The Real Cost of Psychiatric Hospital Beds

A request for funding to renew staffing for 25 psychiatric beds at Catawba Hospital near Roanoke, Virginia failed in the 2008 Virginal Legislature. This state hospital is located less than 50 miles from Virginia Tech where 33 people died in last April’s shooting rampage by Seung-Hui Cho.

This proposal for $2.2.million was defeated for budgetary reasons. Yes, staffing more public psychiatric beds in Virginia will cost taxpayers more money. But having too few beds is already costing Virginia and other states more than they will ever realize.

The Treatment Advocacy Center recently released a new study The Shortage of Public Hospital Beds for Mentally Ill Persons. This study not only reveals the serious shortage of beds that exists in Virginia and other states but also examines the devastating consequences. Some of the consequences that come from a system that does not have adequate facilities to treat the sickest of the sick include greatly increased homelessness, the warehousing of mentally ill people in jails and prisons, overcrowded emergency rooms, and a disturbing increase in violent crime.

While fiscally conservative lawmakers continue to count the monetary cost of adding new beds at state mental hospitals, who will be responsible for counting the enormous social costs that come with a broken system that currently tolerates far too few beds?

After Virginia Tech - much activity, little accomplishment

On Tuesday, the Virginia legislature sent a package of bills to the Governor containing its proposed changes to the state’s commitment laws. Although the end-result was essentially inevitable after a bill to establish a progressive assisted outpatient treatment system was shuttled off to a study committee, the Virginia Legislature made it official on Tuesday – there was much busy work in the wake of the tragedies at Blacksburg but nothing approaching rational treatment laws for the state.

House Bill 499, the chief bill of the package, reworks the present procedural system for outpatient commitment fairly well and offers a slight improvement to the eligibility standard but still leaves Virginia’s laws among the most restrictive of treatment in the country. Essentially, HB 499 will move Virginia law in this area from among the worst to just plain bad.

With the pressure created by the Blacksburg tragedies, the legislators in Richmond realistically had no choice but to (1) do away with the state’s “imminent danger” standard and (2) shore up of the outpatient commitment procedural provisions that let Seung-Hui Cho be placed on outpatient commitment and then just slip away from the treatment system.

HB 499 does both of these.

1. “Imminent danger” is changed to “the person will, in the near future, cause serious physical harm to himself or others as evidenced by recent behavior causing, attempting, or threatening harm.” That is more or less just substituting “near future” rather than “imminent” in exchange for the new requirement of recent acts, attempts or threats of violence.

2. HB 499 sets out and strengthens outpatient commitment procedures. This includes making sure that assigned treatment providers are involved in the outpatient commitment process and responsible for those placed under orders.

The only significant way in which HB 499 exceeds that “bare minimum” in the wake of Virginia Tech is in a modest but significant addition to the “substantially unable to care for oneself” prong of the present commitment standard.

HB 499 adds a new clause that allows the placement in treatment of a person over come by a severe mental illness who is substantially likely to “suffer serious harm due to substantial deterioration of his capacity to protect himself from harm or to provide for his basic human needs as evidenced by current circumstances.” Although still falling far short of the progressive commitment criteria in many other states, that at least is an improvement for Virginia legislators to justifiably claim as an accomplishment, albeit a small one.

Sadly, a small change is not good enough for Virginian’s with the most severe mental illnesses

"How many people have to lose their lives..."

A recent letter to the editor in response to an editorial in the Washington Post:

I wonder how many people will have to lose their lives in Virginia because someone in need of medication for mood and behavior regulation is not monitored to ensure that he takes that medication?

Virginia's failure to protect its residents in this area is truly a disgrace. Why don't lawmakers just fire all the traffic police, too?

I am the mother of a Virginian who was fatally shot in 1999 as she lay sleeping.

My daughter had been seeking help for the young Virginia man who killed her.

There was no law on the books that would have protected my daughter in 1999, and there still is no law on the books that would protect her today.

Wake up, Virginia!
- Laura Hawley - Jarvis

Responding to tragedy

"A wave of recent school shootings, including the bloody attack in Illinois last week, is again prompting calls around the country for reforms. But in Virginia, where the bloodiest rampage of all took place last spring at Virginia Tech, the initial demands for legislative and regulatory improvements have yielded disappointing results. Other states that have grappled with senseless killings can now look to Richmond as an example -- one not to emulate -- of minimal response to maximum trauma."

- Washington Post Editorial

Worst in the nation is not good enough

The deaths of 33 people at Virginia Tech should have been a wake-up call to legislators to provide real reform to the state’s broken commitment laws. Instead, the General Assembly is considering little more than lip-service reform.

Virginia’s mental illness treatment laws are among the most restrictive in the nation. To get help via involuntary treatment, the state currently requires that someone incapacitated by the symptoms of an illness such as schizophrenia be an immediate physical danger to themselves or others. That’s simply too little, and often too late.

The only proposals now still alive for reform in the General Assembly require that individuals be visibly dangerous before getting treatment. These slight modifications to the existing law would keep Virginia’s treatment standard among the worst in the nation. Read more....

What will it take, Virginia?

British statesmen William E. Gladstone famously observed that “justice delayed is justice denied.” Senate Bill 177 offered Virginians the only meaningful hope for true mental health law reform this year.

Now, Senate Bill 177 has been referred to a subcommittee for further study until next session. When it comes to mental health reform in Virginia, special commissions, blue ribbon panels, and investigating subcommittees abound. Everywhere you look, you can still find some group of experts studying about how to change Virginia’s mental health laws.

However, the time for studying laws has ended, and the time for making real change is here. Some people may hail the small incremental changes in Virginia’s commitment standards that will be made this year as major reform. Don’t be fooled.

If experiencing the worst shooting tragedy in American history is not enough to motivate true reform, then what will it take Virginia?

Citizens being warehoused in jails

It is estimated that 16 percent of our jail population is seriously mentally ill. On any given day in the Roanoke Valley, there are about 162 citizens with a serious mental illness being warehoused in our jails. And because they won't be treated by the mental health system, they become the responsibility of the criminal justice system. It is cost shifting of the most cynical kind. It is a return to the 19th-century method of care for our mentally ill citizens.

As a taxpayer, I am outraged at the fraud of this cost-shifting from the mental health system to the criminal justice system. As both a criminal justice and a mental health professional, I am ashamed.

- Roanoke Times op-ed by Isaac T. Van Patten, chairman of the Department of Criminal Justice at Radford University and the principal investigator for a federally funded CIT program and a jail diversion program for the mentally ill

The real cost of assisted outpatient treatment

Virginia has the opportunity to enact meaningful mental health reform by passing Senate Bill 177. This Assisted Outpatient Treatment (AOT) bill enjoys bipartisan support and will allow for people incapacitated by severe mental illnesses to be placed in court ordered community treatment. The availability of such a program might well have prevented the terrible tragedy that happened at Virginia Tech last April.

Sadly, the passage of Senate Bill 177 is now threatened by those who mistakenly claim it will impose too great of a financial burden. This is a myth.

The implementation of AOT as provided by Senate Bill 177 will not be expensive. This program will not mandate any services that individuals with serious mental illnesses are not already eligible to receive. AOT orders merely require the system to facilitate treatment compliance for noncompliant individuals by providing them with the existing services they need to remain stable and to prevent the severe consequences associated with untreated mental illnesses.

The proof that AOT will not require the creation of new services can be found within the language of Senate Bill 177 itself. One of the requirements for granting an AOT order under this new law is a finding that:

“the community services board that serves the jurisdiction where the person resides has the capacity to provide the prescribed treatment or services.”

Not only will AOT not be expensive, it will ultimately save Virginians millions and millions of dollars in alternative costs that come from hospitalizations and incarcerations of persons who do not benefit from the availability of court supervised treatment. In other states where AOT has been enacted, such as New York and North Carolina, participants have experienced a dramatic decrease in both hospitalizations and incarcerations.

Virginians must separate fact from fiction so that true reform can finally occur. The greatest cost that will be paid by Virginians is not in implementing AOT but in failing to do what is necessary to provide for effective and timely treatment for people lost to acute psychiatric illnesses like Cho Seung-Hui.

Virginia needs more than lip-service reform

A statement from TAC's executive director- Kurt Entsminger:

"Virginia’s mental illness treatment laws are among the most restrictive in the nation. To get help via involuntary commitment, the state requires someone obviously incapacitated by the symptoms of an illness like schizophrenia to be an immediate physical danger to themselves or others.

Last April, the failures of Virginia’s treatment laws stunned the nation, and the General Assembly finally began to pay attention. The result is literally dozens of commitment law bills now under discussion.

Unfortunately, the majority of the proposed bills only marginally change Virginia’s antiquated laws. They will give legislators a photo op and a warm feeling, but will not bring real help to the people who most need it.

People who are clearly psychotic and dangerous to themselves or others should get mental illness treatment. But Virginia needs to do better. Virginia needs a law like Kendra’s Law, and must also allow outpatient intervention before someone is in crisis." read more...

A horrific ending

A few weeks ago a homeless man in Fairfax County, Virginia was shot and killed by police officers after he lunged at them with a knife. As the public railed against the officer for using lethal force, one blog comment added a bit of perspective.

However, this incident just highlights how poorly we treat the mentally ill in this country. This homeless man was clearly not of a sound mind. If he were cognizant of reality, he would not have been jabbing anyone, much less a cop, with a knife, totally at random. This man (and literally thousands of more like him) should be in hospitals, receiving treatment.

Yet, because over 70% of all state mental facilities were closed in the late 70’s to early 90’s, we have no place to house these broken people. Many end up in jail. Many more end up on the street. Far too many end up dead.

We cried at the last spring's tragedy at Virginia Tech. We point fingers at ineffective police reactions. Yet, we don’t want to do anything to fix our mental health situation.

If we don’t push for change, what happened at the Rose Hill Shopping Center on Friday will become more common than rare.

There’s no doubt this story had a horrific ending. Rather than be horrified by the police perhaps the horror should be pointed at the mental health system.

Treat severe mental illness like any other illness

ER doctor Greg Christiansen gave striking testimony on Friday at a Virginia House of Delegates subcommittee hearing focused on mental health. As we have previously highlighted on this blog, Virginia’s outdated treatment laws unnecessarily handcuff treatment providers – the question becomes not, “does this person need care?” but “is this person imminently dangerous, and will the local Community Service Board (CSB) agree with me?”

His testimony eloquently laments the sorry state of affairs that marks Virginia’s mental health system – "If you come in as a trauma patient, I have to treat you, if you come in as a psychiatric patient, I have to get permission."

Failing society and the person in need

As the Virginia General Assembly prepares to convene next week, the tragedy of Virginia Tech and the need for mental health reform loom large over the Commonwealth. One aspect of Virginia’s flawed mental system health that has received a great deal of notoriety is the commitment standard – one of the most restrictive in the nation.

Many have focused on the commitment standard’s inability to address those who may pose a danger to others, but few have commented on its similar failure to protect the individuals themselves who are in crisis. As Virginia Delegate Dave Albo explains, the current standard renders families just as powerless to help their loved ones in those situations.

"You have to wait for the person to deteriorate so much that they fit that definition [of imminent danger]. You have to wait right up until the very end when the person is about to kill themselves before you call," said Albo.

Yes, Virginia, Kendra's Law works ...

From the Washington Post December 30, 2007:

Susan Wezel had been committed to the city's hospital wards more than a dozen times in 10 years. Her psychosis was so deep and debilitating that she lost her career and her relationship with her son, as she refused to take her medication or follow treatment.

But because of a New York state law, Wezel hasn't been hospitalized in more than a year. She doesn't wander the streets alone at night anymore. She takes her medication willingly. She even has plans to follow her dream of singing at a neighborhood nightspot, something that was unthinkable 18 months ago.

Wezel and her caseworker agree that the transformation occurred because of the law, which allowed officials to force Wezel into an outpatient treatment program after she was discharged from a hospital.

Cho, Kennedy and other tragedies in Virginia

Today’s Washington Post explores Virginia’s restrictive commitment standard that requires “imminent danger” before a person can be ordered into treatment.

Any mention of “imminent danger” and Virginia’s broken mental health system conjures images of 32 students killed at Virginia Tech by Seung Hui Cho in April of 2007 and memorials for the two officers killed by Michael Kennedy in May 2006. Both Cho and Kennedy had fallen through the gaping cracks of Virginia’s archaic mental health system.

For all of the Virginia Tech and Michael Kennedy stories that grab our attention, there are hundreds more private tragedies that don’t make the news. Virginia families are left helpless as their loved one becomes homeless, threatens suicide, is violent, or victimized. Until their loved one is an “imminent danger”, there is little they can do but wait.

This morning’s Washington Post provides a glimpse into one of the many families in Virginia that was forced to wait.

The Reston man who advocates eliminating the standard called for help recently after his son obsessed that federal authorities were eavesdropping on him. He destroyed a toilet and punched holes in the wall. Fairfax's Mobile Crisis Unit came to their home and "agreed that he was very disturbed," the man said. "But in their judgment, what he was saying and doing would not pass the threshold for imminent danger. And having sat through these hearings before, I had to agree with them."

A few weeks later, with what his father described as "a crazed look in his eyes," the young man attacked his father. The father called police, and the son was arrested. He is being treated in a mental hospital while awaiting trial on an assault charge. It took the criminal charge to get the young man held.

"Ideally, when we see terrible things happening," the father said, "we should have been able, before that point was reached, to say, 'This kid is in danger and needs to be treated.' We just couldn't get past that threshold."

Finding someone to blame

Who is to blame when tragedy results from untreated severe mental illness?

At the end of October in Richmond, VA, Johnny Hughes, a man with untreated schizophrenia, fatally stabbed a woman while she was walking her dog.

The author of a new blog - “families for timely mental health treatment laws” – noticed some of the comments posted on the website of the Richmond Times Dispatch regarding this story. Many blamed the family of Johnny Hughes for not monitoring him.

Posted October 30, 2007 @ 09:55 AM by Anonymousafter reading this man's rap sheet i too am finding compassion a hard sell. i agree the family dropped the ball, this man needed to be under lock and key somewhere and his family should own up to their responcibility.

The author of the “families for treatment” blog responds to these comments with the perspective of someone who has tried to help a loved-one get treatment.

Blame and pointing a finger at families who try desperately to get help for their loved ones and who often are involved in advocating for the changes needed will not resolve the issue of ensuring that someone with a mental illness receives the treatment they need. Enacting common-sense, timely assisted outpatient treatment (AOT) laws with adequate services and programs, as well as providing sufficient support in a hospital when needed, is what should happen.

Reform is long overdue

Few issues have dominated a political landscape like mental health has in Virginia. With the tragedy at Virginia Tech, the death of two police officers in Fairfax County, and the recent murder of Susanne Thompson in Richmond, it is clear that reform is long overdue.

Virginia Capitol Connections Magazine recognized the unprecedented role that mental health will play in the upcoming legislative session, and made it the subject of their fall issue. Contributors include Governor Kaine, Delegate Phillip Hamilton, and TAC’s own John Snook, who calls on the legislature to recognize the reality of severe mental illness and the need for assisted outpatient treatment.

Community members call for better treatment in Virginia

The following quotes are from news coverage of the death of Susanne Thompson, who was stabbed while walking her dog Saturday morning. Johnny Hughes, the man charged with her murder, has a history of mental illness.

He's [Richmond Mayor L. Douglas Wilder] concerned that state law doesn't always allow mandatory treatment of mentally ill people with criminal histories.

“… this situation represents a much larger problem. The real question is how many others are similarly situated across the state and the region who need coordinated mental health resources in order to reduce any possibility of this situation recurring.”

Hughes' younger sister, Chesterfield County resident Jackie Lewis, said the killing could have been avoided.

"We are so deeply sorry for this innocent loss," Lewis said on behalf of her family. "I'm sure if my brother was in his right mind, he would feel the same way."

"Somebody dropped the ball in terms of his care," she said.

Richmond Sen. Henry Marsh: "The purpose . . . is to create an assisted outpatient treatment program so that those mentally ill persons who are capable of being maintained safely in the community with the help of such a program can receive those services."

"The things he [Hughes] was saying, he didn't belong here," said [Richmond Sheriff C.T.] Woody, who has complained that the jail does not have the facilities or resources to care for the hundreds of mentally ill men and women doing time there.

New resource for privacy laws

Questions over privacy laws were among the many concerns surfaced after the Virginia Tech tragedy. Gov. Tim Kaine’s Va. Tech panel pointed to the misunderstanding and confusion surrounding laws like HIPAA and FERPA. And, as families of those with severe mental illnesses know all too well, privacy laws often create barriers to care and treatment of severe mental illnesses.

The US Department of Education, along with the Department of Homeland Security and the Department of Commerce released guides for the Family Educational Rights and Privacy Act (FERPA) for schools, families, and colleges and universities.

The guides are available here.

Shouldering the burden of inadequate treatment

When we think about the added burden untreated mental illness causes for law enforcement, we often think of things like overcrowding in jails or the increased risk in responding to a call for someone who has been deemed an imminent danger.

But untreated mental illness also burdens law enforcement in less apparent ways. Take the case of Mark L. Jackson – a man who allegedly made multiple bomb threats in the Chesapeake, Virginia area. Obviously, every threat of this type must be taken seriously, requiring significant law enforcement resources and manpower. But this isn’t the sort of cost that can be easily included in a budget request – it’s simply another hidden cost of Virginia’s failure to provide effective mental health care.

An unprecedented focus

In November, Virginia will hold a General Election. Every seat, both in the state Senate and in the House of Delegates is up for election. At the same time, the failings of Virginia’s mental health system have been crystallized by the work of the many commissions and task forces and especially the tragedy at Virginia Tech.

There has never been a better time to contact your legislators!

The upcoming legislative session will see an unprecedented focus on mental health, and legislators want to hear from you. They want to know what seeking treatment for someone is like, and what can be done to make it better. Take a few moments this weekend to find out who is running for office in your area, and where they stand on reforming Virginia’s treatment system.

Make sure they know that a winning campaign platform must include a plan for effective mental health treatment reform.