The calls to improve the mental health care system in the wake of last week's elementary-school shooting are welcome, and worrisome, for people like Kate Mattias.
"The good news is there's attention being paid," said Mattias, executive director of the National Alliance on Mental Illness Connecticut. "On the other hand, it's attention wrought by a terrible, terrible incident."
She and other advocates have spent years trying to counter the perception that people with mental illness are violent and dangerous; in fact, research suggests that they're more likely than the general public to be victims of violent crime. And people who work in the mental health system are wary of potential policy changes that are based on the notion that people with mental illness are violent.
"All of the evidence that we have suggests that people with mental illness are essentially not more dangerous on average than ordinary people," said Dr. Harold "Hank" Schwartz, psychiatrist-in-chief at the Institute of Living in Hartford. "If you combine mental illness with substance abuse, the risks go up, but if you combine the range of people with impulsive personalities with alcohol and drug abuse, the danger of violence goes up."
Earlier this year, advocates turned out in force to oppose a proposal to allow people with mental illnesses who are not hospitalized to be medicated, even if they object, if remaining unmedicated would leave them or others at risk of harm. The concept could be revisited in the wake of the Newtown shooting.
The way discussions about the mental health system are framed risks further stigmatizing people with mental illness, Schwartz said.
This is important because the stigma associated with mental illness can be a major barrier to people getting treatment and early interventions that could stave off larger problems, experts say.
That's not to say they don't welcome a discussion about mental health.
Mental health crisis
"We have a mental health crisis, especially among kids," said Dr. Eric Arzubi, a fellow in child and adolescent psychiatry who co-chairs the Keep the Promise Coalition, which advocates on mental health policy in the state. "The fact that we have to wait until now to have this discussion is sad. I think a lot of people on the ground have known there's a problem and there's a crisis."
He said the numbers would surprise most people. In any given year, about a quarter of U.S. adults have one or more diagnosable mental disorders, although a far smaller proportion -- about 6 percent -- has a severe one, according to the National Institute of Mental Health. Close to 50 percent of Americans will have a mental disorder in their lifetimes.
But only about 36 percent of those with mental disorders receive treatment in a given year, according to the NIMH.
Arzubi works in an emergency room. Because of a shortage of psychiatric beds for children, there are some days when children get stuck in the emergency room, waiting for a more suitable placement. That's not uncommon at other hospitals, too.
"Can you imagine if the same thing was happening to kids with an asthma attack?" Arzubi said. "Can you imagine if the same thing was happening to a kid who had a complication from diabetes? That would be national news."
Access to mental health care has long been a problem, whether because of a lack of hospital beds and spots in community-based programs, or because of difficulty getting insurance coverage for it.
"I can't tell you how difficult some of the issues we face with regard to access to care can be," Schwartz said. "We've had a patient who attempted suicide by jumping, and we were asked by the [insurance company] reviewer, 'From what floor?'"
Role of public schools
Federal and state laws require "parity" in insurance coverage of mental health care, prohibiting insurers from placing limits or costs on mental health or substance abuse services that are more restrictive than those imposed on services for physical illnesses. But advocates, patients and providers say there's a long way to go before that's fully realized.
When it comes to young people, the focus should be on the schools, Arzubi said.
"Public schools are literally our mental health system for kids," he said, citing research that found that 70 percent to 80 percent of children who received mental health services were seen by guidance counselors, school psychologists and other providers working in the education system.
It would help to make sure teachers and other school staff are trained to understand child development and signs of mental illness, Arzubi said.
"Not that they need to be the therapist, but at least we are helping them understand how to access the services for kids," he said. "I feel like the mental health community can do a better job of trying to support the school folks."
In addition, he said, it would help to formalize relationships between schools and police departments, to ensure that students with mental health issues are not arrested unnecessarily, as well as relationships with emergency psychiatric services, for when students need them.
There's also the matter of resources.
Community-based mental health care providers that contract with the state have been struggling with no rate increase in five years. They're slated to get a 1 percent raise Jan. 1, but many are also facing cuts meant to address the state's projected budget deficit.
This year's state budget includes funding for 21 additional school-based health centers, which provide both primary and mental health care. Arzubi has been working on getting one set up but said it's been almost impossible because of uncertainty about whether the funds will be there.
Then there's the stigma. It's a major reason that people don't seek help for themselves or for their children, even though earlier intervention could help prevent larger problems later on, experts say.
"Parents don't want to label their children," Mattias said. "If their child had diabetes, they wouldn't probably think twice."
One way to reduce the stigma is to have people with mental illness come into contact with those who don't have it, Mattias said, to be seen as part of their communities.
"We need to move to a place where mental illness is a chronic illness like so many other chronic illnesses that we have," she said. "We've moved there with AIDS. We have not yet moved there with mental illness."
Robert Davidson, executive director of the Eastern Regional Mental Health Board, said identifying people with mental health needs will require instruments that go beyond blunt questionnaires that ask if you've ever thought of killing yourself, which people often won't admit to. And there need to be people available to work one-on-one with those who need help.
For people in Newtown, Arzubi said, it will be critical to have supports in place for the long term. "It's going to be a long, long process," he said.
And ironically, Mattias said, that might help reduce the stigma of seeking help.
"There are going to be so many people who are going to need somebody's help, and we need to make that absolutely OK for those parents and those first responders and those teachers and whoever else in our community has been impacted in a way that they just need to reach out for help," Mattias said. "And I think that may help go a step towards again normalizing that kind of situation."