Mental health care in NH is stressed. Here are some ways to get care.

Lt. Todd Donovan, 53, retired in July from the Derry Fire Department with accolades and honors for 30 years of distinguished service as a firefighter and paramedic. During those decades dedicated to helping others, he was battling his own mental illness.

He first attempted suicide at the age of 8. “I don’t remember why other than just I was extremely angry and I know that I wanted to die,” he said. 

At 14, while hiking with a friend in Oregon, a voice in his head that he said sounded like a drill sergeant told him to jump off a cliff, so he did. 

At 18, he tried to die by carbon monoxide poisoning but was discovered in the act, hospitalized and diagnosed with major depressive disorder with psychotic episodes. 

At the age of 19, he went to paramedic school and found his life’s calling, but he continued to struggle without understanding that he was fighting an illness. 

“I thought it was a moral failing,” Donovan said. “I thought I just wasn’t pulling myself up by my bootstraps. I became very organized. I lived by a schedule. I became very religious. I didn’t have friends. I was doing everything I could to stay alive.” 

Trying Transcranial Magnetic Stimulation to improve mental health

When Donovan was 44, his wife of 30 years, his Merrimack High School sweetheart with whom he has four children, read an article in the Concord Monitor about a new treatment called Transcranial Magnetic Stimulation, which he describes as an “MRI-sized magnet that sends 3,000 pulses over a 19-minute period” to “depolarize neurons” in the pre-frontal cortex. 

Following his 22^nd treatment, Donovan said, “I woke up and had no suicidal images. …. And even more welcoming, I didn’t have a voice in my head. The voice was gone.” Suddenly, Donovan saw the vibrant colors of New Hampshire’s fall foliage for the first time, and he was able to listen to music. Quoting a lyric from “Hamilton,” a favorite musical, he said TMS treatment put him “back in the narrative.” 

Donovan’s inability to understand he was suffering from a mental illness and not a failure of will or morality, is not uncommon. While great effort has been made to raise awareness and educate the public, most people remain unfamiliar with the signs of mental illness and those who do recognize the signs often don’t know how to respond to help a friend or loved one. 

Susan Stearns, executive director of National Alliance on Mental Illness-New Hampshire, said for a person experiencing strong symptoms such as despair and depression, “it can be hard to see past that black hole. It becomes hard to see beyond that.” 

For the caregivers, who are often walking on eggshells around the person who is struggling, it’s tough to know what to say to a loved one in crisis.

Even when everything goes right and a person in crisis is receptive to receiving treatment, getting that treatment at a time when resources are scarce can be a frustrating challenge. 

Donovan, for example, who struggled his entire life and finally found relief through TMS treatment, just received notice that his insurance will no longer cover TMS. 

“Out of the blue, they sent me a letter saying we’re not going to pay for it anymore” (after paying for it for nine years), Donovan said. “So I went four or five months without TMS and wound up in the hospital again. And that cost them $24,000.” 

Mental health care services are stretched to the breaking point.

“I think the pandemic really highlighted all the faults in our system, the cracks in the system, the things that we were patching together and then just couldn’t sustain when we really were stressed by higher volumes of people in need,” said Dr. Seddon Savage, who consults with Dartmouth Health on substance use disorders and mental health.

Things can become so difficult and complicated, particularly for those needing expensive, extended inpatient care at specialized facilities, that some turn to patient advocates like Maureen Tracey, founder of Individual Advocacy Solutions in Merrimack, who learned to navigate the system fighting for her own daughter.

“My goal is to be with a family for a year or less to help them through a crisis but also to give them the skills and resources to continue to advocate for their family member because unfortunately, oftentimes, the need for advocacy never stops,” Tracey said.

In the face of insufficient resources, much of the burden for keeping those in crisis safe and finding them treatment has fallen on their caregivers.

“There are lot of people who are suffering, who need to see a professional, and there aren’t enough professionals,” said Barbara Van Dahlen, PhD, a clinical psychologist who has led several major mental health initiatives at the national level. “We, as a society, need to respond with other tools, other mechanisms, other strategies.” 

How to recognize signs of mental illness 

To help people recognize common signs of mental distress, Van Dahlen launched the Change Direction campaign, which aimed to make signs of mental illness as recognizable as those for a heart attack or stroke. The campaign focused on five signs of mental distress: personality change, agitation, withdrawal, lack of personal care and hopelessness. 

The campaign launched at the White House in 2015, with first lady Michelle Obama serving as the keynote speaker. 

“It’s time to tell everyone who’s dealing with a mental health issue that they’re not alone, and that getting support and treatment isn’t a sign of weakness, it’s a sign of strength,” Obama said. 

It’s important to recognize signs of mental illness, Van Dahlen said, because everyone, not just professionals, can help friends and loved ones in crisis.

“Not everybody who’s suffering, not everybody who meets the five signs criteria, they don’t all need to see someone like me,” Van Dahlen said. “If we help them recognize that there’s something going on that needs to be addressed, it may be that a self-help app or a tool is what they need. Or maybe going to a support group is exactly what they need, so they don’t get to the point of deterioration when they are in a really difficult place and they’re trying to find a bed and there aren’t any.”

Van Dahlen’s latest initiative is WeBeLife.com, which employs wearable technology to track and support emotional well being. Just as telehealth has played an important role in improving access to mental healthcare, she believes technology will help provide mental health services while human capital is in such short supply.

The five signs of mental distress

Here are the five signs of mental distress as defined and presented by Change Direction: 

1) Personality change : The person’s personality changes, as noted by sudden or gradual changes in the way they typically behave. This change doesn’t seem to fit the person’s values, or they may just seem different. 

2) Agitation: The person is uncharacteristically angry, anxious, agitated or moody. They may have problems controlling their temper, seem irritable, can’t calm down, are unable to sleep, or may explode in anger over a minor problem. 

3) Withdrawal: The person isolates or withdraws from family and friends, they stop taking part in activities they used to enjoy, and they fail to make it to work or school. This shouldn’t be confused with reserved or introverted behavior. This is a change in someone’s typical sociability, such as pulling away from their usual social support. 

4) Poor self care: The person stops taking care of themselves and may engage in risky behavior or display acts of poor judgment. This may include letting personal hygiene deteriorate, abusing alcohol or illicit substances, or engaging in other self-destructive behavior that may alienate loved ones. 

5) Hopelessness: The person used to be optimistic but now can’t find anything to be hopeful about. They may be overwhelmed, suffer from extreme or prolonged grief, or have feelings of worthlessness or guilt. They may say the world would be better off without them, suggesting suicidal thinking. 

What to do if someone you care about is struggling with their mental health  

Recognizing someone may be struggling with their mental health is important but it’s just a first step. Next comes what is often a hard conversation.  

From his perspective as someone with multiple suicide attempts, Donovan urged caregivers not to be afraid to ask if someone is feeling suicidal. 

“It’s really hard for most people to broach the subject,” Donovan said. “But it’s brave and shows leadership if you can reach out and be able to say, ‘Hey, I’ve noticed that you’re quiet. I noticed that things haven’t been going your way. Are you feeling OK? Are you depressed? And I’ll even go as far as, if they’re expressing sadness, are you feeling suicidal? I could personally tell you that sometimes words have gotten me out of a suicidal episode.”

Stearns, leader of NAMI-NH, affirmed Donovan’s view it is productive to address suicidal thoughts head on.

“If you’re concerned that someone is considering suicide, ask them directly,” Stearns said. “It isn’t going to give someone an idea they’ve never thought of. It’s the best way to get the conversation out there because obviously if someone is considering suicide, you want to know that. You want them to know that you are going to stay with them until they’re in a safe place.” 

She suggested that if you’re worried you won’t know what to say, to call New Hampshire’s Rapid Response line at 1 (833) 710-6477, the 988 suicide hotline or the website nh988.com which are staffed 24/7 with people who can assess the situation and either dispatch a rapid response team or make referrals for treatment. 

Stearns said if your phone number does not have a (603) area code, using the 1-833-710-6477 number may be better because it will be answered by someone in New Hampshire. 

Many primary care practices now also have behavioral health professionals on staff so if you have a primary care physician that is also a potential resource.

Van Dahlen suggested sharing your own personal struggles may allow your loved one to feel safe to share with you. 

“Stepping in and saying: ‘I see you, I care about you, I want to help. How can I help? That is literally offering a lifeline to someone who may desperately need just that, to be able to take their own steps to get some help,” Van Dahlen said. 

She acknowledged that often the person struggling will push back against a conversation about their mental health. 

“Don’t give up,” she said. 

“If we get more people around someone who’s struggling and hurting, it makes it harder for them to ignore that and dismiss it,” Van Dahlen said. “If people are saying, ‘I care about you and you can push me away but I’m still going to be here’ (it will make a difference). People need to know there is hope, treatment works, support actually helps people. Peer support helps. Professional treatment works. So we need to help people get through that time when they’re feeling like it’s pointless because treatment works, support works, interventions work.” 

Stearns summed up what to do first if you see someone struggling with one word: “Listen.” 

“Start with listening,” she said. “It doesn’t mean you’re not going to try to work on solutions, but really listening is important and really hearing what someone is saying in that moment when they are struggling so they know they are not alone.” 

She said caregivers should not jump to solving a problem before taking the time to listen. 

“You want to be careful with the list of, here are all the things that you could do to feel better, because it can wind up being a message of, ‘Here are all the things you’re not doing.’ So you want to balance that,” Stearns said. 

When it feels appropriate, Stearns recommended helping people remember coping mechanisms they have used in the past to get them through a crisis, “whether it was going outside for some fresh air, gardening, interacting with a friend, calling your mom, whatever that self-care may be.” 

Dartmouth Health designed a program with the acronym REACT, to give non-professionals the tools to help a person in crisis. REACT stands for: Recognize (the signs of emotional suffering), Express (concern and offer support), Act (Now and talk to someone you trust), Care (enough to follow through), Text (‘Signs’ to 741-741 or call (603) 448-4440.

John Broderick, a former New Hampshire Supreme Court chief justice, who launched the five signs campaign in New Hampshire in 2016, said: “The only mistake you can make is to be silent.” 

‘We’re making progress, but it’s too slow’ 

Since launching Change Direction’s Five Signs campaign in New Hampshire, Broderick has been ceaselessly touring the state speaking about the need to improve how we treat mental illness. In that time, he has seen progress.  

“People are talking about mental health now,” Broderick said. “It has become an everyday topic.”

The goal, Broderick said, is to make the signs of mental illness as recognizable as those of a heart attack or stroke. To do that, he said, we need to be able to talk about helping people with mental illness in the same positive way we talk about helping people with breast cancer. 

“Mental illness is the only illness we wait until stage four before we treat it,” Broderick said. “988 (the suicide hotline) is stage 4. So what are we doing before people reach the point of wanting to take their own lives? What are we going to do to lessen that? What are we doing to get them help? 988 is great but it’s like calling the fire department for a three-alarm fire. They may come and put out the fire but (the homeowner) has lost everything in the process.” 

It’s time to stop talking about stigma and start talking about discrimination 

The topic of stigma comes up in nearly every conversation about why our mental health system fails to get the support it needs. Stearns suggested we need to begin thinking about stigma differently. 

“Sometimes I think we like the word stigma because it prevents us from looking at the real issue, which is discrimination,” Stearns said. 

“The reality is, that we do as a society discriminate against people with mental illness. We judge them based on their mental illness.” 

Donovan said that he has not faced any backlash for being open and honest about his struggles with mental illness.  

“I can confidently say that it has elevated me,” Donovan said. “There are no cons to it. I think the benefits have been that it’s really elevated me to a leadership role in this realm.” 

It’s probably no coincidence that Donovan, who is now president of the NAMI-NH board of directors, has named his sailboat “Stigma Free.” 

New Hampshire Rapid Response, by the numbers 

One of the state’s top priorities in its 10-year mental health plan has been to take some pressure off emergency rooms by deploying Rapid Response units to triage those experiencing a mental health crisis. 

“Long wait times for psychiatric hospitalization is one visible symptom of a stressed mental health system,” stated the 10-year-plan, released in 2019, pre-dating the increased demand brought on by the pandemic. “Limited access to care, the difficulties inherent in navigating a complex and fragmented system, shortages and turnover in the mental health workforce, limited alternatives to the Emergency Department (ED), lack of inpatient bed capacity, and the need to comprehensively address the social determinants of mental health are also common concerns raised about New Hampshire’s mental health system. Underlying it all, in the minds of many from whom we heard in this process, is the need to increase funding for mental health.” 

New Hampshire’s Rapid Response units, deployed through the state’s 10 community health centers, offer a layer of response not found in many other states. Staffed 24/7, callers are triaged over the phone and if there is a threat to health or safety, a mobile unit with a clinician and peer counselor will dispatch to the caller’s location. 

In its first year of operation, from January to December 2022, Rapid Response made 22,200 contacts, assisting individuals via phone, text and/or chat, according to Beacon Health Options, which runs the program for the state. 

Of those 22,200 calls, 7,084, or 31%, resulted in emergency mobile dispatches.

Mental health care system is stressed 

Hospitals across New Hampshire are reporting long waits in emergency rooms. One factor cited is the number of patients who arrive at the emergency department with behavioral health needs who are then held for days and sometimes weeks waiting for a behavioral health bed to open. 

As of Feb. 16, 2023, there were 25 adults and 16 minors being held in New Hampshire emergency departments waiting for a behavioral health inpatient bed. 

Emergency departments, said Stearns, “are not an appropriate place for children.” 

“I do believe our mental healthcare system is being stressed to a point we have never seen before,” Stearns said. 

A report from the Centers for Disease Control released Feb. 13 found “The pandemic took a harsh toll on U.S. teen girls’ mental health, with almost 60% reporting feelings of persistent sadness or hopelessness,” the Associated Press reported.

The state is slowly working through the 14 goals it set in its 10-year plan.  

Stearns noted progress on the 10-year-plan and offered praise for initiatives like Rapid Response and efforts to increase New Hampshire’s low Medicaid reimbursement rates. But she noted that “we had a decade of underinvestment in our mental health system before the plan was developed” and the pandemic intensified demand for mental health services. Staffing shortages plaguing all industries have hit health care providers particularly hard.

She pointed to positive developments such as the now widely accepted use of telehealth to provide mental health services and efforts to address the shortage in mental health care workers. Many other efforts to get care to the people who need it are making their way through the state legislature and Congress. But there won’t be a single silver bullet that allows the state to get its mental health crisis under control. 

“I do believe this is truly an issue that there is not any single one entity who is responsible for it, but it is everyone’s responsibility to address our mental health crisis and to work to prevent suicide.” 

NAMI-NH offers the following resources: 

• NH Rapid Response Access Point – Call/Text 1-833-710-6477 – If you or someone you care about is experiencing a mental health and/or substance use crisis, you can call and speak to trained and caring clinical staff. You’ll be served by compassionate providers from mental health centers in your community who can help you access vital resources in an emergency. 
• 988 Suicide & Crisis Lifeline – Call or text 988 for 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals. (Chat option is also available at 988lifeline.org). 
• Veterans Crisis Line – Veterans and their loved ones can call 1-800-273-8255 and Press 1, chat online, or send a text message to 838255 to receive confidential support 24 hours a day, 7 days a week, 365 days a year. Support for deaf and hard of hearing individuals is available. 
• Crisis Text Line – Free, 24/7 support for those in crisis. Text 741741 from anywhere in the US to text with a trained Crisis Counselor. 
• The National Maternal Mental Health Hotline provides free 24/7 confidential support, resources and referrals to pregnant and postpartum mothers facing mental health challenges (and their loved ones). Call or text 1-833-9-HELP4MOMS (1-833-943-5746). 
• Trans Lifeline – Call 1-877-565-8860 for a hotline staffed by transgender people for transgender people. Trans Lifeline volunteers are ready to respond to whatever support needs community members might have. 
• Disaster Distress Helpline – Call 1-800-985-5990 for a 24/7 national hotline dedicated to providing immediate crisis counseling for people who are experiencing emotional distress related to any natural or human-caused disaster. 
• The Trevor Project – A national 24-hour, toll free confidential suicide hotline for LGBTQ youth. If you are a young person in crisis, feeling suicidal, or in need of a safe and judgment-free place to talk, call 1-866-488-7386 to connect with a trained counselor. 
• The LGBT National Help Center – Call 1-888-843-4564. Open to callers of all ages. Provides peer-counseling, information, and local resources. 
• For additional resources, visit NAMI New Hampshire’s The Connect Program.