Odom outlines reform benefits - Fayetteville News

By Rochelle Williams

Staff writer
State officials say they are transforming the mental health system because people have demanded the change for years.

“Consumers wanted this,” said state Health and Human Services Secretary Carmen Hooker Odom. “They wanted us to break down the boxes that providers have put them in. They wanted choices in how they are treated.”

Odom spoke about mental health reform Thursday during a two-hour question-and-answer session involving state officials, consumers, therapists and care providers.

About 200 people attended the forum at the Cumberland County Mental Health Center on Executive Place.

State Rep. Rick Glazier was the moderator.

Mike Moseley, director of the state Mental Health Division, told the group that reform will shift mental health services out of large government clinics and into the offices of private providers.

The change will give consumers more choice when they seek treatment and will reduce inefficiency and overspending in bloated local centers, Odom said.

The government will stop paying local mental health centers to treat patients and will begin reimbursing private providers. Streamlined local centers will oversee services.

But some private providers at the forum seemed frustrated with the county enrollment process that allows them to deliver services and to get reimbursed by the government.

Many people at the forum worried that consumers will fall through the cracks as county providers stop treating patients and private providers take on the services.

On Thursday, the Cumberland County Mental Health Center had enrolled only 30 private providers, said Debbie Jenkins. Jenkins is director of Child and Family Services for Mental Health.

Jenkins said there aren’t enough private providers in the area to take over all of the services the county office has provided.

Odom said, “I would be interested if the providers in the room feel like they have been given an opportunity to be endorsed.”

Odom said the county center needs to work harder to sign up private providers.
Maria Dockery said she lost her case manager at the mental health center but hasn’t figured out how to sign up with a private provider.

“I understand about the improvements for the future that you are trying to make,” Dockery said. “But I am worried about now. I do not feel mentally taken care off.”

Consumers should not experience gaps in service, Odom said. She said the county office can apply for a waiver to continue providing services if there aren’t enough private providers in Cumberland County.

“Mental health reform will be challenging, disruptive and scary,” Odom said.
She said the changes will create better choices for patients.

“When we talk about transforming the system, everyone pines for the good old days,” Odom said. “But it is important to remember that there were no good old days.”

Staff photoby Stephanie Bruce Read more!

ADHD drug risks rattle families. Concern follows conflicting studies - Raleigh News & Observer

JEAN P. FISHER, Staff Writer

Treating children with ADHD gets more confusing by the day.

Last month, an FDA advisory panel called for strict new warnings on Ritalin and many other medicines widely prescribed to patients, including about 2.5 million children and adolescents nationally. The warnings would say that the drugs may increase the risk of heart attack and other serious problems.

Then this week, a different physician advisory panel said no such warnings were needed.

The debate has alarmed some patients, said Scott H. Kollins, a child psychologist and director of the ADHD Program at Duke University Medical Center.

Since stronger warnings on consumer packaging have been considered, he has noticed more patients, or parents of patients, declining to participate in ADHD drug studies. Many cite concerns about possible risks, although no one has dropped out of an ongoing study, he said.

Kollins, who cannot prescribe medication as a psychologist, strongly recommends behavioral therapy to treat attention deficit hyperactivity disorder. But he is also a firm believer in the results that drug therapy delivers for many patients.
"The bottom line is, it works," Kollins said. He is an investigator in several clinical trials studying patient responses to ADHD drugs.

A survey by the U.S. Centers for Disease Control and Prevention estimated that a little more than 6 percent of children in North Carolina ages 4 through 17 are taking medication for ADHD. That puts the state in the top five nationally.

Kollins worries that some parents might react to the safety concerns by pulling their children off drugs that are helping them function. Children and adults with ADHD often have difficulty at school or work, and are at greater risk of injury from accidents.

Be open about risks
But some parents of children with ADHD, including Donna Willis of Cary, are glad to see medication risks in the spotlight.

Many parents and some doctors think ADHD is overdiagnosed, and say medicines to treat it are handed out with too little thought. An editorial in this week's issue of the New England Journal of Medicine, written by a member of the FDA panel that called for stronger warnings, noted that ADHD is rarely diagnosed in Europe.

Willis' son, Reyn, now 19, developed insomnia, nervous tics and anxiety shortly after starting on Ritalin as a first-grader. Donna Willis took him off the drug after he had an anxiety attack and locked himself in his second-floor bedroom for four hours.

Years later, when Reyn began struggling in high school geometry class, he briefly tried the drug Strattera. But he stopped taking it because it gave him migraine headaches. He has been free of medication since then.

"There is not enough of a track record and not enough of a documented history of side effects for this medicine to be prescribed as widely as it is," said Donna Willis, who hired tutors and supervised nightly, structured study sessions to keep her son on track in school. Reyn Willis is now a freshman at the University of Alabama, where he also plays football. He has a 3.2 grade-point average, his mother said.

"I would really encourage parents to consider what they can change to improve the situation before they decide to medicate," she said.

Goes with the territory
James Asbill, whose three sons have ADHD and all take medicine to manage it, has no qualms about side effects.

Two of his boys have taken Ritalin for more than 15 years each with no notable problems. His third and youngest son, now 20 and a student at N.C. State University, experienced mood swings on Ritalin and was switched to Dexadrine.
Asbill said medication helped his sons keep up in school and improved their interactions with other students. "Anytime you take anything, there's going to be a risk of problems," he said. "Every time you turn around, something else puts you at risk for heart problems. Eating food causes risk for heart problems."

Differing opinions about the treatment of ADHD are nothing new. Parents and doctors have long weighed the merits of using medicine against its potential long-term health risks. Clinical research has shown that medication alone, or a combination of drugs and behavioral therapy, is most effective at reducing ADHD symptoms.

Deaths prompt action
The latest round of debate among FDA advisers resulted from a spate of patient deaths between 1999 and 2003.

During that period, 25 people on ADHD medications died suddenly and 54 suffered serious cardiovascular problems such as heart attack, stroke, high blood pressure or abnormal heart rhythms. Children and adolescents accounted for 19 of the deaths.

The results prompted Canadian health administrators to pull one ADHD drug, Adderall XR, off the markets. Last month, a panel of doctors advising the U.S. Food and Drug Administration voted 8-7 to recommend the medicines carry the so-called "black box" warning, the strictest caution the FDA imposes. That was a surprise to many, because the panel had been asked only to determine whether further safety studies of ADHD medicines were warranted.

A different advisory panel, made up mainly of pediatricians and child psychiatrists, held a public hearing this week to discuss the results and offer its own opinion on the need for such warnings. Its members advised against requiring black-box warnings for ADHD medicines such as Ritalin, Adderall and Strattera. Instead, the panel recommended providing clearer information about possible risks to patients and doctors.

The FDA could follow either of the recommendations, or neither. Many physicians think ordering more and better information is most likely.

Dr. David G. Fassler, a child and adolescent psychiatrist in Vermont and trustee of the American Psychiatric Association, testified against black-box warnings for ADHD medicines at this week's hearing and does not think the FDA will impose them.

"The real message that came through," Fassler said, "is the need for close communication between parents and physicians."

Staff writer Jean P. Fisher can be reached at 829-4753 or jfisher@newsobserver.com. Read more!

Abandoning Our Mentally Ill -- Milwaukee Sentinel & Journal

The Milwaukee Journal Sentinel has put together what appears to be excellent series of articles and video on the status of mental health services there.
 
Click here to access Read more!

Study: Changing Medicines May Aid Depressed -- Associated Press

Mar 23, 4:55 AM EST
By MARILYNN MARCHIONE
AP Medical Writer

Other News Video

The largest study ever done on treating depression has found that patients who didn't get well with the first medicine they tried had a good chance of succeeding the second time around.

Up to one-third of those who added or changed medicines recovered from the crushing illness that is America's top mental health problem, researchers said.

This is good news by itself, but the bigger picture is even more encouraging, doctors say. When viewed with earlier results, the new findings mean that roughly half of people who suffer from depression can get over it - not just improve their symptoms - with adequate medication.

"The goal here was to find treatments that help people to get well, not just better," said Dr. Thomas Insel, director of the National Institute of Mental Health. "We have safe and effective treatments."

His agency paid for the $35 million study, which involved thousands of people across the United States and has been widely praised as a real-world test of popular drugs that have received only limited testing until now.

The study found little difference among the five drugs tested - Celexa, Zoloft, Wellbutrin, Effexor and Buspar - and wasn't designed to compare them. All proved similarly effective and relatively safe. The clear message, doctors said, was that antidepressants should be given a 6-to-12-week chance to work and that if one doesn't help, another should be tried.

"It's important not to give up if the first treatment doesn't work fully," or causes side effects, said one study leader, Dr. John Rush of the University of Texas Southwestern Medical Center in Dallas.

Two reports from the study were published Thursday in the New England Journal of Medicine.

About 15 million Americans each year suffer depression, which so often recurs that doctors sometimes talk of it as an emotional cancer that is put "in remission" rather than cured.

"We're talking about a very real public health challenge," Insel said. "This is the leading cause of disability in Americans ages 15 to 44," not just a case of "the blues," he said.

Nearly two dozen antidepressants are on the market; 189 million prescriptions were filled last year alone. Evidence on their effectiveness is limited, and the government recently ordered stronger warnings that some can worsen suicidal tendencies in teenagers in rare cases. The risk in adults is still being studied.

The big federal study first tested Forest Laboratories' Celexa, a newer type of antidepressant called a selective serotonin reuptake inhibitor, or SSRI, mostly because it's an easy-to-take daily pill.

One-third of the roughly 3,000 taking it recovered, though they generally took higher doses and were monitored more closely than most patients, researchers reported several months ago.

The new research, step 2 of the study, was on people who didn't get well the first time around. They had depression for 16 years on average and two-thirds had other mental or physical problems.

Out of this group, 727 chose to switch from Celexa to a different medication and were randomly assigned to get either Zoloft, another SSRI made by Pfizer Inc.; Wellbutrin, a non-SSRI antidepressant made by GlaxoSmithKline; or Effexor, an antidepressant made by Wyeth that works on another brain chemical in addition to the one targeted by SSRIs.
Roughly one-fourth became symptom-free within 14 weeks.

Another 565 patients chose to add a second drug to Celexa and were given either Wellbutrin or Buspar, a Bristol-Myers Squibb anti-anxiety medication that can boost the effectiveness of SSRIs.

Within 14 weeks, about one-third were symptom-free. Those on Wellbutrin had slightly fewer symptoms and side effects than those on Buspar.

The study will continue to test third and even fourth treatment attempts, and to analyze genes to see if any patterns emerge with particular drugs.

"It's quite possible in the near future we may be able to predict who's going to respond to what," said another study leader, Dr. Madhukar Trivedi of UT Southwestern.
In an editorial in the New England journal, Dr. David Rubinow of the University of North Carolina at Chapel Hill wrote that the study is encouraging, because half got well on drugs, but discouraging, because half did not.

Roughly four out of 10 people in the study were unemployed and nearly that many had no health insurance. Without access to treatment and less societal stigma toward depression, millions will continue to suffer, he wrote.
---
On the Net:
Study information:
http://www.star-d.org
http://www.nimh.nih.gov/healthinformation/stard.cfm
New England Journal: http://www.nejm.org
Read more!

Antidepressants double suicidality in children, says FDA - BMJ Journal

New York
Jeanne Lenzer

Children and adolescents treated with antidepressants are nearly twice as
likely to develop suicidality—suicidal thinking and behaviour—as similar
children treated with placebo. This is the finding of a meta-analysis of
24 studies by the US Food and Drug Administration. The studies tested 4582
patients taking nine antidepressants versus placebo for major depressive
disorder, obsessive-compulsive disorder, generalised anxiety disorder,
attention deficit or hyperactivity disorder, and social anxiety disorder.

The FDA's analysis, published in this month's Archives of General
Psychiatry is the final review of data that were previously analysed but
not released by the FDA (2006;63:332-9). News of the secret data emerged
in August 2004, and led to criticism of the FDA when it was learnt that
Andrew Mosholder, an expert in the FDA's office of drug safety, concluded
that antidepressants doubled the risk of suicidality in children, but he
was not allowed to publish his findings (BMJ 2004;329:307, 7 Aug). FDA
advisory hearings in September 2004 led FDA officials to require "black
box warnings" about the risk of increased suicidality on all
antidepressants for children.

The FDA used newly obtained electronic data at the level of the patient
and stricter definitions of suicidality to calculate the risk in this
final analysis. This was necessary, said the agency, to rule out
confounding variables that might have affected Dr Mosholder's earlier
findings.

After excluding 260 of 427 events originally deemed to be potentially
related to suicide, the agency still found that the risk ratio for
suicidality for all drugs across all indications was 1.95 (95% confidence
interval 1.28 to 2.98). The overall risk ratio for selective serotonin
reuptake inhibitors in depression trials was 1.66 (1.02 to 2.68). No
suicides were completed in any of these trials.

Ross Baldessarini, professor of psychiatry at Harvard and author of an
accompanying editorial (p 246-8) told the BMJ that he was not surprised by
the results of the FDA analysis, which he said was "probably done about as
well as one would expect." But he expressed concerns that exposure times
in patients taking the active drug might have been different from patients
taking placebo—a problem that could lead to an overestimation of risk for
children taking antidepressants.

Professor Baldessarini said that the risk profile is "only one-half of a
potential problem. The other half is that the evidence that
antidepressants are effective in juvenile depression is quite weak in
children and adolescents—even for fluoxetine, the only currently FDA-
approved [selective serotonin reuptake inhibitor] antidepressant for this
indication."

He added, "Nonetheless, it would be a mistake to conclude that it's wrong
to use antidepressants for children, and it would be unfortunate if the
FDA's findings were to discourage appropriate clinical evaluation and
treatment of depressed juveniles at risk for suicide, and especially
adolescents."

Irving Kirsch, professor of psychology at the University of Plymouth is
one of only two researchers to have published reviews of antidepressants
based on the FDA database. Dr Kirsch analysed data from all published
placebo controlled trials of antidepressants and reported that 80% of the
drugs' effects were placebo effect (Prevention & Treatment 2002;5:23).

In view of the FDA's finding that the risk of suicidality is doubled, Dr
Kirsch said, "There are three things to consider: the risk, the benefit,
and the alternatives. The benefits of antidepressants over placebo in
children are not clinically significant. On the other hand, the placebo
response is substantial. That means that one should be able to obtain the
same benefits with just about any treatment. So why choose one that may
increase the risk of suicide?"
Read more!

Mental health group struck again by Odom announcement - Durham Herald-Sun

BY GREGORY PHILLIPS : The Herald-Sun
gphillips@heraldsun.com
Mar 22, 2006 : 10:54 pm ET

DURHAM -- Durham mental health officials were thrown a curveball Wednesday in their efforts to retain control over local care.

State officials announced that a private contractor will handle administration and authorization of Medicaid-funded care for the entire state starting in July.

Although it would retain management of state-funded indigent care, The Durham Center -- which currently oversees local mental health care -- would also lose the ability to screen and refer cases outside normal business hours under the state plan.

"This is devastating news, not only for Durham, but for all of North Carolina," said Director Ellen Holliman.

The state had previously said it just wanted to limit the number of local authorities allowed to conduct utilization r
eview -- the power to manage and authorize care -- to cut $28 million from the state budget.
In a letter to local authorities Wednesday, Department of Health and Human Services Director Carmen Hooker Odom said she had "reluctantly concluded" that using a single provider was "the only way to ensure that utilization review for Medicaid Services is conducted in a consistent uniform way."

The letter cited increased oversight of Medicaid spending by the Centers for Medicare and Medicaid Services as the impetus for the decision.

State officials declined further comment.

"We're going to let that speak for itself," spokesman Mark VanSciver said.

Durham officials were braced for bad news -- the state said last month Durham would be losing utilization review, before reopening the application process -- but weren't expecting Hooker Odom's statewide ruling.

"This is not the move I thought she would make," Holliman said.

Officials have said losing utilization review could cost The Durham Center more than $1 million in funding and the loss of 15 of its 55 employees.

Holliman predicted the use of a statewide vendor would lead to more hospitalizations and removal of children from homes because care wouldn't be administered according to what's best for patients in the long run.

"We have real concerns at how state vendors will look at individual needs," she said.
After the state first told Durham officials last month they wouldn't be handling the review anymore, Durham County sued the state on behalf of The Durham Center for acting contrary to its own statutes and violating a contract with The Durham Center to manage care through July 2007. County Attorney Chuck Kitchen said Wednesday's letter doesn't impact that suit, but said local officials won't legally fight the use of a single vendor.

"We will not be contesting that because I don't think there are any grounds to," Kitchen said, although he called the state's move a "bad decision." However, Kitchen said he did anticipate filing a contested case action with the state over its plan to strip Durham of handling after-hours screening.

The state plans to have the Five Counties agency -- which comprises Vance, Franklin, Granville, Warren and Halifax counties -- handle Durham's after-hours referrals.

Reform has seen local mental health authorities gradually shift from providers to referral agencies with decreasing involvement in care as the state announces fresh cuts.

The concern is that those cuts will continue until local agencies are cut out of existence.
""What's next?" Holliman said. "That would be the fear." Read more!

Locals lobby senator for funding – The Daily Reflector

By Amanda Karr, The Daily Reflector

Wednesday, March 22, 2006

U.S. Sen. Richard Burr said Tuesday he would pursue federal funding for local initiatives, including a 24-hour mental health center and biotechnology programs.

Burr met with Pitt County and Greenville officials Tuesday morning at the Technology Enterprise Center of Eastern Carolina. The center, on North Greene Street, serves as a biotechnology incubator, housing startup companies as well as educational facilities.

During the Winston-Salem Republican's visit to Greenville, which also included a stop at East Carolina University, officials sought to highlight the importance of the center and other initiatives.

"All of these programs are for preparing our county for the future," Jimmy Garris, chairman of the Pitt County Board of Commissioners, said.

With the help of a federal lobbying firm, county officials are asking legislators to allocate $300,000 in federal money to go toward projects at the biotechnology center. Among those projects would be a BioVentures initiative that would foster the development of innovative, sustainable agriculture practices.

The county also is seeking $250,000 to fund a new 24-hour mental health crisis facility and $250,000 for job shadowing and mentoring opportunities for high school students.

The three priorities, along with a joint request with the city of Greenville for $250,000 to fund gang prevention activities, make up the county's federal lobbying agenda.

The city of Greenville is asking for $1 million to improve Martin Luther King Jr. Drive, $5 million for the 10th Street connector and $200,000 for west Greenville revitalization.

The city and county developed the priorities in conjunction with representatives of The Ferguson Group. The two municipalities have a $126,000 contract with the firm to push the local priorities in Congress.

"The needs we are asking for are very important. We tried to minimize as much as possible because we realize monies are not as plentiful as they were in the past," Greenville Mayor Don Parrott said.

Burr lauded the partnership between the city and county in developing a joint agenda.

He called the biotechnology center, which he toured, impressive. While contending tobacco has not met its demise, he touted the importance of advances in farming.

"In the global economy, biotechnology will play a large role because that is the edge (the United States) has on the rest of the world," he said.

Bonnie Currie, consumer affairs chief for Pitt Mental Health, showed Burr plans for a 24-hour mental health facility that would be located at 112 Health Drive in a building now occupied by an independent mental health service provider.

"This would be a stable place for those individuals in the middle of their crisis," she said. It would also divert people from seeking services at the emergency room or being taken to jail, she said.

"No doubt, a mental health facility is a needed asset in this community," Burr said. He warned that earmarks may not be available on a particular bill, but said he would look for other opportunities.

Burr also spoke to the group on the need for transparency in health care pricing and the lack of sustainability for Medicare, Medicaid and Social Security over the long run.

The Greenville stop was one in a series for Burr, who will be on the road throughout the week speaking with students, elected officials and civic groups.

Amanda Karr can be contacted at akarr@coxnc.com and 329-9574.


Read more!

Mental Health Screening For Kids: A Movement In The Making? -- National Conference of State Legislatures

By Anna C. Spencer
In keeping with the trend towards prevention and primary-care, some state legislators and others want the nation’s youth to be screened for possible mental illness.

According to the 1999 U.S. Surgeon General’s report on mental health, nearly 4 million children and adolescents suffer from a serious mental illness that significantly impairs their functioning at home, at school and with peers. That said, only 20 percent of these children are ever identified and receive mental health services.

Suicide is the third leading cause of death among youth aged 15 to 24, and research shows that over 90 percent of youth who commit suicide have a mental illness.  Moreover, close to 50 percent of students with mental illness age 14 and older drop out of high school, and many youth with mental illness end up in juvenile detention facilities: 65 percent of boys and 75 percent of girls in the juvenile justice system have a mental illness.  

“We know very well about the extent of mental illness among kids and how failing to identify and treat these disorders can derail the lives of these kids,” said Darcy Gruttadaro, director of the Child and Adolescent Action Center at the National Alliance on Mental Illness (NAMI). Nevertheless, “as a nation, we’ve done a very poor job of identifying children who have serious mental health needs.” But that may be beginning to change.  

In April 2002, President Bush established the New Freedom Commission on Mental Health to identify policies to improve coordination of treatments and services for adults and children with serious mental illness and emotional problems. In its final report, released in July 2003, the Commission included as one of its goals increasing the early detection of mental illness among children and young adults, by expanding screening in primary-care settings and schools.

Meeting Resistance
From birth on, children are routinely screened by physicians and school systems to ensure they are reaching physical and developmental milestones. Screening questionnaires offer a quick picture of a child’s well-being, identifying those who may require additional assessment and follow-up care.

But if vision, hearing, blood lead levels and language development are all regularly tested, emotional and social development are often left out of the picture. Mental health advocates, physician groups and school health officials all argue that children and adolescents should be routinely screened for mental illness. Those who might need treatment could then be further assessed and, if need be, treated. Research shows that early detection, assessment and links to treatment can prevent mental health problems from worsening.

A study in the British Journal of Psychiatry in 2002 found that children who do not receive treatment for depression and conduct disorders continue to have these problems in adulthood, use more health-care services as adults, and have higher health-care costs than other adults.  Children with untreated mental illness also are more likely to experience school failure, have poor employment status and live in poverty as adults. 

Mental health screening can be an “extremely helpful tool,” said Minnesota Rep. Mindy Greiling. There is a “huge range of what is normal during childhood and adolescence,” and mental health exams can “either affirm a nagging feeling a parent has that something is wrong or assure [parents] that everything is normal.”  

But if advocates strongly support mental health screening, others oppose adding yet another assessment to the list of exams that children undergo. Some argue that children’s mental health should be handled by the family, not the school or state, and others add that such screening is based, at best, on shaky science – they fear that mental health testing will incorrectly label healthy children as mentally ill.

“This widespread net-casting doesn’t make any sense, and nobody benefits from screening,” said Dr. Karen Effrem of EdAction, a nonprofit consumer protection group. Effrem argues that mental health diagnoses are based on a subjective process and, as a result, “any screening tool designed to pick up these subjective measures is inherently flawed.”

Effrem said she supports suicide prevention efforts, but she believes that screening for mental health problems in high schools overstates the normal and generally temporary traumas teens experience. As a result, “kids are funneled into long-term counseling and/or drug therapy,” neither of which has been proven to be effective in children or adolescents, she said. “There is very little evidence that psychotropic medications work in children, yet we continue to overmedicate [them],” Effrem said. “It’s dangerous.”
Greiling said she understands the vehement opposition to mental health screening. American culture is “hush-hush” about mental illness, she noted, arguing that’s all the more reason for talking openly about normal social and emotional development and evaluating it on a regular basis. Mental health screening is a “critically important part of ensuring the overall welfare of children,” Greiling asserted. “In the end, it’s more damaging not to help kids than it is to screen them.”

A number of states are considering following the recommendations of the New Freedom Commission report by implementing mental health screenings for children and adolescents. In 2005 the Minnesota Legislature considered a bill that would have expanded pre-school screening to include a “socio-emotional development” component. The bill didn’t pass, but Rep. Greiling is pursuing her agenda by planning to convene a group of legislators in April to discuss mental illness. “We need a critical mass of lawmakers who understand mental illness, as well as the benefits of early screening,” she said.

In 2003, Illinois passed the Children's Mental Health Act, which called for the development of a Children's Mental Health Plan. The plan includes short- and long-term recommendations on how Illinois can improve the coordination of prevention, early intervention and treatment services for children at risk for mental illness from birth to age 18. The plan also proposes increasing the number of “periodic social and emotional development screens” a child receives, as part of regular medical check-ups and in school settings.

A Model Program for Adolescents
Recognized as a model program by the National Freedom Commission, Columbia University’s “TeenScreen” program is designed to identify youth who may be at risk for suicide or are suffering from an untreated mental illness. The program, which was developed in 1991, currently is used in 42 states in over 450 schools (see map). While each site operates independently, they all adhere to the national program’s implementation standards and requirements.

TeenScreen provides consultation, screening materials, software, training and technical assistance free to qualifying schools and communities. In return, partners are expected to screen at least 200 youth per year and to ensure that a licensed mental health professional (at the school or in the community) is available to provide immediate counseling and referral services for the youth at greatest risk.

The program requires that screening be voluntary for students and that parental consent be obtained. TeenScreen also strongly recommends that parental consent be “active” rather than “passive.” This means that parents must sign a consent form and students must return the form prior to answering the screening questionnaire. Roughly 90 percent of TeenScreen programs obtain consent this way. Passive consent would mean that information was sent home to parents, but students were not required to return a signed form to participate. Teens also must agree to participate, and they are given the right to refuse to answer any question. 

While TeenScreen has been proliferating in high schools across the country in recent years, the program has also met strong resistance in some quarters. “There has been a lot of misinformation about the program out there,” said Leslie McGuire, director of TeenScreen. “First, this is not universal or mandatory screening. Kids are not being coerced into taking the TeenScreen questionnaire because we absolutely require parental consent, and teens must also agree to participate.” 

In addition, during the screening process, participants are never labeled with any sort of mental illness. “We’re not in the business of diagnosing teenagers, we simply identify kids who may require a more in-depth evaluation,” McGuire said. And in the end, parents decide how to proceed with the information. “We don’t advocate for any type of treatment or endorse one medication over the other. Our primary goal is simply to see that the kids who need help get it.”

McGuire points to research that “clearly demonstrates” TeenScreen is highly effective in identifying kids who may be at risk for suicide or have other mental health problems. In a study of 2,000 high school students who participated in TeenScreen, 74 percent of students who were contemplating suicide and 50 percent of students who had made a prior suicide attempt were not previously known to be having problems by school personnel. In addition, 69 percent of students who had symptoms of depression were also undetected. “The questionnaire offers students a confidential and safe way to share information that they might not otherwise be able to share with their parents or school personnel,” McGuire said.

Research shows that exposing kids to information about suicide and asking them questions about the topic does not make them any more likely to contemplate or attempt suicide, or cause them undue distress. A study in the April 2005 issue of the Journal of the American Medical Association showed that depressed teens and previous suicide attempters who are screened are less distressed and suicidal than depressed teens and previous suicide attempters who are not screened.  Read more!

Successful treatment of mothers with depression helps their children, too – AMA Journal

EurekAlert! Public News List

DALLAS * March 21, 2006 * Children whose mothers are depressed are more likely to suffer from anxiety, mental-health problems and disruptive behavior than those whose moms aren't. And if the mothers don't get better, these kids' problems often become worse, new research shows.

Conversely, however, children whose mothers are successfully treated for their depressive symptoms show significant improvements themselves * without any additional intervention or treatment of their own.

The study, available online today in the Journal of the American Medical Association, is the first, large-scale examination of the effects on kids when their mothers are treated for depression and scientifically monitored for a period of time. UT Southwestern Medical Center was one of several national sites participating in the study, which emphasizes the importance of evaluation and treatment of parental depression in an effort to help children and adolescents.

"The bottom line message is: 'Mothers who are depressed, go get treated for your depression. It will help not only you, but your child,'" said study co-author Dr. A. John Rush, vice chairman of clinical sciences and professor of psychiatry at UT Southwestern.

About one in 20 teens suffers from moderately severe to severe depression; it is one of the most common disorders of adolescence, according to the National Institute of Mental Health (NIMH). This means that in a high school population of 2,000 teenagers, 100 are likely to have a significant major depressive episode on any given day.

"Depression should not be taken lightly," said Dr. Madhukar Trivedi, study co-author and professor of psychiatry at UT Southwestern. "For kids' sakes particularly, we should be very aggressive in treating patients, particularly mothers. The more improved care we can provide to depressed mothers, the more benefit to their children."

Part of the largest national clinical trial on treatment for depression, called STAR*D (Sequenced Treatment Alternatives to Relieve Depression) * coordinated by UT Southwestern and funded by the NIMH * the mother-child study included more than 150 pairs of mothers and their children, who varied in age from 7 to 17. The mothers were treated for depression in eight primary-care and 11 psychiatric outpatient clinics across the country as part of the $35 million six-year STAR*D study.

Dr. Rush said mothers were studied rather than fathers because the rate of depression is higher in women than men, particularly in women of childbearing ages. Mothers are also more likely than fathers to bring their children in for assessments.

Children participating in STAR*D-Child were evaluated for depression at the beginning of the study and then reassessed after their mothers had been on antidepressant medications for three months. Many came into the study with significant problems * more than one-third had current psychiatric disorders including anxiety, depression and/or other disruptive behavior disorders. Almost half had a previous psychiatric disorder.

Three months later, kids whose moms remitted (or recovered from all depressive symptoms, based on a widely used measurement scale) showed an overall 11 percent decrease in rates of diagnoses for depression, as compared to an approximate 8 percent increase in rates of diagnoses in children of non-remitted mothers.

Of the children who were diagnosed with depression at the study's beginning, remission was reported in 33 percent of those whose mothers remitted, compared to only 12 percent remission rates in those whose mothers did not. Of the children with no diagnoses of depression at the study's onset, all children of remitted mothers remained symptom-free, while 17 percent of the children of non-remitted mothers acquired a diagnosis of depression during the three months.

Mothers who did not fully remit after three months, but did respond (showed a decrease in depressive symptoms by at least 50 percent) also had children who showed improvement. Additionally, when overall study results were analyzed based on mothers' educational levels, or both income and education, the statistics remained unchanged.

"A mother's depression does affect her kids," said Dr. Carroll W. Hughes, professor of psychiatry and rehabilitation counseling at UT Southwestern. "When she gets treated and gets better, lo and behold, her kids improve, too. A parent's depression not only has a strong impact on the family as a whole, but it often affects a child's functioning. It points out the need for parents to seek treatment for their depression."

The study's lead author, Dr. Myrna M. Weissman, as well as several other researchers are from Columbia University and the New York State Psychiatric Institute. Also included were researchers from Vanderbilt University; the University of North Carolina; the University of Michigan; the University of California, San Diego; Virginia Commonwealth University; Harvard University; and the University of Pittsburgh.  of experts to discuss state mental health reform  Read more!

Parents, kids rush to adapt: A shift in mental health funding leaves some without help - Raleigh News & Observer

Raleigh N&O

LYNN BONNER, Staff Writer

The state's mental health services reached a milestone Monday with the launch of a system designed to offer more care close to patients' homes.

This week, the federal government begins paying about two-thirds of the state's cost for mobile crisis teams that go to patients' homes, expanded treatment for drug addicts and alcoholics, and help for teenagers with behavioral problems.

For some parents, though, the weeks leading up to the changes were a scramble to secure classroom help for their developmentally disabled children. The federal government is no longer paying for some classroom aides assigned by local mental health offices to work one-on-one with students.

About 400 children lost classroom aides paid for under a Medicaid program called Community-Based Services. Some of those students were moved to another Medicaid program, allowing their one-on-one classroom help to continue. The state Division of Mental Health is picking up the cost for others. But parents who found no alternatives were jolted by the changes.

"The schools don't appear to be ready to provide services to the end of this year," said Doug Sea, a Charlotte legal aid lawyer who is advising parents how to make sure their children receive the appropriate help.

For Craige Moore of Wilson, the effort to make sure his son, Ramsay, would continue to have an aide for three hours during the school day meant a trip to Raleigh to talk to his legislator and state public school officials and a stream of letters to the Wilson County school superintendent.

Ramsay, 13, has Down syndrome and autism. Moore was frustrated by the Wilson County school district's slow reaction to the lost services. He didn't know until late last week that Ramsay would keep his aide for the rest of the year. Moore doesn't know what will happen next year.

"That'll be a whole new battle," he said.

Larry Price, Wilson's school superintendent, said the changes caught administrators off guard and the district was not prepared to take on the cost of about a dozen aides. He estimated the cost at $250,000.

"We don't do mental health services in the public schools," Price said, "That's not been our responsibility."

The district has tried to compensate for the lost aides by adding teacher assistants to classrooms, Price said, and scheduling individual assessments for students to see if they qualify for extra help offered through the schools.

Some districts relied more than others on classroom aides assigned by mental health offices. Wake County and Chapel Hill-Carrboro schools don't use them. Durham County schools worked to whittle the number of children using community-based services aides from 200 last year to 60 this year, said Ellen Holliman, director of The Durham Center, the county's mental health office. Most of those 60 children who lost the community-based services aides are getting help through other Medicaid programs, Holliman said.

The mental health changes prodded school districts to evaluate the outside services children receive, said Diann Irwin, an official with the state Department of Public Instruction. Some children assigned mental health workers needed assistants to help them with hygiene.

Even with the deadline passed, the advocates for the developmentally disabled remain on alert for cases where help is dropped and no replacement offered.

"The calls I received at this office are from from families with kids who have really significant needs," said Linda Guzman of the Arc of North Carolina. "They need somebody close by for safety."

Staff writer Lynn Bonner can be reached at 829-4821 or lbonner@newsobserver.com.



Read more!

Why Did Nicholas Die? - South Bend Tribune

[Editor's Note: We previously shared another article from the excellent investigative series "Out of Sight," by Alicia Gallegos, which detailed how Nicholas Rice became trapped in the criminal justice system because of actions caused by untreated schizophrenia.

In the final installment of the series, we see how he died - died from the intensified symptoms of his illness, a lack of treatment for them, and - perhaps most of all - unthinking neglect.]

WHY DID NICHOLAS DIE?

By Alicia Gallegos, Tribune Staff Writer

When the first Elkhart County autopsy report surfaced months after Nicholas Rice died, Coroner Jeff Landrum refused to sign the death certificate.

The pathologist had listed "diffuse acute pulmonary edema" as the initial cause of death for Nicholas, an inmate found dead in his jail cell a week before Christmas.

But the coroner had questions about the report from the beginning, he says now, and "respectfully disagreed" with the pathologist's conclusion.

Pulmonary edema is a condition where fluid fills a person's lungs, leading to heart failure.

Landrum, after talking with Nicholas' family and researching his background, believed they should dig deeper.

He would also have been a fool, he admits, not to take into consideration the private autopsy results by Dr. Werner Spitz, a Michigan forensic pathologist and toxicology consultant who has worked on high-profile cases around the country, such as those involving JonBenet Ramsey and Nicole Simpson.

When examining Nicholas' body, Spitz saw the young man's visibly sunken eyes and cheeks. He noted how much weight he'd lost.

In Spitz's opinion, malnutrition and dehydration caused Nicholas' death. His report was based on the inmate's past diagnosis of undifferentiated schizophrenia with "untreated anorexia, refusal to eat, drink, and take medication, severe progressive weight loss" and no evidence of disease or injury.

Even for Spitz, the finding was rare.

"You don't usually (get) dehydrated when you are in jail," Spitz says. "You don't usually die of the condition that Nicholas Rice did."

The famous pathologist concluded that "pulmonary edema" was the result of the process of dying, not its cause.

***

It's hard to believe her son would starve himself to death, Diane Waldrop says.

When Nicholas was younger, he loved to devour any greasy, fatty food in sight. He was in good health when he went to the Elkhart County Jail on the attempted bank robbery charge, she says.

The county's second autopsy was completed in March 2005, and Nicholas' death certificate was signed. The final findings included schizophrenia, malnutrition, and dehydration.

Although mental illness is frequently a factor in deaths, Landrum says that in his experience of more than 1,000 death investigations, it is rarely listed as a direct cause. And malnutrition is certainly unusual in a 22-year-old man.

***

The words "forever in our hearts" are etched into the back of the gray stone. The front reads:

Nicholas Dale Rice

July 17, 1982

December 18, 2004

His parents finally laid their oldest son to rest in July 2005, right before what would have been his 23rd birthday.

The spot in Spring Run Cemetery in Stevensville is next to the grave of his grandfather, who died during the 16 months Nicholas was in jail.

Diane hopes her father is looking after her son.

It feels like more than just a year since Nicholas has been gone, she says. He was in jail for so long.

It's not the same seeing someone behind glass. The last time Diane hugged her son was almost two years ago inside a Michigan psychiatric hospital.

She remembers early December 2004 and how she fixed up his old room, buying brown curtains and throw pillows for his bed, so excited Nicholas was about to find psychiatric help.

She thought he was strong enough to hold on, she says as the tears come.

She thought he would make it home.

***

In his one-bedroom apartment on Third Street in Goshen, manila folders are stacked on Rick Rice's coffee table and lie in groups on his hardwood floor. Piles of medical records, jail logs and research articles are spread around his couch.

Some of the papers are coffee-stained, their corners dog-eared. He often turns to one document dated Oct. 5, 2004, an emergency detention form for his son signed by a jail psychiatrist.

It is a warning that went unheeded, Rick says, and the message continues to plague him.

"Patient is dying from malnourishment," the form reads. "Applicant believes that if the person named above is not restrained immediately he will die."

Nicholas was taken from the jail and treated for dehydration at a local hospital two months before he was found dead.

Rick didn't find out about the visit until it was too late.

"There's so many things that could've been done that they didn't do," he says. "They all dropped the ball. This was such a mess."

Rick and Diane plan legal action against Elkhart County, the sheriff's department and the company that provides medical services to jail inmates. A tort claim has been filed.

Elkhart County Sheriff Michael Books declined to comment about the case. But police attorney Michael DeBoni says Nicholas did not die because of lack of medical care by the police department.

Officers rely on the professional judgment of medical providers, he says, and the sheriff does everything in his power to ensure inmates receive necessary care.

***

After logging many hours at the public library, poring through research manuals on dehydration and reading papers on mental illness during his lunch hour at the RV plant, Rick seems to know every symptom, sign and definition.

If he had known his son was in danger, he says, he would have known to do something to save Nicholas.

"I would've camped out on the lawn of the courthouse," he says.

The Elkhart County Jail, where his son literally starved himself to death, is blocks away from his home. He passes the courthouse every day. Ambulance sirens blaring down the road remind him.

But he also remembers before Nicholas was locked away, the summer barbecues the father and son enjoyed beside the river years ago.

Nicholas always talked about being famous, moving to California to be a movie star like his idol, George Clooney.

"I'll probably make it as an actor someday," he used to say. He wanted to be noticed.

Maybe his son's death will bring attention to mental illness, Rick says.

Maybe Nicholas will be noticed now.
\ Read more!

New Jersey To Extend Age Of Dependency For Health Insurance To 30 - Medical News Today

Article Date: 21 Mar 2006 - 23:00pm (UK)

New Jersey in May will increase the age of dependency for health insurance to 30, the oldest in the nation, USA Today reports. Under a new law, unmarried adults younger than age 30 who do not have dependents and live in New Jersey can receive health insurance through their parents, regardless of whether they are students or reside with their parents.

The law does not apply to parents who receive health insurance through the federal government or large companies with self-insurance. New Jersey Assembly member Neil Cohen (D), who sponsored the law, estimates that the legislation might benefit as many as 200,000 young adults in the state.

Some specifics of the law, such as the additional health insurance premiums for parents of young adults, remain undetermined. Cohen estimated the additional health insurance premiums for young adults at $1,200 to $2,000 annually, but the New Jersey Department of Banking and Insurance estimates the additional premiums at $2,400 to $6,000 annually

The law has raised concerns among health insurers. Susan Pisano of America's Health Insurance Plans said that the law is "too broad and may have unintended consequences, making coverage for those who are part of employer groups more expensive."

According to USA Today, six other states in the past few years have increased their ages of dependency, and several more states have considered such proposals (Jayson, USA Today, 3/16).
Read more!

Violence Against Homeless Targeted - Morning Sentinel, Waterville Maine

MORNING SENTINEL (Waterville, ME), March 10, 2006
[Editor’s Note: Below others debate whether crimes against those who are homeless should be punished differently than criminal actions against others. We remind you that there is another way to reduce the amount of violence against homeless individuals. One-third of the chronic homeless have a serious mental illness. For many of them, treatment can lead to finding or accepting housing and a lessened vulnerability to the criminal aggression of others.]
 
VIOLENCE AGAINST HOMELESS TARGETED
By Susan M. Cover, Staff Writer

AUGUSTA -- Homeless advocates were cheered Thursday after a legislative committee gave a positive vote to a bill that they hope could help reduce violence against homeless persons.

The bill, sponsored by Rep. Patricia Blanchette, D-Bangor, makes homelessness a factor to be considered by judges and district attorneys when determining sentences.

It does not mandate a specific sentence if a victim is homeless. But it is designed to raise awareness of what supporters describe as a growing trend of violence against the homeless.

The four members of the Criminal Justice and Public Safety Committee who were absent for Wednesday's vote on the bill registered their opinions with the committee clerk, changing the committee recommendation from 5-4 against, to 8-5 in favor.

All four who were absent -- Rep. Kimberly Davis, R-Augusta; Sen. John Nutting, D-Leeds; Rep. Christian Greeley, R-Levant; and Rep. Stan Gerzofsky, D-Brunswick -- voted in favor of the bill.

Steven Huston of the Preble Street Consumer Advocacy Project said he's glad the bill will move forward to the House and Senate with a positive recommendation.

"Even a homeless person can go to Augusta and show their cause is important," he said. "It's a clear picture you can go and speak-up."

Those who voted against the bill said they aren't convinced that the homeless are victimized simply because they are homeless.

They also suggested that the state should spend time and resources tackling the problems that cause homelessness, rather than pass new laws regarding sentencing.

Supporters, including Attorney General Steven Rowe, said it's important to make it clear that violence against the homeless, who are particularly vulnerable, is not acceptable in Maine. Recent videos and movies have encouraged what's known as "bumfighting," in which teens beat-up people who are homeless.

The proposed state law now moves forward to the House of Representatives for consideration. Read more!

Mother: "I feel let down by the system" - Shelby Star

Graham Cawthon
Star Staff Writer

SHELBY — A teen featured in a 2003 article in The Star detailing his mother’s fight to find treatment for his mental illness is in trouble again.

And his mother says it’s the same problem as before — the system is letting her down.

Breaking and entering. Larceny. Robbery. Assault with a deadly weapon. Attempted robbery with a deadly weapon. Possession of a stolen firearm.

Those are some of the 11 charges against 18-year-old Jason Jawon Roberts, who was arrested last week after police say he shot Charles Stanley Williams, 40, outside Southern Convenience at 400 W. Dixon Blvd. Police have since tied Roberts to a series of recent crimes.

Roberts’ mother knows this is a situation that didn’t have to happen.

“I am deeply, deeply sorrowful for what happened,” said Lesia Roberts.

Ms. Roberts said Jason has struggled with Attention Deficit Hyperactivity Disorder and bipolar disorder since the age of 10 and just a few weeks ago attempted suicide in the family’s kitchen.

While she makes no excuses for his actions, she said Jason needs more help than she or the county has been able to provide.

“It was senseless,” she said. “He should have still been institutionalized.”

Ms. Roberts, a single parent of five, said she had her son committed after the attempted suicide, but he was released 72 hours later against her wishes.

“I feel let down by the system,” she said.

Ms. Roberts said she was in disbelief when she was told Jason had shot someone: “What mother wants to hear ‘your child has been arrested for attempted murder’?”

While she worries about her son and hopes he receives a fair trial, Ms. Roberts said her heart and prayers go out to Williams.

“I’m more concerned about the man,” she said. “He didn’t deserve this. He’s an innocent victim.”

The Star followed Ms. Roberts for a month in 2003 and documented her struggle to obtain proper care for her son as Jason was in a revolving door in and out of jail, hospitals and group homes.
Read more!

Pauley Talks About Dealing With Bipolar Disorder

Listen to interview

Husband Noticed Mood Changes In Famed Reporter

SMITHFIELD, R.I. -- Jane Pauley's come a long way from telling the story. These days, her own story is making news.

It started with the treatment of a medical illness, hives. That treatment, she said, triggered her bi-polar disorder.

"Unbeknownst to me or anybody else, I had a vulnerability to bipolar disease. I didn't have bipolar. I wasn't bipolar but somewhere in my genetic background was a predisposition," Pauley said.

She would be depressed.

"After some months of a depression, not significant enough to keep me from working, I was still on "Dateline", but it had been kind of a tough slog for me for six, eight months," Pauley said. "Suddenly, suddenly, I am energized, I have ideas and not nutty ideas. I had good ideas. I just had a lot of them."

It was her husband who noticed the mood changes, but the diagnosis came from her doctor.

"I am on medication and will remain on medication my whole life, I assume," she said.

Pauley said she's living proof that treatment works and her goal is to help people realize mental illness is a medical illness.

"You know, the brain is an organ like the other ones that can break down and that in the course of a normal life, getting sick is normal," she said. "Mental illness sounds abnormal, but being sick isn't.

"My goal is that a mental illness simply becomes one of those bad things you don't want to get, but if you do, you take care of it."
Read more!

Our View: Mental health reform still looks like a leap in the dark- Fayetteville Observer

Right now, North Carolina ranks 43rd among the states in providing money for mental health and was given a D-plus by the National Alliance for the Mentally Ill. But don’t worry. All of that is about to turn around, starting next Monday.

“The rubber is hitting the road right now,” said Mike Moseley, the state’s director of mental health. “A lot of people were taking a wait-and-see attitude, but on March 20 that’s going to change. At that point it is about the services and the clients.”

Here’s how the miracle works. The state sends large numbers of troubled people back into their home communities, where they’ll be cared for by friends, family or local providers — preferably from the private sector — with the state putting up money to help ease the transitions.

Unsolicited advice to Dr. Moseley: Be right. Every reasonable person understands that this miracle isn’t going to happen overnight. But if the result is a bureaucratic train wreck, nobody’s going to mistake it for anything else. We’ll know by the shattered lives, disrupted recoveries and rising costs of law enforcement, court hearings and emergency psychiatric admissions.

By the way, it’s not all about services and clients. It’s about getting the appropriate services to the clients, which means it’s also about money, facilities, competence, oversight and accountability — in every city and county in our state. And we know right now that not every community is ready.

As taxpayers and as human beings who want to help those in chronic psychic pain work their way back into society, every one of us should hope for the success of reform. Realistically, we should also be thinking about the wisest, most cost-effective response to failure. The odds are not good.

“The goal of reform,” Moseley wrote a couple of years ago, “ is to ensure that persons with disabilities are provided with the services and supports they need to live productively and fully as residents of our state.”

Anyone can say amen to that. But who’s responsible for the ensuring? Who’s going to pay for the services and supports? Who will administer them? What are their budgets, their qualifications, their experience?

What about the clients whose “family and friends” are in fact part of the problem? And what of patients with brain-chemistry imbalances who are cut from entitlement programs for the sake of a mock fiscal austerity in the nation’s capital, and can no longer afford medicine or psychiatric services? What about those for whom there is no medical route to recovery? Where will they live? Who will care for them?

The legislature has consistently budgeted too little money for this sweeping change, and care costs have skyrocketed, while state and local budgets were being wrung dry. This plan may already have been undermined by new fiscal realities.

“Good luck,” in this instance, is more than encouragement. It’s the best hope for thousands of suffering people who will be anxiously awaiting this miracle.


Read more!

Court Orders Community Mental Health Services for Thousands of California Foster Children

The decision
Background: Court Asked to End California’s Denial of Services to Foster Children
On March 14, 2006, the federal district court in Los Angeles ordered the state of California to provide mental health services that will enable tens of thousands of foster children to avoid institutional care.

The order came in a three-year-old class action lawsuit known as Katie A. v. Bonta, which challenges the longstanding practice of confining abused and neglected children in costly hospitals and large group homes instead of providing mental health services that would enable them to stay in their own homes and communities.

“This order is a tremendous victory for California’s most vulnerable children and should lead to major restructuring of how mental health services are delivered to foster youth,” said Robert Newman, an attorney at the Western Center on Law & Poverty and lead counsel in the case.

“The big question is whether the Governor and the departments of health and social services will accept the challenge and rethink outdated policies,” said Melinda Bird, managing attorney of Protection & Advocacy, Inc., “or will they continue with business as usual, removing children needlessly from their homes and wasting money on services that often do not work.” The court set a 120-day time frame for the state to comply with its order.

More than 80,000 children are in foster care in California. Various studies find that from 70% to 84% of them experience a mental health problem. The state’s current approach to addressing their needs through institutional care is costly. For example, it is spending $540 million each year to maintain 4,500 children in high-level group homes—placements that experts testified could be avoided by offering appropriate services in the community.

In his order granting a motion for preliminary injunction, Judge A Howard Matz found “substantial evidence” that the two key services he instructed the state to provide, wraparound services and therapeutic foster care (TFC), “actually save the State money, compared to alternatives involving institutionalization.” Adding these services to California’s Medi-Cal program will also bring in additional dollars because the federal government reimburses the state for about half of the cost.

Some California counties currently provide these services to some children, but fall far short of meeting the need. Nationally, almost half of state Medicaid programs cover TFC, and several Medicaid programs also cover wraparound services.

“If California meets this challenge, it will set an excellent example for the many other states that continue to neglect their foster children,” said Ira Burnim, legal director of the Bazelon Center for Mental Health Law, a national advocacy group. “The court heard from the leading experts in the field that wraparound and TFC, provided in a family setting, ‘can turn around a child’s negative trajectory and produce virtual miracles.’”

However, “without appropriate services, children with mental disabilities bounce between foster home placements and group homes,” said Patrick Gardner, deputy director of the National Center for Youth Law. “When their worsening mental condition renders them ‘unplaceable,’ they are abandoned to languish in institutions or pushed into the juvenile justice system.”

During 18 months in the foster care system, “Nancy,” a teenager, had shuttled through nine different residential placements and 11 psychiatric hospitalizations, including a group home six hours away from her mother. In one group home she was beaten by older girls and in another she ran away and was raped while wandering the streets. She continually attempted suicide but the local child welfare agency eventually told her mother that they could do nothing for Nancy and that the only way she would get the services she needed was through the probation department.

A consortium of state and national public interest groups represents the children, including Western Center on Law & Poverty, Protection & Advocacy, Bazelon Center for Mental Health Law, the National Center for Youth Law, and the American Civil Liberties Union of Southern California, along with the law firm of Heller Ehrman LLP.Court Orders Community Mental Health Services for Thousands of California Foster Children

More information
The decision
Background: Court Asked to End California’s Denial of Services to Foster Children
On March 14, 2006, the federal district court in Los Angeles ordered the state of California to provide mental health services that will enable tens of thousands of foster children to avoid institutional care.

The order came in a three-year-old class action lawsuit known as Katie A. v. Bonta, which challenges the longstanding practice of confining abused and neglected children in costly hospitals and large group homes instead of providing mental health services that would enable them to stay in their own homes and communities.

“This order is a tremendous victory for California’s most vulnerable children and should lead to major restructuring of how mental health services are delivered to foster youth,” said Robert Newman, an attorney at the Western Center on Law & Poverty and lead counsel in the case.

“The big question is whether the Governor and the departments of health and social services will accept the challenge and rethink outdated policies,” said Melinda Bird, managing attorney of Protection & Advocacy, Inc., “or will they continue with business as usual, removing children needlessly from their homes and wasting money on services that often do not work.” The court set a 120-day time frame for the state to comply with its order.

More than 80,000 children are in foster care in California. Various studies find that from 70% to 84% of them experience a mental health problem. The state’s current approach to addressing their needs through institutional care is costly. For example, it is spending $540 million each year to maintain 4,500 children in high-level group homes—placements that experts testified could be avoided by offering appropriate services in the community.

In his order granting a motion for preliminary injunction, Judge A Howard Matz found “substantial evidence” that the two key services he instructed the state to provide, wraparound services and therapeutic foster care (TFC), “actually save the State money, compared to alternatives involving institutionalization.” Adding these services to California’s Medi-Cal program will also bring in additional dollars because the federal government reimburses the state for about half of the cost.

Some California counties currently provide these services to some children, but fall far short of meeting the need. Nationally, almost half of state Medicaid programs cover TFC, and several Medicaid programs also cover wraparound services.

“If California meets this challenge, it will set an excellent example for the many other states that continue to neglect their foster children,” said Ira Burnim, legal director of the Bazelon Center for Mental Health Law, a national advocacy group. “The court heard from the leading experts in the field that wraparound and TFC, provided in a family setting, ‘can turn around a child’s negative trajectory and produce virtual miracles.’”

However, “without appropriate services, children with mental disabilities bounce between foster home placements and group homes,” said Patrick Gardner, deputy director of the National Center for Youth Law. “When their worsening mental condition renders them ‘unplaceable,’ they are abandoned to languish in institutions or pushed into the juvenile justice system.”

During 18 months in the foster care system, “Nancy,” a teenager, had shuttled through nine different residential placements and 11 psychiatric hospitalizations, including a group home six hours away from her mother. In one group home she was beaten by older girls and in another she ran away and was raped while wandering the streets. She continually attempted suicide but the local child welfare agency eventually told her mother that they could do nothing for Nancy and that the only way she would get the services she needed was through the probation department.

A consortium of state and national public interest groups represents the children, including Western Center on Law & Poverty, Protection & Advocacy, Bazelon Center for Mental Health Law, the National Center for Youth Law, and the American Civil Liberties Union of Southern California, along with the law firm of Heller Ehrman LLP. Read more!

The debate over mandatory outpatient commitment - Harvard Mental Health Letter

[Editor’s Note: This month’s Harvard Mental Health Letter offers an overview of assisted outpatient treatment. It is a balanced and, given its length, insightful summary of the treatment mechanism.

In noting that it "included only a small number of patients, none of whom were violent, and there was no effective enforcement mechanism," the newsletter accurately describes some of the limitations of the Bellevue Study – one of the very few (of many) examinations to find no statistically significant beneficial effect of AOT. It does not mention, however, that members of the control group were hospitalized for a median 101 days in 11 months while the median person under an AOT order experienced only 43 days of hospitalization. Because of the small size of the study, this seemingly dramatic result did not reach the level of statistical significance; as it stands, it was certainly significant for the participants.]
 
Outpatient Commitment.
The emptying of mental hospitals began a half-century ago with the hope that effective treatment would be available on the outside, and patients would be willing to accept it. But for many neither of those conditions has been met. Many thousands of so-called revolving-door patients consume a disproportionate share of the resources of the health care and criminal justice systems as they move between jails, prisons, emergency rooms, psychiatric hospitals, rented rooms, group homes, and the street.

At any given time, a third to half of people with schizophrenia or bipolar disorder are not receiving treatment, and a third of the homeless are mentally ill. Many are too discouraged or disorganized to take any initiative. Some will not agree to treatment because they are isolated and withdrawn, or paranoid and suspicious. Others refuse help because they wrongly believe they are doing well enough without it. Court-ordered treatment -- known as outpatient commitment, mandatory outpatient treatment, or assisted outpatient treatment -- has been proposed as a partial solution to this problem.

What Are The Standards?
The laws of more than 40 states permit outpatient commitment, mainly for patients who are actually or potentially dangerous to themselves or others. The best-known state law is Kendra’s Law, passed in New York in 1999 after a woman was pushed under a subway train by a man with schizophrenia. Under the New York law, which is fairly typical, assisted outpatient treatment is authorized for people who, because of failure to comply with treatment, have been in a mental hospital, prison, or jail within the last three years or have committed an act of violence in the last four years. To be committed, they have to be in danger of relapse or deterioration that would result in physical harm to themselves or others.

Many mental health professionals believe the standards should be less strict, with a focus on deterioration alone. A study group appointed by the American Psychiatric Association issued a report in 1999 recommending outpatient commitment to prevent relapse or severe deterioration that would make patients either dangerous or unable to care for themselves.

It’s much simpler to require mandatory treatment for the mentally ill if they use illicit drugs or (less often) commit other minor crimes. No formal judgments about dangerousness or deterioration are necessary. Addicts can be sentenced to drug treatment in lieu of or in addition to imprisonment. In some places, courts arrange to provide treatment for mentally ill lawbreakers. In mental health courts, defendants who plead guilty are assigned to outpatient treatment instead of prison.

The Debate
Critics say that outpatient commitment is an attack on privacy, autonomy, and the right to travel. They also say that it undermines the therapeutic relationship, reduces the long-term potential for independent living, drives patients away from seeking treatment, and diverts resources from voluntary patients. They insist that the dragnet of outpatient commitment will entrap people who don’t need it.

Defenders of mandatory outpatient treatment say that it promotes compliance, especially regular use of medications; mobilizes support services; lowers the risk of homelessness, psychiatric hospitalization, and substance abuse; and makes it less likely that patients will be victims or perpetrators of violence. They say there is no evidence that people are prevented from seeking treatment and point out that patients and their families rarely raise objections. They say outpatient commitment will not divert resources as long as extra funding is supplied. It will not be authorized for people who don’t need it if they have legal representation, regularly scheduled reviews, and the right to appeal decisions. In response to the argument that outpatient commitment infringes on civil liberties, its defenders argue that people are not free when their minds are in thrall to illness.

Apart from these issues, enforcement is a problem. In some states, patients who do not comply can be brought to a clinic by police. Some think this should be allowed when it is authorized by a judge based on evidence presented by a clinician; others think there should be a formal hearing. Involuntary hospitalization is a solution only for patients who present an imminent danger. Telling them that they will be hospitalized unless they take their medications may sometimes be impractical because resources are limited.

What The Studies Show
The New York State Office of Mental Health issued a report on Kendra’s Law in 2005 and pronounced it a success. From 1999 to 2004, nearly 4,000 court orders were issued, usually for six months, and in two-thirds of cases the orders were renewed. About 70% of the patients committed under the statute had schizophrenia and 13% had bipolar disorder. The report found that after commitment these patients were more likely to take their medications and less likely to be homeless, arrested, or hospitalized. In interviews, nearly two-thirds of the patients said they thought that the court order had been good for them.

There are other favorable reports about outpatient commitment but only two controlled studies. In a trial conducted at Duke University, patients discharged from a psychiatric hospital were assigned at random to community treatment alone or to outpatient commitment with community treatment. The researchers found that after a year, patients assigned to outpatient commitment had a better quality of life because they were more likely to comply with treatment and less likely to be victims of violence. The rate of psychiatric hospitalization was the same in both groups under the original three-month commitment order. Most of the advantage for outpatient commitment arose after that three-month period, when the study was no longer controlled.

The second controlled study, a three-year pilot project at Bellevue Hospital in New York City, found that outpatient commitment made no difference in the effectiveness of intensive community treatment. The study included only a small number of patients, none of whom were violent, and there was no effective enforcement mechanism.

In an independent analysis for the Cochrane Collaboration, reviewers in 2005 concluded that the only strong evidence for the value of outpatient commitment came from the findings of the Duke study on the risk of criminal victimization.

Willingness to accept treatment is only one side of the problem that has led to calls for outpatient commitment; the availability of treatment is the other side. Everyone agrees that mandatory outpatient treatment requires a plan that includes intensive services. But often those services are not available because the public mental health system is poorly organized and underfunded. Mandatory treatment laws, taken seriously, could be an incentive to provide the needed organization and funding. But it’s also possible that if better services were available, outpatient commitment would become a less important issue.

References
American Psychiatric Association Council on Psychiatry and Law. Mandatory Outpatient Treatment Resource Document. American Psychiatric Association, December 1999.
Cornwell JK, et al. "Exposing the Myths Surrounding Preventive Outpatient Commitment for Individuals with Chronic Mental Illness," Psychology, Public Policy, and Law (March-June 2003): Vol. 9, No. 1-2, pp. 209-32.
Hiday VA. "Outpatient Commitment: The State of Empirical Research on Its Outcomes," Psychology, Public Policy, and Law (March-June 2003): Vol. 9, No. 1-2, pp. 8-32.
New York State Office of Mental Health. Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment, March 2005.
Torrey EF, et al. "Outpatient Commitment: What, Why, and for Whom," Psychiatric Services (March 2001): Vol. 52, No. 3, pp. 337-41 Read more!

Involuntary Commitmen ts Strain Police Manpower - Asheboro Courier Tribune

By Mark Brumley -- Staff Writer, The Courier-Tribune
 
ASHEBORO — Several weeks ago, Asheboro police were called to a home in the city where a 22-year-old man had gotten drunk and cut his left wrist.

The man was passed out when officers arrived early that Saturday morning, a report stated. But by the time an ambulance got him to Randolph Hospital for an involuntary mental commitment, he was combative.

It took four officers to control the man, who later that day was sent to another hospital for treatment. All told, the reporting officer spent 11 1/2 hours on the case, records showed.

Such involuntary mental commitments are a common, time-consuming, disturbing and sometimes dangerous aspect of a law enforcement officer’s job, but it’s not one that gets much attention. They frequently involve alcohol and drugs, which complicates and extends the process for police, mental health counselors and health-care workers.

"We’re all concerned about the time that it’s taking for commitments," said Bonita Porter, the Randolph access manager for the Sandhills Center for Mental Health, Development Disabilities and Substance Abuse Services in Asheboro.

Asheboro Police Chief Gary Mason said his officers are averaging 20 involuntary commitments per month, according to a recent analysis conducted by the department. The average length of time for each call is five hours, which is almost half of an officer’s 12-hour shift. But Mason said it’s not unusual for calls to take 11 or 12 hours. And one recent commitment took 21 hours.

"It is certainly a big weight around our necks," Mason said. "What that does is it takes an officer off of the street and takes them away from being able to answer calls."
The burden of involuntary commitments is not just a local issue, Mason said.

"The commitment problem is really growing, and it’s not just here, it’s all over the state," said Mason, who has discussed the issue with other law enforcement officials at professional conferences. "It’s a problem we’re all facing."

With the average length of time that officers spend on involuntary commitment calls expected to increase, Mason said his department sat down last summer and came up with a new system to keep officers on the streets rather than in a chair waiting while involuntary commitments take place.

"We’ve had to strategize and try to do some different things," Mason said. "It’s really helping us. We feel like it is utilizing our personnel to the best of our ability.
 
The Process
Porter said involuntary commitments get started in a number of different ways.
In some cases, she said, a mental client comes in for a routine counseling session and it becomes obvious to the case worker that the individual has become "psychiatrically debilitated." If the client is still fairly clear headed, the counselor might be able to talk the patient into going voluntarily to a hospital for treatment.

Family members, neighbors or friends might also bring involuntary commitments to the attention of police or mental health workers by reporting that an individual is acting strangely, Porter said. In other cases, police may encounter mentally or emotionally imbalanced people as a result of attempted suicide and armed standoff calls.

Regardless of the circumstances, the involuntary commitment process is basically the same.

If it comes up during business hours, the person is taken to the mental center. If it’s after hours or on weekends, the person is taken to the Randolph Hospital emergency room.
During those times, counselors are paged through Moses Cone Memorial Hospital in Greensboro under a contract with Sandhills Center. If the counselors do not live in the area, their travel time to Asheboro extends involuntary commitments for police. During a 21-hour involuntary commitment last year, a counselor took 12 hours to arrive from Greensboro to do the evaluation, Mason said.

The first step is an assessment by counselors who try to determine if individuals need to be committed. Porter said counselors typically look for any significant changes that have occurred in people’s lives, whether or not they are oriented to time and place and if they are at risk of harming themselves or others. If the people have been drinking or taking drugs, the assessments can be more difficult and take longer, Porter said. She said family members, if they are available, can often give counselors valuable information for their assessments.

If a counselor determines that a person needs to be committed, the next step is getting a psychiatrist, a psychologist with a Ph.D. or a medical doctor to approve the commitment. Porter said they will typically go along with the counselor’s assessment, and the next step is to ask a magistrate for a transportation order to send the person to a mental hospital or a substance abuse treatment facility.

"It’s interesting that, really, the last word is sort of left with the magistrate," Porter said. "He or she could say I disagree. ... It happens very rarely, but it has happened."
 
Finding A Hospital
Porter said the next step is usually the most time consuming: Finding a hospital that will accept the patient for a stay of three-seven days.

"That waiting time begins to extend because we’re now dealing with something out of our control that’s beyond us," Porter said. "That’s typically where the clock goes longest."
On good days, when everything "clicks," Porter said, the entire process of finding a hospital takes three to five hours. On other days, it can take much longer, occupying not only police officers but also mental health workers.

"It’s a domino effect that goes beyond your local community," Porter said. "Of course, we are majority affected by that."

Committing a patient is not as easy as just shipping the person off to Dorothea Dix Hospital, the state mental hospital in Raleigh. Porter said Dix is usually "on diversion" on weekends, which means the hospital won’t accept new patients. During those times, the patients may be sent to private facilities that have contracts with Dix, including Holly Hill Hospital in Raleigh and Bryn-Mar Hospital in Jacksonville.

If Dix is accepting patients, Porter said the hospital requires them to sober up before being admitted, due to health risks. That means officers often must wait until a patient’s blood alcohol content drops below .08, the state level for a driving while impaired charge.

Dix is usually the only option for uninsured patients with no money, Porter said. Even if patients have insurance, a hospital might not accept them if they are too unstable or violent, Porter said. She said the hospital might already have a high number of problem patients, making the unit more difficult to manage.

If a patient has insurance, Porter said, Dix requires mental health workers to call at least five other centers before checking for a bed there. She said mental health workers usually check with nearby hospitals offering with in-patient psychiatric services before calling outside the area. Those hospitals include Moses Cone Memorial Hospital in Greensboro, High Point Regional Hospital, FirstHealth Moore Regional in Pinehurst, Alamance Regional Medical Center in Burlington and Stanly Memorial Hospital in Albemarle.
"They (Dix) want to know that all of those hospitals said ‘no’ to us," Porter said. "That takes time."

Placing a patient in an area hospital might not be possible, Porter said. In those cases, mental health workers start to look outside the area to facilities such as Holly Hill, Bryn-Mar and Coastal Plains Hospital in Rocky Mount.

"They’re not very close to Randolph County at all," Porter said.
 
Fewer Hospital Beds
Also making it more difficult to place mental patients has been the declining number of private hospital beds set aside for them. Porter said there just isn’t a lot of money for hospitals in mental health and substance abuse treatment. The services are costly, she said, and the insurance services are relatively low.

"Many of them have just cut back on the number of beds that they have," Porter said. "We saw that trend happening a lot five or six years ago."

Porter said mental health advocates are working to reverse that trend, but another change on the way is the pending merger of Dix with John Umstead Hospital, a state mental facility in Butner.

"A lot of beds are going to be depleted because of that," Porter said.
That’s one reason police expect their average wait on involuntary commitment calls to increase to six or seven hours in coming years.

As mental health workers make calls to try to find a hospital, the clock ticks away for police, and the risk that some patients will become violent increases.

"We’re concerned that this may escalate while we’re waiting to get to that ... psychiatric evaluation, getting papers over to the magistrate and so forth," Porter said.
Mason said he’s had firsthand experience with such cases.

"You’ll have some people that can get very violent and will fight you or could hurt you and might not even be aware of their behavior," Mason said. "It can be very dangerous. Over the years, we’ve had several instances where it could have been a very bad situation."

He remembered on one call at a local doctor’s office where he found himself in a struggle for his life with a mental patient who seemed to have "amazing strength." Mason said the man had already assaulted one of his parents and torn up the doctor’s office by the time police were dispatched. He said he ended up on the floor wrestling with the man and trying to keep him from taking his handgun. Eventually, the man was placed in handcuffs and leg irons and taken to mental health.

"That could have been a life-or-death situation that was a commitment order," Mason said. "You have to go in knowing that you may get hold of someone who is very unstable, somebody that could be very strong that could not be thinking with a rational mind and could hurt you and others."

In extreme cases, Porter said, counselors can ask for an emergency certificate, which allows a patient to be committed more quickly.
 
Impact On Law Enforcement
Asheboro police officials already knew that patrolmen were spending an extraordinary amount of time on involuntary commitment calls when they sat down in June 2005 to analyze the numbers. But even they were surprised at some of their findings.

In addition to determining that they were averaging 20 involuntary commitment calls per month at five hours per call, Mason said, they learned that 75 percent of those calls came in during the peak hours of 11 a.m.-11 p.m. That’s when officers get 65 percent of their daily 911 calls for service.

And about three times per month, Mason said, officers have two or more involuntary commitments taking place at the same time. Days like that can cut a five-officer patrol team’s effectiveness in half, Mason said. And if an officer is standing by with an involuntary commitment at the end of his or her shift, and officer from the next shift must take over regardless of whether the team is already shorthanded, Mason said.

"That’s where it’s hitting us, and it’s really straining our manpower, " Mason said. "What that does is it takes an officer off of the street and takes them away from being able to answer calls."

Involuntary commitments also take a toll on the Randolph County Sheriff’s Office, where deputies are responsible for driving patients to mental health and substance abuse treatment facilities all over the state after magistrates issue transportation orders.
Maj. Allen McNeill said deputies transported patients 457 times in 2004. He said that doesn’t include the times that the patients got weekend passes from the facilities where they were being treated and deputies were required to drive them home and then return them to the facilities.

The state recommends that sheriffs transport involuntary commitments in unmarked cars driven by plain-clothes officers to avoid the appearance that mental health patients are criminals, but that’s not always possible, McNeill said. He said the sheriff’s office has to give the assignments to whoever is available for them. McNeill said patrol deputies, civil deputies and jailers all do the transports, depending on the time of day.

McNeill said sheriff’s officials agree that most mental health patients aren’t criminals, and that’s why they do not believe that deputies should have to transport them. It shouldn’t be a law enforcement responsibility, he said.

"That’s just part of our job that we get stuck with," McNeill said.
 
No Cutting And Running
The quickest way to reduce the amount of time police officers spend on involuntary commitment calls would be to no longer require them to stand by while the process take place.

Some departments around the state have already started allowing officers to walk away from involuntary commitments after picking up the patients and taking them to a mental health center or hospital, Mason said. That may save officers’ time, but it could also put counselors and health-care workers in danger if a patient becomes violent. It could also expose the police department to greater liability.

So cutting and running is not an option for Asheboro police officers, Mason said.
"There’s a growing number of departments across the state that are doing that," he said. "However, we feel like, based on the legal advice that we’ve got and from the opinions given by the Attorney General’s Office ... we just don’t feel like legally that’s the proper thing for us to do. So we keep our people with the commitments until we feel like our duty and obligation have been fulfilled."

But Mason said the department had to find a way to keep patrol officers from spending hours on involuntary commitment calls.

"We just felt like it was getting to the point that we had to look at doing to some different things because it’s absolutely killing us out in the field," he said.
 
Coming Up With An Answer
With the city’s approval, Asheboro police devised a plan last summer to handle lengthy involuntary commitment calls.

The plan involved establishing a roster of officers willing to come in to work on their days off to standby at mental health or the hospital to relieve on-duty officers so they can get back on the streets. Supervisors begin calling officers on the roster only if it appears that a commitment will take longer than a few hours. The officers aren’t required to come in to work, but if they do they receive overtime pay. Mason said the money comes out of the department’s special assignments budget, which is typically used for license checks and other operations.

"This gets an officer back in the field," Mason said. "We feel like it’s good utilization of the taxpayers’ money and the money that’s been allocated to our department. It is relieving officers and getting them back into their cars."

After implementing the system, police officials studied it in July 2005 to see how it worked, Mason said.

That month, the department responded to 15 involuntary commitment calls. Six of those did not require an off-duty officer to be called out. The total amount of time that officers spent on those calls was 16 hours, 10 minutes.

The total time spent on the other nine calls was 56 hours, 30 minutes. On-call officers stood by for a total of 46 hours, 15 minutes, on those calls. They were paid a total of $1,300 for overtime.

"So far it is really helping us," Mason said. "What it’s done is it has relieved us of our manpower being tied up as much. We’re still have a lot of commitments that we’re dealing with but it is giving us some help in keeping sufficient numbers of officers out in the field." Read more!

Mental health services get skimpier in Brunswick - The Brunswick Beacon

The Brunswick Beacon

BY CAROL TRAPANI, Staff writer

The few individuals who manage to make it to a nondescript building in Shallotte every day to learn some jobs skills and to have some contact with other people soon won't have a place to go.

The program they attend is scheduled to shut down March 15.

Although attempts will be made to find other places for them, the reality is it's not likely to happen.

“The people who do show up are going to miss it,” said Art Costantini, area director of the Southeastern Mental Health Center in Wilmington.

Southeastern was once the mental health service provider for New Hanover, Pender and Brunswick counties, but under a five-year state plan enacted in 2002, has become the management entity and must find mental health providers to offer services it once did.

The program that is closing in Shallotte is the psychosocial rehabilitation program provided by the Mental Health Association of North Carolina, a contract agency of Southeastern Mental Health Services. The day program of social activities and educational, vocational and job training is geared for people with mental illnesses, such as schizophrenia, depression, obsessive-compulsive disorder and others.



“Financially, they can't keep it running,” Costantini said of the program.

The closing of the psychosocial rehabilitation program in Shallotte appears to be only the tip of the iceberg as the state moves ever closer to shedding its role as a mental health care provider by 2007.

Some or all of the mental health services available through Southeastern Mental Health Services at the county government complex in Bolivia could be coming to an end, said David Sandifer, chairman of the Brunswick County Board of Commissioners.

“We have been made aware that there will be space in the building” it shares with county parks and recreation, Sandifer said.

“That may be true,” Costantini said.

Now that Southeastern has been switched to a mental health management entity instead of a mental health services provider, and its budget has been cut to $5.7 million from $42 million annually, it now has to determine whether to operate satellite offices in each of the three counties it covers, or operate one central office, he said.

In Brunswick County, mental health patients, including the clients in Shallotte, can receive medical treatment, including prescription medicine and counseling, from private physicians and other medical providers in the county, or from a psychiatrist at Southeastern's office at the county government complex in Bolivia, said Costantini.

A decision about whether to operate three satellite offices or a central office will be made in two or three months, he said.

In addition, Southeastern has to find replacements, or providers, for services it once provided.

A big problem is finding those providers in rural counties, Costantini said.

Even in populous New Hanover County, it's difficult to find providers willing to accept the rates set by Medicare, Medicaid or the state, he said.

“The state has decided it needs mental health (services) to be privatized or go to the county level,” Sandifer said.

“It might work well in Wake or Mecklenburg, but when we (Brunswick County) have people with mental health problems they're basically going to have to go somewhere else.

“It's atrocious.”

Brunswick County Health Director Don Yousey said the state's plan was not a good one and that he, Sandifer and Commissioner Phil Norris have opposed it since it was enacted.

When programs that were once state-operated are privatized, the ones that are left behind are those that don't make money, Yousey said.

Soon, county commissioners might be faced with deciding whether to fund those left-out, non-money-makers, Yousey said.

“David Sandifer, Phil Norris and I have been saying this is a cost shift from day one.”

In addition, Yousey said the state has not fully followed through on its promise to help fund the transition, coming up short to the tune of approximately $31 million.

Begun only about six months ago, the psychosocial rehabilitation program in Shallotte is the only program of its kind in Brunswick County. One is offered in New Hanover County, but when the mental health association became the provider, it wanted to offer the program in Pender and Brunswick, Costantini said.

The program in Pender ended about four months ago, also because of financial reasons, Costantini said.

The Shallotte program needs 15 to 16 clients each day to support its fee-for-service operation, and though it may have that many on its roster, only about seven people show up each day, he said. The program draws clients from all parts of the county.

The mental health association receives from the state approximately $9.36 per hour or about $56 a day for each client who attends for six hours each day, according to Costantini.

“Probably 70 or 80 people are signed up in New Hanover, but they don't attend every day. The New Hanover program has about 30 clients who attend regularly, he said.

John Tote, executive director of the Mental health Association of North Carolina, was not available for comment Tuesday. The director of the rehabilitation program in Shallotte said she needed Tote's approval before she could speak to a Beacon reporter.

Transporting the Shallotte clients to New Hanover County is a possibility, but Costantini said he expected the participation would soon drop, given the distances involved.

Some clients in Shallotte also have access to an assertive community treatment team, or ACT, a community-based team that works with the individual during the day, he said.

A complication is that under the new state legislation, an individual can not have access to the community-based team or the psychosocial rehabilitation program at the same time, Costantini said. Read more!

County considers "Social Justice" goal - Raleigh News & Observer

CHERYL JOHNSTON SADGROVE, Staff Writer

Orange County residents pay the county to build their schools, bury their trash and count their votes, like in most counties. But now they're being asked to consider another duty.

The county may become the first in the country to adopt a "social justice" goal.

Such a goal likely would identify areas the county wants to improve on and include some way to measure progress, said Milan Pham, the county's human rights and relations director.

The county already contributes toward programs that could be associated with social justice, such as public medical and dental clinics, and new bus service between Hillsborough and Chapel Hill.

In the past four years, the county has spent almost $700,000 through its Social Safety Net fund to help low-income people pay for mental health services, day-care and utility bills.

"We're not straying far from what we already do, but sometimes putting words to a concept gives it more power," said Barry Jacobs, chairman of the Orange County Board of Commissioners, who suggested the county create a social justice goal a few years ago.

Having a say

The Human Relations Commission has scheduled several forums and created an exercise for county residents to help shape the social justice goal.
Residents pretend they have $13 in local tax money to spend in five categories: elimination of oppression, civic participation, environmental justice, physically and mentally safe communities, and economic self sufficiency.

Providing 24-hour free public transportation, for instance, could help "eliminate oppression" by enabling a low-income resident to get to work. Creating shelters for victims of domestic violence could help achieve "physically and mentally safe communities."

At the Chapel Hill Senior Center, Mary McCurdy put all $13 into "physically and mentally safe communities." "If you can't live safely, nothing else matters," she wrote in a small notebook.

McCurdy, 74, supports a local social justice goal. Her son recently met a family with young children who said they were being evicted for not paying their rent on time. Their house was in poor shape and moldy.

"We overlook our own people in need far too much," she wrote.

Community character

There is no one definition of social justice, said John Calmore, who teaches social justice lawyering at the UNC-Chapel Hill School of Law and cowrote "Social Justice: Professionals, Communities and Law, Cases and Materials."

"Social justice seeks to really address the opportunity-denying circumstances," he said. "Whatever those opportunity-denying circumstances are, you want to free people from them."

Last year, Calmore met with several county commissioners, the Human Relations Commission and county staff to discuss how a social justice goal could reflect the Orange County community.

"You want it to be thought out," he said. "You want to be programmatic. You want to build in features that allow you to measure it."

That's not so easy to do, Calmore said, which may be why so few communities have set any sort of goal.

Orange County would be joining the likes of the California counties of Santa Barbara, Marin and Santa Cruz, whose governments, in different ways, have acknowledged working toward social justice as a part of serving their communities.

Orange County would be the first to adopt a social justice goal outright, according to research by the National Association of Counties.

Although social justice is difficult to define and achieve, Calmore said, communities should try to do both.

"You're kind of on the map as representing a certain value orientation," Calmore said. "I think that's important for a local government because local government ... is closest to the people."

Staff writer Cheryl Johnston Sadgrove can be reached at 932-2005 or cheryl.sadgrove@newsobserver.com.

© Copyright 2006, The News & Observer Publishing Company
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Mental health care draws fire - Asheville Citizen-Times

By Leslie Boyd
STAFF WRITER
March 9, 2006 6:00 am
ASHEVILLE — The National Alliance on Mental Illness has given North Carolina a D-plus for its efforts to care for people with mental illness.
The state did better than the national average, which is a grade of D, and no state received an A.
One reason for the poor grade is the disarray in the system’s reform, undertaken with legislation in 2001. The state created an entirely new mental health system with the object of moving people with mental illness out of state hospitals and back into their communities whenever possible.
“This is not a tool to beat anybody up with,” said Benjamin Staples, executive director of NAMI of North Carolina, the state affiliate of the national organization. “Rather, it’s a tool to begin discussion about what’s not working and what we can do to improve it.”
North Carolina ranks 43rd among the 50 states in its per-capita spending rate on mental health, at $50.26. It ranks 21st in the amount it spends on its system, with $417 million, according to the report, “Grading the States: A Report on America’s Health Care System for People with Serious Mental Illness.”
North Carolina was praised in the report for its plan to build a new state hospital to replace two antiquated ones and for its five-year mental health plans, which can be accessed on the state Division of Mental Health, Developmental Disabilities and Substance Abuse Services Web site (www.dhhs.state.nc.us/mhddsas/).
But the state was chastised for its unwillingness to pay for mental health care. Adequate funding for the system is one of the urgent needs in North Carolina, according to the report, which was released last week.
“The report acknowledges that we’re going through mental health reform,” Staples said. “But historically, we’ve never funded mental health adequately; it’s been low on the legislature’s list of priorities.”
Lack of funding limits the care people can get and leads to people with mental illness becoming homeless or landing in jails. It also leads to a higher number of people having a mental health crisis and landing in an emergency room.
In its recommendations, the report criticized the state for underfunding mental health.
“There is increased awareness that short-term savings accrued through cuts in public mental health funding lead to increased long-term public costs with associated hospitalizations, incarcerations and other costly consequences of lack of treatment.”
David Cornwell, a member of the WNC NAMI affiliate, agrees that many of the problems with mental health services stem from under-funding.
“Of course, you can reform the reform as long as you like and nothing will change without additional money,” Cornwell said. “And that means our other legislators are going to have to get it, too. People are going to have to realize that properly treating mental illness is far cheaper to the taxpayer than the costs of no or inadequate treatment, costs that manifest themselves in higher law enforcement and incarceration costs, in dealing with school dropouts, homelessness, the uninsured, unemployment and a myriad of other issues.”
N.C. Sen. Martin Nesbitt, D-Buncombe, co-chair of the state’s Legislative Oversight Committee for Mental Health, said funding for mental health services is about to hit the General Assembly’s radar screen.
“I’d give us a D-plus too if I were rating our performance right now,” Nesbitt said. “We tried to go way too fast, way to0 quick with too little money. … We have one big services provider in the state that’s gone under and the one here (New Vistas) is losing money. You can’t have that if you want to bring people out of the hospitals and back to the community.”
Lisa Wainright of the N.C. Division of Mental Health, Developmental Disabilities and Substance Abuse Services, said the division was disappointed with the D-plus rating, but pleased with some of the points in the report.
“We were happy to see acknowledgement of the need for reform,” Wainright said. “That was validation. We know we face an awful lot of challenges.”
The report likens North Carolina’s mental health reform to massive surgery, and the efforts to move ahead without adequate funding as “essentially performing a multi-organ operation. … Too much happens at once with not enough funds and not enough support personnel. Then the bleeding starts.”
The report also recommends passage of insurance parity, which would ensure people with mental illness get the same coverage as they would with any chronic illness.
North Carolina has no such law, so insurance companies can reimburse policyholders at a lower rate than they do for other illnesses.
“We know it won’t put the insurance companies out of business,” Staples said. “The state plan (health insurance for state employees) has parity and it doesn’t cost that much.”
Wainright said her division has advocated passage of a parity law for years.
“We’ve been pushing for it, but it hasn’t gone anywhere in the Legislature,” she said.
Among the other urgent needs cited in the report are slowing down the process of reform and learning from the changes made to date, increasing crisis services and alternatives to hospitalization, and increasing safety-net resources for people who can’t afford care but don’t qualify for Medicaid.
Contact Boyd at 232-2922 or lboyd@CITIZEN-TIMES.com.
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CenterPoint plans to contract out care - Winston-Salem Journal

State expected to approve mental-health agency plan
By M. Paul Jackson
JOURNAL REPORTER
Thursday, March 9, 2006


CenterPoint Human Services, this region's main mental-health agency, is expected to get state approval next week for its plan to contract out some of its administrative services, officials said yesterday.

CenterPoint, based in Winston-Salem, oversees mental-health programs in Forsyth, Davie and Stokes counties. It plans to contract out its late-night patient-referral services to the Guilford Center, the mental-health agency in Greensboro. The N.C. Department of Health and Human Services said last year that it wants to consolidate the number of local mental-health agencies that perform referral and utilization-review services.

The state has 30 mental-health agencies, called local-management entities, which oversee services for consumers. Under the state consolidation, only 10 agencies would be responsible for providing those referral and review services.

The state health department is scheduled to announce Wednesday the 10 agencies that will handle those services.

The change is part of the overhaul of the state's troubled mental-health system.

The General Assembly passed a law in 2001 requiring behavioral-health agencies to either offer services or oversee them, but not both.

As a result, agencies have had to divest their mental-health programs, with many unsure how to effectively meet the law's new requirements.

Mental-health officials said that the administrative change could help streamline some agencies that were having trouble managing their services, but they argued that the agencies had little say in whether to consolidate.

"There are pockets of the state where this is a good idea," said Carol Duncan Clayton, the executive director of the N.C. Council of Community Programs, an advocacy group for behavioral-health agencies.

But "there's still just a little concern over the process itself," she said.

An after-hours referral is made when a mental-health client calls a toll-free number and is referred to an available provider. Utilization review involves determining the medical need of a particular treatment for a client. Most local-management entities provide both services.

Under the proposal, those local-management entities that provide the administration services would get more state money and the 20 remaining local-management entities would receive less.

CenterPoint had planned to contract all of its referral and review services out to the Guilford Center, but it will instead perform its own referral services during the day from Monday to Friday, said Betty Taylor, CenterPoint's chief executive.

"I wanted us to have direct, hands-on control," Taylor said.

"We just need to have that direct interface with our community," she said.

CenterPoint will also use the referral services to determine who arrives for an appointment and who doesn't, Taylor said.

M. Paul Jackson can be reached at 727-7473 or at mjackson@wsjournal.com


This story can be found at: http://www.journalnow.com

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Act Now: Family needs help with mother's mental instability - Winston-Salem Journal

By Jan Warner
Winston-Salem Journal
Sunday, March 5, 2006


Q. After the last of my siblings left home in the 1970s, our parents seemed to be getting along nicely. When Dad retired in the mid-1990s, they took some trips, learned how to golf and traveled around visiting my two brothers and me.

Then, about five years ago, Mom began to change. She became very erratic, didn't sleep well (and therefore kept Dad up all night), stopped cooking and cleaning, and would sometimes disappear for a day at a time. Because we have been concerned about her health and that of our father, we tried to intervene, but she won't go to a doctor and is impossible to talk to. The police have been called to their house by neighbors several times when she went out in the yard screaming at 1 a.m.

Most recently, without warning to Dad and apparently on the advice of her younger sister (age 68), Mom cleaned out several bank accounts, hired a lawyer, and says that she wants a divorce. Her sister has been married four times, has no money and has now leeched onto our mother. My brothers and I called her lawyer in an effort to tell him our concerns about her mental health and what was really going on, but he refused to talk to us.

Now Dad has hired a lawyer, and all of us children are in the middle because we signed affidavits stating we didn't think our mother was in good mental condition.

The last time we saw her, it was obvious that she had not bathed, and she was very disheveled. She and her sister are inseparable. We think that her lawyer knows there are problems and is either not dealing with them or ignoring the obvious.

Our mother needs help - and not from her money-grubbing sister - but we can't seem to get through to anyone. What can we do to help our mother get the treatment she needs and make sure our father does not get crucified by a legal system that has neither the time nor inclination to care?

A. Dealing with clients who may be impaired because of mental or other disabilities is a fast-growing problem area for lawyers in all areas of the law, and the matrimonial segment is no exception. On one hand, the lawyer must protect the secrets provided by the client and, as much as possible, maintain a normal attorney-client relationship; on the other hand, upon determining that a client does not have the ability to make good decisions and act in his or her own interests, the lawyer has an obligation to take steps that may include such protective action as the appointment of a guardian.

The normal attorney-client relationship is based on the assumption that when advised properly, your mother is able to make decisions about important matters; however, if she suffers from a mental disability, a normal attorney-client relationship is not possible. If your mother doesn't have the mental capacity to understand the proceedings and a guardian or guardian ad litem is not appointed to represent her, then the proceedings before the court could well be nullified because an incapacitated person may not be able to make legally binding decisions.

If the facts are as obvious as you state, we think her lawyer should have had your mother evaluated by competent and independent medical experts to determine her mental capacity. In our view, this means that a neurologist, a psychiatrist, a geriatrician, or a combination of these medical professionals should have been consulted early on because there were certainly enough "red flags" to put her lawyer on notice.

Assuming that your mother's lawyer is not going to act, your father's lawyer can approach the court and seek orders (1) requiring your mother to undergo such evaluations, and (2) appointing an independent guardian ad litem to represent your mother's interests. And if it appears that your aunt is exerting undue influence over your mother, as you believe, a complaint to adult protective services may be necessary. A more drastic avenue may be for one of you children to seek guardianship or involuntary commitment in the probate court.

These are drastic remedies, but under the circumstances you state, one or more of them may well be warranted.

o Jan Warner is a member of the National Academy of Elder Law Attorneys and has been practicing law for more than 30 years. Jan Collins is editor of the Business and Economic Review published by the University of South Carolina and a special correspondent for The Economist. You can learn more information about elder-care law and write to the authors at www.nextsteps.net

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N.C. Supreme Court: Couple can't sue agency over shooting

Associated Press
Friday, March 3, 2006

RALEIGH, N.C. - A woman shot at an Asheville intersection can't sue a mental health agency for negligence because it helped operate an alternative public school where some students talked on a school bus about killing someone, the state Supreme Court ruled Friday.

Kathlyn Marie Stein and her husband, Michael Hootstein, sued Blue Ridge Area Authority and others for damages related to a March 1998 shooting involving students who attended the Cooperative Learning Center. Several groups, including the authority, operated the center for behaviorally and emotionally handicapped children.

The couple alleged some students at the school had talked on a school bus about wanting to rob and shoot someone the week before Stein was shot in the head. But the bus driver and an unpaid monitor told neither school officials nor police what they overheard.

On March 17, 1998, students approached three passing vehicles before shooting Stein, leaving her with a spinal fracture, nerve damage, and post-traumatic stress disorder.

A state Court of Appeals panel ruled the couple waited too long to sue the Asheville Board of Education for damages. The Appeals Court also said the state Industrial Commission should handle any claims of negligence against the Buncombe County school board for the bus workers' failure to alert authorities about the violence-laided words.

A majority on the Appeals Court found Stein and Hootstein could sue Blue Ridge for what happened, but the Supreme Court reversed that decision.

"Public school personnel who overhear students discussing robbery or homicide have a moral and civic obligation to respond appropriately," Justice Paul Newby said in writing for the high court. "The power of the judiciary does not extend to purely moral or civic shortcomings, however. Absent legal grounds for visiting civil liability on defendant, our courts cannot offer plaintiffs the requested remedy."

According to state law, the duty of school bus drivers and monitors is to preserve order so that students and employees on the bus are protected, Newby wrote. The duty doesn't include other people who may be harmed by students' actions outside the bus or off school property, he added.

There was nothing in the case to show Blue Ridge could have done anything to stop the students from attacking Stein, Newby wrote.

Four young people pleaded guilty to charges related to the attack, the court said in its opinion.
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Durham group scales back plan

ERIC FERRERI, Staff Writer

Durham's mental health agency -- which had hoped to expand its managerial reach into about 10 nearby counties -- is scaling back its ambitions.

Rather than attempting to become a case manager for mental health clients in a cluster of counties across the Piedmont, the governing board of The Durham Center decided Thursday to apply for that authority -- known as "utilization review" -- only for Durham County.

Doing so would likely improve its chances to keep the review authority under an ongoing statewide mental health restructuring because the center has several years of experience managing cases for clients in Durham, said Ellen Holliman, the center's director.
"We think we are, without question, meeting the standards for Durham," she said.

Though the center has that authority now, all mental health agencies which want to keep it must apply anew as part of the restructuring by the state's Department of Health and Human Services. As part of that reorganization, mental health case management is being farmed out to about a dozen lead agencies across the state. The Durham Center applied to be one of those agencies earlier this year and bristled when its request was denied. Soon after, it announced plans to sue the state over the issue.

The state agency eventually allowed the center and others like it to re-apply for the authority. Durham officials said Thursday they have a better chance if they work solely in their own county rather than attempting to expand. Chuck Kitchen, the county's attorney, acknowledged Thursday that The Durham Center doesn't currently have the necessary personnel to handle the larger workload.

Though Holliman said Thursday that her agency would be happy if it is allowed to retain the review authority, a lawsuit is still possible. Earlier this week, the county took a preliminary step toward a suit by asking the state agency to declare that its attempt to restructure North Carolina's mental health system is unlawful.

If it doesn't, the county may still sue on those grounds, Kitchen has said.

Staff writer Eric Ferreri can be reached at 956-2415 or eric.ferreri@newsobserver.com.
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Durham County asks for state ruling declaring reform unlawful - Raleigh News & Observer

ERIC FERRERI, Staff Writer
In what might be a precursor to a lawsuit, Durham County is asking the state to declare unlawful its plan to restructure North Carolina's mental health system.

The county is asking the state Department of Health and Human Services for a declaratory ruling on two issues related to a recent dispute between the state agency and The Durham Center, which administers mental health services throughout the region.

The state agency has 60 days to respond to the request. If the county doesn't agree with the state's position, it may move ahead with a lawsuit, said Chuck Kitchen, Durham County's attorney.

The Durham Center and the state agency have been at odds since earlier this year. That is when the center discovered that under a statewide restructuring, it was losing the power of "utilization review," which essentially allows the center to manage clients' cases and recommend care.

The county subsequently threatened litigation, claiming in part that DHHS' planned reorganization was illegal because there is no statute specifically allowing it.
The county's request this week addresses that claim, essentially asking the state agency to declare its own restructuring plan invalid.

In the past two weeks, the state agency has decided to allow The Durham Center and other mental health agencies across the state to apply anew for the utilization review authority.

The Durham Center wants to remain a "Local Management Entity," one of the local lead offices across the state that would do review work for a larger regional cluster of mental health agencies.

Staff writer Eric Ferreri can be reached at 956-2415 or eric.ferreri@newsobserver.com. Read more!

Judge should pull reform out of ditch - Hendersonville Times-News Editorial

Thanks to a lawsuit filed by a Fletcher mom, North Carolina's mental-health reform may yet result in a judge's ruling requiring the state to do what it should have been doing all along -- provide mental-health and substance-abuse services equally across the state.

The 2001 reform was aimed at shifting mental health care and substance abuse services from state institutions to communities because, the thinking went, communities would better know their people's needs. Instead, services disappeared and people with mental problems flooded homeless shelters, jails and hospital emergency rooms.

Fed up with the lack of services for her adopted son Thomas, Kathy Reiter, 49, sued the state Department of Health and Human Services in 2003.

Reiter adopted Thomas when he was 3. He suffers from bipolar disorder, severe attention-deficit hyperactivity disorder, post-traumatic stress disorder, autism and reactive attachment disorder. At 6 feet and 220 pounds, the 17-year-old can be too much for Reiter and a trained mental-health worker when he becomes agitated or angry.

She sought 24-hour crisis intervention and stabilization services and a mobile crisis response team to transport Thomas to a center if he had to be removed from the home. Her argument is that Thomas should get the same services here that he would be able to get in bigger cities like Raleigh and Charlotte.

Judge Howard E. Manning has not set a hearing date for Reiter's motion. A ruling in her favor could affect thousands of children statewide whom the state has failed to serve.

The state agreed in a settlement last September to provide the services, but Reiter said the agency hasn't followed through. Two clinics the state referred her to, she said, wouldn't take the boy because of his aggressive behavior and low IQ. State officials acknowledge that the mobile crisis units won't be ready before March 20.

"They haven't done what they promised to do and what they agreed to do," Reiter said.
What's worse, the state is talking about providing only 10 crisis units for the entire state.

More evidence of the cost-shift from the state to local government surfaced last week.
After an unstable patient threatened a nurse in the emergency room of St. Luke's Hospital, administrators proposed $600,000 in renovations to the ER, including a "safe room" for mentally ill patients.

St. Luke's is asking Polk County for $200,000, dipping into $433,000 the county has set aside in a mental health reserve fund. But county officials are balking at giving the money to the hospital for fear the state may ask the county to cover more mental health care costs. St. Luke's officials deserve praise for their boldness, yet commissioners are right to be concerned that the state will send more bills from Raleigh.

Here's hoping Judge Manning will see in the Reiter case a ripe opportunity for holding legislators accountable. Read more!

The Durham Center/Value Options - Durham Herald-Sun

BY GREGORY PHILLIPS : The Herald-Sun
Mar 28, 2006 : 8:15 pm ET

DURHAM -- The latest twist in Durham's battle to retain local control over the management of mental health care saw it petition the state's Office of Administrative Hearings on Tuesday.

The Durham Center, the county's mental health authority, is asking for a contested case hearing over a Department of Health and Human Services announcement last week stripping more control from local mental health agencies.

The petition filed Tuesday claims the decision is illegal, citing breach of contract and violations of both due process requirements and state statutes. It asks the state's announcement to be rendered void.

Last Wednesday, the state announced Value Options, a private contractor, will authorize all Medicaid-funded mental health care across most of North Carolina as of June 1. The state also said after-hours screening and referral of Durham mental health cases will be handled by the neighboring Five Counties authority after July 1 this year.

County Attorney Chuck Kitchen, who filed the petition, said the state violated its own statutes and the Center's due process rights by failing to follow procedure in contracting with other agencies to manage care in Durham.

"Regardless of whether or not the department has the authority to do that, they violated a procedural due process," Kitchen said. "The statute requires the county and its mental health center be notified and a hearing held."

The petition also claims the state breached a contract it has with The Durham Center to manage local care until July 2007.

The Office of Administrative Hearings will request a position statement from each party and set a hearing, Kitchen said. Its decision comes in the form of a recommendation to the Department of Health and Human Services, a recommendation the state can ignore. If the state ignores a ruling in The Durham Center's favor, the case can be appealed to Superior Court, Kitchen said.

The state's plan, part of an initiative to slice $28 million from the state budget, would cost The Durham Center almost $1.4 million in funding, according to the petition. Center officials have said that could lead to the loss of 15 jobs among the center's 55 or so employees.

Mark VanSciver, spokesman for the state's Division of Mental Health, declined comment on the petition.

"We haven't seen anything yet, and we wouldn't comment on pending litigation anyway," VanSciver said. He said he wasn't aware of any similar actions filed by other local authorities, but that in any case, the state is pushing ahead as planned.

"Everything's going to proceed as it is now," VanSciver said.

The petition also asks for a preliminary injunction to prevent the state contracting with any other entities to manage care for Durham. Kitchen said he has no idea when that will be heard, but that the state's June 1 target to shift authorization to Value Options isn't relevant to the action.

"It would not stop the legal process," Kitchen said.

Doug Wright, chairman of The Durham Center board, said the state's decision won't save money because a contractor is more likely to reauthorize expensive services that may not be best for the consumer.

"You don't just continue to authorize services for the heck of it, because someone wants to make more money," Wright said. "Consumers end up getting services they don't need." Read more!