Carlos Larrauri, APRN: There are plenty of unmet needs here that pose challenges for individuals suffering from getting care. I’ll focus on 2 quickly. No conversation would be complete without a discussion of stigma. And stigma continues to be a huge barrier to people getting care. Even if we build a better health system where we have better medications, if people don’t seek care because of the fear of being stigmatized or judged, this is going to delay treatment and incur costs. And the other, which we haven’t talked about much, is the criminalization of mental health. In fact, in many states, the largest provider of mental health services are jails and prisons. And it’s a moral failure in our society that the first encounter for many people with a serious mental illness such as schizophrenia is with a police officer and not with a clinician, a social worker, or a peer. I think it gets back to what we discussed, early intervention is critical. We are currently waiting for people to have heart attacks or have metastasis, waiting for people to be forwardly psychotic and get involved in the criminal justice system when we need to be treating heart disease or hypertension or doing screening. I hope we’ll have biomarkers and objective measures that’ll facilitate that early intervention so that people don’t have to wait until they’re in stage 4 of schizophrenia and are getting involved in the criminal justice system.

John J. Miller, MD: Thank you. And Sandy.

Sandy Dimiterchik: So to me, anosognosia, understanding what it is and how it impacts people and helping families.

John J. Miller, MD: Why don’t you define anosognosia?

Sandy Dimiterchik: That’s where you have a lack of insight. It’s not that you have denial. One of the things I do at work is answering the helpline, and I speak primarily to families and friends. And when I talk to them, we partner with the LEAP Institute. Dr Xavier Amador came up with the LEAP method, [which is] listen, empathize, agree, and partner. And it’s life-changing, builds trusting relationships, it’s a communication tool. When I talk to these people and I ask them, “Have you ever heard of anosognosia?” And they’re like, that’s true, they don’t think that anything’s wrong with them.

John J. Miller, MD: It’s like neglect. It’s like they don’t see or are disconnected from their symptoms.

Sandy Dimiterchik: And I think 45% or so of people who have schizophrenia do have that symptom. I think doing more research, educating the public about it, and trying, as I mentioned with HIPAA [the Health Insurance Portability and Accountability Act], it’s really hard for family members to seek treatment. As Carlos was talking about the criminal side, they can’t get treatment until they’re either a threat to themselves or others. It shouldn’t get that far, but [it’s a matter of] changing the system so that the families are heard so they can get their loved ones the help they need.

Carlos Larrauri, APRN: Stigma plays a major barrier to care. And what that means is that we need leaders to step up and self-disclose and share their narratives of living with mental health conditions so that we can all change the narrative surrounding mental health. The other thing we urgently need is for people to prioritize mental health in their budgets. Budgets reflect our values and our priorities. We need people who control the purse strings to make mental health a priority.

Nev Jones, PhD: I would agree with a lot of what Carlos said in terms of, I think the problems that we face is on a mass scale, criminalization, social abandonment, societal abandonment of people with really the most functional impairments or disability associated with SMI [serious mental illness] and ending up in jails and prisons and revolving-door services and living in poverty. And that it is absolutely critical to develop. Here’s where I would go in a different direction, policy solutions, and policy changes to financing so that we’re putting the money into SMI services that have been needed for decades. And we have just chronic underfunding. Put the money there and then figure out more efficient, more strategic financing mechanisms so that we don’t waste in the process. And really getting people off the streets, out of jails and prisons, and back into society in an integrated way. I think that’s still where we need to go and urgently.

John J. Miller, MD: Thank you. Dr Carney?

Caroline P. Carney, MD, MSc, FAPA, FAPM, CPHQ: I think what underlies Carlos and Dr Jones’ comments is the access and availability of evidence-based care and what we need to do to get there, which will be a result of the right funding and hopefully help to really address problems like criminalization, homelessness, and so on. So that’s No. 1 for me. The second is a little bit different than what we’ve talked about, and it’s the ability to communicate across the health care system. We do that very poorly today. And for really true holistic care, we need to do that better.

John J. Miller, MD: [That’s a] great point.I have to say, I echo all 4 of your comments, and I thank you. One of my great wishes is that we would become a lot more aggressive in identifying first-episode psychosis. As we mentioned earlier in the RAISE study [NCT01321177], people were identified on average 74 weeks after their first episode of psychosis. And ideally, we should be intervening within the first few months to maximize the outcome and minimize the progression of the cognitive and the negative. So it ties into a lot of the inputs that you all just provided. And it’s education, it’s access, it’s financial, it’s funding, it’s getting the communities involved and trying to work together as a progressive and informed safety net to start treatment earlier and provide the resources for recovery.

Thank you again to our viewing audience. We hope you found this AJMC® Peer Exchange to be useful and informative.

Transcript edited for clarity.