Taking Aim at Mental Illness

Since December 14, 2012, when Adam Lanza entered Sandy Hook Elementary School in Newtown, Connecticut, intent on taking the lives of innocent children and the adults tasked with protecting them, the topic of gun control in the United States has returned to the forefront. Some professional organizations, such as the American Academy of Pediatrics (AAP), have made their stance clear. In a letter to President Obama, AAP President Thomas K. McInerny, MD, FAAP, wrote:

“New federal firearms legislation that bans assault weapon sales and the sales of high-capacity magazines, strengthens mandatory waiting periods and background checks for all gun purchases, and promotes strict gun safety policies is a necessary first step. Next, the federal government must take action to improve access to services that meet the mental health and developmental needs of infants, children, and adolescents, and ensures that children and families exposed to violence have access to a medical home and other community supports.”

That “first step” is the central, divisive issue in the debate between gun control advocates and supporters of the Second Amendment, such as the National Rifle Association (NRA). But it is the next step—improving mental health services (and not only for children)—that may actually represent the crux of the matter. The risk is that, as both sides dig in their heels and try to out-shout each other, the nation will either miss or misuse an opportunity to address a complicated and unwieldy problem.

What Is Really At Issue
One week after the shooting at Sandy Hook, NRA executive Wayne LaPierre raised the idea of a “national database” of the mentally ill as one means of stemming gun violence. His comments also raised hackles, as some considered them a diversionary tactic and others worried that the mentally ill would become scapegoats in the debate.

As with all emotionally wrought topics, the intersection between violence and mental illness is complicated and controversial. Even setting aside personal positions on gun control leaves a realm of clinical uncertainty. There are no easy answers.

True psychiatric illness involves cognitive distortion (eg, the paranoia and hallucinations of schizophrenia). That positive symptomatology distinguishes mental illness from sociopathy, which entails a personality or a moral dysfunction.

“We know what neurotransmitters are involved in cognitive processes, and we can treat them,” says Cindy Parsons, DNP, ARNP-BC, FAANP, Associate Professor of Nursing, College of Natural and Health Science, University of Tampa, Florida. “When it comes to moral compasses being off-kilter, we don’t have a tried-and-true methodology that gives us even some hopefulness in terms of improvement. With Columbine and Sandy Hook, these young people were not so much paranoid about the world—they didn’t have a clear perspective on right and wrong.”

Currently, there is no treatment for antisocial personality disorder (which is diagnosed in those older than 18; in younger persons, it is known as conduct disorder). In fact, sociopathy—a particularly severe form of antisocial personality disorder—has not been a true classification in the Diagnostic and Statistical Manual of Mental Disorders. That will change this May, however, when DSM-V is published.

“Our ‘ticking time-bombs’ are probably our young people,” says Parsons. “How are we teaching young people to manage stress or conflict? We don’t. That’s not something we educate them on in school; we assume that families are educating them.”

Catherine R. Judd, MS, PA-C, who practices in Parkland Health and Hospital System’s Jail Health Program at the Dallas County Jail, recalls kids she encountered in the juvenile system. Many of them had been involved in vandalism, theft, animal cruelty, destruction of property, and arson—all criteria for a diagnosis of conduct disorder.

By contrast, “a lot of the seriously mentally ill people we see here in jail, their charges have nothing to do with weapons,” she says. “Their charges are criminal trespassing, stealing bologna out of the 7-11 because they’re hungry, urinating behind lampposts, hanging out under bridges, being ‘used’ by the real thieves to fence the copper they’re stealing off air conditioners, or to cash that ‘hot’ check.”

That isn’t to suggest that persons with mental illness are never violent. But are they necessarily more likely to be violent than those without a psychiatric diagnosis? And furthermore, who is determining that risk? These are just some of the concerns that Don St. John, MA, PA-C, who practices in adult outpatient psychiatry at the University of Iowa, has pondered since the subject of gun violence and the mentally ill has garnered renewed attention.

“If we define mental illness as ‘a DSM diagnosis,’ 25% of the population has had some kind of mental illness, lifetime prevalence,” he points out. “And the vast majority of people with a DSM-diagnosed mental illness are not at risk for doing anything like this.”

He has heard from patients who are concerned about being “labeled” based on their diagnosis. The question has been raised as to whether that increased stigma—already a huge issue with mental illness—will deter patients from seeking help. Another area of concern is how clinicians would respond: Will they avoid diagnosing patients because they don’t want the responsibility? Or will they be ultraconservative and write “paranoia” in the chart, when the patient may only have some mild anxiety?

“The problem is that when you start writing laws, [politicians] don’t have the understanding that we in medicine have about the difference between someone who’s at risk and someone who isn’t,” St. John says. “So some of it is going to be the definition—who is going to define it? And then how are they going to follow up on that?”

How information might be gleaned is another concern, and one that can be misleading. If medical charts or pharmacy records are mined, say, for specific diagnoses or medications, there is room for error.

“I have a patient with multiple sclerosis who takes an antidepressant for urinary incontinence,” St. John says. “She’s not taking it for depression. But, you know, she’s on an antidepressant—so, therefore, she must have a ‘mental illness.’”

What You Can Do
The mainstream media would have us believe that the individuals who represent the greatest threat to public safety walk into a clinic foaming at the mouth and with their eyes rolling back in their head—in other words, they should be identifiable at first glance. But identification of mental illness can be both more subtle and more complex, even for those with a psych/mental health background.

The key sign that someone has a mental impairment is disordered thinking. They may seem as if they can’t quite get their lives together; maybe they have difficulty following what a clinician considers a fairly straightforward regimen. They may appear disheveled or exhibit poor hygiene. Their responses to questions may seem “odd,” or they may convey a sense of fearfulness or paranoia.

With treatment, many people with mental illnesses do quite well. The difficulty is getting them adequate treatment, as well as monitoring to ensure they comply with it. Unlike other patients, who may be “willfully” noncompliant, those with mental illness are often incapable of keeping appointments or figuring out how to refill their prescription or follow the prescribed regimen without assistance.

Where does that assistance come from? That is precisely the problem the US has faced since deinstitutionalization occurred in the 1980s. Yes, there were asylums in which mentally ill patients were abused or neglected or otherwise treated as less than human. But for some patients, the facilities lived up to their names.

“There are a lot of people who actually did well in the institutions, because they needed that regimen—they got sleep, food, and shelter,” says St. John. “There are people who the best thing for them, and for society, is to put them in a place where they have protection. They call them asylums for a reason. And then we just kind of threw them out in the street and didn’t provide the services. That’s where we went wrong.”

The community-based services that were promised when the institutions closed have not materialized in a sufficient way. What is needed, advocates say, is adequate housing for the mentally ill—places where trained professionals can keep an eye on them and assist them with matters of daily living, including treatment plans.

“If you have that case management integrated into the housing component,” Parsons says, “if you have assigned and supportive housing for the chronically mentally ill, you’re going to do a better job getting them into treatment.”

That would rescue many of them from homelessness and perhaps cut down on some of the minor criminal offenses for which many mentally ill individuals find themselves incarcerated. It would also provide a layer of safety, as someone would be monitoring the patient for signs of deterioration.

“When symptoms worsen, what patients do is socially withdraw—they don’t want to be around people because they tend to be paranoid, their thoughts are more disordered,” St. John observes. “So then there aren’t people around to see them, and then you don’t hear anything until something bad happens.”

Equally important, and slowly starting to occur, is the integration of behavioral health services into primary care. Parsons is hopeful that the emergence of accountable care organizations and the expansion of the medical home concept will lead to better communication and coordination between providers, and ultimately better care for mentally ill individuals.

Even before that integration is completed, Parsons says, primary care providers should be networking with their psych/mental health colleagues. For one thing, a patient’s mental status can have a significant impact on his or her physical health and ability to take care of him- or herself. And for another, should a primary care provider have concerns about a patient’s mental status, having a specialist to call can be a lifeline.

“If you have a feeling that this person needs help, just saying ‘You really need to see a mental health provider’ and leaving it at that is probably not sufficient,” Parsons says.

She recommends knowing what specific resources are available locally, offering them to patients, and being prepared to make a phone call yourself if psych/mental health services are so scarce or overbooked that the patient can’t get an appointment for six or eight weeks. “Having relationships with folks who you can pick up the phone and say ‘I really have this urgent situation; can you see this patient or can you get me somebody who can see them within the next two or three days?’ is probably going to be our best bet,” she says. “And if we can integrate behavioral health on the same site, we have that ready access.”

Whatever the outcome of the latest gun control debate, there is no question that it is shining a spotlight on a critical issue for the US health care system. The lack of adequate care for the mentally ill impacts not only affected individuals, but also the public at large. It is a subject that must be handled with care, but everyone needs to participate in the discussion.

“Sticking our heads in the sand certainly is not the best option. I think we all have to take some responsibility for solving these problems,” Parsons says. “We have to engage all of these folks—the gun lobbyists, the gun control advocates, Congress, local leaders—in dialogue. How do we role model conflict resolution when we take very staunch positions and don’t communicate, don’t collaborate, don’t compromise?”

Since December 14, 2012, when Adam Lanza entered Sandy Hook Elementary School in Newtown, Connecticut, intent on taking the lives of innocent children and the adults tasked with protecting them, the topic of gun control in the United States has returned to the forefront. Some professional organizations, such as the American Academy of Pediatrics (AAP), have made their stance clear. In a letter to President Obama, AAP President Thomas K. McInerny, MD, FAAP, wrote:

“New federal firearms legislation that bans assault weapon sales and the sales of high-capacity magazines, strengthens mandatory waiting periods and background checks for all gun purchases, and promotes strict gun safety policies is a necessary first step. Next, the federal government must take action to improve access to services that meet the mental health and developmental needs of infants, children, and adolescents, and ensures that children and families exposed to violence have access to a medical home and other community supports.”

That “first step” is the central, divisive issue in the debate between gun control advocates and supporters of the Second Amendment, such as the National Rifle Association (NRA). But it is the next step—improving mental health services (and not only for children)—that may actually represent the crux of the matter. The risk is that, as both sides dig in their heels and try to out-shout each other, the nation will either miss or misuse an opportunity to address a complicated and unwieldy problem.

What Is Really At Issue
One week after the shooting at Sandy Hook, NRA executive Wayne LaPierre raised the idea of a “national database” of the mentally ill as one means of stemming gun violence. His comments also raised hackles, as some considered them a diversionary tactic and others worried that the mentally ill would become scapegoats in the debate.

As with all emotionally wrought topics, the intersection between violence and mental illness is complicated and controversial. Even setting aside personal positions on gun control leaves a realm of clinical uncertainty. There are no easy answers.

True psychiatric illness involves cognitive distortion (eg, the paranoia and hallucinations of schizophrenia). That positive symptomatology distinguishes mental illness from sociopathy, which entails a personality or a moral dysfunction.

“We know what neurotransmitters are involved in cognitive processes, and we can treat them,” says Cindy Parsons, DNP, ARNP-BC, FAANP, Associate Professor of Nursing, College of Natural and Health Science, University of Tampa, Florida. “When it comes to moral compasses being off-kilter, we don’t have a tried-and-true methodology that gives us even some hopefulness in terms of improvement. With Columbine and Sandy Hook, these young people were not so much paranoid about the world—they didn’t have a clear perspective on right and wrong.”

Currently, there is no treatment for antisocial personality disorder (which is diagnosed in those older than 18; in younger persons, it is known as conduct disorder). In fact, sociopathy—a particularly severe form of antisocial personality disorder—has not been a true classification in the Diagnostic and Statistical Manual of Mental Disorders. That will change this May, however, when DSM-V is published.

“Our ‘ticking time-bombs’ are probably our young people,” says Parsons. “How are we teaching young people to manage stress or conflict? We don’t. That’s not something we educate them on in school; we assume that families are educating them.”

Catherine R. Judd, MS, PA-C, who practices in Parkland Health and Hospital System’s Jail Health Program at the Dallas County Jail, recalls kids she encountered in the juvenile system. Many of them had been involved in vandalism, theft, animal cruelty, destruction of property, and arson—all criteria for a diagnosis of conduct disorder.

By contrast, “a lot of the seriously mentally ill people we see here in jail, their charges have nothing to do with weapons,” she says. “Their charges are criminal trespassing, stealing bologna out of the 7-11 because they’re hungry, urinating behind lampposts, hanging out under bridges, being ‘used’ by the real thieves to fence the copper they’re stealing off air conditioners, or to cash that ‘hot’ check.”

That isn’t to suggest that persons with mental illness are never violent. But are they necessarily more likely to be violent than those without a psychiatric diagnosis? And furthermore, who is determining that risk? These are just some of the concerns that Don St. John, MA, PA-C, who practices in adult outpatient psychiatry at the University of Iowa, has pondered since the subject of gun violence and the mentally ill has garnered renewed attention.

“If we define mental illness as ‘a DSM diagnosis,’ 25% of the population has had some kind of mental illness, lifetime prevalence,” he points out. “And the vast majority of people with a DSM-diagnosed mental illness are not at risk for doing anything like this.”

He has heard from patients who are concerned about being “labeled” based on their diagnosis. The question has been raised as to whether that increased stigma—already a huge issue with mental illness—will deter patients from seeking help. Another area of concern is how clinicians would respond: Will they avoid diagnosing patients because they don’t want the responsibility? Or will they be ultraconservative and write “paranoia” in the chart, when the patient may only have some mild anxiety?

“The problem is that when you start writing laws, [politicians] don’t have the understanding that we in medicine have about the difference between someone who’s at risk and someone who isn’t,” St. John says. “So some of it is going to be the definition—who is going to define it? And then how are they going to follow up on that?”

How information might be gleaned is another concern, and one that can be misleading. If medical charts or pharmacy records are mined, say, for specific diagnoses or medications, there is room for error.

“I have a patient with multiple sclerosis who takes an antidepressant for urinary incontinence,” St. John says. “She’s not taking it for depression. But, you know, she’s on an antidepressant—so, therefore, she must have a ‘mental illness.’”

What You Can Do
The mainstream media would have us believe that the individuals who represent the greatest threat to public safety walk into a clinic foaming at the mouth and with their eyes rolling back in their head—in other words, they should be identifiable at first glance. But identification of mental illness can be both more subtle and more complex, even for those with a psych/mental health background.

The key sign that someone has a mental impairment is disordered thinking. They may seem as if they can’t quite get their lives together; maybe they have difficulty following what a clinician considers a fairly straightforward regimen. They may appear disheveled or exhibit poor hygiene. Their responses to questions may seem “odd,” or they may convey a sense of fearfulness or paranoia.

With treatment, many people with mental illnesses do quite well. The difficulty is getting them adequate treatment, as well as monitoring to ensure they comply with it. Unlike other patients, who may be “willfully” noncompliant, those with mental illness are often incapable of keeping appointments or figuring out how to refill their prescription or follow the prescribed regimen without assistance.

Where does that assistance come from? That is precisely the problem the US has faced since deinstitutionalization occurred in the 1980s. Yes, there were asylums in which mentally ill patients were abused or neglected or otherwise treated as less than human. But for some patients, the facilities lived up to their names.

“There are a lot of people who actually did well in the institutions, because they needed that regimen—they got sleep, food, and shelter,” says St. John. “There are people who the best thing for them, and for society, is to put them in a place where they have protection. They call them asylums for a reason. And then we just kind of threw them out in the street and didn’t provide the services. That’s where we went wrong.”

The community-based services that were promised when the institutions closed have not materialized in a sufficient way. What is needed, advocates say, is adequate housing for the mentally ill—places where trained professionals can keep an eye on them and assist them with matters of daily living, including treatment plans.

“If you have that case management integrated into the housing component,” Parsons says, “if you have assigned and supportive housing for the chronically mentally ill, you’re going to do a better job getting them into treatment.”

That would rescue many of them from homelessness and perhaps cut down on some of the minor criminal offenses for which many mentally ill individuals find themselves incarcerated. It would also provide a layer of safety, as someone would be monitoring the patient for signs of deterioration.

“When symptoms worsen, what patients do is socially withdraw—they don’t want to be around people because they tend to be paranoid, their thoughts are more disordered,” St. John observes. “So then there aren’t people around to see them, and then you don’t hear anything until something bad happens.”

Equally important, and slowly starting to occur, is the integration of behavioral health services into primary care. Parsons is hopeful that the emergence of accountable care organizations and the expansion of the medical home concept will lead to better communication and coordination between providers, and ultimately better care for mentally ill individuals.

Even before that integration is completed, Parsons says, primary care providers should be networking with their psych/mental health colleagues. For one thing, a patient’s mental status can have a significant impact on his or her physical health and ability to take care of him- or herself. And for another, should a primary care provider have concerns about a patient’s mental status, having a specialist to call can be a lifeline.

“If you have a feeling that this person needs help, just saying ‘You really need to see a mental health provider’ and leaving it at that is probably not sufficient,” Parsons says.

She recommends knowing what specific resources are available locally, offering them to patients, and being prepared to make a phone call yourself if psych/mental health services are so scarce or overbooked that the patient can’t get an appointment for six or eight weeks. “Having relationships with folks who you can pick up the phone and say ‘I really have this urgent situation; can you see this patient or can you get me somebody who can see them within the next two or three days?’ is probably going to be our best bet,” she says. “And if we can integrate behavioral health on the same site, we have that ready access.”

Whatever the outcome of the latest gun control debate, there is no question that it is shining a spotlight on a critical issue for the US health care system. The lack of adequate care for the mentally ill impacts not only affected individuals, but also the public at large. It is a subject that must be handled with care, but everyone needs to participate in the discussion.

“Sticking our heads in the sand certainly is not the best option. I think we all have to take some responsibility for solving these problems,” Parsons says. “We have to engage all of these folks—the gun lobbyists, the gun control advocates, Congress, local leaders—in dialogue. How do we role model conflict resolution when we take very staunch positions and don’t communicate, don’t collaborate, don’t compromise?”

Since December 14, 2012, when Adam Lanza entered Sandy Hook Elementary School in Newtown, Connecticut, intent on taking the lives of innocent children and the adults tasked with protecting them, the topic of gun control in the United States has returned to the forefront. Some professional organizations, such as the American Academy of Pediatrics (AAP), have made their stance clear. In a letter to President Obama, AAP President Thomas K. McInerny, MD, FAAP, wrote:

“New federal firearms legislation that bans assault weapon sales and the sales of high-capacity magazines, strengthens mandatory waiting periods and background checks for all gun purchases, and promotes strict gun safety policies is a necessary first step. Next, the federal government must take action to improve access to services that meet the mental health and developmental needs of infants, children, and adolescents, and ensures that children and families exposed to violence have access to a medical home and other community supports.”

That “first step” is the central, divisive issue in the debate between gun control advocates and supporters of the Second Amendment, such as the National Rifle Association (NRA). But it is the next step—improving mental health services (and not only for children)—that may actually represent the crux of the matter. The risk is that, as both sides dig in their heels and try to out-shout each other, the nation will either miss or misuse an opportunity to address a complicated and unwieldy problem.

What Is Really At Issue
One week after the shooting at Sandy Hook, NRA executive Wayne LaPierre raised the idea of a “national database” of the mentally ill as one means of stemming gun violence. His comments also raised hackles, as some considered them a diversionary tactic and others worried that the mentally ill would become scapegoats in the debate.

As with all emotionally wrought topics, the intersection between violence and mental illness is complicated and controversial. Even setting aside personal positions on gun control leaves a realm of clinical uncertainty. There are no easy answers.

True psychiatric illness involves cognitive distortion (eg, the paranoia and hallucinations of schizophrenia). That positive symptomatology distinguishes mental illness from sociopathy, which entails a personality or a moral dysfunction.

“We know what neurotransmitters are involved in cognitive processes, and we can treat them,” says Cindy Parsons, DNP, ARNP-BC, FAANP, Associate Professor of Nursing, College of Natural and Health Science, University of Tampa, Florida. “When it comes to moral compasses being off-kilter, we don’t have a tried-and-true methodology that gives us even some hopefulness in terms of improvement. With Columbine and Sandy Hook, these young people were not so much paranoid about the world—they didn’t have a clear perspective on right and wrong.”

Currently, there is no treatment for antisocial personality disorder (which is diagnosed in those older than 18; in younger persons, it is known as conduct disorder). In fact, sociopathy—a particularly severe form of antisocial personality disorder—has not been a true classification in the Diagnostic and Statistical Manual of Mental Disorders. That will change this May, however, when DSM-V is published.

“Our ‘ticking time-bombs’ are probably our young people,” says Parsons. “How are we teaching young people to manage stress or conflict? We don’t. That’s not something we educate them on in school; we assume that families are educating them.”

Catherine R. Judd, MS, PA-C, who practices in Parkland Health and Hospital System’s Jail Health Program at the Dallas County Jail, recalls kids she encountered in the juvenile system. Many of them had been involved in vandalism, theft, animal cruelty, destruction of property, and arson—all criteria for a diagnosis of conduct disorder.

By contrast, “a lot of the seriously mentally ill people we see here in jail, their charges have nothing to do with weapons,” she says. “Their charges are criminal trespassing, stealing bologna out of the 7-11 because they’re hungry, urinating behind lampposts, hanging out under bridges, being ‘used’ by the real thieves to fence the copper they’re stealing off air conditioners, or to cash that ‘hot’ check.”

That isn’t to suggest that persons with mental illness are never violent. But are they necessarily more likely to be violent than those without a psychiatric diagnosis? And furthermore, who is determining that risk? These are just some of the concerns that Don St. John, MA, PA-C, who practices in adult outpatient psychiatry at the University of Iowa, has pondered since the subject of gun violence and the mentally ill has garnered renewed attention.

“If we define mental illness as ‘a DSM diagnosis,’ 25% of the population has had some kind of mental illness, lifetime prevalence,” he points out. “And the vast majority of people with a DSM-diagnosed mental illness are not at risk for doing anything like this.”

He has heard from patients who are concerned about being “labeled” based on their diagnosis. The question has been raised as to whether that increased stigma—already a huge issue with mental illness—will deter patients from seeking help. Another area of concern is how clinicians would respond: Will they avoid diagnosing patients because they don’t want the responsibility? Or will they be ultraconservative and write “paranoia” in the chart, when the patient may only have some mild anxiety?

“The problem is that when you start writing laws, [politicians] don’t have the understanding that we in medicine have about the difference between someone who’s at risk and someone who isn’t,” St. John says. “So some of it is going to be the definition—who is going to define it? And then how are they going to follow up on that?”

How information might be gleaned is another concern, and one that can be misleading. If medical charts or pharmacy records are mined, say, for specific diagnoses or medications, there is room for error.

“I have a patient with multiple sclerosis who takes an antidepressant for urinary incontinence,” St. John says. “She’s not taking it for depression. But, you know, she’s on an antidepressant—so, therefore, she must have a ‘mental illness.’”

What You Can Do
The mainstream media would have us believe that the individuals who represent the greatest threat to public safety walk into a clinic foaming at the mouth and with their eyes rolling back in their head—in other words, they should be identifiable at first glance. But identification of mental illness can be both more subtle and more complex, even for those with a psych/mental health background.

The key sign that someone has a mental impairment is disordered thinking. They may seem as if they can’t quite get their lives together; maybe they have difficulty following what a clinician considers a fairly straightforward regimen. They may appear disheveled or exhibit poor hygiene. Their responses to questions may seem “odd,” or they may convey a sense of fearfulness or paranoia.

With treatment, many people with mental illnesses do quite well. The difficulty is getting them adequate treatment, as well as monitoring to ensure they comply with it. Unlike other patients, who may be “willfully” noncompliant, those with mental illness are often incapable of keeping appointments or figuring out how to refill their prescription or follow the prescribed regimen without assistance.

Where does that assistance come from? That is precisely the problem the US has faced since deinstitutionalization occurred in the 1980s. Yes, there were asylums in which mentally ill patients were abused or neglected or otherwise treated as less than human. But for some patients, the facilities lived up to their names.

“There are a lot of people who actually did well in the institutions, because they needed that regimen—they got sleep, food, and shelter,” says St. John. “There are people who the best thing for them, and for society, is to put them in a place where they have protection. They call them asylums for a reason. And then we just kind of threw them out in the street and didn’t provide the services. That’s where we went wrong.”

The community-based services that were promised when the institutions closed have not materialized in a sufficient way. What is needed, advocates say, is adequate housing for the mentally ill—places where trained professionals can keep an eye on them and assist them with matters of daily living, including treatment plans.

“If you have that case management integrated into the housing component,” Parsons says, “if you have assigned and supportive housing for the chronically mentally ill, you’re going to do a better job getting them into treatment.”

That would rescue many of them from homelessness and perhaps cut down on some of the minor criminal offenses for which many mentally ill individuals find themselves incarcerated. It would also provide a layer of safety, as someone would be monitoring the patient for signs of deterioration.

“When symptoms worsen, what patients do is socially withdraw—they don’t want to be around people because they tend to be paranoid, their thoughts are more disordered,” St. John observes. “So then there aren’t people around to see them, and then you don’t hear anything until something bad happens.”

Equally important, and slowly starting to occur, is the integration of behavioral health services into primary care. Parsons is hopeful that the emergence of accountable care organizations and the expansion of the medical home concept will lead to better communication and coordination between providers, and ultimately better care for mentally ill individuals.

Even before that integration is completed, Parsons says, primary care providers should be networking with their psych/mental health colleagues. For one thing, a patient’s mental status can have a significant impact on his or her physical health and ability to take care of him- or herself. And for another, should a primary care provider have concerns about a patient’s mental status, having a specialist to call can be a lifeline.

“If you have a feeling that this person needs help, just saying ‘You really need to see a mental health provider’ and leaving it at that is probably not sufficient,” Parsons says.

She recommends knowing what specific resources are available locally, offering them to patients, and being prepared to make a phone call yourself if psych/mental health services are so scarce or overbooked that the patient can’t get an appointment for six or eight weeks. “Having relationships with folks who you can pick up the phone and say ‘I really have this urgent situation; can you see this patient or can you get me somebody who can see them within the next two or three days?’ is probably going to be our best bet,” she says. “And if we can integrate behavioral health on the same site, we have that ready access.”

Whatever the outcome of the latest gun control debate, there is no question that it is shining a spotlight on a critical issue for the US health care system. The lack of adequate care for the mentally ill impacts not only affected individuals, but also the public at large. It is a subject that must be handled with care, but everyone needs to participate in the discussion.

“Sticking our heads in the sand certainly is not the best option. I think we all have to take some responsibility for solving these problems,” Parsons says. “We have to engage all of these folks—the gun lobbyists, the gun control advocates, Congress, local leaders—in dialogue. How do we role model conflict resolution when we take very staunch positions and don’t communicate, don’t collaborate, don’t compromise?”