Inside NoCo’s struggle to bridge the gap between physical and mental well-being.
You walk into the office on Thursday morning and can’t quite figure out what to say to your coworkers. You’re uncomfortable and irritable, your brain is blurry, and you don’t know why. Making basic decisions like responding to emails or picking out options in the cafeteria are painstaking. When your boss talks, it’s hard to pay attention.
One of the voices in your head says, “Call the doctor.” You are told to come in Monday at 9:00. You know that if you complained of heart palpitations or couldn’t feel your legs they’d get you in ASAP. You hope you can make it through the weekend without doing something dangerous.
Can’t you just be normal?
One out of four of us will suffer from mental illness in a given year.
Someone in Larimer County commits suicide every six days.
According to the National Alliance on Mental Illness (NAMI), about 75 percent of all chronic mental illness begins before the age of 24.
See that elephant cowering in the corner of the room? He’s used up all his hiding places.
“We tend to think of mental health as somehow different from physical health, when actually it’s just one piece of physical health,” says Carol Plock, Executive Director of the Health District of Northern Larimer County. “If we’re really going to say that mental illness and substance abuse are health disorders that are chronic and disabling, then we need the same range of treatment that you’d be able to get for any other health disorder.”
These sentiments surely elicit vigorous head nods from the 66,000 Coloradans—probably someone you know—currently living with an untreated mental illness. While adequate treatment for mental ailments has been a challenge in Colorado and nationwide, Plock is confident that change is in the works. The process must start with understanding the problem.
“Mental illness leads to more missed days of work and loss of productivity than any other illness,” says Dr. Bernard Birnbaum, a Fort Collins family practice physician. “If you’re tired and you can’t get out of bed, but you have to get to work, pay your taxes, make sure your kids get to school. All of that has a big ripple effect on a life.”
Here in America, we expect physicians like Birnbaum to dial up traditional medical management for virtually any condition within a couple days, if not sooner. But the experts tell us that disorders of the mind are inherently more complicated than “take two and call me in the morning.” Adequate therapy for that three-pound bundle of neurons, like developing coping and problem-solving skills and a positive self-image, and managing past trauma or social anxiety, can take lifelong devotion and attention.
“Honestly,” says Birnbaum, “being depressed sucks.”
Listen up, all you middle-class, gainfully employed, physically fit folks out there: it’s not just the guy mumbling to himself in the alley behind the Town Pump or that pitiable looking old woman loitering in Jefferson Street Park. The latest Larimer County resident to be diagnosed with a debilitating mental health problem could just as easily be your real estate agent, your kid’s teacher, your surgeon or your spouse.
It might be you.
You were a valued employee for 14 years until you lifted something funny and ended up with chronic pain and collecting disability. To make ends meet, you had to start cashing in on your pension, which is barely enough to live on. Applying for Medicaid is like writing a Master’s thesis. You never see your kids because the ex-wife took them back to Michigan. You can’t work anymore, and you try to save some money by staying in your violent, alcoholic brother’s trailer until you can figure out another way. He gets the only bedroom, so you sleep in the chair, which kills your back.
People tell you to take control of your life. If you were able to deal with it on your own, wouldn’t you have done it already? People tell you there’s hope. Where?
According to Birnbaum, care for mental illness in our country was historically focused on institutionalization; partially because effective treatment didn’t exist, and partially, he says, “on the fundamental notion that if it’s mental, then people are in control of it.” The doctor, palpably exasperated, pauses before editorializing: “As if we’re entirely in control of our chemical makeup. Look, it’s socially acceptable to go to the doctor to have your leg checked out, but less so to follow up with your therapist on your depression or alcoholism. Would you see a doctor for a heart condition or diabetes? So why not for mental illness?”
As a senior faculty member of the Fort Collins Family Medicine Residency program, Birnbaum knows that modern physician training remains shaded away from the psychological side, which tends to require a more time- and energy-intensive approach to patient care. “Doctors see hundreds of patients and often don’t have time for conversations,” Birnbaum admits. It is precisely these missing interactions, he believes, that could profoundly affect how providers diagnose and treat their patients with mental health issues.
Instead, the dual evils of stigmatizing the mentally ill and shaving resources have corrupted our ability to care for a notoriously at-risk segment of our population. Studies continue to suggest that rates of mental illness are higher in socioeconomically disadvantaged groups. Yet Birnbaum posits from a biochemical standpoint, there’s not that much variability across demographics. “Human beings,” he says, “are inherently complicated creatures.”
We reliably respond in different ways to the same stressors, and those environmental triggers can lead to chemical changes in the brain that further affect our behaviors. Adding elements like coordinating multiple appointments and managing costs, for example, augment the complexity of an already complex issue. In the end, a person’s cognitive success often hinges not on body chemistry, but access to resources.
“When’s someone’s in crisis in the hospital, we can pull strings for them, like providing them more intense counseling, medications and a safe place to be if they’re a danger to themselves or others,” says Birnbaum. “But if you’re not in the hospital, waiting a month to see somebody is not going to fly. And with the average person not having good insurance, where mental health access really becomes difficult is for those patients who fall in the middle.”
Your parents deny that you were ever molested. The pediatrician’s voice still echoes in your head: “Forget about it. Let it go.” It’s hard to drown out the memories, so you eat and worry and rearrange things for hours. You must be the only one who’s had to suffer through this; no one else has ever mentioned it. You’ve tried different counselors over the years with mixed results. Pills helped for a while, but the side effects were miserable, like insomnia and gaining 30 pounds. And don’t even mention the disappearing sex drive.
You finally found a new doctor, she seems nice enough, and she’s pushing you to find another therapist. But who takes appointments at 7:00 at night? They’re just going to bring up your dad and the touching again. It’s too painful. You’re doing the best you can but every day is a struggle to mask what you feel like: vulnerable and broken.
Part of the problem is that I can do a test for heart disease and see that you have it. But there’s no simple blood test for mental illness.”
The Centers for Medicare and Medicaid Services report that the U.S. spent $3 trillion on health care in 2014, 17 percent of the Gross Domestic Product. According to the Colorado Commission on Affordable Healthcare, the Centennial State spent $36 billion in 2015, a fourfold increase over two decades.
Where does that money come from? Where does it actually get spent? The answer to both is: us. About $9,000 per individual per year. Yet according to a 2011 paper in the journal Health Affairs, only 5.6 percent of our healthcare spending is devoted to mental health care. A cynic might say that the brain accounts for quite a bit more than 1/16th of our body’s resources.
“Part of the problem,” Birnbaum says, “is that I can do a test for heart disease and see that you have it. But there’s no simple blood test for mental illness.”
Most insurance companies routinely cover physical tests like colonoscopies and pap smears and angiograms, but not ongoing counseling beyond a few visits. And in the cruel reality of our current universe, says Birnbaum, “People tend to limit their healthcare access based on their ability to afford adequate medical care.”
Fort Collins psychiatrist Dr. Glenn Pearson contends that many of the same socioeconomic issues that contribute to more visible diagnoses like heart disease, diabetes and obesity—poor education and lifestyle habits, for example—also impact our mental health and warrant the same gravitas in the medical community.
“If you actually spent more on housing, public education and nutrition and less on ‘healthcare,’ we might have better outcomes,” suggests Pearson. “Two million Americans go into bankruptcy every year because of healthcare costs, and many live on the margins because employers control [their] healthcare. If you have a $3,000 deductible and you need mental health care, do you just put it on your credit card, or use that money for groceries and rent?”
Talk about stress.
You’re 46 years old, working six 10-hour days on a construction site, making $16 per hour. It’s enough to pay most of the bills and have a bit left over for a burger and a beer on Sunday. Your knee swells every night, and there’s no time for physical therapy or surgery, but you don’t complain. Your kids don’t care if Daddy’s in pain. They ache too—to play with you when you get home. But, honestly, sometimes it’s hard to focus with all that other stuff going on. All the “might haves” and “what ifs” from years ago, they keep popping into your head. You hate that you lose your temper so often… that you cry in the car on the way to work… that you can’t tell your boss, or even your wife, any of this.
You are ashamed. You are so embarrassed.
As one member of the Community Mental Health and Substance Abuse Partnership of Larimer County, Carol Plock participated in a collaborative effort between more than 20 organizations that includes consumer and family advocates as well as treatment and service providers, designed to turn things around for the mentally ill. Using the help of the consulting firm NIATx, the report, released in February 2016, outlined the current resources available in our community for those with behavioral health needs, the gaps that still exist and the likely cost of implementing modalities to improve existing services.
One particularly revelatory finding of the 109-page document, entitled “Recommendations for the Development of Critical Behavioral Health Services in Larimer County,” is that only about 2,800 of the approximately 31,000 people in Larimer County that need treatment for substance abuse disorders actually receive that care. And, of the remaining 90 percent, only 1,400 even seek treatment in the first place.
“We have known for a long time that there are big gaps in services for people with mental illnesses or substance abuse disorders [in Larimer County],” Plock says. “One issue is that there are not enough places that have well-trained providers with the expertise to help assess the situation.”
Says Birnbaum, one of the medical professionals on the front lines: “If you have, say, bipolar depression and you have an opiate addiction and you need medication for it, getting that kind of help is exquisitely difficult at best.”
From Plock’s standpoint, having more specialists from which to choose—psychiatrists, certified addiction counselors and therapists—would be a great start. And for those suffering from more severe issues, she advocates strongly for a facility that bridges the gap between an acute crisis stabilization unit (like a mental health–focused ER) and an inpatient psychiatric hospital, like Mountain Crest, University of Colorado Health’s Behavioral Health facility in southeast Fort Collins. While Larimer County has short-term residential facilities for substance abuse disorder treatment, people who may need longer-term rehab of up to 90 days are out of luck.
A major roadblock for Larimer County residents is that the nearest medical detox facility is in Greeley. That distance effectively causes a number of residents of Fort Collins and its environs that need help quitting chemical dependency to end up either in a hospital or jail. Living behind bars, most would agree, may actually equate to the precise opposite of adequate behavioral health care.
The study specifically suggested an 87-bed facility that can handle up to 12,000 visits per year. This prospective behavioral health services center would include acute treatment units for those going through mental health crises, and house a medically monitored detox facility for those working through substance–abuse issues.
Only about 2,800 of the approximately 31,000 people in Larimer County that need treatment for substance abuse disorders actually receive that care.”
In April, University of Colorado Health took its own positive step by adding 15 beds to Mountain Crest’s inpatient adult psychiatric unit, with the goal of reducing ER visits for mental health patients. Still, the majority of gateways into the healthcare system happen through primary care channels, like a physician’s office or a walk-in clinic.
Birnbaum suggests making these services easier to locate by merging entities that have always been segregated. “When you separate mental health care from physical health care, meaning that you have to physically go somewhere else, you also guarantee that people have to access care in multiple different systems,” he says. “But by having therapists physically located inside the doctor’s office, you’re giving people options that they did not have before, and it’s easier to coordinate care.”
With this setup, Birnbaum says he can elicit a phone conversation or email on the spot. This not only improves efficiency and communication across disciplines, but also minimizes the financial incentives to refer patients outside of the office for services or tests by consolidating the bill. Because of the prevalence of third-party reimbursement, however, the current American medical practice model is resistant to unfettered access to ancillary services. Changing this, one might surmise, could take a while.
After 10 years of sobriety, you’ve recently started drinking again because your commission-based ad sales job is stressing you out. But you’re working hard and you deserve it: hell, you’re 32 years old, own a great condo in Old Town, hit the gym three times a week and your love life is booming. So you down a couple quick shots and head into the doctor’s office for your physical, and he says you have hypertension. But he knows what’s going on, says AA is a good idea, maybe Summit Stone. He said he’ll have his counselor call you tomorrow and set up a meeting for all three of you at his office. He writes a prescription for some meds to decrease your cravings. You can tell your boss you’re going to see your doctor, not the shrink. That’s a relief. No 32-year-old should feel so powerless. Right?
Concerned physicians like Birnbaum and Pearson are beginning to elucidate the challenges facing those diagnosed along the mental illness spectrum. The first step, by all accounts, is validating the problem. Pearson also cautions that no one is immune and that trying to heal alone is extremely challenging.
“There is no such thing as an average profile of someone suffering from mental health problems,” Pearson says. “It hits every socioeconomic status. One person might be homeless; another might have a great job and family. Unfortunately, many people are ashamed of their condition, so they often try to keep it to themselves. In the end, though, one person’s mental health can affect the whole community.”
For sufferers of debilitating conditions like bipolar disorder, schizophrenia or obsessive-compulsive disorder, for example, the mundane daily routine is most affected. Yet dire crises like thoughts of suicide or spiraling substance abuse can happen just as easily as accidentally slicing your hand with a steak knife, and warrant similarly expedient treatment. With a serious bleed, you’re seen in the ER then discharged with pain pills and some bandages to change. But during a mental health crisis, just because your tremors have stopped or the voices in your head are a bit quieter doesn’t mean life returns to normal.
With the right help and some patience, anyone suffering from mental illness can capably manage it, says Nicole Prinzivalli, MA, NCC, LPC, a Fort Collins couples and family counselor. She, like Birnbaum and Pearson, fully understands the variability of symptoms and the unique problems that befall each individual. One plan of attack, she says, is to set short-term goals and seek steady improvement, rather than lunging for an ultimate cure.
“I try to teach people to manage their problems, and remind them that they have tools they can use at school or at work,” Prinzivalli says.
One such tool right here in our backyard is Mental Health Connections, a service provided by the Health District. Connections, as is it known, refers its clients to affordable services located inside the community, while bridging the gap between a potentially urgent situation and the first counselor visit. The call center and walk-in clinic are open normal business hours, but the phone line transfers to emergency call service 24/7.
Summit Stone, formerly known as Touchstone, is another indispensable resource for Larimer County residents. It primarily serves those with Medicaid, but also caters to subscribers of Medicare and some private insurance, and even offers sliding scale payment plans. A third of its 7,000 yearly customers come from households earning less than $25,000 annually, and Birnbaum estimates that it provides 20 percent of the county’s health benefits. “It’s absolutely essential for our community,” he says.
Summit Stone case managers can help clients procure concrete services like housing, insurance, and food stamps. Much of its mission, according to Jim Salico-Diehl, Program Coordinator for community-based services at Summit Stone, involves redirecting folks away from the emergency room. Nurse practitioners and psychiatrists at Summit Stone provide individual and group therapy, and can help with medication management as well. Like Connections, its staff is available round the clock. Perhaps best of all, Summit Stone provides peer-supported services, staffed by those who’ve dealt with mental illness themselves.
When you add in anger management classes, jail-based programs, in-home and school-based services, addiction and substance abuse services, among others, you begin to realize that help is out there—if you know where to look.
One of the biggest problems in modern society is that we’re disconnected from each other.”
“There are many ways you can address mental illness,” says Pearson, the psychiatrist. “Medications, lifestyle, counseling, and spirituality. But it’s best to seek help in all of those realms. Holistic doesn’t mean complementary.”
When waxing on the idea of improving mental health care locally and nationally, Birnbaum uses terms like “equitable” and “appropriate,” that while mellifluous, may well translate to nothing more than dreams. That’s because innovations to the status quo in any realm are notoriously sluggish and stigma is a powerful nemesis. What might be needed is a radical shift in consciousness focused less on judgment and more on acceptance. This might prove to be the ultimate challenge. Birnbaum suggests one modality that has nothing to do with medicine.
“One of the biggest problems in modern society is that we’re disconnected from each other,” he says. “But humanity has always been about community, and spiritual community is protective and a valid treatment for depression and anxiety. Reducing the barriers to having a community and improving structure in society is just as much of a treatment for depression as anything else.”
For Prinzivalli, the key to addressing mental illness is a willingness to accept help. “One of the biggest barriers is ourselves,” she says. “And really, everyone can use a little help.”