One of the excuses de jour of why to not enact stringent gun controls is that the problems would be solved if guns were kept away from those who are mentally ill.

There are lots of problems with this contention:

1. Guns kill. They facilitate violence among human beings. The more guns that are in our society, the more likely it is that someone, deemed mentally stable or mentally ill, will be able to use one. The most effective way to control guns is to reduce their number. It’s kind of like the most effective way to combat obesity is to reduce calories.
2. Who really knows how to define or categorize who is mentally ill? Much as we may like to think otherwise, the fields of psychology and psychiatry are inexact sciences. Labels, diagnoses are things that we are forced to do because the nature of human communication requires descriptions to explain even what is uncertain.
3. For what it is worth, researchers have found that at some point in our lives, over half of Americans will experience some sort of mental illness. We move in and out of periods of our life when we are depressed or anxious. The symptoms of other problems such as manic-depression or bi-polarity occur at varying times in a person’s life. For all of us, some days are good ones, other days are miserable.

Considering that we are people in motion, not just physically but also mentally, it is wise to minimize our proximity to weapons that can either do harm to others or to ourselves.

Consider one of the nation’s greatest proponents of gun rights, Missouri Governor Eric Greitens. To say that he had a bad day yesterday would be putting it mildly. He was humiliated to do the perp walk as he was indicted for on a felony invasion of privacy charge for allegedly taking and transmitting a non-consensual photo of his partly nude lover. Details of what exactly happened fall short of actual facts, at least with regard to what the general public knows. But it is rather clear that there was some sadistic, if not masochistic, behavior involved by Greitens. There was clearly hypocrisy involved as he ran for governor as a man of family values (his official gubernatorial portrait is not an individual one; rather it includes his wife and two children).

But hypocrisy may be normal for politicians, in fact, for most of us. But he has other strange behaviors such as disappearing for days at a time. He is very belligerent towards others. He has few friends, even among those who are supposed to like him like his Republican colleagues.

It certainly is not for me to say that Eric Greitens is mentally ill. However, despite his military career which included being a Navy Seal, he still seems to be rather fragile. Again, that is not an indictment of him in comparison to anyone else. It is simply evidence that if we want to have a safe and secure society, we are better off having as few guns as possible within the civilian population.

Unless Greitens is convicted, he will be free to purchase virtually whatever guns he wants. That scares me. I think that it’s scary for America.

How many times has he been called one of the “good guys,” and as Wayne LaPierre, executive vice-president of the National Rifle Association says, “the only way to top a bad guy with a gun is with a good guy with a gun.”

If only LaPierre and his like knew on any given day who are the good guys and who are the bad guys. I think that’s beyond all of our pay grades, even his, which is high. To be safe, let’s get rid of as many guns in civilian hands as we can.

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Hillary Clinton has just released a plan would treat mental health care with the same priority as physical health care. It’s a well-thought-out, comprehensive policy that deserves attention and support. And, according to some observers, it actually has a chance of becoming a reality. Unfortunately, the announcement of the plan came in the midst of the media clamor over Donald Trump’s bogus trip to Mexico and his hate-fueled immigration speech.

Clinton’s plan calls for some very important changes to the way mental health care is currently addressed in the American healthcare system, where it has long been a neglected stepchild.

In broad terms, according to the Clinton website, the plan would

Promote early diagnosis and intervention, including launching a national initiative for suicide prevention.

Integrate our nation’s mental and physical health care systems so that health care delivery focuses on the “whole person,” and significantly enhance community-based treatment

Improve criminal justice outcomes by training law enforcement officers in crisis intervention, and prioritizing treatment over jail for non-violent, low-level offenders.

Enforce mental health parity to the full extent of the law.

Improve access to housing and job opportunities.

Invest in brain and behavioral research and developing safe and effective treatments.

More specifically, the big-ticket item in Clinton’s plan is, according to the Washington Post,

…$5 billion for community health centers providing substance abuse and mental-health treatment as well as traditional medical care…To address a shortage of mental-health professionals, meanwhile, she would encourage telemedicine, among other things. Clinton also proposed pumping up the budget for basic scientific research, some of which would be diverted into studying the brain.

There’s no doubt that these priorities merit attention. According to a government study, about 1 in 5 adults — or 43.6 million people — had a mental illness in 2014, with nearly 10 million of those experiencing a serious condition, such as schizophrenia or bipolar disorder. The same study said that 2.8 million adolescents had a major depressive episode during the past year.

Unfortunately, conventional payment systems have shortchanged mental-health care. While the Affordable Care Act [Obamacare] made some significant changes in requirements for mental health coverage,  there is much room for improvement. The good news, for example is that,since 2014, health insurance companies offering individual and small-group plans can no longer deny enrollment or charge higher premiums to people with medical histories of behavioral/mental health disorders. Also under the ACA, individual and small–group plans  are required to cover ten essential health benefits with no annual or lifetime dollar limits. Mental health and addiction treatment are among the essential health benefits. Nor can these plans offer mental-health benefits that are less favorable than the benefits for medical/surgical care.

But the National Alliance on Mental Illness published a report in 2015 detailing problems with access to behavioral health providers, and limited coverage for some brand-name drugs, particularly anti-psychotics, says healthinsurance.org. .The report also notes that health insurance companies are still more than twice as likely to deny authorization for mental health care, compared with authorization for general medical care.

Clinton’s plan, says the Washington Post, “emphasizes using the federal government’s role as a major payer in the health industry to encourage the integration of mental-health care into medical practices.”

As for practicality, Clinton’s plan is not just another pie-in-the-sky idea with no hope of implementation. The Washington Post notes that…

Congress has over the past several years put serious effort into reforming the federal government’s mental-health efforts, producing — but not yet passing — a slew of bills with bipartisan backing. This is one of the few issues on which lawmakers may be able to agree, even in a severely divided Washington, over the coming months. The House, in fact, has already passed a bill. Ideally, the Senate would pass its own reform before next year. But, if lawmakers fail to send a bill to President Obama — always a high likelihood given Congress’s slow pace — the next president should enter the policy debate, pressing for lawmakers to finally pass something.

As far as I can tell, there’s no parallel proposal from the Republican nominee, whose candidacy has been, essentially, a policy-free zone [until recently, when he doubled-down on an outrageously hateful, xenophobic immigration “plan.”]

For those of us seeking a President who has actual policy ideas designed to help people, and who is willing to do the work necessary to bring them to life, Hillary Clinton’s mental healthcare plan is very reassuring. I’m voting for the policy wonk.

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People who work or volunteer in mental health services in the St. Louis area are plenty worried, with good reason.  Because of Missouri’s budget shortfalls and huge bureaucratic tangles, funds and services for citizens with mental illness have shrunk to crisis proportions.  This problem is hard to untangle because it involves the Missouri Department of Mental Health, numerous local hospitals and community health centers, providers both public and private, and – looming above all else – the closing of Metropolitan Psychiatric Center (MPC) for emergency room services and acute patient beds. MPC was our state supported adult psychiatric facility in the St. Louis area.  For those who are interested in reading about the closing of MPC, look at Jeannette Cooperman’s excellent article, “Losing It,” in the November, 2010 issue of St. Louis magazine.

The ugly reality

To take a simpler look at the current mental health dilemma without wading through dozens of acronyms, let’s see what happens to one individual with mental illness, not a real person, but a young man who is a composite of those affected, whom we will know as James.

James had the usual ups and downs in high school, but graduated successfully.   His freshman year of college was problematic, although he was still living at home and attending a community college.  At the start of his second year, he had to withdraw because of missed classes, failing grades, fears, irregular sleeping, and angry outbursts with family, friends, and classmates.  He voluntarily withdrew.  For the past year he has lived with his mother, who is increasingly worried and fearful about his future.  Now 20, he has no medical insurance and has lost several jobs. He spends most of his days sleeping, staying alone in his room, talking to unseen people and walking the streets when he cannot sleep.  His family suspects he is abusing alcohol and recreational drugs but is afraid to confront him about it because of his outbursts. When questioned about his substance use, he leaves home for days at a time.

Twice he has been taken to emergency rooms by police.  Admitted for a day or two, he has been given a small number of anti-psychotic pills, different drugs each time. Anti-psychotics can stabilize someone with psychosis, but they should only be used when a diagnosis is established and when the patient can be carefully monitored, particularly in the beginning.

His mother wants him to apply for Medicaid (in Missouri called HealthNet), but without some diagnosis of mental illness, he is not eligible. They have called Hopewell, the community mental health center in their area, but have been told that he cannot get intake without Medicaid. They have called the Helpline at the local office of the National Alliance on Mental Illness for advice, and been told that their son needs a psychiatric evaluation, a diagnosis, as a first step to getting treatment and possible services.  The community mental health centers (Hopewell, BJC Behavioral Health Care, Crider, and Comtrea) have been set up to offer services to those with mental illness living in their areas, but by order of the governor in December 2009, all incoming clients must have Medicaid.

Here’s the crunch for James and his family. He needs a psychiatric evaluation as a starting point for applying for Medicaid, but there is no agency that offers an evaluation to him at no cost, low cost, or sliding scale.  If his mother could afford to take him to a private psychiatrist for this evaluation, (roughly a $300-400 charge), and if he would cooperate, he could get a diagnosis.  At the moment, she is struggling just to make her rent and utility payments for herself and her three children.

Meanwhile, James is in limbo, and he is highly unlikely to get better without treatment.  If he becomes violent or threatening, his mother can call the police and have him involuntarily admitted, but that hospital, like the two previous institutions, is highly likely to discharge James in fewer than three days with a small amount of medication.

What’s missing

Before Metropolitan Psychiatric Center was closed to acute care patients, James could have been admitted through the Emergency Room and kept long enough to get a diagnosis, his medication stabilized, and some social services put in place.  Immediately upon his dismissal, the hospital would get him an appointment at one of the four community mental health centers, where he would regularly see a psychiatrist, get medication, counseling, case management and support for applying for Medicaid.  But those days, unhappily, are over.

Years ago, both St. Louis University and Washington University had psychiatric clinics that saw patients for psychiatric evaluations at a much lower cost than a private doctor.  But they stopped accepting outside patients several years ago.

If James lived in St. Louis county, which he does not, his family could call the Family Mental Health Collaborative, but none of those agencies currently has a psychiatrist on staff.  He is unlikely to profit from counseling until he is stabilized on medication.

James is young, intelligent and articulate, but mentally ill.  He is fortunate in having a home and a mother who has tried her best to get him treatment. With the right diagnosis, medication, and case management, James might very well be a productive member of the community.  But time is passing, and the untreated mental illness continues to do damage to his brain. His window of opportunity is not unlimited.  Every person who cannot get help, like James, is a tragedy for our community, both now and in the long years ahead.

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