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Work is Recovery
Filing Discrimination Charges: Sad Truth
Coleman on Managed Care
Comments Concerning Research
Nicotine & Schizophrenia
The Connection Between Smoking and Depression/Bipolar Illnesses
Work is Recovery
After a number of years working in consumer organizations, I have noticed something
missing in the overall mental health systems. Consumers diagnosed as severely
mentally ill have unemployment rates approaching 90 percent statewide and nationally.
These rates are generally not true for other disability groups. Although the mental
health system has been successful in moving consumers from institutional settings,
they have failed to integrate consumers fully back into communities. In fairness,
some of these issues that prevent reintegration are due to pervasive societal
prejudices that inhibit reintegration.
There seems to be a traditional mental health model based on the training and background
of administrators that places an undue amount of emphasis on medication, diagnosis and
therapy as the only way to recover. Consumers coming into the mental health system are
introduced into a system that has few expectations of their clients other than medication,
therapy and day programs. Often and very quickly consumers can settle into a lifetime
role of a patient. The consumer learns that he/she is not capable of leading a productive
life due to mental illness. The focus simply becomes the illness, spend downs, benefits
and a rather narrow world consisting of the agency and any activities that it might
sponsor. This type of picture can quickly destroy an individual's dreams, aspirations
and squash incentive. Since no one has ever presented a different reality, this
situation can even turn into a sense of entitlement among some consumers. This group
of consumers often views their life status as a right to life long benefits with no
obligation during periods of recovery to return whatever they have to others in the
community. I don't feel these tendencies are any different than others since humanity
and human nature are essentially the same everywhere, including my own. However the
system has an obligation not to encourage self-centereness but to encourage engagement,
employment, reintegration, etc.
When we talk of work, this term can apply to any meaningful activity that successfully
engages the consumer. The key word is engage. I see many consumers who are existing but
not engaged. Initially all consumers need a protective and caring environment with
appropriate medication/therapy to recover. As a consumer recovers and is stabilizes
he/she should be engaged by the system. I think everyone should have sufficient time
to recover and that includes an extensive amount of personal and emotional work that
is required for a complete recovery. I don't believe in moving folks out of the hospital
directly into work.
Statewide there are only a small of consumers involved in supported employment
programs even though we know these programs work. An expectation should be created
early in the consumer's recovery that everyone has a gift that needs to be returned
to the community. Furthermore, as research has demonstrated, recovery and work are
directly connected. One realizes that not ever consumer can move out of the system
but surely we could improve on a 90% unemployment rate, fewer than ten percent of
consumers enrolled in supported employment programs or generally consumers not engaged
in volunteer or other meaningful activities even after 20 years in the sytem.
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Filing Discrimination Charges: Sad Truth
I was employed previous to the Recovery Network in a Human Resource position where periodically
I was required to gather facts and write responses to charges of discrimination filed by employees.
I noticed after answering these charges and supplying extensive information to governmental agencies,
including the Equal Opportunity Commission (EEOC), that a pattern started to emerge. Investigators for
the EEOC and other agencies were overloaded with high numbers of charges of discrimination and seemed
more interested in obtaining the necessary paperwork than investigating the claim.
Some of the things that I observed while working in this area have been published by the Psychiatric
Rehabilitation Journal concerning persons with disabilities. Investigators Kathryn Moss and Matthew
Johnsen presented their findings in an article that represents the first in-depth study of how the
employment discrimination charge (focus on mental health discrimination claims) process, mandated under
Title 1 of the American Disabilities Act (ADA), is working.
A sampling of their conclusions include:
"There is an incentive for investigators to find that there is not reasonable cause to
believe that a charge is true. "During most of the time period covered by this study, investigators were
evaluated annually on standards that reward the number of cases closed - without formal regard to the
investigation quality or outcome. While such standard may be understandable in light of the EEOC's backlog,
they obviously serve as an incentive for investigators to limit the time spent assessing and confirming
documentation, interviewing witnesses, and conducting on-site investigations."
"Once an investigation has begun, on-site investigations and in-person interviews with
witnesses are rarely conducted because of insufficient investigative time and limited travel funds. Of
the six private practice attorneys interviewed four believed that EEOC investigators are so overworked
that 'they just don't care."
"Another attorney reported that she and her colleagues almost never get cause findings
issued for their clients by EEOC, regardless of the amount of evidence provided... "
Also indicated: "while the sympathies of investigators tend to be with the charging
parties, rather than with the employers, it is easier and less time-consuming for investigators to believe
employer-furnished information than to look beyond it. Both felt investigators tend to do what is easier
because of the enormous pressure to move cases, not because they are sympathetic to employers."
Long delays were, reported in the charging process e.g., two years simply to "determine
that the charging party was not a qualified individual with a disability and, therefore, to dismiss the charge."
One implication of these cases may be that the long processing time associated with
assigning and investigating complaints may have an especially deleterious effect on complaints with
psychiatric disabilities. One person said "there is one thing in all of this that bothers me, doesn't
anybody care about my mental illness and the effect that this charge process is having on me?"
What does all this mean to the consumer? I don't wish to discourage consumers from
filing charges as long as consumers are realistic about the above process. Secondly, if consumers can
afford a private attorney, although some will work on a contingency basis, their claim has a better
chance to be investigated more thoroughly and the outcome is more likely to be in their favor. Beneficial
outcomes were reported as low as 10 to 16 percent in the above study for charging parties. Lastly consumers
should realize that this process whether filing privately or governmentally is a long, difficult and
emotionally draining process.
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Coleman on Managed Care
Excerpt taken from Jim Coleman's statements on managed care at the Cincinnati City Council Chambers:
I am not categorically against managed care, only the abuses of manage care. But managed care cannot be
held privileged to escape accountability and scrutiny for their actions any more than any other industry is immune from
the consequences of their decisions.
Society is going to have to establish what are acceptable practices in medical treatment and what is
not acceptable. It not acceptable to have a suicidal person trying for days to get treatment anymore than it is
acceptable to have a mother vacate her hospital room within twenty-four hours of giving birth. Lassiez-faire economics
can be a disaster in the medical field. We need comprehensive regulations establishing treatment protocols. And not the
treatment protocols we have now. Government that governs less is always ideal but still government has a legitimate role
to play by setting minimum medical coverage standards. We establish a minimum wage to protect our most vulnerable wage
earners, require government inspection of our food to protect from us food poisoning, and issue driving regulations to
protect us on the highways. Are we now saying that our citizens can receive what every level of medical care offered by
the lowest bidder without any minimal standards? Again this is a legitimate role for government to play. We cannot always
ask the marketplace to determine standards; this was never the role of the private sector. The market should only provide
the most efficient price based on contract standards. If the contract does not state that a woman giving birth will
receive a minimum 48 hours stay, then the market will go for 24 hours and eventually outpatient birthing. The market
does not determine ethical standards, society does! When manage care companies bid on a contract, society should be
saying this is our minimal standard of humanitarian care, this is what we are willing to pay for as a society, we will
not accept less. Then the playing field is level and the competition can begin! Let's not have regulation dependent on
people dying first. And then only regulating procedure by procedure. We need inclusive standards not ad hoc responses to
each crisis.
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Comments Concerning Research
In the Northern Kentucky/Cincinnati area there are a
constant bombardment of advertisements (TV, radio & newsprint) soliciting mental health
consumers, including children, to participate in the latest drug trails. Persons are
recruited for diverse areas of mental health studies including bipolar, depression and
schizophrenia. What is alarming in these advertisements are no mention that candidates
should be treatment failures from standardized treatment protocols. If a woman had breast
cancer, her doctor would recommend standardized methods of treatment. Only if the
standardized treatments failed would the doctor discuss experimental drug studies.
Somehow with mental health patients we permit a different standard of care. A person
should not be recruited off the street, compensated and placed on a drug trail for
depression without first going through standardized treatment protocols.
Additionally performing challenge studies or
enrolling newly entered psychotic patients who have not been stabilized in placebo
studies are not examples of ethical research. The duty of the physician is to stabilize
the patient and then after an extended period of stability, if medically appropriate, a
trail may be suggested.
Consumers, family members, professionals and others
should support ethical research in an attempt to relieve the symptoms of mental illness.
Just a few studies out of thousands legitimate studies can severely damage the confidence
consumers have with the medical profession.
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Nicotine & Schizophrenia
One of the most devastating experiences a person can
face in life is cancer. Yet consumers daily expose themselves to lung cancer and a host
of other diseases because of their addiction to cigarettes. A report from the Harvard
Medical School reveals how a medical evaluation of mental health patients shows half
with significant physical disease. It is difficult enough for a person to quit smoking
but in the case of a consumer there other reasons that make this process even more
difficult.
Science is now discovering the connection between
smoking and mental illness:
"Individuals with schizophrenia who smoke do not do
so because they have poor judgment or because they have been encouraged by institutional
rules. They smoke because nicotine stimulates the subcortical brain reward mechanisms and
the prefrontal cortex, which may be hypoactive in schizophrenia. In addition, for
individuals with schizophrenia, nicotine may also improve concentration, and reduce
anxiety, positive and negative symptoms and symptoms of movement disorder."
"Individuals with schizophrenia who smoke are, from
where they sit, making what could be considered a very rational decision. For these reasons,
the joint Commission on Accreditation of Health Care Organizations, the New York State
Legislature, and the New York City Council have all included provisions that would allow
individuals with neurobiological disorders who smoke to continue to smoke in discrete
areas, even when hospitalized."
Edward D. Levin, Ph,D. in an article titled Nicotine
and Schizophrenia: Cognitive Aspects and Possible Novel Treatments (1994 NARSAD Young
Investigator from Duke University Medical Center) reports the following findings:
"Cigarette smoking is very prevalent among patients
with schizophrenia, who have more than triple the smoking rate of the general population.
Over the past 30 years, overall smoking in the United States has declined to about 25% but
the smoking rate in people with schizophrenia remains very high at about 80%. As with other
cigarette smokers, the key to smoking in schizophrenic patients seems to be nicotine. An
important characteristic of nicotine is that it has a wide variety of pharmacological
actions that go beyond simple addictiveness. Some of its effects, such as those on
cognition, can be beneficial, despite the variety of other adverse health consequences
of tobacco use, Groups who smoke most heavily such as patients with schizophrenia may be
engaging in self-medication with nicotine."
* Some research literature suggest smoking among
persons with schizophrenia is as high as 90%.
Improvement in Memory Deficits
Schizophrenia patients have been found by Dr. Robert
Freedman and his group at the University of Colorado to have a deficiency of nicotinic
receptors in the hippocampus, an area of the brain important in attention to new sensory
stimuli and memory formation. Cigarette smoking can normalize the deficit in sensory
gating (i.e. screening out repeated stimuli) seen in patients with schizophrenia. At
Duke University Medical Center, Drs. McEvoy, Wilson, Rose and I have found, In research
sponsored by NARSAD, that nicotine attenuates the memory deficits and bradyphrenia
(slowness of thought) caused by the antipsychotic drug haloperidol and more generally
improves attentiveness In patients with schizophrenia regardless of haloperidol dose.
Haloperidol causes a dose-related increase in ad lib smoking. Patients with schizophrenia
may smoke at high rates to both treat the cognitive symptoms of schizophrenia and to
alleviate the adverse side effects of classic antipsychotic drugs."
Novel Treatments
"Certainly we are not advocating cigarette smoking
in patients with schizophrenia. Cigarette smoking has a variety of health impairing
effects. However, nicotine delivered by other means, such nicotine skin patches,
may be useful for treating some of the cognitive symptoms of schizophrenia and
cognitive deficits which result from antipsychotic medication. To date, the only
FDA approved general use for nicotine skin patches is to help people quit smoking.
Other uses, including use as an adjunct in treating schizophrenia, are under
investigation. In addition, sister drugs to nicotine, nicotinic agonists, are
being developed by a number of pharmaceutical companies for possible therapeutic use. "
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The Connection Between Smoking and Depression/Bipolar Illnesses
In an article in the October 1993 Harvard Mental
Health Letter "What is the Relationship Between Depression and Cigarette Smoking?" Dr.
Glassman, of Columbia University College of Physicians and Surgeons notes:
"Over the last five years, studies of large
populations have shown that cigarette smoking is associated with affective disorders.
People with a history of major depression are more likely to smoke and find it harder
to quit smoking than the average person without a psychiatric disorder. Moreover,
studies that compare identical with fraternal twins suggest a hereditary component:
a genetic makeup, that makes an individual vulnerable to depression or manic depression,
may also make him or her vulnerable to nicotine addiction."
Tom Ferguson, M.D., in his book "Guide To Quitting
Smoking" (titled abbreviated) says that smoking serves as a "mood thermostat". Further
he indicates:
"When persons wish to regulate moods, they achieve
a "stimulating effect by taking short, quick puffs. This produces a low level of blood
nicotine, which stimulates nerve transmission. When they wish to relax, they take deep
drags, which produce high levels. This depresses the passage of nerve impulses,
producing a mild sedative effect."
There is increasing scientific evidence that smoking
can relieve symptoms. The dilemma then becomes how can a consumers quit smoking and not
have a negative impact on their recovery? It is my feelings mental health agencies offer
a program for smoking cessation that includes drastically reduced prices on nicotine
patches, nicotine gum, etc. Many consumers have voiced a real desire to stop smoking
but feel frustrated over the cost and the logistics involved in obtaining nicotine
replacement therapy products. Indeed I would rather see a consumer maintained on
nicotine replacement therapy for the rest of their lives versus the disastrous damage
that smoking does to the lungs, heart, and organs of the body. Since this is not
currently possible, any nicotine replacement therapy must be combined with a smoking
cessation program that takes into account the role of nicotine as a self-medicating
agent for consumers. Consumers are being treated with medication to improve their
everyday functioning but if they experience lung disease, heart disease or cancer at
a relatively early stage in life (45-55) due to smoking, the cost to themselves and
society will be enormous. What good is improved mental functioning if you need an
oxygen tank and mask to breathe at the age of 50?
From a purely economic point of view, the cost
to the system will greatly be reduced if mental health management agencies would
provide nicotine replacement therapy to consumers combined with a smoking cessation
program. Imagine for a minute the alternative: consumers requiring the repeated
attention of pulmonary specialists or other medical professionals with additional
expensive medications or treatments for prolonged periods or even decades. A small
number of consuumers hospital bills and related medicine/follow up expenses, as the
result of smoking, would most likely pay for the entire cost of the program on an
annual basis to all consumers. It would appear to be a huge financial mistake to
ignore the economic and demographic consequences of this situation. I currently
see consumers who have chronic bronchitis, the early stages of emphysema and other
smoking related problems who have been informed by their doctors to quit smoking or
face significant illnesses. When asked about nicotine replacement therapy, the
universal response is " I can't afford it." As consumers who have smoked for 20+
years continue to smoke for another 5 to 10 years, the bill will come due. As the
saying goes "you pay now or you pay later."
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