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LANAI CITY, Lanai, Hawaii — When her mother was dying of breast cancer, Jozy Malacas-Kinoshita felt the familiar pang of addiction take root.
She did not want to give in to it. After a decades-long cycle of treatment and relapse that caused her to lose her home, parental rights over her two daughters and nearly her life, the 61-year-old Lanai City resident had achieved sobriety in 2009.
But the grief and fatigue of providing around-the-clock care to her ailing mother during the darkest days of the coronavirus pandemic cracked the foundation of her hard-fought recovery, leaving her anxious, irritable and barely able to sleep.
Her marriage was deteriorating. To get through the day, she had come to rely on copious amounts of caffeine.
By the time her mother died a week before her 88th birthday in June 2020, Malacas-Kinoshita was thinking about starting to use methamphetamine again.
“I was losing control of my life and I was losing my sanity,” said Malacas-Kinoshita, who was born in the Philippines but moved to Lanai when she was 4 years old so that her parents could work on what was then the world’s largest pineapple plantation.
Diagnosed with bipolar and substance abuse disorders, Malacas-Kinoshita found stability a short flight away at Aloha House on Maui, the nearest inpatient mental health and addiction intervention program, where she previously had sought treatment in the ‘80s and ‘90s.
She was reluctant to board a nine-passenger airplane to access the treatment center on the larger neighboring island. But she agreed to go at the urging of her Lanai-based case manager, who made house calls to explain how intensive care could help her claw her way back from the netherworld of mental illness.
Outsourced to the Mainland
When she returned home after completing treatment, Malacas-Kinoshita maintained her sobriety by leaning into her support system, although she had to adjust to pandemic-era changes.
Her psychiatrist, Dr. Kathleen Iannitello, who is based on Maui, traveled to Lanai by ferry to meet with her every two weeks until coronavirus prevention measures halted in-person visits and moved her treatment online. Her case manager, Reynold “Butch” Gima, who over three decades helped her navigate the highs and lows of mental illness, continued to see her weekly, but with masks and 6 feet of distance between them.
Soon Malacas-Kinoshita would lose these twin pillars in her life.
In October 2020, the Hawaii Health Department informed Malacas-Kinoshita that her psychiatrist of seven years, in addition to not providing in-person visits, would be replaced by a psychiatrist in Michigan.
Suddenly, telepsychiatry was no longer merely a temporary consequence of COVID-19. It had become a necessary, 4,000-mile bridge between Malacas-Kinoshita and her new doctor, who was working for the state on a short-term, part-time contract.
“It came at a time when I really needed her,” Malacas-Kinoshita said of her longtime psychiatrist. “My reaction was, ‘I really need help right now and I’m going to have to do it without you?’”
All told, 25 patients on Lanai who receive psychiatric care from the state Adult Mental Health Division were affected by the change. Some patients and staff say the department never offered a clear explanation as to why their care was outsourced to the mainland.
The changes in community-based mental health services on Lanai, an arid island northwest of Maui that has just 30 miles of paved roads and no traffic lights, have exposed a jarring gap in Hawaii’s strained health care system.
Prior to COVID-19, AMHD patients had access to a full-time on-island social worker and in-person appointments every two weeks with a Maui-based psychiatrist. Availability of in-person mental health care of any kind is now sporadic, amounting to a few days per month.
Of the 122 psychiatric visits Lanai patients received this year, only nine of them were in person, according to the DOH.
Increased difficulties in accessing mental health care is a troubling trend across the 50th state even as the need has grown. A recent survey found that more than three-quarters of the health care providers who responded said the greatest demand for patient referrals was for mental health counseling and psychiatry, with most resources concentrated on the most populous island of Oahu.
The report released in late July warned that overall health care access issues in rural areas like Lanai and the nearby island of Molokai were “particularly troubling” due to their remote geography and could lead to greater disparities. The report surveyed 3,287 Hawaii residents and 324 providers online from April 1 to May 9.
“About 70% of the care residents of Lanai and Molokai receive requires a trip off island, which is arduous and expensive,” the report said.
No Full-Time Staff On Lanai
The situation on Lanai was the result of staffing issues within the Adult Mental Health Division, which is the state provider of services for uninsured or underinsured adults diagnosed with a serious mental illness.
Iannitello, who still works for the AMHD on Maui, declined to comment for this story, according to DOH spokeswoman Kaitlin Arita-Chang. But AMHD Chief Administrator Amy Curtis said the agency made a clinical decision in late 2020 to temporarily switch patients to a new psychiatrist in Michigan.
“The team felt that this was the best care that they could deliver,” she said, adding that the agency has long relied on a mix of employees and temporary fill-ins to meet patient needs.
But some AMHD patients on Lanai say they also feel forsaken for another reason.
The agency lost its only Lanai-based staff member when Gima retired in August 2021 from the position he had held for 31 years after he was suspended for insubordination over his opposition to outsourcing mental health services for Lanai patients.
Gima was suspended for five months in November 2020 after he apologized in an unauthorized letter to Lanai patients for what he called the “haphazard” change in delivery of their treatment. He wrote that he and Iannitello opposed the change, were never consulted about it and did not know what triggered it. He also informed patients of their right to appeal.
Gima was suspended again in June 2021 for sending a personal email to a nurse at the Maui Community Mental Health Center in which he questioned the impact of the change on the quality of patient care. He retired during his second suspension.
Since then, AMHD has not had any full-time staff based on Lanai for the first time since 1990.
Maui staff now provide itinerant in-person services. A case manager travels to Lanai twice a month to see patients and a nurse makes the 50-minute ferry ride monthly. A psychiatrist goes to the island less frequently, treating patients primarily by video or phone.
For patients experiencing a mental health crisis, the standard practice is now this: call the Maui Community Mental Health Center in Wailuku and leave a message if a nurse or doctor is not immediately available.
It sometimes takes several hours to hear back from a clinician, according to Manny Dugay, whose wife, Betty Lou, has bipolar schizoaffective disorder, a serious mental condition characterized by hallucinations, delusions and severe mood swings.
With no AMHD staff physically on the island to help him manage his wife’s psychosis, Dugay said he feels isolated and more pressured than ever to make medical decisions on his own.
“What’s missing is that immediate response,” he said. “I have to just call and wait now. And while she’s having these mental health breakdowns, every minute, every hour, it counts.
Neda Rajaei, 61, became so frustrated by the reduced in-person services that she abandoned her psychiatric care last year.
Symptoms associated with her major depression diagnosis have worsened, she said. But she doesn’t want to have to retell her story to a new psychiatrist. Worse, she said, is the state’s inability to hire a new on-the-ground case manager.
“It disrupted everything,” said Rajaei, who became suicidal after she moved to Lanai in 1997 to style hair at one of the island’s luxury resorts. “It felt like all the doors were closing.”
The state is trying to fill the full-time social worker position vacated by Gima, a Lanai native. Two candidates accepted job offers but pulled out when they couldn’t find an affordable place to live on Lanai, a common problem in Hawaii.
“What happened with Lanai Counseling Services is what happens to a lot of services on Lanai,” said Gima, whose retirement exposed the fragility of a system that depends so heavily on one person. “We’re out of sight, out of mind. People in power on Maui and on Oahu make changes without knowing how it affects us on Lanai.”
Hawaii’s Fractured Mental Health System
All Hawaii residents have 24/7 access to Hawaii Cares, a one-stop shop for help with any mental or behavioral health issue. The hotline is staffed by counselors who can dispatch the state’s crisis mobile outreach team immediately to anyone at acute risk of harming themselves or others. On Lanai, the crisis mobile outreach team consists of Gima and his daughter.
But some patients say they didn’t know about the hotline. Others say they miss having fast access to in-person assistance from a case manager who knows them in situations that don’t rise to crisis level.
“I would not say that there is change with individuals being able to get their face-to-face case management visits,” the AMHD chief administrator said. “We do feel like anyone who has a need, they’re able to have that need addressed with what we have. But we still … prefer to have a person that’s in that area and can help them and be there as much as possible, so we’re actively recruiting.”
On this island of roughly 3,000 deeply rooted residents, critical staffing vacancies plague numerous state departments, prompting some unique solutions.
In an effort to correct a teacher shortage, for example, the Hawaii Department of Education sent two officials to the Philippines in January 2020 for its first international teacher recruitment effort. Three Filipina teachers were hired and now work at Lanai’s only grade school.
Barriers to staff recruitment and retention include the island’s finite housing stock and, for some, the undesirability of living on an island where the axis deer population outnumbers residents by about 10 to one.
Also to blame is a statewide doctor shortage, a consequence of Hawaii’s high cost of living and limited medical training opportunities that have plagued health care facilities across the islands since long before the pandemic.
At last count, Hawaii has the equivalent of about 2,857 full-time doctors. But the state estimates it needs an additional 732 physicians to meet patient demand, down from 1,008 in 2020, according to the most recent annual report that tracks Hawaii’s medical professional needs. The greatest shortage is in primary care, with 163 doctors needed across all islands.
Rep. Sylvia Luke, who controlled the state’s budget during the pandemic as chair of the House Finance Committee, traveled to Lanai earlier this year to examine the consequences of persistent staff vacancies, particularly in mental health services.
“In 2020, we were looking at a $3 billion state budget deficit,” said Luke, who is the Democratic nominee for lieutenant governor in the upcoming election. “So COVID compounded the problem.”
The state, she said, should do more to partner with nonprofit organizations to plug the gaps.
Daily life on Lanai is a reflection of another unique dynamic: Billionaire tech entrepreneur Larry Ellison owns 98% of the island, including a third of the housing, the water utility and twin luxury resorts.
Wedged between two Four Seasons hotels, a quaint community of mostly Filipino former pineapple field workers and their descendants now rely primarily on hospitality jobs. The island was once owned by James Drummond Dole, who transformed it in the 1920s into the world’s largest pineapple producer. Cheap labor in Asia forced the plantation’s closure in 1992.
Workforce housing was short long before Ellison started pumping his fortune into the island’s redevelopment in 2012. But the problem has been worsened by an influx of hotel and construction workers employed by Pulama Lanai, the management company that oversees Ellison’s monopoly stake in the island.
Then the pandemic hit, prompting a wave of people to leverage their remote work flexibility to flee the mainland for the Hawaiian islands. Among the crop of newcomers is Ellison, who announced in December 2020 that he had moved full time from California to tiny Lanai.
With demand for homes on Lanai far outpacing supply, sale prices hit record highs during the pandemic. In June, a 1935 plantation home with single-wall construction sold for $720,000 — 18% above the list price.
Perks And Pitfalls Of Telepsychiatry
A silver lining from the pandemic has been the expansion of telemedicine for mental health care.
Its use was steadily rising prior to the COVID crisis. Then it shot up by more than 550% in the first five weeks of the pandemic, according to a Substance Abuse and Mental Health Services Administration report.
In rural communities that are a long drive or plane ride away from the nearest psychiatrist’s office, the ability to access treatment over the phone or internet has helped shore up neglected health care infrastructure.
Benefits of virtual help include easier access for patients who can “see” a doctor at home while doing laundry and without having to coordinate child care. By meeting patients virtually in their bedrooms or living rooms, doctors gain access to a whole new set of environmental cues: art on the wall, clutter in a room, family dynamics.
But it’s harder for clinicians to detect more subtle cues, such as whether a patient reeks of alcohol. Telemedicine is not always comfortable for people who are unfamiliar with video chat platforms, don’t have access to the required technology or have privacy concerns.
The use of video teleconferencing for mental health patients has been understudied, although the pandemic generated a new, massive trove of data about how well it’s working for patients and clinicians.
Many studies suggest patients who access mental health care via telehealth experience similar symptom improvement compared to in-person treatment. But this literature focuses on patients with mild to moderate symptoms.
“One of the things we know about milder symptoms is they get better with just about any treatment,” said Dr. John Markowitz, a research psychiatrist at Columbia University.
It’s unclear whether new virtual tools are as effective for people with serious mental health diagnoses. There’s also a lack of understanding about whether patient preference for in-person care affects telemedicine treatment outcomes when patients do not have a choice. Most doctors prefer treating patients in person, saying it’s easier to discern how well a patient is doing.
People with schizophrenia, for example, might exhibit involuntary movements as a feature of psychosis or a side effect of medication. Without a full-body visual, it can be difficult for a doctor to detect these jerking tics or tremors.
On Lanai, a schizophrenic patient, whose hands shake so severely from her medication that she lost the ability to write her name on paper, said it has been hard for her to concentrate during video visits because she can’t hold her cellphone steady.
A lack of emotional expression is another prominent symptom of schizophrenia that further complicates the delivery of care over video.
“One of the problems with these disorders is you can lose touch with reality,” Markowitz said. “If you’re prone to losing touch with reality, it’s helpful to see another body in the room with you.”
Now that the COVID crisis is subsiding, Curtis said Lanai AMHD patients can choose whether to receive psychiatric care online or in person. But interviews with patients reveal some don’t know they have this option.
AMHD is partnering with the University of Hawaii John A. Burns School of Medicine to examine the best way to integrate technology into patients’ health care routines going forward. Recent surveys show AMHD patients tend to favor telepsychiatry, while clinicians express less comfort delivering remote treatment, Curtis said.
Yet part of some Lanai patients’ dissatisfaction with virtual psychiatry has little to do with the technology itself. Some patients simply yearn to continue seeing the psychiatrist with whom they’d developed years of trust and rapport.
“In psychiatry, it’s not necessarily like having an allergic reaction and you go online and find some doctor for a virtual visit and it’s one and done,” said Alice Medalia, director of cognitive health services at the New York State Office of Mental Health. “But in psychiatry, because it’s an ongoing condition, having a relationship with somebody is really important.”
Since November 2020, patients on Lanai have cycled through two part-time psychiatrists working on short-term contracts, including the one based in Michigan. Dr. Channing Slate, a psychiatrist who is also the medical director of the Maui Community Mental Health Center, has been treating Lanai patients primarily by phone or video since May 2021.
There is one exception, however. Although none of her grievances were substantiated, the state allowed Malacas-Kinoshita to revert back to telepsychiatry with Iannitello after she filed complaints over the changes in the state’s delivery of her psychiatric services with AMHD, the Hawaii State Ombudsman and the Hawaii Office of Commerce and Consumer Affairs.
It is a partial victory framed by guilt. At times Malacas-Kinoshita is overwhelmed to tears by the fact that other patients have not also been able to continue treatment with their longtime doctor.
“They’re not well enough to do what I did,” she said. “It feels so unfair.”
This reporting is part of a collaboration with Honolulu Civil Beat, the Institute for Nonprofit News, The Daily Yonder, Carolina Public Press and Shasta Scout. Support from The National Institute for Health Care Management (NIHCM) Foundation made the project possible.