A new generation of wonder drugs is helping Montana's mentally ill
HAMILTON - A new batch of anti-psychotic drugs introduced in the 1990s - dubbed the decade of the brain - has brought sense to confusion and relief from anguish for some of the region's severely mentally ill.
For some, it's meant the difference between confinement and freedom.
With biotechnology stocks among the hottest investments on Wall Street, mental health officials are encouraged that even better drugs soon will be discovered.
"There's been an upsurge in dollars dedicated to research in treating brain disorders," said Dr. Noel Drury, a Flathead County psychiatrist and president of the Montana Psychiatric Association.
"Biotechnology companies are the darlings of Wall Street," he said. "There's been a tremendous amount of financial interest in them."
For mental health care providers in Montana, where care for clients is in a state of transition, the new drugs have become another tool to treat the mentally ill who are increasingly leaving hospitals and returning to society.
How to ensure a person continues taking his or her drugs while living in the community is not always an easy task, although the newer drugs that cause fewer side effects give patients less reason to stop taking them.
Among the newer anti-psychotic drugs are Zyprexa, Clozaril, Seroquel and Risperidal.
They have proved effective at treating the symptoms of paranoid schizophrenia, while old standby Lithium and Depakote are two medications that often reduce manic symptoms such as hyperactivity, constant speech and grand delusions.
The antidepressants Prozac, Serzone, Effexor and Wellbutrin have worked to help people suffering from severe depression.
All of the "wonder drugs" may produce side effects to varying degrees such as weight gain, Drury said, but they appear to be easier to tolerate for most patients.
Like other illnesses such as diabetes and heart disease, the severity of mental illnesses can vary and so can responses to medication, he said.
"With the terrible cases, maybe you don't respond to the medication," Drury said. "You never know with any one individual what their response will be."
Sometimes, the response borders on the miraculous. A Hamilton mother, for example, marvels at the change a new medication produced for her 21-year-old son, who suffers from paranoid schizophrenia. The newer drug, Zyprexa, changed his whole outlook on life, said the woman whose son didn't want to be identified for this story. He previously took Haldol, lived at home and suffered numerous side effects that included severe insomnia, nightmares, tics, constant pacing and grinding of his teeth. But within less than a week on Zyprexa, he felt so well that he decided to find an apartment of his own and look for a job.
One drawback to the new drugs is cost. Haldol cost $7 to $10 a month; Zyprexa runs about $480 a month. Fortunately, insurance covers this cost.
Haldol is one of the older drugs still in use, but sometimes it causes unbearable side effects. Drury said a class of 50 medical students in New York took the drug along with a placebo to see the tolerability of the medication.
"All of them couldn't stand taking it after a day or two and refused to take it any longer," Drury said. They questioned how anyone could prescribe such a thing to anyone, given the severe side effects.
"But it was the best we had to offer 10 years ago," Drury said.
Drury commended state leaders for not being stingy about including the newer drugs in the list of those psychiatrists may prescribe to patients on Medicaid.
"The state took a forward-looking approach," he said.
Though the newer drugs are more costly - sometimes $200 to $1,000 a month for one patient - they have a better chance of paying off in the long run for both the client and the state.
"If the patient is willing to take medications and doesn't suffer serious side effects, they are much less likely to need inpatient hospitalization," he said.
Boyd Roth, 61, of Kalispell, has taken several psychotropic drugs on and off since 1972, when he was diagnosed as having bipolar disorder.
He said the newer drugs have allowed him to become a productive citizen and a resource to others who suffer from mental illnesses.
The disease took hold when he was working long hours as a seventh-grade math teacher.
"I left school in the middle of the night and never returned," he said.
Over the years, he struggled with his medications, although he worked successfully for 17 years in sales in the 1970s and 1980s before he had a difference of opinion with his boss and quit his job in 1988.
For two years, Roth fell into a deep depression, but in 1990 his strong religious faith, supportive family and various treatments helped him recover, he said. He opened House of Second Chance, a house for homeless men. In 1992, he started a support group for manic-depressives that served as many as 50 participants through Lamplighter House in Kalispell.
But in 1996, Roth went off his medication again because of money problems and ended up at the Montana State Hospital in Warm Springs. He declined to discuss the incident that landed him there, but when he was discharged he was on a new and better psychotropic drug - Risperidal - that produces less side effects and has allowed him to remain stable since.
He is three-time president of the National Alliance for the Mentally Ill's Flathead chapter. The organization provides leadership and organizes programs, fund-raisers and membership drives. It brings in speakers monthly to provide education on mental health issues.
And Roth also now serves on the Governor's Mental Health Oversight and Advisory Council, made up of consumers, family members and others who advise the state on mental health issues.
Judy Willetts' son, formerly of Kalispell, had far less success with treatment because he refused to take prescribed medications for his paranoid schizophrenia, choosing instead alcohol and illicit drugs.
Kurtis Kameron Wolcott thought he didn't need the medications.
"He didn't have an appreciation for the drugs and I didn't either … for what the schizophrenia could do in causing him to become delusional," Willetts said.
So the dangerous whispers continued in his ear until one day in 1997, when he shot and killed a woman because he believed she planned to kill her 4-year-old son.
In Wolcott's reality, he did the right thing.
The voices in his head told him the mother was a danger and he should save the boy, Willetts said.
Now Wolcott is confined to the Montana State Hospital and ordered to remain in custody and treatment for the next 100 years unless there is a medical miracle that cures schizophrenia.
Willetts said she knew her son was in trouble, but the laws prevented her from forcing him to get help.
"It's probably the worst thing that could happen to a family … for a person within it to lose their mind," she said. "There is hope only when you have a son or a loved one willing to get help."
The problem with the system, she said, is that it relies upon the mentally ill to determine how best to treat the mentally ill.
With tighter budgets, medical professionals don't always spend enough time with outpatients to know for sure they are doing as well as they say they are, she said.
Willetts supports changes in laws that would allow families to participate more in patient treatment. She knows some oppose that idea and view it as a threat to the civil rights of the mentally ill. She suggests that viewpoint comes from abuses in the past.
"As long as there were mental hospitals, there have been abuses," she said. "That's why many hospitals were closed, but now these people are on the streets or in our prisons."
Willetts hopes that some day legislation will permit involuntary treatment in certain cases, when it can be shown that a person could be a threat to themselves or someone else before they have committed a crime.
"Somewhere there has to be some sort of ability and support for the person who hasn't committed a murder to save them from getting to that point," she said.
Some in the judicial system agree that psychotropic drugs can be a great tool, if patients stay on them. That doesn't always happen.
Bob Long, Lake County deputy county attorney, witnesses the problem firsthand in court, when some of the mentally ill who commit crimes end up back in front of a judge because - for whatever reason - they stopped taking their medications and committed another crime.
"It seems to be a consistent theme," Long said. "The drugs are only as good as the person taking them."
Flathead County Attorney Tom Esch has seen treatment improve, and more alternatives are available to sending someone to the state hospital.
Although his caseload of commitments hasn't dropped in the 1990s, it has leveled off at about 40 to 50 cases per year in one of the state's fastest growing counties, he said.
"There are those in the community who have responded well to treatment through use of psychotropic drugs," Esch said. "Some are business owners and even lawyers. They are able to function well in the community."
Then there are those who, in spite of medicine's best efforts, can't be stabilized, and they end up in a revolving door.
Side effects still can be a problem, Esch said.
"As much as we'd like them to be the silver bullet, they come with their own set of risks," he said.
"I've seen judges yell at patients for not taking their meds, but for some there is a reason they don't," he said. "They don't want to drool like a St. Bernard. … They don't like what it does to them."
Esch has confidence new drugs will only get better. Medications for the mentally ill are better now than ever before.
"It's a good tool for some people," he said. "If I had one wish, it would be that the medications improve, and I have tremendous hope that they'll only get better."
At the end of last year, Montana launched a new pilot program designed to improve care for severely mentally ill living in select communities.
The pilot programs use an approach that is more proactive than the old system of care. A team of health-care workers - including a part-time psychiatrist, a registered nurse and clinical workers - try to reach the mentally ill rather than wait for a client to seek help.
They also help integrate and support a patient after he or she is discharged from the state hospital.
The approach, Drury said, wraps treatment around individual needs and puts the consumer of mental health services at the forefront of determining what services should look like.
Pilot projects were launched in Helena and Billings. If they succeed, state officials hope to expand them across the state.
Mental health officials say the program has worked elsewhere in the country and is effective in treating those suffering from the most severe mental illness and those who resist or avoid traditional mental health services.
"We're trying some excellent programs that have worked elsewhere and imported them to Montana," Drury said.
Meanwhile, smaller rural areas continue to try to stretch dollars to cover community-based treatment. The newer drugs are just one piece of that treatment package.
In Ravalli County, about 80 clients receive intensive case management. Case managers help clients take their drugs, monitor their responses, receive treatment, access services, pay bills and even grocery shop.
But limited funding has meant a heavier caseload for each case worker, and the term "intensive" case management might becoming a misnomer, said John Schaack, office director at River Front Counseling and Support Center in Hamilton.
"Caseloads for case managers have increased significantly to the point where it is difficult to provide that much time to each individual," Schaack said.
The county has the equivalent of four full-time employees to serve the 80 or so clients. The maximum number of clients a single caseworker should manage under state guidelines is 22.
When Schaack was hired five years ago, the average caseload in Ravalli County was 10 to 17 clients to each caseworker.
Compounding the funding situation, he said, is the lack of a drop-in center or a day treatment facility for the mentally ill to socialize and do activities. Such facilities are available in Missoula and work well, he said.
"It's one of our greater needs," Schaack said. "Case managers are left to provide all of that support, so perhaps there is even a greater inequity in case management numbers."
Schaack said the new psychotropic drugs have made a huge difference with the majority of the people he serves.
"The consumers are much more willing to take the medications and stay on them," he said. "There are fewer relapses, allowing us to build on their skills. The support system stays intact and so does their self-esteem."