Uncertainty looms over Nevada’s already deficient mental health care

According to Nevada’s Office of Suicide Prevention, more residents die annually by taking their own lives (558 in 2015, the most recent year with available data) than by homicide (191) or automobile accidents (321). It’s the second-leading cause of death in the state for ages 10 to 19, and one strongly linked to mental illness.

A 2016 report from the nonprofit Mental Health America ranked Nevada last in the nation for access to mental health care. It’s an issue all too familiar to Dr. Lesley Dickson, a psychiatrist serving as executive director of the Nevada Psychiatric Association and medical director of the Center for Behavioral Health, a Las Vegas clinic for opiate addicts.

Dickson has been treating addiction and mental illness in Nevadans for more than two decades, and she spoke to the current turmoil around health care through that lens.

Nevada has historically been short on psychiatrists. Why?

There are not enough psychiatrists in the country, not just in Nevada. But other states have decided to meet the needs of their mentally ill. They have more psychiatrists and social workers in places like New York or Massachusetts, where psychiatrists in residency programs are tripping over each other. Once their residency programs are done, the graduates don’t like to leave the state. In Massachusetts, there are approximately 32 psychiatrists per 100,000 residents. Nevada has seven per 100,000.

This year, six psychiatry residents graduated in Las Vegas, and four left the state. Their leaving was partly an issue of money — they can earn more elsewhere — partly because they didn’t come from here in the first place ... and partly because Nevada’s insurance reimbursement rate is lower, and once they finish their training, they are concerned with earning money and paying back medical school debt.

Nevada has never had much of a mental health system. ... In the 1950s, there were a lot of new (and effective medications) emerging in psychiatry, so we didn’t need all the hospital beds, but patients needed outpatient care. We never built community health centers instead of state hospitals, and then the population of those with a mental illness increased as the state’s population grew. Now they’ve been building private mental hospitals because the companies are getting paid more per patient, per day. Still, the problem isn’t the availability of beds; it’s appropriate use of beds, keeping patients there a little longer.

Nevada’s suicide rate has been one of the highest nationally for decades. In 2015, there were 558 deaths by suicide. Why is it so prevalent?

I am on the state Committee to Review Suicide Fatalities. We review every suicide fatality in Nevada, trying to figure out what happened. Many suicides in Nevada are gun-related. The deceased individuals didn’t necessarily have an ongoing, long-term mental health problem. Most completed suicides in Nevada are impulsive. People get very emotional, and then suddenly there’s a gun available. Sometimes it’s a result of alcohol or other drug use. Then there are the people coming to Las Vegas deliberately to commit suicide, and there’s a lack of mental health services for them. And even if they do get care, there’s often no follow-up.

Does the Nevada Psychiatric Association support stricter gun control?

We supported Question 1, the Nevada Background Checks for Gun Purchases Initiative that passed last November, but Nevada’s Attorney General Adam Laxalt determined that the measure could not be enforced.

What recommendations do you have to improve the situation in Nevada?

Back in 2002, when I moved here, the Legislature had a negative attitude toward mental health issues. Places like New York and California are more accepting of these issues, and their residents with mental illnesses don’t experience the extremely high amount of stigma that people in Nevada do. Nevada’s (news) media don’t address mental health issues a lot.

We need suicide-prevention training for doctors who are not psychiatrists, so this past legislative session we passed a bill addressing this. Mental health awareness needs to get out into the whole community, such as in schools. Workplaces need to be much more sensitive when a colleague is suffering emotionally.

I’ve testified on behalf of a lot of mental health-related legislation. I’ve attended many state meetings. Some Nevada politicians are educated about our state’s mental health issues — most are not. ... Many psychiatrists are now working on salary, like for the Veterans Administration, and Nevada’s salaries are lower than the national average, so it makes it hard to recruit physicians. I don’t think the state of Nevada understands that.

Most other states all have regional mental health councils, so there’s more local control and appreciation of local needs. Nevada legislators just pushed a bill through this past session that created four regional mental health advisory boards to come up with ideas to address problems, though no money is involved.

You also work with patients with opiate addiction issues. How do you see this national crisis unfolding in Nevada?

We need to look at why doctors are giving their patients a lot more opiates — pain medication — than they really need. Most opiate pill addictions start with a prescription, then patients go buy it on the street. Sometimes, elderly individuals end up with prescriptions for 90 pain pills a month, then they sell them to a third party to supplement their Social Security income. There are people on the streets in Las Vegas carrying bottles of opiates, selling a pill at a time. ... Opiates are so easily abused, and people can get addicted even within a week.

It’s been getting worse over the past three or four years. Now, opiates can be bought online from China and Mexico. Plus, drug companies are great at pushing pain medications on doctors. Many physicians buy into it because they want their patients to be happy. Nevada received $5.6 million this year from the federal government to fight our opiate addiction problem. Of that, 20 percent will go to education and 80 percent will go to treatment. It’s really not enough money.

How has the Affordable Care Act affected mental health services in Nevada?

Access to mental health care has improved greatly. More psychiatrists now accept Medicaid, but some only take a few Medicaid patients because it does not compensate doctors as much as private health insurance. If you have too many Medicaid patients, it’s hard to keep your private practice running; there’s not enough money. But it’s an improvement because in the past, many patients with mental health issues were uninsured, so doctors couldn’t take them at all.

Republican Sen. Dean Heller was against the Better Care Reconciliation Act, the U.S. Senate’s attempt to repeal and replace the ACA that did not go to a vote before the July 4 recess. Why did you support him?

It was going to take away Medicaid coverage and other insurance for Nevadans, which would have affected patients with mental health and substance-use issues. More than 200,000 Nevadans are on Medicaid. Before (the ACA), a lot of people had trouble getting prescriptions filled. We opposed it, and I hope Sen. Heller will stick by his decision.