Mental Health

Dr. Pandurangi received the MBBS degree from JIPMER, Pondicherry, India in 1975 and an MD degree in Psychological Medicine from Bangalore University, India, in 1978. He completed two residencies in Psychiatry, one at NIMHANS, Bangalore, India, and the second at Upstate Medical Center, Syracuse, New York. He completed a 2-year fellowship in schizophrenia research in the Department of Psychiatry at Columbia University in New York in 1984 and is board certified in Psychiatry. He has garnered numerous awards among which are the Young Investigator Award in Schizophrenia Research, the Distinguished Academician Award from the Indo-American Psychiatrists Association, the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill, the Public Service Award from the Global Association of Physicians of Indian Origin, the Hippocampal Award for Residents in Psychiatry, and he is listed in “Best Doctors in America”. Dr. Pandurangi is a two term appointee to the Board of Behavioral Health by the Governor of Virginia and is a member of the teaching faculty of Howard University in Washington, DC. He is a Distinguished Fellow of the American Psychiatric Association, and a member of numerous other professional psychiatric societies, community organizations and mental health boards and advocacy groups. His interests and work are in understanding the relation between brain and behavior in serious mental illness and medications for psychiatric disorders and brain stimulation therapies. His work is also concerned with developing collaborations between public mental health and academic psychiatry. He is currently serving as chair of the State Board of Behavior Health and Developmental Services, and on the Governor’s Task Force on Improving Mental Health Services and Crisis Response. In light of recent events involving the tragic death of Senator Deeds’ son Austin Gus Deeds I wanted to focus our discussion today in particular on institutional responses in treatment of youth in situations of acute mental health crisis. The 2014 session of the Virginia Assembly adjourned on March 8th having passed some key elements of Senator Deeds’ Omnibus SB260 Mental Health Bill which increases the emergency custody order period from six to eight hours, creates a real time bed registry with once daily updates in order to aid clinicians in locating an appropriate bed for a patient, extends the temporary detention order to 72 hours and stipulates the provision at a state facility for a “bed of last resort” in the event that one cannot be found. It also mandated a four year study of the mental health system in Virginia which will conclude in 2018. Senator Deeds has expressed satisfaction with what was achieved thus far while acknowledging that obviously much more needs to be addressed in order to provide for youth in crisis. In a Washington Post March 11 article by Annys Shin the author notes that there are two proposals which yet await consideration by the assembly. One adds $1.5 million over two years to increase children’s crisis response services and child psychiatry. The other would set aside $7.5 million over two years to outpatient services for older teens and young adults. On December 10th, 2013, an executive order was established to recommend solutions for improving Virginia’s mental health crisis services. Welcome again, doctor.

Dr. Ananda Pandurangi: Well, thank you, Jan. That was a very generous introduction and an excellent background I think for our dialogue.

Jan Paynter: Doctor, in beginning our discussion together today, share with us if you would what you see are some of the most pressing needs in mental health services both for youth and adults and also specifically in what areas you anticipate the Governor’s task force will be placing greatest emphasis.

Dr. Ananda Pandurangi: I would suggest that providing some relatively quick outpatient counseling, outpatient professional connection help, outpatient care is a top priority both for children as well as for adults and I include…when I say children and adults I include that particularly vulnerable group which we call as the youth at risk, people between say 15, 16 years of age and about 23, 24 years of age, that eight or nine years is included in that and I would prioritize that. The second one, which has in fact received more attention recently, is the crisis response. So beyond one saying, ‘I need some help, I need some counseling or I may have depression or I have anxiety I need to see a doctor or a therapist,’ beyond that, what if there is actually a crisis as unfortunately there always is a crisis, there are crises all the time. What does one do during a crisis time? So that is the second biggest need I would say but luckily, fortunately or in a way unfortunately in that often these recognitions and responses come after an unfortunate event like the Virginia Tech incident or the more recent Creigh Deeds—Senator Creigh Deeds’ son incident, these things bring to the forefront how much we need. But there is more attention and in that regard we have now the crisis intervention teams which are actually the local police being trained in how to respond in a situation where behavior issues, emotional issues, psychiatric issues may be involved and what would be the right techniques for them to use, the crisis stabilization units or the CSUs that are being developed. So that remains a top priority, that remains an area of large need but one that has gotten some attention.

Jan Paynter: I see. I see. Doctor, what percentage of youths between 13 and 18 experience acute mental disorders in a given year would you say?

Dr. Ananda Pandurangi: So we could divide the mental health problems or disorders broadly into two types. One would be called as serious mental illness or SMI and the other would be called as common mental health disorders or common mental disorders or CMD. So the World Health Organization divides mental health disorders that way, SMI for the more serious illnesses like schizophrenia, bipolar disorder, severe depression and CMD are common mental disorders such as anxiety disorders, such as adjustment disorders, adjusting to stress for example. So these are two broad categories and the percentage—these are estimates—they comes from national studies, they come from local statewide studies, the percentages are something in the range of about 13 to 15 percent for CMD or common mental disorders and about four to five percent for the serious mental illness. So the total number adds up almost to 20 percent.

Jan Paynter: And how many of those in a year for instance get seen?

Dr. Ananda Pandurangi: That’s a very good question. So the numbers that I just mentioned are those we think are having a disorder. The next question is, how many of them are identified and diagnosed by a doctor or a therapist or a psychologist, etc., and how many of them seek treatment and ask for treatment and then how many of the people who seek treatment actually are able to get it. So you have a three or four layer issue here. One is identification or detection. If the community at large, if families, parents, teachers, students, consumers, clients, patients don’t know what mental illness is, what mental health disorders are, how do they manifest, how do they come out, what are the symptoms, then it is not very likely that we would actually identify them because we don’t know what we are looking for.

Jan Paynter: Oh, I see. Yes.

Dr. Ananda Pandurangi: So the first issue is a huge amount of public education, community education, leadership education as in say pastors, as in teachers, as in police and law enforcement agencies, as in community leaders, as in political leaders, as in legislators, academicians, professors, etc., etc., various community leadership and the population or citizenry at large need to be educated so that’s number one. Second is the diagnosis or the proper identification. For that you need a large workforce. You need people who are properly trained who can actually administer a survey or a questionnaire or do an interview or an evaluation and say, ‘Yes, I think you have ADHD.’

Jan Paynter: And you need funding.

Dr. Ananda Pandurangi: Right. And then—‘I think you don’t have ADHD. I think this is something else or I think this is depression,’ and so on or the more serious illnesses, this may be bipolar disorder or this may be schizophrenia or early psychosis so you need a well trained professional workforce to do that so that would be the second step. The third one is, okay, people know, have identified, have even possibly been diagnosed or been evaluated then can they get the—are they willing to seek the help. As you may know, there are many challenges, stigma being one of them.

Jan Paynter: Of course, yeah.

Dr. Ananda Pandurangi: That who would want to raise their hand and say, ‘I actually suffer from depression.’ It has lots of negative connotations; will I get employment, will I get insurance and so on, will I just be labeled by somebody, how will my fears be treated so you’ve got that. Then you get into the fourth one which we are struggling with. Okay, you crossed through these three challenges and you are seeking treatment and how many can get. So sum in substance is that approximately 50 percent of the people seek treatment, the other 50 percent are not seeking and we need to reach out to them. And of the 50 percent who seek treatment—and I’m kind of summarizing here, I’m giving you the broad strokes—is of the 50 percent who seek treatment, about half are able to get it. That means in one way of looking at it, almost 75 percent of people who should be getting treatment in an ideal situation are not and 25 percent are getting it.

Jan Paynter: Doctor, what are some of the greatest risks and outcomes for children with untreated mental illness? Obviously some people self medicate, drugs and alcohol play a role. What are some other things?

Dr. Ananda Pandurangi: Right. So again, excellent question. I could talk a lot about it because there are various what I would call as trajectories that people can follow. So there are one or two good trajectories and if there is a good support system, good role models, you are connected to a school system and so on, then a person who is undiagnosed may do okay because there are various protective factors holding that person back from actually manifesting the illness but that is probably a small group. Then there is the larger group and there are several trajectories. One is into substance abuse so one could start self treating. One finds out that you have some alcohol and somehow that particular day it makes you feel better and then you do it again and you do it again and before you know the person is abusing alcohol or a recreational drug and that becomes—we see this, problems occur or begin to manifest probably in childhood, around age eight, nine, 10 but during teenage years these various trajectories seem—being to break out so one is going the self medication abuse of drugs and alcohol route. Another unfortunate trajectory is problems with the law; violence, aggravation, fights, anti-social kinds of threats, ending up in jail or unfortunately sometimes prisons so that’s a second trajectory. The third one is becoming sick, not being able to take care of oneself, become alienated from one’s own family and become homeless, wander around the country. We see people traveling all the way from Boston in Massachusetts down to Florida and people traveling from Virginia all the way to California, back and forth, who actually have serious emotional disorders and serious mental health problems so that’s another trajectory. And these are not either or so one could be in more than one. And then there is the trajectory that we like which is actually accessing treatment, getting connected with a doctor or a therapist or a counselor, getting medication, getting psychotherapy, getting counseling and getting healthier that way, coping better and getting help. So there are multiple trajectories, unfortunately some of them have very bad outcomes.

Jan Paynter: I know that various organizations believe very much in mentoring for kids in need. That’s something that I think people can be trained to do and there are many good organizations. I’ll ask you at the end just to give us a list of a few that you feel are particularly effective in dealing with youth in crisis.

Dr. Ananda Pandurangi: Sure.

Jan Paynter: What changes do you foresee as a result of the Affordable Care Act and will more young people do you think gain access to mental care in the end as a result?

Dr. Ananda Pandurangi: Yeah. If we can do it right, I think if Medicaid is expanded. I’m told that between 350,000 and 400,000 people in Virginia would become eligible and that would be a substantial addition and substantial benefit to empower that many people to have some reliable health insurance that they can seek treatment or help from providers, private and public. So I think the—this would include children. Now the child programs have gotten some attention again over the recent years, rightly so, as they have been neglected for many, many years and if we could have more waivers, for example. These are—waivers are essentially instead of a standard, traditional service there is an alternative service, home health or counseling or mentoring or role modeling and the Big Brother, that type of thing, or services at school, services provided by families, so on. So these are various services that have unique benefits but are not reimbursable in the traditional models. So when one allows those services to be reimbursed it is called a waiver and so if we can have more waivers for a variety of services that the adolescents, the teenagers, the youth at risk need, that would help. The Affordable Care Act Medicaid expansion would help. There are other areas, for example, developmental disabilities, intellectual disabilities, as you may know there is a huge need for waivers.

Jan Paynter: Yes.

Dr. Ananda Pandurangi: So there are many areas I think but in terms of you look at the average child out there, I think their parents having some form of insurance, they becoming eligible for Medicaid and some waivers for the special needs would all go a long way.

Jan Paynter: I know one of the things that’s gotten complicated is many people wanted to keep their—with the Affordable Care Act—their preexisting plans and so as a result the unintended consequences that grandfathered plans however do not provide for the mental health coverage in many cases so that I would guess in itself is going to present quite a dilemma going forward.

Dr. Ananda Pandurangi: So I think we’ll end up having at least for some time to come two or three different classes here.

Jan Paynter: Exactly so.

Dr. Ananda Pandurangi: One which is hanging onto their old health insurance for good reasons obviously because we need it, they need it but which does not have what the federal government has defined as the essential benefits and then another group that’s gone into the newer programs which has the benefit and yes, mental health unfortunately has suffered from this discrimination from various third party payers that is not always included as a primary care or an essential care benefit and to the extent that many plans have been grandfathered for at least one year and sometimes I believe it is two years then they will be at a disadvantage. And so I hope that the administration at both the state level and the federal level will look at that and sort of reach out and offer an extra helping hand during this transition period. So you’re going to have the old health plan, under the old plan, you’re going to hold onto it for a year or maybe two but you don’t have the mental health benefit under that. And so maybe while that adjustment was made I wish they had also looked at what benefits would be lost and how those benefits could be provided to these policyholders or subscribers and I hope it will be looked at.

Jan Paynter: Well, in the—awhile back when Creigh Deeds did the 60 Minutes interview, one of the questions Scott Pelley asked him—asked a mother who was interviewed as well about her teenage son, he said, Pelley said, ‘Okay, so what is the difference between you as a mother of a mentally ill child and the mother of a child with cancer or other problems?’ And the response was very chilling. The mother just said, ‘Sympathy.’

Dr. Ananda Pandurangi: Yeah.

Jan Paynter: And certainly what you’re talking about—getting communities more involved, de-mystifying and also de-stigmatizing mental illness, it is to see it as any other disease that needs to be treated.

Dr. Ananda Pandurangi: Absolutely, especially in view of the advances on the science side in our field. We know that genetics plays a large role in many disorders. We know that there are various biological factors. We know that many—all adolescents by the very definition—ultimately work their way through the brain, various mechanisms of the brain, and so why discriminate against depression or anxiety or panic disorder and say in comparison to high blood pressure or seizure disorder or some physical disorder. There is no particular reason to discriminate other than our own ignorance.

Jan Paynter: And I think people are afraid too, I think afraid to look at it. Finally doctor, there are so many things I wanted to talk to you about today and our time is getting short but discuss if you would some of the most effective entities and organizations that we have not mentioned thus far which might help point parents and caregivers in the right direction. You mentioned the National Alliance for Mental Illness which has wonderful information. What are some others?

Dr. Ananda Pandurangi: Sure. NAMI is probably the biggest of them. There is the Mental Health Association of America, there is the Depression and Bipolar Depression Group or Network, there is in Virginia something called VOCAL, V-O-C-A-L. There is FACES, F-A-C-E-S, which is family and children. NAMI’s branches are called for example NAMI Virginia and NAMI Central Virginia and other groups I mentioned like VOCAL and FACES, the family network that we were talking about earlier, Children and Family Network. These—what I find is that they bring several different values to this field. They’re de-stigmatizing this, very much so. When a group of people meet together and they find out, ‘Oh, you have a son with depression, I have a daughter with this and I myself had that and your spouse had this type of a problem,’ this has a tremendous de-stigmatizing effect that we are not alone, we don’t need to hide this, we can feel free to share our pain and our anguish and our experiences with another person who looks very much like us, our neighbor, our coworker, so on. The advocacy and support organizations bring education, bring de-stigmatization, serve as a clearinghouse, obviously serve as a support group for fellowship and for sharing experiences and help in planning for as much of the uncertainty as is possible at this time.

Jan Paynter: Doctor, I want to thank you very much for taking this time to discuss this very vital and important topic with us today. I wish we had more time and I hope you’ll come back.

Dr. Ananda Pandurangi: Yeah, sure. Again, I thank you for this opportunity. I think it’s been really good. Yes, I agree there is so much to talk and so much to do but I’m glad we are doing this.

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