Mental health: Personal and policy perspectives

0:00:01 Speaker 1: Good afternoon, everyone. Welcome. I'm Paula Lantz, I'm a professor here in the Ford School of Public Policy and also the associate Dean for Academic Affairs. And I'm really thrilled to welcome all of you here. Those who are in the audience here and also the people who are viewing us online in real time. Thank you so much for joining us today. Our program today is made possible by generous support from the Dr. Gilbert Omenn and Martha Darling Health Policy Fund. And as many of you are aware, I assume, September is National Suicide Prevention Awareness Month. So let me start with a few numbers and statistics for you.

0:00:46 S1: There are about 45,000 suicides a year in the United States. That is 120 per day. There are over 1,400 suicides in the state of Michigan every year, and that is actually above the national average. Suicide is the 10th leading cause of death, out of hundreds of causes of death, let me repeat, it's the 10th leading cause of death overall. And it's the second leading cause of death for young people between the age of 10 and 24. There are disparities in suicide by many different kinds of social characteristics. For example, suicide is the number one cause of death among LGBT youth who are overall four times more likely to attempt suicide than other adolescents and young adults. Depression is the number one cause of suicide. Over 16 million people a year in the United States live with clinical depression, and it's the number one cause of disability in the United States. And depression is only one of many different kinds of mental health issues and problems that affect people and their families. And as all of us know, mental health issues affect everyone. There's no family that has not been touched somehow by depression, suicide, and other mental health problems. In public policy, we admittedly tend to focus on numbers and populations, communities, institutions, and systems. It's important because that's the beauty and the strength of policy, right?

0:02:15 S1: Through policy interventions, we can efficiently affect a large number of people sometimes. But also, the experiences of real people, their real lives, and their families often get lost in the numbers, in the data, and the research evidence. So today, we do want to talk about mental health policy, but in a way that acknowledges, respects, and honors the millions of individuals and their families who are affected by depression, suicide, and other mental health issues. And to do that, I'm gonna start with a list. Number one, ice cream. Number two, water fights. Number three, staying up past your bedtime and being allowed to watch TV. Number four, the color yellow. Number five, things with stripes. Number six, roller coasters. Number seven, people falling over. Number eight, my favorite, chocolate. Number nine, kind, old people who are weird and don't smell unusual. I'm jumpy now. Number 1,002, when you learn something about someone that surprises you and makes perfect sense at the same time. 1 Million, listening to a record for the first time.

0:03:34 S1: Those of you who have seen the play Every Brilliant Thing, know that I'm reading the list from that play. The interactive play, Every Brilliant Thing, is playwright Duncan Macmillan's poignant, autobiographical story about growing up with a depressed, suicidal mother whom he unsuccessfully tried to make happy by creating a list of every brilliant or wonderful thing in the world. Let's watch a very short clip from this play. Thanks.

0:04:01 Speaker 2: No problem.

0:04:12 Speaker 3: The list began after her first attempt. A list of everything brilliant about the world, everything worth living for. Number one:

0:04:22 Speaker 4: Ice cream.

0:04:22 S3: Number two:

0:04:23 Speaker 5: Water fights.

0:04:24 S3: Number three:

0:04:25 Speaker 6: Staying up past your bedtime and being allowed to watch TV.

0:04:28 S3: If you get through your entire life without ever once feeling crushingly depressed, then you probably haven't been paying attention.

[laughter]

0:04:43 S3: And there's a moment in it when Ray Charles sings the word "You" and it sounds like it's coming out of someone else's voice. We all used to just crowd around the piano and howl it like wolves. Children with depressed parents, they have a heightened reactivity to stress because children with depressed parents, they are left to fend for themselves. But the real risk, as I perceive it, was that I would one day feel the same as my mom and want to take the same course of action. Because along with the anger and the incomprehension, was an absolute crystal clear understanding of why someone would want to take their life. We're walking through the park at night and we got to the middle and she stopped and bent down, I thought to do her shoelaces. I kept on going and then when I turned around, she looked at me, and she looked me in the eye, and she took my hands and she said...

0:05:37 S4: Will you marry me?

[laughter]

0:05:40 S3: I said, "Yes, let's kiss later."

[laughter]

0:05:50 S1: Thank you, thanks. I hope many of you had a chance to see this wonderful play through the recent University of Michigan Musical Society offerings or also it's available on HBO. If you have on-demand on HBO, you can watch it anytime if you haven't seen it yet. With this personal story as a backdrop and a potential point of focus during our question and answer portion later, I would now like to move on and introduce to you our panel of amazing local policy and clinical experts. So each of our panelists will be making a short presentation, and then we'll move to audience questions and comments. Those of you here in the auditorium can write questions on cards that are going to be passed out. And those of you who are watching us online, you can tweet in your questions using the hashtag policy talks.

0:06:48 S1: So now this is my distinct honor to introduce to you our four panelists in the order that they'll be speaking. And they're sitting in the front row now, they'll remain sitting in the front row until the Q&A period and then they'll all come up front. Our first speaker today is Dr. Michelle Riba. Dr. Riba is a practicing psychiatrist and the Director of the Psycho-Oncology Program here at the University of Michigan Comprehensive Cancer Center. She's a Clinical Professor and Associate Chair for Integrated Medical and Psychiatric Services at the UM Department of Psychiatry. She's a national leader in mental health and she's the immediate past President of the American Psychiatric Association.

0:07:29 S1: We also have with us here today Dr. Shervin Assari. Dr. Assari is also a psychiatrist with training in Public Health. He's a research investigator with the University of Michigan Department of Psychiatry. His research focuses on the intersection of Community Mental Health and Social Epidemiology. As a Community Mental Health Researcher, he's interested in the relationship between mood disorders and social identities. And the social determinants of health, and depression, and mental health issues such as ethnicity, gender, social class, and places where people live. Dr. Nancy Baum is also here with us today. She's a Health Policy Researcher and the Health Policy Team Lead at the Center for Healthcare Research and Transformation, otherwise known as CHRT, here in Ann Arbor. She leads CHRT's work and the development of health policy projects focused on health reform, health status improvement, and access to healthcare.

0:08:26 S1: And we're also fortunate to have with us today Trish Cortes. She's the Executive Director of Washtenaw County Community Mental Health, which is the safety net mental health provider serving individuals with serious mental health and developmental disabilities in our county. Trish's a registered nurse with a Master's Degree in Community Health Nursing and she brings to our discussion today a wealth of experience and leadership regarding Community Mental Health. And so delighted all four of our panelists are with us. Can you please give them a round of applause as Dr. Riba makes her way up to the podium.

0:09:11 Speaker 7: Thanks so much. Hi, everybody. And thanks to Paula and Emily for inviting us and for doing such a wonderful job in the arrangements and thank you all for coming. So before we really begin this presentation, let me just ask, and I'm already standing, how many of you either in yourselves, or in a family member, or a close friend, or colleague has had some depression, suffered from some depression, maybe you could stand up.

[pause]

0:09:50 S7: Okay, thank you. So this is a personal topic, it's obviously going to... We'll be talking about policy, but this is a very personal topic and very important. So we'll be talking in the next couple of minutes about the significance and prevalence and then we'll talk about depression and suicide across the life cycle, and if we have time, something about treatment options. Well, why is this so important? It's number one, in terms of depression, and number six in terms of bipolar disorder on the World Health Organization's list of Global Burdens Of Diseases for ages 15 to 45. One and six. Depression and bipolar illnesses affect one in six of us but it touches all six of us. We don't really understand depression and suicide. Many of us don't seek treatment and even if we do, it may not be the right treatment and there are tragic consequences if this goes untreated or ignored. The past director of National Institute of Mental Health, Tom Insel, cited depression as the top cause of medical disability. And what about the burden of depression worldwide?

0:11:17 S7: Well, it's the largest cause of death by suicide, as Paula mentioned. It's very expensive in terms of human suffering and in financial aspects. It costs a lot and we're starting the new workplace mental health, a program at the Depression Center at East Ann Arbor, and it impacts in absenteeism and presenteeism. Well, how do you diagnose this? In 1952, we started with the diagnostic and statistical manual right after World War two, and we're up to DSM-5, and we classify all the psychiatric conditions in this manual and we update it regularly.

0:12:03 S7: In terms of depression and DSM-5, there are many types of depression. So it's really not easy to diagnose and there are many... Often we talk about major depressive disorder. We'll focus on that today. But I wanted you to understand that there are many types of depressions. And with these depressions, there are often modifiers. So, here in Michigan, this is a common one right, seasonal changes that come with, let's say, major depression and people can also have seasonal problems in the summer as well as in the winter.

0:12:43 S7: In terms of bipolar disorders, there are also many types of bipolar disorders and illnesses. So it's complicated. It's not easy to make this diagnosis. And it's also, I want you to understand that it's not just a specific symptom that's pathognomonic for anyone. It has to be over a certain course of time. So, sometimes somebody comes into the emergency department and we can't make the diagnosis just on seeing somebody in a snapshot. We need to see and understand somebody's life course and understand them over a period of time.

0:13:22 S7: But, with people of depression often they have a depressed mood, they have a lost of interest or pleasure. And sometimes, in children, they're irritable. So, depression looks different depending on how old you are, circumstance, and other medical conditions. And we'll talk about that in a moment.

0:13:41 S7: In terms of symptoms of depression, one can have these problems and there's a mnemonic for it. It's called SIG-E-CAPS. So that you can remember sleep disturbance. Sometimes people sleep more or less. They may feel guilty. They may have too much energy or a lack of energy. So it's very variable and not everybody has to have all of these problems. But, often people have many of them. What about the epidemiology, Paula mentioned some, but in terms of lifetime risk for women, it's 20%, 10% for men. At any one time, about 5% to 10% of women may have depression, less for men. There's a gender distribution two to one women to men in adulthood and we'll talk about children and adolescents.

0:14:35 S7: There's a high concordance for monozygotic twins, 50% to 75%, and also if you're in a family with somebody who has depression you have a higher risk. So let's talk about in terms of life course, in terms of children, there are children who are depressed. We are understanding more and more that depression starts in youth. And, in children, it's an equal distribution for girls and boys. And it's higher for children who have co-occurring medical conditions, such as type one diabetes, for example.

0:15:14 S7: There is a different acronym for depression in children. This one can be used DUMPS. So it looks different in children. It's hard, you don't use the same sort of symptoms. But, it does have a youthful beginning and usually the peak of depression is between 15 and 24. So, our thought is to get it earlier, treat it, and the quality of life improves. But often, there are delays in treatment and diagnosis, and there is misdiagnosis.

0:15:53 S7: What about adolescents, and we see many, many adolescents coming to our emergency department. Well, in early adolescence, about 8%, and by 18, about one in four adolescents have had an episode of depression. Up until the age of 12 or 13, it's equal distribution between girls and boys. And then around 12 or 13, girls go up higher, just probably related to some inter-chronological or other mediators.

0:16:25 S7: And then what about late life depression? Well, about 20% in community samples, and then the first onset of depression we often see it after the age of 60. And we can see it even more with those who have co-occurring medical conditions such as heart disease, post-myocardial infarction, diabetes, post stroke, and neurodegenerative illnesses such as Alzheimer's or Parkinson's.

0:16:56 S7: What about death by suicide? This is a public health problem many of you have probably heard the NPR this morning or this afternoon that was about the suicide in veterans. Many die by suicide each year. It's probably underreported and I think Paula gave some of the statistics about this. But, we see it and we've had several unfortunate suicides in youth here in Ann Arbor in the last couple of months.

0:17:31 S7: We're very fortunate to have prominent researchers here at the school of public health who organize and run the healthy minds study which looks at campuses across the United States and many countries. Daniel Eisenberg and Sarah Ketchen Lipson are... Daniel is the PI for this and they try to intervene early and they are doing such innovative work working, with others such as Cheryl King, trying to identify and outreach students in their dorm rooms and working with RAs in trying to target certain populations that we know who are at risk in the college and graduate school years. And this is just one example, I think Paula mentioned that as well, the LGBT group.

0:18:22 S7: In terms of late life depression and suicide, elderly white men have a lot of good things about them and for them but not in terms of suicide rates, unfortunately. They have amongst the highest rates of suicides, about five to six greater than others. The majority of these folks have seen a primary care doctor in the last month and so it's very important for us to think a bit how to intervene and to ask about this. And as Paula mentioned, most suicidal patients have a diagnosable depression. These are some of the suicide risk factors and there are... Let me just read them out 'cause it's important. Depression, substance abuse or dependence, physical decline, illness, terminal illness, pain, loss of independence... And I have to stop.

[laughter]

0:19:21 S7: And there are many treatments. So we can talk about that, but psychotherapy in combination with pharmacotherapy and augmentation with these other exercise, the behavioral aspects are very important. So let me stop and thank you very much.

[applause]

0:20:00 Speaker 8: Good afternoon, everyone. In my five to seven minutes, I wanna talk about three mechanisms. How social factors influence mental health, particularly depression. Most of our research understanding comes from two studies. One, National Community Survey and one, Board Mental Health Survey, both conducted by Kessler who was here in Michigan and is now at Harvard. So of course, genetic predisposition has a role and many other factors like physical health but my talk is focusing on economic, and social, and public. How social factors can influence distribution at the level of society. And please make a distinction between determinants or social determinants of depression from social determinants of use of services for depression. I am exclusively looking at or explaining social determinants of the prevalence. Starting from the outcome being depression, most of the social determinants, like how we get exposed to a social risk factor, like trauma, rape, fear of violence. So the first one is the stress, which its distribution is socially determined. The second one is social support. The type of job that you are performing in determines do you have social support or not and many others like education and income.

0:21:48 S8: And also the place that you live, like physical and social aspects of your environment. Then there is a personal asset which comes following the social determinants of health, like do you have a high agency or sense of control over life. That comes from education. If you have higher education and you get higher pay, you have higher agency to control your life. And also, do you get a good emotional regulation? Again, each year of sitting at the school, having the chance to go to school increases our emotional regulation potential. Then the pattern of our time use. How much privileged life you have to be able to spend some time to do gardening, walk, and other behaviors, including how much our sleep is influenced. That is a social patterning of a risk factor of depression. So by here, I have two clusters.

0:23:04 S8: One, social determinants like social exposures and resources and one, personal assets. Both being determined by our education, income, employment and marital status and other social resources, which themselves are under influence of these factors that I have listed here. Education quality, do we live in New York, Detroit or Ann Arbor determines our education quality that determines our emotional regulation. Employment, if you are living in Detroit, lower chance of employment if you are a black male. So that has implication for the pattern of many of those factors, from time use, social support exposure. Then does our policies, which if you need money are there in place to lend, or they would discriminate you against and they would not give enough lending that you need, so you cannot borrow money. Or public transportation, do you have public transportation to go to work so you can have lower financial distress? So you see all these policies have implication for depression through a number of constructs. And of course they are determined by public policies. So this is... The whole message here is not for who gets treatment for depression, but who gets depression, determinants is mostly social, and it is a social patterning.

0:24:56 S8: So this is mechanism one. Our exposure and our resources is different depending on who we are ranking. The second one is that, how much we can use our resources and use them to become tangible health outcomes, depend on who we are. With almost no exception, social determinants have a strongest effect for white men in United States. So there are very few exceptions like religion and social support. But if it is an economic or social resource, that path from having access to protecting yourself depends on the intersection of race, and gender, and place. So it is our group membership or what part of the society are we located determines not only the access, but can we use that resource to protect ourselves. So this is mechanism two.

0:26:12 S8: And then, the third mechanism is that because of mistrust or discrimination. So this is continuation of that, sorry. This is... There are a considerable empirical evidence suggesting that education and employment, social environment, suffered at health, do not become tangible health outcomes depending on who you are in United States. And then, this is mechanism number three, which is; because depression differently correlates with those factors which are important. Like depression is correlated with higher stigma if you're a black male. So that means depression is more consequential if you're a black male.

0:27:00 S8: Or also dysfunctional belief about self, others, and future, from some mechanisms, blacks with depression can maintain high hope, maybe through social support or religiosity. So a white individual with depression would have lower level of hope compared to black counterpart. So you see this third mechanism of how society shapes our incidence, prevalence, and consequence of depression is, society shapes also correlates of depression. So this is the third mechanism. So I stop here, thank you very much.

[applause]

0:28:02 Speaker 9: Hi, everybody. It's nice to see some friendly faces in the audience. I'm not gonna use slides today, you could just look at this general slide while I'm talking. I think it's really important to start with those really dramatic statistics about prevalence and our understanding about these mechanisms that lead to depression. Some of the other things that matter, though, are some of these public policies that Paula referred to early on.

0:28:32 S9: And so I'm gonna talk a little bit about insurance policies and the way we've structured things using insurance and give you a little bit of information about some things we're doing locally and that'll lead into Trish's talk. So I'm gonna give you a little bit of history of some relatively recent, in the last few decades, federal laws, that have an effect on people's abilities to actually use the services that they need when they have depression and anxiety and other mental health issues.

0:29:06 S9: So in the late 90s, and then again in about 2008, we had two federal laws that were passed, that we refer to today as the Parity laws. And these were laws that were put in place in order to combat a problem with the people who needed mental health services faced, when they understood that these services were very expensive, needed to use insurance to pay for them. And then, once they looked closely at their insurance policies, recognized that the benefits for mental health services and for subsidy services were far inferior to the benefits for physical health services. So for a very long time, insurance benefits that might pay all but 80 or 90% of the cost of a physical health benefit, only paid something like 50% of the cost for mental health services. Insurance policies that didn't have an annual limit or didn't have a lifetime limit for benefit for physical health services, did have those kinds of limits for mental health services. And so this was really problematic and this is really a result of our misunderstanding about mental health services being really different from physical health services, and people's body that includes both their brain and the rest of their body together.

0:30:36 S9: And so Parity laws were really important. They were passed and they made giant leaps forward by saying if insurance policies offer mental health services, then they have to do it at the same level that they do for physical health services. So you can't have a limit, a lifetime limit on your mental health services if you don't have it on physical health services. That didn't, though, require insurance policies to include mental health benefits. For a very long time, especially skinnier policies, policies that were offered by small employers, policies that people were buying as individuals had very little, if any, mental health and substance use services in their policies.

0:31:19 S9: So in 2010, the Affordable Care Act was passed and in the Affordable Care Act, there was some expansion of those Parity laws to cover more policies. Now almost all policies have to abide by the rules that were put in place with the Parity laws. And the Affordable Care Act said in the essential health benefits, which most of you have probably heard about, it includes the requirement that mental health and substance use services and treatment for the identification of those problems are included. Most large employers who were offering benefits were offering sort of richer packages and they already had mental health and substance use services, to some extent, in them. And so the essential health benefits then required those plans that were sold on the marketplace that individuals were buying, and eventually many other plans to include a requirement for that. That's sort of the history of where we are in terms of insurance policies.

0:32:26 S9: When Medicaid was expanded in the state of Michigan, which it was in 31 or two other states in the nation, 600,000 plus more people were covered by Medicaid than prior to the Affordable Care Act's provision to expand Medicaid. The supreme court saying that states had a choice, Michigan deciding to go ahead and expand, over 600,000 people more are enrolled. Look, these are people who had been uninsured for a very long time, most of them, and so you can imagine there's a lot of pent-up demand for services, including mental health and substance use services. All of a sudden, there's a huge demand for... A greater demand for mental health and substance use services. It's terrific that more people are covered, but it's really important to understand that insurance coverage is not equal to access to services.

0:33:20 S9: Insurance coverage is really important because services are expensive, but it's not enough. And in the world of mental health and substance use, unfortunately, we have a real shortage of providers. And so this is not a problem that's specific to Michigan, this is a problem across the nation. But when you have a shortage of providers and it's complicated as to why we have such a shortage, a shortage of psychiatrists, we have a shortage of in-patient beds to treat people for mental health issues, and we can go into some of the reasons for the shortages a little bit later if you are interested. So you have a shortage of providers, you have greater demand and so do we have maybe even a bigger problem than we had before, it's hard to say.

0:34:07 S9: Lots of ways that we think about trying to address this great demand for services. One of the things that we talk about a lot at the mental health world is something called integration, integrated services. And this is the idea that mental health... Some people have mild or moderate needs for mental health services and other people have more severe mental health issues or substance use issues, there's a real continuum. Some of those needs can be met in primary care. If primary care providers are trained in order to address the needs of people with mild to moderate mental illness, that would be one way to sort of extend our specialty providers who we don't have enough of.

0:34:51 S9: We talk a lot about this, there's actually decades of evidence that this kind of integrated care that sometimes we call... There are other names for co-located and coordinated care, that there are really good health outcomes as a result of this kind of delivery of care. What we don't do very well is pay for integrated mental health and primary care services. For example, it would be a beautiful thing, it is a beautiful thing in some places, in a primary care clinic where there will be a psychologist or a psychiatrist in an office right next to the room where somebody is talking to their primary care provider. And their primary care provider can take them by the elbow and give... And do what's called a warm hand off and say, "In our primary care setting we've identified this need," and instead of giving somebody a referral for mental health services and hoping that they show up weeks later when they finally get an appointment, if you just walk them right next door and hand them off to a professional, it's a nice way for people to access services.

0:35:57 S9: It helps with that stigma, they don't have to go and wait in a waiting room that they're not comfortable with, etcetera. So integrating care is a really nice idea, but when the psychiatrist and the primary care provider are having a consultation that takes 15 minutes or half an hour to talk about this patient, we don't have any good way of paying them for that time. And so, if we don't have a great way of paying them for that time where they're doing this curbside consultation, one with the other about how best to treat this patient, then we have a problem. So we have evidence that this kind of integrated care works but we have... We don't have a lot of really good solutions about how to pay for it. Integration is a hot topic in Michigan. There's something referred to as the 298 problem. And 298 is the number of the section in the governor's budget, proposed budget where they use some boilerplate language to say we want to integrate mental health services with the primary care services and other physical health services, by taking all the dollars that we spend in our public mental health system, which Trish will talk about, and handing them over to...

0:37:12 S9: One take on this. Handing them over to the manage care plans who now deliver the care for most people who are covered by Medicaid. And so, as you can imagine, people who are receiving these services had a very hard time understanding how it was that they wouldn't lose their very important providers. You make really solid relationships with providers when you have mental health issues, for a lot of people. And that was really hard to imagine. And so, it was sort of thrown into this bucket of privatization and a bad policy idea. So in the state, right now, over the last couple of years, we've had lots of stakeholder engagement conversations, lots of proposals about how we might integrate care. And there are still a lot of people who are very opposed to it. Not because they don't think that conceptually clinically integrated care is good, it is. But just taking the dollars that we typically spend in the Community Mental Health system and giving them to the managed care organizations is really controversial. So I will end there and we can talk more about those issues in the discussion.

[applause]

0:38:39 Speaker 10: Alright. Well, thank you. Very excited to be here. Super excited that we are talking about these issues. These are really, really important issues. So I wanna thank Paula for inviting me to come here today and Emily for your... I appreciate how much you hounded me to make sure I got my stuff in. So thank you for putting up with me. [chuckle] So I'm gonna be talking a little bit about what's happening here in our own backyard. Does anybody know anything really about Community Mental Health? If you do, please raise your hand. Okay. That's what I thought. So let's start with what Community Mental Health does. Community Mental Health is our safety net mental health provider in our state. There's 46 CMHs in the state of Michigan. And essentially, we serve people who are low income, Medicaid and who have kinda deep end needs. So adults with serious mental illness, youths with serious emotional disturbances, and youths and adults with intellectual developmental disabilities and certainly also individuals who have a co-occurring condition. And what's different about CMH, and it's a little bit talking kind of what both Dr. Assari and what Nancy, is that mental health provides a much broader array of service.

0:40:01 S1: Because of the exact issues that Dr. Assari talked about with social determinants of health. So a typical coverage for mental health is you see a doc, you can see a nurse, get an injection, you have some therapy. And that's pretty much the basic package. Community Mental Health, one of the bread and butter services that we provide is case management because one of the things that we talk about in the Community Mental Health world, is that the medical model is necessary, but it's not sufficient. In Community Mental Health, we have to get people housed. That is a form of treatment. We need to get people secure with their food needs. We need to do a whole array of issues to address the, what Dr. Assari had on his slide, before we can get to treatment. So that is one of the fundamental differences, in that in what we do, versus what traditional insurance plans cover. In addition to lots of other services like people who need residential support, people who need support with getting employed, people who have a whole host of issues that need to be addressed.

0:41:11 S1: Community Mental Health, also we are a 24/7, 365 mobile crisis. We respond to any crisis in the community. We also are, because of the reasons I just discussed, also are very integrated in a lot of other social service systems. We are the mental health provider in the jail, we staff the mental health court, we are in the primary care safety clinics, helping with the integrated care efforts that Nancy just talked about, and the list kinda goes on and on from there. So one of the big impacts that happened to us in the last couple of years is that, concurrent with the implementation of Medicaid expansion, which here in the state of Michigan is called Healthy Michigan, HMP, Healthy Michigan Plan, the state made a decision around financing.

0:42:01 S1: And what the State did at that time is, concurrent to the implementation of HMP, they took about $200 million out of the CMH system statewide, which for us, was about a 60% reduction in our funding. And it was not the Medicaid but it was what we call our State General Funds, and those were precious at the time because those are not as regulated as Medicaid is, and those were the dollars that we had to do flexible, creative things like have a psychiatrist in a safety net clinic, like paying for jail services, and most importantly, for us, is that we kind of... Anybody who kind of met the diagnostics and functional limitations, we served everyone blind a pair; and they got case management and they got assertive community treatment services, and the list goes on and on. So when this funding went away, it was an extremely challenging time because at that time what we had to do is that we had to actually discharge people who maybe just had Medicare. Medicare does not cover all those services. And so we needed to go through and start looking to see who could we hand these individuals off with with not really super great resources and issues, as Nancy talked about.

0:43:20 S1: So what happened is that we ended up no longer being able to be the safety net provider for all. This kind of shows you in 2014, we served roughly just about 650-ish or more individuals who did not have a form of Medicaid, that we paid for their services out of our general funds. Now we are down to about 115 who are now currently in our system and we're holding on to them because they're so ill that really it would be like an emergent or urgent situation if we did not serve them, so we've held on to the deepest end people because out of sheer necessity. We've had to close our front door, and so unless people meet an urgent/emergent need, we cannot bring them in and we have to try to refer them to the best resource we can find in the community. So this gives you an idea of kind of the impact that this has had. What we're seeing locally in our trends, we're seeing that... And also, why I say that Healthy Michigan... We are now serving roughly about 700 individuals on Healthy Michigan in the CMH system, so it has been a wonderful resource because on Healthy Michigan they do get the full array of services covered under other traditional forms of Medicaid. What we're seeing is, the blue line is people who are actually Medicaid and with us; we serve them, we know them, we hang on to them.

0:44:49 S1: That our inpatient is, it's going up a little bit, but what we're seeing kind of exploding is that there is another population, mostly Healthy Michigan, who are showing up in ERs and our inpatient rates we're seeing is just kind of skyrocketing year over year. Our corrections data, this is from our Washtenaw County jail, again, the blue line, you can see over the years we've kind of kept it steady of what individuals who are ours are also in our county jail, but again, we're seeing this other trend of another population that has now exceeded the number of people who are actually enrolled in Community Mental Health, so we're seeing that people are landing in other places. This is a slide from the Washtenaw County Public Health Department; there's a lot of information on there but I'm just going to point out that the startling increase of suicides that we're seeing in our young and our youth. Between the ages of 15 and 24, we are seeing, in the last six years or so, a 433% increase in the number of completed suicides in our county. So, as we have been experiencing all of this and when we received our funding cuts back in '14, '15, some of the things that we did in our community was that we needed to really do a thorough analysis of what are we gonna do, how are we gonna handle this.

0:46:20 S1: So I reached out to our good friends and colleagues over at CHRT, and Nancy actually was one of the staff at CHRT that helped us do this, to do kind of a deep analysis of gaps around substance abuse and mental health services in our community. Washtenaw County Sheriff, Jerry Clayton and I also because it intersects between our two worlds, is not insignificant, also hosted a sequential intercept mapping workshop, two-day workshop, where we had everyone from kind of the public safety, justice, mental health, substance abuse, housing and others world all come together to really look in every single kind of intercept where an individual is having some interaction with law enforcement, etcetera, what are our resources, what are our gaps, and what do we need to do, and so we conducted that.

0:47:12 S1: In addition, our two major health systems in our community did a joint needs assessment, what's called UNITE, and they also did their assessment. The overwhelming conclusion of all of it is, mental health, substance abuse, is the top priority in this community. And what we are also experiencing is that the community capacity to serve individuals with behavioral health issues is very limited. And this is something that we are seeing, as Nancy said, it's not just a Washtenaw County issue, it's a state and national issue that we are facing. So part of the consequences of these limited resources, what the CHRT report also found, is that what it's leading to is, there's a delay in people getting to services, whether it's outpatient, inpatient, substance abuse, etcetera.

0:48:04 S1: We are seeing there are extended wait times in our psychiatric emergency, our psych departments are literally... University of Michigan or Michigan Medicine now is now... They're actually having a look at the physical plant, because they can't have... They have so many bodies that are coming in right now. We're also seeing a discharge of getting people off inpatient units, because we don't have the most appropriate, or can't access the most appropriate kind of step down for that individual. And we are asking our community providers, who historically see MHs, taking care of these kind of deeper end people. We are asking primary care physicians and other providers that haven't really typically worked with individuals who experienced schizophrenia, for example. And so, we are really pushing our community partners to really kind of expand their scope of practice.

0:49:02 S1: So, the major conclusion is that we are really at a point where we need to strategically expand our community-based care across the full continuum of services for mental health and substance abuse. And one of the things has been popped up in the CHRT analysis is that we really need to do a better job of having a comprehensive community-based crisis care program that can take people. People who just need to walk in, short stays, find out what they need, and get them to the right place. That has been one of the... Number one priorities that have come out of all of these analysis.

0:49:40 S1: With our sequential intercept workshop that we did, again, the same theme's coming up. We need to expand our crisis response strategies as a community, we need to expand our substance abuse treatment. Another piece that came out of that, because of the nature of that workshop, is that we also need to make sure that first responders such as law enforcements, such as paramedics, also need to know how to address or at least identify that there is a mental health crisis before them and not necessarily whatever else it may be. And so we've done a lot of training, particularly with the Sheriff's Office, of training all 150 sheriff deputies on how to manage a mental health crisis. And then, also expanding the use of peer supports, which has really been a very effective way of kind of addressing some of these needs through peers with lived experience.

0:50:39 S1: So, our kind of local reality is that there's kind of a perfect storm that's happened here in Washtenaw County. We've got an opioid epidemic. I think just about everybody knows about that. We are seeing increases in suicide, we are seeing increases in inpatient crisis services, we have a capacity issue in the community, we've got funding restraints like we haven't seen before. But we've also had, our community has really analyzed the situation and I do believe that we are really at a point right now where we're gonna be transitioning out of reactive mode and really going into more proactive strategic planning together as a community.

0:51:21 S1: Some of the advantages that I think is unique to Washtenaw County is that we are really a community rich with partnerships. So we are now working with leveraging those partnerships, working with our community providers, our housing network, etcetera. Because this is really kind of... It's gonna take a village to really start addressing some of this. We are all trying to expand, as we... We also need to make sure that we are lining our efforts, that right now, whether you're in the substance abuse world or mental health or you're a part of a health system, everybody's trying to... Try to address the same issues. So there's a lot of moving parts, but we need to make sure that we are doing those in concert. And so, that's what we are also discussing. Education, that's part of what this whole event is about. So we need to get a lot of education and advocacy around these issues.

0:52:15 S1: We have started talking about a community-based crisis program. Again, we're the right service at the right time that's not necessarily need to be in the jail or the emergency room. That work is underway as well as trying to kind of stabilize the system by doing more integrated care efforts, for example. And really trying to make sure that we are kind of doing a better job of helping. We have the historic knowledge and expertise around some of these issues from our perspective, but then how do we help our partners kind of expand what they're doing.

0:52:54 S1: So, I already talked these other things that we're doing. We are doing a lot of law enforcement training, we are doubling down our efforts in terms of our partnerships with our schools. We have an Ann Arbor public schools alone. We lost nine youths last year to either overdose or suicide. That is a startling high statistic. And I think one of the most important things we need to do is just a full blown, everybody needs to get on board with kind of busting the stigma around mental illness. And really taking it is that the brain is an organ just like your heart, just like your lungs, just like anything else, and we need to stop treating it like it's something different. That's it.

0:53:32 S1: Thank you.

[applause]

0:53:42 S1: Thank you. I'd like to invite our panelists to come up front. They were all under extreme time constraints and packed a lot into their short presentation, so please, join me again in thanking them for working under challenging circumstances. We've covered a lot of ground. And I see that there's been a lot of audience questions coming in, so as our students sort through them, I would like to just give them another moment. I'm gonna start off our Q&A session by just asking any of the panelists, you don't all have to respond to this, but I don't know if any of the panelists had an opportunity to see the play Every Brilliant Thing and just want to share any reactions to any aspect of this performance that resonated with you and the work that you do in the area of mental health.

0:54:36 S9: I will start, is this on?

0:54:37 S1: I don't think it's on. Hit it. [chuckle]

0:54:49 S9: Yeah, I can talk loud. I did have the opportunity... Thanks Sherman, to see the show at the Arthur Miller Theatre on North Campus. And so, as most of you probably know, this is a theater in the round and it's very inviting. And the other thing that's very inviting about it is that the show engaged the audience. I'm not sure you can get this from the clip, but the show engaged the audience constantly. Throughout the entire show, almost, there was somebody from the audience on the stage, and some of them were there for a really long time. And I started thinking about this is a really interesting metaphor for the way we need to address mental illness. It really requires our community. It requires our family and our friends and professionals and everybody. Addressing mental illness is not a one man show, even though this was a one man show. So that was sort of my thoughts about it.

0:55:48 S1: Thank you. Dr. Riba?

0:55:50 S7: It's one of the hardest things for a child to have a parent with any illness, including a mental illness. I was thinking, I work at the cancer center, and we have camps, summer camps, for children whose parents have cancer. And they can go for years to these camps. We don't have that for children whose parents have psychiatric problems. Think about it.

0:56:16 S1: Yeah. Let's get one. Now, I'm gonna turn to our students, who will be asking the questions that people in the audience have sent in. Again, I want to remind our viewers who are watching online that you can tweet your questions into hashtag policy talks. We have two students here with us today. They're gonna introduce themselves. And they're being assisted by Professor Natasha Pilkauskas as well in sorting through and organizing your questions. So thank you.

0:56:48 Speaker 11: Alright. Good evening now. Thank you so much for being here. My name is Nadine Joad. I'm a senior in the BA program, studying public policy, with a concentration in women's health policy. The first question from the audience is "It seems that there is a tension between wanting to diagnose people with official DSM-defined conditions so that their conditions and challenges can be seen as legitimate, but simultaneously wanting to avoid further stigmatizing these individuals by labeling them. How do you personally reconcile with this and how can policymakers help?"

0:57:24 S1: Anyone? That's a great question.

0:57:30 S8: Just to make it clear that I'm not a psychiatrist. And Paula was kind enough to say I'm a psychiatrist, but I'm a primary health care physician. So I have not practiced in [0:57:41] ____ research. So if I didn't respond anything related to diagnosis because I'm not a practitioner.

[laughter]

0:57:50 S1: He's dodging a question that I know he could answer.

0:57:56 S7: Why are we talking about stigma and trying to have a correct diagnosis for somebody. I guess that's an important question. You wouldn't wanna have an oncologist treat you without having the right diagnosis based on pathology and radiographs and testing. And so, even very fundamentally talking about diagnosis, it's an interesting issue. We don't... We use... DSM is used by all mental health practitioners, not just psychiatrists. And the idea is for us to have a common language so that if you come to see me in one building, but you go to see somebody in another building and we look at the records, we can understand what the course of treatment is or how do we treat to remission of that problem. And so we're trying to... We use this to try to help people, but I guess others think of this as stigmatizing. So that's a really important question, I think, as a policy issue, and would be really interesting to have a conversation about this with others in the room if you are interested.

0:59:12 S1: Right. Thanks.

0:59:15 Speaker 12: Hi. I'm Katie Allen and I'm a dual master's in the School of Public Health and the Ford School, and I'm also interested in women's health issues. So this is a slightly different, not quite related question, but Dr Baum talked about how mental health issues often require a different kind of care than physical health issues. For moderate to severe cases of things like depression, is treatment seen as something that can be done effectively in a certain number of months, or is depression more of an across the lifetime issue?

0:59:43 S7: Probably best answered by clinicians. The idea is to try to treat it early and to prevent recurrences. We're not doing a very good job with this prevention and especially as we were talking about services and funding, that's really the issue because we're seeing more and more people coming into the emergency department, not just for psychiatric problems, but for all conditions because they don't have the money to go to primary care to get testing for all sorts of medical problems, and by the time they have a problem, it's very severe. So we are trying to prevent recurrences. But in fact, there are many illnesses in psychiatry, just like in other conditions, where we think of it as a chronic condition, but we wanna try to prevent severe episodes of that condition. That's really the goal, to try to improve quality of life for everybody.

1:00:50 S8: And knowing some of the literature, there is a literature saying that after three hits of depression, the biology changes significantly much more than the hit number one and hit number two. If someone has experienced three episodes, the risk of recurrences just is proportionately higher in future compared to two previous episodes.

1:01:16 S7: Just to say, often we see young people not getting the right diagnosis and they turn to drugs or alcohol to treat their fidgetiness, or hyperactivity, or mood, to try to make themselves feel better or put on drugs because they are misdiagnosed where psychotherapy or other treatments like exercise, sleep, might... Change in diet. And poverty, we were talking about homelessness, poverty, but what impact that is on children who have to not be able to see regular teachers or get educated. So all these determinants really impact on people having three episodes. What we are trying to prevent is people having three episodes, trying to help them earlier on in their life.

1:02:15 S8: Yes, there is something called "Telescoping effect," which means if you are a vulnerable member of a vulnerable population, like a minority or not that much access, the same disorder would result in worse conditions. Like a telescope, you would transition faster to the worst outcome. That is why social determinants are also important after development of depression.

1:02:43 S1: Okay. So that was a good segue into the next question. So there's a little bit of context to it. Right now, there's a national push to recognize Middle Eastern, North African checkbox as a point of census data. It's more specific to the state of Michigan because South Eastern Michigan has a large population of Middle Eastern and North African persons. I guess the question would be then if we are classified a large population in this community as white, how do we look at their trends, especially with many of them coming from war-torn situations? How do we look at their trends over a long span of time? And how do we make sure we're servicing those people as a marginalized identity and not as a homogenized identity?

1:03:24 S8: If I can answer that, first, my personal opinion is that that's a wrong decision to count Arab-Americans or Middle Easterners as white because particularly, for example, the first generation of immigrants is a group of immigrants, which means high risk, even if the ethnic backgrounds of centuries ago have some similarities to whites, still their risk profile is totally different. So my answer, very sure, is that that's a wrong start to call them white. So, yeah.

1:04:03 S1: Sorry, I think I may have said that wrong. So they're pushing to have a Middle Eastern-North African checkbox because currently, they're white.

1:04:09 S8: Yeah. Okay, that would be great. [laughter] That's a step forward, because I myself, I'm a Middle Eastern and I take white, which makes me very angry. [laughter] And, okay, I don't even myself benefit from my ethnic identity. I am an ethnic researcher. I do these type of stuff, and then I check the wrong answer for my service. So that is a terrible situation but... Okay, so the first issue is that the profile of exposure and experiences are very different and specific and being an immigrant, especially a first generation immigrant, comes with a lot of adversity, social adversities, and being a Muslim, who many of those people are, also increases religion-related discrimination and all of the exposures, especially in the current climate. So, yes, unfortunately, even this is the thing, we know what exposure is happening and we know what is the solution, but still, exposure is happening and solution is not being provided. That's the same situation with blacks or Hispanics that we know there is discrimination. We know that it is poverty which has a very particular type of solution. We know they do not get the same care or treatment but we continue, despite knowing the situation, it's happening and continuing. So I think that is the same case for another ethnic minority to be added to the census data collection.

1:06:05 S1: Is this on?

1:06:06 S1: Yes.

1:06:07 S1: It is? Okay. So in our world, we have to collect lots and lots of demographics and so we are now having to add more checkboxes in all the things that we are required to track. The state did also implement a policy around that everyone within the CMH system, all of our providers are required to go through cultural competency training. So I think that those are the beginnings which that then those trainings will become more robust as we continue kind of track who is it that's hitting our systems and what do we need to do to add to those trainings.

1:06:45 S9: I'll add one more thing. Trish may be too modest to add this herself, but our Community Mental Health organization here in Washtenaw County is a leader in finding ways to share data, appropriate ways to share data with protections, but that are sufficient for providers to know enough about their patients and to know enough about what their patient's challenges are to actually address them well. And my [1:07:12] ____ in Trish's shop is a leader and somebody who we hold up all the time as really forward thinking and trying to be creative, because, of course, there's that tension between privacy and having enough information for providers to really know what challenges their patients are dealing with.

1:07:33 S1: So I have a two part question that's coming from two different people, they tie in together. So why has there been an increase in suicide rates among youth over the past six years and what are some early interventions that could occur as to [1:07:45] ____ later interventions?

1:07:52 S7: Well, I can start it off and I'm sure others can add to it, but it's probably multifactorial. We don't really know the answer but some things that we think are occurring is bullying, has been shown to be a real strong determinant, Facebook and other electronic media out there, a lot of children and youth are going on and seeing what others are doing and feeling envious or feeling left out. They're using that as a way to communicate without really friendships, talking... I don't know about you, I think I'm a lot older than many of you, but in my day, I was on the telephone too much and using the telephone and nowadays, I don't know about you, but the telephone in my home doesn't ring, in fact, many of us don't even have a land line anymore. So kids are just thinking that they're having friends but they really don't.

1:09:01 S7: They're doing video games and that friendship, those bonding, being in somebody's home where there's a parent perhaps, they don't have a parent in their own home supervising. So kids are being unsupervised. A lot of activities, after school so they're tired and maybe they're not sitting around the dinner table talking about issues and problems and so there are a range of issues. And then also the lack of, perhaps, preventive care, that many children may not be able to see a pediatrician or their physician who may be able to screen for depression and other issues in themselves or in their parents. So these are some of the issues but probably not all of them, I think. Homelessness, poverty all those issues are, as well, major issues.

1:10:02 S1: Yeah, I think what I can add is we don't know what exactly is causing the increase in youth suicides. What I can tell you of the deaths that we've seen here in Washtenaw County, for CMH, our suicide rates for the people that we serve are extremely low, extremely extremely low. And the suicides that we're seeing are not actually necessarily low income youths that we're seeing. So one of the things that we did for after one of the more recent, end of the summer suicides that had a tremendous impact, they all have a tremendous impact on our community, but one that happened in our local schools. A lot of families come out to ask, "What am I supposed... How do I talk to my kid who was in his class?" Or "My younger siblings go with their younger sibling's elementary... Same elementary school," or what have you. And what we also talked about, we had a psychologist coming to also talk to these parents and I know...

1:11:04 S1: Paula said I'm a nurse but it's been so long since I've been a nurse, so nobody can have a medical emergency right now, I've been an administrator for way too long. But what I also kind of learned, even in that session, is that the frontal lobe, correct me if I screw anything up, I'll... Is kind of the part of your brain that makes you kind of think before you do, and that that doesn't get fully developed until you are in your 20s. And so combine that with social media and the culture of instant gratification, I mean, you gotta send that text back right away, you have to... It's almost like we're pouring fuel on an underdeveloped "think before you do" part of the brain and so I think between the bullying and the social media and the culture of instant gratification, like "Must respond, must respond," that that is all playing into what we're seeing, but interestingly enough, our low income folks, the other piece is that culturally...

1:12:04 S1: I don't know if they're still talking about it but it's a culture of everybody wins, everybody gets a trophy. One of the things that we also kind of talk about is that the folks that we serve because they've been living in poverty or that they're pretty resilient. Is there also... Are we building a culture where our youths are losing some of that resilience because maybe the worse thing that could happen to someone is when they get their heart broken for the first time? What are all the previous experiences that happened to that. So I think that there's also a piece of the culture around resilience that also could potentially play a factor in all this. But we're trying to figure this out.

1:12:49 S8: And if I can add just briefly, if you look at the trend of psychiatric disorders over the past five decades or four decades, there is an increasing trend. So those type of increases are not new and are not specific to suicide. Overall, they are increasing. And then the second one is that a structure of the family and also function of the family is changing. So the more families are single-headed and now the conversations are less or the type of social support. So the trend in a structure and function of family over the past decades, which result in, of course, that increase in mental health problems, including suicide.

1:13:35 S7: I mean, the other aspect is the substance problems, substance use and dependence and the opioid crisis. And so often that's in adults, so often they have children. So we're seeing that as a widespread national problem which has a lot of tentacles into society.

1:14:02 S1: Okay. So this is a long one. [chuckle] Is it fair to say that conservative legislators and policymakers believe that mental health problems are more of a family and personal issue to be addressed by support systems gained through individuals, families and churches or private community organizations rather than society of larger government infrastructures? So I guess the question is... Yeah, that was the question.

[laughter]

1:14:32 S8: If I can start. The whole ideology of right and especially extreme right that the person is responsible and nothing is more than individual responsibility. So if there is a problem, then we should be able to see the cause, like a parent is absent or something is wrong with the person. So they blame the person. So this is the ideology. The same thing with poverty. So the right has the belief that the poor is doing something wrong or something immoral is with the poor. So that is part of the ideological view of a big part of this country.

1:15:22 S9: Yeah, it's a really complicated question. I think it's very hard to look into the minds and the hearts of any politician. I will say that the more conservative policies that have really been challenging the Medicaid expansion and are really important for us to think about. The reason I say this is that Medicaid is the major payer for mental health services. People with mental health and substance use needs are very expensive. There's about 20% of the people who are covered by Medicaid have a mental health or substance use issue. We spend about half of our Medicaid dollars on those individuals. So you can see with this problem, this disproportionate problem that anytime we make really significant changes to the Medicaid program like ending the Medicaid expansion in the 30 plus states who have expanded or adjusting from the way we currently pay for this entitlement program to something that is limited to a per capita cap or to a block grant type of funding, we really start to threaten our ability for those particular low income individuals to get the mental health and substance use services that they need. So I think without looking into hearts and minds, we can say that certain policies are more challenging for the very people who need these services.

1:17:07 S7: You know, would anybody suggest that cancer should be treated by the family? Yet, for some reason, it's hard for some people, some may be legislators, to think that depression and bipolar illnesses are medical conditions, just as Trish said, these are brain illnesses. This is why public education and fora like this are so important because this is not about just toughening up and doing better. This is about treatment and this is why you have to get a proper diagnosis, legitimate diagnosis and get evidence-based treatment.

1:17:55 S1: I am so sorry to say we're out of time. I know we haven't gotten to many of your questions. We've talked about so many different things today. We've talked about prevention and social aspects of that, we've talked about diagnosis and treatment, we've talked about Community Mental Health issues, public policy, again, I apologize if we didn't get to all of your questions. We are having a reception right outside of this room, and the panelists will be staying around, so we can have some more informal discussions for those of you who are here. And also, I do wanna mention that right outside the door here, there is a table and a staff member from the Depression Center, here at the University of Michigan with some resources, if anyone wants to talk about what's available here at the University of Michigan Depression Center. We do have some information there. Thank you so much for joining us and please join me in thanking our wonderful panelists for the day.

[applause]