Ned Barnett

In Wake, steps to improve mental health care

June 29, 2013 

It’s said that we are always at risk of becoming what we oppose. The idea seems to fit the way society fights mental illness. To care for irrational people we have established irrational systems.

To live in Raleigh is to see the paradox up close. Dorothea Dix Hospital, a state hospital for the mentally ill, has closed and a new mental health wing has opened across the street at Central Prison.

Some in the General Assembly propose cutting funds to treat mental illness even as more is spent warehousing the mentally ill in jails and prisons. We have ignored the urgency of fully funding and refining treatment yet keep getting caught up in emergencies.

Now in Wake County there’s another effort to do something about what we can’t seem to do anything about. Starting Monday, responsibility for the care of nearly 2,000 people with mental health issues will be switched from the county’s Human Services Department to doctors and therapists at private agencies and UNC Health Care. About 500 of the most serious patients will be treated by UNC Health Care, which is assuming operation of WakeBrook psychiatric hospital, a county facility opened in 2011.

One of WakeBrook’s buildings will reopen with 16 new beds for psychiatric patients starting on July 10. Sixteen beds aren’t that many in a county in which up to 450 people a month are brought in for psychiatric evaluation and treatment. But after the bed shortage created by the closing of state hospitals, the addition of any beds where patients can receive more than a quick cycle in and out is a victory.

On Friday, Dr. Brian Sheitman, a UNC psychiatrist and the new medical director at WakeBrook, stood in the hallway of the empty and waiting building and discussed the prospects and needs for mental health care. He’s working at WakeBrook because of an agreement that ended WakeMed’s attempt to buy Raleigh’s Rex Hospital, which is part of the UNC system. The agreement includes a provision that UNC Hospitals would help ease the burden mentally ill patients were placing on WakeMed’s emergency room.

Now many of the emergency cases will be sent to WakeBrook. Sheitman knows the beds will make a difference. But he knows they won’t fix a system that is constantly being realigned, but never reformed.

“We’ll be part of the solution to the in-patient bed shortage and then they’ll be looking for the next solution,” said the doctor, a tall man of 56 with salt-and-pepper hair and the gentle manner of a good listener.

Sheitman doesn’t give in to illusions of progress through reorganizations and cures through psychiatric drugs. He said that treating people with mental health problems means measuring success and keeping up with – and keeping after – patients once they leave a treatment center.

For Sheitman, one answer is better communication about patients. He’s frustrated that in today’s wired world the system loses track of or declines to follow patients. Mental health care centers, he said, consider it progress if the percentage of people being readmitted drops. But that is progress based on a presumption that the missing are well.

“I would ask: ‘What happened to the people? Are they in jail? Are they in prison? Did they overdose? Did they disappear?’ I don’t know what happened,” he said. “We can figure all that out now, the technology is there.

“If people stop taking their medication ... why don’t we know it? Why can’t someone alert us? You would think in this day and age you could get an email that says this person has not filled their prescription. It’s been ten days or whatever.”

The problem isn’t only one of technology. It’s the system. Sheitman said the incentives for mental health care promote more of a churn than ongoing treatment. If patients don’t come in for a follow-up visit, the system offers no incentive to providers to find those patients. Instead, it points them toward the next wave.

“The providers are just shell-shocked. Nowadays you just see one person after another person and usually people leave and you just get the next group coming in,” Sheitman said. “I don’t think the incentives are in the right place.”

Sheitman served at Dorothea Dix Hospital, including five years as its clinical director. He says the hospital’s namesake – the mental health reformer of the mid-1880s – would have a mixed reaction to how care of the mentally ill has changed in the last 150 years.

“I think she would be disappointed that with the resources available today we’re not doing more,” he said. “I don’t think it’s as bad (as in Dix’s era), but the jails are still overflowing with patients. I think we’re still kind of pretending the problem doesn’t exist when it exists.

“I think we probably aren’t allocating enough resources for these people who cannot fight for themselves. We’re not doing as much as we would if they were more verbal and had more power.”

But shortly after Independence Day, more beds will become available for the mentally ill and in one corner of the world an often overwhelmed and frustrating system will become a little less so.

Editorial page editor Ned Barnett can be reached at 919-829-4512, or nbarnett@newsobserver.com

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