Transitioning Care of Patients With Severe Mental Illness

In this video, psychiatrist Ilan Melnick, MD, discusses the transition of care of patients with serious mental illness such as schizophrenia, including the difficulties such patients face, how mental health clinicians can aid in the transition, and the benefits of using long-acting injectables.

Dr. Melnick is Chief Medical Officer, Passageways Residences of Dade County, Miami, Florida. He is a member of the Psych Congress Elevate Steering Committee and presented "Now What? Transitional Care of Patients with Severe and Persistent Mental Illness" at Psych Congress 2020. 

Read the transcript:

Hi, my name is Ilan Melnick. I am a psychiatrist here in Miami, Florida and have a lot of different hats. I run 4 private offices here in Miami, Florida. I have two high-end concierge psychiatric practices, mostly dealing with celebrities, models, and athletes.

I toured with a rock band all over Europe, like relapse prevention, conflict resolution, but that's a very small part of my practice. Another thing that I do is I run a charity clinic in which I see what I call the in-betweeners, the ones who make too much money for government assistance, not enough money for private insurance.

Lastly, I am the chief medical officer of the largest forensic community control program in the United States. It's a program called Passageways. We treat patients who have been found not guilty to reason of insanity for first-degree felonies, so rape, arson, and murder. We developed a paradigm in which we transition people from the forensic state hospitals and the jail settings, and we transition them into the community. We follow them for most of their lives.

The idea is to keep our patients stable and teach them life skills and coping skills so that they can be more functional members of society.

What deficiencies do you see in our societal systems for people with severe mental illness?

One of the things that I see with issues with people with severe mental illness is the fact that we don't have a lot of places in which our patients can go to.

A lot of the places that they have either include just housing, but they don't teach life skills and coping skills. The other piece is that, when they get to some of these places, they try to push them out fairly quickly, as they only have limited resources and oftentimes aren't able to get the care that they actually need.

What we really need is a more enveloped, like where all services are all provided at the same time, so that the patients get the best chance of long-term care. Because of that, we start having issues with patients with severe mental illness in which they really can't deal with this, as it affects them permanently.

These patients themselves have a hard time finding housing, food, and medical treatment. A lot of times, stigma within the medical treatment becomes a big issue, and they don't get the proper care for their health care issues, like diabetes or high blood pressure, oftentimes leading to early death. This becomes a big issue.

Another problem that we have is also dealing with drug and alcohol abuse. A vast majority of our patients with severe and persistent mental illness have issues with substance abuse. Because of that, it becomes very challenging for them to find shelter as well, as most homeless shelters and programs require sobriety as being the first step in getting them in.

The problem is, without the care or the support system, a lot of times, they are not able to give up the drugs or alcohol that they're using. Again, that whole enveloped care becomes a big issue.

Those are the big challenges that we have. Finding proper care for our patients and allowing them to get the resources. Hopefully, we'll be able to manage this in a better way in the near future.

How can mental health clinicians help people with severe mental illness successfully transition into a community setting?

One of the things that we deal with with patients with severe, persistent mental illness is trying to find true, continuous care. When you transition patients from a mental health hospital and bring them into the community without proper wraparound, it becomes a big challenge.

We know that if you don't provide proper medical care and psychological and social services, the chances of them succeeding in the outside world is very low. One of the things that we can do as clinicians is to tell them and explain to them about all the seriousness that they have, between taking their medications, keeping their heads as clear as possible, so that they can find the services that they need. Also, pointing them in the right direction, whether it's health services, legal services, or social services, so that patients can go out and become members of society.

This is one of our biggest challenges, as a lot of times mental health clinicians have a very difficult time, as we don't have the actual time to be able to spend with them to give them all this. So relying on our services is vital. The key here is to know what services are available in your area to be able to truly transition the patients effectively.

How can long-acting injectables improve outcomes in people with severe mental illness?

One of the ways that we can improve outcomes in patients with severe mental illness is by using long-acting injectables. We at our facility have about 87 percent of our patients on some type of long-acting injectable, most of them on atypical antipsychotic injectables.

The idea of using a long-acting injectable allows us to not only assure their compliance to the court system, in our case, but also, it allows us to prevent covert nonadherence. The idea of covert nonadherence plays a big role, because one of the biggest challenges that we have in patients with schizophrenia or bipolar disorder is that these patients don't really know that they're sick.

Because they don't know that they're sick, oftentimes taking a medication, especially once they start feeling better, they feel it's not necessary. The assurance of compliance is vital for our patients to maintain stability and hopefully keep their brains healthy.

One of the things that we know is that long-acting injectables really don't improve compliance. They just assure it. As our patients themselves know, that by taking a long-acting injectable, they know they're being compliant or they're being adherent.

If they miss their injection today, well, then the clinician and the patient both know that they're being nonadherent. The idea of this knowledge is vital for doctor-patient relationships, and there have been numerous studies that have shown that using long-acting injectables improved doctor-patient relationships as well.

In our facility, we've been able to get our patients down to a zero recidivism rate because of the use of long-acting injectables, and we use them all. Each one of them has its particular positive and negative, and knowing those are vital for our patients to get the best care that they need.