- [Narrator] Live from the Geisinger Commonwealth School of Medicine in Scranton, WVIA, Presents Mind Over Matter, the State of Mental Health in Northeastern Pennsylvania.

Now, moderator Tracy Matisak.

- Hello everyone.

Thanks so much for joining us for this very important conversation about the state of mental health in Northeast Pennsylvania.

A recent survey of community leaders across the region, identified behavioral health as a top concern, and you can find the full report at the web address on your screen.

But I wanna clarify that when we use the term behavioral health, we are also referring to mental health and we will use the two interchangeably for the purposes of our conversation.

Now, here's why community leaders are so concerned.

Community leaders across Northeastern Pennsylvania, have identified behavioral health as the top health concern in the region for several reasons.

Northeastern Pennsylvania has higher rates of suicide than the rest of the state and the nation.

Lackawanna and Luzerne counties also have some of the highest rates of mental health hospitalizations in the state.

The region's young people seem to be struggling the most.

Nearly half the youth in Lackawanna, Luzerne and Wayne Counties, report feeling consistently depressed and more than 10% have attempted suicide.

Substance use disorders are another big concern.

While opioid overdoses and deaths have declined, pain medication overdoses have increased.

Often the areas of the region with the greatest mental health needs are those with the greatest socioeconomic needs.

And in a few minutes, we will meet some people who have graciously shared their own mental health journeys with us and how they have found help and hope in the process.

But first, a closer look at the state of mental health in the region, how we got here and how to move forward.

And for that, we turn to our expert panel.

Dr. Sanjay Chandragiri is associate professor of psychiatry at Geisinger's Department of Medical Education North Campus.

He was also the founding program director for the right center's residency program in psychiatry.

Dr. Janice Mecca is director of Assertive Community Treatment at the Scranton Counseling Center.

She has been working with individuals living with mental illness for nearly a decade in both residential and outpatient settings.

And Dawn Zieger is associate Vice President of Psychiatry and Behavioral health at Geisinger.

She has extensive experience in community health and in helping people access and utilize healthcare services.

So that said, many thanks to our panel for being with us, Dawn Zieger, let me begin with you by asking if you were surprised at all that mental and behavioral health was at the top of the list of concerns among community leaders.

- Absolutely not.

We are seeing the need for mental health rising up through all care settings, all domains, from schools to churches to our own emergency department.

The need is just rising.

And I think a lot of that is due to the erosion of social supports that happen during COVID, making more people needing to engage in formal mental health care.

- Dr.

Mecca, it seems that one of the most alarming findings from this survey was that Northeast Pennsylvania has higher rates of suicide than the rest of the state as well as the nation.

And in some counties it is significantly higher.

How do we account for that in this region?

Why do you think that is?

- I think it's because lower socioeconomic status.

There's a need for more resources in the community to help address mental health and to help individuals who are in crisis.

- So access has also been listed as a concern as part of that report.

And it sounds to me like that is part of the problem that people who are struggling, often don't have access to the appropriate care that they need.

- I agree with that.

And individuals are afraid to reach out for help when they need it.

- And Dr. Chandragiri, it sounds like what we're talking about here are diseases of despair to a large degree.

Can you talk about that?

About what diseases of despair are and why we might be seeing more of them in certain parts of the state and the country than others?

- I think there's been an increase in incidents of certain psychiatric problems.

One of them is depression and anxiety.

And related to despair, again, is an increase in substance use disorders.

So these are problems that are both biological in origin and largely shaped by socioeconomic stressors, environmental stressors.

And as the stress that people are facing has increased and the social support networks have decreased, we see an increase in these illnesses.

- When you say environmental stressors, what do you mean?

Give me an example.

- Job loss, economic problems in the person's environment, not the environment.

That's a large not, not the air or pollution, I didn't mean that.

- And certainly throughout the COVID pandemic, we've seen so much of that.

There have been so many losses on so many levels that there's been a collective trauma for all of us.

- Yes, that's very true.

And that's, we are noticing an increase in incidents of these illnesses.

- And Dawn, back to the issue of access because that was, as we mentioned, a big concern in the report.

What is most concerning to you as it relates to the gap between the need that is so great and the help that's currently available?

- The volume of demand is just astounding.

We had 18,000 referrals waiting for outpatient care.

We've reduced that backlog down to about 3000, but we get 180 referrals a day, which means I would have to hire a therapist every day to manage that.

And there's just not enough therapists in the country to be able to manage that.

So we have to think creatively about how we intervene sooner, to manage things before they exacerbate.

- And I just wanna underscore what you just said, that you had at one point a backlog of 18,000 cases that have been reduced to a mere 3000, at this point.

We also have been hearing reports about people coming to emergency rooms for mental healthcare, in the absence of other opportunities, what have you seen as far as that's concerned?

- We've seen people coming in and staying a lot longer because the community resources are really constrained.

So one example is pediatric boarding time in our emergency department is 27 hours on average.

And so if you can imagine a teenager having a mental health crisis needing an inpatient bed, inpatient beds aren't available, they're in the emergency department.

And if you think about what that feels like, there's alarms going off, there's people running by, there's all kinds of things going on that if you're experiencing anxiety, it's not an ideal setting.

And so we really need to think about this differently and create alternate access points and alternate models given how serious this issue is.

- Right.

- And the challenge is that it prevents for the clinicians who are in the emergency room, who are taking care of all manner of injuries and accidents and everything else.

And now there's this whole other group of patients that are needing care and stressing the system no doubt.

- Absolutely.

And it's a different type of care than they were really equipped to be able to provide.

And so we're trying to think about how do we do this differently.

- Dr.

Mecca, are you concerned to someone who has, worked in a counseling center?

When you think about what we've gone through over the last couple of years with a COVID pandemic, and here we are now in a place where we're talking about potentially at another resurgence of COVID, we're talking about flu coming back with a vengeance, we're talking about RSV, how concerned are you about what that will mean in terms of the additional mental health needs that we may see?

- I think everyone is just getting used to coming back out of isolation.

And an up rise of other viruses might put them right back into isolation.

And isolation is a large factor in poor mental health or suicidal ideation.

So it's a concern that individual's mental health will decrease with a research of physical health.

- And I'm curious what you've seen as someone who works at a counseling center, when we're talking about access and we've heard about what emergency rooms can be like.

Have you seen that at the counseling center where you work, where there is just an incredible need and a difficulty filling it in terms of being able to help people process some of these mental health issues?

- There's definitely an increase in individuals coming for services and there are wait lists for services.

Luckily we're able to move them along pretty quickly, but there's definitely a need for expansions in services.

- And speaking of that, Dr. Chandragiri, what would you like to see in an ideal world to be able to help handle the sheer volume of people who are coming in with all manner of mental health concerns?

What has to happen to be able to meet that need well?

- Several things have to happen.

One is we need to have, number one is we need to have more people to provide these services.

More psychiatrists, more nurse practitioners, more therapists, expanded access to care.

That's the number one thing.

Then we can work on, and more inpatient beds too.

So it is a real problem now if somebody is, somebody wants to establish care.

There is a wait period of anywhere from one to two months, that's too long.

People should be able to access care when they need it.

And to access care in an emergency has become even more difficult.

If you go into a psychiatric emergency room right now, with an emergent, with a person who is suicidal, any other serious psychiatric issue, they end up waiting for days like Dawn said.

And it's very difficult.

Emergency rooms are not equipped for that.

We may also need a different model for managing emergency situations like a mobile crisis unit or an expanded care or something like an urgent care center for psychiatric treatment.

And if some places have developed mobile crisis teams that have been effective in this, we have suicide hotlines, we have other places, they can help, but they cannot help everyone.

Some people still would need hospitalization or some kind of acute intervention.

- Very quickly, before we move on, Dawn, I want to ask you about the role of telehealth in all of this, in terms of increasing access to care and what a role that has played.

- Yeah, it's been a huge opportunity for us.

84% of our visits are currently through telehealth.

And so we're able to bring care to Northeast PA with providers all over the country.

And so it's really been key for us creating a surge capacity to be able to meet the needs of our patients.

- Well as we mentioned earlier, behavioral health has been identified as one of the biggest areas of concern among community leaders across Northeastern Pennsylvania.

Under that banner, nearly half the leader surveyed listed substance use disorders as a top concern with drug and alcohol use, as key contributing factors.

Benjamin Gonzalez has long been an advocate for people who struggle with substance use disorders.

It is a challenge he knows all too well.

(soft music) - Hi everyone, I'm Ben Gonzalez.

I'm the operations manager for virtual care at Geisinger's Department of Psychiatry and Behavioral Health.

And I'm also a person in long term recovery.

And what that means for me is that I haven't used drugs or alcohol in over eight years.

The first day of my recovery, I think is probably one of the most significant days in my life, but it's also probably one of the most traumatic for myself and my family.

I got sober on August 11th, 2014, after my sixth and final overdose.

My family witnessed that I actually snuck the heroin into their house after being sober for about 90 days.

That's how powerful this disease is, it'll make you make horrible decisions even when things are going well.

My entire family was now affected by the behaviors that I was bringing into their home and had to contending with the fact that I was actually potentially gonna die from this disease.

One by one by one, I continued to cross lines that I thought I would never cross.

A lot of my behaviors were in total contrast to my beliefs.

So things like stealing from family members, having to drop outta college, getting arrested, none of that aligns with my personal beliefs or values.

But I think that my family members were really effective at reflecting what's important to me and how that is in total opposition, and total conflict with what my values really are and who I want to be.

I went to a residential treatment center for 90 days, which was the last thing I wanted to do, but it's what my recovery needed me to do.

That led me to developing a relationship with the guy that was the CEO of that treatment center.

It led me to having a wonderful job in that space, both at the at the bedside, as well as being a recovery advocate and getting to advocate for folks like myself and the legislature, the media, and all sorts of other places I never saw myself.

And you know, ultimately it's what led me to wanting to become a leader in this space.

Everybody has a perception of what a person that has an addiction looks like, but nobody really has much of a perception of what somebody in recovery looks like and what that renewal can bring to our community.

We're seeing some improvements.

I think we've all lived through a couple stressful years through the pandemic, and I think the community is seeing that it's okay to reach out for help, but ultimately I think there's still a lot of work to do.

There's a lot of examples throughout society where we know that these disorders are treated differently than a typical physical health disorder.

So everything from our language, our perception, the way that it's addressed by the community and even our reaction to the word addiction, there's two things that always tend to say to loved ones.

And the first is, is that they really only have two roles in a loved one's recovery.

The first is maintaining boundaries and holding their loved one accountable.

Ultimately, we can't learn, unless we have some pushback and our family, holds us accountable for our behaviors.

And the other is that they need to take care of themselves.

You can't really pour into another person , unless you're pouring into yourself.

Otherwise, when that person is ready to get the help that they need, you're not gonna be healthy enough to be there for them.

You really can't have quality care without access to care.

If you can't get the care you need in a timely manner, there really is no way, despite how educated or skilled the provider is, you have to have that access and able to provide good care.

- Many thanks to Ben Gonzalez for sharing his story with us.

Dr. Chandra Chandragiri, in an earlier conversation, Ben told me that he is genetically predisposed to substance use disorder.

That there were other members of his family who had similar struggles.

I wonder if you could explain for us the role of genetics in substance use disorders.

- Genetics plays a major role in many substance use disorders.

What that would mean is that you, a person would have a genetic predisposition and then if other circumstances align, if they are exposed to the drug, if there are other stresses in their life or if they are experiencing another illness, they may be more prone to develop a substance use disorder than someone else.

And there are many biological processes that end up in this.

One of the things is that the way their reward system, dopamine is a neurotransmitter in the reward system and the way their reward system is structured, they may need more and more of that to get the same satiation or reward than someone who does not have the genetic predisposition.

This is to put it in very simplistic reductionistic terms, but that's what the essence of it is.

So there are certain people who may be more prone to develop a substance use disorder biologically than others.

- So if you have the genetic predisposition and the right circumstances happen to come along, it can be sort of the perfect storm.

- Yes, compared to a person who does not have the genetic predisposition.

You are more likely then, to develop a substance use disorder.

- Dawn, I was struck by what Ben said about how 90 days into his recovery, he brought heroin back into his parents' house and it really speaks to how easy it can be to fall into old patterns again, even with all of the consequences that they bring.

Can you speak a bit to the challenge of recovery, of resisting the pull of that substance that can really overrule our rational minds?

- Yeah, absolutely.

The environment that you're in and your normal really influences your decision.

So something like going back to the street where you used to purchase your drugs may be a trigger, something like a, a certain situation or escalation in your life, that may be a trigger.

So people in recovery, it's very important that there's community and that it becomes a part of the fabric of your daily life, your daily existence, that people help keep you in check when those triggers happen and you have a support network.

- Well, in speaking of keeping people in check, Dr.

Mecca, one of the points that Ben made was that loved ones have two responsibilities.

One is to have boundaries and to keep their loved one accountable and the other is to take care of themselves, so that they can continue to fight the fight.

So I'm wondering as someone who works in a counseling center, what might that look like?

The accountability piece?

What might that look like for loved ones?

- Being honest with the other individual, making sure that you're involved in their treatment and supportive of them as best you can be.

That's really important for individuals to be surrounded by individuals who support them.

- And also what about the idea of challenging?

I can imagine in a situation like Ben's, he talked about stealing from his parents' house, different things like that that.

That he would never do apart from that substance.

And so just the idea of maybe challenging some of those behaviors.

Do you have suggestions for loved ones who might find themselves in that situation?

Maybe some language that they can use to help keep that person in check or to challenge those behaviors?

- I would say to be honest with them about what they're doing and not hide it, not make it less than what it is.

I think that would be a good way to start.

- And Dawn, we hear so much about self care these days, but in the case that Ben is describing when he says that loved ones do need to take care of themselves, so that they can take care of the person who is struggling, what might that look like?

- Oh, I love that you asked that question.

We have recreational therapists that teach you how to enjoy activities and love life.

And so for me, it's been wonderful to think about self care as going for a walk in the woods or enjoying time with your family and being intentional about that.

Sometimes we are so busy that it almost feels like a guilty pleasure to stop and do that, but it's actually an important part of your mental health.

- Think we could all use that kind of therapy.

No doubt we could all use a little more enjoyment in life.

Dr. Chandragiri, the other point that Ben made was about language that we use as it relates to behavioral health and mental health issues.

And it was not unusual to hear people use words like addict or substance abuse as opposed to substance use.

Can you talk about the importance of language, particularly as it relates to mental health?

- It's very important to use the right language and language that emphasizes recovery and language that emphasizes support.

We should not label a person by their disease.

So it's really not right to call someone a schizophrenic patient or an alcoholic.

Those are archaic terms, but we still use them and it's unfortunate.

That judges the person, labels them.

And with substance use disorders, especially the word addict or addicted denotes kind of blame on the person for using the substance.

It's important to realize that these are illnesses and even in talking about how Ben was still craving and got heroin 90 days into his recovery, we have to consider these as chronic illnesses, just like diabetes or high blood pressure and they need chronic management and there could be relapses, there could be worsening in the illness and we have to be prepared for that and not blame the individual, rather support them through this process of recovery.

- So would it be better to say that this is a person who struggles with substance use disorder or what would be a better way or better language to use?

- Struggles, or a person who has substance use disorder or who is, who is recovering from substance use disorder, that would be the most appropriate term.

which shows that they're making, they're participating in treatment, they're invested in their recovery and that's what their goal is.

Now they may have some relapses, but that doesn't mean that they're not in recovery.

They're still in the process of recovery and we should encourage them along in that pathway.

- Yeah, the road to recovery is bumpy often times, yeah.

Dawn, I was also struck by something that Ben told me in an earlier conversation, which is that there's often a very small window of time, where a person who has a substance use disorder, is willing to concede that this is bigger than them, that they do need help.

And I wonder what advice you would have for loved ones maybe when they reach that point where the person is now willing to get help and maybe it is only a small window of time where they're willing to do that.

What do family members and friends need to know about how to try to access help as quickly as possible?

- Yeah, absolutely.

211 is always a great option, if you're not sure where to start.

But if you look for local resources, for example, recovery.

Marworth, we take admissions 24/7.

We're happy to get your call at midnight when the crisis has happened and plan that admission for the next day.

And we've really worked on being available for when patients are ready.

'Cause this doesn't happen from nine to five Monday through Friday.

We've gotta be really resilient and that's the case actually with any of the situations we're talking about.

People have mental health crisis not on our schedule, right?

So being available on demand is really key and take the step when the folks are ready.

- Dr. Chandragiri, what is the most effective treatment for substance use disorders?

Or what does treatment look like?

- It depends on the substance.

It depends on how long the person has been using the substance or the suffering from the substance use disorder and at what stage of recovery they're in.

So for many substances, initially that may be a period of withdrawal.

So you may need medication to manage the withdrawal, especially with alcohol, with opiates, there's a withdrawal period and once that part is over, then the maintenance treatment, that's the recovery period.

They would need a combination of treatments, they would need to see a counselor, support groups, the self-help groups like AA and NA, they're excellent resources and they have one of the best outcomes.

In addition, they could, if people don't want to go to self-help groups, there are other groups that they can go to which would help in recovery.

Seeing a therapist on a one-to-one basis or in a group therapy situation would also help.

And then there are medications, especially for opiate use disorder, opioid use disorder, and alcohol use disorder that are medicines.

There's a medicine called commonly known as Suboxone, which is a buprenorphine naloxone combination, which may be taken orally and also given as an injection once a week or once a month.

There is another medicine called naltrexone, which can be given once a month.

These are the most commonly used medicines for alcohol and opioid use disorder.

But there are several medications coming which are, which have been there and some new ones, which hopefully will come out soon for treatment of substance use disorders.

So it's a comprehensive treatment that would involve medication therapy, self-help groups, group therapy, and family and friend support.

A support network is very important.

- Ben also said that he went to a 90 day residential treatment program and I'm sure that recovery looks different for different people.

But can you give us a sense of how long it can take for a person to get from the point where they begin treatment to the point where they feel like they are back to functioning well, that they are on the road to recovery.

- It's different for every person, but generally I would say between three to six months.

For some people it may take longer.

So Ben was lucky that he could go to a 90 day program.

Most of the time the problem is that kind of program is not covered, it's not paid for by insurance.

Depending on what kind of healthcare coverage a person has, they may be covered for a a four week program.

Less than that, more than that.

Sometimes if they don't have coverage, it's very difficult.

There are other resources, but it's still difficult to get a person into a 90 day program.

- Dawn, what do loved ones need to know about what to look for if they're not aware necessarily that someone that they care about is struggling with substance use?

What are some signs that people can look for that might be red flags?

- Changes in behaviors, perhaps hiding things, not being as transparent, really looking to have an authentic conversation about what's happening in folks' lives.

What's changed that's caused this behavior that you're seeing?

Dr. Chandragiri probably has more experience in this than I.

- So several things may, may be noticed by significant others, close family, relatives and some of them are changes in behavior.

But the problem is these changes in behavior, not abrupt, they don't happen suddenly.

This has happened over a period of time.

But a lot of substances also themselves cause changes in behavior.

A lot of times we see patients with stimulant use disorder.

Methamphetamine is a big substance of use and misuse in Northeastern Pennsylvania.

And this can cause the person to become paranoid, to lose touch with reality, be begin to accuse others of trying to hurt them.

These kind of red flags should raise the suspicion that the person is suffering from a substance use disorder.

And the problem then begins how to seek help.

Because you cannot force a person with substance use disorder, even if they're self destructive, you cannot force them to enter treatment against their will.

There's no process for that.

- And I imagine that that is the great frustration for families many times.

Because to Ben's point, there's just that small window sometimes and when that window closes, it may be a lot more difficult to get that person into treatment.

Dawn, I'm wondering about alcohol abuse because it is so common and the report said that here in Northeast Pennsylvania that there is slightly higher alcohol use than in other parts of the state.

I wonder if you could talk about that and just because that is something that is so common.

It's legal if you're over 21 and so easy to abuse.

- Yeah, and it's a part of our social fabric.

A lot of times we're getting together for happy hours.

It's a part of our meals at times.

And so it can be easy for that to evolve into a problem that disrupts your daily life.

And so I think it's important for us to be talking about that earlier and often.

I feel like we're not detecting and having those hard conversations with our primary care providers and folks are not comfortable engaging in that topic.

And so I think we have a lot to do, to arm our provider community, to arm our teachers, to arm folks to have these conversations earlier in the process before the situation escalates.

- Dr.

Mecca, I wonder if you could talk to the importance to Dawn's point about teachers, parents, friends, connection and community, and the importance of really having a support network of some sort.

- Individual support networks can identify things early in stages.

They can identify mental illness, they can identify substance use and talking about it and not being afraid to ask questions, to individuals that are suffering, can really make a difference.

- And I think that that is so key, right?

Just being willing to sometimes ask the hard questions that might be a little bit uncomfortable, but that might be the first step on the road to recovery.

So the Community Health Needs Assessment found that Lackawanna and Luzerne counties have some of the highest rates of mental health hospitalizations in the state.

And behind each of those hospitalizations is a name and a story.

Monica Mongiello lives in Scranton and has been hospitalized numerous times in her long battle with schizoaffective disorder.

It's a condition marked by both hallucinations and delusions, as well as depression or mania.

Recently she shared some of her journey with us.

(soft music) - This is my 19th birthday.

This was after the onset of my psychotic symptoms get so effective, causes depression abolition, like the inability to do anything, hearing voices, hallucinations.

I would feel things on my skin.

I've been hospitalized 23 times in 20 years.

It's dehumanizing.

You feel like you're not even a person anymore.

You're just a collection of symptoms and problems.

And that's not what I wanted to be.

- You touched my butt.

- I'm sorry.

In times of crisis, my mom puts on a brave face for me.

- No matter what she does or what she tells me, no matter how shocking it is or upsetting it is, I have to do, nope, we're all good.

I got this, you're okay.

We're okay.

- Are these the mixing bowls that we.

- The large ones?

- Yeah - This is psychosis.

I removed my eyebrows and eyelashes.

I felt like I had parasites in the hair follicles.

- Had to be excruciating both mentally and physically.

I just took a breath and said, so that's a new look.

Like she just went, she went, yeah.

- She deescalates the situation, stays calm, does the joking and trying to lighten things up.

I'm alive because of her, not just because she, she's my mom, but because I had a very serious suicide attempt.

This is when I was 16 and my mom asked me to promise her I would never do that again.

I absolutely would've killed myself if I hadn't made that promise to her.

I know for sure that I would have.

People don't think that something as simple as a promise can literally keep someone alive.

I need to keep that promise to my mother.

Hi bud.

Hi.

What a good boy.

Now I deal so much better with the psychosis.

It's not gone.

I hallucinate literally every day.

But you wouldn't know it to look at me.

Let's say I'm hallucinating.

I think there's bugs.

If I'm by myself and my cat's there, if he's not reacting to what I'm seeing, it's probably not there.

Come on the 25 year plan for a bachelor's degree, I'm still working on it.

But sometimes I'm not in the right mindset or well enough to be doing my more academic pursuits.

But just making some truffles and sharing them can give me a sense of accomplishment, even if I'm not doing the things I normally like to do.

I will never be without mental illness.

It is part of who I am and the people around you in the same situation become your community.

- We know each other for 20, 30 years.

If somebody has to go to the hospital, you go visit them.

Even if it's a psych ward, it's what we do.

It's what we do here.

- Any mainstream conversation about mental illness is a good thing.

But it only goes so far.

The seriously mentally ill have been left behind in this conversation because it's uncomfortable for people to talk about us.

You don't want to confront that that could happen to you, that that could happen to someone you love, your child, your brother, your sister.

People like me should be going into college classrooms to talk to the students coming into this field because you can have all the professional training in the world.

It's not the same as living in.

Being sick is a condition that I'm in.

And illness as a state of being, is not something to be proud of.

But the fight that I've put up against the illness, the fact that I still am trying, the fact that I still have goals, that I still make something of my life to make an impact in the world is.

- And many thanks to Monica for sharing her story with us.

If you have had these kinds of struggles, please know that you are not alone.

If you need someone to talk to or you'd like to maybe explore some treatment options, dial 211 to speak with a caring person who can help.

I was so struck, Dawn, by what Monica said about people who are seriously mentally ill have been left behind in this conversation that we talk a great deal about mental health, but we're reluctant to talk about some of these more serious issues because they're uncomfortable, she said.

Can you talk about that and the importance of shedding light on some of these concerns?

- Yeah, absolutely.

We talk about diabetes openly, right?

We talk about cancer openly, but we don't talk about serious mental illness openly.

And being in a family I had actually three relatives with schizophrenia, it was always a shadow and my aunts and uncles would just go away for a while and then they would come back and the behavior was never explained.

And now as an adult looking back, if I'd had a greater understanding, I could've had much more compassion in how I engage with my own family members.

So I think that we have to be talking about the full spectrum of mental illness and her point is really key.

- Dr.

Mecca, that is one of the objectives of Mind Over matter is lifting the stigma around mental health issues.

Can you talk about why mental health has been stigmatized for as long as it has?

I think it was Ben who said that these kinds of issues are treated differently and we've put it into a separate box.

Why have we done that?

- I think like Dawn said, it was swept under the rug.

It was hidden for so many years.

And I think we're coming to a time now where individuals are more open to talk about mental illness and sharing their story.

So things like depression and anxiety, they're more freely talked about.

But some of the severe mental illnesses are still kind of, they're uncomfortable to talk about.

So individuals don't know a lot about them and we're afraid of the things we don't know.

- Dr. Chandragiri, one of the points that Monica made was that she believes that people who struggle with serious mental health issues like hers ought to be talking to the next generation of clinicians.

That it's one thing to have a textbook to study about some of these illnesses, but it's another thing to me to flesh and blood human being who is in recovery or who is dealing with this on a day to day basis.

What do you think about that idea about exposing the clinicians of tomorrow in a more intimate way?

- That's a very good idea.

So it's very, very necessary that they have exposure to especially patients with serious mental illnesses and mend the medical training, at least, they do get that exposure.

There are patients, many times people in recovery come in to speak to first and second year medical students in their class when they do the brain block, mind block.

And then in their clinical years they do rotate in patient psychiatric units and outpatient settings where they do meet these patients with serious mental illness.

And many times they can get to see how they recover from an acute crisis.

And that may give them hope and hopefully will encourage them to pursue career in psychiatry.

But it's very important to have that exposure.

- And Dr.

Mecca, speaking of giving hope, one of the observations that we've all made over the last year or two is that we have seen celebrities, athletes come forward, people that we thought were invincible and they have come forward and they have talked openly about their struggles with anxiety, with depression, with difficulties around being able to do the kinds of things athletically that we would think are second nature, but sort of the mental blocks that they can develop.

And I wonder what you think about that and whether that has maybe given the rest of us a degree of permission to talk about our own struggles.

- I definitely think hearing about other people who have struggles with their mental health allows the community as a whole to talk about it more openly.

The stories we've heard tonight have been inspiring and I'm sure we'll open up the conversation for individuals with severe mental illness or substance abuse.

- And Dr. Chandragiri, you had said to me in an earlier conversation that schizoaffective disorder, which is what Monica has been battling for so many years, that that particular disorder is often wrongly diagnosed.

Why is that, and what is it typically mistaken for?

- Schizoaffective disorder, the diagnosis requires a person to have symptoms of which fulfill the criteria for schizophrenia and an effective disorder.

An effective disorder is depression or bipolar disorder.

And more interestingly, it requires you to have two weeks of psychotic symptoms in the absence of any mood symptoms, which is a very difficult thing to diagnose, especially if you have not followed the person for a while.

So generally, when people are diagnosed with schizoaffective disorder, what it means is that they have symptoms with psychotic symptoms, which you mentioned, where the person is out of touch with reality, may hear voices have, paranoid delusions or other delusions and have significant thought disorder and mood symptoms, either depression or mania or both.

So it's important to realize that these illnesses are not that clear cut.

A person with schizophrenia could have mood symptoms.

A person with mood symptoms can have psychosis.

It always is not, schizoaffective disorder really is a very specific diagnosis.

But it's okay, even if it's misdiagnosed or overdiagnosed, that treatment does not change a lot.

You still have to treat the mood symptoms and the psychotic symptoms.

- Well, and I wanna talk about treatment.

But before that, what causes it?

Are some people more predisposed to it or what's the cause of it?

- Within the schizophrenia spectrum, schizoaffective disorder fall center, that spectrum, the illnesses have a very strong genetic component.

What causes it, again, to put it simplistically, is disorder in certain neurotransmitter pathways.

The most important neurotransmitter that we know to date that is involved in schizophrenia is dopamine.

And there are certain pathways of dopamine called the mesolimbic pathway.

And the mesocortical pathway, which are more involved and these cause some of the positive symptoms, which is the TARP disorder, the delusions, hallucinations and involvement of the mesocortical pathways also cause some of the negative symptoms of schizophrenia, the depression, lack of motivation, lack of energy, and many other symptoms that go with these psychotic illnesses.

- And what does treatment look like?

- The treatments we have to date are targeted at the dopaminergic system, but we have some new treatments coming out, which are acting in other ways through the glutamine system.

But finally, what the treatments are trying to do is to treat both the positive symptoms that is the hallucinations, delusions, and thought disorder and the negative symptoms.

That is a motivation withdrawal, social isolation, treating the whole spectrum of symptoms without, we want to have medicines.

We have got medicines more refined now.

So 30 or 40 years ago, even 25 years ago when I start to practice, most of the treatments we had for these illnesses caused a lot of other symptoms.

They blocked dopamine in many other symptoms, caused stiffness, targeted dyskinesia, drug induced Parkinsonism.

We have medications that can target certain pathways and things like that and those symptoms have decreased.

Not entirely gone away.

We have fewer side effects.

The other advances we have had is for a lot of people with schizophrenia for example, one of the symptoms is lack of insight and that's why they may not be adhere to their treatment.

We have long acting injectables that the patient could be administered once a week, once a month, sometimes once in three months or even once in six months.

And these are major advances, which will help to keep these patients better.

- Sounds like there are some exciting things in the pipeline.

- Yes, a lot.

- As relates to treatment.

Dawn, one of the things that really jumped out at me from Monica's story is her mom and how she said that she is alive today because of her mom.

And it speaks to the power of one person in your life as a stabilizing influence in a really unstable mental health situation.

I wonder if you can speak to that and the influence that one person can have.

- Yeah, that was a wonderful example and we talk a lot when somebody had a suicide attempt about a safety plan and what do you do when you're escalating?

And I love that they brokered that conversation and her safety plan was her commitment to her mom and to some degree.

And so I think mom understanding how to be steady for her as she's having challenges, that's invaluable to have that close knit support system to help keep you safe and keep you healthy.

- And to that point, Dr.

Mecca, one of the things that Monica said was that her mom did not react outwardly, when she would say or do upsetting things.

And I can only imagine as a mom, hearing some of those things to be able to just keep a straight face and to remain calm.

Can you speak to that and how loved ones can best help someone who has a rather severe mental condition.

How do we sort of maintain that sense of stability, that sense of calm, even if on the inside we're feeling anything but calm?

- I think it comes down to good self care for the caretaker as well.

So seeing a therapist, reaching out to family support groups, making sure you're spending time doing things that you enjoy doing because you're spending a lot of time supporting the other person.

All of that's important because you can't help someone else if you are not feeling well yourself or you're struggling.

- Dr. Chandragiri, getting back to the treatment, Monica talked about having had 23 hospitalizations over the years and we talked earlier on about how this part of the state tends to have a higher degree of mental health hospitalizations.

I wonder if you could speak to that and also to what happens in that situation.

If a person is hospitalized for a more severe form of mental illness, what happens then?

During that hospitalization period?

- What happens during the hospitalization is the person is assessed first.

We tend to see what the symptoms are, try to arrive at an appropriate diagnosis, make sure that there are nothing else that's causing the symptoms to get worse.

Also, then we look at the history of treatment, whether the person is a adhering to their treatment, have they stopped medication?

The problem many times is each time you stop treatment and you relapse, it becomes more difficult to treat.

And of course, sometimes even if you continue treatment, the illness can get worse and you could relapse.

So then you might have to change medication, put them on a long acting injectable, or there are medications that can treat symptoms that are not amenable to treatment by other medications.

We have a medication called Clozapine to treat in situations like this, but these all involve assessment, treatment.

The medications have to be adjusted to the right dose.

They take a few weeks to take full effect.

Meanwhile, why there are so many hospitalizations in Northeast Pennsylvania, Why we are deviating from the norm here, many times it's not just an acute hospitalization.

You need then step down treatments.

So many times for a person with a serious illness like this, with schizoaffective disorder, for example, it's difficult to go from just being hospitalized for a week to outpatient treatment.

They need other services, they may need to be in a partial hospitalization program or a psych rehab program.

And there are measures now for patients with serious mental illness who have had numerous hospitalizations.

The team that Dr.

Mecca leads, the assertive community treatment team, they actually go out to their homes.

They make sure they take their medications, they provide support, they provide therapy.

If the patient needs an injection every month, a nurse goes with the team and administers that.

So their goal is actually to prevent people like her who had many hospitalizations from being rehospitalized.

But we do need more of those services.

We do need more partial hospitalization programs, acute intensive outpatient programs where the patient could be seen several times a week.

Psych rehab programs.

The problem is many of these services are not covered.

And we don't have enough of them in Northeast Pennsylvania.

And sometimes people are spread out and it's difficult for them to be transported to these services on a regular basis.

And all these are roadblocks that I think we can overcome and that would help us to prevent the hospitalization.

- And it really speaks, Dawn, to the challenge before hospital administrators in terms of coordinating all these levels of care.

Because to Dr. Chandragiri point, it's not like you can have someone who's hospitalized for a week and then we'll come back next week for an outpatient appointment.

There's so many levels that most of us are not even aware of.

- Yeah, absolutely.

That's one thing I love to talk about with behavioral health is the continuum of care.

So we know that is the case for physical health.

You have primary care, you have urgent care, you might have to go to a rehab.

There's a whole parallel structure for behavioral health.

So these day programs that we're talking about here are critical and I think are under scaled for our community here.

So I completely agree that we need to focus on some of those more acute services and they need to be ready when the people are ready for them.

- Dr.

Mecca, I was struck by Monica's willingness to continue to pursue her education.

And she has such a great sense of humor.

She said, I'm on the 25 year plan, but I'm still working on it.

And it really speaks to her willingness to play the long game here.

And I wonder if you could talk about why that is important, that sort of longer view of things, particularly when you're dealing with a more serious form of mental illness.

- Having goals like going back to school or getting a job.

They help keep you engaged.

They give you something to strive for.

So we always encourage individuals to get community oriented, to build supports, to set goals like going back to school or going back to work.

- And speaking of community engagement, Dawn, I saw you smiling and nodding when Monica talked about Katie's Place Clubhouse and the work that she has been doing there and how it has benefited her.

Can you speak to that larger picture of community involvement and what that does, especially for someone who is struggling with a more severe form of mental illness, who is, as Monica is doing, playing the long game here.

Can you talk about why that's why that's so important and what role that plays in helping a person on their road to recovery?

- It's critical.

You can probably talk about this for forever given your work.

That social fabric and community supports and activities that you look forward to and being able to be authentic and have people accept you with that mental illness is key to recovery.

So what I saw there is we're just friends.

It doesn't matter that the person's in a psych unit at the hospital, you go to the hospital and visit.

And that's so key that we normalize psychiatric illnesses and treat them like any other physical condition.

- And also just the need for opportunities like that.

I don't know how many Katie's Place Clubhouses there are, but it seems that that would be a service that is really needed and I don't know whether there are enough to really meet that need at this point.

- I would say no because if we can engage folks in a positive way, we can identify when things are going off the rails.

If you're coming in daily and we notice changes, that's where we have an opportunity to avoid the escalation to the emergency department, to that inpatient hospitalization.

Because you're seeing the same people early and often.

- Well we will have to leave our discussion there, but Dr. Chandragiri, Dr. Janice Mecca, Dr. Donzieger wanna thank all of you for being part of tonight's program and also for your ongoing work in the area of mental health.

For more information, visit WVIA.org/mindovermatter.

And remember, you are not alone.

On behalf of WVIA, I'm Tracy Matisak.

Thanks so much for watching.

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