A mental health house call

Eight years ago, when I first began this journey to explore why our mental health system is so dysfunctional in America, I was impacted by the heart-wrenching story shared by Pete Earley, in his book, Crazy:  A Father’s Search Through America’s Mental Health Madness.    He described the  byzantine system he had to navigate to try to care for his over-age 18-year old son who struggled with schizophrenia.  Our American system defaults to requiring that our 18-year old sons or daughters be treated like an adult when it comes to pursuing care and treatment for a mental illness.  Over the years, through books, blogs and testimonies I’ve heard from NAMI parents, I’ve encountered countless similar stories describing how parents have been excluded from conversation about how to care for their mentally ill adult child and are relegated to watching hopelessly as their loved one disintegrates in front of their own eyes.  I have to imagine this is one of the worst nightmares a parent can experience.

So, yesterday, Dr. Alessandra Oretti asked if I would like to make a house call with herself and one of her colleagues.  She had been asked to provide an assessment of a situation that had very recently come to the attention of the Dipartimento di Salute Mentale (DSM).  Apparently, a family had approached the Barcola Community Mental Health Center the previous week as they were at wit’s end with respect to the symptoms displayed by their 18-year old daughter.  Initially, they had sought the assistance of a private psychiatrist, but after two months, he said she would be better served by the DSM.  As an example of the radical accessibility of the Trieste system, they showed up at Barcola last Friday without an appointment.   (Again, that is what is known as accoglienza.)  They and their daughter and were immediately able to talk with someone.  Everything was set into motion as a result.

A lovely drive along the coast to Sistiana

Last year, the DSM created a new service for the city – Supporto e Trattamento Intensivo Domiciliare (STID).  I was witnessing the power of this in action:  intensive home treatment service.  Giampiero Prelazzi, a psychiatric nurse who has worked over 30 years in Trieste, had paid the first visit to the family the previous day.

On Tuesday morning, we drove to the neighborhood of  Sistiana, north of Trieste, along the road that hugs the sea.  When we arrived, we were greeted by a happy dog and a mother who was delighted and relieved to welcome us.  I was introduced as a colleague from Los Angeles.

The young lady emerged from her room – let’s call her Serena – and I was immediately struck by her lassitude.  It seemed as if she could fall asleep standing up.  She greeted me, and as she has been learning English in school, we exchanged a greeting in English.  I noticed her hands were raw and chapped, and I had been told in advance that one of her symptoms was an obsessive desire to keep her hands clean. 

Alesassandra began a casual conversation with Serena and her mother.  We stayed for about 40 minutes.  Because of my inability to understand everything that was said, I found myself relying upon my reading the emotions in the room – similar to what I had resorted to the previous day with Giulia.   There were some phrases that I could pick up on.  I could tell that Serena sentire le voci (is hearing voices).  She was also sleeping a lot and even I could tell that perhaps the medication that had been prescribed was too strong.  Her mother brought out the Haldol prescription to show Alessandra. 

So many aspects of this encounter seemed radically different than anything that would be experienced in Los Angeles.  First, the family had actually driven to the community mental health center last Friday, in desperation, and were seen!  How many stories have I heard about caseworkers taking people in crisis to a local mental health clinic and being told that they have make an appointment for a week or two later!  You have to strike while the iron is hot!

Second, this new service that has been instituted by the DSM here in Trieste allows for a psychiatric nurse to do site visits as needed.  So, Giampiero, will return again tomorrow to see how things are going.  The goal is to avoid a crisis, an acute situation that will result in Serena ending up in a traumatic place, like the Ospedale Maggiore, for example.

Third, the family is clearly motivated to help the situation.  Alessandra recalibrated the medication to be delivered, to help perhaps reduce the lethargy.  The mother took note of that.  The family is included in the care plan.

Fourth, the private practice psychiatrist deferred to the state-funded system for the quality of care necessary for Serena.  Arguably, the state-funded system is where the talent and the resources for long-term sustainable care and recovery reside.

Finally, I am not a trained psychiatrist, but I have read quite a bit about the importance of early intervention to foster recovery and prevent  brain damage.  For those who believe an adult (over 18) has the constitutional right to refuse care, it is possible that because of the lack of care, this “civil freedom” is going to dispatch the young person down a road of irreparable brain deterioration.  Instead, the Trieste system makes the package of care attractive and accessible.  The hope is that Serena, by arresting this onset of symptoms very early, can get onto a path toward recovery.  Yesterday I felt like I had the unique opportunity to view this very early intervention phase up close and personal.

The Central Hospital in Trieste, originally built in the early 1800’s.

After the home visit, we returned to the hospital, where, again, out of six beds, only one was occupied.  La mia amica, Giulia.  These community-based services are intended to avoid an admission to the psychiatric unit in the hospital.  It appears to be working.

Sono stanca (I am tired). Waiting for my #11 bus to head home at the end of the day.

13 thoughts on “A mental health house call”

  1. Kerry, when and where it makes sense on the journey can shed more light on the issue of “stigma” in Italy vs the US. Mental health can carry such a burdesome stigma in the US, and especially within a number of U.S. subcultures. How, if at all, does stigma manifest itself in Italy. Simarslty, how does Italy’s seemingly monolithic culture contribute to delivery system outcomes?

  2. How could a system that relies on universal health care and societal connectedness ever work in LA? Or work for the more than a small %? Wouldn’t exploring models closer to home be more valuable/practical?
    Though perhaps not as beautiful!

    1. Marcia, I had two years to explore a better way in the U.S. I could not find one. Our system in the US is so broken, it perhaps requires a BOLD IDEA to jump-start change. Incremental change will not lead us out of the hole we have dug. One idea we are playing with as we look at a potential pilot for a small area in LA County (to start) is to apply a budget that is based upon a per-capita expenditure. Scrap the medical model, Medicaid fee-for-service, and provide a budget that allows us to take care of the whole gamut of needs for people. This will require more time in the field working with people, a 24-7 commitment, psychiatrists being willing to leave their office (which is the norm in Trieste), partnering with the greater community around social recovery aims. Thank you for following. I value your comments.

  3. Kerry-

    Does the young woman recognize that she’s ill? Is that part of why it was so easy for her family to get her to the doctor?

    Anosognosia is the biggest hurdle for most people I know who struggle with psychotic illness. Can you share how that’s managed in Trieste in a future post?

    1. Kathy – you raise a good point, and I will look into how anosognosia is manifested in situations like this. One potential answer is that this system in Trieste, which has been in place for 40 years, has achieved a level of trust with the community. Witness how the private psychiatrist so quickly referred the family to the DSM. But I will look into this, and thank you for following!

      1. Thank you! Here, more than 50% of people with schizophrenia are thought to have anosognosia. I wonder if it’s similar everywhere. And if not, why not?

        Thanks for your research and for sharing it with us!

  4. The potential of home visits is being explored in Los Angeles too but on a limited basis, given the need. Knowing different elements that make up the web and then being able to assess what we do and don’t have here will be valuable.

    1. This is good to hear Caroline, and what this story also shows us is that there is a need to have a 24-7 accessible place for people to come to (by themselves, or by transport) to have access to consultation. I hope this is something we can demonstrate in the pilot.

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