Guide to the Mental Health Maze

by Stephen Ditmore

“Today I like to say I’m very pro-psychiatry but very anti-force. I don’t think force is effective as treatment, and I think using force is a terrible thing to do to another person with a terrible illness.” – Elyn Saks TED Talk, 2012

“No State shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any State deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws.” – The Fourteenth Amendment to the Constitution of the United States of America, ratified 1868.

You’re hanging precariously off the edge of the George Washington Bridge with one hand clinging to a cable and your smart phone in the other, searching the web for the number of the National Suicide Prevention Lifeline, 1-800-273-8255. The powers that be understand the problem. Distracted dangling being hazardous to your health, they’re working on an easy-to-remember 3 digit number you can dial instead.

That 3 digit number isn’t ready yet, but if you’re on or near the George Washington Bridge you’re in luck, because the Psychiatric Emergency Department I’m going to recommend is nearby. It’s in a big hospital with lots of other departments and programs, but what you want is the

New York Presbyterian / Columbia University Irving Medical Center

Comprehensive Psychiatric Emergency Program (CPEP)
622 W 168th Street
New York, NY 10032

Come to think of it, you’re better off skipping the bridge and going there directly.

That description may bear little relationship to your situation, or that of your loved one, and New York Presbyterian / Columbia is a journey from the East Bronx. But there is a CPEP nearby, on Pelham Parkway at Jacobi Medical Center. It’s on the west side of the complex, in Ambulatory Care, building 8 (not in the regular ER).

Jacobi Medical Center, run by the City of New York, may never be as prestigious as the top Manhattan hospitals, but it’s the real deal. The letters CPEP signify a dedicated psychiatric emergency program that will undertake to diagnose and treat a person from the time they are admitted, not warehouse them for days while they look for an inpatient program to accept the patient. They’re a trend inspired in part by California psychiatrist Dr. Scott Zeller.

Jacobi Medical Center also offers outpatient psychiatric services on the 4^th floor of building 4, where they have designated walk-in hours. These and other services are conveniently described at https://www.nychealthandhospitals.org/jacobi/our-services/behavioral-health/. While this reporter has not had direct experience with Jacobi Medical Center, they’re on the right track when it comes to mental health services, and may be in a position to benefit from recent City Council efforts to consolidate NYC Health + Hospitals, the NYC Department of Health & Mental Hygiene, and NYC Well / Thrive NYC (run by Vibrant, formerly the Mental Health Association of New York City). They also benefit from sharing a campus with Yeshiva University’s Albert Einstein College of Medicine.

New York City is launching something worth finding out about, especially if you don’t have health insurance or have a minimal plan with a high deductible. It’s called NYC Care, The Bronx is the first borough to get it, and they promise not to inquire about your immigration status. To find out more, call 646-NYC-CARE. Of course, if insurance is what you need, take a look at the NYS exchange at https://nystateofhealth.ny.gov/, and ask to speak with a “navigator”.

I’ve attempted to put some useful information at the start of this article. Keep reading, there’s more, but before going on I want to acknowledge that I’m writing in first and second person: you-and-me. You may not have a dramatic plan to end it all, but perhaps you’re depressed – feeling that life is dreary, dull or not worth living, or you’re feeling desperate or anxious – that the challenges of your life are overwhelming, that things are spiraling out of control. Perhaps you’re not getting out much, or when you do, everything you encounter looks like trouble; or maybe something traumatic has happened in your life, and you’re angry, or just confused. When you or I are having a mental health issue, it can look like the problem is everyone else. We see the world through the filter of our own minds. What makes me anxious, depressed, or confused is all there is – like water to the fish. If someone tells me I should get help, I say: why? What good will that do? That won't change the world around me, and what do you mean, I'm broken? Perhaps I’m not, and you’re not; sometimes we really are victims of events outside our control. It happens. If anxiety, depression, voices, suicidal thoughts, or other symptoms keep coming, or if a loved one's behavior or excessive, over-the-top reactions confuse, we may realize we need help – or at least, answers.

If that’s the case, talk to someone. Human contact is important, and whatever your next move, you should have a partner, a friend, a champion you trust by your side, friend or family. Ideally you’d be in contact with your own doctor, counselor or clergy you trust. Perhaps you’re reading this article because you ARE that champion, or have been, or may be called upon in the future. I’m here for you – not as a mental health professional but as a journalist who has been there, asks a lot of questions, and would like to share a few thoughts.

If you can get the help you need while staying out of the emergency room, stay out of the emergency room. Use the search function of your insurance, (even if it's Medicaid funded) or ask around your neighborhood concerning where the services you or your family need are available. For child & family services, a group called Rising Ground has a center at Williams Bridge Rd and Poplar St near the Montefiore Medical Park. Pelham Bay Family Counseling is located at 44 Westchester Square. For adult services try 2527 Glebe Ave, where the Montefiore Behavioral Health Center at Westchester Square adjoins the Westchester Square Branch Library. The Soundview Throggs Neck Community Mental Health Center may still have an office there, but they also have a mall location at 1967 Turnbull Ave. There’s the Parnes Clinic, 1165 Morris Park Ave, where Yeshiva University graduate students of psychology train as counselors. What appears to be a group in private practice, the IFH Center for Counseling, is in the medical building at 2590 Frisby Ave. The South Bronx Mental Health Council has an office at 1401 Glover St, across the street from a Montefiore Urgent Care Center. Vibrant Emotional Health operates a peer support center at 975 Kelly St, and a group called The Acacia Network has addiction recovery programs in The Bronx. If you or a loved one needs help, your point of first contact with New York’s mental health system may not be your last. Even the most qualified professionals don’t know everything. You’ll find some are better than others, or more knowledgeable of one category of mental health struggle than another, and things take time. The resources are there, but not the signposts.

The NYC Well website seeks to provide such signposts, and they have a phone number, 888-NYC-WELL. For the person who wants direct access to resources, though, the most useful tool is not on their opening page. Click <Find Services> on the banner, and you’ll see a search window. Type a letter, perhaps ‘d’ for ‘depression’, and you’ll see a <Show Filters> button. Click that. Use the filters, and as you read and learn, experiment with other search terms. To take control of your situation, there’s the dashboard.

The New York State Office of Mental Health also has a website, and their Find a Program: Basic Search page is likewise useful, if you use the filters. The rest of the website is bureaucratic and overwhelming, but it’s useful to understand the basic types of services available, which the Program Definitions page defines as:

Emergency (CPEP means its dedicated psychiatric)
Inpatient
Outpatient
Personalized Recovery-Oriented Services
Residential
Support

The Outpatient category is further broken down to include:

In addition, a number of child & family services of an outpatient nature are listed under Support.

When people recommend specific doctors or clinics, you may find they don't take insurance – not just YOUR insurance, ANY insurance. The Child Mind Institute, highly recommended, does not take insurance. Neither does CUCARD, the Columbia University Clinic for Anxiety Related Disorders, a leading training center for evidence-based therapies like CBT. These clinics and some private practitioners may have sliding scales based on income, but for whatever amount is set, you’ll be out-of-pocket.

New York Presbyterian publishes a useful guide to community based services, available online at https://issuu.com/catherineborzym/docs/nyp_mental_health_directory. Because the New York Presbyterian / Columbia University Irving Medical Center and the New York State Psychiatric Institute (PI) are located in Washington Heights, the whole neighborhood is a nexus of top talent in the mental health professions, and you’ll have an easier time getting an appointment with a community clinic in that area than at the hospital. Some clinics require that you live in their “catchment area”, others do not.

If you go to a psychiatric emergency room, it matters which one – but nobody wants to stick their neck out and recommend one over another. You should be wary; reforms are needed to the way we deliver mental health services in New York in the opinion and experience of this reporter. Pack some snacks and a change of clothes. Leave water for the cat, or better, make arrangements for someone to care for your pets for a while, and your kids.

The better private hospitals are in Manhattan. Besides the NYP/Columbia emergency department mentioned earlier, I’d recommend Mt. Sinai (Madison Avenue and 101st Street) or Weill Cornell. Weill Cornell has a great range of programs in many respects, but if you have a difficult-to-diagnose condition, the other two would be my choices for serious diagnostic chops. This article is about access, though, and one thing I’ll say for Weill Cornell: they answer the phone. For an emergency psychiatric assessment, that 24/7 number is 888-694-5700.

What about Montefiore? Isn't that a top rated teaching hospital that the Bronx can be proud of? First off, you should know that their Eastchester Rd. emergency room doesn’t have a psychiatric staff, and while their Moses Campus on Gun Hill Road does, it is not a dedicated psychiatric ER (a CPEP). The problems are numerous, including the food – inedible except for the Lorna Doone cookies. If that’s where you’re stuck, there's a separate NYC dedicated psychiatric emergency room, North Central Bronx, on the other side of the same Gun Hill Road buiding.

Here’s the rub. What if the need REALLY IS URGENT, yet not so urgent that an ER or inpatient hospitalization is required? Your loved one has a family to go home to at night, but some sort of treatment or medication adjustment is urgently needed. Recent advances make many forms of mental illness treatable, but it doesn't happen by magic. Sometimes a weekly appointment with a therapist is enough, sometimes not. If a month in a hospital is what you want, that's available, but what if that's not what you need?

At Crisis Services > Know Who To Call on the NYC Well website a critical distinction is made between a "crisis" and an "emergency". The reform this writer would like to see is expansion of walk-in psychiatric urgent care centers on an open, not a locked ward model. One type of service, a partial hospitalization program (PHP), is available at some of the Manhattan hospitals. The problem is that there are waiting lists, so this is not available on-demand and not considered an immediate discharge option by psychiatric emergency rooms. The various programs described on the Jacobi website, especially CPEP Crisis Outreach and ACT, appear to address some urgent care needs, but ACT is something you apply for, not an urgent care option for a new patient.

The things the system cares about are not what you and I care about. We care about accurate diagnosis and effective treatment. Diagnosis is important because some mental health issues seem to be amenable to talk therapy, while others are much less so and may require very carefully monitored and adjusted medication. There are professionals who specialize according to different types of issues. Addiction is one area, trauma/PTSD another. Borderline Personality and Bipolar can present similarly, yet their root causes and treatment are thought to be quite different. Is Temporal Loeb epilepsy a mental illness? If not, is it the domain of neurologists alone? The professionals most informed about Sensory Processing Disorder are apparently occupational therapists. While I have more questions than answers, the professionals who interact in the mental health space seem to as well. Therefore, as a consumer and advocate, I’d like to leave some breadcrumbs for others concerning what I have learned as it relates to the treatment of depression and suicidal ideation – thoughts and planning, whether acted on or not.

The accepted manual, the DSM, is in its 5^th edition. Perhaps because doctors have recognized that antidepressants do not work for everyone, there has been a much needed expansion of categories other than Major Depressive Disorder (MDD), particularly variations on "Bipolar" (formerly Manic-Depressive Disorder). Some doctors think the changes to the latest edition go too far, some not far enough, but the best thinking is clearly trending toward the idea that, if SSRI-type antidepressants are not working, the root problem might NOT be MDD.

Dr. James Phelps, an Oregon psychiatrist, has created a superb website concerning this subject: https://psycheducation.org/diagnosis/, which offers the view that people to the right of point 'B' on the mood-stability spectrum below are better off treated NOT with an antidepressant, but with a mood stabilizer alone. My family’s experience with Bipolar II confirms the view of Dr. Phelps.

Unfortunately, some prescribers will keep you on an antidepressant long after you’ve established that it’s not working. Whether you are patient, family member, friend or other champion, this may be when you need to assert yourself, switching doctors if necessary.

Each person and each crisis is individual, and as psychiatrists gain experience with new medications and various types of brain scans, new knowledge is changing some categories of mental health diagnosis and treatment. Implemented properly, this could mean more people can be helped while remaining members of our communities and families, contributing workers and citizens. Whether you are best served by one type of talk therapy or another, treatment for a sleep disorder, diet & exercise counseling, group sessions or individualized treatment & possibly medication, the right guidance for you should be available, and probably is if you know where to look.

If you‘ve had experience with mental health care, in our area or elsewhere, and would like to share what you’ve learned, The Parkchester Times is interested. Please let us know whether there are additional mental health issues we should cover in the coming months.

[Sidebar A]

Four Elephants and a Unicorn

Crisis Stabilization Centers are effective at providing suicide prevention services, addressing behavioral health treatment, diverting individuals from entering a higher level of care and addressing the distress experienced by individuals in a behavioral health crisis. – Behavioral Health Crisis Stabilization Centers: A New Normal; Verletta Saxon, Dhrubodhi Mukherjee, and Deborah Thomas (2018)

In 2005 the Technical Assistance Collaborative, Inc. of Boston issued an informational and instructional monograph titled A Community-Based Comprehensive Psychiatric Crisis Response Service, in which they detailed how to establish psychiatric urgent care outside an emergency room setting. A number of communities have embraced and implemented their ideas. Not New York. Another interesting program category, Assessment & Referral, is listed by the accrediting agency CARF International, but not by the State of New York. Walk-in and urgent care centers that attend to general health concerns have proliferated with the blessing of health insurance companies; why not create some for psychiatric patients who want to trust and be trusted in an open clinic setting?

New York is blessed and cursed with four mental health care behemoths, three of which, NY State, Columbia, and New York Presbyterian, are partners at the Irving Medical Center in Washington Heights. Their websites boast of having a Community-based Crisis Stabilization Program, but what they have is a failure-to-launch. And perhaps it’s not that surprising three elephants can’t seem to give birth to the unicorn that’s not in the room.

But what about that fourth elephant, the City of New York, and their media-minded partner Vibrant Emotional Health? And what of the more agile creatures of the urban health care jungle including Weill Cornell (part of New York Presbyterian, but associated with a different medical school) and Mount Sinai with their affiliated network of urgent care and walk-in centers?

Good partial hospitalization (PHP) and ACT programs exist, but there are waiting lists, and some spots are taken by people transitioning OUT of inpatient care. In order for crisis assessment and referral to be effective they need good referral and follow-up options. PHP programs are such an option; they need to be expanded and made available without the wait.

With Mayor Bill DeBlasio just back from his presidential effort, assisted by his wife, Chirlane McCray and Public Advocate Jumaane Williams, isn’t it time to make the establishment of Crisis Stabilization Centers a central part of an updated Thrive NYC roadmap? Win over the insurance companies, build it and they will come.

[Sidebar B]

Lockdown

What came as a shock was how little legal protection we had. We were innocents, we had no idea. Keeping my friend in the ER for one night was a good idea, but rather than release him the next day they threatened him with involuntary commitment for 30 days if he didn’t sign on the dotted line to be “voluntarily” committed for 7 days.

Mentally ill people are far more likely to be crime victims than perpetrators. In this instance my friend had just been through a traumatic experience and was being re-victimized by the prospect of being locked in a psych ER. He wanted to go home to his kids, who were bewildered and shaken by their father’s absence. Anywhere but in a hospital, detaining my friend against his will would have constituted false imprisonment under New York’s criminal law. He was in crisis and needed help, but he was still competent, and the loss of agency that the doctors seemed to take as given was deeply shocking & traumatic for him.

This wasn’t his first time in an ER. At Huntington Hospital on Long Island, they had given him a fast-acting anti-psychotic medication, stabilized him, and sent him home a few hours later. This is what we were expecting would happen again – or perhaps, since he was already on a mood stabilizer and the prescribing physician was associated with the same hospital, they would increase the dosage of that medication and keep him there long enough to observe his reaction. But this second ER undertook nothing resembling diagnosis, treatment, or stabilization. To make matters worse, nobody undertook to contact and consult the psychiatrist prescribing my friend’s medication.

New York State’s MHY Title B 9.27.11(d) reads:

Before an examining physician completes the certificate of examination of a person for involuntary care and treatment, he shall consider alternative forms of care and treatment that might be adequate to provide for the person's needs without requiring involuntary hospitalization. If the examining physician knows that the person he is examining for involuntary care and treatment has been under prior treatment, he shall, insofar as possible, consult with the physician or psychologist furnishing such prior treatment prior to completing his certificate. Nothing in this section shall prohibit or invalidate any involuntary admission made in accordance with the provisions of this chapter.

So the law that’s needed is already on the books, but it’s watered down by the last sentence, and it doesn’t specify that consultation must include the prescribing physician if the patient is already taking a psychotropic medication. It should, and the patient’s regular doctor should be given the opportunity to suggest dosage adjustment to be made immediately.

Relating this to a group that’s in the news, why do police officers not seek help when they need it? Perhaps they are not as innocent (in the knowledge sense) as we were. If it’s a goal to encourage people in crisis to get help, certain practices must end, especially locking the door behind folk when that’s unnecessary. People will tell you to go to an emergency room if you’re not sure what else to do, but the choices you make DO MATTER, and if it’s not the right answer for you, showing up at an emergency room is putting yourself at the hospital’s mercy. Should you be wary? Given the current state of things, yes. Under New York State law, psychiatrists DO have the ability to commit you. They WILL use your words against you, even those spoken in confidence; no one will read you a Miranda warning first. While you have a right to a judicial hearing, the Patients’ Bill of Rights they post at the hospital doesn't tell you that, and you will not have your smartphone with you to read the statute for yourself. This writer finds these practices hard to square with the goals of getting people the help they need to stay with their families, return to work, and benefit from recent advances to live successful, independent lives.

I have two other stories to relate concerning fast-acting antipsychotic drugs and emergency rooms. In one case, a friend in Weill Cornell’s Partial Hospitalization (day) Program was given such a drug, had a bad reaction, was treated in their ER and released a few hours later.

The other goes back in time many decades. My father, now retired, was both a psychiatrist and an emergency room physician. He was working an ER one shift when a prominent chief of police was brought in having become out-of-control at a party. With two governors on the phone wanting him to handle the situation and his patient wreaking havoc in the ER, Dad made a judgment call: to inject the chief with Thorazine, an early (and even at that time possibly dated) fast-acting anti-psychotic, jabbing it into his arm through his clothes when the chief refused to take off his jacket and roll up his sleeve. Dad knew it would be a painful injection (some types are more painful than others), but it worked, to everyone’s relief. The chief started calling Dad “Doc”, and seemed to regard him with new respect, as though the pain had got his attention in a helpful way.

None of the three cases I mention above involved the fast-acting anti-psychotic drug Dr. Phelps (psycheducation.org) prefers, Olanzapine. For long-term treatment of bipolar symptoms, Dr. Phelps prefers mood-stabilizers as a class (over anti-psychotics or anything else).

We sometimes ask ERs, and psychiatrists, to take bold action. Observation and follow-up are critical. That said, to detain people who don’t want to be there breeds mistrust among people who potentially do.