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Richard Helppie
Hello, welcome to The Common Bridge. I'm your host, Richard Helppie. And today we've got a very critical and very important topic all about mental health and psychiatric services. We have a true expert here. Dr. Victor Hong is the medical director for the Psychiatric Emergency Services at Michigan Medicine. That, of course, is at the University of Michigan, one of the leading academic medical centers in the United States - in fact, the world - Dr. Hong, welcome to The Common Bridge.
Dr. Victor Hong
Thanks so much for having me.
Richard Helppie
I'm so glad that you're here. Mental health and psychiatric services have really been in the news a lot. This is a place that you've devoted your career. Our audience likes to know a little bit about our guests, so where were your early days and your academic preparation and maybe some of the positions you held?
Dr. Victor Hong
I bounced around. I grew up in Michigan, however, till I was about 11 years old, then moved out to Los Angeles. I spent most of my life in Los Angeles and the Bay Area, came back here for training, went back to California for a few years, and have finally landed back here and laying down some roots with my family.
Richard Helppie
Right. What exactly does your department Psychiatric Emergency Services do?
Dr. Victor Hong
I appreciate the question. It is a unique place in Michigan, it is not unique in the entire US - there are many, if not hundreds of psychiatric emergency services in our country - however, in our state, it's the only one. And the reason it's somewhat unique is that there are many, what people call, crisis centers in our country where people can be referred from emergency departments to be screened, evaluated for mental health crises. However, if you are a true dedicated psychiatric emergency department, people can come off the street, ambulances can bring people to our doors, law enforcement sometimes, or people can be referred by family and members who are concerned. And so it's sort of a true dedicated emergency department on its own. We happen to be next to our adult medical emergency department and we have a lot of float back and forth, but people can walk directly into our services. I'll tell you a few other things. So we see kids and adults - that's good - and that we can serve a larger population but it causes some problems to have the pediatric and adult populations together in one setting. And we see an acute population; about a third of our patients are admitted to an acute, locked inpatient psychiatric unit.
Richard Helppie
So they are at risk to themselves or to other people.
Dr. Victor Hong
Basically. There are a few different rules, reasons why people can be admitted to a psychiatric unit. Legally, there are four reasons. One is a risk of harm to themselves. Second, harm to others. Third, they are unable to care for themselves - provide shelter, food, etc. And fourth, which is a recent addition, they don't have enough insight into their mental health problems and because of that, we'll likely decompensate. So you kind of have to have one of those four to meet criteria.
Richard Helppie
I see. That's very, very interesting. You mentioned some of the other resources for mental health services. And I'm thinking of things for when there are counselors, there are facilities, there are ERs - I'm kind of getting the impression that the psychiatric emergency services kind of sits at the pinnacle of this, is that a fair representation?
Dr. Victor Hong
I wouldn't say a pinnacle, I would say it's at the center. We deal with all of the other entities that you're mentioning. So why do I say that? Well, we get referrals from counselors, we get referrals from schools, we get referrals from primary care doctors, the emergency department side, as I've mentioned before, law enforcement. And what happens after they enter our doors, and once we evaluate them, is then we have to then refer them out to other hospitals, into our own inpatient psychiatric units, to counselors, to what are called day programs, substance use facilities. So there are a lot of things in terms of inflow and outflow that places us at the center of the system. I've heard the term before assisted outpatient treatments. This was something that Judge Milton Mack talked about; I'm not sure I understand exactly what they do and how they operate. My impression, if memory serves me correctly, they were someplace between the hospital and the jail as a better way of treating people that are in distress. I won't go too far back, it would take too long to describe all of the details around AOTs, is what they're called. But basically, in short, it's court ordered treatment. So as a result of one of the four reasons for inpatient admission as I described before, a judge may decide that even after the patient is released from a hospital, they are so ill that they need court ordered treatment. A lot of the time that is because it has been tried - treatment has been tried, not court ordered - and the individual has either stopped their medication, not followed up with treatment recommendations, and has decompensated time and time again. So at a certain point - and sometimes it does take a few tries - a court will decide this person really needs court ordered treatment to maintain their mental health. That may include mandatory medications, it may include mandatory counseling, etc. And usually they're for 90 days at a time.
Richard Helppie
There has been a lot of discussion now about mental health. For a long time, it was kind of in the background, something not to be talked about and now we're looking at links to medical treatment and we're looking at social costs. What, in your experience, leaps out as the impacts either into the medical treatment, or into social costs that we need to do a better job of treating?
Dr. Victor Hong
The first thing I would say is, is when you say that it was in the shadows before, a lot of that, frankly, had to do with stigma, a lot of stigma against mental health, a lot of misunderstanding. And we as a nation, and as a world, are coming out of that a little bit. There's still a long way to go. There are still pockets where stigma leads to people not seeking care, but we're doing a lot better. In terms of the question about how does this impact medical treatments? How does this impact society as a whole? I would say a couple of things. More and more evidence comes out every year, every decade, about how, when people have a concurrent mental health issue, their prognosis for medical health or physical health goes way down. And that's for a lot of different reasons, which we don't have time to go into today. But it's very, very clear that if you don't have your mind, right, it's very difficult to keep your body right. In terms of societal impacts, I mean, they're almost too numerous to count. We, in our country, have a very high suicide rate unfortunately. Now, not every one of those individuals was in mental health treatment or actually needed mental health treatment, there are environmental interpersonal factors in why people take their own lives. But certainly when there are people who die by suicide, the ripple effects are just tremendous and just can't be discounted. The other thing I would say, and we could go on for hours about this in terms of societal impacts, is that again, when you have a system in which there are 50% of people who need mental health treatment or more who are not accessing care, you can just imagine what that leads to in terms of even just from a bottom line perspective; workdays lost, people are unable to be employed regularly, people not attending school, etc., and all of the repercussions of that.
Richard Helppie
As you're going through that I think about things we've learned from public service announcements; get your colonoscopy, here's the warning signs of a heart attack coming, how do you prevent stroke. It seems to me that we could use something similar because, correct me if I'm wrong, but the diagnosis of a mental illness in a clinical way seems to be not as precise as perhaps in a medical. How do I know if I'm just feeling blue that day versus I'm depressed? And I think about things like alcoholism, is that self-treatment of an underlying depression or is that the substance abuse that I'm dealing with? How do you think about gaining a diagnosis and maybe letting people know, hey, it's okay if you've got these symptoms to come on in because you're not going to be stigmatized.
Dr. Victor Hong
Really good questions. I think, first of all, in terms of public service announcements, billboards, other types of advertisement, I think it's starting to happen and it's coming. I took a trip out west this summer and I saw multiple billboards saying, if you're feeling down, please call XYZ number. And sometimes, if I'm watching a YouTube video, an advertisement will come up. This is heartening to a mental health professional to see those kinds of so I think it's coming. I forgot the second part of your question.
Richard Helppie
Well, I was talking about the precision, how do you know? Like if you get chest pains or unexplained pain in your left arm, you might be having a heart attack; is there a similar like, if this is happening, you might need to see a professional.
Dr. Victor Hong
Fortunately, or unfortunately, there are no lab tests for mental illnesses, there is no x-ray or CAT scan that you can do to diagnose a mental illness. But, luckily, we have now reached the point where everyone is so educated about the presence of mental illness that, if somebody is struggling, if you have a family member or loved one who's struggling, there's help out there. And oftentimes, it really is by going to your primary care doctor, pediatrician for kids, maybe your internal medicine doctor if you're an adult, who should be able to do at least the screening necessary to determine, okay, this is what's going on. Either we start treatment here, or we refer to a specialist.
Richard Helppie
And that, of course, presupposes that we have enough resources, which I know, we don't at this time. We could get into that. But in your experience in dealing with patients and helping people right themselves, do you look at it more as cure or containment or is it some kind of combination?
Dr. Victor Hong
Very good question. I think it's both and I'm going to speak out of both sides of my mouth, because it depends on the situation. There are people who go through, for example, a very severe major depressive episode, which could even be life threatening, are treated, get back to their baseline, the way that they were before and never have another episode again. In that case, you could say, you could surmise that the treatment was a cure. For a lot of individuals, unfortunately, they deal with chronic mental illnesses. And it's not that we don't have the treatments, it's not that they don't get better, sometimes it's that they have recurrences of the illness over and over and over again. It could be depression, it could be bipolar disorder, it could be schizophrenia and unfortunately, thus far for those chronic mental illnesses, it is a little bit more of a chronic disease model, containment risk management model. It's we're just trying to reduce the amount of times they need to go to the hospital, reduce the amount of times they have a suicidal crisis, but they still may be struggling in between.
Richard Helppie
Dr. Hong, in mental health services are there issues and diagnoses that are more prevalent than others?
Dr. Victor Hong
Sure. So the bread and butter in this country that we deal with is anxiety and depression. For many decades - and whether it's because we're recognizing it more now, I'm not sure - but for many decades, depression really was the predominant diagnosis. Now, anxiety disorders have overtaken them. Maybe that says something about where we are as a society, and all of the numerous issues that we have to be worried about but those are the two most common. When you look at other diagnoses such as bipolar disorder or a psychotic illness like schizophrenia, substance use disorders, autism, attention deficit hyperactivity disorder, while these are quite prevalent, they're not as prevalent as depression/anxiety.
Richard Helppie
Have you noticed any difference pre-pandemic, during the pandemic, and post pandemic, in terms of the kinds of things that you're seeing?
Dr. Victor Hong
So there's one thing that jumps out at me when you ask that question - and this is not just a mental health answer - and that is certainly those who are struggling with mental illness have this more but I think we as a society have this more and it's just a general sense of being more agitated, irritable, lashing out more, whether violently or verbally. You see it in the news every day, where there are these increases in just people's sense of unrest, whether that was exposed by the pandemic, caused by the pandemic - it's going to be really hard to say definitively - but it is notable, and is something that we in the hospital even see and are trying to deal with. So for example, with our security leadership, they're dealing with tremendous increases in both patient, and family member of patient, bad behavior. So it could be verbally abusing a nurse, it could be actually physically assaulting a staff member; far more than we saw before. So I think things have unfortunately reached somewhat of a fever pitch, and we're sort of all trying to catch up and figure out what to do about it.
Richard Helppie
Is there any difference in population segments? I've read, but I haven't been able to get my hands on anything that is really definitive; children out of school, how are they affected or is it too early to tell yet?
Dr. Victor Hong
I think it's too early to tell. I think that...so first of all, kids are very resilient, however, to assume that there's not going to be a widespread long term effect. For some kids two years outside of school away from their peers, where you get that social emotional learning, not just the academic learning. And by the way, some people - I mentioned ADHD, before - kids with ADHD really struggle having zoom classes and five minutes into class, they may be off thinking about something else and being very distracted. So I think both academically, but more importantly, socially, I think there will be impacts that we'll continue to have to research in years to come.
Richard Helppie
I know some school systems I'm involved with, and through other experiences, the kids were relieved to get back to school, and they didn't have the language skills to define how they were feeling because being kept out of school that was, well, that was just a natural thing. Nobody said, well, how do you feel about this? They were told and they've also coupled with that, as they go back in, they forgot how to behave. How do you file into an assembly? What's proper behavior in the classroom, etc? So I'm cheered that you think that the jury's still out on this and there's still more work to come. What should a family member do if they think a loved one is experiencing psychiatric symptoms, with or without risk of injury to themselves or others? What should they do?
Dr. Victor Hong
I'll answer that in two parts. If there is possibly an emergency issue, where somebody is in such a crisis that they do feel like there are safety concerns, if those concerns are imminent, like something's going to happen now, it still is a 911 call; it still is oftentimes involving law enforcement in evaluating the situation. And we can talk more about how ideally to do that as a society later but it's still a 911 call if there are urgent concerns. That's really where sometimes you do have to reach out to the primary care doctor and say, this is what's going on with my loved one, what advice do you have? And then if you have more time to kind of research the issue, try to convince your loved one to go in for care. Obviously, there are specific mental health clinics that you can approach and these exist all around the country.
Richard Helppie
This might be a good time to jump into the 911 call, in that in recent weeks, Detroit police shot and killed KiÃAzia Miller and Porter Burkes. Both times families did call the police department. And this is really interesting, I've looked into this. Officers that responded were trained in crisis intervention and the Detroit Police Chief reports that already this year, almost 20,000 calls for assistance in mental health are handled. So these are clearly two outliers, but with tragic consequences; the families were calling for help and they ended up with a loved one that's deceased. From your perspective, short of lethal force, which seems really inappropriate, is there something that could have been done differently?
Dr. Victor Hong
Certainly tragic consequences, but unfortunately, not uncommon. There have been a number of cases in which law enforcement have been involved in shootings of those undergoing a mental health crisis. And I think we have to be very careful and cautious in not pointing fingers at law enforcement because they are put in a very, very tricky situation. There are times that individuals in a mental health crisis truly are at risk for hurting themselves or others imminently, and they have to act in the way that they feel is necessary. That being said, there are models coming out that have shown to be effective, again, we need more evidence and research, but there are crisis intervention teams now being formed across the country. Luckily, we, here in our county, Washtenaw County, and Michigan, have such a crisis intervention team that's being developed. Florida has one. And so what this, generally speaking, involves is pairing law enforcement with a mental health professional crisis team of sorts, where they jointly assess and manage and evaluate these types of crisis situations so that the mental health professional can engage in verbal deescalation; sort of doing a little bit of a quick, on the spot diagnosis of what may be going on and then recommend what the next steps are, as opposed to just a law enforcement officer themselves trying to evaluate. And yes, they are trained but let's be honest, it's a limited training in terms of complete understanding of what's going on with that individual. By pairing these two entities - it is really thought, and there's a lot of evidence so far for this - that it can lead to a lot less incidents like this and violence.
Richard Helppie
Well, certainly police officers are trained that they can go to one level of violence higher, yes, than what they're faced with and if that's where your training is, and the person has a knife, a club, whatever, the next thing can be deadly force. It seems that there needs to be something else for subduing them. I can think of a long list of things that can be done. The thing that was interesting to me is that 20,000 calls for mental health assistance, and so by and large, most of them presumably, are being handled without incident or without violence, or getting people where they need to go. But it's got to be one hundred percent; nobody wants to lose a family member when they call for help.
Dr. Victor Hong
Absolutely. And the one other thing I will point out, which is important about this, is that too often the incidents in which violence does occur, or God forbid, somebody gets shot and killed, are people who are minorities, people of color. We see that over and over in terms of statistics. And it's not because the law enforcement officers themselves are racist - it's not a productive conversation to label them as that - it's more that there are systematic and structural biases that lead us to those discrepancies between who ends up getting shot and killed and who doesn't. And I think we have to be very open and honest about those biases and try to dismantle them as much as we can.
Richard Helppie
I'm wondering if you think we need to change the way that we train psychiatry residents, but perhaps more in the communities where they're needed most. If I'm not mistaken, most of the psychiatry training occurs in hospitals or academic medical centers, but maybe if the training was done in the neighborhoods, in the places that violence occurs more frequently, we'd have a closer match between what the medical community can do and the local police departments, with that population.
Dr. Victor Hong
It's not a bad thought. I think geographically it kind of depends where you're training. Is there an urban center or neighborhoods that you can go into? Fortunately, here at the University of Michigan, there is a training ground for that where the community mental health center is located in Ypsilanti. However, some geographical locations don't have that capability. I think it would be nice that people have a diverse array of experiences and are dealing with individuals who may have severe and persistent mental illnesses who may be from under-served communities. I totally agree.
Richard Helppie
The law enforcement part of that is the jail system and it we've had Sheriff Clayton on, we've had Judge Mack on, and we talk about how often the jail becomes the de facto mental health facility. And I can't imagine you driving to work and thinking that's a great situation. How did we get into this and is there a way out?
Dr. Victor Hong
Huge issue. It's something that we see here in our community. It's something that we're seeing across the country where, in some settings, the majority of those who are being treated for severe mental illnesses are actually incarcerated, believe it or not. How did we get there? I mean, there are a lot of things I could point to. There is one that comes to mind. There was an effort to de-institutionalize America and this was a very noble effort started by JFK in the 60s. It was basically an effort to remove people with chronic severe mental illnesses from these large institutions where they housed hundreds or even thousands of patients, often in dilapidated conditions, because that was no place for them to live, either. The promise of that, unfortunately, has not come to fruition and that is for a lot of different reasons. What was supposed to happen is that we would take people out of these large institutions, but bolster our community mental health systems to the level that we could engage them in a lot of wrap-around care so they didn't need to be in the hospital. Our community mental health systems are not well resourced enough at the current time, which brings us to perhaps legislative changes that need to be made. But there's just not enough of a budget to do what that Community Mental Health Act in the 60s was proposed to do. What we are left with then is a lot of individuals who traditionally would have been in those large institutions who are now on the street, who are possibly engaged in criminal behavior and end up incarcerated. So just one layer, but it is a huge problem.
Richard Helppie
When I think about that timetable, there was President Kennedy some 60 years ago, saying, we're going to move people out of these dilapidated facilities - makes all the sense in the world - let's have community centers. Of course, if somebody has anxiety or depression, instead, if you go away for three months and then come back and try to restart your life - stay in school, stay at your job, stay with your family, but get treated - it just makes a lot more sense. But it seems like we forgot to do that. And the dysfunctional political system that we have has difficulty getting after those core issues. Frankly, I think some of the anxiety comes from that and then it comes from the news media, trying to keep people excited all the time. We'd have more calm conversation about the benefits of investment in mental health facility, we're going to see it in less incarceration, less violent acts, less people in distress; seems like a great thing to spend tax money on.
Dr. Victor Hong
It seems like a no brainer. It seems like a bipartisan issue. Unfortunately, we just haven't gotten there. There is a lot of, as we know, infighting that occurs anytime a bill is proposed. There have been some victories, but a lot more needs to happen in terms of how to restructure both our federal, state and local mental health systems, because - this is a cliche - but everyone says and continues to say we have a broken mental health system.
Richard Helppie
Under resourced and aimed in the wrong places and our de facto is that the jail has become that mental health facility. In fact, Judge Mack talked about a person that did not want to leave jail because he was getting treated in the jail. In recent days, going into the criminal side of this, we've had yet more mass shootings; diversity of locations, a diversity of victims, a diversity of perpetrators. When you look at this from your professional lens, do you see common denominators in these mass shooting events?
Dr. Victor Hong
That is probably a series of ten podcast episodes by itself. It goes into a lot of issues that actually have little to do with mental health and it has more to do with societal factors. That being said, one of the side effects of having more and more mass shootings is that we're able to study them more. We have learned some things about these perpetrators. I will just point out a couple of things, which is that, by and large - there are exceptions - but by and large, there are some signs before the shooting that this individual is struggling: whether it's with mental health issues, whether it's with anger issues, whether it's with a fascination for weapons, et cetera, et cetera. And the second thing that usually happens is in the days, weeks, months prior to the shooting there is usually what is called some leakage of information from that individual that advertises to the public or to people in their lives that something is going on here and somebody needs to intervene in some way. Not 100% of the time; there are cases in which there don't appear to be either of those things, warning signs or leakage, but by and large, in most cases, there are one or both of those things. And those may be targets for intervention before the shooting occurs.
Richard Helppie
One of the things that I've advocated, written about, is the use of firearms and separating the person that shouldn't have them from the deadly weapon storage requirements and such. Part of this, I call it graduated licensing; that just like anything else, you get a small privilege or right to use something, prove that you're safe with it and move to the next level. I've written on this and people can look that up. But here's one question I have from a lay perspective; if to go to a higher level of weapon - more deadly weapon - that there needed to be a psychiatric review, would a screening be able to detect somebody that wasn't stable, given that, as you said earlier, there are no lab tests for this? You can't run an x-ray and say, oh, that's not working right. Would it be helpful?
Dr. Victor Hong
That's a very interesting question. I'm going to go a little back into my history to answer that. So I grew up in western Michigan. Michigan has one of the highest rates of gun ownership in our country. I shot a gun when I was seven years old, my neighbor's 22 rifle, just for fun, the bad guy. So I think the first thing I will say is, it's very important when we enter in discussion about firearms to not approach it from one or another corner or camp because whenever the left approaches somebody from the right about firearms, it has an immediate and sort of aggressive response about no, you're going to take away my guns, and unless you approach it from a standpoint of, we understand firearms are an important part of your culture. Some people grew up with law enforcement backgrounds, some people grew up in a hunting family. Until we understand some people have firearms for protection, legitimately. Until we can approach people from a more balanced perspective, I don't see the conversation moving forward and progressing. I just think there's no way to do that. Because again, we're coming from the two opposite corners and trying to find a solution from those corners, I think we have to meet in the middle. So in terms of being able to screen somebody for dangerousness, I would answer that in a cautious way. There are ways to screen somebody for an acute, in the moment mental health issue, and say that person is very likely to perpetrate violence in the near future, relatively reliably. What is not very reliable - it's more of a coin flip - is to say, as a profile, this seems like an individual who sometime in their lifetime is going to perpetrate violence. There are things we can look at in terms of statistics but if you try to screen people just in terms of lifetime risk, you're going to have what's called a lot of false positives; you're going to be preventing a lot of people who might have been okay from getting a firearm. So it's a really tricky question to answer that.
Richard Helppie
Well, I like the way you framed it, that the right is never going to be able to convince or threaten or drag the person from the left all the way over here. And the person from the left is never going to be able to grab this person here. What I would say to my friends on the right would be this; our second amendment, which I think is central to our constitution, is real clear. It's the right after the freedom of speech. It's the well-regulated militia. Somebody walking into a nightclub, a grocery store, a school, that's not a well-regulated militia, and everybody's going to lose their firearms if you keep making that argument. And for those people on the left, the framers didn't say our greatest risk 200 years from now is that we're not going to be able to have to deal with a musket, as it was to keep government that might want to practice tyranny at bey. So how do we meet those two? This is why I propose this graduated licensing. The perpetrator in Chesapeake, Virginia, bought the gun within hours of his violent act that took five or six lives and that's just insane. We need to be able to slow it down, at least have people talk to...I asked people this question - and as you know, I'm not a psychiatric professional - I said, if I gave you a gun, would you shoot somebody with it? And universally it's a no, I would not. I I say, but why not? And they'd say, well, I don't have it in me. And by the way, without regard to where their political views were, that was the answer. And then they said, well, maybe if someone was attacking my spouse or my family or breaking into my house, then I might have to; reasonable things. We need to make sure that our society gets to that middle ground, that there is a place and a proper use for firearms, proper storage, proper training, but leaving them out there for anybody that has a violent impulse is insane. It's not going to get any better if we don't deal with it. I don't think we want to end up [like] Australia. I had a gentleman on our show who was from Perth, and they disarmed the civilians. During the pandemic, there was military meeting you at the gates of your boat or plane, and there were barricades set up at state lines. So these are our very, very real trade offs. The only thing that occurs to me is that during the pandemic, nurses and doctors were just under such strain, they were suffering burnout. So when I think about what must be happening to mental health workers today, whether you're a counselor, or an ER nurse in your department, or a physician, how are the caregivers doing these days?
Dr. Victor Hong
I appreciate the question. It's something that's on all of our minds, and is central to the struggles that we're dealing with in hospital systems, and then outpatient centers as well. So, even pre-pandemic, we knew that doctors, nurses, therapists, counselors, all good teachers, all across the board, were struggling with their own mental health, have rising rates of suicide even. It's something that deserves and is receiving more attention and research. And I will say, unfortunately, the pandemic has pushed us over the edge in many ways. It's beyond the concept of burnout, people are leaving the field as a result of not wanting to deal with these stresses. Unfortunately, hospital systems are overtaxed and understaffed. So if you think about somebody who's struggling pre-pandemic and then you add on top of that additional responsibilities at work, how many people can survive through that? Not many, and so it's something that's going to need to receive a lot more attention - and I hate to say it - a lot more funding, ultimately, to deal with the issue. I do want to say one other thing about the firearm issue, which is that all of this being said - right versus left, and policies and things of that sort - the statistics are the statistics and math just doesn't lie, which is that if you have a firearm in the home, you are at more risk of suicide, and your children are at more risk for suicide. So that's why we certainly advocate for - if somebody is in a mental health crisis - to at the very least temporarily, remove the firearm - not saying forever, but temporarily - because when a lot of people say, well, I need that for protection, our response should be - as mental health professionals - well, the danger right now is actually from within your home, it's not from without your home. So that's just one thing I would say about that.
Richard Helppie
I would be at 100% agreement. And again, the fundamental concept is keep the deadly weapon away from the person that shouldn't have that, whether it is a crisis situation that might be resolved, or if it is something permanent, but there needs to be a screening process and a over a period of time demonstration that you can safely handle it, at least some screening and what do you plan on doing with this? And then most importantly, how do you plan on storing this? I know way too many people that have a revolver between their mattress and their box-spring and people that have a gun on their nightstand. I'm horrified because the chances of using that for home protection versus an accidental tragedy...the numbers just don't make any sense; two thirds of our gun deaths in the United States are suicides. And I don't know what studies have been done. Is it just a more efficient way? Would they still try suicide, just not be as successful if the firearm wasn't there? Would they not attempt to end their life?
Dr. Victor Hong
Well, so when we talk about firearms and suicide specifically, there's a reason why there's so much attention paid to firearms versus any other method of suicide. There are many methods of suicide out there. But the immediacy and the lethality the firearm method of suicide is far above and beyond any other. If you have a loaded weapon, you pull the trigger, 90-95% of the time that's going to end up in a death. There's no time now to reconsider. The fuse has been lit. There's no time to think - after you've taken an overdose of pills for example - actually, I now want to live, let me go to the hospital and get my stomach pumped or what have you. It's done. That's one of the reasons why firearms are such a focus for us.
Richard Helppie
Dr. Hong, this has really been educational. I really appreciate you coming out here and talking with me today and I know our listeners and our readers and our viewers are going to get a lot from this. We do try to clear the air and try to get some real knowledge in from your perspective. Are there any policies that we as a nation should be putting in place today or ones we need to stop doing?
Dr. Victor Hong
There's one that has come to my mind a lot and continues to come to my mind. And that is what's called mental health parity. There is a Mental Health Parity Act. Basically, what that law mandates is that insurance companies are mandated to cover mental health illnesses the same way they cover physical health illnesses. It's already been passed.
Richard Helppie
So what's the problem then?
Dr. Victor Hong
The problem then is that it's not being enforced adequately. So there have been very rare cases in which insurance companies have been forced to either financially pay consequences for not having mental health parity in their policies. But on an everyday basis, for example, in our emergency department, if somebody comes in with chest pain, and it's shown they're having a heart attack, they are admitted to the hospital, treated and released. It's not the same when somebody comes in, in a suicidal crisis, for example. What happens then is, it's sort of in reverse; before we're able to admit them to the hospital, we contact the insurance company for authorization or permission, financial permission. Are we allowed to admit this person? Fortunately, most of the time they say yes. But it's not uncommon for them to say actually, no, we don't agree that this person needs admission, even though you're the mental health professional. Where sometimes a clerical person is going down a checklist what happens then, sometimes the patient may get flooded with a bill with consequences from that financial stress. Sometimes, they only contract with certain hospitals so that if they are admitted, they could ship three hours away, and so on and so forth. So we really aren't in a position where we have true mental health parity laws with teeth strong enough to incentivize these companies - which often obviously are multi-billion dollar companies - to change their practices.
Richard Helppie
Well, you and I, again, would be in agreement that the health insurance system - well, it is not a system, it's health insurance methods - we have today makes no sense for today. Having the financial decision and the clinical decision in the same place can't lead to a good outcome. Dr. Hong, thank you so much for being here. This has been really interesting. Are there any closing thoughts you've got for our audience?
Dr. Victor Hong
I appreciate you having me on. This is obviously something I'm passionate about dealing with it every day, and we're fighting the good fight. And there are so many people, from nurses, social workers, psych techs, who are out there fighting the good fight. I just think that from a legislative perspective - federal, state, local - we need help. I think, hopefully, as the conversation progresses, as stigma continues to be reduced, hopefully we can get some small battles in our favor.
Richard Helppie
We can only hope. Thank you for being here and sharing this. Thank you. We've been talking today with Dr. Victor Hong of the University of Michigan, Michigan Medicine. He is the medical director of Psychiatric Emergency Services, talking about mental health and where we are as a society. This is your host Rich Helppie, signing off on The Common Bridge.
(Read, Watch or Listen) Mental Health Crisis in America