Mental Health

When residential psychiatric treatment services for youth aren’t available in the state, children are sent out of Alaska. But Bartlett Regional Hospital in Juneau is trying to change that by building a treatment center in the state’s capital.

According to reports earlier this month, about 120 children have been sent out of state for high-level psychiatric treatment. In 2004, the number of children sent out of state was six times that. That number has dwindled largely due to a statewide initiative that ended two years ago.

Bartlett Regional Hospital began planning to a build treatment center in Juneau in 2004. Now, things have changed.

“A lot of the discussion was more about an acute care level of service,” said Mark Johnson, one of the hospital’s board members. “And so this kind of changes the service to a different level, and I think it takes a bit of time for that discussion to take place in the community.”

That different level of service is a residential psychiatric treatment center, or RPTC, which has a longer treatment model and focuses on children who’ve experienced severe trauma and suffer from multiple mental illnesses.

“There is a need, there are kids who need this level of service, it is not available in this region right now,” he said. “There’s not enough available in this state right now, and when the kids have to be sent somewhere else it’s very challenging for the families of those kids.”

Although RPTC services are offered around the state, there is none in Southeast. Bartlett hopes to change that with a 28-bed facility.

Sally Schneider is the hospital’s chief behavioral health officer and oversees the project, which is still in the feasibility stage.

“We started looking at what is called a residential psychiatric center that allows children a longer spectrum of care, to be able to better their development needs,” she said.

But running these services is expensive, and some other organizations in Alaska have tried to provide these services, then down-sized or shut down. According to the state Department of Health, the cost of providing these services has increased by 25 percent in the past 11 years, while reimbursement rates from the state have barely changed.

Brita Bishop is a program manager with the state’s Division of Behavioral Health and helped coordinate the Bring Back the Kids Initiative, which helped reduce the number of kids being sent out of state.

“In terms of what we’re seeing in kids who are going out of state, what we’re seeing at this point is that it’s not the kinds of children and youth that are easily served in other community programs,” Bishop said.“And so if we are going to develop additional services in Alaska, one of the things I’m concerned with is that we develop the services we actually need.”

An example, Bishop said, is a child with fetal alcohol syndrome, who also suffers from intellectual disabilities and has other behavioral needs. They’d seek out-of-state services because the child’s needs are so specific.

Bartlett officials will present an update to the Juneau Assembly in September. Aside from finding potential land, they’re asking if providing this type of care in Juneau makes sense financially.

There’s something that really bothers Stanford psychiatry professor Keith Humphreys. When he thinks of all the years he has spent training the next generation of psychiatrists, the enormous investment in medical school and residency, he wants those doctors to devote that education to taking care of people with serious mental illness.

But, he says, many of them instead set up a private practice, where they can charge $400 an hour in cash to help people who Humphreys calls “the worried well” –- people who enjoy the self-exploration of therapy but don’t necessarily have a mental health problem.

“A minute I spend training that person is a minute of my life wasted,” Humphreys says. “That very well-trained person should be taking care of very, very troubled people. When they don’t, everyone who needs that care loses out.”

Humphreys says this trend of mental health clinicians shunning the health insurance industry and decamping to the cash market dates back 70 years, to the end of World War II.

In 1946, the majority of veterans cared for by what was then called the Veterans Administration were mental health patients, Humphreys says. But there weren’t enough psychologists and psychiatrists to take care of them. So the VA partnered with several universities, including Stanford, to train mental health professionals.

The VA became the largest employer of psychologists, and those schools started turning out hundreds and hundreds of psychologists a year. The expansion dovetailed with soaring American affluence — and soaring American interest in self-exploration.

Having a psychoanalyst became “a sort of status symbol,” Humphreys says.

A lot of psychologists who were trained to work in the public sector saw a better financial opportunity and jumped ship. They hung shingles and started their own private practices where they could charge wealthy people much higher rates.

“When you put in a free market in a society where people were very interested in self-exploration, a lot of them went out and did their own thing,” Humphreys says.

The reason this was possible is because of how the overall U.S. health care system was established, Humphreys says. Most people got their health insurance through work. Employers competed with each other for the best employees by offering better benefits.

So the standards for coverage developed over time in a piecemeal, haphazard way.

As health policy evolved, mental health benefits continuously lagged, Humphreys says. Coverage for mental health treatments or hospitalizations was meager or nonexistent.

“We don’t seem to have this problem with cardiology or oncology,” Humphreys says. “You don’t see people lining up to pay cash for those services because the benefits are so low.”

This wouldn’t happen in places that have single-payer health systems, like Canada, Humphreys says, because all the health care payments are controlled by the government. Mental health care was baked into that system earlier on. But in the U.S., he says, “If it’s a market where you pretty much have to pay for yourself, the rich are always going to win.”

The growing workforce of psychiatrists, psychologists, marriage and family therapists, and licensed social workers has responded to that market demand.

And not just because it’s better money. Treating high-functioning professionals in a private office is a lot less stressful than doing rounds on a psychiatric ward in a public hospital.

Especially in affluent places like the San Francisco Bay Area, this creates a divide, a culture of mental health haves and have-nots. Mental health clinicians don’t need to participate in the health care system or take insurance to keep their schedules full — making it harder and harder for people of lower income to find a therapist.

“That’s why you can have a lot of mental health professionals in an area, but still have a shortage of care for people in need,” Humphreys adds. “The person who’s hurt is the person who’s suicidal, maybe they’re horribly addicted to OxyContin or their child is showing signs of bipolar disorder, and they can’t find somebody to take their insurance. It’s unjust.”

Mental health advocates have worked to shift this balance, passing the Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act in 2010. Together, those laws require health plans to offer mental health coverage on par with other medical coverage.

But so far, it hasn’t put a dent in the cash market for mental health. Humphreys says given the nature of mental health care and the American obsession with self-improvement, the cash market will be here to stay.

“Accessing mental health care is often pleasurable and enjoyable, and accessing a lot of other health care isn’t,” Humphreys says. “I mean, who goes to the dentist for fun?” As grateful as we are for dentists – nobody.

This story is part of a reporting partnership with NPR, KQED and Kaiser Health News.

Copyright 2016 KQED Public Media. To see more, visit KQED Public Media.

Bullying and cyberbullying are major risk factors for teen suicide. And both the bullies and their victims are at risk.

That’s according to a report from the American Academy of Pediatrics that urges pediatricians and family doctors to routinely screen teenagers for suicide risks.

“Pediatricians need to be aware of the problem overall,” says Benjamin Shain, a child and adolescent psychiatrist and lead author of the report published online Monday in the journal Pediatrics. “They should be screening for things like mood disorders, substance abuse as well as bullying.”

Suicide is the number two cause of death of teenagers, after accidents including car crashes and accidental overdoses. The leading methods of suicide were suffocation and guns.

A CDC survey last year found that 17 percent of teens in high school said they had seriously considered suicide in the previous 12 months, and 2.7 percent had made an attempt that resulted in an injury.

Shain calls those numbers “phenomenal.”

The AAP report says there is a clear relationship between bullying and suicide thoughts and attempts.

Suicidal ideation and behavior were increased in victims and bullies and were highest in people who were both bullies and victims of bullying, the report says.

And cyberbullying increased suicide attempts as much as face-to-face bullying.

Shain tells Shots that online bullying is particularly damaging because it’s hard for the victim to get away from it.

“It’s in black and white, you can see it, everyone else can see it, it doesn’t go away,” he says. “You’re not safe in your own house.”

The report recommends doctors talk with teens directly about suicide risk factors, including bullying, drug and alcohol abuse, mood disorders and physical or sexual abuse.

The report includes suggested dialog and questions for doctors to ask their teenage patients and said the children should be interviewed alone, away from their parents.

“Physicians, including pediatricians, can play a critical role in identifying mental health conditions and in preventing suicide,” Dr. Christine Moutier, chief medical officer at the American Foundation for Suicide Prevention, said in a statement.

She recommends that doctors get training in how to identify teens who may be thinking of killing themselves.

Beyond bullying, the effect of the Internet on suicide risk was mixed. The report found that teenagers who spend more than five hours a day online are a greater risk of trying to kill themselves.

But the the Web provides a cushion of sorts, too.

Teens who search the term “suicide” online are much more likely to find information on suicide prevention, help lines and other support than web sites that support or describe suicide, the report found.

Copyright 2016 NPR. To see more, visit http://www.npr.org/.

Juneau Police responded to a false report of a hostage situation Thursday.

Lt. Dave Campbell says a 25-year-old man called police and reported that a man with a gun was in his backyard holding a female hostage. The man said shots had been fired.

JPD responded to the home on Slim Williams Way expecting a hostage situation. But after talking with the man, his grandmother and neighbors, police determined there was no threat.

“We had our critical incident person go out there and talk to him, and it looks like we’re looking at setting up some services for the guy,” Campbell said. “Fortunately what we responded to and what we were told, it just didn’t happen.”

Campbell said JPD has encountered the man before.

During the wars in Iraq and Afghanistan, the U.S. military did an about-face on detecting and treating brain injuries caused by explosions. After years of routinely sending blast-exposed troops back into combat, the military implemented a system that requires screening and treatment for traumatic brain injury.

The change came about in large part because of a remarkable campaign by an elite team of military officers who were also doctors and scientists. They worked for the highest-ranking officer in the armed forces. And they were known simply as the Gray Team.

The Gray Team began with a contentious job interview between the doctor who would lead the team and the man who would be his boss.

It was 2008 and Army surgeon Christian Macedonia had been told there was a high-level opening for a doctor who wanted to change the military’s approach to battlefield brain injuries. When Macedonia arrived for the interview, he found himself face to face with Adm. Michael Mullen, chairman of the Joint Chiefs of Staff.

“And he looks at me and he goes, ‘Who are you and what are you doing in my office?’ ” Macedonia says.

Macedonia explained he was there about the job. Mullen replied that he had decided he didn’t need a doctor on his staff. “And I said, ‘Sir, I’m going to disagree with you,’ ” Macedonia recalls.

Macedonia, a lieutenant colonel, told the admiral that if he really wanted to do something about brain injuries, he did need a doctor. What’s more, he needed one with combat experience, strong scientific credentials and a high-level security clearance. “I said, ‘Sir, you really only have one person and that’s me.’ ”

Mullen smiled. He had been looking for someone he might have to rein in, but would never have to push. “And Macedonia fit that model for me perfectly,” he says. “He’s very outspoken, very straightforward. We talk about out-of-the-box thinkers; he just lives outside the box.”

Assembling The Gray Team

Macedonia’s first assignment was to put together a team. He recruited four other military doctors with combat experience and impressive resumes.

They were called the Gray Team, after the brain’s gray matter, the gray issues surrounding traumatic brain injuries and the graying team members themselves.

Their mission was to challenge something military doctors had been taught about blast exposure since World War I:

“If you don’t have blood coming out of your head, if you don’t have a penetrating injury, you have not been injured,” Macedonia says. “Your job as a doctor at that point is to say, ‘You’re gonna be fine’ and basically minimize any of the symptoms.”

Macedonia himself believed that when he was deployed to Iraq in 2004, to serve as chief of a combat support hospital near Fallujah. He was seeing horrendous injures, so he didn’t have much time for people who looked OK, even if they’d been dangerously close to a blast.

Macedonia and other military doctors actually became suspicious of service members who suggested blast exposure was the cause of their headaches, fatigue or sleep problems. “The attitude was that these people were trying to get a Purple Heart or something like that,” he says. “In retrospect, it was just awful. It was really a bad thing to do to people.”

Macedonia’s conversion occurred one day in Iraq, when he got caught in a mortar attack.

“I was out with a young Marine. We were in the middle of the attack. And the mortar was probably about 50 meters away,” he says.

The blast wave shook them violently. But they were alive. And they weren’t bleeding. So Macedonia went back to the hospital. He did surgery until midnight. Then, he headed for bed.

“I had a shaving mirror hung up by my cot and I looked in that mirror and I didn’t recognize the person looking back at me,” he says. Macedonia realized that he couldn’t remember anything from the operating room that night.

And he recognized the vacant expression he saw in the mirror: “The same sort of strange look in the eye that I had seen in people who had been in IED blasts up and down the route near our base.”

Macedonia was pretty sure he wasn’t having a purely psychological reaction to combat. The blast had injured his brain.

The Brain Battle Begins

In early 2009, Mullen’s Gray Team headed for Iraq and Afghanistan. By this time, IEDs had become the weapon of choice for insurgents attacking coalition forces. Tens of thousands of soldiers were being exposed to bomb blasts. And many were experiencing memory loss, confusion and sleep problems.

But the military still wasn’t taking the problem seriously. “We would tolerate multiple blasts [in] deployment after deployment,” Mullen says. “And I was determined to see if I could do something about this.”

So he sent the Gray Team to the battlefield to have a close-up look at what was happening to troops exposed to bomb blasts. “Quite simply, the Gray Team was there to establish ground truth with respect to traumatic brain injury,” Macedonia says.

And the truth was pretty grim. Often, troops weren’t even being checked for TBIs.

The military relies on something called the MACE exam — Military Acute Concussion Evaluation — to assess service members who have sustained a TBI or concussion. And Macedonia had been told the MACE exam was being administered to pretty much every service member near an explosion.

“But then you would go out and you would talk to these young medics and corpsmen — who are great patriots and doing wonderful things — and you would say, ‘Hey, son, how often do you administer the MACE exam?’ And they would look at you and say, ‘Sir, I’m sorry, what’s a MACE exam?’ ”

Because the military wasn’t doing much to look for TBIs, it was usually up to individual service members to report their own brain injuries.

“If you were in a blast, you basically had one of two choices,” Mullen says. “You either didn’t admit you had a problem, or if you admitted a problem we put you on a plane, sent you home.”

And Mullen knew from visiting hundreds of wounded troops that they didn’t want to get sent home. “The first thing they tell you is they want to get back in the fight,” he says. “So nobody would admit they had a problem.”

When the Gray Team got back to the U.S., they began suggesting reforms. Their ideas got a hostile reception in the Pentagon.

“I would literally have people behind closed doors say, ‘Who gave those people medical degrees?’ ” Macedonia says. It was a surprising allegation, considering the team members included people like Geoffrey Ling, an M.D.-Ph.D. considered the military’s leading expert on traumatic brain injury.

But many senior medical officers just couldn’t accept that there were real brain injuries you couldn’t see on MRI or CT scans, Macedonia says. “The organized military medical system was still trying to hold back the ocean and say: No big deal, most of these injuries are psychiatric and our job is basically to provide counseling centers and get these people over the shock of being at war.”

In the Pentagon, some medical officers feared that TBIs could become the next Gulf War syndrome — a poorly defined problem with no obvious cause and no good treatment.

Others had visions of the military medical system stateside being overwhelmed by newly diagnosed TBI patients. And more than a few just didn’t like having someone outside their chain of command telling them what do.

Macedonia says bureaucratic concerns often seemed to trump the growing scientific evidence that blast-induced TBIs were real. “I can’t tell you the number of times I walked out of rooms just being sorely disappointed at people who knew what the right thing to do was but chose to look the other way,” he says.

But Macedonia was equal parts tenacious and ferocious. “He was a dog on a bone,” Mullen says.

“Christian Macedonia doesn’t give a f*** what anybody thinks if he believes he’s on the right course,” says Kit Parker, a Harvard professor and Army lieutenant colonel who served on the Gray Team in 2011.

MRIs On The Battlefield

The conflict between the Gray Team and the military medical establishment reached a peak over the issue of MRI scanners.

Conventional scanners usually couldn’t detect the damage from a blast. But the Gray Team now included David Brody, a civilian scientist from Washington University in St. Louis, who was using a new MRI technique to study troops at the U.S. military hospital in Landstuhl, Germany.

“We went out there to Landstuhl, started enrolling patients, and started discovering immediately all sorts of injuries that were completely invisible to the conventional scans,” Brody says.

Even though the Department of Defense was paying for Brody’s research, the military medical establishment wasn’t embracing the results. “There was a strong current in the military at that time that this was a problem that was going to go away if we ignored it,” he says.

Macedonia wanted to deploy the new technology to hospitals near the battlefield. So during a Gray Team trip to Iraq, he made a pitch to a group of senior medical staff.

“I said, ‘We’re very seriously considering putting MRI machines in theater, what say you?’ ” he recalls. The reaction was as if he had proposed “bringing in a pile of radioactive waste to drop in your hospital.”

Macedonia eventually got his MRIs, largely because his boss, Mullen, had clout. As chairman of the Joint Chiefs, Mullen was the highest-ranking officer in the armed forces. “But even the chairman can be ignored,” Mullen says.

To make sure that didn’t happen, Mullen, Macedonia and the Gray Team had been building a coalition that included Gen. Peter Chiarelli, the Army’s vice chief of staff, and Gen. James Amos, assistant commandant of the Marine Corps. The Gray Team’s allies simply outranked its opponents.

The team’s decisive victory came in 2010, when the Department of Defense issued a memo that transformed the system for managing battlefield brain injury. “I can still remember Macedonia coming into my office saying, ‘Chairman, we got it,’ ” Mullen says.

The memo requires evaluation and a 24-hour rest period for troops within 50 meters of a blast, and several other measures to ensure that TBIs are detected and treated. It also includes special provisions for service members who sustain multiple TBIs.

And the 2010 mandate was just the beginning. Today, combat troops often wear sensors that indicate when a bomb blast is strong enough to cause a brain injury. Military doctors are taught that blast waves really can cause physical brain injuries. And service members can get treatment for a TBI without being put on a plane and sent home.

The sweeping changes have brought solace to Macedonia, who still regrets that he once doubted blast waves could physically injure the brain.

“Doing the Gray Team’s missions was probably the most awesome healing process that could have ever happened for me,” says Macedonia, who has retired from the military. “It really was a way for me to make up for the lapses, the lack of understanding about TBI.”

Copyright 2016 NPR. To see more, visit http://www.npr.org/.

Working through a self-help program online can prevent or delay major depression disorder in people who are vulnerable, a study finds. Similar programs have been used to treat depression, but this may be the first one tested to prevent it, the researchers say.

Online programs for mental health problems can be as effective as face-to-face treatment and offer some advantages: Low cost, available at any time and customizable. But they’re not panaceas.

In this experiment, half of the participants were asked to do six half-hour-long exercises that were based on cognitive behavioral therapy and problem-solving therapy, which are techniques commonly used for in-person therapy.

In the cognitive behavioral therapy, participants were asked to identify positive activities they used to engage in and then are asked to actively plan those activities again. At the next session, participants reflect on their experiences.

For the problem-solving therapy, people were asked to create a list of the things that matter most to them in their lives and brainstorm on how to incorporate those things into daily life. They next were asked to categorize problems and worries into “manageable” and “unmanageable”; the main focus in problem-solving therapy is to tackle those problems that are considered manageable.

Both cognitive-behavioral therapy and problem-solving therapy are intended to change negative thinking in order to alter mood and behavior.

After completing each exercise, participants in the intervention group received written individualized feedback from an online trainer. The trainers did not offer any therapeutic advice, only motivation and encouragement to continue the exercises. Participants also could repeat the online sessions as often as they liked.

The control group received information about depression but was under no obligation to read it.

The study, which was conducted by researchers from Leuphana University in Lueneburg, Germany, recruited 406 people with subthreshold depression, which is defined as having some symptoms of depression but not enough to be diagnosed with major depressive disorder. It was published Tuesday in JAMA, the journal of the American Medical Association.

Of the 406 participants that began the study, 335 completed the telephone follow-up at the end of 12 months. Twenty-seven percent in the intervention group experienced depression compared with 41 percent in the control group.

It is unclear if the people who went on to develop major depressive disorder had experienced it before. Lead author Claudia Buntrock, a PhD candidate in clinical psychology at Leuphana, says that because the study only tracked participants’ mental health over the course of 12 months, the long-term effectiveness of the intervention is unknown.

It’s also not clear if this kind of program could be scaled up. It took the trainers about 30 minutes to provide feedback for each session, and they also stayed in touch with participants via instant messaging, Buntrock says.

Other experiments with online therapy have found that people didn’t continue it if it wasn’t guided by an actual human. One reason could be that when people are depressed, they can have a hard time getting motivated to do things.

“More studies are needed to evaluate the preventive effects of unguided web-based interventions on the onset of major depressive disorder,” Buntrock wrote in an email. Still, Buntrock seems pleased with the results, especially since the German insurance company BARMER GEK that sponsored the trial is now providing it to its customers.

“I was surprised by the big response to our study,” Buntrock wrote. “And of course, I’m surprised about what happens now; that a health insurance company offers the intervention to its members. It’s a success story you might dream of when you start, but it actually seeing to happen is a great feeling.”

Copyright 2016 NPR. To see more, visit http://www.npr.org/.