The dire lack of access to mental health care represents a moral, medical and financial catastrophe worldwide. To tackle this enormous crisis, DMU decided to start somewhere: It is the nation’s first medical school to partner with the National Alliance on Mental Illness to provide training for osteopathic medical students to recognize and respond to patients with mental illness.
Autumn Brunia, D.O.’19, had a solid business career with the Principal Financial Group in Des Moines when she volunteered to work with a local therapist who served women who’d escaped domestic violence. Observing the “extreme shortage” of care options for traumatized patients changed her life: Brunia left the Principal to pursue her biology degree while also working as a certified nursing assistant in a mental health unit at a UnityPoint-Des Moines facility. She became keenly aware that mental illnesses affect people of all ages, backgrounds and income levels, but their ability to access care is difficult.
“In Iowa, there’s such a need for mental health care,” she says. “When I was on a psychiatry rotation, I saw people living in the acute psychiatric unit for two years because there was no other place for them to get care. There are patients who spend two days in the emergency room waiting for psychiatric care because the hospital can’t release them for ethical reasons. Obviously, we need providers who understand mental illness and can help those patients.”
Iowa indeed has a need: The state ranks 48th in the nation in the number of psychiatrists per capita. Of its 99 counties, 89 are designated as Health Professional Shortage Areas (HPSAs) in mental health. For Iowans who need inpatient psychiatric care, the situation is even more dire: There were just two state psychiatric beds per 100,000 residents in 2016, making Iowa last in the country.
The problem isn’t just in Iowa, however. In its Mental Health Atlas 2017, based on data representing 97 percent of the world’s population, the World Health Organization (WHO) reports a global shortage of health workers trained in mental health and a lack of investment in community-based mental health facilities.
“In low-income countries, the rate of mental health workers can be as low as two per 100,000 population, compared with more than 70 in high-income countries,” the report states. “This is in stark contrast with needs, given that one in every 10 persons is estimated to need mental health care at any one time.”
The failure to meet the need is costly, the WHO report adds. A recent calculation of treatment costs and health outcomes in 36 low-, middle-and high-income countries for the 15 years from 2016 to 2030 shows that low levels of recognition and access to care for depression and another common mental disorder, anxiety, result in a global economic loss of a trillion U.S. dollars every year. The American Journal of Psychiatry and the U.S. Surgeon General estimate the cost of lost earnings is $193 billion just to the United States.
“People are just accepting the cost because there aren’t other options,” Brunia says. “I feel a moral obligation to become a psychiatrist in Iowa. And with my business background, I hope I can work on the issue through health administration.”
The numbers are staggering Mental health facts in America
43.8 million adults – one in five – experience mental illness in a given year.
10 MILLION ADULTS
live with a serious mental illness.
An estimated 49.5 percent of adolescents ages 13-18 have had a mental disorder.
Of adolescents with a mental disorder, an estimated 22.2 percent have had severe impairment.
Amid this darkness, DMU lights a candle
When Angela L. Walker Franklin, Ph.D., came to DMU as its 15th president, she brought her background as a clinical psychologist and a passion for the importance of mental health. As chair of the Health Cabinet for the United Way of Central Iowa and a member of the Central Iowa Community Health Needs Assessment Team, she formed a vision for a comprehensive and sustainable mental health educational opportunity for DMU’s osteopathic medicine students.
At about the same time, Lisa Streyffeler, Ph.D., chair of behavioral medicine, medical humanities and ethics, was looking for ways to strengthen the mental health component of the University’s osteopathic curriculum. Because the program’s course work already is so densely packed, however, she began looking for other approaches, such as certification programs.
Those explorations led to an opportunity for DMU to consider a partnership with the National Alliance on Mental Illness (NAMI) in Iowa. Turns out NAMI, on national and chapter levels, offers programs that include provider education. This 15-hour in-service training program is designed to transform the ways psychiatric care is delivered by increasing participants’ comfort level and compassion in helping individuals suffering from mental illness. NAMI’s approach fosters clinical empathy for patients and their families and provides tools to help overcome stigmas.
The program is taught by three-person teams consisting of an adult who has been treated for a mental illness, a family member who has been affected by mental illness and a mental health professional.
“The program focuses on helping people understand the lived experience of being diagnosed and treated for mental illness, or being a family member of such individuals,” Streyffeler says. “The goal is to give providers a framework for understanding the patient’s needs and developing a treatment plan.”
An agreement was born last fall between NAMI and DMU to offer the provider education program to osteopathic medical students. While the program has been used by hospitals, social services entities, institutions and other organizations for more than two decades, the University is the nation’s first medical school to facilitate this training. Furthermore, as DMU’s ophthalmology clinic became slated to close this year, the possibility of adding a behavioral health clinic in its place arose as an important new resource for the University and the public.
President Franklin’s vision for bringing psychiatric and psychological care to the campus was becoming crystal clear, and discussions quickly grew on the feasibility of the new clinic and related curriculum. She and Streyffeler shared the plans with members of the DMU Board of Trustees during their May meeting. They enthusiastically ratified the ideas and encouraged the administration to proceed.
“This is a very powerful opportunity for DMU to deliver much needed services to our students and the community at large. It is our time to take a leadership role with a behavioral health care model,” says Board Chairman Steven Morain, J.D. “It is rare for an
organization to have all of the elements of a whole new business segment come together in complementary ways, and to do so quickly.”
“The stars aligned. It really felt like the time was right for this,” Streyffeler says. “There are a lot of pieces to the problem that need to be addressed, but this is a piece that DMU can logically provide. We can help our students feel more comfortable with patients displaying signs of mental illness and understand that the conditions are common, treatable and just another aspect of being human."
ONSET OF ALL CHRONIC MENTAL ILLNESS
One-half of all chronic mental illness begins by age 14; three-quarters, by the age of 24.
Approximately 10.2 million adults have CO-OCCURRING MENTAL HEALTH AND ADDICTION DISORDERS.
• Affects 16 million American adults
• The leading cause of disability worldwide
SUICIDE IS ...
• The 10th leading cause of death in the United States
• The third leading cause of death in youths ages 10 to 24
90% of persons who die by suicide have an underlying mental illness.
When the DMU-NAMI partnership was announced, central Iowa mental health advocates took note. Des Moines Register columnist Kathie Obradovich wrote about it enthusiastically, and gubernatorial candidates at a December forum held on campus underscored the need for more primary health care providers to have an understanding of the dynamics of mental health. These providers are often on the frontlines of encountering and treating individuals with mental illness but often are ill-equipped to address the conditions.
“That especially resonates at DMU, because we’ve been recognized by the American Association of Family Physicians as a top producer of family physicians in the nation,” President Franklin says. “The state likely will never have enough psychiatrists, but by further educating primary care physicians on how to recognize, diagnose and manage mental illnesses, we can accelerate the process of delivering vital care to those in need.”
Sitting in the audience at that gubernatorial forum was Suzanne Mineck, president of the Mid-Iowa Health Foundation. She and her board members recognized how well the project aligned with the foundation’s goals to encourage system-level change around the most critical care needs. On Dec. 14, the foundation announced a lead gift of $50,000 to help launch the DMU Provider Education Project. The funds cover some project costs including materials and speaker compensation.
“We know from our recent Community Health Needs Assessment that improving access and quality of mental health care is a top priority, and that expanding mental health training for primary care providers is of critical importance,” says Joseph Jones, a Mid-Iowa Health Foundation board member. “There is not a simple solution to address this challenge, but programs such as the NAMI provider program are an important step in the right direction, leading to a more holistic approach to health care and early intervention and prevention.”
Nearly 60% of adults and nearly 50 percent of youths, ages 8 to 15, with a mental illness DID NOT RECEIVE MENTAL HEALTH SERVICES in the previous year.
26 percent of HOMELESS ADULTS STAYING IN SHELTERS live with a serious mental illness, defined as a mental, behavioral or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.
24 percent of STATE PRISONERS have a recent history of a mental health condition.
27% exhibit symptoms of depression
11% have thought of taking their own lives
However, only 16% seek psychiatric treatment
A new program comes to life
In March, national NAMI leaders came to campus to train 30 individuals to serve on the three-member provider education teams. In June, the first 50 DMU osteopathic students, who have indicated a preference for serving in Iowa, participated in the intensive three-day program. NAMI provided program facilitators, materials and certification; DMU provided the physicians and facilities.
Another benefit of the project is research that will assess the NAMI program’s impact on the trainers and students. That will include evaluations of participants’ cognitive and attitudinal changes, such as their skills in working collaboratively to serve mentally ill patients and the stigma levels they attach to mental illness.
“People avoid treatment because of the stigma of mental illness, so we’re very interested in reducing that among providers,” says Jerrit Tucker, Ph.D., assistant professor of behavioral medicine who’s managing the research process. “That’s particularly important in primary care. The WHO says if we’re going to reduce the burden of mental illness, primary care is the way to go.”
The University now is seeking a public-private partnership to expand the project: first, by requiring all third-year D.O. students to go through the training following their clinical rotations; second, expanding it to students in the College of Health Sciences and the College of Podiatric Medicine and Surgery. Finally, the program will be made available to other medical providers in Iowa as continuing medical education.
For now, though, DMU has taken a step toward addressing a critical global health issue.
“I can’t say strongly or passionately enough what it means to me to get this training in primary practice curriculum,” says Teri Brister, Ph.D., LPC, director of information and support for NAMI on the national level. “That’s what makes this partnership so important and potentially powerful. We want students to know how mental illness affects people’s lives, to understand the traumatic experience it is for families and to see them as people.”
Another goal: to help future health care providers see mental illness “as a disease versus a character flaw,” says Erika Jaworski, D.O.’20, among the first cohort of students to experience the NAMI provider training in June. That’s important to her personally as well as professionally, as she struggled with anxiety and depression for about six months in her first year at DMU.
“That was so much lost time and productivity, but I became my own stigma,” she says. “As medical students, we’re trying to not look weak. We think we need to be perfect. But it’s a treatable illness, and no one should be embarrassed to get treatment.”
Jaworski finally did, and she went a step further – she shared her experiences with classmates on a “Mental Illness Among Us” panel on campus. “All the love and support I got from classmates, even people whom I didn’t know well, really helped me and let me stand up for mental illness,” she says. “I’m not happy that I experienced anxiety and depression, but I’m thankful for my growth and the opportunity to help patients because of that personal experience.”
Sources: National Alliance on Mental Illness; National Institute of Mental Health; Substance Abuse and Mental Health Services Administration; Department of Justice; Journal of the American Medical Association.