Mental health series: Limited access to medication

Aug. 10--Editor's note: This is the second installment in a series exploring our community's mental health network. In our first installment, we looked at how the state's broken mental health system is taxing the Howard County jail. Today, we look at access to prescription medication.

Cenica Salinas was a singer and musician. She was good enough to land a spot playing in the talent show at the Indiana State Fair.

And last year, the 29-year-old Kokomo native committed suicide.

Salinas struggled with a severe mental illness most of her life, according to one of her closest friends, Suzy Stroup.

In high school, Salinas was diagnosed with borderline personality disorder with schizo-effective tendencies.

Her treatment entailed heavy doses of psychiatric drugs and daily therapy sessions -- which Salinas got when she was covered by insurance from her father's employer.

But that changed in her early 20s, when she was no longer covered by her dad's insurance and was forced to obtain Medicaid.

"After she was switched to Medicaid, it was almost like night and day," Stroup said. "It felt like they just didn't have any patience for her anymore. Before the switch, it felt like the clinicians were there to help her. Afterwards, she was just a nuisance."

In the past, it only took a simple phone call to refill her medication. With Medicaid, the red tape and bureaucratic hurdles to getting treatment became too much for Salinas to handle, Stroup said.

Without the follow-up from clinicians and easy access to medication, Salinas began to fall apart, and Stroup said she believes it contributed significantly to her suicide.

"She never had enough follow-up or treatment to get stabilized," she said.

Salinas' story is a tragic example of a common obstacle facing the mentally ill in Howard County and across the state -- limited access to psychiatric medications that sometimes mean the difference between life and death.

"We know drugs are so critical to an individual's success," said Stephen McCaffrey, president of Mental Health America of Indiana. "Medication could be that one thing that makes a difference in a person's life suffering with a mental illness."

The creation of powerful psychiatric drugs in the last 20 years has ushered in a new age of treatment for the mentally ill. But without easy access to the latest, greatest medication, that new age of mental-health treatment is only a pipe dream for those who can't get it -- or afford it.

AVAILABLE, BUT OUT OF REACH

Top-shelf psychiatric drugs are expensive, and the price is only getting higher.

Between 1996 and 2001, the cost of drugs used to treat mental illnesses ballooned by around 20 percent a year, according to a study published in the America Journal of Psychiatry.

Since then, costs have continued to climb for antidepressants, antipsychotics and mood stabilizers. By 2013, people taking the antipsychotic drug Abilify, for example, were paying more than $700 for a month's dose, according to the North Carolina Division of Medical Assistance.

It's the kind of price tag most people can only afford with top-notch medical insurance.

"It's very difficult for people to get access to the psychiatric medications that they need," said Jill Snyder, executive director of the Mental Health Association of Howard County.

And it's not only a matter of price, Snyder said. It's also a question of people getting their hands on the appropriate drugs that best treat their specific mental illness.

For someone to receive an accurate diagnosis, the patient needs to see a clinical psychiatrist who performs an intensive intake evaluation to pinpoint a person's mental-health issue. Without that, Snyder said, most doctors only prescribe mild mood stabilizers that sometimes don't treat the real illness.

But with only St. Joseph Hospital, Community Howard Regional Health and the Kokomo Family Psychiatric Center providing psychiatric evaluations in Howard County, Snyder said it can be up to a three-month wait before patients get in to see a psychiatrist.

After receiving a diagnosis, it can take another six weeks or more to get the proper medication, that is if they can afford it or their insurance pays a significant portion of the cost.

For many people with a mental illness in Howard County, the money just isn't there.

"There are so many people not getting the help they need because of lack of insurance or money," she said. "The bottom line, it's all about money."

FIGHTING FOR MEDS

Money isn't the biggest obstacle for the mentally ill receiving treatment through Medicaid, which is the single largest payer for mental health services in the United States.

It's wading through the bureaucratic maze to get medication, Snyder said.

Mental Health America of Indiana President McCaffrey said coverage for mental health services in Indiana is actually very robust, thanks to recent legislation requiring the state's Medicaid program to cover a full array of psychiatric medication, and not just generic drugs.

But good coverage doesn't mean it's easy to access.

"With Medicaid, it's always a fight over what they will pay and what they won't pay," Snyder said. "You can wait forever for an answer sometimes."

That was the case for Cenica Salinas, who often had a hard time getting the help she needed under Medicaid, according to her friend Stroup.

Although governmental red tape can hinder access to medication, Snyder said it's still a program that's helped hundreds of thousands of Hoosiers struggling with mental illness who likely would never receive treatment without it.

"Medicaid is there for those who need it, and thank goodness it is. But it could be a lot better," she said. "It's all the rigmarole you have to go through to get someone to the place they need to be.

"If they get lost somewhere in between the beginning and the end of the process, they're not going to make it to that end, where they're stable and functioning," she said.

GO TO JAIL, LOSE YOUR BENEFITS

One of the groups most vulnerable to getting lost in the shuffle is sitting at the Howard County jail.

When people are incarcerated, they can keep their Medicaid and Social Security benefits for 30 days. If they remain jailed for more than a month -- and even if they're never convicted of a crime -- federal law requires that they're dropped from the program and have to reapply.

That can be a four- to eight-month process. In the interim, people released from jail who are suffering from a mental illness and trying to get back on to Medicaid aren't getting any medication.

That's bad news, said Kristie Shirey, the nurse at the Howard County jail. And it happens a lot -- eight times a month, sometimes.

Shirey said it's much too common for incarcerated people with mental illnesses to lose their benefits and medication after a stint at the jail. They spiral downward, become homeless and eventually land back in a cell, she said.

"They're scrambling to find a place to live and it ends in disaster," Shirey said.

And for someone suffering from bipolar disease or schizophrenia, the application process to get back into Medicaid can be daunting, if not impossible.

"If you're mentally impaired, you don't know how to do that," Shirey said. "You don't even know where to begin."

It's an ugly cycle, and it's one the Howard County Sheriff's Department has worked to break.

Jail Commander Capt. Harold Vincent said department officials work closely with the local Social Security Office and court system to expedite the reapplication process for mentally ill people released from jail after more than 30 days.

Through their collaboration with local agencies, Vincent said they can cut the time it takes for someone to requalify for Medicaid from four months to just two weeks in some cases.

The accelerated reapplication process means people with mental illnesses are getting their psychiatric meds quicker. That can mean the difference between a smooth transition back into society or mentally deteriorating and serving another stint at the jail.

Even with the expedited reapplication, it's still not a good situation for people with serious mental health issues, Vincent said.

"It doesn't take nearly as long to get them their benefits back, but in the meantime, they've still lost their access to services and their medical contacts," he said.

SWITCHING MEDS? BAD IDEA

Then there's the problem of receiving mental-health treatment when people are actually at the jail.

Vincent said jail nursing staff members try to communicate with inmates' health-care providers to keep them on their current psychiatric medication. If they can't provide an inmate with the exact prescription, staff find the next best thing to keep them stable.

But that's not the case at a lot of jails, said Mental Health America of Indiana President McCaffrey.

Many jails switch inmates' psychiatric medication to different, cheaper drugs to save money, he said. If they end up in the Indiana Department of Correction, prison staff there could change their prescriptions once again.

"There are 92 different jail systems [in Indiana], and 92 different ways on deciding on how to provide for mental health medications," he said. "It's a patchwork system with varying degrees of access and lack of access ... But nobody would say switching medication that works makes good clinical sense."

McCaffrey said in the long run, it is more fiscally responsible to spend money up front to provide the appropriate medication to inmates to keep them stable. If they remain untreated, former inmates could once again act out from their mental illness and end up back in jail.

And keeping someone incarcerated is a lot more expensive than providing the proper mental-health treatment the first time and keeping them out of a cell a second time, he said.

HIP 2.0

One of the biggest steps the state could take to get more people access to mental-health treatment is expanding the Healthy Indiana Plan, McCaffrey said.

Currently, more than 390,000 Indiana adults don't have insurance because they make too much money to qualify for Medicaid, but they don't make enough to qualify for insurance supplemented by the Affordable Care Act, commonly known as Obamacare.

That's a big problem for people with mental illnesses.

"It's awful. They have no place to go," McCaffrey said. "They can't get access to the drugs they need or the therapy they need. Only bad things can happen from that."

Pence has been steadfast in his refusal to expand traditional Medicaid, as provided for in the Affordable Care Act, which would also offer coverage for Hoosiers left in limbo by their income.

Instead, Pence is choosing to pursue federal approval for state-level coverage called HIP 2.0., which was denied last week in his first meeting in Washington with Health and Human Services Secretary Sylvia Burwell.

But while the state and the feds debate which program to implement in Indiana, McCaffrey said the uninsured mentally ill continue to struggle with their disorder.

That leads to a host of other social problems, including domestic violence, kids dropping out of school and criminal offenses that erode the state's social fabric and safety, he said.

"If people had received the treatment they needed, we'd like to think that incidents like that would never have occurred," McCaffrey said.

Carson Gerber can be reached at 765-854-6739, carson.gerber@kokomotribune.com or on Twitter @carsongerber1.

___

(c)2014 the Kokomo Tribune (Kokomo, Ind.)

Visit the Kokomo Tribune (Kokomo, Ind.) at www.kokomotribune.com

Distributed by MCT Information Services