Saturday, November 10, 2007

Community Support Services: REHABILITATION OR BUST

Marsha V. Hammond, PhD: Clinical Licensed Psychologist, Asheville, NC
E mail: cell: 404 964 5338 fax: 828 253 2066

November 9, 2007

RE: rehabilitative model associated with Community Support (as per new guidelines receiving comment at this time); recommendation to remove psychotherapy from CSS

Dear NC Department of Health and Human Services Director, Mr. Benton (and associated ‘make a comment’ e mail address:

I read with interest the latest information about Community Support Services (CSS): (as per DHHS announcement): “An emphatic statement that Community Support is a rehabilitative treatment service and not a social support, recreational or mentoring program…. Last month, the department announced the first stage of the community service improvement plan – proposed new definitions for the services. Those changes, which are in a 45-day public comment period…”

I’m afraid I call this notion ‘rehabilitation or bust.’ I would like to propose that there are some problems w/ that thinking.

While the notion of ‘rehabilitation or bust’ may be issued at the federal level, which we trust less and less, the state of NC has a ‘choice’ (like consumers were supposed to have re: mental health treatment, but which has faded drastically with time) about treatment guidelines. Basically, I want to know what the state’s intention is in terms of mental health consumers who require interventions over a sustained period of time.

Research indicates that many DSM diagnoses require sustained intervention, though diminishing over time. There are two issues here, one which is current and one which is surely eminent. State funded consumers with target population diagnoses have had their psychotherapy included with CSS. It is my understanding that as of July, 2007, Basic Services was created which included psychiatric f/u, inclusive of medication f/u, and psychotherapy.

****I would like to support the notion of removing psychotherapy from CSS. It does not belong there. ****

Specifically, Smoky Mountain Center LME continues to include psychotherapy w/ CSS and my clients are not being availed of necessary services. The second point is this: if Medicare and Medicaid go the way of state funded services, the inclusion of psychotherapy within CSS will collapse the entire mental health apple cart.

I hope to make my points below about the following two matters:

(1) Psychotherapy is as necessary as medication in mental health recovery. It therefore needs to be included w/ psychiatric f/u for state funded consumers and NOT grouped w/ CSS which is being defunded, say what you will.

(2) For state consumers/ Medicaid or Medicare consumers (or privately insured consumers, for that matter) all targeted mental health illnesses are NOT the same in terms of the trajectory of their recovery. Therefore, applying a rigid template of ‘rehabilitation or bust’ is not appropriate for all mental health illnesses.

As a doctoral level psychologist, I find it very dismaying that all target population diagnoses (and those below are such) are treated in the same manner. Major depression is assumed to be as ‘curable’ and can be rehabilitated utilizing the same time-table as, say, PTSD; ditto Borderline Personality Disorder.

Prior to July 2007, CSS included therapy and emergency services for state funded consumers. My concerns are particularly acute as pertaining to state funded mental health consumers. They appear to be more ill in terms of physical and mental illnesses as they have no health insurance and they are availed of many fewer services until they at last become so ill that they qualify for social security disability and Medicare/ Medicaid-----when the remedying of the matter was BEFORE they became that ill.

As regards adult consumers, research by the American Psychiatric Association and the American Psychological Association and their associated peer-reviewed journals, indicate that mental health illnesses, like schizophrenia, schizoaffective disorder, major depression, dissociative identity disorder, substance dependency, head injury (Cognitive Disorder NOS) and personality disorders, to name most of what comes into the clinician’s office---ALL----require follow-up years into the future.

YES, unequivocably, people improve given appropriate and medically necessary treatment. Yes, as per research, target population disorders such as PTSD are more treatable and research as developed, for instance, by the VA System, has moved treatment along to the point we are now. However, many mental health challenges, either acquired or congenital, require sustained but diminishing follow-up. There appears to be no room for the research and therefore, I’m afraid, NC mental health reform will simply fail. The following is simply a quick overviewing of the matter as can be gathered by any interested party who knows how to use google and recover the research:

Item 1: Schizophrenia and Schizoaffective Disorder have a low recovery rate

The American Journal of Psychiatry notes the following as associated with recovery from schizophrenia and schizoaffective disorder in the following article ‘Symptomatic and Functional Recovery From a first Episode of Schizophrenia of Schizoaffective Disorder’ Am J Psychiatry 161:473-479, March 2004 © 2004 American Psychiatric Association:

“…after 5 years, 47.2% of the subjects achieved symptom remission, and 25.5% had adequate social functioning for 2 years or more. Only 13.7% of subjects met full recovery criteria for 2 years or longer….”

Item 2: Major Depression requires maintenance treatment Guideline Watch: Practice Guideline for the treatment of patients with Major Depressive Disorder, 2nd Edition Laura J. Fochtmann, M.D. Alan J. Gelenberg, M.D.

“…..Psychotherapy combined with pharmacotherapy
As noted in the guideline, studies examining combination treatment with psychotherapy and
pharmacotherapy have shown mixed results. Although this has continued to be true in subsequently published studies (66, 67, 72, 73), a recent meta-analysis suggested that a combination of psychotherapy and pharmacotherapy is more effective than pharmacotherapy alone (74). Combination therapy may be particularly useful in improving treatment adherence (73, 74) and might be of some use in targeting particular symptoms or patient subgroups (75–77). _ CONTINUATION AND MAINTENANCE TREATMENT
At the time the guideline was published, much data suggested the importance of continuation and maintenance treatment in individuals at high risk of recurrent depression, although the
majority of studies on this practice examined the use of tricyclic antidepressants. Several more
recent studies have confirmed the benefits of continuation and maintenance treatment with
antidepressants in other classes (e.g., sertraline, venlafaxine, and mirtazapine) in decreasing the
likelihood of recurrence (78–82). Supplementing the earlier data on continuation and maintenance psychotherapy, most (83–87) but not all (88) additional studies of CBT support its use either alone or in addition to pharmacotherapy in decreasing depressive recurrence...."

Item 3 The most common personality disorder, Borderline Personality Disorder, requires ‘extended psychotherapy’
American Psychiatric Association (2001): Practice Guideline For The Treatment of Patients with Borderline Personality Disorder : WORK GROUP ON BORDERLINE PERSONALITY DISORDER John M. Oldham, M.D., Chair
Glen O. Gabbard, M.D. Marcia K. Goin, M.D., Ph.D. John Gunderson, M.D. Paul Soloff, M.D.
David Spiegel, M.D. Michael Stone, M.D. Katharine A. Phillips, M.D.

“Borderline personality disorder is the most common personality disorder in clinical settings,
and it is present in cultures around the world…. most patients with borderline personality disorder will need extended psychotherapy to attain and maintain lasting improvement in their personality, interpersonal problems, and overall functioning

Item 4: With appropriate treatment, current PTSD treatments render good results; however, PTSD commonly has co-occuring DSM diagnoses e.g., depression

"....The majority of patients treated with psychotherapy for PTSD in randomized trials recover or improve, rendering these approaches some of the most effective psychosocial treatments devised to date…. Studying PTSD in an urban population, Breslau and colleagues (15) reported that 83% of individuals with PTSD met criteria for one or more other disorders…. psychotherapy for PTSD produces substantial effects… Across all treatments, 56% of all those who entered treatment, including those who did not complete the study (i.e., the intent-to-treat group), and 67% of the patients who completed treatment no longer met criteria for PTSD posttreatment (Table 5). ..."

In summary, my first point is this: I hope that my request that psychotherapy be removed from CSS and included consistently w/ Basic Services will provide it some protection from the defunding process occurring w/ CSS. It is as critical as psychiatric f/u.

Secondly, I also am advocating that as per quality peer-reviewed research, various target population mental health diagnoses merit more than just a 'one size fits all' treatment policy. 'Rehabilitation' is only a useful term if it adequately addresses the matter of the diverse natures of mental health diagnoses that fall into the target population.


Marsha V. Hammond, PhD

Cc: North Carolina Department of Health and Human Services Mark Van Sciver; NC Advocacy; Smoky Mountain Center LME, Bill Hambrick, Steven Puckett, PhD, Smoky Mountain Center; NAMI director


Blogger jay said...

I cannot agree more on the premise that CSS should only fix 'em up and ship 'em out in such rigid timeframes. I provide CSS in a rural area where alternate levels of care simply do not exist for consumers, especially children. I do have some "long term" cases which are making more progress with CSS than with all of their other previous attempted interventions, and they do have a long way to go still. I collaborate with many team members to make step down a reality, rather than a distant and lofty goal, and we inch toward that. Should I close the cases based on a rigid timeline, their lives would be in upheaval as many forms of mental illness, especially in children, do not follow a bus schedule of arrival and departure. With kids especially, the "higher level of care" is almost always going to be residential (there's no intensive in-home in Transylvania), which itself is a terribly destabilizing and inappropriate option for some (but most certainly not all) cases. The State again has incurred my wrath by making cuts to critical services like CSS that has already been drastically reduced, while increasing spending beyond the mental health savings margin (last calculated when CS rates were cut to be over 30 million) to rehab historic buildings in "tourist zones" and provide corporate welfare rather than find more creative and localized solutions to regional economic problems.

Phew, that was far more than I intended to write, but excellent work on your letter and I suppose it's time for mine to hopefully count in Raleigh (my consumers are writing letters, too, as they are mostly staunch advocates for meaningful and supportive MH reform).

8:27 AM  

Post a Comment

<< Home