Reaching Across Stockton by Ron Risley, MD

Take a walk along Stockton Boulevard. Head south from U Street, and on the right you'll pass 2250 Stockton Blvd: the

Sacramento County Mental Health Treatment Center (affectionately known as SCMHTC). Keep heading south, past the Coca Cola bottling plant, and you'll reach the UC Davis Department of Psychiatry and Behavioral Science. It's an attractive but low-key building, also on the west side, nestled between a telephone company switching station and a La Bou fast food restaurant. Now look east across Stockton and behold the monument to modern medicine that is the University of California, Davis Medical Center. The sprawling campus has it all: lush lawns, a rose garden, hospital towers, clinic buildings, parking structures, water fountains, the emergency room. Gurneys, elevators, operating rooms, MRIs. There's radiology, burn management, and surgery for everything from your eyes to your toenails. There's internal medicine and family practice. You can get care for you liver, kidneys, stomach, intestines, colon, skin, lungs, heart, bones, muscles, nervous system, ears, nose, neck, spine, and reproductive organs. Oncology, neurology, nephrology, urology, pathology, cardiology, pulmonology, surgery, dermatology, ophthalmology, gynecology... it seems there's a clinic and hospital beds for every imaginable medical problem... except mental health. For that, you have to cross Stockton. Psychiatrists are fully trained and licensed medical doctors. They go to the same medical schools as other doctors, take the same medical board exams. Yet, somehow, a year or two after graduating from medical school they pack up their MD degrees and cross Stockton to the mental health ghetto. The gulf between mental health and the rest of medicine might not always be as tangible as Stockton Boulevard, but that gulf is there wherever health care is practiced. Insurance companies offer different benefits, limits, and co-payments for mental health. Where the law prohibits that practice, they often farm out the "mental health benefit" to a different company to manage it in a separate (but equal?) fashion. Imagine if your health insurance required you to use an entirely different set of telephone numbers, forms, utilization reviewers, diagnostic codes, and procedures for a lung problem like asthma than for a broken bone... and heaven help you if you get a rib fracture that affects your breathing! If you're a family physician, an internist, a radiologist, or a dermatologist you might practice in a fancy building with your name, credentials, and specialty emblazoned on a sign over your door. If you're a psychiatrist, you're more likely to be practicing in a nondescript office suite with discreet parking and minimal signage. People hide their psychiatric medications and fear that, should they have the misfortune of having to go to the ER for a medical emergency, they will get labeled a "psych case" and won't have their symptoms taken seriously. You might be "a schizophrenic" or "a borderline," but you'll likely never be called "a colon cancer" or "a multiple sclerosis." So what's wrong with Stockton Boulevard? Is it really so bad to separate mental health from "real" medicine? Yes, it is. The combination of stigmatization and separate (but equal?) Jim Crow funding of mental health care makes it all too easy to single out a group whose public face is shunned by society. Use Google to search for "cancer care cuts" and you get about two million hits. Perform the same search for "mental care cuts" and the figure climbs to over twenty-five million. The Stockton Boulevards of health care also directly affect the quality of care. Patients with psychiatric illness are usually seen many times by primary care physicians before being referred to a psychiatrist. Their diagnosis is often delayed because primary care physicians -- who have trained and practiced east of Stockton -- don't always have ready familiarity with the signs and symptoms of psychiatric disease. They might have a low threshold for consulting with or referring to the cardiologist or orthopedist they had lunch with last week, but when they have to refer across Stockton they are confronted with an unfamiliar system of care and doctors whom they have never met. Psychiatrists often prescribe medications with profound side effects such as weight gain, diabetes, high blood pressure, and high cholesterol. Yet most psychiatrists can't easily reach across Stockton to ask a primary care or specialist colleague how to screen for, identify, and treat those side effects. They often aren't able to do much more than say "see your primary care doctor." Yet the primary care doctor (if the patient has one) might not be aware of the implications of the medication. Would the consequences of stopping the medication be worse than the consequences of high cholesterol? Those kinds of decisions require an interdisciplinary approach that's hard to maintain across a busy four-lane street. Diabetes is a particularly telling case: psychiatrists often have greater access to patients, more time and experience communicating with them, and a lot of insight into how the patient perceives their chronic illness and their own role in managing it. The psychiatrist might also have a much better understanding of the role that psychotropic medications play in causing or exacerbating diabetes, and what other options might be available. Yet it is left to the primary care physician to do blood tests, prescribe medications, and educate a patient who might be seen as difficult or even frightening.

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