Tagged Mental Health

FCC Unanimously Approves Three-Digit Suicide Prevention Number Amid Escalating Crisis In U.S.

San Francisco Hopes To Improve Care For People With Mental Illness Living On Streets

San Francisco Mayor London Breed has promised to tackle her city’s homelessness crisis, a vexing situation involving drug abuse and mental illness that is compounded by the city’s high housing costs. Breed has asked Dr. Anton Nigusse Bland, most recently the medical director for psychiatric emergency services at Zuckerberg San Francisco General Hospital, to help solve the problem.

In March, she appointed him to the newly created position of director of mental health reform. His main role is to help the city improve its mental health and addiction treatment for people experiencing homelessness.

“I had the opportunity being there on the front lines, providing services directly to clients, to better understand and appreciate when a person has that combination of homelessness, mental illness and substance abuse,” said Nigusse Bland. He has worked in several Bay Area county mental health systems, first as an integrated care psychiatrist with Alameda Health System, then as chief of psychiatry for Contra Costa County.

The mayor backed a new state law, SB-1045, which establishes pilot programs to expand the use of conservatorship — a controversial practice that allows the city to take people with mental illness or substance abuse issues off the streets without their consent and put them into treatment.

To identify the people most in need of services, city employees used data on the 18,000 residents in need of immediate shelter. They identified about 3,700 who were experiencing what Nigusse Bland calls the “trifecta” of homelessness, mental illness and substance use. Many of them have repeatedly visited ERs or been jailed multiple times in the past year.

Of those 3,700 people, 237 were identified as immediate priorities. Nigusse Bland said the key is coordinating care to get them into housing and services they may not know are available.

San Francisco is the only jurisdiction so far to create such a conservatorship pilot program, though the law also allows Los Angeles and San Diego counties to do so.

San Francisco officials also recently reached an agreement on how to allocate mental health funding for those with the most urgent needs. Their plan includes a 24-hour service center and an outreach team.

Nigusse Bland sat down last month with California Healthline at the San Francisco Department of Public Health in the city’s Civic Center, which has long been a hub of homelessness and open-air drug use, to talk about the daunting task facing him. His comments have been edited for space and clarity.

Q: What were some of your first steps when you took this job?

We had a couple of challenges ahead of us, one of which was being clear about who is affected by homelessness, mental illness and substance abuse and finding the root cause of why they’re having this experience right now. In this population, care coordination works, and you have to be very thoughtful about deploying evidence-based practices to get those services to those individuals.

One of the overwhelming assumptions about this group of individuals is that they’re all getting high on crystal meth, but we were surprised to learn that 95% of these people have an alcohol-related problem. The good thing is that there are many things we can do about alcohol.

Q: What services will be available to the 237 people you identified as having the most urgent needs?

Dr. Anton Nigusse Bland was recently appoint San Francisco’s new director of mental health reform to help the city improve its mental health and addiction treatment for people experiencing homelessness. (Courtesy of the San Francisco Department of Public Health)

Those individuals will receive an advanced care coordination team coupled with street responders, mental health specialists, a psychiatrist, and caseworkers who are actively reaching out to these people in the community.

If they are found in an emergency setting, we will go to that setting and help navigate them to a safe place, which might be a substance use treatment program, a mental health residential program or directly into housing.

Q: Allowing city officials to hold people against their will is controversial. What do you think about using conservatorship to treat people with mental illness or substance abuse disorders?

We have to be very thoughtful in the balance between autonomy and restoring a person’s dignity and health. It’s inhumane to allow someone to suffer on the streets with serious mental illness and substance abuse when there are alternatives available to them. In many of those cases, those individuals who are so severely affected may not even understand what’s happening to them at that moment. They’re struggling.

Through conservatorship, we have an opportunity to help restore that person’s capacity. I see it as an opportunity. In some cases, it can be the right thing to do to help that person get back on track.

Q: How will you get people the services they need given historically limited funding?

Our mayor has made a significant investment by adding over 200 new behavioral health beds into our pipeline with plans to add over 800 new beds.

We have commitments to increase the number of our intensive case managers, especially in mental health services for individuals with complex mental health and substance abuse issues.  We’ve made a commitment to reduce intensive case managers’ workloads to be able to meet the needs of these clients.

We want to make sure the ones most severely affected are getting into housing and get the support to stay in housing.

Q: How will you gauge success?

We should see changes in people experiencing homelessness, the amount of time they spend in jail and the emergency room, and their engagement in some kind of meaningful activity.

There are a couple of things that I think are going to make an impact, one of which is our Drug Sobering Center for those suffering the consequences of methamphetamine use. If someone appears confused, is having difficulty keeping their clothes on or yelling at someone, there’s a safe place that’s not jail, that’s not the emergency room, where they can recover and get counseling. And, if they’re ready, they can go into a treatment program as a next step.

That person doesn’t have to spend another night on the street and has the opportunity to get into services rather than having a jail record. And there’s the indirect impact of our emergency departments likely experiencing less crowding.

Q: What else should people know about this work?

Thirty-five percent of those 3,700 individuals in that trifecta are black and/or African American, a group that represents only 5% of San Francisco’s population, so they are disproportionately represented in the most vulnerable among us. We want to see an equitable San Francisco so everyone has a fair shot at wellness and recovery.

Sometimes that first opportunity isn’t successful and you might have to engage again to get that person on the right track, but what we know is that with every opportunity, they can make progress. It might be incremental, and it’s on their own timeline, but they can get better.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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In The Fight For Money For The Opioid Crisis, Will The Youngest Victims Be Left Out?

Babies born to mothers who used opioids during pregnancy represent one of the most distressing legacies of an opioid epidemic that has claimed almost 400,000 lives and ravaged communities.

In fact, many of the ongoing lawsuits filed against drug companies refer to these babies, fighting through withdrawal in hospital nurseries.

The cluster of symptoms they experience, which include tremors, seizures and respiratory distress, is known as neonatal abstinence syndrome, or NAS. Until recently, doctors rarely looked for the condition. Then case numbers quadrupled over a decade. Hospital care for newborns with NAS has cost Medicaid billions of dollars.

Studies indicate more than 30,000 babies with the condition are born every year in the U.S. — about one every 15 minutes. Although their plight is mentioned in opioid-related litigation, there are growing concerns that those children will be left out of financial settlements being negotiated now.

Robbie Nicholson, of Eagleville, Tenn., tried to comfort her second child while the baby slowly underwent withdrawal from drugs Nicholson had taken during pregnancy.

“The whole experience is just traumatizing, really,” Nicholson said.

Nicholson’s ordeal began right after her first pregnancy. To help with postpartum recovery, her doctor prescribed her a pile of Percocets. That was the norm.

“Back then, it was like I was on them for a full month. And then he was like, ‘OK, you’re done.’ And I was like, ‘Oh, my God, I’ve got a newborn, first-time mom, no energy, no sleep, like that was getting me through,’” she said. “It just built and built and built off that.”

After developing a full-blown addiction to painkillers, Nicholson eventually found her way into recovery. In accordance with evidence-based guidelines, she took buprenorphine, a medication that helps keep her opioid cravings at bay. And then came another pregnancy.

Robbie Nicholson now works as a mentor with a company called 180 Health Partners that helps women with addiction go through pregnancy. Her own newborn went through drug withdrawals, related to the medications she took to control her opioid cravings. She says most women she works with need a stable place to live and reliable transportation.(Blake Farmer/Nashville Public Radio)

But buprenorphine — as well as methadone, another drug used in medication-assisted addiction treatment — is a special kind of opioid. Its use during pregnancy can still result in withdrawal symptoms for the newborn, although increasingly physicians have decided that the benefits of keeping a mother on the medication, to prevent a potentially fatal relapse and overdose during pregnancy, outweigh the risk of her giving birth to a baby with neonatal abstinence syndrome.

Treatment protocols for NAS vary from hospital to hospital, but doctors and neonatal nurses have become better at diagnosing the condition and weaning newborns safely. Sometimes the mom and her baby can even stay together if the infant doesn’t have to be sent to the neonatal intensive care unit.

But not much is known about the long-term effects of NAS, and parents and medical professionals worry about the future of children exposed in utero to opioids.

“I wanted her to be perfect, and she is absolutely perfect,” Nicholson said. “But in the back of my mind, it’s always going to be there.”

There are thousands of children like Nicholson’s daughter entering the education system. Dr. Stephen Patrick, a neonatologist in Nashville, Tenn., said schools and early childhood programs are on the front lines now.

“You hear teachers talking about infants with a development delay,” he said. “I just got an email this morning from somebody.”

Studies haven’t proven a direct link between in utero exposure to opioids and behavior problems in kids. And it’s challenging to untangle which problems might stem from the lingering effects of maternal drug use, as opposed to the impacts of growing up with a mother who struggles with addiction and perhaps unemployment and housing instability as well. But Patrick, who leads the Center for Child Health Policy at Vanderbilt University, said that is what his and others’ ongoing research wants to find out.

As states, cities, counties and even hospitals go after drug companies in court, Patrick fears these children will be left out. He pointed to public discussion of pending settlements and the settlement deals struck between pharmaceutical companies and the state of Oklahoma, which make little or no mention of children.

Settlement funds could be used to monitor the health of children who had NAS, to pay for treatment of any developmental problems and to help schools serving those children, Patrick explained.

“We need to be in the mix right now, in schools, understanding how we can support teachers, how we can support students as they try to learn, even as we work out [whether there was] cause and effect of opioid use and developmental delays or issues in school,” he said.

New mothers in recovery for opioid addiction meet with a support group in Oak Ridge, Tenn. Most had newborns who endured drug withdrawals at birth, known as neonatal abstinence syndrome.(Blake Farmer/Nashville Public Radio)

But it’s a nuanced problem with no consensus on where money is most needed, even among those who have worked on the problem for years.

Justin Lanning started Nashville-based 180 Health Partners, which works with mothers at risk of delivering a baby dependent on opioids. Most are covered by Medicaid. And Medicaid departments in each state pay for most of the NAS births in the U.S.

“We have a few departments in our country that can operate at an epidemic scale, and I think that’s where we have to focus our funds,” he said.

Lanning sees a need to extend government-funded insurance for new mothers, since in states like Tennessee that never expanded Medicaid, these moms can lose health coverage just two months after giving birth. That often derails the mother’s own drug treatment funded by Medicaid, he said.

“This consistency of care is so key to their recovery, to their productivity, to their thriving,” Lanning said of new mothers in recovery.

Nicholson now has a job at 180 Health Partners, assisting and mentoring pregnant women struggling with addiction. Nicholson said their biggest need is a stable place to live and reliable transportation.

“I just feel kind of hopeless,” she said. “I don’t know what to tell these women.”

There are many needs, Nicholson said, but no simple fix. Those who work with mothers in recovery fear any opioid settlement money may be spread so thin that it doesn’t benefit their children — the next generation of the crisis.

This story is part of a partnership that includes Nashville Public Radio, NPR and Kaiser Health News.

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State Highlights: Cold Temperatures In Maryland Claim First Fatality Of Season; Minnesota Police Take New Look At How To Respond To Suicide Calls

Viewpoints: Fight Against Fake Medical News Shines Important Light On Life-Saving Vaccines; U.S. Lags Behind Other Countries In Providing High-Quality Primary Care

When Teens Abuse Parents, Shame And Secrecy Make It Hard To Seek Help

Nothing Jenn and Jason learned in parenting class prepared them for the challenges they’ve faced raising a child prone to violent outbursts.

The couple are parents to two siblings. They first fostered the children as toddlers and later adopted them. (KHN has agreed not to use the children’s names or the couple’s last names because of the sensitive nature of the family’s story.)

In some ways, the family seems like many others. Jenn and Jason’s 12-year-old daughter is into pop star Taylor Swift and loves playing outside with her older brother. He’s 15, and his hobbies include running track and drawing pictures of superheroes. The family lives on a quiet street in central Illinois, with three cats and a rescued pit bull named Sailor.

Jenn described their teenage son as a “kind, funny and smart kid,” most of the time.

But starting when he was around 3 or 4 years old, even the smallest things — like being told to put on his swimsuit when he wanted to go to the pool — could set off an hours-long rage.

“In his room, his dresser would be pushed across the other side of the room,” Jason said. “His bed would be flipped up on the side. So, I mean, very violent. We’ve always said it was kind of like a light switch: It clicked on and clicked off.”

Jenn and Jason said their son’s behavior has gotten more dangerous as he has gotten older. Today he’s 6 feet tall — bigger than both of his parents.

Jenn said most of the time her son directs his initial anger and aggression toward her. But when the 15-year-old has threatened to hit her, and Jason has intervened, the teen has hit his father or thrown things at him.

“The way he will look at me is just evil,” Jenn said. “He has threatened to slap me in the face. He’s called me all sorts of horrible names. After an incident like that, it’s hard to go to sleep, thinking, ‘Is he going to come in and attack us while we’re sleeping?’”

Drawings made by Jenn and Jason’s 15-year-old son lie on the family’s dining room table in their home in central Illinois. Though his angry outbursts reveal a violent side, his parents say that most of the time he is “kind, funny and smart” — a teen who enjoys drawing pictures of superheroes.(Christine Herman/Illinois Public Media)

People who are victims of domestic violence are advised to seek help. But when the abuse comes from your own child, some parents have said there is a lack of support, understanding and effective interventions to keep the family safe.

While research is limited, a 2017 review of the literature found child-on-parent violence is likely a major problem that’s underreported.

Jenn said she’s concerned about everyone’s safety and worries about her 12-year-old daughter being exposed to recurrent violence in their home.

The stress has taken a significant mental and emotional toll on Jenn. She sees a therapist to cope with the violence at home and to deal with her anxiety.

“There are days when it’s hard to breathe,” Jenn said. “You just feel it in your chest — like, I need a breath of air, I’m drowning. We say to each other all the time, ‘This is insanity. How can we live like this? This is out of control.’”

Blamed And Shamed Into Silence

It’s hard to know exactly how common Jenn and Jason’s experience is, since research is sparse. In one nationally representative survey in the mid-1970s of roughly 600 U.S. families, about 1 in 11 reported at least one incident of an adolescent child acting violently toward a parent in the previous year. In about a third of those cases, the violence was severe — ranging from punching, kicking or biting to the use of a knife or gun.

Other more recent estimates of the prevalence of child-on-parent violence range from 5% to 22% of families, which means several million U.S. families could be affected.

A 2008 study by the U.S. Justice Department found that while most domestic assault offenders are adults, about 1 in 12 who come to the attention of law enforcement are minors. In half of those cases, the victim was a parent, most often the mother.

While most children who are abused or witness domestic violence do not go on to become violent themselves, and while most people with mental illness are not violent, those life experiences have been identified as risk factors for children who abuse their parents.

Lily Anderson is a clinical social worker in the Seattle area who has worked with hundreds of families dealing with a violent child. Along with her colleague Gregory Routt, she developed a family violence intervention program for the juvenile court in King County, Wash., called Step-Up.

Anderson said, in her experience, many parents feel ashamed about their situation.

“They don’t want to tell their friends or their family members,” Anderson said. “They do feel a lot of self-blame around it: ‘I should be able to handle my child. I should be able to control this behavior.’”

Anderson said many of the incidents take place at home, where the assaults are hidden from the public eye. That contributes to the lack of public awareness about the issue and makes it even harder for affected parents to find support.

“The whole issue becomes perceived as being the parent’s problem and the parent is to blame for the youth’s behavior,” Anderson said. “I think the main issue is that we need to talk about this. We need to talk — be willing to put it out there and make it an important issue and bring resources together for it.”

Unpredictable Anger

Jenn said that she has talked to her son’s therapists about why he has such trouble regulating his emotions, and they’ve told her it could be linked to the severe trauma he experienced as a baby and toddler.

When the couple began fostering the siblings in late 2007, the boy was 3 and his sister younger than 1. They had been removed from the home of their birth parents, where police were regularly called for drug and domestic violence issues. Jenn said her son remembers being beaten by men in his home and watching as his biological mom cut herself.

Jenn and Jason started their son in therapy at a young age, and he has been diagnosed with reactive attachment disorder, PTSD, attention deficit hyperactivity disorder and autism.

Jenn, Jason and their kids together at home last spring. Before they were adopted, the kids experienced or witnessed significant abuse in their birth family, Jenn says. That severe trauma, according to therapists, is likely a source of their son’s difficulty in regulating his emotions.(Christine Herman/Illinois Public Media)

The teen has attended art therapy and equine therapy regularly for years. He also participated in a mentorship program and attended a school designed for children with behavioral health needs. Jenn and Jason participated in family therapy sessions with their son, where they learned coping skills and practiced de-escalating situations at home.

The teen was also prescribed medication to help regulate his emotions.

Jenn said her son enjoyed going to therapy and seemed to be making some progress, but his anger remained unpredictable.

During the worst of the conflicts, the teen has kicked holes in walls and broken appliances. He has attempted to run away from home and created weapons to try to hurt his parents and himself. In recent years, Jenn and Jason have had to call police to their house about once a month to get help restraining their son. They’ve also sometimes had to have him admitted to the hospital for brief psychiatric stays.

‘Seems Like It’s Not Enough’

Keri Williams is a writer in North Carolina who advocates for parents raising children who have trauma-related behavioral issues, including attachment disorders that can manifest as intentional violence directed toward parents.

Williams’ own son became so violent that her family had to place him in a residential facility at age 10. He’s now 18.

“I actually thought I was the only person going through it,” Williams said. “I had no idea that this was actually a larger issue than myself.”

Williams manages a blog and Facebook page where parents like herself — who feel isolated and unsure of where to turn — can find others who can relate.

Many parents she meets online struggle to accept that they’re dealing with a serious domestic violence issue, she said.

“You just don’t want to think like that,” Williams said. “That’s just not how our culture is and how parents perceive things. And that denial actually is what keeps parents from getting their kids help.”

Jenn — the mother of the 15-year-old in Illinois — said parenting her son often feels like being stuck in an abusive relationship.

“But it’s different when it’s your son,” she said. “I don’t have a choice. I can’t just, you know, shove him away or break up with him.”

Jenn said anytime she sees a news story about a child who has killed a parent, she worries. Such events are extremely rare, and Jenn doesn’t want to think her son is capable of that.

“But, unfortunately, the reality is, when he is in those rages and in those meltdowns, he really isn’t thinking straight, and he’s very impulsive,” Jenn said. “So, it’s very scary.”

Despite all the challenges, she and her husband both said that adopting their son has brought them a lot of joy.

“It’s made me a better, stronger person, a better and stronger wife and teacher,” Jenn said.

But, she adds, she wishes there were more effective treatments that could help kids like her son live safely in the community and more places where traumatized parents could turn to find help.

“I feel like we’re doing everything that we can for him, but it just seems like it’s not enough,” Jenn said.

A Difficult Decision

Just before the beginning of the school year, Jenn and Jason made the difficult decision to send their son to a residential facility for children with severe behavioral health issues. He’s living there now.

The couple wrestled with that choice for some time. The boy had already spent almost three years in residential treatment all told, starting when he was 10. He’d moved back home last year because they thought he was ready.

But the family continued to deal with almost-daily standoffs involving verbal threats, angry outbursts and property destruction.

The boy’s 12-year-old sister said she has mixed feelings about her brother leaving home again to reenter residential treatment.

“It makes me feel happy and sad,” she said, “because, well, I love my brother. And I know he’ll be getting the help he needs.”

She’s comforted knowing her parents will be safe but said she’ll miss her brother a lot.

“I just love him,” she said. “And I don’t want to see him go through that.”

This story is part of a partnership that includes Side Effects Public Media, Illinois Public Media, NPR and Kaiser Health News.

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Among U.S. States, New York’s Suicide Rate Is The Lowest. How’s That?

“I just snapped” is how Jessica Lioy describes her attempt in April to kill herself.

After a tough year in which she’d moved back to her parents’ Syracuse, N.Y., home and changed colleges, the crumbling of her relationship with her boyfriend pushed the 22-year-old over the edge. She impulsively swallowed a handful of sleeping pills. Her mom happened to walk into her bedroom, saw the pills scattered on the floor and called 911.

In 2017, 1.4 million adults attempted suicide, while more than 47,000 others did kill themselves, making suicide the 10th-leading cause of death in the United States, according to the federal Centers for Disease Control and Prevention. And the rate has been rising for 20 years.

New York’s efforts to prevent suicides include testing a brief intervention program for people who have attempted suicide — because they are at risk for trying again. “They steal you for an hour from the universe and make you focus on the worst thing in your life and then coach you through it,” Jessica Lioy says.(Courtesy of Jessica Lioy)

Like other states, Jessica Lioy’s home state of New York has seen its rate increase. But New York has consistently reported rates well below those of the U.S. overall. Compared with the national rate of 14 suicides per 100,000 people in 2017, New York’s was just 8.1, the lowest suicide rate in the nation.

What gives? At first glance, the state doesn’t seem like an obvious candidate for the lowest rank. There’s New York City, all hustle and stress, tiny apartments and crowds of strangers. And upstate New York, often portrayed as bleak and cold, is famously disparaged in the Broadway musical “A Chorus Line” with the comment that “to commit suicide in Buffalo is redundant.”

Experts say there’s no easy explanation for the state’s lowest-in-the-nation rate. “I can’t tell you why,” said Dr. Jay Carruthers, a psychiatrist who is the director of suicide prevention at the New York State Office of Mental Health.

Guns And Urbanization Are Likely Factors 

There’s no single answer, but a number of factors probably play a role, according to Carruthers and other experts on suicide.

Low rates of gun ownership are likely key. Guns are used in about half of suicide deaths, and having access to a gun triples the risk that someone will die by suicide, according to a study in the Annals of Internal Medicine. Because guns are so deadly, someone who attempts suicide with a gun will succeed about 85% of the time, compared with a 2% fatality rate if someone opts for pills, according to a study by researchers at the Harvard Injury Control Research Center.

“The scientific evidence is pretty darn good that having easy access to guns makes the difference whether a suicidal crisis ends up being a fatal or a nonfatal event,” said Catherine Barber, who co-authored the study and is a senior researcher at the Harvard center.

New York has some of the strongest gun laws in the country. In 2013 — after the mass shooting at Sandy Hook Elementary School in Newtown, Conn. — the state broadened its ban on assault weapons, required recertification of pistols and assault weapons every five years, closed a private sale loophole on background checks and increased criminal penalties for the use of illegal guns.

This year, the state enacted laws that, among other things, established a 30-day waiting period for gun purchases for people who don’t immediately pass a background check, and prevented people who show signs of being a threat to themselves or others from buying guns, sometimes referred to as a “red flag” or “extreme risk” law.

The population is also heavily concentrated in urban areas, including more than 8 million people living in New York City. According to the Census Bureau, nearly 88% of the state’s population lived in urban areas in the 2010 census, while the national figure is about 81%.

Suicide rates are typically lower in cities. In 2017, the suicide rate nationwide for the most rural counties — 20 per 100,000 people — was almost twice as high as the 11.1 rate for the most urban counties, according to the CDC. The trend is accelerating. While the suicide rate in the most urban counties increased by 16% from 1999 to 2017, it grew by a whopping 53% in the most rural counties.

Loneliness, isolation and access to lethal weapons can be a potent combination that leads to suicide, said Jerry Reed, who directs the suicide, violence and injury prevention efforts at the Education Development Center. The center runs the federally funded Suicide Prevention Resource Center, among other suicide prevention projects.

People in rural areas may live many miles from the nearest mental health facility, therapist or even their own neighbors.

“If your spouse passes away or you come down with a chronic condition and no one is checking on you and you have access to firearms,” Reed said, “life may not seem like worth living.”

Intervention Helps ‘Force You’ To Move Forward 

New York’s efforts to prevent suicides include conducting a randomized controlled trial to test the effectiveness of a brief intervention program developed in Switzerland for people who have attempted suicide — because they are at risk for trying again.

The trial has yet to get underway, but clinicians at the Hutchings Psychiatric Center in Syracuse were trained in the Attempted Suicide Short Intervention Program, as it’s called. They began testing it with some patients last year.

Jessica Lioy was one of them. After her suicide attempt, she spent a week at the inpatient psychiatric unit at Upstate University Hospital in Syracuse. A social worker approached her about signing up for that outpatient therapy program.

The program is simple. It has just four elements:

  • In the first session, patients sit down with a therapist for an hourlong videotaped discussion about why they tried to kill themselves.
  • At their second meeting, they watch the video to reconstruct how the patient moved from experiencing something painful to attempting suicide.
  • During the third session, the therapist helps the patient list long-term goals, warning signs and safety strategies, along with the phone numbers of people to call during a crisis. The patient carries the information with them at all times.
  • Finally, during the next two years, the therapist writes periodic “caring letters” to the patient to check in and remind them about their risks and safety strategies.

In the Swiss trial, about 27% of the patients in the control group attempted suicide again during the next two years. Only 8% of those who went through the intervention program re-attempted suicide during that time.

“The difference with ASSIP is the patient involvement. It’s very patient-centered,” said Dr. Seetha Ramanathan, the Hutchings psychiatrist overseeing the program. It’s also very focused on the suicide attempt, not on other issues like depression or PTSD, she said.

Lioy said that, at the beginning, she didn’t have high hopes for the program. She had already told her story to many doctors and mental health therapists. But this felt different, she recalled.

“They steal you for an hour from the universe and make you focus on the worst thing in your life and then coach you through it,” Lioy said. “They force you to feel something, and they force you to just reflect on that one situation and how to move forward to not end up back in that place. It’s very immediate.”

It hasn’t all been smooth sailing. Shortly after returning home, Lioy felt depressed and couldn’t get out of bed. But she had learned the importance of asking for help, and she reached out to her parents.

“I was able to talk with them, and it felt amazing,” she said. “I’d never done that before.”

There have been other changes. Since returning home, Lioy finished her bachelor’s degree in molecular genetics and is working as a pharmacy technician. She’s applying to doctoral programs and she has a new boyfriend, although she said she no longer needs a boyfriend to feel OK about herself.

“It’s been a really big journey,” Lioy said.

If you or someone you know may be considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (en español: 1-888-628-9454; deaf and hard of hearing: 1-800-799-4889) or the Crisis Text Line by texting HOME to 741741.

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Drunken Driving Epidemic Has Mostly Stagnated Over Past Decade. Experts Say It’s Time To Focus On Root Cause.

‘Warm’ Hotlines Deliver Help Before Mental Health Crisis Heats Up

A lonely and anxious Rebecca Massie first called the Mental Health Association of San Francisco “warmline” during the 2015 winter holidays.

“It was a wonderful call,” said Massie, now 38 and a mental health advocate. “I was laughing by the end, and I got in the holiday spirit.”

Massie, a San Francisco resident, later used the line multiple times when she needed additional support, then began to volunteer there.

Now anyone in California who needs a little help — or even a referral to a professional therapist — can receive it by phone or instant message. In October, the San Francisco-based warmline expanded beyond Northern California to cover the whole state through a state budget allocation of $10.8 million for three years.

Unlike a hotline for those in immediate crisis, warmlines provide early intervention with emotional support that can prevent a crisis — and a more costly 911 call or ER visit. The lines are typically free, confidential peer-support services staffed by volunteers or paid employees who have experienced mental health conditions themselves.

“People pay attention when the biggest state in the union decides to say mental health services are not just for crisis,” said Mark Salazar, the San Francisco association’s executive director.

Such help lines aren’t limited to California, though. About 30 states have some form of a warmline within their borders, including in Salt Lake City and Omaha, Neb. Still, the loose network of call lines faces no regulation or standardization. They’re relatively new, so they haven’t been extensively studied. And their advocates admit quantifying results can be difficult.

Better known are the suicide crisis lines for those who need help immediately. This summer, the Federal Communications Commission proposed a 988 national hotline number for those considering suicide or having a mental health crisis. Yet mental health advocates say warmlines help fill another important health care gap.

“Warmlines help people who think, ‘I don’t know why I’m not feeling great, or who to turn to, or where to get care, and I don’t know for sure if I even need care,’” said Sarah Flinspach, a project coordinator for the National Council for Behavioral Health, which advocates for mental health care services. “It might be the call that helps someone go back to work that day.”

Filling Gaps, Saving Money

Since the San Francisco Peer-Run Warm Line began in 2014, it has answered more than 100,000 calls and served more than 5,000 people. Approximately 85% of callers were repeat users, said Salazar, and that’s just fine.

“Many people are housed, have jobs and function in society, but they’re struggling,” said California state Sen. Scott Wiener, a Democrat from San Francisco who backed the statewide expansion of the line. “They don’t necessarily need full intervention — they just need support. In the peer-to-peer situation, they can take from someone’s firsthand experience and learn how to navigate these problems.”

People often struggle to access basic mental health services without such help, according to Wiener. “They have the choice between nothing, a friend or going to the ER,” he said.

Warmlines can fill a need in rural communities where access to care is limited or provide after-hours support in urban areas, said Rebecca Spirito Dalgin, who has studied warmlines and directs rehabilitation counseling at the University of Scranton in Pennsylvania.

Advocates say they also can save public money by preventing simmering teapots from boiling over.

Angel Prater, a peer support expert, co-authored a federally funded report in 2015 of Oregon’s Community Counseling Solutions warmline that found the average cost of a single call to the line was about $10 over a five-year period, far less than the estimated $100 cost of a 911 call or a trip to the ER, around $700. By giving callers direct referrals to health care providers and helping them avoid higher levels of care, she added, the warmline saved approximately $1.2 million per quarter by 2016.

In addition, the warmline reduced crisis line calls and psychiatric hospitalizations, she said. It also gave police a resource if they encountered people undergoing a mental health challenge who didn’t require a higher level of services.

“We gave local law enforcement a little warmline card with our phone number,” Prater said. “They could pass it along if they felt someone needed no further intervention at that time.”

The Salt Lake County Warmline, begun in 2012, is part of an effective larger crisis intervention and diversion services program “that saves millions of dollars a year,” according to Barry Rose, crisis clinical manager at the University Neuropsychiatric Institute at the University of Utah. The line receives approximately 2,500 calls monthly, which includes repeat users.

“We’re making relationships as we get to know people and they get to know us,” said Rose, who is also a licensed clinical social worker. “Emotional support keeps us all healthy and establishes the kinds of connections we need in our lives.”

In Omaha, 9 in 10 people who contact Safe Harbor Peer Crisis Services reported its warmline prevented their hospitalization, said Aileen Brady, executive vice president and chief operating officer of Community Alliance, a mental health agency that operates the program.

Safe Harbor’s state-funded warmline also began in 2012 and fields roughly 1,000 calls a month. An annual budget of $670,000 funds the line and a complementary on-site program for people to resolve their distress in person.

Calls Change A Day And A Life

A 2018 survey from the National Council and nonprofit philanthropy Cohen Veterans Network cited knowledge gaps as one of the primary barriers that prevent Americans from getting mental health care. It said 46% of those who have never sought treatment would not know where to go if they needed mental health services for themselves, a family member or a friend.

“It’s unimaginable, hard to conceptualize, for those who don’t work in this field, what the level of need really is,” said Quinn Anderson, who manages the National Alliance on Mental Illness HelpLine, which offers referrals to all sorts of mental health support.

Mental health advocates and users admit the warmline system isn’t perfect. Even people who are aware they exist may not get through immediately depending on the volume of calls.

Unlike some crisis lines, the network of warmlines doesn’t blanket the whole country, and many warmlines won’t take out-of-state calls. A caller out of geographic range may be directed to a line with closer resources. The quality of service offered by those who answer calls can be uneven, and few warmlines offer services in another language.

It can also be difficult to assess how effective the help is, said Spirito Dalgin, who authored studies about warmlines in 2011 and 2018.

“If services are funded on outcomes, how do we measure the outcome of these calls?” she said. “You need access to be able to follow a group of people using the warmline, and they need to self-report.”

Even then, quantifying results is tough. Brady said, “It’s hard to measure what doesn’t happen.”

The lack of tangible proof of success could jeopardize the widespread adoption of warmlines, even while basic and affordable mental health care remains hard to access. Still, some warmline operators are optimistic.

“We could see a national network for warmlines in about five years,” said Salazar. “That’s really needed since, day-to-day, no one really focuses on people who are not yet in crisis.”

How To Find A Warmline Near You 

  • An unofficial list by state location is available at warmline.org. The site notes which lines are nationally accessible and welcome calls from anywhere. Every line varies by hours, geographic coverage and training of the person answering the call.
  • The National Alliance on Mental Illness also can refer callers to a list of warmlines through its HelpLine at 800-950-NAMI (6264), Monday through Friday, 10 a.m. to 6 p.m. ET.
  • Someone in immediate danger can call 911 and declare a psychiatric emergency or call the National Suicide Prevention Lifeline: 800-273-TALK (8255).

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Black Mothers Get Less Treatment For Postpartum Depression Than Other Moms

Portia Smith’s most vivid memories of her daughter’s first year are of tears. Not the baby’s. Her own.

“I would just hold her and cry all day,” Smith said.

At 18, Smith was caring for two children, 4-year-old Kelaiah and newborn Nelly, with little help from the partner in her abusive relationship. The circumstances were difficult, but she knew the tears were more than that.

“I really didn’t have a connection for her,” said Smith, now a motivational speaker and mother of three living in Philadelphia. “I didn’t even want to breastfeed because I didn’t want that closeness with her.”

The emotions were overwhelming, but Smith couldn’t bring herself to ask for help.

“You’re afraid to say it because you think the next step is [for the authorities] to take your children away from you,” she said. “You’re young and you’re African American, so it’s like [people are thinking], ‘She’s going to be a bad mom.’”

Smith’s concern was echoed by several black women interviewed for this story. Maternal health experts said some black women choose to struggle on their own rather than seek care and risk having their families torn apart by child welfare services.

Nationally, postpartum depression affects 1 in 7 mothers. Medical guidelines recommend counseling for all women experiencing postpartum depression, and many women also find relief by taking general antidepressants, such as fluoxetine (Prozac) and sertraline (Zoloft).

In March, the Food and Drug Administration approved the first drug specifically for the treatment of postpartum depression, which can include extreme sadness, anxiety  and exhaustion that may interfere with a woman’s ability to care for herself or her family. The mood disorder can begin in pregnancy and last for months after childbirth.

But those advances help only if women’s needs are identified in the first place — a particular challenge for women of color and low-income mothers, as they are several times more likely to suffer from postpartum mental illness but less likely to receive treatment than other mothers.

The consequences of untreated postpartum depression can be serious. A report from nine maternal mortality review committees in the United States found that mental health problems, ranging from depression to substance use or trauma, went unidentified in many cases and were a contributing factor in pregnancy-related deaths. Although rare, deaths of new mothers by suicide have also been reported across the country.

Babies can suffer too, struggling to form a secure attachment with their mothers and increasing their risk of developing behavioral issues and cognitive impairments.

‘I Was Lying To You’

For many women of color, the fear of child welfare services comes from seeing real incidents in their community, said Ayesha Uqdah, a community health worker who conducts home visits for pregnant and postpartum women in Philadelphia through the nonprofit Maternity Care Coalition.

News reports in several states and studies at the national level have found that child welfare workers deem black mothers unfit at a higher rate than they do white mothers, even when controlling for factors like education and poverty.

During home visits, Uqdah asks clients the 10 questions on the Edinburgh Postnatal Depression Scale survey, one of the most commonly used tools to identify women at risk. The survey asks women to rate things like how often they’ve laughed or whether they had trouble sleeping in the past week. The answers are tallied for a score out of 30, and anyone who scores above 10 is referred for a formal clinical assessment.

Uqdah remembered conducting the survey with one pregnant client, who scored a 22. The woman decided not to go for the mental health services Uqdah recommended.

A week after having her baby, the same woman’s answers netted her a score of zero: perfect mental health.

“I knew there was something going on,” Uqdah said. “But our job isn’t to push our clients to do something they’re not comfortable doing.”

About a month later, the woman broke down and told Uqdah, “I was lying to you. I really did need services, but I didn’t want to admit it to you or myself.”

The woman’s first child had been taken into child welfare custody and ended up with her grandfather, Uqdah said. The young mother didn’t want that to happen again.

April McNeal (left), a community health worker with the Maternity Care Coalition, made visits to Stephanie Lee’s home while Lee was pregnant with and after she gave birth to son Santeno Adams. After testing Lee for postpartum depression, McNeal recommended she take advantage of the coalition’s free, in-home therapy. “You don’t have to tell anybody,” McNeal says about the program. “They’re not coming here with their therapist super hat — it just looks like, oh, my girlfriend is coming over, and lo and behold, they’re giving you therapy.”(Kimberly Paynter/WHYY)

Screening Tools Don’t Serve Everyone Well

Another hurdle for women of color comes from the tools clinicians use to screen for postpartum depression.

The tools were developed based on mostly white research participants, said Alfiee Breland-Noble, an associate professor of psychiatry at Georgetown University Medical Center. Often those screening tools are less relevant for women of color.

Research shows that different cultures talk about mental illness in different ways. African Americans are less likely to use the term depression, but they may say they don’t feel like themselves, Breland-Noble said.

It’s also more common for people in minority communities to experience mental illness as physical symptoms. Depression can show up as headaches, for example, or anxiety as gastrointestinal issues.

Studies evaluating screening tools used with low-income, African American mothers found they don’t catch as many women as they should. Researchers recommend lower cutoff scores for certain African American women in order to better identify women who needs help but may not be scoring high enough to trigger a follow-up under current guidelines.

Bringing Treatment Home

It took Smith six months after daughter Nelly’s birth to work up the courage to see a doctor about her postpartum depression.

Even then, she encountered the typical barriers faced by new mothers: Therapy is expensive, wait times are long, and coordinating transportation and child care can be difficult, especially for someone struggling with depression.

But Smith was determined. She visited two different clinics until she found a good fit. After several months of therapy and medication, she began feeling better. Today, Smith and her three daughters go to weekly $5 movies and do their makeup together before big outings.

Other mothers never receive care. A recent study from the Children’s Hospital of Philadelphia found that only 1 in 10 women who screened positive for postpartum depression at the hospital’s urban medical practice sites sought any treatment within the following six months. A study examining three years’ worth of New Jersey Medicaid claims found white women were nearly twice as likely to receive treatment as were women of color.

Noticing that gap, the Maternity Care Coalition in Philadelphia tried something new.

In 2018, the nonprofit started a pilot program that pairs mothers with Drexel University graduate students training to be marriage and family counselors. The student counselors visit the women an hour a week and provide free in-home counseling for as many weeks as the women need. Last year, the program served 30 clients. This year, the organization plans to expand the program to multiple counties in the region and hire professional therapists.

It was a game changer for Stephanie Lee, a 39-year-old who had postpartum depression after the birth of her second child in 2017.

“It was so rough, like I was a mess, I was crying,” Lee said. “I just felt like nobody understood me.”

She felt shame asking for help and thought it made her look weak. Lee’s mother had already helped her raise her older son when Lee was a teenager, and many members of her family had raised multiple kids close in age.

“The black community don’t know postpartum,” Lee said. “There’s this expectation on us as women of color that we have to be … superhero strong, that we’re not allowed to be vulnerable.”

But with in-home therapy, no one had to know Lee was seeking treatment.

The counselors helped Lee get back to work and learn how to make time for herself — even just a few minutes in the morning to say a prayer or do some positive affirmations.

“If this is the only time I have,” Lee said, “from the time I get the shower, the time to do my hair, quiet time to myself — use it. Just use it.”

This story was reported as a partnership that includes The Philadelphia Inquirer, WHYY, NPR and Kaiser Health News.

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Patient-Induced Trauma: Hospitals Learn To Defuse Violence

SAN DIEGO — When Mary Prehoden gets dressed for work every morning, her eyes lock on the bite-shaped scar on her chest.

It’s a harsh reminder of one of the worst days of her life. Prehoden, a nurse supervisor at Scripps Mercy Hospital San Diego, was brutally attacked last year by a schizophrenic patient who was off his medication. He lunged at her, threw her to the ground, repeatedly punched and kicked her, and bit her so hard that his teeth broke the skin and left her bleeding.

The incident lasted about 90 seconds, but the damage lingers.

“Even if I didn’t have a scar, the scar is in your head,” said Prehoden, 58. “That stays with you for the rest of your life.”

Nurse supervisor Mary Prehoden was brutally attacked by a patient with schizophrenia at Scripps Mercy Hospital in San Diego. (Heidi de Marco/KHN)

Prehoden was left with a bite-shaped scar on her chest.(Heidi de Marco/KHN)

Violence against health care workers is common — and some say on the rise.

According to the Occupational Safety and Health Administration, workplace violence is four times more common in health care settings than in private industry on average, yet it still goes underreported. Patients account for about 80% of the serious violent incidents reported, but stressed-out family and friends also are culprits. Co-workers and students caused 6% of the incidents.

In a 2018 poll of about 3,500 emergency room doctors conducted for the American College of Emergency Physicians, nearly 70% said violence in the emergency department has increased in the past five years.

About 40% of the doctors believed the majority of assaults were committed by psychiatric patients, and half said the majority were committed by people seeking drugs or those under the influence of drugs or alcohol.

In California, a state law requires hospitals to adopt workplace violence prevention plans and report the number and types of attacks to the state. The state then compiles the data into annual reports.

In the first full report, 365 hospitals tallied 9,436 violent incidents during the 12-month period that ended Sept. 30, 2018, ranging from scratchings to stabbings. Workers were punched or slapped in one-third of the assaults and were bitten in 7% of cases.

“I don’t know that you ever expect to have to defend yourself at your workplace,” Prehoden said. “It’s not anything you’re prepared for.”

Scripps Mercy Hospital officials have made a number of changes to help protect employees from what they refer to as an epidemic of violence. They’ve launched a “rapid response” team made up of staff members who try to defuse potentially violent situations. And the hospital has introduced a behavioral screening tool to help identify patients prone to violence. When patients get flagged, they must wear a green wristband, and a green peace sign is placed on their door.

Security manager Ryan Sommer leads a de-escalation training for hospital staff at Scripps Memorial Hospital Encinitas. Sommer asked participants to raise a hand if they have been assaulted on the job. Nearly all did. (HEIDI DE MARCO/KHN)

Ryan Sommer, who is the head of security at Scripps Memorial Hospital Encinitas, leads violence de-escalation training for Scripps staff at different locations throughout San Diego County.

On one recent morning, about 20 employees at the Encinitas facility learned how to deter an agitated and combative patient. One tip Sommer shared: Behavior influences behavior, so listen with empathy and establish a personal rapport with the patient. And, he told them, don’t lose your cool; the goal is to get agitated patients to calm down.

Scripps hospital employees learn defense tactics from security manager Ryan Sommer at Scripps Memorial Hospital Encinitas. Workplace violence is four times more common in the health care sector than in private industry. (HEIDI DE MARCO/KHN)

Sommer also taught self-defense tactics should the situation escalate. In groups of two, employees practiced how to disengage from a hold and block strikes from an attacker.

“How many of you have been attacked on the job?” Sommer asked. Nearly all the participants raised their hands.

“This happens daily. They get punched, scratched, spit on, yelled at,” he said later.

Sommer said the number of violent incidents at the Scripps hospitals is rising and the injuries are becoming more severe.

All Scripps Memorial Hospital’s security guards have been armed with stun guns and stab-proof vests for the past year due to what the health system calls an epidemic of violence against its workers. “We hope they work as a deterrent,” says security manager Ryan Sommer. (HEIDI DE MARCO/KHN)

Since earlier this year, security guards at all Scripps hospitals have been armed with stun guns, said Janice Collins, a spokeswoman for Scripps Health. They wear stab-proof vests and are stationed strategically around the facilities. The stun guns are used when security guards believe they are needed to protect life, Collins said. Prehoden’s situation would have met that criteria, she said.

Hospitals across California are taking similar measures with the hope of reducing violent confrontations, said Gail Blanchard-Saiger, the California Hospital Association’s vice president of labor and employment.

Some sites use panic buttons, metal detectors, security dogs, increased police presence and security cameras, in addition to de-escalation training.

The efforts vary by location and risk, Blanchard-Saiger said.

Scripps hospitals use a behavioral screening tool to help identify which patients might be prone to violent behavior. If a patient gets flagged, they must wear a green wristband upon admission and a green peace sign is placed on their door.(Heidi de Marco/KHN)


Additional support from local law enforcement would make a difference, she said. “Unfortunately, I’ve heard plenty of stories where they don’t even come to the hospital,” she said. “They’re short-staffed, underfunded. They’re prioritizing.”

Prehoden has attended the de-escalation training and is now on the rapid response team at Scripps Mercy Hospital.

It took her three weeks to return to work after she was beaten in August 2018. A nurse for almost 40 years, she admits being a little on edge now, and feels as if her attacker robbed her of her confidence. He served six months in jail for the attack.

“This cannot be the new face of nursing,” Prehoden said. “We can’t afford to lose our staff because somebody decides not to take his medication.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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An Atlanta Nonprofit Brings Medical Care And Connection To The Homeless

Herman Ware got his seasonal flu shot while sitting at a small, wobbly table inside a mobile health clinic. The clinic-on-wheels is a large converted van, and on this day it was parked on a trash-strewn, dead-end street in downtown Atlanta where homeless residents congregate.

The van and Ware’s flu shot are part of a “street medicine” program designed to bring health care to people who haven’t been able to pay much attention to their medical needs. For those who struggle to find a hot meal or a place to sleep, health care can take a back seat.

As he anticipated the needle, Ware recalled previous shots and said, “It might sting.” He grimaced slightly as the nurse injected his upper arm.

After filling out paperwork, he climbed down the van’s steps and walked back to a small cluster of tents. Ware lives in the nearby homeless encampment tucked below an interstate overpass, next to a busy rail line.

Mercy Care, a health care nonprofit in Atlanta, operates brick-and-mortar clinics throughout the city that mainly treat poor residents. Since 2013, Mercy has also sent out teams of health care providers to treat homeless people.

It’s a public health strategy that can be found in dozens of cities in the United States and around the world, according to the Street Medicine Institute, which works to spread the practice.

Joy Fernandez de Narayan, who runs Mercy Care’s Street Medicine and Community Health Outreach programs, talks with Danielle Storms about her health and treatment outside the Atlanta Day Shelter for Women and Children.(Chris Ryan at Once Films courtesy of the Catholic Health Association)

Relationship Leads To Care

Getting homeless patients to accept help, whether it’s a vaccination or something simpler — like a bottle of water — can be challenging. And giving shots and conducting exams outside the walls of a health clinic often requires a different approach to health care.

“When we’re coming out here to talk to people, we’re on their turf,” said nurse practitioner Joy Fernandez de Narayan, who runs Mercy Care’s Street Medicine program.

“We’ll sit down next to someone, like, ‘Hey, how’s the weather treating you?’” she said.

“And then kind of work our way into, like, ‘Oh, you mentioned you had a history of high blood pressure. Do you mind if we check your blood pressure?’”

It can take several encounters to gain someone’s trust and get them to accept medical care, so the outreach workers spend a lot of time forging relationships with homeless clients.

Their persistent encouragement was helpful for Sopain Lawson, who caught a debilitating foot fungus while living in the encampment.

“I couldn’t walk,” Lawson said. “I had to stay off my feet. And the crew, they took good care of my foot. They got me back.”

Sopain Lawson gets a hug from an Emory nursing student. Emory nursing students can choose to do a four-week rotation with Mercy Care’s Street Medicine program. Lawson developed a debilitating foot fungus while living in a homeless encampment.(Chris Ryan at Once Films courtesy of the Catholic Health Association)

“This is what street medicine is about — going out into these areas where people are not going to seek attention until it’s an emergency,” said Matthew Reed, who’s been doing social work with the team for two years.

“We’re trying to avoid emergencies, but we’re also trying to build relationships.”

‘Go To The People’

The street medicine team members use the trust they’ve built with patients to eventually connect them to other services, such as mental health counseling or housing.

Access to those services may not be readily available for many reasons, said Dr. Stephen Hwang, who studies health care and homelessness at St. Michael’s Hospital in Toronto.

Sometimes the obstacle — not having money for a bus ticket, for example — seems small, but is formidable.

“It may be difficult to get to a health care facility, and often there are challenges, especially in the U.S., where people [may not] have health insurance,” Hwang said.

Georgia is among a handful of states that have not expanded Medicaid to all low-income adults, which means many of its poorest residents don’t have access to the government-sponsored health care program.

But even when homeless people are able to get health coverage and make it to a hospital or clinic, they can run into other problems.

“There’s a lot of stigmatization of people who are experiencing homelessness,” Hwang said, “and so often these individuals will feel unwelcome when they do present to health care facilities.”

Street medicine programs are designed to break down those barriers, said Dr. Jim Withers.

He’s the medical director of the Street Medicine Institute and started making outreach visits to the homeless in 1992, when he worked at a clinic in Pittsburgh.

“Health care likes people to come to it on its terms,” Withers said, while the central tenet of street medicine is, “Go to the people.”

A drone view of what the Mercy Care Street Medicine team calls “the bridge to nowhere,” where people experiencing homelessness set up camp.(Chris Ryan at Once Films courtesy of the Catholic Health Association)

Licensed practical nurse Stephanie Dotson, case manager Matthew Reed and psychiatrist Dr. Juntira Laothavorn, all part of Mercy Care’s Street Medicine team, stand on “the bridge to nowhere.”(Chris Ryan at Once Films courtesy of the Catholic Health Association)

Help And Respect

Mercy Care in Atlanta spends about $900,000 a year on its street medicine program. In 2018, that sum paid for direct treatment for some 300 people, many of whom got services multiple times. Street clinics can help relieve the care burden of nearby hospitals, which Withers said don’t have a great track record in treating the homeless.

“We’re not dealing with them well,” Withers said, speaking about American health care in general. In traditional health settings, homeless patients do worse compared with other patients, he said.

Those extra days and clinical complications mean additional costs for hospitals. One estimate cited in a 2017 legislative report on homelessness suggested that more than $60 million in medical costs for Atlanta’s homeless population were passed on to taxpayers.

Mercy Care said its program makes homeless people less likely to show up in local emergency rooms and healthier when they do — which saves money.

It’s past sundown when the street medicine team rolls up to the day’s final stop: outside a church in Atlanta where the homeless often gather. A handful of people have settled down for the night on the sidewalk. Among them is Johnny Dunson, a frequent patient of the Street Medicine program.

Dunson said the Mercy Care staffers have a compassionate style that makes it easy to talk to them and ask for help.

“You gotta let someone know how you’re feeling,” Dunson said. “Understand me?

Sometimes it can be like behavior, mental health. It’s not just me. It’s a lot of people that need some kind of assistance to do what you’re supposed to be doing, and they do a wonderful job.”

Along with medical assistance, the staff at Mercy Care give patients doses of respect and dignity.

This story is part of a partnership that includes WABE, NPR and Kaiser Health News.

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