them," said Kazan who holds court in a conference room at the community mental health center.

Some constitutional rights lawyers and mental health experts believe the courts actually add to the criminalization of people with mental illness.

Bernstein, the Bazelon Law Center director, is skeptical of mental health courts. He warns that they present some unintended negative consequences: "People denied service actually look for ways to get arrested so that they can have access to a caseworker."

Psychiatric Advance Directives

This approach allows those with mental illness to designate someone who can compel them to get treatment in the same way people empower a family member or friend to make medical decisions in case they are incapacitated.

These are especially useful for patients who suffer from a side effect of some mental illness, known as anosognosia, the inability to understand that they are sick.

Studies by Swanson and his colleagues showed that mental patients were more likely to follow an advance directive that they had agreed to than a court order imposed upon them.

Wisconsin allows a person to appoint someone as a health care agent to make decisions for you, but it does not allow you to write advance instructions for specific psychiatric care in a freestanding document. The documents can't be used to authorize inpatient treatment, experimental mental health research, psycho-surgery or electroconvulsive treatment.

This is a byproduct of the Lessard decision. Lawmakers did not want to create an opportunity for someone to force the will of a mental patient and create a document that could be abused

A special Legislative Study Council is meeting Monday to consider a host of changes to the state's commitment laws, including a proposal to amend the law to allow advance directives for mental health care and treatment.

Spellecy, the medical ethicist, sees directives as a way to foster a person's autonomy by giving him or her the right to say what kind of care and medications should be administered.

Even with the greatest care to guard against tragedies like Tucson and Virginia Tech, some people with mental illness who are violent will elude care.

"That's the heartbreaking thing about mental illness," Spellecy said. "We can't prevent everybody from dying. But we don't give up, either."

___

By Meg Kissinger, Milwaukee Journal Sentinel
McClatchy-Tribune Information Services
Dec. 14--


Visit the Milwaukee Journal Sentinel at www.jsonline.com

Tuesday, December 13, 2011

Senate-Health & Welfare Subcommittee

Folks, hopefully Tennessee is getting closer to an AOT Law on the books.

The video of the Senate Health & Welfare Subcommittee is up and KUDOS go to Sen. Doug Overbey for defending his proposed Senate Bill SB0608.

Sen. Overbey asked the State to explain the exorbitant fiscal note that was tacked on this bill that does not mandate any new services or programs and stated "this fiscal note is not properly calculated".

Will stay tuned to see result of "additional work" requested by Sen. Overbey.

Senate-Health & Welfare Subcommittee

"Commissioners believe there is no real plan in place to take care of patients who will be displaced."

Thank you, Knox County Commissioners. Your action yesterday demonstrates your concern for those in our State who cannot advocate for themselves, our citizens who suffer from severe and persistent mental illness.

~~~~~~~~~~~~~~~~~~~~


Knox County commissioners are speaking out against the state's plan to close the Lakeshore Mental Health Institute.

At a meeting Monday afternoon, Commissioners unanimously recommended a resolution that Commission Chairman Mike Hammond send a letter to state lawmakers in Knox County.

That letter would ask Governor Haslam to delay the closure of Lakeshore for a period of two years.

Commissioners believe there is no real plan in place to take care of patients who will be displaced.

They are concerned some of those patients could end up living on the streets or in jail.

"I endorse this resolution that we ask the state to move perhaps a little bit more slowly. let's have a process so that we as the legislative body can have, not input, but just clarification on what the plan is. And I don't think that's too much to ask," said Hammond.

The letter would also go to Speaker of the House of Representatives Beth Harwell, Senator Randy McNally, Lieutenant Governor Ron Ramsey, and Mental Health Commissioner Doug Varney.

The commission is also working to set up a meeting with Commissioner Varney in Knoxville.

They will officially vote on the resolution at their regular meeting next Monday.

Commissioners believe there is no real plan in place to take care of patients who will be displaced.

Commission to meet with mental health commissioner about Lakeshore Mental Hospital

As a family member of someone with a severe and persistent mental illness, I understand firsthand how speaking out on their behalf is a very difficult thing to so.

Not only do we risk alienation of our loved one - we are vulnerable to misunderstanding by others, misalignment by zealous consumer advocates and, of course, the nasty S word - stigma.

So kudos to this mom, Susan Vanacore, for her compelling testimony to the Knox County Commission yesterday.

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

Susan Vanacore is taking a stand.

She's a licensed clinical social worker whose son is mentally ill.

Licensed Clinical Social Worker Susan Vanacore/says, "Although my son had never been violent, he had a psychotic break and stabbed my husband."

She doesn't want her son or other sick patients disregarded.

Vanacore says, "These are our mothers, our fathers, our sisters, our brothers and our children. They deserve to have a life where they're respected and treated."


Commission to meet with mental health commissioner about Lakeshore Mental Hospital

Monday, December 12, 2011

Breaking News: Knox County Commission UNANIMOUSLY votes to ask State to Keep Lakeshore Open!

In a voice often choked with sadness, Susan Vanacore told Knox County commissioners on Monday about her son, a 27-year-old mentally ill man who had "a psychotic breakdown" and stabbed her husband more than a year ago.

He now sits in jail, awaiting trial.

Instead, she told officials, he belongs in a hospital, or some place that can take care of him.

"We need places for people to get treatment who need more long-term treatment," said Vanacore, a retired social worker who lives in Farragut. "We need to remove the mentally ill from the jails so they can also get treatment."

Vanacore was one of three who pleaded to commissioners Monday to find some way to keep the doors to Lakeshore Mental Health Institute open.

"These are people, these are our mothers, fathers, sisters, brothers, children," she said. "They deserve to have a life where they are respected and treated in their communities."

As it stands, the state plans to close the facility by the end of the fiscal year, as part of a plan to outsource mental-health care to private inpatient facilities and community-based programs, state Department of Mental Health Commissioner Douglas Varney announced in mid-November.

Commissioners say they were blindsided by the proposal and want answers. A number of them said they tried to reach Varney and have not heard back.

Now, they're asking the local legislative delegation to step in and see what it can do.

"I've talked with some people involved in mental health in Knox County and the question I've asked is: 'What's the plan?' and no one seems to know," Commission Chairman Mike Hammond said. "That isn't to criticize anyone, but if Lakeshore closes, we don't know the plan."

The commission, at the request of Commissioner Jeff Ownby, agreed to ask a number of state leaders, including Gov. Bill Haslam, to delay closing the facility for at least two years. They also agreed to seek a meeting with Varney.

The commissioners unanimously backed the proposal at Monday's work session, with an official vote to come next week.

Officials said they are concerned the community doesn't have enough programs to serve many of the patients who end up at Lakeshore. They also said they expect a rise of mentally ill in the homeless and jailed populations if Lakeshore closes.

State Rep. Joe Armstrong, D-Knoxville, commended the commission and said he'd look into what could be done. He said a complete shutdown could create an "additional burden and additional costs" to city and county coffers.

Meanwhile, the commission also agreed to send a letter to the local legislative delegation requesting that members oppose any proposed changes that would weaken the state's Open Meetings Act. They'll further discuss the measure during next Monday's regular meeting.

© 2011, Knoxville News Sentinel Co.

Sunday, December 11, 2011

"If you are mentally ill, an awful lot of the family doesn't stay as close as it used to. It does take a lot of extra work."

MENTAL ILLNESS: IT'S A FAMILY AFFAIR

Steve Pitman understands what it's like for families of those struggling with mental illness. At 64, he still looks out for his troubled brother. Board president of the Orange County chapter of the National Alliance on Mental Illness, Steve is shown with his older brother, John, 66, who has had a decades-long struggle with mental illness.

John Pitman fuels the midmorning with a large Coke and several refills. Steve Pitman sips at his same cup of coffee.

John is the older one, 66. Steve, 64, is, in a way, his brother's keeper.

John has been diagnosed with schizoaffective disorder, characterized by paranoia, delusions and moods that swing from mania to depression.
Steve is the only one of John's five siblings who wants contact with him.

In recent months, John's troubled life has settled into a state of relative stability. Steve, who sees his brother at least once a week, is a big reason for that.
They came to a fast-food restaurant not far from John's board-and-care home to talk about something many families have tended to keep private – until recently.
Mental illness has become a much discussed topic in Orange County since the beating death of Kelly Thomas in July. Two of the Fullerton police officers involved in the altercation are facing trial.

Thomas was 37, schizophrenic and living on the streets without medical attention. His family provided what support he would accept, but under current law they could not make him seek treatment for his condition. Thomas has become the face of the renewed debate over Laura's Law, a 2003 state law that allows a court – with input from health care providers and family members — to order assisted outpatient treatment for the severely mentally ill.
Counties must decide to put Laura's Law into action. So far only one – Nevada County – has fully implemented it. Orange County officials are discussing whether to enact it.

Steve Pitman can relate to the Thomas family's anguish all too well. He has lived it with his brother John for nearly 50 years.
The past few years he's been involved with the National Alliance on Mental Illness Orange County, or NAMI-OC, an organization that offers advocacy, education and support for people close to the mentally ill. He started out as someone seeking insight for himself, and now serves as president of the organization's local chapter.
But Steve's concern goes beyond the organization and even John. As it does for a lot of people related to the severely mentally ill, the issue touches his entire family.

There's his 25-year-old granddaughter, Melissa Nemeth, who has major depressive disorder. She has accepted help from her family and the treatment of doctors in a way that John didn't at her age. Will she stay so accepting? She and her grandfather can only hope.

BLAME
John Pitman is the oldest of six children. His father served as an Army chaplain until retiring as a colonel after a 25-year career.
As a young man in the mid '60s, John's trajectory seemed as promising as his country's efforts to put a man on the moon.
"If not the perfect son, he was close to it," Steve says. "My brother was the one that was always held out. You know, 'John's so well behaved. John does his homework.' John won science fairs. John got straight A's. John was going to be an astronaut. We all had great hopes and aspirations for John."

But John, at about 19 or 20, began acting oddly while in college in Marin County. Or, as Loraine Pitman says of her son, "He wasn't right."

His parents brought him back home to live with the family in Okinawa, where his father was stationed. John continued to act strangely. John, blinking behind his thick glasses, remembers how he liked to take walks that stretched six to 10 miles, "not every day but a lot of times." He pauses to think when Steve asks if those walks had anything to do with being manic. "Well," John concedes, "it's possible."

More worrisome was John's combativeness. He and another brother got into such a fight one night that Loraine Pitman feared they would kill each other. A psychiatrist told John's parents that his behavior was their fault and they should just leave him alone – something that Steve says he still hears from many parents today, resulting in the same kind of self-blame that his parents felt.

"We were almost tempted to send our youngest children to someone else to raise, if we were that bad, if it was our fault," says Loraine Pitman, now 90 and a widow living in Indianapolis.

Steve, away at college in Missouri, heard long distance about what was going on: "I would get these letters from my parents, my mother in particular, about John's unimaginable and unexplainable behavior. I used to just weep because how could my brother, who we had such great expectations for, how could he be this way? I mean it was just completely beyond my understanding."

DENIAL
John returned to California and settled in Orange County. Between episodes of mania and depression, he managed to get married, have kids and hold jobs.
He also was extended credit. Loraine Pitman recalls cleaning up John's mania-induced spending sprees on items he would give away or abandon – cars, jewelry; once even a huge crystal ball.

She describes seeing him in jail for the first time as "shattering." Later she decided he was better off in protective custody.
Over the course of his disease, John has been prescribed various psychotropic drugs. Some helped for a while, some didn't. Others, he just refused to take.
John doesn't like to talk about the multiple times he's been hospitalized. Most times it was after authorities determined he posed a grave danger to himself or others, the standard that current law requires.

"It was just almost hopeless," Loraine Pitman says. "I just felt powerless."
Looking out for John eventually became Steve's responsibility. The toll of his illness extended beyond money.
"My brother had a home that he lost, had a wife that he lost, had children that he lost."
Since Steve became his conservator – after having to prove that John was gravely disabled – the two brothers have developed a relationship closer than at any time before.

Steve, who runs his own insurance agency, knows John's behavior patterns and will suggest that his brother visit his psychiatrist to adjust his medication when he senses a manic episode is coming. But it is still John's decision.

John's other siblings – who live out of state – might ask their mother or Steve how John is doing, but otherwise keep their distance. Steve says it is because of painful memories.

John seems both wounded and indignant that he got only one birthday greeting – by email – on his last birthday.

"If you are mentally ill, an awful lot of the family doesn't stay as close as it used to," he says. "It does take extra work. I don't think the average family wants to be that involved."

ACCEPTANCE
Steve Pitman is convinced things would have been better for John – and his relationship with his family – had John gotten the same kind of consistent intervention as his granddaughter, Melissa Nemeth.

"The difference is John was in denial. Melissa was willing to embrace it."

Melissa, raised in Lake Forest most of her life by her grandparents, lives in San Francisco. She works as a nanny while saving to pursue a master's degree in psychology. She also teaches classes for the National Alliance on Mental Illness, something she did along with her grandfather when she lived in Orange County.
The family says she was molested by her biological father at 13. She reported it to authorities when she was 15. A few days afterward, her father killed himself. Already depressed, Melissa sunk even deeper. She withdrew from family and friends, began drinking and cutting herself, became suicidal.

The last 10 years have been marked by hospitalizations, intensive therapy, prescriptions for antidepressant and antipsychotic medications. It made a difference that while she was underage, her grandparents could make decisions about her care.

It made an even bigger difference that she continued to live with them as a young adult and, with their help, willingly sought treatment.

"I look at him," Melissa says of John's life, "and I wish that I could give people some of the willingness that I have, some of the hope. There are a lot of people out there who don't have a lot of hope about their future. Even with a mental illness you can still do a lot of amazing things with your life."

The medications she has to take – Abilify, Seroquel, Pristiq and Wellbutrin – cause bothersome side effects: drowsiness, lack of concentration, tremors. She doesn't
drive because of it. But she accepts it.

"I totally understand when other people don't want to take meds. It's not something that I really enjoy, but it is something that I need," she says. "I want to be well bad enough that I am willing to deal with it."

Contact the writer: 714-796-7793 or twalker@ocregister.com


Mental illness: It’s a family affair