The first Tuesday of each month from 4-6 pm Arizona time, except for holiday weekends, ACMI will have a featured guest to discuss a relevant Behavioral Health topic; after the speaker, we will discuss current issues with the Behavioral Health System attendees. This month, come hear about Assertive Community Teams (ACT). We have Mercy Care discussing ACT teams and checkbox items and measurements. We have both Valleywise and CopaHealth describing their ACT team services.

Dr. Darling is the current medical director and psychiatrist for the Valleywise Health Assertive Community Treatment program. She has been in this role since graduating from her psychiatry residency in 2017. She is core faculty with the Creighton University Arizona Health Education Alliance Psychiatry Residency Program and faculty with the departments of psychiatry at The University of Arizona College of Medicine Phoenix, Mayo Clinic College of Medicine and Science Phoenix, and Creighton University College of Medicine. Dr. Darling completed her undergraduate education in psychology at Arizona State University in 2004. She then worked in case management for the outpatient SMI system in Maricopa County before attending medical school at Midwestern University Arizona College of Osteopathic Medicine. She completed her psychiatry residency training at Maricopa Integrated Health System in 2017. During her residency, she served as the chief resident for two years and was the Arizona Psychiatric Society resident of the year in 2017. Dr. Darling is board certified by the American Board of Psychiatry and Neurology, with a primary focus on treating refractory serious mental illness. In addition to her clinical work, Dr. Darling trains Creighton Alliance PGY3 psychiatry residents, hosts Creighton Alliance family medicine residents during their psychiatry rotation, and supervises 4th-year medical students on psychiatry rotations. She teaches two didactic courses for the Creighton Alliance residents, covering community resources for PGY1 residents and advanced psychopharmacology for PGY3 and PGY4 residents. Dr. Darling is involved in mentoring current residents and received the Howard E Wulsin Excellence in Teaching Award from the Arizona Psychiatric Society in 2022.

Dr Winona Z Belmonte, MD, is a board-certified psychiatrist.  She is the Asst Medical Director for ACT Services and Chief Psychiatrist for Metro Clinic of Copa Health. She is a product of the University of Virginia   Health Systems at Charlottesville, Virginia, where she graduated in psychiatric medicine with subspecialty/fellowship training in geriatric psychiatry.   She accepted a position to serve the full spectrum of psychiatric practice in the rural underserved areas of Virginia for three years. Challenging as it was, the experience galvanized her knowledge and acumen in clinical work and deepened her passion to provide the best service to those struggling with mental illness.  This passion took her to Phoenix, where she saw an opportunity to provide services in an environment where a team-based approach to care is alive.  She has served under multiple RBHA in Maricopa County since 2005 in various capacities but mostly as chief psychiatrist of clinics and Assertive Community Treatment psychiatrist. She was the first Medical Director of People of Color Network.  She is a dedicated psychiatrist with extensive experience in complex psychopharmacology and complicated social determinants of health issues.  

Blythe FitzHarris, P.h.D., LCSW is the Chief Clinical Officer at MercyCare and is responsible for clinical program development, including Adult and Children’s Systems of Care and the Central Region Behavioral Health Crisis System. Blythe oversees multiple Mercy Care service delivery systems, including integrated care, the Office of Individual and Family Affairs (OIFA), grant services, cultural diversity, and tribal affairs. She directs initiatives, strategies, and programs to address social determinants of health (such as housing and employment) and system performance. Blythe also oversees coordination of care with system stakeholders such as the Arizona Department of Economic Security and the Arizona Department of Justice and works closely with system advocates. She works across the organization to address member, family, provider, and/or contractor concerns to ensure positive clinical outcomes, care coordination, and quality service delivery. Previously, Blythe served as the Adult Systems of Care Administrator for Mercy Care. In this position, Blythe oversaw the Adult SMI System of Care, which included outpatient behavioral health services, Assertive Community Treatment, housing, rehabilitation, and employment services for members in Maricopa County and parts of Pinal County. She also served as Mercy Care’s lead for the Arnold v. Sarn settlement agreement. Blythe has more than 30 years of experience working in public behavioral health in a variety of clinical and operational positions and has taught social work at the university level.   Blythe is a licensed clinical social worker and has a master’s in social work and a Ph.D. in social welfare with a focus on mental health and recovery from Arizona State University.

Topic: ACMI Stakeholder’s Meeting

Time: June 6th, 2023 04:00 PM Arizona

Every month on the First Tuesday until December 25th, 2023,

July 11th, 2023, 04:00 PM – Population Health- interventions for high Utilizers, Dr. Mike Franczak

August 1st, 2023, 04:00 PM Dental- Brighter Way, Kris Volcheck

Sept 12th, 2023,  04:00 PM Hom Inc

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Secure residential
Secure residential

Introduction:

Serious mental illnesses can be highly debilitating, affecting individuals’ ability to function in society and diminishing their quality of life. It is imperative to recognize the significance of secure facilities as essential tools for providing comprehensive care to those suffering from such conditions. By establishing secure facilities that prioritize treatment, insight, and rehabilitation, we can empower individuals with serious mental illness to gain invaluable insight into their conditions and facilitate their successful reintegration into the community. In this essay, we will explore the compelling arguments supporting the need for secure facilities as vital components of mental healthcare.

Safe and Controlled Environment:

Secure facilities offer a structured and controlled environment, ensuring the safety and well-being of individuals with serious mental illness. These environments provide a supportive framework to prevent self-harm, protect patients from external harm, and maintain a stable routine conducive to healing. By removing external stressors and triggers, secure facilities allow individuals to focus solely on their recovery journey, ultimately enhancing their chances of gaining insight into their illness.

Comprehensive Treatment and Rehabilitation:

Secure facilities are uniquely equipped to provide comprehensive treatment and rehabilitation programs tailored to the specific needs of individuals with serious mental illness. These facilities often employ a multidisciplinary approach involving psychiatrists, psychologists, therapists, and other mental health professionals. Through evidence-based therapies, medication management, counseling, and skill-building workshops, individuals can develop coping mechanisms, increase self-awareness, and acquire essential life skills. This comprehensive treatment approach empowers individuals to manage their conditions effectively and take steps towards reintegrating into the community.

Insight into Illness:

Secure facilities create an environment that encourages self-reflection, insight, and understanding of one’s mental illness. Through therapy sessions, group discussions, and educational programs, individuals can gain a deeper understanding of the causes, symptoms, and impact of their condition. This insight is a crucial stepping stone towards accepting their illness, embracing treatment, and making informed decisions about their recovery journey. By fostering self-awareness and providing psychoeducation, secure facilities empower individuals to actively participate in their own healing process.

Stigma Reduction and Community Reintegration:

Secure facilities play a pivotal role in combating the stigma surrounding mental illness and fostering community reintegration. By providing individuals with the tools to manage their conditions, secure facilities empower them to challenge societal misconceptions and stereotypes. The supportive environment within these facilities allows patients to practice and develop social skills, rebuild relationships, and establish a support network. As individuals gain insight into their illness and demonstrate progress, they are better equipped to reintegrate into the community, fostering understanding, empathy, and acceptance among society at large.

Long-term Benefits and Cost-effectiveness:

Investing in secure facilities for serious mental illness yields long-term benefits and is a cost-effective strategy for society as a whole. By providing intensive treatment and support, these facilities can reduce the frequency and severity of relapses, emergency room visits, and hospitalizations. As individuals gain insight, acquire coping skills, and reintegrate into the community, they are more likely to become productive members of society, contributing to the workforce, and reducing reliance on disability benefits. Furthermore, the overall economic burden of untreated mental illness, including lost productivity and increased healthcare costs, can be mitigated through early intervention and comprehensive treatment within secure facilities.

Conclusion:

The establishment of secure facilities for individuals with serious mental illness is an essential aspect of a compassionate and effective mental healthcare system. By providing a safe and structured environment, comprehensive treatment, insight into illness, and opportunities for community reintegration, secure facilities empower individuals to reclaim their lives and realize their full potential. Investing in these facilities not only benefits the individuals themselves but also society as a whole, promoting well-being, reducing stigma, and fostering a more inclusive and understanding community.

Thank you to those who could attend our May 2nd Stakeholder’s meeting.

Rachel Streiff, Dr. Robert Laitman, and Dr. Ann Mandel presented.

Below are the links to the webinar and slides:

Webinars – Association for the Chronically Mentally Ill (ACMI) (acmionline.com)

Downloads – Association for the Chronically Mentally Ill (ACMI) (acmionline.com)

Please join us for our next informational event on June 6th, 2023, at 4 PM AZ time. Experts will be discussing Assertive Community Treatment teams. (ACT)

ZOOM ACCESS INFORMATION:

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The first Tuesday of each month from 4-6 pm Arizona time, except for holiday weekends, ACMI will have a featured guest to discuss a relevant Behavioral Health topic; after the speaker, we will discuss current issues with attendees with the Behavioral Health System.

This month, come hear about Innovations in Clozapine Therapy with SMI advocate Rachel Streiff and special guests Dr. Robert Laitman and Dr. Ann Mandel.

Dr. Robert Laitman practices internal psychiatric medicine in New York City alongside his wife, Dr. Ann Mandel Laitman, and is a co-author of “Meaningful Recovery From Schizophrenia and Serious Mental Illness with Clozapine: Hope and Help.”

Rachel Streiff is a chemical and biomedical engineer who became an advocate for families struggling with Serious Mental Illness after a member of her own family achieved recovery.

…………………………………………………………………………….

Topic: ACMI Stakeholder’s Meeting

Time: May 2nd,, 2023 04:00 PM Arizona

Every month on the First Tuesday until December 25th, 2023,

June 6th, 2023, 04:00 PM

July 11th, 2023, 04:00 PM

August 1st, 2023, 04:00 PM

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Sign up in support of SB1710 Arizona State Hospital (ASH), governing board, and governance, which is being heard on Monday, March 13th, 2023, at 2:00 pm in House Room HHR 4.

To request to speak, follow the process indicated in this manual RTS (azleg.gov)

Note: you must sign up for an account initially in person at the Capitol using the kiosk. After you sign up initially in person, you can subsequently submit comments and request to speak online.

The first Tuesday of each month from 4-6 pm Arizona time, except for holiday weekends, ACMI will have a featured guest that will discuss a relevant Behavioral Health topic; after the speaker, we will have discussions with attendees on current issues with the Behavioral Health System.

Housing in Arizona for SMI & GMH/SA- What are the plans for the H2O waiver implementation? AHCCCS plans for Housing

David Bridge is the Special Needs Program Administrator for the Arizona Department of Housing. He will talk about the H2O waiver which addresses housing for homeless and General Mental Health/ Substance Use (GMH/SU) and Serious Mental Illness (SMI) members. Also, what is the H2O waiver?

Alex Demyan, Interim Assistant Director, Arizona Health Care Cost Containment System (AHCCCS), and Elizabeth da Costa, Housing Program Administrator, Arizona Health Care Cost Containment System (AHCCCS) will answer questions that were pre-submitted:

  • What are the goals for this H2O waiver?
  • Can you talk about what the current need is for housing units of various types?
  • Can you talk about the current and predicted number of vouchers?
  • How is Hom Inc related to this initiative, will they manage the transitional housing as well?
  • How will people waiting for housing be prioritized for housing?  
  • What is the plan to get the people Permanent supportive housing (PSH) after the six months of transitional housing ends?
  • If someone gets six months of transitional housing and then does not get PSH are they again eligible if they become homeless for another six months of transitional housing?

This is an important topic as we believe housing is an essential part of healthcare.

Topic: ACMI Stakeholder’s Meeting

Time: March 7th, 2023 04:00 PM Arizona

Every month on the First Tuesday until December, 25th, 2023,

April 4th, 2023 04:00 PM

May 6th, 2023 04:00 PM

June 6th, 2023 04:00 PM

July 11th, 04:00 PM

August 1st, 04:00 PM

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Meeting ID: 863 1776 0372

Passcode: 795774 Find your local number: https://us02web.zoom.us/u/kc1xiBw0Jl

The first Tuesday of each month from 4-6 pm Arizona time, except for holiday weekends, ACMI will have a featured guest that will discuss a relevant Behavioral Health topic; after the speaker, we will have discussions with attendees on current issues with the Behavioral Health System.

Housing in Arizona for SMI & GMH/SA- What are the plans for the H2O waiver implementation? AHCCCS plans for Housing

David Bridge is the Special Needs Program Administrator for the Arizona Department of Housing. He will talk about the H2O waiver which addresses housing for homeless and General Mental Health/ Substance Use (GMH/SU) and Serious Mental Illness (SMI) members. Also, what is the H2O waiver? Alex Demyan, Interim Assistant Director, Arizona Health Care Cost Containment System (AHCCCS), and Elizabeth da Costa, Housing Program Administrator, Arizona Health Care Cost Containment System (AHCCCS) will answer questions that were pre-submitted:

  • What are the goals for this H2O waiver?
  • Can you talk about what the current need is for housing units of various types?
  • Can you talk about the current and predicted number of vouchers?
  • How is Hom Inc related to this initiative, will they manage the transitional housing as well?
  • How will people waiting for housing be prioritized for housing?  
  • What is the plan to get the people Permanent supportive housing (PSH) after the six months of transitional housing ends?
  • If someone gets six months of transitional housing and then does not get PSH are they again eligible if they become homeless for another six months of transitional housing?

This is an important topic as we believe housing is an essential part of healthcare.

Topic: ACMI Stakeholder’s Meeting

Time: March 7th, 2023 04:00 PM Arizona

Every month on the First Tuesday until December, 25th, 2023,

April 4th, 2023 04:00 PM

May 6th, 2023 04:00 PM

June 6th, 2023 04:00 PM

July 11th, 04:00 PM

August 1st, 04:00 PM

Please download and import the following iCalendar (.ics) files to your calendar system.

Monthly: https://us02web.zoom.us/meeting/tZIudu6vqDspHdaOPI66YyVO1EYY3UYrWtCI/ics?icsToken=98tyKuGurTotHdKVsx6FRpwAA4j4KO3wpmJegqdcsy_MVXZqezXZZ8d7C-FKKcrn

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Meeting ID: 863 1776 0372

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Clinical depression has never really had satisfactory treatment options. Recently some newer pharmaceutical medications are showing promise. More research is needed in the area of behavioral health treatments. Read the heart-wrenching Op-Ed from David Brooks, which was recently published in the New York Times, on how it impacts family and friends.

Laurie Goldstein, ACMI Vice President

********************************************************************************

David Brooks: How do you serve a friend in despair? https://www.sltrib.com/opinion/commentary/2023/02/12/david-brooks-how-you-serve-friend/

A friend’s job in these circumstances is not to cheer the person up.

(Photo illustration by Thomas Sauvin; photograph via the Marks family) At camp, David Brooks gave Peter Marks a lift. How do you serve a friend struggling with mental illness?

By David Brooks | The New York Times

  | Feb. 12, 2023, 5:00 a.m.| Updated: 12:37 p.m.

My friendship with Peter Marks was created around play. Starting at age 11, we played basketball, softball, capture the flag, rugby. We teased each other, pulled pranks, made fun of each other’s dance moves and pretty much everything else. We could turn eating a burger into a form of play, with elaborate smacking of lips and operatic exclamations about the excellence of the cheese. We kept it up for five decades.

My wife has a phrase that got Pete just right — a rare combo of normal and extraordinary: masculine in the way you’re supposed to be masculine, with great strength and great gentleness. A father in the way you’re supposed to be a father, with great devotion, fun and pride. A husband in the way you’re supposed to be a husband, going home at night grateful because the person in the whole world you want to talk with the most is going to be sitting right there across the dinner table.

Over the years, Pete and I often spoke about the stresses he was enduring over the management of his medical practice, but I didn’t see the depths of what he was going through, until we spent a weekend with him in the spring of 2019. My wife noticed a change immediately. A light had gone out; there was an uncharacteristic flatness in his voice and a stillness in his eyes. One bright June afternoon, he pulled us aside and told us he wasn’t himself. He was doing what he loved most — playing basketball, swimming in the lake — but he couldn’t enjoy anything. He was worried for his family and himself and asked for our continued friendship and support. It was the first time I had seen such pain in him — what turned out to be severe depression. I was confronted with a question for which I had no preparation: How do you serve a friend who is hit with this illness?

I tried the best I could, but Pete succumbed to suicide in April. This article flows from what I learned from those agonizing three years and that senseless tragedy. It reflects a hard education with no panaceas.

(Photo illustration by Thomas Sauvin; photograph via the Marks family) New York Times columnist David Brooks, left, with Peter Marks, a friend since childhood.

First, I need to tell you more about Pete. We met as kids at Incarnation Camp in Connecticut. We were campers and counselors together for a decade and remained close for life. At camp, Pete was handsome, strong, athletic and kind. There was an exuberant goofballism about him.

I remember once, in a fit of high silliness, he started skipping around the dining hall, singing, and leaping higher and higher with each skip. He tried to skip right out of the room, but there was a door frame, probably about 7 feet tall, and Pete slammed into the top of the frame and fell flat on his back. The rest of us, being 16-year-old junior counselors, found this utterly hilarious. Pete, also being 16, found this utterly hilarious, too. I remember him lying there in a fit of giggles, with a doorframe-shaped bruise forming on his brow.

One summer, Pete and I led a team of 12- and 13-year-olds in a softball game against a team of 14- and 15-year-olds. Our team miraculously won. In the celebration afterward, Pete, I and the boys piled on one another on the mound in a great wriggling heap of disproportionate ecstasy. We hugged and screamed and high-fived.

I think our celebration lasted longer than the game — a volcano-like pile of male self-approval that is lodged in my memory as one of life’s moments of pure joy.

As the years went by, Pete did well in college, joined the Navy, went to medical school and became an eye surgeon. On evenings before surgery, Pete took great care of himself, didn’t stay out, made sure he had enough sleep to do the job that he loved. On evenings after surgery, he’d call his patients to see how they were feeling. His wife, Jen, a dear friend who was also at camp with us, used to linger around just to hear the gentleness of his tone on those calls, the reassuring kindness of his manner.

He seemed, outwardly, like the person in my circle least likely to be afflicted by a devastating depression, with a cheerful disposition, a happy marriage, a rewarding career and two truly wonderful sons, Owen and James. But he was carrying more childhood trauma than I knew, and depression eventually overwhelmed him.

At first, I did not understand the seriousness of the situation. That’s partly temperamental. Some people catastrophize and imagine the worst. I tend to bright-icize and assume that everything will work out. But it’s also partly because I didn’t realize that depression had created another Pete. I had very definite ideas in my head about who Pete was, and depression was not part of how I understood my friend.

Over the next months, severe depression was revealed to me as an unimagined abyss. I learned that those of us lucky enough never to have experienced serious depression cannot understand what it is like just by extrapolating from our own periods of sadness. As philosophers Cecily Whiteley and Jonathan Birch have written, it is not just sorrow; it is a state of consciousness that distorts perceptions of time, space and self.

Journalist Sally Brampton called depression a landscape that “is cold and black and empty. It is more terrifying and more horrible than anywhere I have ever been, even in my nightmares.”

Novelist William Styron wrote brilliantly about his own depression in “Darkness Visible.” He wrote that “the madness of depression is, generally speaking, the antithesis of violence. It is a storm indeed, but a storm of murk. Soon evident are the slowed-down responses, near paralysis, psychic energy throttled back close to zero.” He continued: “I experienced a curious inner convulsion that I can describe only as despair beyond despair. It came out of the cold night; I did not think such anguish possible.”

During the COVID-19 pandemic, Pete and I spoke by phone. In the beginning, I made the mistake of trying to advise him about how he could lift his depression. He had earlier gone to Vietnam to perform eye surgeries for those who were too poor to afford them. I told him he should do that again, since he found it so tremendously rewarding. I did not realize it was energy and desire that he lacked, not ideas about things to do. It’s only later that I read that when you give a depressed person advice on how to get better, there’s a good chance all you are doing is telling the person that you just don’t get it.

I tried to remind Pete of all the wonderful blessings he enjoyed, what psychologists call “positive reframing.” I’ve since read that this might make sufferers feel even worse about themselves for not being able to enjoy all the things that are palpably enjoyable.

I learned, very gradually, that a friend’s job in these circumstances is not to cheer the person up. It’s to acknowledge the reality of the situation; it’s to hear, respect and love the person; it’s to show that you haven’t given up on him or her, that you haven’t walked away.

Time and again Pete would talk about his great fear that he would someday lose his skill as a surgeon, that he would cease to be a healer, that he would lose his identity and self.

As Pete spoke of his illness, it sometimes seemed as if there were two of him. There was the one enveloped in pain and the other one who was observing himself and could not understand what was happening. That second self was the Pete I spoke to for those three years. He was analyzing the anguish. He was trying to figure it out. He was going to the best doctors. They were trying one approach after another. The cloud would not lift.

I am told that one of the brutalities of the illness is the impossibility of articulating exactly what the pain consists of. Pete would give me the general truth, “Depression sucks.” But he tried not to burden me with the full horrors of what he was going through. There was a lot he didn’t tell me, at least until the end, or not at all.

I never told him this, but there were moments during that hard plague year of 2020 that I feared that my own mind was slipping. Cheerfulness is my normal default state, but that year my moods could be dark and troubled. When your oldest friend is battling his demons, it’s natural to wonder about your own.

While I’ve devoted my life to words, I increasingly felt the futility of words to help Pete in any meaningful way. The feeling of impotence was existential.

After a while, I just tried to be normal. I just tried to be the easygoing friend who I always had been to him and he had been to me. I hoped this would slightly ease his sense of isolation. Intellectually, Pete knew that his wife and boys lavishly loved him, that his friends loved him, but he still felt locked inside the lacerating self-obsession that was part of the illness.

Perhaps the most useful thing I did was send him a video. My friend Mike Gerson, a Washington Post columnist, had been hospitalized with depression in early 2019. He had delivered a beautiful sermon at the Washington National Cathedral about his experience before he died of complications of cancer in November. Depression, he said, was a “malfunction of the instrument we use to determine reality.” Then he talked about the lying voices that had taken up residence in his mind, spewing out their vicious clichés: You are a burden to your friends, you have no future, no one would miss you.

That resonated with Pete and gave him a sense of validation. He, too, would describe the obsessive-compulsive voices that would attack him from inside his own head. Mike also talked about the fog eventually thinning, at the glimpse of beauty or of love, and reminded Pete that “there is something better on the far side of despair.”

Still the clouds refused to lift. Jen had some wise words when I asked her what she learned being around him during those years.

“I was very aware this was not the real Pete,” she said. “I tried not to take his periods of negativity and withdrawal personally.”

I wish I had bombarded Pete with more small touches. Just small emails to let him know how much he was on my mind. Writing about his own depression in The Atlantic last year, Jeffrey Ruoff mentioned that his brother sent him more than 700 postcards over the years, from all 50 states, Central America, Canada and Asia. Those kinds of touches say: I’m with you. No response necessary.

“There are moments in our lives,” Honore de Balzac wrote, “when the sense that our friend is near is all that we can bear. Our wounds smart under the consoling words that only reveal the depths of pain.”

The years went by and medications and treatment programs continued to fail. Pete and Jen began to realize how little the medical community knows about what will work. They also began to realize that mental health care is shockingly siloed. Pete saw outstanding doctors who devoted themselves to him, but they work only within their specific treatment silo. When one treatment didn’t work, Pete would get shuttled off to some other silo to begin again. Jen recently emailed me that when she had a cancer recurrence, in the middle of Pete’s depression, she had a “tumor board” — three different cancer experts (a surgeon, an oncologist and a radiation oncologist) — who coordinated her care.

“In our experience, there is none of this in mental health,” she wrote me. In many places, there is no one looking at the whole picture and the whole patient. “If one more mental health professional tells me ‘Everyone did their best,’ I will scream,” Jen wrote. “If this is our best, it is not nearly good enough.”

Pete developed theories to explain why this had happened to him. He pointed to a series of traumas and neglect he had suffered at home as a child — events he had vaguely referred to during our friendship but had never gone into in detail with me until his final years.

He thought part of his illness was just straight biology. Think of it like brain cancer, he’d say. A random physical disease. I agree with some of that, but I’m also haunted by the large number of medications doctors put him on. He always seemed to be getting on one or getting off another as he ran through various treatment regimens. His path through the mental health care system was filled with a scattershot array of treatments and crushing disappointments.

Pete and his family joined us for Thanksgiving in 2021. By this point I was just trying to be as I always had been toward him, in hopes that he might be able to be as he always had been toward me. We all played basketball and board games and enjoyed the weekend. I felt some hope. But Pete appears in one of the photos that were taken that weekend, sitting on the couch, still-faced, enveloped in shadow. One afternoon, he asked my wife to pray over him in the kitchen, plaintively, grasping for hope.

The experts say if you know someone who is depressed, it’s OK to ask explicitly about suicide. The experts emphasize that you’re not going to be putting the thought into the person’s head. Very often it’s already on her or his mind. And if it is, the person should be getting professional help.

When Pete and I gestured toward the subject of suicide, we just talked about what a magnificent family he had, how much they all loved one another. Like Jen, I tried to tell him that this darkness would lift, though as the years went by and the therapies failed, his faith in this deliverance waned.

Pete was always the braver of the two of us. He was the one who would go cliff diving or jump over bonfires without fear. And he was never more courageous than over his last three years. He fought this malady with astonishing courage and steadfastness against a foe that would bring anybody to his knees. He fought it minute by minute, day by day — over a thousand days. He was driven by his selfless love for his family, which he cherished most in the world.

We had dinner a few days before he died. Jen and I tried to keep the conversation bouncing along. But, apparently, their car ride home was heart-rending. “How can I not be able to talk to my oldest friend?” Pete asked. “Brooksie can talk to people. I can’t.”

I don’t know what he was thinking on his final day, but I have read that depression makes it hard to imagine a time when things will ever be better. I have no evidence for this, but knowing Pete as I did, I strongly believe that he erroneously convinced himself that he was doing this to help his family and ease the hardship his illness had caused them. Living now in the wreckage, I can tell you that if you ever find yourself having that thought, it is completely wrong.

Depression can be bitterly ridiculous. Pete died a few weeks before his younger son’s college graduation, enmeshed by loving relationships and friendships.

It’s ridiculous that we still know so little about the illness and how to treat it. I find it unfathomable that it’s been well over a century since Sigmund Freud started writing about psychology. We’ve had generations of scholars and scientists working in this field, and yet suicide rates in 2020 were 30% higher than they were in 2000 and 1 in 5 American adults experience mental illness each year. We need much more research funding to figure this out.

If I’m ever in a similar situation again, I’ll know that you don’t have to try to coax somebody out of depression. It’s enough to show that you are trying to understand what this troubled soul is enduring. It’s enough to create an atmosphere in which the sufferer can share her experience. It’s enough to offer him or her the comfort of being seen.

My friend Nat Eddy, who also accompanied Pete through those final years, wrote to me recently: “Do whatever it is you do to give the wives and children a break — an hour or two when they don’t have to worry that the worst will happen (and pray that it doesn’t happen on your watch, because that isn’t a given). Do whatever it is you do so you can look at yourself in the mirror. True friendship offers deep satisfactions, but it also imposes vulnerabilities and obligations, and to pretend it doesn’t is to devalue friendship.”

I feel sorrow that I didn’t know enough to do this more effectively with Pete. I might have kept him company more soothingly. I might have made him better understand what he meant to me. But I do not feel guilt.

Pete had teams of experts walking with him through this. He had his wonderful wife and kids, who accompanied him lovingly and steadfastly every day.

I’ve talked to Jen about this. Pete used to say he found talking to Jen more helpful than talking to any of the experts. So there is no reason for any of us to feel like failures because we could not alter what happened. Every case of depression is unique, and every case is to be fought with as much love and endurance and knowledge as can be mustered. But in this particular case, the beast was bigger than Pete; it was bigger than us.

I feel like I’ve read a lot about the grieving process for family members but not so much about what grieving is like when your friends die. Death and I were too well acquainted last year. I lost three good friends — Pete, Mike Gerson and my longtime “NewsHour” partner, Mark Shields. I’ve been surprised by how profound and lasting the inner aches have been.

Pete’s death has been a cause of great disorientation. He’d been a presence for practically my whole life, and now the steady friendship I took for granted is gone. It’s as if I went to Montana and suddenly the mountains had disappeared.

One great source of comfort has been the chance to glimpse, from time to time, how heroically Pete’s boys, Owen and James, have handled this loss. In their own grief, they have rallied forcefully and lovingly around their mother. Two months after Pete’s passing, my eldest son married. To my great astonishment and gratitude, Jen and the boys were able to make the trip to attend. At the reception, the boys gently coaxed their mother to join us on the dance floor. It felt appropriate since this is what we did at camp; dancing skeined through the decades of our lives. I have a sharp memory of those two fine young men dancing that evening, and a million memories of the parents who raised them so well.

If you are having thoughts of suicide, call or text 988 to reach the National Suicide Prevention Lifeline or go to SpeakingOfSuicide.com/resources for a list of additional resources.

(Nam Y. Huh | AP photo) New York Times columnist David Brooks at the University of Chicago, Jan. 19, 2012.

David Brooks is a columnist for The New York Times.

By David Brooks | The New York Times

Please read the latest report on Reimage Schizophrenia: transforming how we are treated function and thrive.

Published from the Schizophrenia & Psychosis Alliance, the summary of findings published Feb 2023.

BREAKING! Click here to read our new Voice of the Patient Report (https://sczaction.org/insight-initiative/pfdd/), which captures the powerful stories of people living with schizophrenia and those who care for them. The report summarizes the compelling testimony provided during our Externally-Led Patient-Focused Drug Development meeting on Nov. 2, and was submitted today to the U.S. Food and Drug Administration.

The meeting gave our community a voice – and it was heard. FDA’s Dr. Bernard Fischer told us during the meeting that “the FDA recognizes that there is more work to be done to get better treatments for schizophrenia.”

We thank our meeting co-hosts, who joined us to provide a united front in the fight for treatment equity for people living with schizophrenia: American Foundation for Suicide Prevention, Mental Health America, National Council for Mental Wellbeing and NAMI. And we are indebted to the people living with schizophrenia and their caregivers who participated in this effort and made their voices heard.

People with schizophrenia have the right to effective medicines – just like anyone else with a serious disease. We are working every day to make that happen.


Executive summary

Schizophrenia is a serious, disabling brain disease. While medical treatment for schizophrenia has existed for many years, these treatments are often ineffective and can cause debilitating side effects. The result: countless people with this severe brain disease are subjected to a trial-and-error approach, switching from one medicine to another in hopes of finding something that will curb what can be disabling and life-disrupting symptoms.

Many people with schizophrenia have yet to find a medicine that works for them — creating an entire population of people who cannot
work or live independently and can suffer devastating symptoms of psychosis that can lead to incarceration or homelessness. Just as with
heart disease, diabetes or any other serious illness, if schizophrenia isn’t treated properly, it can get progressively worse. With the goal of turning the tide and improving drug-treatment options for schizophrenia, people with the brain disease and their caregivers gathered virtually on November 2, 2022, to describe what it’s like to live with this serious disease and share their experiences with available drug treatments.
Participants not only pressed drug developers to intensify efforts to develop more effective drug treatments with fewer side effects— they also urged the U.S. Food and Drug Administration (FDA) to allow broader access to the “last resort” drug clozapine, which many patients credited with restoring their ability to attend school, work and live healthy and productive lives.

The meeting, “Reimagine Schizophrenia: Transforming How We Are Treated, Function and Thrive,” was co-hosted by the Schizophrenia & Psychosis Action Alliance, the American Foundation for Suicide Prevention, Mental Health America, the National Alliance on Mental Illness and the National Council for Mental Wellbeing as part of the FDA’s Externally-Led Patient-Focused Drug Development (PFDD) initiative. The FDA launched this initiative in 2012 to collect information about patient and caregiver perspectives on drug development — in particular, what people living with a disease consider to be meaningful treatment benefits and how they want to be involved in the drug development process.

Many people with schizophrenia have yet to find a medicine that works for them — creating an entire population of people who cannot work or live independently and can suffer devastating symptoms of psychosis.

What will it take for the Centers for Medicare & Medicaid Services (CMS) to realize that an amendment is needed? The cost to society of not providing care and treatment results in the use of emergency rooms, fire and police resources, and public community environments. It comes with a high price tag and dismal results. Refer to the report “Housing is Healthcare https://morrisoninstitute.asu.edu/housing_is_health_care.

People with serious mental illness live in squalor and end up dead or in jail or prison, often for crimes of street survival. Mental illness is the only “medical” condition that is criminalized (e.g., while psychotic, destroying property while failing, or not complying with officers, vocalizing against perceived threats, and creating a public disturbance ).

Laurie Goldstein- ACMI Vice President

 Matt H. Wade via commons.wikimedia.org | CC BY 3.0


REGULATION

Why One State Is Pushing Back Against Medicaid’s IMD Exclusion

By Chris Larson | January 20, 2023

Why One State Is Pushing Back Against Medicaid’s IMD Exclusion – Behavioral Health Business (bhbusiness.com)

New York state hopes to strengthen and remake state-managed behavioral health care by getting around the so-called IMD exclusion.

It’s doing so by securing federal Medicaid funds typically forbidden from covering facility-based behavioral health through its latest 1115 waiver amendment.

On Jan. 5, the Centers for Medicare & Medicaid Services (CMS) announced New York applied for a waiver to Medicaid’s now-antiquated institution for mental disease (IMD) exclusion. New York has asked for federal matching funds for Medicaid to be allowed to cover IMD services to address serious mental illness (SMI), substance use disorder (SUD) and serious emotional disturbance (SED) for adults and children.

New York specifically is seeking matching funds to reimburse short-term inpatient, residential and other services for SMI and SUD by IMDs. The state is also applying for matching funds to help transition patients in state psychiatric facilities back to the community up to 30 days before their discharge.

“The objective of the demonstration is to transform the role of some state psychiatric inpatient facilities and [SUD] residential treatment facilities, improve care transitions and access to community-based treatment and support services, and improve health and behavioral health outcomes in individuals with chronic and/or [SMIs] by transforming selected (pilot site) state-run psychiatric hospitals, facilities, and campuses from long-term care institutions to community-based enhanced service delivery systems,” the 1115 waiver amendment proposal states.

Since the beginning of Medicaid in 1965, the Social Security Act forbade federal funds for Medicaid from covering treatment provided by facilities where 16 or more beds are dedicated to treating behavioral health issues of people aged 21 to 64.

This move was intended to prevent states from offloading state psychiatric hospital costs on the federal government through the jointly funded and managed Medicaid program. It was also part of a political and regulatory retreat from treating behavioral health issues in large hospital-like settings, with champions of that movement including President John F. Kennedy.

The movement is sometimes referred to as deinstitutionalization.

However, some see the start of the deinstitutionalization movement as the start of the present psychiatric bed shortage, even within the federal government.

“There’s been an understanding in the past several years that this lack of federal funding contributes to high levels of unmet need,” Madeline Guth, senior policy analyst for Kaiser Family Foundation (KFF), told Behavioral Health Business. “The federal government has been providing some new mechanisms in the past few years for states to get an exception to this exclusion and get some federal financing for IMD services for non-elderly adults.”

The mechanisms, including the Medicaid 1115 waiver, allow states to secure some federal funding for certain IMD-related services.

Medicaid 1115 waivers, if approved by the federal government, allow states to experiment with different ways of implementing the Medicaid program.

There are three specific 1115 waiver benefit expansions that are related to behavioral health.

KFF, which tracks these waivers, found that 34 states have received approvals for an IMD exclusion payment exemption for SUDs. Additionally, 10 states have an exemption for mental health treatment, with 23 states having other exemptions for community-based health and behavioral health. 

Recent presidential administrations have enabled ways around the IMD exclusion through the 1115 waiver.

In July 2015, the Obama administration allowed for 1115 waivers to “develop a full continuum of care for individuals with SUD, including coverage for short-term residential treatment services not otherwise covered by Medicaid,” which included the IMD exclusion. 

The Trump administration announced in November 2019 that it approved the first-ever 1115 waiver related to IMD exclusion for SMIs and SEDs for adults and children.

Addressing the IMD exclusion did come up during the legislative work in 2022 that culminated in a sweeping behavioral health bill included in the omnibus funding bill passed just before Christmas. However, it was not included in the final bill that was signed into law on Dec. 29

While New York’s latest 1115 waiver application is not unprecedented, it does reflect a two-for-one application for two IMD exclusion exemptions — including both SMI and SUD funding.

Further, the New York waiver and the other waivers tracked by KFF show that states of all political leanings seek to address mental health via innovations to Medicaid.

Medicaid is the single largest payer of mental health services in the U.S.