FEATURE: Cowboys in Crisis

By on June 7, 2017

The good, the bad and the ugly of mental health care in a small Western town.

JACKSON HOLE, WY – “Welcome to the Wild West of mental health care.” That’s how Stephanie,* a 40-something professional and Jackson native, described the day she checked into the emergency department at St. John’s Medical Center a few years ago. She has struggled with depression, anxiety, PTSD, and addiction, with some issues dating back to her teens. Her constellation of mental health challenges has meant several bouts of crippling depression, despite medication and therapy.

At the time, she was severely depressed and suicidal. She didn’t feel safe to be alone, so she called a friend to take her to the hospital. Because there is no other crisis facility in the valley for mental health patients, the hospital was Stephanie’s only option. And though the ER staff kept her from harming herself, the experience was less than optimal. She was placed in a sparse, sterile room, asked to change into a hospital gown, her belongings stored elsewhere, and then literally locked in the room whenever a staff person couldn’t be with her.

“When things are critical, we don’t have options in Jackson,” Stephanie said. “When you are in imminent danger to yourself, you are put into involuntary lockdown.”

Having grown up in the valley, Stephanie is not new to seeking mental health care from local providers. An intelligent, proactive woman, she is skilled at gleaning the best of what’s available in Jackson Hole. She is also all too familiar with the ramifications of a community in which physical health is exalted and mental health too often neglected until people reach a crisis.

When Stephanie was a teenager in the 1980s, the first time she sought mental health care was from her family doctor. No licensed psychiatrists were practicing in the valley at the time, so general practitioners were often patients’ first option for mental health care. That situation hasn’t changed much, and it’s not exclusive to Jackson. According to the Institute for Behavioral Health Integration, as many as 70 percent of all visits to primary care are the result of psychosocial issues.

Stephanie said she was lucky to have a doctor who understood the seriousness of her symptoms. “Had I not had that I would not be alive today,” she said.

 While primary care providers play a crucial role in helping patients with mental health issues—whether in the ER or the doctor’s office—they only have so much expertise. A recent St. John’s Hospital Foundation study found that Jackson is in dire need of psychiatrists, with only two practicing in the valley. The search is on for ways to serve this need.

In the meantime, a dedicated community of mental health care professionals— counselors, addiction specialists, psychiatric nurses, and others—work with scarce resources. But in a state with nearly twice the rate of suicides as the national average and in a county where an average of three people per year die by suicide, mental health crises, and how they are addressed, is a life and death matter.

From a 10,000-foot view, Jackson Hole is lucky compared to other communities in the rural West. But when all that’s between you and oblivion is the life raft you cling to, you’re not thinking about the sky above. You’re just focused on immediate conditions that might rescue you, or threaten your grasp.

Shrinking stigma

According to a 2009 study in the journal Psychiatric Services, in the U.S., almost four out of five prescriptions for psychotropic drugs are written by physicians who aren’t psychiatrists.

Patients often feel more comfortable going to their GP for psychiatric complaints, perhaps feeling safer with a doctor they know. Also, they might think they are avoiding negative stigma attached to “seeing a shrink.” But this is problematic. “Primary care providers do not have the time or the expertise to obtain a really good psychiatric history and complete a thorough assessment,” Victoria L. Dunckley, M.D., wrote in a 2013 column in Psychology Today. “They’re not able to sit down with the patient and the patient’s family to discuss potential short- and long-term risks of medication in detail, and may not even be aware of them. They also can’t fully assess or address psychosocial issues that may be relevant to the person’s well-being and safety.”

In a “frontier” town, however, it’s common for generalists to assume the role of specialists in a variety of health issues. Ethan,* a Jackson resident who struggles with depression, said he has been impressed with local GPs willingness to help him. “The primary care physicians are very open to discussing those topics and helping you begin a process of treatment,” he said. “But at some point, you need to find more specialization.”

A doctor trained in psychiatry can better discern whether to prescribe medication at all. Depending on the severity of the condition, like mild depression versus severe depression, talk therapy may be more effective.

A 2012 article in Monitor on Psychology noted, “A growing body of research suggests that antidepressants aren’t as effective as many people believe … Psychotherapy may be just as effective as antidepressants in many cases, without the risk of side effects and with lower instances of relapse, according to some studies.”

GPs who prescribe psychiatric meds may not be as thorough or as trained in diagnosing illnesses. This opens the door to patients abusing the system. For instance, websites abound with “five easy steps” advice on how to get a doctor to write you a script for Adderall, known as the “get-ahead drug” that can help with focus and energy, but is intended for people with ADHD and is not without serious side effects, like addiction. One Jackson resident said all she had to tell her doctor was that she was having trouble concentrating at work and she walked out with a prescription for Adderall. When her usage began to feel like addiction, she was the one to “shut it down,” not her doctor.

Psychiatrists, in contrast to general practitioners, provide a thorough evaluation of patients and can diagnose illness based on the Diagnostic and Statistical Manual of Mental Disorders, not merely the patient’s reported complaints. Psychiatrists monitor patients’ responses to medication, and work with them to find the correct medication at the correct dose. A psychiatrist would know not to suddenly switch a patient taking Effexor to another antidepressant (as happened to the author after a visit to her GP). Effexor is notorious for severe withdrawal symptoms and must be discontinued slowly over weeks. The psychotic behavior and extreme stress of a sudden Effexor withdrawal is uncomfortable at best, if not dangerous, for a depressive patient.

 Still, local psychiatrists praise local GPs. According to O’Ann Fredstrom, one of Jackson’s two practicing psychiatrists, family doctors in Jackson do a good job of prescribing psych meds within their comfort level. If they have questions, they often call Fredstrom, or her husband Stuart Sugarman, the valley’s other psychiatrist, for advice.

“In this community, primary care physicians are astute in their assessments and use of psychiatric medications,” Fredstrom said. “They’ve had to be. Before Stuart and I were here, there were no psychiatrists.”

Prevention management specialist and licensed counselor Matt Stech sees pluses and minuses in GPs offering psychiatric care. With only a few licensed psychiatrists in town, family doctors might be able to provide care in a timelier fashion, Stech said. But problems may arise when GPs step beyond their knowledge and comfort zone in treating mental illness, mood disorders and addiction.

“General practitioners will have varied training and experience in dealing with mental health issues and addiction,” he said.  “Sometimes, the patient wants the medication but doesn’t want to see a psychiatrist when that would be more appropriate.”  

Because psychiatric issues and substance abuse can exist concurrently, diagnosing a patient correctly can be challenging, especially for GPs. “The practitioner may or may not be well equipped to manage the situation,” Stech said. “Even if the practitioner wants to engage the patient in more supports and services, the patient may—for reasons that are related to stigma, finances or due to the nature of the disorder—resist engaging in psychiatric services or counseling.”

In addition to Fredstrom and Sugarman, Jackson has a few nurse practitioners that specialize in psychiatric meds. Fredstrom serves local mental health agencies like the Jackson Hole Community Counseling Center and Teton Youth and Family Services. She also maintains a private practice. Sugarman practices privately. Together, they have managed to serve most of the community’s psychiatric needs. However, Fredstrom recently announced she will retire in the   coming years, raising the question of what options will be available to patients who have little choice in doctors to begin with.

Unfortunately, more psychiatrists would not have changed Stephanie’s lockdown experience in the ER (which was dictated by an arcane state statute, Title 25). But there is no doubt that more options and broader expertise among practitioners would be a boon to residents who struggle with mental health issues. The challenge is how to attract those professionals to Jackson Hole amidst a national shortage of psychiatrists. In the meantime, psychiatric and mental health care is available in the valley if you know how to piece it together.

One size does not fit all

What Stephanie experienced in the emergency room was what St. John’s emergency medicine specialist Dr. Albert Wheeler calls “a last resort” approach to care. When a patient is brought to the hospital, or checks herself in, and appears a danger to herself or others, the hospital staff may begin what is known as a Title 25 process.

This Wyoming statute delineates rules for hospitalization of mentally ill persons. Once the Title 25 process begins, the patient’s rights are compromised, something that Wheeler doesn’t take lightly.

“Telling someone they are staying in the hospital against their right of issue is very serious,” he said. “The Title 25 process is the last-ditch effort to assist someone.”

It’s also a catchall for any kind of mentally ill person, including those who are violent or homicidal. The same kinds of protocols get applied to all patients under Title 25, regardless of whether or not they are a danger to others.

“Certainly we don’t want to dehumanize people,” Wheeler said. But he can understand why the process might feel that way. “We need a protocol in place that protects everyone. We are starting from scratch. We don’t know what’s been going on prior to them coming in. It may not be ideal, but it’s the safest.”

But from Stephanie’s point of view, one-size-fits-all care does not work for everyone. Though her stay in the hospital did stop her from attempting suicide, she did not receive the care she hoped for. “We need a hospital that treats us as human,” she said. “We are not meat puppets. We are minds inside of bodies.”

The need for more psychiatrists was one of six key mental health needs highlighted in the report conducted by the St. John’s Hospital Foundation. The study surveyed 75 participants, including representatives from the valley’s various mental health service agencies, as well as physicians, elected officials, and law enforcement. 

The purpose of the study was two-fold: to provide a snapshot of the mental health system in the valley, and to identify possible gaps in care. Adolescent psychiatry and geriatric psychiatry were two noted areas of need.

Additionally—and importantly—having more than one or two doctors to choose from enables patients to find someone they can really talk to. Stephanie, for one, didn’t click well with Fredstrom. Personality matters. More than one patient interviewed for this article said Fredstrom was gruff or callous. Another psychiatrist who recently left the valley was described as “arrogant.” An iffy bedside manner may be annoying in an orthopedic surgeon, but finding a mental health specialist with whom you feel comfortable talking candidly is crucial.

Patients like Ethan and Stephanie, who have struggled with bouts of severe depression for years, have experience working with a variety of doctors and counselors.

“I find psychiatrists in general to be socially awkward,” Ethan said. “How can they be supportive when they try to play such an objective role? Maybe by their professional code they can’t provide that kind of support.”

“It’s hard to find a good therapist or psychiatrist who fits you,” Stephanie said. “And managing medication is trial and error. It’s hard to do unless you find someone with whom you have actual interchange and discourse. I want to find someone I trust.”

Local agencies do trust Fredstrom and rely on her almost exclusively.

“Our psychiatric needs are met very well by Dr. Fredstrom,” Teton Youth and Family Services executive director Bruce Burkland said. “When O’Ann does officially retire that will be more of a challenge, but we will look to meet that need with some form of a new psychiatrist, telemedicine or psychiatric nurse practitioner, or some combination thereof.”

Of meds and telemedicine

What Stephanie’s story illustrates is that while the basics of psychiatric care are covered in Teton County, including garden-variety prescriptions from general practitioners, specialized psychiatric care is more elusive.

“I don’t think I’ve gotten all the care I’ve needed, but I’ve gotten enough care to make do,” she said. She has sought care through the Jackson Hole Community Counseling Center, as well as via private practitioners.

Stephanie doesn’t fault the counseling center for her frustrations. “They are doing a great job with the demand they have and the amount of money they have to answer that demand. But that doesn’t mean it’s enough for the community or serving patients to the highest possible standards.”

For his part, Ethan is pleased with the counseling he receives through the counseling center, which includes talk therapy as well as med management by a psychiatric nurse. “The counseling center has been my best resource,” he said. “I’ve found their counselors to be so helpful. I worked with two or three people until I found the right fit.”

But even the professionals in the mental health field acknowledge that Jackson has areas where it could improve. Sugarman noted that, “Jackson and Teton County can’t be all things to all people. It is similar in other fields of medicine. We’re simply too small to provide everything.”

Jackson Hole Community Counseling Center executive director Deidre Ashley says the community is experiencing growing pains. “We’ve hit a tipping point,” she said. “We are trying to come to terms with the scale. This is not a frontier town anymore when you look at the influx of people in the summertime. The needs for mental health care are rising. We are seeing more people at higher levels of crisis.”

Ashley said Jackson’s seasonal, transitory population is a factor, as is a nationwide trend toward an increased need for mental health services. In 2016, local hospital assessments for being in danger of doing harm to self or others were up 30 percent, Ashley said, and 2017 looks to be on that same trajectory.

“As we grow, we start to see bigger city problems,” she said. “Cities have similar issues, but they have more resources.”

While Fredstrom’s impending retirement increases the urgency of the search for additional psychiatrists to serve the valley, attracting psychiatric doctors has been a challenge. Housing costs are likely a factor, both Sugarman and Fredstrom agreed. They also said that psychiatrists don’t make as much as, say, surgeons.

“It would be a risk for somebody having to support themselves while they built up their practice,” Sugarman said.

Fredstrom pointed to another factor that she has learned about attending conferences around the nation. “Younger doctors are looking for either a flexible schedule, or to be in an inpatient psychiatric unit,” she said.

Instead of an inpatient unit, the hospital has taken a different tack to addressing Jackson’s dearth of psychiatrists. Starting this summer, St. John’s will test-drive a telephsychiatry program that will allow clinic physicians to access psychiatrists remotely. According to Goettler, St. John’s will soon sign a contract with Aligned Telehealth, a behavioral telemedicine provider based in California. Beginning July 1, providers at St. John’s can connect with psychiatric specialists via live video for consultations about their patients. Goettler said the service should also include ways for patients to access psychiatrists directly via smartphone apps.

“Strategically, it is more viable to contract with a telemedicine firm,” he said. “It may not be as ideal as in-person consultations, but a telemedicine approach is consistent with what we’ve found with other specialists and subspecialists in this region.”

 Aligned Telehealth has 2500 psychiatrists on staff or on retainer. At least eight of those are licensed in Wyoming. How well patients will respond to telehealth consultations remains to be seen. For patients like Stephanie, it could be a godsend. She would have a choice of doctors, and perhaps find one who specialized in her specific concerns.

Fredstrom is tentatively supportive of the hospital’s move toward telepsychiatry, which she says is a logical next step. “It’s some place to start,” she said. “It will depend on the quality and the usefulness to patients. People tend to want to work with someone in person.”

Local patients and health care providers may have to utilize telepsychiatry, whether it is ideal for them. A nationwide shortage in psychiatrists means that Jackson Hole’s shortage is part of a larger problem.

According to the American Medical Association, the total number of physicians in the U.S. increased by 45 percent from 1995 to 2013, while the number of adult and child psychiatrists rose by only 12 percent, from 43,640 to 49,079. Additionally, a recent survey by the Association of American Medical Colleges found that 59 percent of psychiatrists are 55 or older, and may be preparing for retirement.

Insource, outsource

It’s not just psychiatrists that are needed to improve the valley’s psychiatric care. Ashley says that an intermediary level of care is needed that would serve people in crisis. Ashley and others would like to see a crisis stabilization facility in the valley.   

Currently, the state of Wyoming operates a regionally based crisis stabilization system. The nearest facility is in Rock Springs, where trained staff is available 24 hours a day, seven days a week. Ashley said the counseling center helps approximately 10 people per year get into the regional program.

The state defines crisis stabilization service as “a short-term, residential service for persons experiencing a mental health crisis, with a focus on retaining connections to the family and community.”

A local facility would be used as a “step-down” from more restrictive settings like inpatient hospitalization or correctional facilities. “It would help people with bipolar issues such as mania or depression to stabilize their mood,” Ashley said. Though the crisis stabilization facility would still not be able to treat acute suicidality, it could help a patient like Stephanie from becoming suicidal in the first place.

“We have most of the components of a project like this,” Ashley said. “But not a facility where patients could stay, nor the 24/7 staff.”

However, with land and building costs so high in Teton County, a crisis stabilization facility is just a dream on paper at this point. Still, it’s the kind of whole-person care a patient like Stephanie could use.

When Stephanie was at her worst and could not cobble together the care she needed here, she checked herself into a depression treatment facility in Salt Lake City. “At that point, I was so desperate that I told myself I would do the inpatient treatment for 30 days but if it didn’t work, I would kill myself when I got back to Jackson.”

Fortunately, the inpatient treatment was effective and Stephanie’s situation stabilized. “It was an intense and holistic treatment,” she said.

Referring patients out of the county for intensive care is part of local psychiatrists’ quiver of options. “The reality of our hospital is that we are more of a psychiatric triage place,” Fredstrom said. She refers clients with crisis or intense care needs to facilities in Idaho Falls, Riverton, Casper, Salt Lake City, or even further afield like the prestigious Menninger Clinic in Houston, Texas. She said she looks for places patients might have friend or family support.

Despite the resources available in Jackson, locals say mental health care is still not addressed adequately. “It’s ridiculous that in one of the most physically healthy counties in the country, mental health care is all but ignored,” Stephanie said. She feels that Jackson’s reputation as a playground for the wealthy obscures the importance of mental health care here. “Mental health care is not pretty,” she said. “And we like to define ourselves as this pretty, aggressively physically fit community where things like poverty and mental health problems don’t exist.”

As for Ethan, he would like to see more collaboration between medical and therapeutic treatments, as well as access to mental health care innovations. He mentioned that mindfulness training has been helpful to him. He’s also curious about new approaches to treating depression, like the theory that it’s caused by allergies. “There should be a way of looking beyond meds,” he said. “I’d like to see some kind of clearinghouse for resources beyond what we have here.”

While providers recognize improvements can be made in the available mental health care in Jackson, many say the care available is good, especially in comparison to other places in the state. St. John’s Hospital Foundation vice president Jen Simon said Jackson is fortunate to have the resources it does. “One of the things I learned from doing the Mental Health Report is that as much as we as a community are striving to do a better job, we are resource-wealthy compared to the rest of the state,” she said.

This was a sentiment Sugarman expressed as well. “In our community we have many mental health resources along the continuum of care, including various psychotherapies, more intensive outpatient interventions, residential programs, and expertise in psychopharmacology, just to name a few such resources.”

But comparing Jackson to other towns in Wyoming may not be the best measure. Jackson’s shifting demographics from frontier outpost to cosmopolitan small city mean the demand for comprehensive psychiatric care is rising to meet the demand for other quality health care. Residents increasingly value fixing torn minds as expertly as torn ACLs.

“In Jackson, they can have you back skiing in 10 weeks, but it’s not the same schedule for psychiatric care,” Ethan said. “When you have to go outside the valley for care, that adds stress. And when you are in crisis, stress is exactly what you don’t need.” PJH

*This person’s name has been changed.

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About Meg Daly

Meg Daly is a freelance writer and arts instigator. She grew up in Jackson in the 1970s and 80s, when there were fewer fences, but less culture. Follow Meg on Twitter @MegDaly1

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