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Oregon doesn’t have enough treatment or housing for people with mental illness
Oregon doesn’t have enough treatment or housing for people with mental illness
Oregon doesn’t have enough treatment or housing for people with mental illness

Published on: 03/17/2023


Editor’s note: Throughout 2023, OPB is taking a deep look at the biggest social and economic challenges facing Oregon today – their origins, their impacts and possible solutions. This week we are looking at the gaping holes in the state’s mental health system, including how Oregonians with the most serious mental illnesses often have inconsistent access to services and housing options.

Oregon’s system for people with profound mental illness is broken. Below, we explain the roots of two major problems and explore two promising strategies that could address these issues.

PROBLEM ONE: Some people with the most serious mental illnesses cycle between Oregon’s public psychiatric hospital, county jails and homelessness.

People with serious mental illnesses often receive treatment for a time and then drop out or discontinue it.

Here’s what too frequently happens next: Without treatment, some mentally ill people deteriorate and end up homeless. An arrest – easy to come by when living on the streets – can land them in county jail. Unable to stand trial due to psychosis, they’re sent to the Oregon State Hospital on a court order to be treated.

While they’re at the Oregon State Hospital, they get medication, therapy and a safe environment. Most people staying in the Salem psychiatric hospital are also isolated from friends and family. It’s an hour drive for visitors from Portland and much further for people from the east side of the Cascade Mountains or the southern part of the state. Patients are also often cut off from any therapists or health care providers they had been seeing before because of a rule in the federal Medicaid statute. And in any case, the majority of patients can only stay until they’re well enough to understand the charges against them and stand trial.

Though some have to leave before they have hit even that relatively low bar for wellness. As of September 2022, people accused of felonies can be held for treatment for a maximum of one year. For misdemeanors, the maximum stay is 90 days.

Some people are eventually able to stand trial. Others are found to be never able to understand the charges against them. Prosecutors pursue “guilty but for insanity” verdicts in the most serious cases. Less serious charges are dropped, and a person is discharged to a hospital, to the street or to the oversight of a county mental health department. Often, they end up homeless. Then the cycle repeats.

“We’ve become very dependent on the criminal punishment system as our de facto mental health system,” said Jesse Merrithew, a civil rights attorney who is part of a high-profile lawsuit over delays admitting patients to the state hospital. “It doesn’t make sense clinically. Doesn’t make sense morally.”

PROMISING STRATEGY: A statewide program to assess and assist people ages 12 to 25 who are in their first year of experiencing psychosis could result in early and more successful treatment for people with the most serious mental illnesses.

One statewide program aims to intervene far upstream of the revolving door cycle by helping people maintain their sense of identity, family and agency through the initial onset of a mental illness.

Caruso worked with the Early Assessment and Support Alliance Center for Excellence (EASA), a two-year state-wide program that supports people ages 12 to 25 who are in their first year of experiencing psychosis. Early intervention could result in more successful treatments for people with the most serious mental illness, avoiding a lifetime of disability.

For many who have these disorders, symptoms begin in their late teens or twenties. Without early intervention, young people first developing a mental illness that involves psychosis will often spend one to two years after their symptoms start before getting any treatment. That delay can upset the course of their lives, disrupting their chance of finishing school, finding a job and maintaining family ties.

“These conditions can lead to the dissolution of a family pretty rapidly,” said Tamara Sale, who runs the Early Assessment and Support Alliance Center for Excellence at the OHSU-PSU School of Public Health. ”It can lead to them being kicked out in the street because their families [are] trying to draw boundaries.”

When people do finally receive treatment, it’s sometimes in the form of involuntary civil commitment, which is difficult to obtain, controversial and increasingly rare. But people have a better shot at recovering if they get early treatment and support, experts say. That’s because most people who experience psychosis due to a mental illness like schizophrenia or bipolar disorder have initial symptoms that are milder, Sale said.

“There’s a window where we can identify and interact with the person before it’s gotten to that really acute level,” Sale said.

In the early stage, people start to experience changes in their sensory perceptions and new ideas that don’t make sense to other people. They are also more likely to consider suicide during the early onset phase.

“They are met with a lot of misunderstanding,” Sale said.

Crucially, during this early period, people are often relatively motivated to figure out what’s happening to them and receive treatment.

But for many people, navigating the rules of the health care system and insurance feels impossible. It requires people to show up on time to appointments and be organized at a time when they are losing those abilities.

“If you think about a program for people in wheelchairs being placed on the second story of the building with no elevator and no ramp and no outreach,” Sale said. “That’s kind of how the mental health system has been set up.”

Sale says it’s easy for a person experiencing the first onset of a mental illness to be mislabeled as lazy or pressured to perform.

“Other people don’t understand how hard they’re working,” Sale said.

This is where the Early Assessment and Support Alliance, EASA for short, comes in. The program is set up to accommodate the needs of people who have experienced psychosis, and to show them that the mental health system can be a friend, not the enemy.

Similarly to the Intercept program for children experiencing mental illness, EASA program staff come to people’s homes and work with their families to figure out how to connect with a person and engage them in treatment.

Another distinguishing feature of the program is its approach to antipsychotic medication. Taking medication isn’t a requirement of the program, and when meds are used, clinicians focus on getting the dosing right for each participant.

“If we identify people a little earlier, it’s easier to focus on a start low, go slow approach.”

Some people, Sale said, do need medication and may need help working through the grief associated with that decision. While many antipsychotic drugs are effective for most people, they are controversial because they can be sedating and cause heart problems, among other issues.

The program uses strategies to help people who want to minimize the dose that they’re on. A person might opt for a dose that’s just enough to stop scary hallucinations, but that doesn’t completely eliminate the voices in a person’s head, if those voices are friendly.

The program teaches skills that can reduce the symptoms of psychosis, like getting adequate sleep and regulating stress. And it helps people understand the often predictable pattern of their illness.

“If they can understand what their personal pattern is, they can often prevent it from progressing,” Sale said.

Author : Amelia Templeton

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