As Cascadia changes, mental health risks are feared

from The Oregonian, June 25 2008

Some 900 clients are getting new care providers because of Cascadia Behavioral Healthcare’s financial meltdown, a difficult process

Multnomah County’s plan to move more than 900 mental health care users from financially troubled Cascadia Behavioral Healthcare to new providers carries serious medical risks.

Oregon’s biggest mental health provider, Cascadia is financially overextended, losing about $400,000 a month and risking bankruptcy unless it can cut staff and increase efficiency, county officials say. To stabilize Cascadia and ease problems if the nonprofit collapses, they say, they must move clients.

But changing clinics or counselors can damage people’s hard-won progress. Avoiding breaks in care is vital for people with schizophrenia, multiple psychiatric diagnoses or poorly controlled depression. It often takes years to find the right medicines, counselors and routines that can help them live and thrive independently.

“Folks who have conditions like this adapt very poorly to changes in the system of care,” said Dr. George Keepers, chairman of the Psychiatry Department at Oregon Health & Science University. “This stuff is not good for people.”

At any time, Cascadia helps 6,000 Multnomah County residents deal with issues from addiction recovery to psychotic crises. Many should move to a new provider without a hiccup.

But for some, especially the most vulnerable, as little as a week without medication or a few missed appointments could spur a big setback — in the worst case, a psychotic episode. That could mean more hospitalizations, more people slipping into homelessness and other problems rippling out into the community.

“If that goes badly, and it often does, people can free-fall in terms of level of functioning,” said Derald Walker, the clinical psychologist who took over Cascadia in April.

Mental illness is so complex and individual it’s hard to pinpoint who might have setbacks, Walker said. But he recalled a Clark County woman whose case showed the dangers of off-and-on medical care.

Walker met the woman when, as a college freshman, she withdrew from friends, grew emotionally explosive and began hearing voices. He diagnosed her first schizophrenic break and had her hospitalized involuntarily. Tranquilizers and antipsychotic pills helped the young woman improve enough to move home. But she didn’t understand she was ill, didn’t like the drug side effects and didn’t want to live with her parents again. She secretly quit taking her medication and started sneaking out at night. This led to a cycle of hospitalizations, homecomings and returns to the street, which slowly made the woman sicker.

“She was pretty much always psychotic” after five years, Walker said. “She got pregnant by a transient and started doing street drugs. The last time I heard of her, I think she got HIV. It was in the ’80s. She could very well be dead by now.”

It’s not unusual for uncontrolled mental health problems to spill into homelessness, addiction, poverty or other physical health problems — all risks of a health care interruption. Because of such concerns, Keepers said, “the average life span of somebody with a serious mental illness is dramatically shorter than someone in the general population.” In some cases, patients’ only access to health services is through their mental health providers.

Even if care isn’t interrupted, getting a new provider can pose problems.

“Once you’ve established that you’ll be a caregiver to somebody who has some dependency on you, if you break that trust, it’s the worst thing that can happen,” said Patricia Backlar, a Portland State University bioethicist who is on the county’s Adult Mental Health and Substance Abuse Advisory Council.

Backlar, who wrote “The Family Face of Schizophrenia” and has a son with the illness, said society has an obligation to help “people who on occasion can’t necessarily care for themselves,” and see that care through. With severe mental illness, she said, “to thrive, you really do need some continuity of caregiving.”

If detailed medical notes don’t move with the patient, for instance, a new caregiver may try therapies or drugs that already have failed.

And changes force patients to find the time, trust and emotional strength to start a tough process again.

“It’s hard to tell your story and have people set up a plan, say, ‘We’re going to do this,’ and then three months later start over again,” said D-Borah Forrest, who gets care for anxiety, insomnia and post-traumatic stress disorder at Cascadia. “I figure, why bother? It just becomes too overwhelming.”

Forrest’s counselor took another job last week. But she feels lucky: The county’s plan lets Cascadia keep the Southeast Portland clinic where Forrest goes, and one of her group-class leaders will take over as her counselor.

But she worries about other Cascadia users, especially in areas where another company is taking over.

“It’s hard for a lot of us to change where we have to be and when we have to be there,” she said. “If we don’t have that structure, the disease gets worse. . . . We start kind of wandering.”

Health providers and county officials say they are working to give a clear road map to every person changing providers so they don’t get lost in transition.

Cascadia clients will get letters detailing changes in their care, Walker said. Staff are working to schedule prompt appointments for people switching counselors and to transfer records, including medication notes. Walker and county officials are urging new providers to hire Cascadia employees for the same jobs, though no one can force that.

The timeline adds urgency: With Cascadia losing money every week, the county and the nonprofit want to make the changes as soon as possible.

“It’s a big chore that they have on their hands,” said OHSU’s Keepers, who is not involved in the process. “Especially since Cascadia is such a big mental health provider. There are a lot of people at risk.”