Fact, Not Politics, Should Guide Mental Health Policy

For almost a year, the Ventura County Board of Supervisors and various stakeholder groups have debated the desirability of shifting the Behavioral Health Department from the Health Services Agency to the Human Services Agency.

The former is responsible for running the Ventura County Medical Center and its array of outpatient programs and public health and prevention services. The latter is responsible for welfare, licensing facilities that provide care to the elderly, protection of children in foster care or in jeopardy of abuse, and conversion of welfare recipients to workers.

In April 1998, the supervisors voted 3-2 to create a superagency by merging Behavioral Health with Human Services. Recently, however, the Federal Health Care Financing Agency ruled that this would contravene federal regulations requiring medical oversight of mental health services and could result in the loss of millions of dollars of federal reimbursements through Medicare and Medi-Cal. The Board of Supervisors quickly reversed its decision.

Even so, the debate rages on: Should mental health and substance abuse services be led by a medical or social service administration? The answer to this question and the decision of the supervisors should be informed by the available facts.

First, medical services that are traditionally supervised by the hospital and health agency have always included interdisciplinary teamwork. From the operating room and emergency room, to the decisions about when a patient is to be discharged and where that patient should recuperate, to home visits made by physicians, nurses and social workers, teams of health professionals work effectively to provide the best possible services for their patients. These teams are led by physicians because the disorders that necessitate the teamwork are, at their basis, biomedical disorders, albeit influenced by psychological and social factors.

Diseases of the brain--that is, mental and substance abuse disorders--are just as biological as heart, kidney and endocrine diseases with personal and social factors influencing their course and outcome. If the teamwork that is needed to produce favorable outcomes for open-heart surgery or AIDS is the responsibility of medical care systems, then why should it be any different for brain diseases such as schizophrenia or depression?

Second, psychiatric and substance abuse and addictive disorders have only in the past decade been understood by the scientific community as true diseases of the brain. Societies have long viewed these problems as signs of “moral weakness or degeneracy,” consigning individuals who are addicted, psychotic, depressed, compulsive or manic to alms houses, jails, prisons and even to the stake, at which “witches” were condemned to burn and die.

With the advent of new technologies for imaging the living brain, medications designed to specifically influence neurotransmitter systems (the chemical messengers that transmit signals among the more than 10 trillion neurons in the brain), reliable diagnostic techniques and methods for cracking the genetic code that determines a person’s susceptibility to a brain disease, practitioners can now rely on biomedical breakthroughs to assist them in prevention, treatment and rehabilitation.

The 21st century promises to open up the last frontier of brain research to discoveries that will directly lead to new biomedical treatments. Deep inside the brain, the caudate nucleus, which is responsible for spontaneity in our movements, has been shown to be hyperactive in obsessive-compulsive disorder. By normalizing the activity of the caudate nucleus with medications or behavior therapy, researchers at UCLA and other medical centers have shown that persons with obsessive-compulsive disorder can now recover.

Prevention of the dreaded schizophrenia is fast becoming a reality when the earliest signs of the disease are recognized and treatment is begun immediately.

Moreover, the different genes that increase the vulnerability to schizophrenia, depression and manic depression will be identified during the next decade as the Human Genome Project completes a map of the hundreds of thousands of variants in our genetic endowment. Being able to identify who is vulnerable to a mental disorder will permit doctors to begin prevention early in childhood, before the first symptoms arise.

The biology of addiction is being unraveled by identifying a pathway in the brain that originates from cells in the brain stem that produce the neurotransmitter dopamine to a nucleus tucked under the brain to the prefrontal cortex. This brain pathway regulates our natural drives, such as the desires for food, drink and sex. Drugs of abuse produce long-lasting changes in these brain areas, leading to craving and a high risk of relapse. The fact that drugs of abuse potently influence gene expression, turning genes on and off, underscores the importance of developing medications that counteract or prevent these alterations. Indeed, this is a major strategy of medication development currently underway.

These are but a few examples of the progress being made by neuroscientists and medicine in the fight against mental illness. But there already are a host of effective treatments available that permit psychiatrists and other members of the treatment team to achieve even better results than physicians who treat diabetes, heart disease and cancer. Why aren’t these effective treatments being fully utilized in Ventura County?

The models for delivering behavioral services are in clear view, as Los Angeles County has amply demonstrated in its implementation of integrated service agencies that provide the full spectrum of effective services--from residential supervision to the latest drug therapies.

If mental care in Ventura County is organized and delivered in ways that do justice to the various phases of mental illnesses--acute, stabilizing, stable, recovery--significant improvements in the quality of life of the mentally ill will be possible.

But first, policymaking decisions and initiatives at the level of the Board of Supervisors must follow the bio-behavioral facts of mental diseases.

However well-intentioned it is, ill-conceived and seemingly arbitrary decision making that combines dissimilar services and results in the loss of $15 million is medically unsound and antithetical to the well-being and interests of not only the seriously mentally ill but the taxpayer as well.