For any significant progress to occur in our mental health system, we must first identify practices that are working, remove barriers that hinder them and provide incentives for others to follow. In Hawaii, psychiatrist Chad Koyanagi provides a model for what works with a simple approach that is often the answer for many without hope.

Hawaii has the nation’s highest homeless rate per capita. According to the Substance Abuse and Mental Health Services Administration, more than 60 percent of this population suffers lifelong mental health problems. These figures are well known to Koyanagi, for they are more than statistics. They are his patients.

On a Sunday afternoon, as he often does, Koyanagi makes his way through one of Hawaii’s many homeless camps with his medical kit in hand. He does not wait for them to come to him. Instead, he seeks out the most remote patients and goes to them.

One Honolulu psychiatrist who treats homeless people looks for those on the fringes first. They may need his care most.
One Honolulu psychiatrist who treats homeless people looks for those on the fringes first, because he says they may need his care the most. P.F. Bentley / Civil Beat

Simple as it sounds, a doctor going to the patient is rare when treating mental illness. Federal and state laws require a patient to take the initiative and seek help before treatment can be given. The patient must choose to “go to the doctor.”

Think about this irony for a moment: Would you entrust your health decisions to someone suffering from schizophrenic delusions? Then why do we require those suffering from schizophrenic delusions to be responsible for their own health decisions?

And while going to the doctor may be a natural response for someone with the flu, those with psychosis are not aware they need help. This is a condition called “anosognosia” — the inability to recognize one’s illness. It’s a debilitating catch-22 for the patient. Their illness prevents recognition of being sick, they refuse treatment, the illness worsens, the anosognosia worsens … and a downward spiral of increasing insanity begins.

This is why the Koyanagi method is effective. By going to the patient, remedies can be prescribed before it is too late.

Justin Phillips, director of outreach for the Institute for Human Services, regularly accompanies Koyanagi on his work in the homeless camps and recalls one such case. Koyanagi noticed a troubling infection on an elderly women’s foot one day as she rested on a busy sidewalk. Suspicious, he admitted her to a hospital and discovered her infection to be so severe that she would have died in a matter of days, had she not been treated.

We must more correctly define “mental illness” as a “brain disease.” By doing so, we effectively redirect our laws and policies away from psychological biases to more accurate physiological origins.

Fortunately, her infection and mental disorder were treated successfully, and she was subsequently reunited with a son who had been frantically searching for her.

Attorney Diane Haar of Hawaii Disability Legal Services shares a sentiment common to many Koyanagi colleagues.

“I first came to know Dr. Koyanagi through my work at the IHS Men’s Shelter,” she recalls. “In my line of work, his name will crop up with my most seriously ill clients. It gives me hope every time I find this out. I know they are in the hands of a doctor who will often succeed in easing their suffering.”

But it is not just the homeless who benefit. Koyanagi is also known to assist family caregivers, a segment of society largely ignored by the mental care system. Known as the silent sufferers, family caregivers are literally left with no solutions to deal with loved ones’ psychotic outbursts. Often the only brief respite is to call 911.

Given that every homeless person with a psychotic affliction at some point in his or her past had a family, one could argue that our homeless epidemic could be drastically reduced, simply by following Koyanagi’s proactive approach of strengthening family caregivers.

So why isn’t the Koyanagi method more prevalent when it comes to treating severe mental illness? This question begs an answer.

As May is observed as National Mental Health month, a commitment to change the treatment of mental illness is needed. Modalities like the Koyanagi method must be encouraged. To enhance physician participation, home and field treatment must be rewarded with financial compensation worthy of a doctor’s standing. Perhaps even more importantly, passing laws that enable patient families to care for their own will lessen the need for a caretaker society.

We must also follow former National Institute of Mental Health Director Thomas Insel’s admonition to more correctly define “mental illness” as a “brain disease.” By doing so, he argues, we effectively redirect our laws and policies away from psychological biases to more accurate physiological origins.

Dr. Koyanagi is what is right in our mental health system. We need to celebrate the efforts of people like him, inspire the next generation of physicians, and remind ourselves that the malady of brain disease is truly physical, not just a state of mind.

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