Biloxi blues - setting the bar low

The study The Shortage of Public Hospital Beds for Mentally Ill People performed by the Treatment Advocacy Center is complete and the results are dismal. Since 1955, the number of public psychiatric beds across America has dropped from 340 per 100,000 people to 17 per 100,000 people. There is now a shortage of nearly 100,000 public psychiatric beds in the United States.

A panel of experts concluded every state should have at least 50 public psychiatric beds per 100,000 people to meet minimum acceptable standards. That assumes that all other mental health services are optimum.

The one very small silver lining in this dark gray cloud is that Mississippi, of all states, meets the minimum standard of 50 beds per 100,000. Every other state fell short, and most fell very short. In the last census, Mississippi ranked last among all states in per capita income. If a state as resource poor as Mississippi can meet the minimum number of public psychiatric beds, then what possible excuse can the other 49 states have?

New Report: Deficit of nearly 100,000 public psychiatric beds

The Treatment Advocacy Center released a report today that shows a nationwide shortage of nearly 100,000 public psychiatric hospital beds.

In 1955 there were 340 public psychiatric beds available per 100,000 U.S. citizens. By 2005, the number plummeted to a staggering 17 beds per 100,000 persons. Mississippi was found to have the most beds available in 2005 (49.7 per 100,000 people), while Nevada (5.1) and Arizona (5.9) had the least.

“The results of this report are dire and the failure to provide care for the most seriously mentally ill individuals is disgraceful,” said lead author, Dr. E. Fuller Torrey, president of the Treatment Advocacy Center. “Our communities are paying a high price for our failure to treat those with severe and persistent mental illness, and those not receiving treatment are suffering severely. In addition, untreated persons with severe mental illnesses have become major problems in our homeless shelters, jails, public parks, public libraries, and emergency rooms and are responsible for at least 5 percent of all homicides.” More...

Read the full report

Blue in Baltimore

This week in Baltimore, the fire department issued a rare “blue alert” – usually seen during only the most severe weather emergencies. It overrides all other directives and allows medics to take patients to the nearest ER regardless of how crowded it is.

Why?

Across Maryland, beds are full in the ERS – many filled by those in psychiatric crisis.

Dr. Jeff Sternlicht, director of emergency services at the Greater Baltimore Medical Center … said that the unusual issuance of a blue alert in Baltimore County is the direct result of a growing problem in Maryland and across the country.

"There are not enough emergency beds or hospital beds in Maryland right now or nationwide. But the problem is worse in Maryland," he said.

Sternlicht admitted the problem is complex.

He said that overcrowding is caused by growing patient need, due in part to a shift in primary care abilities, decreasing hospital beds, and, in Maryland, inadequate psychiatric care that leads patients who need mental help to the ER for care.

Re-institutionalization?

In the waves of deinstitutionalization of the 1950s and 1960s the number of people with severe mental illnesses in public inpatient psychiatric facilities dropped dramatically.

In 1955, 558,239 patients were in public psychiatric hospitals. By the
mid-1990s, the number had dropped to fewer than 72,000. By 2002, the total had fallen below 50,000.

Where did they all go? Too many ended up on our streets, in homeless shelters, in emergency rooms, and in jails and prisons.

In Colorado, the director of the department of corrections is requesting nearly $60 million to double the size of a 250- bed correctional facility to house mentally ill inmates.

Colorado isn’t alone. In Maine, Governor John Baldacci announced a plan to have the state assume control of all 15 county jails. Some jails, according to the plan, will be turned into “specialty facilities for people with mental illness.”

Almost 50 years after the first push for deinstitutionalization it seems we’re still housing people with severe mental illnesses in institutions. Now we require them to commit crimes to get there.

An overloaded criminal justice system

A news article in the Eagle Tribune in Massachusetts describes the current situation in the Rockingham County Jail in which an estimated 15 percent of the jail population has a severe mental illness. Jail superintendent Al Wright says it feels like he’s running a psychiatric ward rather than a forensic facility. “I tell people I’m the superintendent of Rockingham County jail, the biggest provider of services for the mentally ill in the county.”

The article continues:

Also, there is a shortage of psychiatric beds at the state hospital — down from 3,000 beds in the 1960s to 300 today. This leaves police little choice but to transport mentally ill suspects to jail.

There is no doubt the criminal justice system is overloaded with patients who should have received psychiatric treatment long before they landed in jail.

Ken Braiterman, coordinator with the National Alliance for Mental Illness in New Hampshire, hit the nail on the head when he said:

Treatment has never been better for mental illness, but it has never been harder or those in need to get it.

It's time for treatment before the crime

An op-ed by Jeff Gerritt at the Detroit Free Press calls for treatment rather than incarceration for those with severe mental illnesses who have committed a crime. Before suggesting a solution, Gerritt delves into the sad history of abandoning the mentally ill. As he so explains:

A solution is long overdue. When Michigan closed most of its mental hospitals in the 1990s, the mentally ill didn't just disappear. They ended up on the street, in homeless shelters, and, increasingly, in jails and prisons. One sheriff called the state's jails and prisons the new asylums. Today, nearly 25% of Michigan's 51,000 prison inmates are mentally ill.

No doubt, putting mentally ill people in a freer, less costly setting was a good idea. But as institutions closed, the state failed to invest in community mental health programs. People with severe mental and emotional problems went untreated.

The op-ed goes on to support the creation of mental-health courts to steer people with mental illnesses who have committed a crime into treatment rather than jail or prison. This is a good step for those already in the forensic system.

An even better step? Using Michigan’s assisted outpatient treatment law – known as Kevin’s law- to get treatment BEFORE a crime is committed.

Closing state hospitals doesn't eliminate need for care

The use of general hospitals to treat serious mental illnesses increased 34.7% between 1995 and 2002 according to a new study published in Psychiatric services this month. This raises a number of questions, not the least of which is whether psychiatric units in general hospitals are equipped to provide the kind of treatment, rehabilitation and discharge planning that state psychiatric hospitals can provide.

Take Virginia for instance. In 2006, the average length of stay for acute admissions to a state psychiatric hospital was 47.2 days compared to 5.4 days in community psychiatric inpatients beds. The abbreviated treatment provided in general hospital psychiatric beds may account for these hospitals’ “revolving doors” through which 3,514 patients passed 3 or more times in 2002 at a cost of about $111 million. Maybe closing state psychiatric hospital isn’t such a good thing – for patients or budgets.

Analysis of U.S. Trends in Discharges From General Hospitals for Episodes of Serious Mental Illness, 1995–2002, Shinobu Watanabe-Galloway, Ph.D. and Wanqing Zhang, M.D., M.Ed., Psychiatr Serv 58:496-502, April 2007

No beds in Oregon

In a recent article, Joseph D. Bloom, M.D. correlates the significant drop in civil commitments in Oregon over the past 20 years to the virtual disappearance of psychiatric inpatient beds. While the number of investigations for civil commitment have more than doubled over the last 20 years (from 3996 to 8315), the number of actual commitments has dropped by a third (1165 to 785). The other dramatic change in Oregon is the number of civil psychiatric beds. The state psychiatric hospital system has a total of 741 beds, of which 307 (41%) are civil beds and 434 (59%) are designated for the forensic system. Dr. Bloom concludes that it is primarily the decrease in available beds that has resulted in reduced inpatient commitments rather than a reduced need for commitment. Based on his analysis, he warns that:

The use of civil commitment as a method of diverting individuals from the criminal justice system to the mental health system has been replaced by diversion from one part of the criminal justice system to another, from jails to mental health courts. Reversing this trend toward criminal justice sanctions will take a concerted effort to restore civil commitment to a meaningful place in the mental health system.

Criminal justice professionals should heed Dr. Bloom’s warning if they don’t want to see their jobs permanently transformed into being mental health professionals. Law enforcement and corrections officials should be advocating the restoration of a meaningful civil commitment system, both inpatient and outpatient.

Hospitals as scapegoats

Across the country, the few state psychiatric hospitals left are taking the blame for failures in the mental health community. TAC executive director Mary Zdanowicz outlines the problem in an opinion piece in New Jersey's Star Ledger.

“New Jersey already closed one hospital and "reinvested" the money in the community. Yet the psychiatric hospitals are overcrowded because community mental health providers can't -- or won't -- do what is necessary to keep patients out of the hospital. Thus, tragedies among this very vulnerable population are inevitable both in and out of hospitals.

Blaming the hospitals is the easy way out, and allows the mental health community to again dodge blame for the crisis we are now facing. The community providers aren't doing their part, and it is far past time to hold them accountable.

There are now more patients in fewer hospitals than 10 years ago. Community mental health must step up and do more for hospital patients than just take their money.”

Read more from Zdanowicz’s editorial published in the New Jeresy Star-Ledger.

Hurricane Katrina and the treatment crisis

In New Orleans, Hurricane Katrina decimated the city’s psychiatric services.

In the 16 months since the storm hit, the number of hospital beds has plummeted. Remaining facilities have limited space and people in crisis often end up being treated by – or held in – the city’s emergency rooms until a bed opens up somewhere else. And as for police, “two officers always escort psychiatric patients to emergency rooms, where they often must wait for hours until the hospital can accept them. The wait prevents officers from patrolling.”

Some small measure of relief may be coming in the form of a new psychiatric facility.

"That would be tremendous," [Dr. Joseph ] Guarisco [chairman of emergency medicine at Ochsner Medical Center] said. "Psych is our No. 1 crisis right now in the emergency department. The city's outpatient and inpatient psych capacity was plundered by the storm. We have been inundated with chronic mental illness without any available resources for these patients."

The country overall is facing very similar problems. Just because it took 40 years to reach this crisis nationwide doesn’t mean it isn’t worth addressing just as aggressively.

Our national system was plundered by a different kind of storm, waged not by nature, but by well-meaning advocates who saw all hospitals as negative and all commitment laws as paternalistic.

Warped priorities

In Pennsylvania, still more hospital beds are being phased out – leaving precious few for anyone other than those accused of crimes.

Under a settlement of a lawsuit reached last year, the hospital agreed to phase out 210 of 304 patients, most diagnosed with schizophrenia, in the civil section over four years. The forensic section, for people accused of crimes, will be unaffected.

And in California, mental health workers, physicians, and pharmacists are rapidly shifting from hospital jobs to prison jobs, where pay is a remarkable 40% more. The result is significant staff shortages at the hospitals.

Although several of the state hospitals still accept patients committed through the civil courts, the vast majority of mental hospital patients statewide now are channeled through the criminal justice system … Abysmal medical and mental-health care in the state's prisons prompted federal overseers in two separate lawsuits to order the soaring pay increases as a way of luring competent clinicians to the California Department of Corrections and Rehabilitation.

The California debacle leaves Atascadero State Hospital with only 30% of its allotted psychiatrists. (And now the prisoners who are supremely ill and require inpatient psychiatric care cannot get transferred into Atascadero – and are being sent straight back to prisons, where hopefully all those newly hired medical professionals will find a way to treat them …)

It would be nice if the recent surge in concern over improving prison mental health care was paralleled by a concern for improving care in inpatient psychiatric hospitals. Alas, it seems that the search for quality inpatient beds is being totally abandoned in lieu of improving prison and other forensic beds.

As today’s Washington Post notes:

Patient advocates say the long-term solution to the problem is simple: Make
more beds available. ... [As one expert says] "There is no more expensive way to access the mental health system than through the court system.”

Hospitals are victims as much as villians

A series from the Atlanta Journal Constitution earlier this month focused on at least 115 suspicious deaths of patients in Georgia’s seven psychiatric hospitals and more than 190 cases of physical or sexual abuse. The series also documents violence against hospital employees and ties much of the horrors back to gross understaffing and underfunding of these institutions.

There are calls for a legislative commission – and NAMI wants the U.S. Justice Department to launch an investigation.

For decades there has been a widespread and concerted effort to close down hospitals and move patients into community treatment. Community providers take the money that comes with such a shift with ease, but then balk at performing some of the more critical hospital functions, including involuntary treatment. At the same time, there is little realization that some people need intensive inpatient care – and for those people, the cry should be not to kick them out of the hospitals, but to make the hospitals better. The result is that some of the sickest people are left behind, because neither the much-touted community services or the outdated and underfunded hospitals can address their very real and immediate treatment needs.

Horrors like those listed in the AJC stories are eye-opening and terrifying – but the hospitals did not end up underfunded and understaffed by their own choosing. As Dr. Jeffrey Geller says in the series:

"Ultimately, do the taxpayers want to do what's needed to be done in their state hospitals, or not?" says Dr. Jeffrey Geller, director of public sector psychiatry at the University of Massachusetts Medical School.

"It's too simplistic to make the state hospital the isolated villain," he says. "The state hospital is as much a victim as a villain — a victim of inadequate funding, a victim of the general population of the state not caring enough about its most unfortunate and disenfranchised, a victim of ineffective utilization of resources that do exist."

Development or treatment?

If nothing else, we hope that Kenneth Smith instilled in readers of the News & Observer a measure of perspective, a tad of guilt for their own preoccupations, and a spark of desire to improve the care of people like those no longer in Dorothea Dix Hospital. In his excellent letter to the editor, he says, in part:

Years ago the decision was made to close Dorothea Dix ... Collectively discussed was whether this priceless piece of real estate should be park land, condos, offices or
other forms and combinations of the ubiquitous development that crawls like
kudzu over Raleigh.

Conspicuously absent from the discussion is the asking of a simple question: Are mental patients better off as a result of closing Dix?

Overbuilt prisons, underfunded mh systems

Mary Beth Pfeiffer weighs in on the terrible situation in Florida in today's Miami Herald.

Pfeiffer is author of the forthcoming book Crazy in America: The Hidden Tragedy of the Criminalized Mentally Ill.

Pfeiffer, a well-respected author, notes that the small number of inmates who are drawing all the attention are just the tip of the iceberg. We would like to add that Florida has one tool that could help - a reformed Baker Act allows people to get court-ordered community treatment. Counties just need to start using it and may then be able to help some of these people who end up instead behind bars.

These inmates are a vivid reminder of the price to be paid when a society overbuilds ts prisons and underfunds its mental-health system, a demonstration of how long erm care of the mentally ill has shifted to the place where there is always a bed. Since 1997, Florida's prison population has swelled by 44 percent, to 89,000 inmates. Meantime, in a state that had 56 state psychiatric beds per 100,000 people in 1990, there are now eight. Squeezed by flagging reimbursements, 36 private psychiatric hospitals have closed in Florida since 1992 -- taking an additional 4,400 beds ....

Just 5 percent [of those inmates] were known to the mental-health system before they were jailed. Had they received care, they likely would not have gotten so sick -- and their prospects for recovery would not be so dim. They also might not have committed crimes that put them behind bars.

Not a happy Thanksgiving in Mass.

Thanksgiving is looking more grim than ever if you live in Massachusetts.

The Department of Mental Health appeared poised last night to go ahead with its plan to freeze admissions to state psychiatric hospitals today in response to recent budget cuts, despite intensive meetings with Romney administration officials who want the agency to find less painful ways to reduce spending.

The department has notified private hospitals that "admissions are shut down starting tomorrow until further notice, and we haven't gotten any further notice," David Matteodo , executive director of the Massachusetts Association of Behavioral Health Systems, said yesterday.

...Mental Health Commissioner Elizabeth Childs is planning to reduce spending on hospital staffing by $1.9 million, meaning some of the 850 or so beds in the hospitals would have to be left empty. The agency also plans to cut services to the mentally ill in the community. Advocates for the mentally ill on Monday circulated an analysis estimating 170 agency jobs would have to be cut.

Your tax dollars and hospital closures ...

"Deinstitutionalization is a thing of the past" – at least that is what most people think.

But, in fact, psychiatric hospital closures have proceeded at a furious pace over the last 15 years. There were so few beds when this new assault started that the people who remain in institutions are those who really need intensive care. Some can be “integrated” with sufficient support, but for others, life becomes a living hell once they are “freed.”

There are many factors driving the closures, but the most egregious is that the very groups that are paid by the federal government to “protect” the mentally ill, Protection and Advocacy (P&As) are the ones forcing many of the closures.

And when the doors are closed, the displaced residents are on their own.

In his book Crazy, Pete Earley investigates the tragic life and death of Deidra Sanbourne, the named plaintiff in the Florida P&A 1988 suit to close a hospitals (pg. 108 – 207).

The Bazelon Center, another group heavily funded by the federal government, joins many of these suits … and they aren’t satisfied with closing hospitals. In New York, Bazelon brought a suit to close boarding homes. In Connecticut, Bazelon brought a suit to get the mentally ill out of nursing homes. Where do they expect seriously ill people to live?

One need only read about M., who was placed in his own apartment when Harrisburg State Hospital closed. The P&A was nowhere to be found when M. ended up lying on a sidewalk – he was scared of his apartment.

For years, these federally funded “advocates” have imposed their own values on people who don’t have the resources to live independently. Rather than advocating to improve conditions in hospitals, boarding homes, and nursing facilities – they try to close them down.