Primary care provides hope for mentally ill
This story was originally published in the Modesto Bee.
Matt Freitas doesn’t believe in turning sick people away.
As mental health budgets shrink and services erode, Freitas, a nurse practitioner, is driven by a sense of mission to help patch the holes in the Stanislaus County safety net. Housed under a bright yellow awning in a strip mall off McHenry Ave., his primary care clinic, Aspen Family Medical Group, has taken on a key role in treating the county’s uninsured mentally ill.
“The purpose of primary care is to take care of people in pain, whatever that pain might be,” said Freitas, 63, who has untamed gray hair and a penchant for printed Hawaiian shirts. “There’s a dramatic need. And somebody has to do it.”
Freitas is a strong believer that the answer to the local – and national – crisis in access to mental health care lays not with the government, but with primary care providers like him.
In Stanislaus County – and around California – a struggling economy has combined with ongoing budget cuts to significantly reduce services for adults with mental illnesses. Locally, the county mental health department’s budget has dropped $18.5 million in the past five years, about 21 percent. That reflects what’s going on around the state: since 2009, California has cut $765 million, more than 21 percent of its mental health budget, according to a November 2011 report by the National Alliance on Mental Illness.
Freitas’ 34-year-old daughter, Tama, has schizophrenia, so he has seen firsthand the struggles that uninsured, mentally ill adults can face.
While some patients find him by word of mouth, he says growing numbers get his name from the county mental health agency, Doctors Behavioral Health Center – the inpatient psychiatric facility - or the local chapter of the National Alliance on Mental Illness.
Joyce Plis, executive director of that chapter, said she frequently refers people in need of care to Freitas, because he sees them quickly and is able to give them needed medications without a long delay.
“It’s been a godsend that we have Aspen,” said Dr. Manuel Chua, who worked as a psychiatrist for Stanislaus County for 13 years, and after retiring last year began volunteering with Freitas. “If they don’t do it, then there will be really nothing.”
Around the country, a great deal of attention is being paid to the role of primary care offices in caring for the mentally ill. Experts say that, with proper training and support, the doctors and nurses on the frontlines of health care are in a unique position to identify and treat mental illness in a large segment of the population – and do so without the stigma that the public sometimes attaches to traditional psychiatry and therapy.
Primary care doctors commonly treat those with mild cases of depression or anxiety, and already prescribe the vast majority of anti-depressants.
But experts say that, in collaboration with mental health professionals, those providers can do even more for the mentally ill – and do it better. In recent years, mental health leaders have begun a nationwide push to integrate primary care and mental health care services. Ideally, that means that a psychiatrist is actually located in a primary care clinic, said Randall Hagar, director of government relations for the California Psychiatric Association. At the very least, he said, a psychiatrist should come in regularly as a consultant.
Locally, both Golden Valley Health Centers and the county’s Health Services Agency – which provides primary care for very low-income residents - have moved toward integrating care in the past several years. Both agencies have brought on psychiatrists, at least partly in response to the influx of mentally ill patients seeking help in their offices.
“It’s a compromise,” said Dr. Del Morris, medical director of the Health Services Agency. “It helps expand the scope of care in a primary care setting…. But it’s not the same as being under the care of the mental health department.”
Rusty Selix, director of the Mental Health Association of California, cautions against primary care providers treating complicated mental illnesses without the help of a psychiatrist. He and others say lack of training and the short window of time most primary care providers have with each patient make it difficult to effectively treat such illnesses.
“It’s not a substitute for the more intensive care,” he said, though he adds, “When people can’t get what they need, they get what they can get.”
Freitas – whose nurse practitioner training qualifies him to prescribe medication and dispense drug samples -- feels more comfortable than many primary care providers treating mental illnesses, in part because he has made it such a focus in his practice. But he concedes that he lacks the time and training to provide important services like counseling. He consults with Dr. Chua on his most complex cases.
“Dr. Matt,” as some patients call him (the term makes him grimace, since he is not an MD), estimates that maybe a quarter of those he treats these days have mental illnesses or addiction problems. He doesn’t charge them, he says, because people with mental illness already face so many obstacles to care.
On the medical side, he charges a $50 per visit fee for cash-paying patients – though he waives or reduces it for those who can’t afford to pay. After expenses, he uses the money he has left to pay for all the free care he provides. Last year, as a result of a flood of uninsured patients, his total income dropped by 25 percent, he says, while the number of patients he saw increased by 25 percent. In just a year, the total number of mental health patients tripled, he said. For the first time, the clinic ended up investing all of its profits into providing free care. He attributes the funding shortfalls to an increase in need and a decrease in insurance reimbursement rates. Freitas expects that this year, for the first time, he’ll have to borrow money.
“We are no more than a reflection of what’s going on,” he said.
In the waiting room of Aspen Medical Center, the walls are covered with baby pictures, a large painted tree and signs in various languages.
Inside the clinic, 25 employees – including five who are either nurse practitioners or doctors -- hurry back and forth along the rainbow colored carpet.
Tim Hallinan, 45, of Oakdale, said he started drinking as a way of medicating himself for suicidal depression. He said he lost his jobs as a custodian and a truck driver – and his health insurance – and eventually moved in with his father. After spending three days in the behavioral health center in December, he was referred to Aspen and has been coming for treatment since.
“There’s just no resources anymore,” Hallinan said. “The county’s cut back. I was one of those people that fell through the cracks. I was not qualified for this. I was not qualified for that. I was kind of in this limbo. And this place threw me a life raft.”
He said Freitas talked with him about his background and eventually put him on three different medications, most of which Aspen gives him for free.
“He understands people like me,” Hallinan said.
Freitas spent decades undertaking other pursuits before deciding to take up nursing.
He did stints as an Air Force medic, a health educator, a health insurance underwriter and a professional photographer, amassing enough money from the health insurance sales to retire for a time in his mid-30s. Finally, at the age of 38, he decided to go back to nursing school. The first patient he saw as a student committed suicide – affecting him profoundly and driving home for him how hard it was for people with mental illness to get appropriate help.
After graduating as a nurse practitioner at the age of 41, he used savings, some of his wife’s income, and profits from a business he owns distributing the San Francisco Chronicle newspaper to open Aspen. His goal, from the beginning, was to provide help to people who didn’t have access to health care.
He and his wife, Brenda, 66, adopted their daughter Tama when she was six months old, and then, a few years later, adopted her brother. The couple knew Tama’s family had a history of schizophrenia. Still, at the time Freitas started providing mental health care through his practice, his daughter’s illness hadn’t yet been diagnosed.
Tama says her illness started to appear in her teens. Her grades got worse, and she started acting out in school. Eventually, she became paranoid and started hearing voices. But it took a long time for Tama – or the rest of her family - to recognize that she was sick.
Even with devoted parents who were financially successful and had medical know-how, Tama’s journey toward wellness has been a rocky one. She’s had stints with drug addiction and alcoholism, abusive relationships and homelessness.
Overall, though, Freitas sees in his daughter the potential that good mental health treatment can unleash in even the sickest of patients.
Brenda – who works part time as Aspen’s office manager – says she and her husband talk about it all the time.
“There’s nobody out there and that’s what I think is so sad for people who have a mental illness,” she said. “There’s not the funding out there, there’s not the facilities out there, and these are people who just walk the streets and could probably be very functional, different people if they had the right kind of help.”
Freitas provides that help to Tama himself, even though he says medical practitioners aren’t ideally supposed to treat their family members. He pays thousands of dollars a month for her medications. Tama is uninsured and has been rejected on her first application for Social Security, which would qualify her for Medi-Cal.
Today she is a warm, talkative woman, who works three days a week in Aspen’s front office. Her boyfriend, Mike Yates, Jr., stands by her despite his own mental health issues. The pair lives together in an apartment paid for by Tama’s parents. Last summer, after Yates stuck with Tama while she struggled through a psychotic episode, he finally earned the long-coveted right to call Freitas “Dad.”
Father and daughter both say the other is their “hero.”
“The thing about Aspen is, he’s another ally for people who don’t have somebody to turn to,” Tama said.
Sometimes, Freitas tells his mentally ill patients and their family members about his daughter. Sometimes she comes in to share her story with them directly.
“I want people to see Tama as the image of a mentally ill person,” Freitas said. With the right care, “all those other people on the street, most would look like Tama, too.”