Do we need more screening of patients or more treatment?

The NY State Office of Mental Health has a gaudy document--a new set of guidelines for mental health clinic standards of care that is sure to impact on the mental health clinics up here. It's borne out of a planning document undertaken by a NYC team in 2008 meant to improve services to people with mental illnesses who are at risk for poor outcomes or violence. And that document came about after the woman died in the mental health unit of a Brooklyn hospital and episodes of violence seemed to engulf the city that year.

The OMH is taking up the new standards as part of its renewed licensing process. The idea is to help it decide if a clinic has high standards of care, just adequate ones or ones needing improvement, and if it's the latter, to push the clinics in the higher direction. That's all right but they put too much attention on testing and not enough on treatment, in my opinion.

To the OMH Office of Quality Management:

I have a response to the draft Clinic Standards of Care that you have put out for comment. What is being proposed that is new? Don't we do these things now, that is, question patients during an evaluation about mental health history, drug use, violent and suicide ideation, general physical health? If any of these are missing it's obvious the clinic should get its act together. But to propose a horde of extra features for clinics to follow in the column marked "exemplary" and insist these are the ones recommended for all seems extravagant.

It suggests that you've added sophisticated test batteries, the sort run by psychological testing companies and specialists and you've put more emphasis on quality control. While helpful I doubt if they are essential to the good working of a publicly subsidized mental health clinic. I think they are too costly to justify.

To my mind the real problems to be tackled lie in treating the assortment of people with complicated mental and physical conditions who come to the clinic nowadays. Particularly, those whose problems are largely sociological--stemming from their environment. Now, assessment is coupled with treatment. But it's only part of it and you can't have a treatment clinic that only does assessment. The clinic has to identify the most seriously mentally ill and sort them out from behavior problems like "problems of living"and those who come from stressful situations such as living in poverty, or homelessness or who are drug addicted, or sexually deviant, for instance.

I don't think the screening tests get at these kinds of people. Their main problems are simply outside the standard questions. For example, sexual offenders--what are the treatment options for them? Elderly people with dementia and/or serious mental illness require health care, housing and supports outside the mental health system; large numbers of teenagers and young adults have drug addiction and unsocialized behavior coupled with mental disturbance, coming from conditions in which they grow up; men and women coming out of jail and prison need to be reintegrated into society; people who don't speak English, and are among legal and illegal immigrant populations need all kinds of help, as do those with overlapping mental health and developmental and physical disability, and the people in outlying rural areas who can't easily access health care.

As I understand, more and more people are showing up with variations of mental illnesses and physical disorders which can't easily be separated out at a single evaluation. Yet each disorder needs to be treated in its own right. So the patients are presenting with more complications than formerly. And the screening tools won't make their treatment any easier, will it?

So I suggest instead of promoting more elaborate testing schemes for patients entering the system (while it's important to do evaluations right), what is needed more is for the state Office of Mental Health to add high quality staff to the clinics. We need better trained and better paid people working there, to do more than just offer talk therapy. The staff have to become more expert on benefits and entitlements like SSI and Medicaid; in how to place people in jobs, in housing and support services; how to help them find meals and food pantries, overnight shelter, where to get food stamps and cash assistance, child care, bus passes, an affordable lawyer, for example. That's what's missing now. And it's what gets them through a crisis or with confidence to face another day. (Roy Neville)