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mental health mondays :: crazy money

as some of you already know, dom and i got engaged at a devo show in toronto in november 2009. we'd spent the hours before wandering around some of my old haunts from when i used to live there, trying our best to keep our spirits up despite the gloomy weather, we shuffled from record store to bookstore to clothing store to whatever we felt like exploring for most of the day. we'd gone into a video store on queen street so that dom could indulge his perpetual thirst for new cinematic titillation when we got trapped.

there was one narrow entrance to the store and standing in front of it was a derelict old man who was, hm, pleasuring himself, in the doorway in a most frantic fashion. he seemed quite agitated and determined [although i have to say his hands stayed mostly on the outside of his pants, so the whole display was pg rather than x-rated. because he seemed so worked up, we were a little uncomfortable leaving the store, since doing so would have forced us to pass within a few inches [go ahead, make a joke] of him. moreover, the only other person in the store was a fairly waifish young lady and both of us were a little reluctant to leave her alone with this guy getting so hyper in the doorway. so we stood and waited and at one point, i'm fairly certain i looked at dom and said "welcome to toronto".

you see, having lived in toronto, i wasn't entirely unfamiliar with this kind of thing. when i moved there, i was deeply, deeply creeped out by the fact that the downtown streets seemed to function as some sort of open-air psych ward. the stretch of queen street that passes in front of the city's best-known mental hospital was an encampment for the indigent insane, expelled from the facility proper with the decision of former premier mike harris to close large numbers of beds. these former patients have gradually moved on, spreading out all over downtown, but being in the city just after the bed closures was borderline tragic. they'd simply moved onto the street and stayed there, having nowhere else to go. they still don't, of course, it's just that they're not crammed into one or two blocks.



by slashing hospital budgets, of course, premier harris was making good on a promise to restore a sense of fiscal conservatism in the wake of five years of textbook keynesian economics courtesy of the ndp. harris had promised that he was going to make sure that the underclasses weren't taking advantage of the social safety net by making it tougher for them to get the benefits that safety net provided. closing those beds probably saved the province millions of dollars in immediate health care costs, which looks great on a budget ledger. conveniently, there is no line on the budget for the costs of the mentally ill ending up going through the judicial system because they end up being arrested for any one of a variety of infractions [probably including self-gratification in a public area].

the "disguising" of costs related to mental illness is a fairly typical tactic of governments seeking to make their financial acumen look better. it's like measures taken to cut off [un]employment insurance at an earlier date and then claiming that unemployment has gone down. sure it has, because there are fewer people collecting insurance...

the tacit understanding with cuts to mental health programs is that those who are affected are largely addicts- in ontario, the facility on queen street that faced bed closures was a centre for addiction and mental health- who are, on the whole, not a  group for whom right-thinking taxpayers are likely to have a great deal of sympathy. in fact, in the wake of those cuts, the harris government specifically excluded patients with a history of substance abuse problems from eligibility for other forms of government assistance. of course, one could make the point that people who are already homeless and suffering from illnesses such as schizophrenia or bipolar disorder might not be in great condition to apply for government aid anyway. or one might point out that the incidence of substance abuse is generally higher among people with mental disorders, as are compulsions of all sorts. but the bottom line is, mental illness went from costing a lot of money to costing a great deal less. on the books.

however, the actual cost of mental illness is staggering. an article in time magazine- hardly a bastion of progressive thought- estimated the costs in the united states alone as being just under $200 billion per year. and, lest you think that that number is inflated, that is only taking into consideration the roughly 6% of the population deemed to have serious mental impairments- conditions like autism or schizophrenia that would severely impair one's ability to work on a regular basis. people who do suffer from these conditions earn just over half of what those who do not have a serious mental illness on average. that's a lot of people earning less and putting less money into the economy as a direct result of mental illness.

what is truly sad is that, given their limited ability to advance in their work- or even their ability to work at all- means that this demographic is also the least likely to be able to afford medications that would help stabilise their condition and make daily life easier and the least likely to have insurance plans that cover the cost of necessary drugs. in a country like canada, with a broad public system, that means that someone without insurance from their employer [which would include a lot of mentally disordered people who do hold jobs, let alone those who don't] could easily expect to pay $50- $75 a month for their prescriptions. that may not sound like a lot, but on a low income, it can add up. and keep in mind, those are the costs that they could expect to pay if they were taking only drugs that were covered by the provincial health care plan. newer drugs, particularly anti-psychotics and other drugs for mental disorders, generally take a long time to get approved under provincial plans. if you want to try one that's not covered, you're stuck paying the entire cost.

in the united states, the situation is more similar than you might think. medicaid, the resort of most people with serious mental illnesses, covers only more established drugs and even then, covers only a portion of the cost. many employer-funded medical plans do not offer coverage for the "heavier-duty" psychiatric medications [possibly an indication that neither the employers nor their insurance companies are that eager to employ people with mental disorders]. so instead of paying $50- $75 a month for pills, that probably means someone could end up paying double or even triple that to get their medication, right? not exactly.

let's take a couple of examples. the prices i'm using come from drugstore.com, but i've taken the time to verify that these are reasonable for the marketplace [i.e., not inflated because they're on the internet, as many prices are].

geodon :: approved for treatment of schizophrenia and manic episodes of bipolar disorder
starting dosage :: 20mg twice/ day
cost of one month supply :: $478.01

olanzapine :: approved for treatment of schizophrenia and bipolar disorder
starting dosage :: 10-15mg/ day
cost of one month supply [based on 10mg/ day] :: $25.99

abilify :: approved for bipolar disorder, schizophrenia, clinical depression
starting dosage :: 15mg/ day
cost of one month supply :: $1,569.90

seroquel :: approved for treatment of schizophrenia and manic episodes of bipolar disorder
starting dosage :: 50mg/ day, but normally increased after only a few days up to 400mg/ day
cost of one month supply [based on 200mg/ day average] :: $358.99

you can see that the costs are extremely variable. olanzapine is far cheaper than any other option, because it has been around for a long time [and in fact, its patent is due to expire this year, making it effectively a generic already]. the newer the drugs get, the more expensive they get. guess which drug is the newest?


the problem is that newer drugs are often more effective, because they've built on previous research, or have lower side effect profiles [for much the same reason]. those who are forced to subsist on lower incomes may have no choice but to take the cheapest drugs available, which may or may not be drugs that work for them. psychiatrists often go through many iterations of drug combinations before finding one that addresses the specific problems that a patient faces. and keep in mind, what i've given above [with the exception of seroquel] are the minimum costs- those based on the lowest dosage generally prescribed. most patients do not take the minimum dosage. and just to confuse things more, it's also important to note that it's comparatively rare for a patient with a severe mental disorder to be on one medication. more than likely, they would be on several, meaning that the costs of the anti-psychotic- although quite possibly the most expensive- would be only part of their monthly medication bill.

the options, then, for those who struggle to be able to function in a work environment are to direct an inordinately high proportion of their pay into drugs to keep them stable or to try to get by without drugs and hope that they don't end up wandering the streets intimidating people in video stores.
although they might not admit it, everyone in government, everyone in the insurance industry, everyone in the health care industry and a lot of people who just know how things work are aware that mental illness costs a shocking amount of money every year. hiding those costs by pushing them out of the public sphere, or by restricting the impact they have on employer-funded insurance programs, does not make the costs go away. it just means that the people who they effect are in a lot worse shape than they would be otherwise.

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