Point of View

How ‘carefrontation‘ can help treat North Carolina’s mentally ill

June 14, 2014 

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Fresh out of medical school 20 years ago, I received a phone call no parent should have to make: A patient’s frantic mother asked, “Have you seen our daughter?”

My patient, Anna, an 18-year-old suffering from bipolar disorder, had stopped taking her medicine. She appeared to have boarded a bus out of town without a word. To where, we never learned. Years later, we still didn’t know.

It was a sobering wake-up call about my chosen profession. Our country has a complicated history understanding and treating those like Anna with serious mental illness. For many years, we hospitalized hundreds of thousands and administered medications that worked well, but at a price. Sedation, weight gain and neurologic side effects at times added to the isolation patients and families felt.

We still face challenges, including the reality that about half of U.S. adults diagnosed with serious mental illness don’t take their medications properly, or at all. That amounts to about 3.5 million people who go untreated each year, according to the Treatment Advocacy Center, a national nonprofit organization focused on these issues.

The costs of mental illness – personal, financial and societal– are significant and often tragic. In the U.S., homeless adults with untreated serious mental illness number in the hundreds of thousands. Those who suffer from such illnesses lose more than $190 billion in earnings each year, and around 60 percent are unemployed. Approximately 13,000 suicides are committed by those with untreated serious mental illness, and approximately half of adults diagnosed with serious mental illness are affected by substance abuse.

Yet we are making real strides with the potential to improve millions of lives. Today we can diagnose illnesses faster and new generations of drugs have lessened side effects. And recently developed testing methods can help health care providers assess whether a patient is taking medication through a simple urine test.

All these advancements are fueling a growing trend toward what I refer to as “carefrontation.” While this slang term usually refers to the quasi-intervention of loved ones to redirect a friend in need, our professional carefrontations aren’t dissimilar in that they allow behavioral health specialists to treat the whole patient, not just the illness. Like many health issues, mental illness can have an enormous impact on other aspects of life – job, family and housing, to name a few.

One of the biggest lessons we’ve learned is that patients with mental illness respond better to treatment in their own communities, not in hospitals away from their support networks. Second, we can go a lot further in treating the whole patient if we’re not spending the bulk of a doctor visit trying to assess medication adherence.

More doctors and clinicians should integrate urine drug monitoring into their practice.

In the past, we’ve relied on make-due methods such as input from family, prescription refills and self-reporting. Blood work was an option, but an expensive and invasive one that offered information about a small window of time in a patient’s behavior. For the last year, my practice, Carolina Behavioral Care, has used urine drug analysis to assess medication adherence. It’s completely changed my discussions with patients.

Recently, after looking at the urine test results of Joe, a 32-year-old patient with schizophrenia, I determined that, despite what he told me, he wasn’t taking his prescribed medication to prevent hallucinations. Finally he confessed that the medication caused him terrible hand tremors, and he took it only when his symptoms became unbearable. Thanks to medication monitoring and carefrontation, I was able to improve my patient’s quality of life by simply writing a different prescription.

It’s not always that easy. But when I have information that helps determine whether patients are taking medication correctly, I can focus instead on how they’re feeling physically and mentally, how their job is going, where they’re living – in other words, what happens outside the doctor’s office. And the odds of that being positive increase enormously when a patient is taking medication properly.

More behavioral health centers are now working with community partners to ensure their patients’ successes. My practice, for example, has an in-house pharmacy to eliminate the need for a separate trip to the drug store. We help patients find housing, jobs, day programs and activities that connect them to the community. And by linking them with primary care doctors, we help ensure all their medical needs are addressed.

So let’s put everything together in a way that best benefits our patients and the communities where they live. Our new ability to gain insight into whether they’re taking their medications correctly is a game-changer. If they are, let’s help them find additional paths to success. And if they’re not, let’s use the information not to accuse or punish, but as a way to help understand how we can help.

When those with mental illness receive the treatment they need, they are less likely to be hospitalized and more likely to lead healthier, fuller lives in the communities they call home.

Robert Millet, M.D., is the assistant medical director of Carolina Behavioral Care in North Carolina.

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