Quotable Bad News, Empowering Good News
by PSV President Helen M. Foster, MD, FAPA

You may have noticed that I often wear a leather holster on my hip. Have you wondered if I pack a firearm? As you may have read in the paper, we’re allowed to wear guns when we visit the general assembly building. Many of us have seen our legislators lately to lobby for on remedies to our profession’s woes, and I am pretty stirred up. Actually though, a pager, not a pistol, is packed in my suede purse on a belt. I mention it, not just to get your attention, but as a reminder that I hope we’ll stay in touch when I finish my term as president. I have so many of you to thank that I can’t do it all here. Instead I’ll just get to the bad news that’s gotten me so angry that I’m writing murder mysteries in my spare time.

Bad News: Statistics to Quote
Did you know that Virginia is ranked 12th of the states in personal wealth and is next to the last in state expenditures per personal income? Forty-ninth sounds even worse when you consider that $800 million of our state budget goes to reimburse localities for what they’ve lost by reducing the local car tax. We look worse still when you read the Bazelon Center for Mental Health Law’s recent report, “Disintegrating Systems: The State of States’ Public Mental Health Systems,” and see how poorly the rest of the fifty states are doing. Did you know that total state spending on mental health services in the USA was 30 percent less in 1997 than in 1955, when adjusted for population growth and inflation? Did you know that more state hospitals were closed in the first half of the 1990s than in the 1970s and 1980s combined? And that between 1990 and 1997, state per capita expenditures for mental health fell by 7 percent, when adjusted for inflation? Here’s another statistic to memorize: Nationwide, the share of state spending devoted to mental health dropped by 15 per cent from 1990 to 1997. And then there is managed care. The insurance companies are authorizing a few more visits now, even letting some of you make your own decisions about how often to see your patients. But with your caseload, are you able to see your patients as often as would benefit them? Aren’t they having trouble getting the medication you prescribe? Are any of us pleased by the shambles that managed care has left behind? Years ago, I resigned from most of the panels, and my heartburn resolved immediately.

Still, my conscience bothers me when I turn away patients whose insurance I don’t take. I don’t take a lot of consolation from the knowledge that primary care doctors and emergency room are also maximally stressed.

In the 1990s hospital closures and lack of profitability led to the disappearance of around 500 emergency rooms in the United States. Meanwhile (from 1992 to 1999) emergency room visits rose 14%, and the percentage of patients who were privately insured fell from 43.3% to 38.9%. The 1986 federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires emergency rooms to offer care to all comers, insured or not, so emergency departments have been taking it on the chin.

More Grim Statistics
A recent APA article in Psychiatric Practice and Managed Care reported psychiatric bed shortages in 16 states. They had inadvertently left out Virginia. Yesterday when I called the APA, I was told that although a formal poll of states had not yet been completed, spontaneous reports to the Managed Care Helpline have raised the tally of states with psychiatric bed shortages to twenty states. And what is the effect of the psychiatric bed shortages?

According to the Bazelon report, “More than 3.5 million people rely on public health services every year.” But 284,000 adults with serious mental illness are jailed each year. The public sector has always struggled with economic restraints. The Bazelon Report that I cited earlier complains that the predominant level of care in the community mental health centers nationwide is case management by overloaded case managers and monthly medication checks by busy psychiatrists. Often this means NO PSYCHOTHERAPY SERVICES. I'm glad that evidence-based medicine shows that PACT teams are effective for people with serious mental illness, but I don’t think that it is a new idea that people with mental illness respond better to attention than neglect. And thus far, the good evidence we have accumulated for the efficacy of mental health and substance abuse treatment hasn’t persuaded legislators and insurance companies to provide adequate funding. It is people who do the persuading. So remember the California study data: For every dollar spent for substance abuse treatment, seven dollars is saved by reductions in crime and increases in employment. And the Callahan study from the University of Pennsylvania: It costs only $1000 more a year to provide good residential treatment and services care for a seriously mentally ill homeless person than it does to fund the police, courts, ER visits, and homeless shelters that are otherwise necessary.

Empowering Good News
As I write this column, the Virginia General Assembly is still in session hashing out differences in the House and Senate versions of the budget. Our legislators were presented with budget cuts that would have drained $25.6 million over the next two years from community programs for people with mental illness, mental retardation and substance abuse. It was estimated that over 15,000 people would have lost access to services in the next fiscal year. Thanks to valiant advocacy, both the Senate and the House have reversed significant portions of the cuts. And thank goodness that Governor Warner has done away with the gag rules that kept state officials at the Department of Mental Health, Mental Retardation, and Substance Abuse services from telling the cruel truth to the legislature in previous administrations.

Thank goodness for our forefathers who established this free country. We have the right to vote, contribute to political campaigns, and to speak out. What have we accomplished this year? In cooperation with the Washington Psychiatric Society, the Virginia Association of Community Psychiatrists, the Medical Society of Virgina, the Coalition for Mentally Disabled Citizens, NAMI-Virginia, and Viriginans for Mental Health Equity, PSV has actively addressed many of the problems I’ve mentioned above. At our request and with great leadership by our lobbyists Cal Whitehead, Mark Rubin and Mike Woods, the General Assembly passed legislation adding a psychiatrist to the board of the Department of Mental Health, Mental Retardation, and Substance Abuse Services. Through his own diligence, diplomacy and hard work, our own public sector chair and newsletter editor, Dr. Jim Reinhard, was appointed Acting Commissioner of the DMHMRSAS. A resolution to study the psychiatric bed shortage has passed in the Senate and made it out of the rules committee. I think our level of vigilance has made it clear to psychologists that they can’t, at this point, steamroller through a bill for prescribing privileges in Virginia the way they just did in New Mexico. I’d like to thank every one of you for your advocacy. Every phone call, donation, and letter to your legislators has made a difference. What I ask now is that we practice advocacy like some people practice golf. If you get out there on the legislative turf, advocacy may become so natural and so gratifying that it will cause you more dysphoria to abstain than to participate. Look at these silver- haired legislators who can’t get the process out of their blood. Quite frankly, our patients and their families are more vigorous and effective advocates than we are. We can learn from them. Thank you, my friends, for your participation.

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