Ending DACA Could Have Dire Public Health Consequences

September 21, 2017 by · Leave a Comment 

President Obama signed an executive order in 2012 protecting undocumented immigrants who were brought to the United States as children, and studies suggest that this order, known as Deferred Action for Childhood Arrivals (DACA), markedly improved measures of mental health among its beneficiaries and their families. The pending termination of DACA may reverse these mental health benefits for the 800,000 DACA beneficiaries, and trigger a public health crisis, according to an essay in the New England Journal of Medicine, co-authored by Atheendar. S. Venkataramani, MD, PhD, an assistant professor of medical ethics and health policy at Perelman School of Medicine at the University of Pennsylvania.

“DACA was not a public health program by design,” Venkataramani said, “but numerous studies have shown that implementing it had positive effects on mental health that truly rival those from large-scale health policies.”

DACA is meant to cover undocumented immigrants who were born after June 15, 1981, were brought to the U.S. before turning 16, and have lived in the U.S. continuously since 2007. It provides legal access to work permits, which can be renewed every two years, and confers freedom from deportation. Eligible applicants must provide evidence of current school attendance, completion of high school or GED certification, or U.S. military service, and must not have serious criminal records.

Several recent studies, including one by Venkataramani and essay co-author Alexander Tsai, MD, PhD, an assistant professor of Psychiatry at Massachusetts General Hospital, have indicated that measures of psychological stress and mental illness among DACA-eligible immigrants fell dramatically after the policy began. Another study, which used data from the Emergency Medicaid program in Oregon, suggested that DACA’s mental health benefits may have extended even to the children of DACA-eligible mothers—among whom rates of adjustment and anxiety disorders fell by more than half after DACA started.

Given that DACA improved mental health for beneficiaries and their families, its termination is expected to have the opposite effect. That termination will occur in March 2018 if no DACA-preserving legislation is passed by Congress and signed into law by the President.

“Health care and public health professionals now have a limited window of opportunity to engage policymakers about protecting Dreamers through legislative action, with an emphasis on the potentially dire mental health consequences of failing to enact a definitive legal remedy,” Venkataramani said.

If such efforts fail and DACA does expire next year, the health care profession will face a serious challenge, he added. Many former DACA beneficiaries, in the absence of the law’s protections, will not only experience adverse effects on mental health and psychological well being, but will also be less likely—because of their status as deportable illegals—to seek help from health care professionals.

Venkataramani and Tsai argue that if DACA expires, health care and public health organizations will need to proactively reach out to undocumented immigrants, to reassure them of continued access to quality health care and to provide them with information about public mental health care resources.

“On a broader systems level, tracking health care utilization and health outcomes will help organizations monitor health at the population level and provide hard data to policymakers seeking to implement other supportive remedies,” they note.

County to Review Options for Mandating Mental Health Treatment

April 6, 2017 by · Leave a Comment 

The Board of Supervisors voted Tuesday to review its options for helping mentally ill homeless individuals who refuse treatment, including the potential for legislative changes.

Supervisor Kathryn Barger said it was time to consider changes, as the county prepares to spend hundreds of millions of dollars to counter homelessness. She estimated that about 30 percent of individuals living on the street suffer from some kind of mental illness.

“There needs to be a higher standard of mental healthcare,” Barger said in her motion. “With a short 10-year window to address homelessness using Measure H funds, the county must review and revisit the application of California’s Lanterman-Petris-Short Act to ensure that we have requisite authority to provide care for those who are suffering from mental illness and are unwilling and/or incapable of accepting care.”

The 1972 Lanterman-Petris-Short Act was designed to safeguard rights of the mentally ill and end the indefinite, involuntary commitment of those suffering from mental illness.

Barger said the law limits options to help the homeless, both because the standards to commit someone to treatment are difficult to meet and because the typical time limit for mandated treatment is 72 hours. As a result, some mentally ill homeless end up “hospitalized in our jails,” she said.

Department of Mental Health Director Dr. Jonathan Sherin agreed that too many of the resources for the mentally ill exist in jails and other “punitive environments … not designed for people to flourish.”

However, Supervisor Sheila Kuehl raised civil rights concerns and skepticism about efforts to “help” those who don’t want it.

“Let us be honest about how we draw the line,” Kuehl told her colleagues.

She warned that the county could end up taking on the responsibility for defining who is severely impaired, a decision typically left to the courts.

When Kuehl asked Sherin how he would approach the review, he told her, “We need to exhaust all options that are available to us currently,” but added that he was interested in “new care models.”

Sherin said the reassessment would include a fresh look at Laura’s Law, a state law that allows courts to mandate outpatient treatment for severely mentally ill individuals.

Carolyn Kelly, chair of the county’s mental health commission, echoed Kuehl’s interest in allowing mentally ill individuals to maintain their autonomy.

“Nothing about us without us … is something we want to very much honor,” Kelly said.

Kelly asked that the District Attorney’s Office be looped into the conversation as soon as possible, telling the board that enforcement and application of regulations is more important than the language of any law.

Just how many people would be affected by changes in the law or its application was another subject of debate.

The nonprofit organization Step Up on Second houses hundreds of people with serious and persistent mental illness who have been without a home of their own for decades, said Step Up CEO Tod Lipka. He told the board that “just 2-3 percent” need a new approach, while Barger said a “significant segment” of the chronically homeless population would benefit.

A report back is expected in 45 days.


Military Care for Mental Health Ailments Needs Improvement, L.A. Study Finds

February 18, 2016 by · Leave a Comment 

Care provided by the U.S. military health system to service members with post-traumatic stress disorder or depression is good in some areas, but lacks in other realms, a study released Thursday by a Santa Monica- based think tank said.

In particular, the military health system performs well in following up with patients after they are discharged from a mental health hospitalization, according to Rand.

The period after a patient is discharged can be a vulnerable time, making follow-up visits critically important for these patients.

The Rand survey also found that the vast majority of patients with a diagnosis of PTSD or depression received at least one psychotherapy visit.

This suggests that military patients who receive such a diagnosis have access to at least some mental health care.

“Regardless of where they serve, where they live or who they are, all members of the U.S. armed forces should receive high-quality mental health care,” said Rand psychologist Kimberly A. Hepner, lead author of the study.

“Developing transparent assessments of care that can be routinely reviewed both internally and externally are essential to ensuring excellent care for all service members and their families.”

The study found that there was need for improvement in some areas of PTSD and depression care.

Although most patients received at least one psychotherapy visit, the number and timing of subsequent visits may be inadequate to deliver evidence-based psychotherapy, Hepner said.

The survey reviewed administrative data and medical records of more than 14,500 active-duty service members diagnosed with PTSD and about 30,500 diagnosed with depression from January to June 2012. The review examined whether those service members were receiving evidence-based care in the year after diagnosis.

Mental Health Awareness Coming to Montebello Schools

May 18, 2015 by · 1 Comment 

Social workers at all four high schools in the Montebello Unified School District will conduct interactive activities next week to teach students techniques aimed at releasing tension, coping with stress and providing information about the various peer-support groups on campus.

The programs have been scheduled to coincide with Mental Health Awareness Month.

Christine Mariano, a social worker at Vail Continuation High School in Montebello, says the district wants to reduce the negative stigma tied to accessing mental health services.

“Mental health comes in all shapes and forms” and not everyone readily recognizes the signs, Mariano said Tuesday.

Students often believe they only need to speak to a social worker or counselor if they are “crazy,” Mariano explained, adding she’s seen it all.

Vail High School student Jorge Leal speaks about his day with on-site social worker Christine Mariano.  (EGP photo by Nancy Martinez)

Vail High School student Jorge Leal speaks about his day with on-site social worker Christine Mariano. (EGP photo by Nancy Martinez)

“Yes there’s schizophrenia, yes there’s bipolar or suicide,” but these illnesses start with other feelings before that, she said. That’s “why we’re here,” to be proactive, she said.

The National Institution of Mental Health reports that about 8 percent of teens ages 13 to 18 have an anxiety disorder, however, only 18 percent of the teens received mental health care.

According to a report from the U.S. Surgeon General, “Early and effective mental health treatment can prevent a significant proportion of delinquent and violent youth from future violence and crime.”

“It also enables children and adolescents to succeed in school, to develop socially and to fully experience the developmental opportunities of childhood,” the report states.

Many students experience low self-esteem, depression, aggression or anxiety, but don’t understand how those feelings relate to mental health, says Mariano, who has also helped students deal with the loss of a loved one.

These problems are especially prevalent at Vail High, a continuation school whose 400 or so students were referred by their home school because they were at-risk of not graduating on time.

“We want them not to be ashamed… everyone deals with anxiety,” said Mariano. For students, feelings of anxiety can be triggered by a romantic breakup, speaking in public, a traumatic experience, school workload, troubles at home or with social situations.

For 17-year old Jorge Leal, who learned earlier this year he would soon be a teen father, the support he has received from Mariano has helped him adjust to the big changes coming in his life. He told EGP he thought he was handling his emotions well, but soon realized the benefit of having someone to talk to about his situation.

“I like to deal with my problems on my own, but I know she is there if I need her,” Leal said about Mariano.

He admits he was at first confused when his guidance counselor recommended he speak to the school’s social worker, not having any idea what that meant or what would be involved.

“I thought it was psychological, with testing involved,” the teen said. “I wondered if they thought something was wrong” with me.

But that wasn’t the case, he said.

According to Leal, he’s never been in trouble for fighting at school, but he decided to join a peer-group focused on dealing with aggression as a way to help him prepare for his new role as a father.

“They taught me techniques I can apply to my life, ways to manage anger,” he explained.

It took time, but Leal says he eventually came to see the peer-group and Mariano as resources to help him deal with the anxiety and stress he would have otherwise tried to deal with on his own, but perhaps not as successfully.

According to Mariano, the school and her goal is to help students deal with their issues, large and small, “so they don’t resort to something negative,” like drugs, drinking, getting into fights, or hurting themselves, she said.

Next week, as part of MUSD’s focus on Mental Health Awareness Month, some district students will be given a stress ball and taught breathing and muscle relaxation techniques to help them cope with the stress in their lives.

Having an outlet to vent and taking the time to relieve tension allows students to acknowledge and address their emotions, according to Mariano.

“It’s okay to have feelings,” she explained. “We just want to teach them the skills to cope with them.”

Proposed Merger of County Health Services Decried

January 15, 2015 by · Leave a Comment 

A proposal to consolidate the county’s public health, mental health and health services departments drew fire from mental health advocates and others Tuesday.

Supervisor Michael Antonovich proposed the consolidation as a way to “enhance patient care and access” and “streamline bureaucratic processes.”

Dozens of mental health advocates argued that consolidating services would ultimately short-change mentally ill patients.

“Large health systems have not typically provided enough focus on mental health,’ said Brittney Weissman, executive director of the Los Angeles County Council of the National Alliance on Mental Illness.

When mental health services were previously grouped with general medical care, “mental health became a stepchild,” she said.

Many who said they live with mental illness praised the Department of Mental Health for helping them dramatically change their lives.

Some opposed the plan outright, while others urged the board to get feedback from stakeholders, invoking the slogan “Nothing about us without us.”

“We all agree about having stakeholders in the process,” Antonovich said.

Dr. Jonathan Fielding, who headed the Department of Public Health for 16 years, warned that if his old department became a division of the Department of Health Services, it would “jeopardize the health of Angelenos” as “public health has a fundamentally different mission than DHS.”

Still, Fielding said it was “well worth considering” an umbrella agency over all three departments to promote coordination and collaboration.

The Department of Public Health is responsible for managing outbreaks of communicable diseases; runs programs to promote health goals such as childhood vaccination; and inspects restaurants and nursing homes. It is designed to serve all 10 million county residents, Fielding told the board, rather than the roughly 10 percent of residents that make use of county clinics and hospitals run by DHS.

The union representing county healthcare workers signaled its potential support, calling consolidation a “bold idea.”

“Done right,” the change could cut through bureaucratic red tape and improve patient care, said Bob Schoonover, president of Service Employees International Union Local 721.

Supervisors Hilda Solis, Mark Ridley-Thomas and Sheila Kuehl each expressed support for breaking down walls between departments.

Schoonover voiced his confidence in Dr. Mitchell Katz, who runs DHS and could be chosen to lead an umbrella agency. No permanent replacement has yet been hired for Fielding, who retired last year.

Dr. Marvin Southard, who has run the Department of Mental Health since 1998, said he would work to make sure that Los Angeles County remained a “national leader in providing for hope, wellness and recovery” in whatever organizational structure the board put in place.

Katz told the board he envisioned “three independent departments working together,” each with its own budget. He said no jobs should be lost as a result of the new structure.

In an interview with City News Service, Katz offered more details.

The three departments would work “as equals … each helping each other to do a better job,” Katz said.

Staffers would be more likely to collaborate to solve problems if they were part of a single agency with a common set of priorities, he said.

“We don’t have to shake everything up,” said the DHS director, but he pointed to substance abuse as a problem that typically requires attention from all three departments.

One  ”compelling” statistic, Katz said, is that those suffering from serious mental illness have a life expectancy roughly 20 years shorter than non-sufferers. This is true even though they typically die not from suicide, but medical causes, he said.

Supervisor Don Knabe stressed that the proposal amounted to a “look-see,” saying he had fielded many calls about the issue by telling constituents to “take a deep breath.”

The board directed a working group to report back in 60 days with a potential structure for consolidation, a timeline for implementation and drawbacks to integration. The group was asked to gather input from various stakeholders.

At Ridley-Thomas’ urging, the group will consider merging the Sheriff’s Department’s medical services bureau, as well.

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