California Forum

It shouldn’t take a crisis to address mental illness. There’s a better way.

Steven Stanford, left, and Damon Flenaugh kneel by flowers in memorium of Flenaugh’s brother, Dazion, a mentally ill man shot last year by Sacramento police.
Steven Stanford, left, and Damon Flenaugh kneel by flowers in memorium of Flenaugh’s brother, Dazion, a mentally ill man shot last year by Sacramento police. rpench@sacbee.com

As you gather with children this Father’s Day weekend, consider how far you would go to ensure their well-being: If your child had cancer or diabetes, would you wait until the disease were critical before you called doctors to intervene?

Of course not. And yet this year, as in every year, thousands of young adults will cross the threshold into serious mental illness and go untreated because of a health care paradigm that California must change.

To understand the need, consider that threshold, which typically involves a marker known as a psychotic break. Those who’ve experienced it describe a form of waking nightmare. Forces outside your control invade your thoughts and carve up your sense of self, sometimes questioning your right to exist, or threatening or demanding destruction.

People with mental illness can learn to manage their conditions. If we can catch young people in the early stages, we have strategies that help them not only to cope – but to thrive.

You might believe that people are following you, or can steal your thoughts. You might even believe that a portion of your brain has gone missing, the piece that held components critical to your identity, such as your love for friends and family.

Psychotic episodes are a defining factor in diagnosing schizophrenia and schizoaffective disorder, and often accompany the onset of mood disorders such as depression and bipolar disorder. These are illnesses that generally manifest themselves in adolescents and young adults – with 40 percent of serious mental illness developing by age 14 and 75 percent by age 25.

Every year in the United States, 100,000 young adults – sons and daughters – experience their first psychotic break. Some get help, but tens of thousands stagger forward in frightened isolation. Some go years without treatment even as their illness progresses, undermining their family life, friendships and ability to function.

For decades, this has been the paradigm for mental health care in this nation: intervention and treatment that come well after the illness has taken hold.

Consequently, much of the conversation continues to revolve around crisis care. We see thousands of homeless people – their lives broken by mental illness – living on the streets, and we wonder how to reach them. We see thousands of inmates living behind bars with mental illness, and we wonder how to fix them.

Try to think of another serious illness that we routinely treat only after it’s reached crisis status. When it’s cancer, our goal is to intervene at Stage 1, and bring the disease into remission. With heart disease and diabetes, it’s the same. Our whole approach is about intervention, education, lifestyle changes and medication – all with the goal of managing the disease.

Why, then, when it comes to mental illness, do we routinely intervene at Stage 4?

The truly outrageous factor in this cycle is we know how to intercede in the early stages of mental illness and effectively change the outcome of a disease such as schizophrenia. The treatment models exist. We have reams of data, out of Britain and Australia, which have led the way on this research, and also out of New York, Oregon and California that show early intervention works.

With appropriate treatment, most young people who receive these intensive services see a remission of symptoms. Through the course of their lives, they have fewer hospitalizations and suicide attempts. If we can catch young people in the early stages of illness, we have strategies that help them not only to cope – but to thrive.

Are they cured? Not exactly. But much like someone in the early stages of heart disease or diabetes, people with mental illness can learn to manage their conditions.

In Sacramento County, UC Davis operates the EDAPT clinic, funded largely through the state’s landmark Mental Health Services Act. The services, launched in 2004, specialize in early intervention with psychosis-related illness. EDAPT staff see patients who present within two years of their first psychotic break. And for the majority of patients, they can change the course of the illness.

The clinic’s approach works on several tracks. Generally, treatment involves both cognitive behavioral therapy and low doses of medication. The staff also provides “whole person” care that addresses physical health, and support for school, jobs and housing. Most importantly, the young person’s family is included in care, receiving education and support.

So, if we know these programs work, how is it not every county in California has one?

In Sacramento County, the EDAPT program has capacity to treat about 175 patients a year. And yet each year in the county, we can expect to see about 630 new cases of psychosis. That’s 630 young people living with delusions and personal terrors. And we’re failing to provide services to hundreds of them.

Throughout California, 24 counties are drawing on MHSA funds and in some cases private insurance to offer versions of this program. Another 12 counties have programs in development. It’s an exciting start – but the need in these counties outpaces capacity. And another 22 counties have no such programs at all.

The issue is rooted in both funding and training. In 2004, California voters passed the Mental Health Services Act, which taxes millionaires to bolster funding for care. This year, MHSA will generate about $2 billion. By statute, 80 percent will go to community services for people already seriously ill, and just 20 percent to early diagnosis, prevention and intervention.

No one argues we can afford to cut services for people already in crisis. The need is tremendous. So, how then, do we ever get ahead of the problem? How do we turn the ship so we’re committed to intervening well before lives are wrecked?

Toward that end, the Steinberg Institute is sponsoring legislation, Assembly Bill 1315, by Assemblyman Kevin Mullin, D-South San Francisco. We think it’s a game-changer. The bill would set up the state’s first-ever public-private partnership to create a fund that gives counties financial incentive to infuse far more resources into early intervention for psychosis and serious mood disorders.

This special account would be fully supported by contributions from private industry and government grants. Counties could apply for awards to fund early detection and intervention strategies; if chosen, they would have to provide matching funds.

The tech industry already is engaged in research, eager to devise technology that would help identify biomarkers and other early indicators of serious mental illness. This bill provides an opportunity for leaders in Silicon Valley and throughout the private sector to sit at the table as full partners with our counties and most experienced providers in the battle to transform the treatment model.

Envision a California in which brain health really were treated with the same urgency and sweep as physical health. We believe this is a crucial step toward that future.

Darrell Steinberg founded the Steinberg Institute in 2015 with the aim of advancing sound public policy and inspiring leadership on issues of mental health. He is mayor of Sacramento. Dr. Cameron S. Carter is a professor of psychiatry and psychology at UC Davis, where he is director of the Behavioral Health Center of Excellence and Early Psychosis Clinical and Research Programs.

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