Grading the States 2006: North Dakota - Narrative
Living in North Dakota can feel very isolating, and when it comes to mental healthcare, perhaps North Dakota's greatest need is to integrate better with approaches found in other states across the country.
Responsibility for mental health services in North Dakota rests with the state's Department of Human Services (DHS). Within the DHS, the Division of Mental Health and Substance Abuse (DMHSA) oversees services delivered through the state's eight regional human service centers and the lone North Dakota State Hospital in Jamestown.
For individuals with serious mental illnesses, the state provides a range of options through Extended Care Treatment Units within each of the human service centers. While these Units do offer a variety of services, evidence-based practices (EBPs) are notably missing from the menu of available options in the state. North Dakota does offer supported employment services at each of the human service centers, but the state admits that it does not use the evidence-based SAMHSA model for this important service. Without adhering to standards for supported employment services, it is hard to know exactly what type of services are delivered to consumers in North Dakota and to ensure uniformity across the state for this critical service.
North Dakota also reports no Assertive Community Treatment (ACT) teams. The state's stagnation on implementing ACT contradicts an August 2004 memo from the North Dakota Mental Health Planning Council stating that ACT implementation was "feasible" in North Dakota and that one pilot program was planned for introduction in the next year. More than a year later, the state has not brought this service to fruition.
North Dakota has also failed to implement the evidence-based practice of integrated treatment for co-occurring substance abuse and mental illnesses, although one pilot is planned for 2006 in the Fargo area. In fact, the organization of the Division of Mental Health and Substance Abuse may be one of the impediments to progress in this area. According to the state's fiscal year 2005 Community Mental Health Services Block Grant Application, DMHSA functions with one director, but "two distinct tracks: one for mental health issues, the other for substance abuse issues" that "allow distinct approaches to be taken in prevention, intervention, and treatment." This type of thinking is antiquated in a field where 31 percent of individuals with a serious mental illness also experience substance abuse. Even more disturbing, North Dakota has been hit hard by the growing methamphetamine epidemic, contributing to increased admissions at the state hospital for methamphetamine addiction.
And while the DMHSA indicates that there are a variety of housing options available in the state, it remains a major area of concern. For example, the state has a plan to address the long-term housing needs of individuals with serious mental illnesses, but there are no supported housing programs and no staff person within the DMHSA responsible for coordinating housing services for this population. What good is a plan, one might ask, with no one to implement it and no outcomes to show for it?
The scarcity of evidence-based practices is not the only problem facing North Dakota's mental health system. The population of this rural state is spread out over a vast land area, and 36 of the state's 53 counties are designated frontier areas, defined as fewer than seven people per square mile. To help reach these areas, staff from each of the regional human service centers travel on a regular basis to outlying communities.
In the future, the state plans to depend upon other health-care professionals (such as local public health nurses and social workers) in these communities to help fill the gap in care for these rural areas. While this plan may have some merit, the state would need to invest heavily in appropriate training for these individuals, and even then, it is no substitute for the knowledge base of psychiatrists and other specially trained mental health providers. The use of telemedicine and other interventions should be explored to supplement this plan.
Additionally, almost five percent of North Dakota's population is American Indian, and four federally recognized tribal nations lie within the state's borders. The DHS has a tribal liaison to facilitate between tribal social services and the state. This relationship has opened the lines of communication and resulted in trainings and the development of a booklet for tribal healthcare providers across the state.
On a positive note, in the Minot area, advocates are gaining traction on important programs such as Crisis Intervention Teams (CIT) to address the criminalization of individuals with mental illnesses. Additionally, human service center staff in the Fargo region are collaborating with a variety of officials to implement post-booking jail diversion strategies. This is a promising step and should be promoted with support of the DMHSA.
And, despite North Dakota's low ranking in this report, the state is making efforts to learn from others in the mental health field. Small teams from selected human service centers and the state hospital will be attending the Research Recovery Institute in Ohio to learn about a recovery-model education program for providers and consumers. This is a good first step toward climbing the ranks for North Dakota, to a better system of care.
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