EDITOR’S NOTE: This six-part series on health care reform is a joint effort of the Denton Record-Chronicle and graduate students from the University of North Texas Mayborn School of Journalism, along with professor George Getschow, formerly with The Wall Street Journal and a Pulitzer finalist.
Suffering from diarrhea and dehydration for more than a year, Bob King lost 46 pounds and grew so weak he could barely stand up.
His wife, Carol, found him unconscious on the floor when she returned from work one day. She called 911 in a panic, and he was rushed to the emergency room.
King fell into a coma. For the next four months, distant relatives drove to Duncanville from all over the country to say their last goodbyes, and members of his church prayed for him. But to everyone’s surprise, King woke up.
King’s doctors discovered he had celiac disease, an intestinal condition that leads to malnourishment. His immunity low, King succumbed to a series of other illnesses that left him weak and exhausted during his five-month hospital stay.
All his adult life, King has suffered from a dizzying array of serious physical ailments — from Type 2 diabetes to kidney failure that required a transplant to a recent bout with pneumonia so severe he had to be hospitalized. And physical illness has proved inextricably bound up in his mental health, too.
King has manic depression, also known as bipolar disorder.
A recent hospital confinement for pneumonia put King in a deep funk, he says. His psychiatrist called him with a free prescription for improved mental health.
“All you have to do is stay out of the hospital for at least six months,” he told King, promising him a much better outlook on life if he did.
King’s case is no anomaly; the connection between mental and physical health is well understood in the health care profession. Mental health experts say the evidence is clear: Patients suffering from schizophrenia, bipolar disease and major depression are at an increased risk for diabetes, heart disease, high blood pressure and many other conditions.
For decades, the close connection between mental health and physical health was little known or understood except by a handful of researchers. But the National Association of State Mental Health Program Directors transformed the mind-and-body connection from obscure research to a pressing public policy issue when it released a bombshell in 2006: The mentally ill die an average of 25 years earlier than the general population, the association stated in its report Morbidity and Mortality in People with Serious Mental Illness.
“That got a lot of people’s attention,” says Darcy Gruttadaro, a policy director at the National Alliance on Mental Illness.
Despite public awareness of the problem, however, mental health care experts say treatment still remains fragmented and the mentally ill are less likely to receive primary care than the general population.
“Their lives can be difficult if they don’t have the right kind of support,” Gruttadaro says. “They may not earn enough money to have an easy time with transportation. They can often have issues with housing and employment and some of the things that create stability in your life. When those things are missing, it can be difficult to get to doctors appointments and access the health care they need.”
Take for example Frank Delgado, who was diagnosed with bipolar disease 10 years ago after spending the previous 23 in prison as a self-medicating drug user.
Today, Delgado is an award-winning consumer advocate for MetroCare, the Dallas public mental health care provider. He’s also living with Type 2 diabetes, glaucoma and hypertension. Getting proper treatment for one major illness is hard enough, he says; a second, third, fourth can be overwhelming.
“The stress [of mental illness] can cause a lot of [physical] problems,” he says.
The 2010 Patient Protection and Affordable Care Act recognizes that mental health and physical health are closely connected and offers what proponents say is a big step forward in mental health care: integrated care. Beginning in 2014, Medicaid enrollees with two chronic conditions — or one serious condition and a severe mental illness — can choose what the new legislation calls a “health home” designed to foster coordinated care.
The legislation provides $50 million in grant money for what many consider the most promising model of integrated care: co-location of mental health and primary care services. In the co-location model, primary care physicians are stationed under the same roof as mental health care providers and offer checkups and treatment at the same time that consumers receive mental health services, eliminating many of the obstacles to integrated care.
For a patient like King, it would mean the psychiatrist he sees for his bipolar disorder and the endocrinologist he sees for his diabetes would treat his physical and mental health disorders in tandem, rather than operating apart. If King’s physical and mental care and treatment were coordinated through a “health home,” his psychiatrist would be aware of an insulin dosage increase that might affect his bipolar medication and his endocrinologist would be aware of stress-related events that might affect his blood glucose levels.
“In health care, the right hand has to know what the left hand is doing,” says Janie Metzinger, public policy director for the Mental Health Association of Greater Dallas. The goal of the mental health care provisions of the health care reform act, she added, is to stop fragmenting the treatment of body and mind.
The greatest obstacles facing psychiatrists and primary care physicians who recognize the benefits of integrated care are the money and time commitment required to make it work, says Lee McCabe, professor in the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine.
“The problem is that primary care docs and pediatricians are the worst paid, and primary care physicians are the most overworked,” McCabe says. “Their case loads are incredibly big. There aren’t enough of them, and they’re not paid well for it. So [for physicians] to take on mental health care, there’s gobs of problems associated with it.”
Laura Galbreath, deputy director of the Center for Integrated Health Solutions at the Substance Abuse and Mental Health Services Administration in Washington, D.C., acknowledged that “there are challenges at every level.”
She sees one simple remedy: Engage nurses in primary care coordination, relieving physicians and psychiatrists from those duties. In mental health care, case managers could handle the coordination, she says, so that psychiatrists “don’t spend all day on the phone with other doctors.”
An encounter with Sammy Davis Jr.
King says his manic episodes haven’t been published in any medical journals, but they probably belong in the pages of a Hemingway novel. In the Kings’ first 12 years of marriage, Bob left his Duncanville home eight times for Atlantic City without ever bothering to inform his wife, Carol.
He’d plan his trips for weeks — stashing new clothes of all different sizes in the attic in case he lost or gained weight. He installed new tires on his car with the white lettering facing inward so no one would notice. Every detail of his stealth flights was worked out in his mind before he left.
“My brain would be racing, racing, racing,” he says. “What else do I need to do? What else do I want to do?”
On his way to Atlantic City, King would stop at a garage to flip his tires around. He always stayed in the fanciest suite in town, and curried favor with one of the hotel managers to earn VIP seating for a Sammy Davis Jr. concert. Dressed in a shiny silver vest and Rolex watch, King twice sidled up to Davis during a show, smiled and shook his hand.
Through the madness, King was always thinking about his loved ones. He bought each member of his family a gold necklace. He bought a pair of Honda motorcycles for his little brother and himself. He didn’t gamble much. But he enjoyed putting $100 bills in the palms of strangers — just for the fun of it. It made him feel like he was on top of the world.
“I’d be subject to doing anything,” King says.
At the end of one three-week binge, King calculated he had spent far more than he earned — $95,000. King’s manic escape-and-splurge adventures took place 25 years ago. He eventually restored his credit but is still healing his body, hammered from days on the road, endless nights and an all-junk-food diet.
After he was diagnosed with bipolar disorder, he spent the next month in a mental hospital, and was administered lithium to control his manic moods and behavior. He never left Carol again.
“You can’t imagine the relief I had [after receiving the bipolar diagnosis] knowing that I wasn’t just a creep because I had taken off like seven times from my wife,” King says.
After his kidney failure and transplant, King had to stop taking lithium, substituting drugs his kidneys could tolerate. But his drug regimen — 20 pills daily — leaves him worn out soon after he awakes in the morning.
King’s group therapy sessions
In the couple’s Duncanville home, ceramic angels cover every shelf and table — one of the many collections King has amassed during his manic binges over the last quarter century. Carol King adores the angels. Her Christian faith helped sustain her during her husband’s manic episodes and hospital stays, she says.
And he adores her.
“Poor girl,” he says. “If it weren’t for her, I’d either be in jail or I’d be dead or in an institution.”
Today, the couple hosts a monthly support meeting in their own home, one of many gatherings that form the Depression and Bipolar Support Alliance of Dallas. King reclines on the pink couch in the pink-carpeted living room of their home, his thinning gray hair and ocean blue eyes shielded by a Texas Rangers ball cap. He owns a hat for every baseball team and more than 20 titanium necklaces worn by his favorite players. Carol sits to his left, and 15 others are circled around the room.
No counselors are present. Group members share common concerns and offer encouragement. As vice president of the organization, Bob King typically leads these meetings. But at the moment, he’s still recovering from his most recent hospital stay. The skin of his arms is a purplish hue from the needle pokes, a testament to his time there. His new walker lies nearby.
Carol opens the support group meeting with an upbeat tone.
“Tonight, as we each share, we’re going to start by talking about at least one thing we’re thankful for,” she says.
She is worn out. Between juggling the responsibilities of her job as a manager at AT&T and taking care of her husband, she’s visibly flustered.
“Does anyone want to volunteer to begin?” Carol asks.
A woman raises her hand. She has bipolar disorder, she reminds everyone, but her most immediate problem is being treated by a cardiologist. She developed heart problems during a three-month depressive period earlier in the year because of malnutrition. She had been starving herself.
While she speaks, King pulls out his blood glucose meter to check his blood sugar. “Too much pie,” he confesses.
Like many members of the support group, most people struggling with mental health have so many health conditions that they tend to neglect some of them, Galbreath says.
“A lot of time, it [physical health care] does come second,” she says. “When it comes to getting out of bed and trying to function and deal with your recovery and going to see your doctor about your high blood pressure, a lot of times it doesn’t rise to the occasion in terms of priorities.”
She has witnessed scores of patients with mental health disorders who have been diagnosed and treated for diabetes and high blood pressure — conditions that can quickly become emergencies when untreated. She mentions one mental health patient who spent needed time with a primary care physician for the first time in her life because of co-location. What was at first a convenience may save that patient’s life, Galbreath says.
“She knows she can go down the hall while she’s there and have someone that will listen to her,” Galbreath says. “She’s built a personal rapport with this physician. She can take her time and know that she’s not being judged for her mental illness and get positive reinforcement for the changes she’s trying to make. She was just really excited because she got off one of the meds she was just on.”
It’s little victories like these, health experts say, that enable mental health patients like King to live a more fulfilled life.
On a recent night, King says, he sat on the edge of his bed before heading to the bathroom, contemplating whether it was all worth it.
“Boy, I wish I didn’t have all these issues, like going to the restroom so much and all the meds that I take, my illness and my bipolar,” he says he told himself. “Wouldn’t it be a lot easier if I just weren’t here?”
He says he got up, turned on the light in the bathroom and looked himself in the mirror.
“Nah, I got a couple more years.”