Catch it Early: What Doctors and Practitioners Miss About Mental Illness (Ep. 112)

Guests:  Robert C. Smith, MD and  Vinod Srihari, MD, 

Every day, millions of Americans face untreated mental health challenges—and too often, their first point of contact is a medical doctor unequipped to help. Most physicians - and many others who teach and advise youth - aren’t trained to recognize or treat mental health conditions, yet they’re the ones patients turn to first. This gap in training has devastating consequences, contributing to the mental health crisis we see today.

Dr. Robert Smith, a seasoned physician and thought leader, is sounding the alarm: medical doctors need fundamental training in mental health care. His new book, Has Medicine Lost Its Mind? Why Our Mental Health System is Failing Us and What Should Be Done to Cure (Prometheus Books, March 4, 2025) addresses the poor state of mental health care in the US, why it occurred, what needs to be done, and how to accomplish this politically.

Our Second Guest, Vinod Srihari, MD, spearheads a new program in CT which has just been expanded to reach the whole state after a trial run in 10 towns around New Haven. STEP is a clinic staffed by mental health providers in different fields – psychology, psychiatry, nursing, and social work. This "interdisciplinary" team seeks to provide comprehensive care for individuals who are early in the course of a psychotic illness in order to prevent symptoms from becoming disabling.

We Find Out:

• Why so many mental health issues go untreated and misdiagnosed—and what it costs us as a society.
• The value of early detection and treatment in Mental illness to help with prevention and recovery
• How medical doctors can better address mental health needs with proper training. And tips on how patients should talk to doctors about mental health.
• The hidden consequences of the mind-body split in modern medicine. The importance of integrating mindfulness and exercise into "treatment."
• Practical solutions for integrating mental health care into the broader medical system.
• 
  

LINKS:

Bob’s website:

https://www.robertcsmithmd.com/

 Bob’s Book:

https://a.co/d/2yOHhlp

Mindmap:

https://mindmapct.org/

Mindy and her book: https://mindygreiling.com/

Randye and her book: https://www.randyekaye.com/

Miriam and her book: https://www.miriam-feldman.com/

Hosts:

Who:

Randye Kaye - was a morning Radio Personality bringing humor to CT families when her own son was diagnosed with schizophrenia. Now she is still a Broadcaster, Actress, Voice Talent, Speaker, and Author (Ben Behind his Voices, Happier Made Simple)

Miriam Feldman -  is an artist, writer, and the mother of an adult son with schizophrenia. Her book, He Came in With It chronicles her family's story and was released to rave reviews on July 21st, 2020.

Mindy Greiling - Mindy Greiling was a member of the Minnesota House of Representatives for twenty years. She helped found the nation's first state mental health caucus, which successfully lobbied for a significant increase in Minnesota's mental health funding Her acclaimed memoir is Fix What You Can.

Transcript

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SPEAKER_03 0:00

Unrecognized mental illnesses lead to divorces, school failure, job failure, addiction, homelessness, incarceration. It is not their fault. Don't blame your primary care doctor for this. They've not been trained.

SPEAKER_02 0:20

When a person has a psychotic illness, it's it's a puzzle for the entire community. They might have this illness, and the first responder might be a pastor in a church, it might be a high school teacher, it might be a college professor. Our effort is to educate everyone in the community and to activate them as a network of people.

SPEAKER_01 0:40

Study after study confirms that early detection of serious mental illness makes a huge difference in recovery. So why don't we catch it earlier? Our guests on this episode explore the problem and provide solutions. Welcome to our podcast, Schizophrenia, Three Moms in the Trenches. From the place where schizophrenia and real life collide. With Miriam Feldman, Mindy Gryling, and Randy Kay. We're very excited about this episode of Schizophrenia Three Moms in the Trenches. If you're new to the podcast, welcome. Who We Are is pretty much in the title. We are three moms. We each have a son with schizophrenia in various stages of recovery. We've written books about it, and this is our 112th episode of this podcast. And I want to thank you so much for your support and for listening or watching on YouTube and for being with us on this journey. Throughout so much of what we've been through with our loved ones, as many of you may feel, is that early detection, catching this brain illness early, can make a huge difference in recovery. This has it's a theme that sort of runs through everything. So in a moment, we're going to bring in, we have two guests this evening. One is Dr. Robert Smith, who's written a book called, it's all in the title, Has Medicine Lost Its Mind? Why our mental health system is failing us and what should be done to cure? And he's going to talk about the value of early diagnosis. Then we're going to bring Vinod Shrihari, who runs a program in Connecticut that I just learned about called STEP, and they are stepping up to the plate to do something about this. And so this is very exciting. Um I'm Randy Kay here with Mindy Gryling and Mimi Feldman. So how are you guys? What's uh Mindy, what's new?

SPEAKER_04 2:51

I am on top of the world. As you know, as our listeners know, we've been trying to get Jim into supportive housing for a long time. And last summer we finally got an interview, and then he had a reaction to one of his meds and couldn't even walk and hardly talk when we were there. So we got uh postponed until last week. And we went last Thursday, filled out all the paperwork, had an interview, had a tour of the building, which we couldn't do before because Jim was not able to walk unless he was pushing a cart, which wasn't really very safe. And now we still have to have the final bow tied with our paperwork approved. And Jim has to have a background check. And as we know, his background check isn't perfect. But I think they're they said they're looking for people that set fires or harm other people, and he hasn't thankfully done those things. So um we're all but there, and so I'm on top of the world this week. You never know about next week.

SPEAKER_01 3:55

Well, this is true. I hope Jim is on top of the world too. Is he looking forward to it?

SPEAKER_04 4:00

Jim is so excited and he's Googling, you know, what is around this place. He's planning, you know, where he will put his furniture. That is, I think, the most exciting part is that he's excited about it. And I should say one other thing, you know, we had our program that people may have watched, and the financing last summer meant he would have a lot less money left over once he paid for this program, but they've changed the financing program. And so now he will basically um have the same amount of money he has now because they've changed the program. So somewhere along the line, we can maybe talk about that. But the story, the moral of the story for us and for our listeners, is no matter what you learn, you have to keep learning.

SPEAKER_01 4:50

Yeah, absolutely true. And I don't know when you, dear listener, are listening to this podcast as we speak. This day is February 4th, 2025. I guess I should say that, although it's always in the show notes. And uh things are a little bit in flux with our government, not gonna lie. So we never know what funding is, what funding isn't. But right now, we just gotta deal with the here and now and what it is. And for our listeners, your son Jim is how old?

SPEAKER_04 5:18

Jim is 47 now. So I say never give up hope. Things get better over time. You know, there's still the ebb and flow, but you're making progress usually the older you get, unless there's some tragedy like COVID that knocks you off your meds or something. Right.

SPEAKER_01 5:34

I know that well. Thank you so much. Mimi, how are you?

SPEAKER_05 5:38

I'm fine. Um, just running into some issues with Nick and his meds, and now all of a sudden the REMs have put a hold on his closapine, and I don't understand why. And so just doing a lot of scrambling. Um, do you have a back uh a supply of yeah? I do.

SPEAKER_04 5:58

You do, yeah, good.

SPEAKER_05 5:59

I do, so I don't have to freak out on that level, though I do have a bag of Nick's meds. This is meds, guys. Wow, I have to sort through and figure out and get everything set up because I'm leaving town tomorrow and I have to leave everything in order. And Nick's good caregiver that he's been so happy with this last year is out now and may not be coming back. So I've got a different caregiver coming every day. So we don't it things are not uh being handled too efficiently right now. So the good caregivers mean all the difference, everything, everything. It just uh, you know, and then you get a good one, and then I I sort of start slacking off and leaning on the caregiver and counting on the caregiver, and then you wake up one morning, the caregiver's gone.

SPEAKER_04 6:53

Yeah, you're so parents are always the bottom line, and that's why we're trying to get Jim settled because you know, Roger's 80, and I will be 77 in uh two or three weeks. Oh my god. But we gotta get we can't be the bottom line after we're dead.

SPEAKER_01 7:10

No, yes, and you know, in case you're wondering, we do have episodes about all of these issues, um, clozapine and the REMs required to take them. So please just check our list of episodes. And if if you're new to us, you've got 111 other episodes other than this. So pick and choose the topics that are really helpful to you, and topics about uh closeril. We have stories from other people who are on different medications, long-acting injections that are helping them. And so we try to be here for you. With that said, I do want to mention and thank you so much for your fan mail. There is a way to write to us through our podcasting host, which is Buzz Sprout. Unfortunately, we can't answer you on that platform yet. But those of you who have been listening know this, and I put a note if you put your email address, I will get back to you, or one of us will get back to you. But please know that we are three moms and legislator and an artist and a broadcaster. You know, we have many jobs, but we are not doctors. We're gonna have one on in a minute. We're not doctors, we're not social workers. Thank God for the social workers. When we're moms and we're volunteer moms. And if you're calling to ask us for advice, we're not qualified to give you that. What we can do is steer you toward an episode that has the information that you need. We are here to educate and help you not feel alone, which so many of you have said we've done, so we're doing. So thank you for that. But we can't advise you in your situation as to what meds he should take or you know what to do. We're gonna do our best, and I promise I'll write back if you give me your information and give you empathy. But we legally we can't prescribe stuff and all that. So, but thank you for writing. We really appreciate it. My quick update is um unfortunately, I am I've been trying to get assisted outpatient treatment passed in Connecticut. It didn't make it past committee, I'm sad to say. They said there was going to be too much pushback. We're gonna try again next year. Um, my son is currently safe for the moment. He is in a program that is a transitional program and refusing to take medication. So, but he is agreeing to be drug tested. So we count our blessings and we keep our fingers crossed. That's really a step in the right direction. For today. There's a song in Avenue Q that's like that. For today. I get all my therapy from Broadway Musicals. Okay, so that that's our update. Um, my son's 42. Um, Nick is how old, Mimi? 39. 39. So we all you know, we've all been at this a while, and this is why I want to bring in um our first guest, um, Dr. Robert Smith. We have permission to call him Bob. And Bob is a seasoned physician and thought leader, and he's sounding the alarm. Woo! We're gonna sound it with you that medical doctors need fundamental training in mental health care. So welcome, Bob.

SPEAKER_03 10:19

Yeah, thank you. I'm honored. I love your, all the three of you, your energy and your positivity of this critical.

SPEAKER_01 10:28

Thank you so much. So I'm excited about your book. I've read about it, I read the synopsis and I skimmed it, not gonna lie. But I did speak to you at length on Zoom. So if you're and if you're on uh um YouTube, Mindy's holding it up. It's called Has Medicine Lost Its Mind? Raise your hand if you've wondered that yourself on occasion. All our hands are up. Um, because what it does, I've never seen a book like that, it exposes the problem of many mental health practitioners not having let's just say enough education in mental health care. And but you lay out a roadmap for reforming the system. So why don't you tell us, you know, about this book, about what you found, why is early detection important? Go ahead.

SPEAKER_03 11:17

Sure. Well, I I've been in this business since 1978, and I and many others have been working to get mental health care improved in the US. Um, medicine is not doing much about it, and so I decided to go to the public. That's the reason I wrote this book. Um your listeners and viewers are apt to be a little upset about what I'm going to tell you right now. Everybody knows there's a mental health crisis. What people don't know is why it's happening. Simply put, primary care doctors are providing care for 75% of all mental health patients in the US. But they haven't been trained for this job. And the result is predictable. They overlook the vast majority of diagnoses altogether. The few they make and proper treatment, it is ineffective. The downside of this is absolutely devastating. Unrecognized mental illnesses, depression, anxiety, addiction, serious mental illness. Unrecognized problems like this lead to divorces, school failure, job failure, addiction, homelessness, incarceration. And it is not their fault. Don't blame your primary care doctor for this. They've not been trained. In fact, if you talk to any of them, I've been always talking to them. One the other day told me, said, Bob, there's no psychiatrist in my town. Another one says there's two or three psychiatrists, but it takes nine months to get in to see one of them. And the point I'm making here with these examples is that psychiatry sees no more than 12% of all mental health patients in the U.S. Psychology sees probably another 12%. That means 75% are being left to untrained primary care doctors. And the solution to this is fairly straightforward. Train the doctors who are providing the care. But medicine has resisted this, and this is why the public needs to become informed and inflamed and start taking charge and doing something about it. And we can perhaps talk about that and it's detailed in the book.

SPEAKER_04 14:01

One thing I really liked about the B the maybe the first third of your book, you go through why this is the case. And I'm just going to cite what I thought was the most graphic example in your book. And that was in the 16th century, um, the Catholic Church dictated that dissections where medical students were learning about the body. First, the head had to be sawed off because that was, they wanted to take that head and put it in the church or wherever they were dealing with, that sort of thing. And then the body was what was dissected, but they weren't even looking at the things in the brain that we now know show the progression of schizophrenia and other other diseases. So I thought that was really interesting. Um, and then you mentioned that this um the training of doctors hasn't really been updated for 120 years. And um, so I'm wondering what kind of um steps have you taken? You said there's resistance, what have you done? And is there any kind of a growing movement? Um, and do you think your book will be a catalyst for just simply changing the education? You showed how there isn't hardly any. You had the charts of what they actually get each year, the students.

SPEAKER_03 15:25

Sure. Well, let me make it explicit about training, and you're right, it hasn't changed in a hundred years as far as mental health is concerned. Medicine, this is now over four years of medical school, three to five to six years of residency, provides no more than two percent of all of that time in mental health training. Now, this is in spite of the fact that mental health problems are the most common health problem in the US. They're more common than heart disease and cancer combined. There's some one-fourth of all people in the country will have a mental disorder sometime in the next year, one-half over a lifetime. So it's incredibly common. And what's medicine doing? It's not training, it's graduates to care for the most common problem they'll see. This is where the title of the book comes from. Has medicine lost its bloomin' mind? Um and so and and this relates in particular, this isn't just garden variety, depression, or anxiety, or drug abuse. This relates to serious mental illness. As you all know, I'm sure but better than I do. I again I'm a primary care doc internal medicine. Uh, but I've had had psychiatry training and so on. But I'm not expert in psychiatry, but there is a two to five-year pro-dromal period before people actually become schizophrenic. Um this happens in at least three-quarters, if not more, of all patients. Now, in this prodromal period, people are not accessing psychiatrists at all. Now, for serious mental illness, once diagnosed, does require a psychiatrist. Primary care people can't manage that primarily. But where they play a key role, if they were trained, is in spotting problems early. The kid or the woman who suddenly loses interest in school, starts becoming depressed, withdrawn, all of these are warning signs that something is wrong. Minor psychotic episodes, lack of interest in things, difficult relationships. All of these are warnings. Now the doctor would need to spot the problem and simply be aware this is possibly prodromal schizophrenia, and then make proper referral. They won't take care of it. Right now, they don't even have a chance of recognizing. Most of them don't even know there is a prodromal period to schizophrenia.

SPEAKER_00 18:24

Wow.

SPEAKER_03 18:25

So these these are critical issues all across the board. It isn't just minor mental illness, if you can say that, but it's serious mental illness also. And in serious mental illness, I'm sure you know better than I, but the mortality rate is much higher. Many people with serious mental illnesses are dying 15 and 20 years younger than other people.

SPEAKER_01 18:54

And and and not living such great lives until then, Mimi, you look like you want to say something.

SPEAKER_05 18:59

Yes, I I I have a question because we've been we hear this, and I've been hearing this for many, many years, these red flag signs, loss of interest in school, grades dropping, friends. But the thing that I always say is if you were to make a list of uh red flags for mental illness and normal teenage behavior, you'd have the same list. They're oppositional, they're confused, they're angry, they don't know what they're doing, they're impulsive, all these things. And um, I know that's what I went through with my son. It's like, well, this is how teenagers just are. So my question to you is as a doctor, you know, if you identify these symptoms, if you will, that can be um found during that perdermal stage, can you assign a probable diagnosis of schizophrenia to it and do any kind of um mitigation or treatment that's going to make it any better? Because you see, I think back to my my experience, and uh, you know, believe me, every night of my life I lie in bed and I think about what could I have done different? What didn't I see? But even if I had known all that then, what would they have done when Nick was 17 and it and and showing all these signs, but kind of just like a regular teenager does.

SPEAKER_03 20:28

Sure. And that's that's a problem. Um throw into that untrained primary care doctors who who you who will simply think it's probably just a teenage problem. Um in fact, there are things that can be done. Many of these people become depressed, it can be treated. But the critical thing or minor psychotic issues, this this would worry me about some incipient problem. But the critical thing is recognizing if any kid starts failing in school or they've been doing fine before, of course, you look at drugs, but also incipient prodromal schizophrenia, and it's simply getting it on the table. It has been shown that the sooner the diagnosis is made, the shorter this prodromal period is, the better the response to treatment once they become schizophrenic, and the better the follow-up is, and the shorter the subsequent episodes are. And so I I agree with you, and I having raised three kids, I know what you're talking about, huh? But uh it has to be on the radar right now. These people are coming. I used to work on the inpatient service, supervised at Michigan State. And we would see psychotic or schizophrenic, overtly schizophrenic people coming in there to make a first diagnosis. And when you go back into their history, this has been going On for three, four, five years, problems, they all of a sudden start falling off the cliff. And I I can't answer your question how you're actually going to diagnose it, but I do think it does some good in getting attention and perhaps getting them into the psychiatry system early.

SPEAKER_05 22:18

Well, one thing that comes to mind for me is that one thing is if back then somebody had said to me in no uncertain terms, this could be schizophrenia, keep him away from marijuana at all costs. That would have made a huge difference. Yeah. Because we didn't know.

SPEAKER_01 22:42

Exactly. Um, Mindy, and then I have a question for Bob, and then we're gonna bring in Vinod. Okay.

SPEAKER_04 22:49

Um, I was when Jim uh went, Jim actually himself made an appointment, went to our primary doctor um when he was in college and having these symptoms. And the doctor did uh say that he thought Jim had depression and prescribed an antipsychotic. I liked your answer better when you said you would refer to a psychiatrist because by getting that, it was a very strong uh antidepressant we found out. And by getting that and adding to it his produromal schizophrenia, which we didn't know about at the time, it just set him on fire. He went manic just like that and you know, punched holes in our walls, and we had all sorts of issues and had to call the police. And um, if he'd been referred and maybe gotten a softer antidepressant or not so much, or somebody who knew a little more about it, then that might not have happened. But um, so I liked your answer to refer. I think that's a good practice for all specialists. You know, the primary should refer the minute that gets it, he or she gets in the DPIN. My question then is though, what about um nurse practitioners? You know, you can't get in to see a psychiatrist. There don't seem to be even enough general practitioners anymore. And so often when I go to the doctor, I end up with a nurse practitioner if I need to go in and I can't get my regular doctor. Are they trained any better than um general practitioners?

SPEAKER_03 24:30

Um not really. There are so-called psychiatric nurse practitioners who are extraordinarily well trained, and if you have access to them, that that's ideal. But nursing trains a bit more in the so-called biopsychosocial model and in mental health things, but they are not trained to diagnose and manage even garden variety depression, much less serious mental illness and recognize it any more than medical people are. And so I don't think you can be comfortable in thinking that nurse practitioners or physician assistants or primary care doctors, any of them are going to be much better at recognizing and treating mental disorders, or in the case of serious mental illness, recognizing them quickly and referring them quickly to uh sick.

SPEAKER_04 25:31

Uh, I'm their training hasn't been updated either, then that's discouraging. Well, whatever we can do to help promote uh when you get some kind of movement that we that I would love to plug into it as in my state and get people on it to update that education. Sounds very interesting.

SPEAKER_03 25:52

Is I'm not advocating that every doctor that goes on in primary care become a psychiatrist. They simply need to be as competent with mental health problems as they are with medical problems. Psychiatry and psychology still have a big role, but I think it will largely be in a referral from a skilled primary care doctor.

SPEAKER_01 26:15

Thank you. Yeah, I I love what you say, put it on the table, because I will echo what Mindy and Mimi were saying as a mom, is that no one, first of all, I did not educate myself about schizophrenia. When you have a baby, you're like, you don't go, oh, let me educate myself about schizophrenia. You know, you're you're doing diapers and you're doing all those pediatrician things. If you've never had schizophrenia in your family, Mindy, I know you did with your grandmother, but if you've never had it, you don't think to educate yourself. And when my son was going through the prodromal stages, if if someone had said to me, you know, just in case, let's put this on the table, you know, then I would, and because who's on the front lines? We are. And if they had said, This is an I, you know, here's a pamphlet, this is what you need to look out for, you know, I'm gonna give you a name of a doctor just in case, just to get it out there so that when the families see what the signs are, or even if it gets to the case of first psychosis, which we're going to bring in another guest to talk about in a minute, that would help us. And I will mention this, I don't know the exact title of the book, but I'll put it in the show notes. With what you said, Mimi, about marijuana. There's a book called, I think it's called 10 to 25. It's about, um, and they're considering adolescents now starting a 10 in this particular book about the brains of adolescents and how to reach them. And basically, in in this book, he speaks about it's not so much getting the mom to talk to the kid about marijuana. It might be the nurse practitioner or the doctor saying, hey, you might have this thing. If you have this thing, here's what you need to look out for. And putting putting the responsibility on the adolescent is something that I'm not sure about mental illness, but I know with diabetes, they've they've had studies that show if you tell the kid, hey, you can't do this, it's much more effective than telling the mom to tell the kid what they can't do, because we're all moms and we know how that goes. So um Bob, just real quickly, and you know, you're not leaving us, you're just kind of going in the background for a minute while we talked to Vinode, but do you feel that medical schools don't properly have this in their curriculum? Is this part of your roadmap for reform?

SPEAKER_03 28:45

Yeah, serious mental illness is as ignored for medical students and residents as much as lesser degrees of still uh difficult mental illnesses, depression, anxiety, drug abuse, that those are kind of the common mental health problems you see in primary care. But none of this is addressed. Uh there is only the only training, only supervised training students and residents get is an average of 5.1 weeks in the third year of medical school on a psychiatry rotation where they might see somebody with schizophrenia or psychosis and have some attention to it. But the idea of supervised care has not covered mental health, particularly serious mental illnesses, throughout the entire rest of seven rest of seven years or so of training. And so they get a smattering of it there, but it's long gone by the time they end up in practice. Uh, it's simply two percent of training time, is all that goes. Medicine supervises training to who laid the rail of heart attacks, cancer, strokes, emphysema, name it, can't all everything. They don't do that with mental illnesses, even though they're the most common health condition in the US.

SPEAKER_01 30:13

Wow, that is that is eye-opening. Thank you so much, and I'm so glad you wrote this book. Again, the title, Has Medicine Lost Its Mind? Why our mental health system is failing us, and what should be done to cure? You have a roadmap in that book. With that in mind, I'm gonna bring in um Vinod Shrihari. And I I've just met Vinod, but I did speak to um someone who works with him named Nina. And I was in a mental health committee meeting, and she spoke about this program in New Haven, and uh it's called STEP, and the only thing I'll say, and I'm gonna let you explain it, Vinod, is that it's a clinic staffed by mental health providers, but it's not just about doctors. Other people can be educated early for these early signs for early treatment, like social workers and nurses and school psychologists. So, Vinod, tell us about STEP and tell us what your mission is and what's going on.

SPEAKER_02 31:16

Sure. Yeah, and thank you for having me on. Um so STEP is uh the specialized uh treatment early in psychosis program, and it's based at the Connecticut Mental Health Center in New Haven. And we started as a clinic in 2006, um, and we were really implementing something that had been shown in other countries around the world, which is uh if you organize care um for people who are early in the course of schizophrenia uh using a specialized team that is oriented towards young people and towards new families who've not interacted with the mental health care system before. And you provide um what are already available and established treatments that are based on empirical evidence, uh medication, psychotherapy, assistance with going back to school or college, assistance with finding work. So interventions that are not um uh novel in the sense that they aren't experimental but have already been shown to work. But if you pay some attention to packaging it together with a team that's oriented to young people, you're much more likely to engage them into care and to keep them in care and to get better outcomes in terms of functioning, avoiding relapses, getting back to school and work. So about 30 years ago, uh there was uh a series of articles and some innovative programs in Australia, uh, Canada, the UK, Northern Europe that had shown that this was possible to do um and that it was cost effective. And so uh we implemented this program in 2006 based on some of that information and completed a randomized trial with NIH funding showing that you could run this program within a publicly funded community mental health center and improve outcomes compared to usual care in the community. So that was the sort of the first iteration of step and since um since addressing that issue of quality of care, we did another study that was funded by the NIH to try to reduce access delays, which is um a different kind of challenge. It involves having the clinic engage with the community around, because as you all know, pathways to care after um a psych a psychotic episode can be quite prolonged and tortuous and confusing. Um and so we we ran a campaign for four years in the greater New Haven area to demonstrate that we could shorten this delay from psychosis onset to treatment. It's called the duration of untreated psychosis. And we did it in a controlled way. We had a we had a site in Boston that provided very similar treatment but did not mount this public awareness campaign because we were trying to demonstrate to ourselves and others that any reductions we saw in delay were because of what we were doing uh in the community to campaign uh to shorten the delay and were not just related to accidental factors that happened to change over the course of time. So this campaign, which we uh branded as Mind Map, used a combination of media messaging, uh social media, mass media, to try to find people who had y had not yet tried to seek help. Uh these might have been individuals or families who didn't even know that they were confronting psychosis. They might have been confused about what it was. So there was a lot of education, educational messages we put out into media. The other part of our campaign was to target uh providers. So these are individuals who might have identified psychosis, but we all know uh that from that point to getting someone into ongoing care is another journey. And so we wanted to make it very easy for providers in our region to send individuals to us. Um and the third part of our campaign was reducing wait times at our front door, uh by which I mean we we don't we never had a wait list, we we still don't, but between the time a young individual agrees to come to care and when they actually show up for care, many, many weeks or months can elapse. And so we had a quality improvement approach to drive that down to less than a week, and we we now average at less than three days. So the idea being that people are very ambivalent about getting care, especially if they've never been in treatment before. And the best way to cut through that ambivalence is to bring the person into the clinic to see what care is like, which tends to be an anticlimax. It's just people talking to you.

SPEAKER_04 36:12

Uh, but can I just uh yeah, can I just excuse me? I just have I am just blown away that you have never had a waiting list and you still don't. Um we have a first episode program in uh Minnesota with, I know you work with Yale and we work with the University of Minnesota and NAMI and um a hospital, and and uh it started after years. Maybe we copied what you're doing, but um, it's a wonderful program, but there's always a waiting list, and people beg to get in and they can't get in or they don't know about it. And so you have this wonderful outreach campaign where they know about it and they can get in. What kind where do you get the funding that you don't have a waiting list?

SPEAKER_02 37:00

Yeah, no, it's it's um it's a great question, and um, I think in every system and setting and state there are different kinds of challenges. So uh the center in which uh the the clinic was built is a public academic collaboration between uh Connecticut's Department of Mental Health and Addiction Services and Yale's Department of Psychiatry. So the operational funds come from the state and all the leadership and staff are from the university. Um and when we built the clinic, it was very important to us that we not have um delays related to insurance status, which uh in our state and in many others, ironically, having commercial insurance often leads to delays because there's a lot of confusion about where you can go for care. So our public center, which um traditionally serves people with Medicaid, Medicare, or no insurance, uh agreed to take individuals with commercial insurance as well. Um so we have since 2006 taken people without regard to what their insurance status is. Um and they were provided two years of care. So here's the catch, I guess, Mindy, which is we still provide a limited number of years of care. It's now three years of care. And before that time elapses, we graduate individuals to routine care in the community so that we keep we can keep our front door open. So that's the way we manage flow is we provide early intervention, but we also move people along so we can keep um slots open for people coming in. So we've managed to to run without um having a wait list um since 2008.

SPEAKER_04 38:44

We move people along too. We move people along as well, but still we have a wait list. So congratulations.

SPEAKER_01 38:51

Um my understanding, Vinod, is also that see, part of this is uh the um awareness and the willingness of a young person. And when you say young define young, what's your population you treat?

SPEAKER_02 39:04

16 to 35.

SPEAKER_01 39:06

16 to 35. So that's a wide range. It's almost 20 years of of early psychosis treatment. Isn't there a number they can call? Like I I remember Nina saying something about a number that if they call for help, you'll help them. Is there if somebody's how do you get people in? Is it referrals? And tell and I want to also know more about your campaign to educate everybody about early signs so that you can get these referrals.

SPEAKER_02 39:36

So I I just put the background that our marketing team would have wanted me to have. But so the campaign is called Mind Map. Um, so if you Google Mind Map or you Google Step Yale, um you'll find all the information on our website. Uh, and there is a single number that anyone can call from around the state. Uh it's 203-200-0140. And if you can't remember the number, uh Mind Map or STEP or Psychosis and Yale are terms that will help you find our websites. Um this campaign mind map we tested for four years between 2015 and 2019. And we targeted just 10 towns in the New Haven area because we calculated that that's the capacity we'd be able to absorb in our clinic. Um and we were able to uh half the delay from about 10 months to about five months over the course of those four years of campaigning, and that's the campaign that we're now scaling up across the state. Um where we've partnered essentially with all the local mental health agencies. So this is the the publicly funded mental health system that's I like to think of it as like the skeleton of public mental health services in the state, who have all agreed to take individuals that we send to them, that we screen when they call this number and determine that they're uh likely early in the course of a schizophrenia inspecting disorder. We do this on the phone or on Zoom within 24 hours, and then we refer them to this network of 20 clinics that have all accepted to take them again without regard to insurance status and with no waitlists. And we're one year into now this statewide effort to scale up uh rapid access to care. And we are gonna follow outcomes for everyone. So um our goal is to over time provide workforce development to all the clinics that need them and to share lessons across this network so clinics that are doing better on hospitalization outcomes or vocational functioning can share their lessons with clinics that are not doing so well in terms of the outcomes of the populations they're treating. So we we've built a uh a statewide learning health system which is collecting data on outcomes and uh aims to use that to improve performance over time. Um so that's the that's the that's the goal.

SPEAKER_01 42:11

Can you thank you? So interesting, and I'm hoping that this is a model that I know you're you've just spread it out across the state. So as you gather more data, it might help other states as well. Can you speak to the value of early education for many providers into the signs of mental health? And and Bob, you can turn your microphone on as well. You know, so what what you're doing, how does that relate to what Bob is talking about with people being more educated?

SPEAKER_02 42:46

Yeah, I know Bob spoke about this eloquently. I I agree with everything he said. Um, I guess what I'll add there is um, you know, primary care is absolutely a vital part of this um network of care that we conceive uh, you know, in the state. So when a person has a psychotic illness, it's it's a puzzle for the entire community. They might have this illness, and the first responder might be a pastor in a church, it might be a high school teacher, it might be a college professor, but they almost always in the year prior to coming to us have seen either a pediatrician or an internist or required vaccinations for school for some reason. There has been contact. Um, so it is a challenge though, given the busy workflows in primary care, to have providers screened for mental illnesses. So um our campaign doesn't rely on any one of these nodes. Our effort is to educate everyone in the community and to activate them as a network of people. So I I would say most people want to know how to help. Uh, when they see something wrong, they often are not empowered to know what to do. And our goal is to give them a simple call to action, a telephone number. We take calls from anyone, uh, any of those people, any agencies, bystanders, police, uh, to try to help figure out how we can get that young individual into care in as comfortable a way as possible. And of course, that isn't always the way it usually goes. Um, there are sometimes unwelcome interactions with the police, with emergency rooms. But we've been reaching out to police departments in the state, and some of them are incredible leaders in their community who are very open to the notion of serving as a conduit to care rather than to jail, you know, when they can. So our message for identifying signs and symptoms is going to every stakeholder group, uh, not just primary care. And it's in part an acknowledgement of what Bob has already talked about is it's it's been very difficult to um to get primary care to function as a kind of referral node for reasons I think that have to do with partly what Bob said, training, but also just time and all the different tasks they have to do. Um, and I would add too that young people um having these illnesses, as you all know, sometimes have reasons not to want to divulge what's on their mind. And so they might arrive at a very receptive clinic, but uh not want to talk about symptoms they're having for fear of being strapped down and sent to the EER or shocked. So I think some of the fantasies they have about mental health care get in the way of their willingness to tell even an attentive clinician what's happening. Um, and mental health systems have not been very good at marketing our services either. And so some of our efforts are to try to use marketing actually in a very deliberate way to advertise what we do in our clinics that could help them, which might mean help finding a job, help going back to school. You don't have to take medications to come to our clinic, for example. And our intent is not to send you to the hospital and lock you up against your will, even though, as you all know, sometimes that's necessary. In the main, we're talking most of the most of the time. Yeah.

SPEAKER_01 46:21

I have there are five of us here, so yeah, so I was just gonna say it's good to raise our hands now, and I'll call on you. So Mindy, you go ahead.

SPEAKER_04 46:31

Okay, I have a question for both of you. Uh Randy mentioned anasygnosia, and um you were saying the node about uh maybe the young person doesn't want to talk about what's going on, or they have preconceived notions about the mental health system. What if they have anasygnosia? And that means they don't really believe their brain does not allow them to know that they have mental illness. And so no matter what you do, they're gonna maybe think it's scary or they're maybe gonna think it's fine for somebody else, but they themselves do not have any mental illness. So there's no need for them to participate. What if Mimi showed up with Nick? She somehow saw your outreach and uh got him to go, but then he said, uh, you know, heck no, I am not going to participate and went home. Is can Mimi participate? Can she um what can she, you know, what do you do about people with anasygnosia? Because that's a big, the biggest reason people don't get treated.

SPEAKER_02 47:40

Yeah, um, so I I've you know I've been working with individuals with psychotic illnesses for more than 25 years now. And I I will say something that I think would sound strange to people who have not um um uh uh been with a person with schizophrenia or treated them, which is much of the time we learn to work with people uh effectively, even though they don't agree that they have an illness. And I think it's something that seasoned clinicians do all the time. Um and I think it's it's it's a mix of offering something that the person does find uh attractive. Uh so like I mentioned, there are some individuals who come to our clinic because we help them find ways to get back to school or work to meet some personal goal that was interrupted when they became ill. Uh, admittedly, some initially come in because their mothers uh twist their arms and bring them in. Um we we never make um acknowledging that one is ill or having insight um a requirement for being in care, because if we did, that would just be a recipe for prolonging the duration of untreated illness. Um while I agree this is a real challenge, um and in terms of a public campaign, uh, we are often campaigning to people around the person uh because the person themselves, once they've had a psychotic illness, may be uh not as receptive to the message that this is something that requires professional care. So I'll say it is a challenge, but I found that um we're very happy with many individuals who have an excellent course of treatment, but but if we had to sit them down and argue with them about what it is they have, we would not be on the same page. And that's a win for me. I'm willing to live with that. Um but but you're absolutely right. This is this remains a challenge, and um and especially with individuals we find early in the course who often respond very well to treatment, uh, they will often stop treatment because they responded so well. Um, and they don't see evidence of needing to continue medications. So, so it's it's a yeah, I I don't know. Uh I will add one more thing in relation to what Bob mentioned. We have done some um, we have some evidence to show that people who are in the prodromal phase, that is before they've had a frank psychotic episode, uh often have much better awareness that they might be ill and are more willing to seek out care themselves, versus once they've um had a frank psychotic illness, we're often relying on their mothers to bring them in. Um so you know, there is an opportunity with earlier detection to bring someone into care um before they've had an episode that might bring them into conflict with their neighbors, with the police. So in some ways, that is the next phase of progress uh is identifying people before uh in a way that welcomes them into care, that doesn't uh label them with a concern that they may not welcome at that point.

SPEAKER_01 50:51

Thank you. Bob Bob, anything to add to that thoughts?

SPEAKER_03 50:56

Well, I Vinode uh has expressed it nicely, but the the critical thing I think would be establishing a good relationship. And I think Vinode has expressed that already so nicely, but in getting someone into treatment of any sort, uh often when they don't agree that there's a problem, you first have to establish a strong doctor-patient relationship, and that may not occur at the first visit, it may occur over weeks to months, but it it requires that, and and even then, and I think as Vinod was alluding to, you can get them into treatment and seeing you and accepting that they don't think that they have a problem. I don't think you have to convince them to articulate that they are schizophrenic to be effective in treatment, but I would certainly defer the the loan on that.

SPEAKER_02 52:02

No, I totally agree. Thank you for bringing that up, Bob. I think the building an alliance is so key. Having said that, um, as providers, we have to work hard at that. Um, I think as mothers, you're actually living with a person who's often refusing uh care. So it's uh uh I I think you're dealing with something far more complex than we are. And sometimes it's helpful to have a clinician who's not who's not in that fight because um, unlike you all, we can get fired. Um, and so I often explain to family members that while I agree with them that it's frustrating to have a person being unwilling to come for care, we we have to rely on our marketing skills, so to speak, because we could get fired at any moment. And even with assisted outpatient treatment, you know, it it's tricky to maintain a treatment relationship without some kind of mutual shared alliance, even if it's not based on um an awareness that one is ill.

SPEAKER_01 53:04

That that's quite true. And you know, we're we're down to our last five minutes, and I I just I keep thinking of this story that might illustrate it. One of the most I've heard you both say very powerful things, but one thing that's really hitting home for me is that if you can catch them before that first psychotic episode, before it, and that's when you get the diagnosis, because it's this much from Column A and this much from Column B in the DSM. I get that. But I remember my son, he must have been about before he dropped out of school, so 15 maybe, so prodromal, but not yet psychotic. And I remember I was having a tough time with him in that, oh, tough adolescence phase. But one he was in his room looking through photographs, and there were photographs of him with his best friends and youth group who he hadn't spoken to in a while because he was getting very isolated and writing poetry and thinking that everything's a government plot. And and I remember he sat in his room and he just looked at the pictures and he started crying and he said, Mom, I used to be so happy. Why aren't I happy anymore? I'm gonna go take a walk and figure it out. Because he thought he could figure it out by himself. But that is the moment if I had known, or if someone at school had been able to say to me, or if a rabbi or a pastor or, you know, somebody had said, I took this class in school, and you know, maybe we could consider that this might be the beginning of something serious, and if we can catch it sooner, you know, here's a pamphlet. You know, there's it just like I remember I I've heard that there's brain damage every time you have a psychotic break. So I don't know where my son's recovery can be. I know when he was on closer, he was doing really well, but I would say we got him back 65% and I'll take it. And it was enough because it was working, and you know, now he's 10%. I I don't know. I haven't seen him because I'm doing with his practitioner exactly. I'm they keep saying he trusts us now, and that's where I'm leaving it. I they he doesn't even know I'm speaking to them because I need to be out of it. He needs to find that trust. But so that's very powerful to me. That like see the signs, see if you can catch it before the psychosis. So, what I'd like to do is just focus in the last few minutes on what would you like the system to do? What would you like to happen in the system? And that includes educating everyone, like, what would you like to vouch for so that more people can be caught and helped before they reach the stage where recovery might not be as possible? Uh, Bob, I'll go to you first.

SPEAKER_03 56:04

Sure. Um on my website, and it's Robert Csmithmd.com. On the very first page, there is a spot where the you can, it's called join in to there's a sample letter that can be plugged into your own email, and then there's a link to email addresses of relevant people, including senators and congress people, where you can find their email and then plug it into your own with the sample letter below. There's a space to even give your own experiences with it, but it is advocating that medical education be investigated for its lack of a scientific approach and failure to address mental health care, and it's only at this level with federal action and then direction that anything's going to happen. And here is a way you can have input uh directly to your representatives.

SPEAKER_01 57:14

Love that. Thank you, Vinod. So we have roadmap and mind map. Okay.

SPEAKER_02 57:22

I'll turn the question around. You know, I I am I am in the healthcare system in Connecticut, so I want to know from people in Connecticut what we should be doing better. We are trying to collect data and we're trying to um publish an annual report every year on how many people we're getting into care, how fast. And our goal is to get everyone with a new onset um schizophrenia spectrum disorder in Connecticut into good care fast. Um if you're asking what my wish list is, I would want uh more resources for research to help with better early identification. And some of this is happening at Yale, and we have a sister clinic that if you have us back, um Randy, we can I can introduce you to my colleagues who are working on improving early detection before the psych the first uh episode. And I think on the other side, uh better payment models that don't punish clinics for spending time coordinating services that are currently very hard to bill for, um, or spending time with family members, which again is something that's hard to bill for. So maybe those will be my two things.

SPEAKER_04 58:32

Thank you, Mindy. I wonder, Vinot, have you gotten involved in what Randy's gotten involved in, the push in Connecticut for AOT, which is one of the tools in the toolbox? It would be so much better to do what you two are saying, get in early, develop relationships, you know, rule people in, don't argue about if they have schizophrenia or not, just get going on something. But in um extreme circumstances, which my family has certainly been in, our son has been civily committed seven times and extensions because he had severe anasygnosia, and now he doesn't, and he's doing really well. But have you gotten involved in that discussion? And if so, could you share what you think?

SPEAKER_02 59:21

Yeah, no, I I have been involved in discussions around that. I I think um uh I think we would want a society where when a person is clearly not able to make good decisions, we don't wait for them to actually hurt themselves or someone else or inadvertently commit a crime before we provide care. So I think we we have to do better than the current approaches we use. Um, I think when it comes to nudging people into care, whether it's some kind of outpatient commitment or AOT, I think those are good tools to have, and we just need to be very careful about how we implement them and make sure that that as far as possible we use uh a shared decision-making approach. And when that's not possible, we're very careful about um not inducing disparities that might occur quickly when um people are being forced into care. So my my answer is it needs to be done well, uh, maybe is is a is and I think I think we can do it in Connecticut. We just need to think through it and and move ahead. Yeah.

SPEAKER_01 1:00:28

Thank you.

SPEAKER_05 1:00:29

Um you know what I keep coming back to in my mind is this division that's created by having one guy is in charge of from here up, and another doctor is in charge of from here down, and knowing so clearly it doesn't work that way. And again, the communication, you know, what's ended up happening in as Nick's life has unfolded, is it was actually the doctor who delivered him who helped me when he started having a psychotic break because I couldn't get to anybody else. And it was also a general practitioner when we moved to the country who helped me because there were no psychiatrists, and it just seems to be that it's so splintered, and it's communication because if we had been given as moms, if we had had the knowledge we have now back then, there's I would have handled things so differently. When they're 15, 16, 17, you have to worry about HIPAA, you don't have to worry about, but but you're busy worrying about the rules of parenting, and you don't want to overstep this bound and overstep that bound. And if I had known that this is what I was dealing with, I wouldn't have cared about you know what anybody thought. I would have done what I knew was best for my kid. And that again is the education and the psychiatrist talking to the doctors and the doctors listening to the parents, and it's this education of um listening. And I look at it and I think that that's really where the solution lies.

SPEAKER_01 1:02:11

And uh and on that note, really a question, it's more of an opinion, but now that's a great opinion. Now I share it.

SPEAKER_05 1:02:18

I think Nick was the doctors will appreciate this. When Nick was first sick, and they told me to that he was first diagnosed with bipolar, first depression, then bipolar, and then eventually. So from 16 to 20 were all these diagnoses and all these different medications, and he didn't want to take them. And so I said to the doctor, I said, you know, the only thing I can possibly think of is I could offer to pay him if he would take his meds, but that just seems like the worst thing in the world to do. And that doctor gave me good advice. He says, all bets are off. Everything that you think you know about parenting, put it aside. All that matters on the earth right now is you get this medication into this kid every day. And I remember sitting in the kitchen around the kitchen counter there with my younger daughters there, paying Nick $10 a day to take his medication. And these girls look at me like, well, nobody ever paid us to take our amoxicillin. What is going on here? And it was just like, but I knew, I knew because the doctor had given me permission. He had explained to me that it doesn't matter. Get the meds into it, into him. And I mean, these are the things we need to know, these are the conversations and the communication that needs to happen. Not everybody running around walking on eggshells, afraid to do anything.

SPEAKER_01 1:03:47

Thank you. Thank you for that. This has been a fantastic discussion, and I'm so glad we had you on together. Dr. Robert Smith, his book is Has Medicine Lost Its Mind? And the website RobertCsmith.com. Is that what you said?

SPEAKER_03 1:04:06

Robert C SmithMD.

SPEAKER_01 1:04:08

Robert CsmithMD.com. And on then mindmapcct.org is the website, and you or you can just Google step, what did you say? They should Google psychosis CT, early intervention, you'll find it. It's right there. Thank you so much for the work you're doing and the information you're spreading. And if you're listening and you're thinking of going into pastor work, social work, high school teacher, guidance counselor, take that elective in mental health. Take that elective because you may have a family. We're three moms in the trenches. Thank you so much for joining us. Thank you so much for tuning in to this episode of Schizophrenia Three Moms in the Trenches. You can help out the podcast and help others by sharing the podcast and by subscribing wherever you get your podcasts and or on YouTube. And remember, you can reach us at mindygryling.com, randyk.com, or Miriamfeldman.com.