The District of Columbia has a fairly strong healthcare delivery system, particularly for children.  We also rank among the top jurisdictions that provide health insurance coverage for the majority of our residents.  Unfortunately, our strengths in the physical health coverage arena have not translated into increased access to and use of behavioral health services.  This is troubling considering that residents with serious mental illnesses are known to have a life expectancy that is 25 years shorter than the residents without such mental illnesses.

According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) 2013 Health Barometer, 23,000 D.C. adults experienced serious thoughts of suicide between 2011 and 2012.  Additionally during this timeframe, 14,000 adults were identified as suffering from a serious mental illness.  Nationally, it is estimated that 1 in 4 adults will experience some mental illness in their lifetime (i.e. depression, etc.) unfortunately, a significant number of these individuals will not seek treatment.  The scope of this problem highlights the critical need to expand access to treatment and services for all residents.  This is particularly true when we look at our performance in treating children experiencing mental health or substance abuse problems. 

Between 2011 and 2012, 25% of middle and high school students self-reported symptoms of depression, while one in seven youth actually made a plan about how they would attempt suicide.  Annually, 10% of youth experience a severe mental health problem.  In addition to mental health challenges, national estimates for D.C. indicate that anywhere between 2,000 and 3,000 youth below the age of 17 are abusing or are dependent on alcohol and drugs.  Further, in 2013, 350 D.C. children were referred for substance abuse treatment, yet only an estimated 70 children completed the treatment program.

The picture is crystal clear—our residents need mental health and substance abuse services.  They need early preventative care that identifies their needs and treats them appropriately.  Reflecting on this problem in our city, this summer I took the opportunity to tour seven specialty mental health clinics and substance abuse providers across the city, as well as, Saint Elizabeth’s Hospital. 

During my tours, I learned about a wide range of treatment programs, including assertive community treatment (ACT).  ACT is a service delivery model that combines comprehensive psychiatric treatment with rehabilitation and includes the necessary support for persons with serious and persistent mental illness.  ACT team members see clients where they are, frequently making home visits and coordinating with a host of partners to provide high-quality services. 

I explored another critical program, trauma-informed care, on my tour of Community Connections.  Trauma-informed care programs recognize that many individuals suffering from mental illness and co-occurring substance abuse have experienced some sort of physical, sexual, mental or emotional trauma in their lifetime, necessitating a comprehensive look at the factors that have contributed to their mental illnesses. 

The trauma-informed care program was eye-opening because it reinforced the fragility of our circumstances.  Any life event, from the death of a loved one, the loss of a job, involvement in a car accident can be traumatic, leading to bouts of grief.  Falling into homelessness is a prime example of a trauma that could send any of us along a downward spiral and the city’s housing and homelessness crisis is well-known. 

Our housing challenges were further underscored as I visited Pathways to Housing, a provider that specializes in housing our mentally ill.  Pathways to Housing employs a “housing first” model, providing immediate, low-barrier access to permanent housing and then combining it with supportive treatment services.  The apartment homes are scattered throughout the city and while the program maintains an 85% retention rate, barriers persist.

For example, the D.C. Housing Authority (DCHA) provides vouchers to help pay for apartments across the city.  Due to rising rental prices however, many residents are being steered to properties located in Wards 7 and 8 because vouchers for those apartments cover the entire rental cost, with money left over—while, in more affluent sections of the city, the vouchers rarely cover even half of the rental cost.  Despite this challenge, Pathways to Housing continues to press forward and typically is able to house a person, from the point of entry into the program through housing placement, within three weeks.

While touring McClendon Center, I had the opportunity to observe a day services program, which enables those dealing with mental illnesses, primarily schizophrenia and other psychotic disorders, to learn life skills to assist them in readjusting to life back in society.  Day services programs challenge participants to engage with others, learn about their illnesses and how to manage them and assist them in becoming advocates for themselves.  What struck me about this particular program is that while the service is often viewed as “glorified adult day care,” participants are less likely to be re-hospitalized, demonstrating that this treatment effort not only brings about long-term cost savings by reducing hospitalizations, but significantly improves a participant’s quality of life. 

During several of my visits I learned, in greater depth, about Health Homes, similar in concept to a patient-centered medical home, but with an explicit component addressing the delivery of addiction and substance abuse services.  The Affordable Care Act’s (ACA) Health Home provision allows a state entity to define a vulnerable population, provide primary care integration and receive 90% Federal Financial Participation through Medicaid for two years, rather than the current 70%.  This program is important because people with serious mental illnesses have a greater number of medical problems, often caused by smoking or self-neglect, co-occurring substance use, or even the medications they take for their psychiatric illnesses.  Because mental health consumers often do not tend to these conditions, they continue to worsen and treatment becomes increasingly more costly.  For this reason, the integration of medical services into a mental health facility is critical.  In addition, it is also valuable to have mental health providers in the medical clinics.   Health Homes is necessary, which is why the District of Columbia is currently working to implement this model with a proposed start date in 2015.

For me, the most heartbreaking tour took place at a facility specializing in the treatment of children impacted by grief and trauma.  The Wendt Center employs the Resilient Scholars Program, which is currently available in 21 different schools (charter and DCPS) in D.C.  The program helps children cope with trauma, which is challenging because many of the students suffer from polytraumas, the occurrence of multiple traumas.  These students are burdened by poverty, the experience of violence in their home or community, and so much more.  Recognizing that the stress of all this weight sometimes manifests as physical pain, the Resilient Scholars Program helps students to identify where they are hurting and why they are hurting; helping them to develop healthy mechanisms to begin to heal.  Viewing the students’ artwork was painful.  To read about their daily struggles and view the images of violence they had drawn was overwhelming and highlighted the critical need for this type of program in all of our schools.  The District of Columbia’s increased emphasis on standardized testing is an added stressor but programs like this one can work to improve student performance by addressing their grief and trauma. 

A common thread across all of the mental health and substance abuse clinics was a fervent commitment to the humanization of mental illness.  This was never more apparent than at Saint Elizabeth’s.  Saint Elizabeth’s residents are treated with dignity.  Upon their admission they are no longer, “prisoners” or “patients,” they are simply individuals receiving care.  The facility provides “homes” where residents are housed in dormitory style living quarters and afforded the opportunity to participate in various programs and other outlets to include a Patient Advisory Council.  Further, those residents preparing to transition back into the community are equipped with life skills such as learning to cook, do laundry, and operate a computer. 

Perhaps the most interesting part of my Saint Elizabeth’s tour was that residents, those on the transitional therapy floor, are not quarantined off from staff but allowed to freely walk the halls and actively participate in their treatment.  At the new facility, residents are not stigmatized; they are not caged nor subjected to a prison inspired atmosphere but treated as whole human beings.  By the conclusion of my tour, I was impressed with the staff, the facility and the level of care provided.

In addition to the facilities mentioned, I also had the opportunity to tour Green Door, Catholic Charities and CATAADA House of Calvary Healthcare.  All of these tours left me with the sense that our city is moving in the right direction.  While our mental health providers are unsung heroes treating some of the most vulnerable among us, there is still work to do.  With the deinstitutionalization of mental health services in D.C., community mental health providers expanded significantly.  At the time, the supply of services met the demand; however, as time has worn on the demand for services continues to increase.  This has presented some challenges, especially for our youth, who find it increasingly more difficult to get treatment from qualified child psychiatrists due to their scarcity.  Additionally, as providers ready themselves for the ability to now bill Medicaid for substance abuse treatment, new concerns will arise. 

We have a significant number of residents, especially youth, who need services but are not getting treatment.  This cannot continue.  City agencies and the providers themselves must continue to reduce the stigma associated with mental illness and substance abuse and actively work to market and promote their services.  Our residents deserve the best treatment and it appears to me that we are providing it but those in need cannot take advantage of what they do not know about.  Mental illness and substance abuse issues affect us all.  The links between homelessness and mental illness as well as the mental illnesses of those that are incarcerated are well-studied.  For this reason, I made it a priority to not only visit our service providers but also a homeless shelter and the D.C. jail to better understand the full spectrum of these complexities.  The health and wellness of our residents is a priority for me and I will continue to advocate for quality services and work with D.C. agencies and providers to address the barriers that they face and promote the services they provide.