Infrastructure for People Matters Also

At times I like and choose to highlight short advocacy pieces that are opinion pieces written regionally that are so eloquent I feel they are worth sharing. They also serve as crystal clear reminders that mental health reform issues are really quite universal in our country.

One such piece was just published in The Buffalo News just today, August 30, 2017, still during the continuing agonizing events of Hurricane Harvey down in Houston Texas. This is a Wednesday as I write this and it has been raining in the Houston now for 5=6 days straight with over 50 inches all told having fallen in many areas, covering now up to 50 counties. It is dawning upon all of us, and without a doubt that domestically this may be not only one of the “defining issues” of the Trump Presidency but likely one of the “dominating” social issues of his tenure. The initial help efforts have been monumentally large, fast in onset and heartening to all who witness the “citizen” led and self-initiated efforts portrayed on the news outlets.

The infrastructure costs and time to repair will be higher than anything this nation has ever seen and will clearly take years. This is an incredibly sobering realization for this country which is many ways been spared because of its temperate climate the magnitude of many natural disasters that seem to inflict cruel pain and hardship on poorer regions of the world such as Bangladesh’s almost annual massive floods, displacing up to a million people during its monsoon season. I mention this because it is also happening there this very week also.

But there is another thread that I wish to emphasize in this post as no doubt many other citizen writers/bloggers and most of the national media will discuss and likely also argue over for a few weeks. That is the national physical infrastructure that has been neglected and minimally maintained in most parts of the country for a number of years if not decades. Urban plumbing, water systems, waste treatment capabilities and plants, water resources, roads, highways, airports, and bridges have come to be on the minds of governments at local, state and national levels.

Continue reading “Infrastructure for People Matters Also”

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Drug Free Inpatient Psychiatric Care in Norway

Asgard Psychiatric Hospital, Tromso, Norway, credit “Mad in America” blog, March 2017 [http://bit.ly/2wbRrJW]
In my previous post I ended up writing an overview of the changes over the time of the last 24 years since I personally date “mental health reform” commencing in this country as being the year 1992 when news of the beginning sweeping changes (at first budgetary adjustments due to the falling state’s revenues during the implosion of the Big Three Automakers) that surfaced in Michigan under then Governor John Engler. In short the progression went something (very approximately) like this: cutting of mental health budgets, closing of public inpatient psychiatric beds (downsizing of out of date, out of code, aged state hospital relics), closure of multiple facilities, conversion of the “county mental health center” based system of care delivery from the 1963 JFK Comprehensive Mental Health Center Act (that name is from memory and may not be completely correct) to regional agencies that covered larger areas and population groups, conversion from combined state and county funding to various forms of block grant funding still heavily reliant upon federal Medicaid funding (this is ‘mucho importante’–as my Texican father would say for emphasis–and must NOT be forgotten as it is still pivotal today), to beginning versions of degrees of privatization of these regional mental health care delivery agencies, opening outpatient mental health services to entrepreneurial provider-business groups who were somewhat free to pick and choose what types of services they wished to deliver and which they wished to avoid and not pick up.
In the early phases of this general blueprint of national mental health reform, as it came to assume the stature of as more states adopted this governmental approach, there was much optimism that fueled understandably this effort. Many different groups seemed to be more involved than ever before, including private enterprise, a novelty in and of itself. The boundaries between private mental health care centered previously in private free standing psychiatric hospitals and units in private community or university medical centers and the world of private office psychiatry, and (whew), the worlds of public mental health centers and state psychiatric hospitals began to blur especially on the outpatient side of things. Hospitals bought psychiatric practices as they had been doing with medical practices. Small private psychiatric groups either had to greatly expand numbers of sorts of practitioners and services (more non-MD staff and services) and expand patient volume, or be absorbed by hospitals that had gobs of capital and could assume and handle the higher and higher costs of overhead (billing especially which became a nightmare in the late 1980’s), or close. There seemed to be at least in my part of the world a phase of retirement by choice of more than the usual attrition-retirement rate of private psychiatrists. I recall a medium small city of less than 100,000 in which all three private/public child psychiatrists other than myself left practice and the area in the mid 2000’s as the enormous forces of the change washed over the practice world. A number of practitioners affiliated with highly capitalized hospital groups and survived in that manner. Others simply moved lock stock and barrel in more affluent metropolitan areas with strong economies and higher standards of living to a cash only, no insurance practice model that had long existed especially in affluent cities with large university medical schools and departments of psychiatry that quietly influenced their training program graduates to stay in those areas and practice the solo cash only model since the 1960’s or so.
Now I think we are in the post revolution phase. Many models are in use, many are finally getting stable footing, strengths are being recognized and resources more appropriately developed and mobilized (mobile crisis intervention and outreach ACT teams). Similarly on a not so good, no reason for victory dances yet, side of things that deficits are now more glaring than ever. Inpatient services have contracted dramatically everywhere. Private psychiatric hospitals closed or were converted to other uses, some nationally sized private psychiatric hospital chains closed dramatically in the very early 2000’s as once abundant insurance reimbursements (at least a fair to a hefty portion of such poorly managed and spent causing 20 years of a “private psychiatric hospital bubble” to implode. Inpatient beds decreased in this country for mental health treatment decreased perhaps by as much as half which is mind bending if one ponders that as the population was still growing, drug abuse was increasing exponentially. Even the VA Hospital system was not prepared as seen in its inability to handle and furnish adequate services for several years after Desert Storm (brief as it was) and especially after the War on Terror began in earnest in 2003 with Iraq. The VA Hospital went through its own version of excruciating upheaval as it had to “reform” its mental health services, head rolled, appointment scheduling scandals erupted (please recall the Phoenix Indian School Road VA Hospital mess ten years ago).
The streets, ERs, and jails became the new “receiving units” for the chronically and acutely mentally ill, the trans-institutionalization consequence of the above shrinkage of the existing5130-year-old mental health infrastructure. This has been and is still being more than adequately covered in local, regional and national media of all types and I will not further belabor here.
I would like to direct our attention to one new and not so new treatment model that is making a comeback in the midst of all this controlled change and “disruption” of existing models (Internet speak), or paradigm shift of the philosopher Clifford Kuhn. That is inpatient psychiatric treatment without psychiatric medications.
At the top of this post is a picture of a psychiatric hospital Asgard, in Trosmo, Norway (I must confess I am totally unschooled in the existence of either before I found this blog post article). This hospital is as the article/post details 215 miles north of the Arctic Circle. I have lived for some months on three occasions in my youth following my peregrinating international rambling mining engineering father to his contracted job sites that were snowy cold climates but none of them would compare at all to what I imagine the clime of this location.

The means by which I came upon this article entitled, “The Door To A Revolution in Psychiatry Opens,” is worth detailing. The author of the blog post is Robert Whitaker, a journalist and author of two books about the history of psychiatry, one of which I have and have read with great enjoyment, fascination and a good for the soul dose of humility, Mad In American: Bad Science, Bad Medicine, And The Enduring Mistreatment Of The Mentally Ill [click link for Amazon review etc.]. Mr. Whitaker is in the foe of psychiatry camp along with perhaps better known anti-psychiatry physician Peter Breggin MD. Mr. Whitaker’s book focuses on the failings and disasters, failed theories, bad side effects of many psychiatric medicines and so on. In all fairness I follow him with searchbots on the Net and this turned up. If you loathe all things psychiatric, then this is one of the books for you in truth. Form my point of view it is a needed viewpoint and one to help us in the guild…though I do not think of myself as all that nefarious and evil, and talented writers such as he are to be commended and accepted for their necessary work.

So why is this seeming sidebar important in this post? Mr. Whitaker is a founder of the aforementioned blog, Mad In America and his perspective and where he starts from is reflected in the blog and his book. And the article in the blog that one of my trusty bots found which is referenced for the intrepid reader above, is about the manifestation and another test and trial of medication free treatment. This is being conducted by well meaning and very well trained professionals. From the blog’s post which is very lengthy (even moreso than my usual oververbal posts) details the enormous and creditable preparation that has gone into this movement in Norway. This is no heretical nut job splinter movement. The government of Norway is mandating the trials of this mode of inpatient treatment which is apparently being, or gong to be tried in other psychiatric hospitals as well. The post makes for absolutely fascinating reading.
In the United States we have had a few experiences with such models in this general realm. A few exclusive (I guess that would be an appropriate word to apply to hospitals for the wealthy and famous) psychiatric hospitals tried this approach on small scales in those heady days of the 1960’s and 1970’s when some might say a bit derogatorially, “anything went.” Most of the practice groups were spearheaded or led by charismatic psychiatrists operating within a small clique or group with similar beliefs. In Great Britain the most well known, at least in hippie and college circles in those years was Ronald Laing who treated psychotic patients with little or no medicine, small patient units, and great amounts of time spent in individual and group therapies. Dr. Laing wrote a number of books over a span of almost 2 decades but his book, The Divided Self, is what put him on the map internationally. Almost every student in psychology in the colleges of those two decades of the 60’s and 70’s read this book. Laing came to be a highly sought after speaker at least on the slightly or very avantgarde college circuit. I myself heard him speak twice. Outside of a minority of devotees in international psychiatry, he was viewed as mostly a charismatic oddity and very much as a product of what was going on those days and years. The only fairly well regarded psychiatric researcher practitioner who practiced in an arena that could be regarded as in the camp of psychiatric treatment without medication was Sir Humphrey Osmond also of the same time period. He was more mainstream and a clinical researcher. His departure from the mainstream or whatever one wants to calls the ?silent majority? of psychiatrists was marked by his openly peer reviewed and published trials of hallucinogenics, mainly LSD in the treatment of psychiatric issues ranging from psychoses to the terminally ill. Most if not all his data was anecdotal, case reports of fantastic religious like euphoric life changing experiences of LSD for patients. The response to his work was underwhelming, to say the least in all fairness. In those times of the experimentation with LSD, DMT and the other designer hallucinogenics, many of us standard, perhaps stuffed shirt psychiatrists did not see these wonderful results. All I remember as a green medical student and then a green psychiatric resident was handling people in great psychiatric distress, having hours and hours of terrifying LSD induced experiences that were unnerving to witness and work with and for a while hard to treat. So the rest of us had a different view of the hallucinogenics. The use of ‘natural’ hallucinogens such as psilocybin in Native American cultures is different for the most part and I will not address that here as it is altogether different.
In spite of my huge built in bias and years of standard experiences in the current world of psychiatric treatment, I want to see what the Norway efforts and experimental treatment models can accomplish, what they evolve into, what factors they may be able to tease out since we no longer have too many sponsored or approved studies along these lines going on in the western world of medicine. I can predict that almost all “IRBs, “Institutional Review Boards” of clinical psychiatric research centers would almost never give approval to such work. More the pity as perhaps there are still interpersonal and talking therapy approaches that work better than others with standard inpatients and it might be possible to see those stand out in relief without medicines in some patients. I am more than willing to give the Norwegian effort a go at things and am personally glad that it is possible. I hope that it is studied “up one side and down the other,” that as much data as possible is gathered and presented to the world of treatment practitioners for all to review.
Lastly, I must comment on the other rare element contained in this article, all my own past bias coloring experiences aside.
This article goes to great and eloquent lengths to trace the history of various politico-social movements that have grown in Norway, and to at least comparable extent in the most of the other Scandinavian countries, of the right of what I would call a different form of self-choice, self-determination that almost has little or no parallel in our social views, spoken and unspoken mores and standards. The narrative of the author is marvelously woven drawing upon years of social thinking in Norway, exemplified by various social thinkers, commentators, critics, leaders of a number of “citizen advocacy” groups as I would term them. The author successfully brings the reader to a depth of historical feel and appreciation for how all this has developed in Norway so that even if you are not an instant convert, you can very much appreciate this psychiatric treatment model’s origins and roots. For this reason alone, this blog post is well worth the read.

Healthcare Costs: The Perpetual But Evolving Seesaw

It is no news at all to anyone reading this or anything else at all in the media for the last couple of decades that in the United States, we have the costliest health care services in the world and that we do not get our full “bang for our [many] bucks” in the cost equation. Yet as far ago as the 1970’s the world’s wealthiest groups in the world came to our hospitals and big name healthcare clinics for the “top healthcare.” I recall then when certain families of a certain “royal” family born of petroleum revenues and riches came to my training, teaching and later, practice affiliated hospital for all sorts of medical and very secret psychiatric care. Those folks always created a great stir in the entire hospital system. They usually took over at least an entire wing of a floor of the hospital and had instituted all their dietary restrictions, religious requirements, and at times brought some of their own staff; contrary to the usual undertone of some prejudice, their trappings and accouterment of their societal practices actually made things easier. But the greatest stir was always when they left the hospital to return home at the end of the treatment stay for whoever the patient(s) was or were. These folks would bestow expensive “trinkets” upon the hospital staff they had liked and favored. The gifts were in the league of Rolex watches and whatever was in vogue at the time but included eye-popping jewelry, expensive Italian shotguns and on and on. Cost of the medical care was of course no impediment for these folks and their new contemporaries in the decades since, in the rapid incubating industries of high fashion, investment, mergers and acquisitions, international banking (and who knows, maybe even money laundering), drug lords under assumed identities (usually in highly securable and ‘safe’ free standing clinics instead of rambling hospitals with as many security holes in them as one one of my old sweaters. This phenomenon of perhaps ostentatious consumerism of costly healthcare is one of the weird epiphenomena of our healthcare ‘industry’ that illustrates its almost bizarre contradictions. And it occurs in all the big name medical institutions in the countries in the northeast, south, midwest, far southwest, upper far west; you name a region with big world beating specialty medical care in one or more disease and you will find from time to time, the world’s supremely wealthy beating a path to their door.

Some countries have taken difference copycat or “opposite-cat” approaches to this medical social snobbism of extreme consumerism. India and Thailand have in the last few years gotten into or started the cheaper markets for elective surgeries especially for fractions of the costs of standard American healthcare institutions. There does not seem to be too much wrenching of scrub scrubs suits, self-flagellation with IV lines by surgeons decrying this development but it is going to be interesting if this development starts to significantly cut into the receivables of lots of hospitals.”Oh, I had my gall bladder done in the Punjab, I had a great time, and save $9,000 too!” Which is to say we still do not have true competition in this country. Any of you free marketeers listening out there? All we have is siloed, protected from almost any similar medical business, sectors, having no overarching economic influences that touch more than one sector and therefore the Great God of Free Market Competition that has for 30 years been supposed to have controlled prices. What we have are ‘cooperative co-monopolies.’

Let us review for a few lines what we have tried.

Continue reading “Healthcare Costs: The Perpetual But Evolving Seesaw”

Shortage of Child Psychiatrists

Several weeks ago I was incredibly saddened by the news from a colleague and dear friend of mine, also a Duke child psychiatrist, that one of our mentors had passed away in his mid-80’s. He meant so much to me, I wish to mention and memorialize his name in my own little way in this humble esoteric blog. He was Dr. Marc (Marcelino) Amaya (with ‘Amaya y Rosas’ being his full last name).

He was one of the original child psychiatrists in a group that came down to Durham NC from Northeastern training centers to help start the department and to staff it. The other faculty was as were in all major medical centers of the last 50 years, superb instructors and fantastic clinicians that often left us rookies with our veritable mouths open at their insights.

Dr. Amaya started a complete children’s psychiatric hospital I think in the early or mid-1960’s to house what Duke could not offer on its grounds because it was private and not state affiliated and for funding issues. The Children’s Psychiatric Institute (CPI) was a fabulous training center on the level of such other state hospital affiliated and also lesser known than the more celebrated upper crust programs, but every bit as good as any of the Ivy League (Boston, NYC, Philly, etc.) centers such as the late and venerated Dr. Ralph Rabinovich of the University of Michigan at Ann Arbor. CPI has a short term and long term outpatient clinic, a family therapy program that was expanded by this writer and one of the veteran incredibly skilled social workers at CPI, Anne K. Parrish ACSW, LCSW, into a training program for child mental health trainees from Duke and UNC-Chapel Hill medical and graduate schools. Dr. Amaya was a superb supervisor and I always learned untold concepts, techniques, and gems at his feet so to speak. I also accompanied him to the testify in the Golden Days of Psychiatry and Psychology in this country to testify annually before the NC General Assembly (state legislature) as we would advocate for our state funded programs, but also for the private inpatient and outpatient programs at Duke and UNC! So there we would be harassing clinically and statistically the legislators (who in those days seemed to listen better..no matter their party affiliation). It was quite ironic but demonstrated the dedication that Dr. Amaya had to the delivery of mental health services to ALL children of the state and to any agency, institution, training program that was trying to provide such. His program was not his first concern in the statewide scheme of things, it was just another important part of the overall system of resources he foresaw for the state decades before some of them came into existence. He was a short man with a lyrical Hispanic accent that I as a Southwesterner could listen all day long and always feel like, when I was with him, I was a little bit ‘back home’ in the Southwest.”

Continue reading “Shortage of Child Psychiatrists”

South Dakota Illustrates the Shortage of Psychiatrists

A recent and typical article in the South Dakota newspaper, the Argus Leader, “Psychiatrist shortage worsens court bottleneck,,” sadly but truthfully illustrates one of the worst reasons for one sector or causative reason for one aspect of the mental health crisis of delivery of services in this country in all sectors, public and private, inpatient and outpatient whether clinic or private office based. There is a tremendous shortage of shortage of psychiatrists in this country. This issue has been building for over 30 years!

It started when the ability of hospitals and training centers for many kinds of residencies in subspecialties in all aspects of training of “residents,” who are doctors in training in specialties such as family medicine, pediatrics, OB=Gyn, general surgery, psychiatry, internal medicine, and even the subspecialties such as all kinds of cardiology (interventional, electrophysiologic), pediatric surgeries (orthopedic, neurosurgical) dermatology, endocrinology, all the subspecialties in radiology etc. This obviously stupid development came about when during the Reagan administration, Congress in its misplaced attempt to do something about Medicare and Medicaid fraud, thought that training centers should be allowed to transfer (divert was pejorative condemning word that was  back then to convey some kind of behind the the scenes skullduggery in money manipulation) those revenues to help fund training programs.

Now it must be understood that ALL training programs in medical residencies are expensive. Residents have to have salaries to live on, though they have always been just enough to make ends meet especially if you have a family…and residents are NOT paid wild, glorious fantastic salaries and live the good life, driving Benz’s, Beemers and Lexus’es. They drive used cars (I sure did for years, but the truth being I do anyway as my motto became with bunches of daughters in 2 different cohorts and one later adopted son, “Never Buy Retail.” Buyin Easter shoes for all the girls annually was something we saved for after the Christmas-Hanukkah holidays and even then we shopped at place called “Discount Shoes,” which was almost a 200 drive away from our home in Durham so we could afford the Easter “pony shoes,” as I jokingly called them for the feminine horde.

Residents in training also generate very little revenue from their clinical work. In the old days (imagine old man reminiscing vocal sounds and harrumphs in the background), residents at least in surgery could be billed to insurers including Medicare and Medicaid as “assistant surgeons,” and generate some lower fees which helped. This disappeared under the new punitive regulations until residents in the surgeries and other specialties that had procedures they could charge full rates for. That circumstance would typically come legally at the end of their training when they were “chief residents,” could function autonomously and ran the lower level residents and interns’ services, scheduling, teaching, assigning patients, reviewing work-ups, approving studies, in other word, the junior attendings. In this way the essential supervision of all residents lower than the chief, was handled and parcelled out at different levels and handled as appropriate to the training of the resident, by the resident one year ahead of the next resident. It worked for deacdes since the aftermath of the “Flexner” report which occurred in 1910 or so. It catalogued the incredibly sad state of medical training then in the USA and proposed virtually the entire modern training system we have today. It was a masterful work of presience with Dr. Flexner foreseeing what would be needed to train doctors to high standards, generally how to involve modern developments not even dremaed of then and legislate firm, universal standards of training at all training centerss. For instance courses were standardized and required, and another telling example is that surgery residents started to have to keep verified surgical diaries listing all the procedures they had performed, assissted in, and observed throughout their residencies. Even now these have to be reviewed and presented at the time being considered for board certification.

In psychiatry things were different as they always were. With the exception of psychological testing, psychiatry had no expensive, bodily invasive medical or surgical procedures that could be charged for with nice high fees. Psychiatry residents in training even in wealthy settings such as Cambridge, San Francisco, Westword in LA, the tony areas of New York City bordering Central Park, Ann Arbor, Chicago, Georgetown in DC, mostly had patients who were poor, had little or no insurance, even Medicaid especially in the early days of Medicaid. And when insurers began to pay for psychiatric services, they were paid for at the discriminatory rate of half, 50%, of medical/surgical rates. And so the residents in psychiatry did not generate enough monies to pay their own expenses to their training programs, office, staff, salaries and especially the time of their superising psychiatrists. Although youger pscyhiatrists in training always had psych resident mentors above that offered peripheral supervision, formal superision was conducted by one’s supervising faculty psychiatrist. It was very expensive, given the nature of what the psych trainee did, which was an interview. The supervision onsisted of the faculty psychiatrist who followed the case as long as the trainee treated the adult, teen or child, heard all the “material,” and then taught, offering advice how to interpret, how to supportively interview, how to form all alliance, how to foster self insight, how to help the person effect and move to real points of change in their lives, how to see them through crises in their lives. And of course, all the ancillary social issues were handled and learned as well, what to do with substance abuse, dysfuntional families and marriages, deaths and losses and on and on.

The point is that training of psychiatry and psychological Ph.D. level mental health clinicians was and still is tremendouls costly. Some experts estimate that until recently with the coming monies from the former Congressman Patrick Kennedy’s and other’s reparative training fund bills for the mental health professions, that some 80% of training funds nationally disappeared.

So what happened; by the end of the 1980’s training programs closed, not many but a fair number. Most reduced staffs and residents, especially the latter by half or more. My own program reduced the number of residents by 2/3.

All the big cheese observers of the “psychiatry scene,” especially but also all the other mental health discipline began to complain, then warn, then project the coming crisis of shortage of mental health provider crisis with astounding statistics and then starting to scream from the national battlements (a la the battlements of the French Bastille in my fertile imagination). We were not replacing the measley 6,500 or so child psychiatrists we used to have TOTAL in this country by the 2000’s. Those that died or retired were lost to service and most of the time communities did not have replacements.

My own experience with this was telling. In 2006 i lost my psyhiatry partner to a terminal diagnosis of cancer in a close member of his family. He was in his mid 70’s and decided to retire, moved with his wife to be near their family. This was an unexpected and rapid necessary exit from our practice but it left me in the veritable “lurch.” Our practice was an almost half child oriented practice. At the time mental health reform in NC was a true disaster mostly because it was in the middle of its development, little was finished or formed or ready in the new outpatient service delivery structures across the state. Long term employee professional of the local county or combined several county mental health centers were told they had to re0\-apply for their positions, including the Ph.D.’s and MD’s. So what happened in our town was typical; all three lady child psychiatrists left within two months and there were no practitioners other than me for the entire country. I worked for two years trying to recruit another child psychiatrist to come to my practice. I thought the prospect of the magnitude of the immediate need would surely attract someone. I recall telling several visiting candidates, ‘Don’t worry, you’ll be full in one or two weeks. guaranteed.” They all had better offers elsewhere in the medical centers or big cities. I worked two years on Saturdays and Sundays seeing and caring for the public mental health center county kids, and finally truly “burned out,” something I thought would never, ever happen to me! I finally had to face reality and closed my practice of many years and took a salaried job, but a wonderful one working as the first psychiatrist on the Cherokee Qualla Boundary Indian Reservation, my wife’s ancestral home. It was wonderful for both of us and my wife was able to return to her childhood home and be with all her relatives especially her elders. I worked my contract and helped to find a Native American replacement psychiatrist finishing psychiatric training (there was only one in the entire country) and persuaded him to come and after nearly five years’ development work there, my work was done and I then faced my now olde rage ‘category-status’ and decided to return to my original first rotation at my training residency and become a state hospital psychiatrist and “give something back.” However, slightly selfishly this state hospital offered a full range of psychiatric residency teaching opportunities that made me “teaching self” water with great anticipation since it took residents in psych rotations from several medical schools. But it so doing I in effect contributed to the growing shortage myself of psychiatrists in the country.

So what does all this have to do with South Dakota? South Dakota has a smaller population and only one state hospital. It has had even FAR worse problems staffing their one hospital with psychiatrists and has had to close beds the last one or two years because of lack of coverage or clinicians to treat them.

But as in the rest of the country the huge new influx of “legal patients,” has swamped the hospital, doing as this near tsunami of “incompetent to proceed” to trial patients has done is almost ALL the other state hospital hospitals [including my own], taken beds always for ordinary psychiatric patients in crisis.

The result as this article typically reports patients have been stranded for days to weeks in ill equipped small community hospital ERs, waiting for an acute admission bed to ‘open up.’ This practice is so widespread in the country that it has acquired a convenient name, “psychiatric boarding,” or just plain “boarding.” In some states, advocacy organizations have sued states and their hospitals for such practices. It is a widespread problem with presently no real solutions. Most state legislatures are not willing to fund and construct the many dozens or hundreds of beds that would accommodate these legal patients so they are treated and accepted first by the admissions units of the state psychiatric hospitals who have NO choice but to do so because these patients are court ordered.

I will take the liberty and quote three paragraphs from the above referenced article to illustrate the problem as it currently bottlenecks both the inpatient psychiatric hospital’s mission and obligation to treat its patients and the legal system that must observe and uphold the constitutional right for a defendant to be able to understand and participate in a capable manner in their court proceedings and to fully cooperate with their counsel.

From the Argus Leader, “A shortage of psychiatrists in South Dakota is hampering efforts to address a bottleneck for court-ordered mental health evaluations in the state.

An Argus Leader Media investigation found mentally ill defendants were jailed for half a year or more as they waited for exams to determine whether they are competent to stand trial.

The state’s mental health hospital says it is not responsible and does not have the resources to conduct all of the exams, and that’s forced counties to seek out private psychiatrists to help manage a surge in criminal cases involving defendants with mental illnesses.

The problem is that few private practitioners in the state are qualified…”

Finally, to close out this long winded treatise on the shortage of psychiatrists, I will further take the liberty to quote the Argus Leader’s data in this article which gives startlingly information on how understaffed the entire state is with (or if you prefer from a pessimistic standpoint) without psychiatrists, the following passages will delineate the dimensions of the shortage that exists NOW:

“A Kaiser Family Foundation analysis this year found South Dakota has enough mental health professionals to meet only about 15 percent of the need for services in the state. There were an estimated 30 psychiatrists statewide in 2014, according to the U.S. Bureau of Labor Statistics.

The South Dakota Department of Labor and Regulations puts its estimate at just 20 psychiatrists statewide.

Based on BLS and Census data, South Dakota has fewer than one psychiatrist for every 30,000 people, one of the lowest ratios in the region.”

At the end of the article, the author listed the relative ratio’s of psychiatrists per 100,000 persons in 2014 that last year for which such data was fully available. These statistics are woeful as one accepted statistic commonly accepted for urban areas is ONE psychiatrist per only 3,000 people to 30,000 persons at most. The Midwest illustrates its serious shortage more than almost any area of the country. But all areas have them, except by and large cities in which there are one of more medical schools and concentrations and availability of specialty training programs.

Psychiatrists per 100,000 people, 2014

Nebraska   3.2

South Dakota  3.5

Iowa  4.8

Minnesota  6.6

Wyoming  6.8

Montana  11.7

North Dakota  Data not available

Sources: Bureau of Labor Statistics, U.S. Census Bureau

 

Drastic Soluution to Court Ordered Psychiatric Evaluations: Stop Doing Them

In an article published this date,July 20, 2017 in the Argus Leader of Yankton South Dakota, “State hospital no longer performing court-ordered mental health exams,” and referenced articles published several months ago in the same paper which I have referenced and linked below, there is explained in some of the best and most clear, succinct reporting I have seen in several years, all the fuss and complicated issues surrounding one very critical part of the national mental health service delivery crisis for which there appears no end or easy solution in sight.

The problem is that in South Dakota specifically to start there as our study example, the state psychiatric hospital system (the state has only one such hospital because of its relatively low population) has been and is still been flooded with court ordered inmates from county jails all over the state for admission to be given forensic evaluations for fitness (competency is the legal term) to stand trial. Most of these persons are truly mentally ill, which is another part of the Gordian knot comprising this crisis that has been developing for over three decades nationwide. South Dakota’s hospital came under review and journalistic investigation by the Argus Leader some six months ago because 1) overcrowding was at a crisis level; 2) the hospital was running full and could not literally admit in a prompt and responsive manner the growing number of “ITP” patients (incompetent to proceed to trial); 3) mentally ill inmates were logjammed in unrelenting and overwhelming numbers in the state’s country jails; 4) counties’ budgets were being decimated by the costs of housing and trying to treat as much as they could with very limited resources, the psychiatric needs of these stalled patients/inmates; 5) the rights of the inmates/patients to a reasonably speedy trial-disposition of justice-were being far exceeded.

This is NOT a problem particular to way up there northern plain state of ‘lil ol’ South Dakota with its very small population, perhaps limited state revenue and budget. This is a NATIONAL CRISIS that is being seen in virtually every state in the United States. There are many factors for this and on the occasion of this post I will not go into much detail on why this has grown into the “Feed Me” monster plant of the famous play of decades ago that is devouring resources, facilities, budgets, policy wonk’s best ideas and stretching our mental health delivery system past its breaking point. The one factor I will briefly waggle my “I told you so” sorrowful finger at, is the predicted result of trans-institutionalization that I have written about quite often in this blog. ‘Nuff said for now. But it will be a very thorough conversation and historical revelation and analysis for another time.

Another very telling factor that I have not included in my list of causative/exacerbating factors above because it is literally out of South Dakota’s control, is the extreme shortage of psychiatrists and allied psychological professionals especially both forensic psychiatrists and psychologists. Training programs for these specialists have been too small since I was a resident in the 1970’s and the output of teentsy numbers of these subspecialists is now catching up with us in a big way and forming a “chokepoint” in the delivery of these systems for which there is no timely solution.

So what did poor South Dakota’s state psychiatric hospital do? They decided bravely to completely STOP performing such psychiatric forensic evaluations. This decision somewhat flabbergasted (I have loved that word since I was a blabber mouthed kid) at this really brave and somewhat bureaucratically perilous, singular decision. I think South Dakota is the only state to make such a governmental service decision. In my world, this is almost akin to stop paving the highways, or shut down half the public schools or some other state governmental function that we all take for granted whether we are aware of its importance or not.

The state went so far as the leave monies for all these legal-psychiatric services completely out of the state budget! To read the account of this very unusual move, read the following article: “ Mental health court money left out of state budget.”

Perhaps other states have done the same thing recently but honestly my Google and other search news bots have not alerted me that such has occurred at all anywhere. As we say in the South, I have not “heard tell of”  anything like this.

Were State Psychiatric Hospitals Better 100 Years Ago?

A fundamental intellectual tenet of mine is that to have a comprehensive and ‘honest with oneself’ grasp of historical and social long term processes, history of the subject being studied should be included. George Santayana’ famous quote that those who ignore history are ‘doomed’ to repeat, seems to hold more and more power of truth the older I become.

The history modern mental health care began in almshouses, shelters for the developmentally disabled and intellectually disabled, earliest perhaps by the Quakers of the early 1700’s in Pennsylvania. Theirs was an extraordinary (and still is) ethos of charity, helping those in need and one of the original origins of the philosophy of “non-violence,” embodied in conscientious objects in our wars and taking on the needs of the shunned, ‘repugnant,’ disabled persons who frightened the average person. It is no new concept that state hospitals were built intentionally out of the ‘boondocks,’ the countryside, away from towns so delicate sensibilities of citizens were not disturbed by the sight of unpredictable persons, that in reality before the era of modern treatment in the middle half of the 1900’s NO ONE really understood beyond crude empirical approaches, i.e., “we do not know how but this medicine works on hallucinations so let’s give it for that.”

There are many, many articles, books, some films from the earliest days of the then miraculous, wondrous Brownie 8 movie camera, that record the abysmal conditions of many state psychiatric hospitals in the Western world and the US, Latin America, Scandinavia, Europe and a few other regions and countries where modest efforts at housing the chronically mentally ill occurred. For instance, it is not well known that the famous country singer, Johnny Cash, established and supported an orphanage for children in Jamaica and did so very quietly as a true philanthropist.

If it were not for Google’s miraculous search bots, I would never have come across or read the article to which I wish wholeheartedly to refer the reader. It is from this week’s edition of the English newspaper, The Daily Mail. In the usual British brutal journalistic tradition it has simply ghastly title: “EXCLUSIVE: Chained to their beds with no heat or water, and left to lie in their own excrement: How the 19th century mentally ill were sent to hide away in grisly insane asylums and categorized as ‘idiots’, ‘imbeciles’ or ‘lunatics,’

This article itself is based on what appears to be a singularly striking book with lots of old pictures of life and patients in state psychiatric hospitals in Scotland and England, entitled, ” Lunatics, Imbeciles, and Idiots: A History of Insanity in Nineteenth Century Britain & Ireland, by Kathryn Burtinshaw and Dr. John Burt.

Continue reading “Were State Psychiatric Hospitals Better 100 Years Ago?”