Pres. Trump Orders Medicare to Expedite TeleHealth Efforts

A few days ago, on October 4, 2019, President Trump took an action by Executive Order that I totally agreed with and wholeheartedly applauded. He ordered essentially a jumpstart in the federal government’s support of telemedicine and telehealth services.  This was quite a sweeping action and well written, formulated and intentioned. It may in the future be looked upon as one of the more forward-looking actions taken by his Presidency. Years ago, President George W. Bush took such an action that helped to propel the electronic health medical record movement in this country. He got the whole business off the dime so to speak by issuing an Executive Order of his own, that standardized the electronic standard of content of records in EHRs that helped to make them more interchangeable. That helped get things going and was not as well recognized in its time as it should have been.

A very good summary of President Trump’s order appeared in the healthcare periodical “mHEALTH INTELLIGENCE” article entitled: “Trump Pushes Telehealth, Adoption in Medicare Executive Order,” by E. Wicklund.

This action mandates many things. Mostly it asks the Centers for Medicare & Medicaid (CMS) to accelerate the adoption of Medicare Advantage plans of just about anything that facilitates the use of telehealth/telemedicine services and capabilities. This encompasses adoption of coding/reimbursement mechanisms, payment mechanisms and technologies.

This is long overdue. Whoever spearheaded this initiative and Executive Order within the Trump administration is to be commended.

My own hope is that this will also spill over into the mental health services field so that innovative measures can be supported via telepsychiatric means as well.


Dementia Patients and Virginia’s Law of Unintended Consequences

This article is very much worth reading and I would recommend it to the reader that they follow the link and read this article which is extremely well written and full of very telling observations, and statistics. It details a compelling story and timeline that follows the challenges a caretaker faced in placing her partner – wife into a suitable facility that could handle medical, geriatric and dementia treatment needs. It is very humbling in reading this article to realize that the caretaker was a sophisticated supremely well-educated physician, and neurosurgeon, who ended up in the final analysis being defeated by the bureaucratic rabbit holes and dead ends in her supreme efforts to find adequate care for her partner.

Many state figures in advocacy organizations, Virginia governmental agencies, etc., were gracious enough to consent to be interviewed by the intrepid reporter for the Virginia Pilot newspaper. But I could not shake my impression that very few of them tried to exit their circumscribed bureaucratic governmental roles and go the extra mile in this situation. All of them offered credible systemic observations and reasons that did not help the Kafka-esque situation that the caretaker physician found herself in and ultimately defeated by.

On a closing note, I wish to apprise the reader that the state of Virginia actually has really only one designated geriatric psychiatric hospital in the state. This is the Piedmont Geriatric Hospital.

Piedmont Geriatric Hospital is a geriatric hospital located in Burkeville VA, south of Roanoke and Richmond. It has 123 beds and is located at the site of the previous Piedmont Sanatorium which actually was a TB sanatarium for African Americans. This facility was almost closed in 1999-2000 under then-Republican Governor George Allen (the former football coach), then again in 2002 under the administration of Governor Mark Warner but this was also averted, and then again in 2004 under a cost-cutting proposal of State Senator Frank Ruff which was also avoided. One can see that even this solitary resource for the geriatric state hospital patients of the entire state of Virginia almost was lost several times when cost-cutting in mental health was still being pursued as a rational move by Virginia before wise heads prevailed. If this facility had been closed, one can only imagine how dire the plights of the geropsychiatry patients in Virginia would now be.



Generic Drug Houses Face Price-Fixing Lawsuits

Remember years ago when generic drugs had the promise of drastically lowering prices of the superstar medicines when the patents expired. Prozac was one of the first drugs that had that allure. And there is a story behind that.

Mylan, one of the generic drug firms accused of price-fixing

When Prozac came out it was the first serotonin acting antidepressant. It had far fewer side effects. It did not constipate you, make you dry and drowsy and as my early deep South patients said, it didn’t take my Johnson away.” [But actually, it did that also in some fellows.]

And Prozac came out at the end of President Reagan’s administration when de-regulation had begun to hit its stride. In my highly speculative, inferential view of the drug industry back then, the companies looked around the national landscape and decided the regulation and informal strictures upon drug pricing were gone, that the Feds in the form of the Department of Justice AntiTrust law enforcement bodies would not be unleashed upon them. And so, the first drugs that started to come out in those days that truly represented NEW medicines in terms of their modes of actions and improved efficacies such as Prozac, were suddenly priced many times the usual and customary prices ranks of their ancestral brethren. Prozac and its following related serotonin blocking antidepressants that came out in the 1990s were priced MULTIPLE times higher than the preceding generations of tricyclic antidepressants.

This happened in other medication families, such as the anti-lipid (cholesterol, blood fats) medications, more potent antibiotics, the several new category anti-hypertension medications, but especially the new oncology cancer drugs. Those latter drugs still set records for their cost to this day. [I should know, I take two currently and owe my ongoing gift of longevity to them, but their cost still takes my breath away.]

Then, the patents of many of this ‘generation’ of medications that started to come out in the very late 1980s and through the 1990s, ran out and expired. And generic drug manufacturers raced onto the scene offering non-branded chemical twins of those previously outrageously expensive drugs and all of us millions of patient-consumers were happy at the cost relief we were afforded. The system of patent expiration and market lowering of prices through generic medications WORKED. Competition among the secondary off-patent drug companies lower prices the way they were supposed to. The American model of market competition reaffirmed our beliefs in this system and we worshipped at the altar of purses relieved by drug discounts.

Then something started to happen somewhere in the early 2000s. The generic manufacturers started to GET BIG. They bought each other, with the model of mutual cannibalization leading to huge (or “yuge”–I am not sure which adjective applies here LOL), generic drug companies. And for a while, their claims of bigger manufacturing efficiencies preserving cheaper prices lulled us into naive ignoring of what this trend really meant.

By 2014, a new trend had emerged in price gouging. But first, to entities that did not hit the consumer individually so directly, but rather to the national drug middle man, the national drug store chains, the pharmacy entities selling to the national managed care companies. Those entities initially bore a fair amount of the early years of price increases, trying to retain subscribers, large health plans and to stay competitive. And we consumers let them fight the battles, absorb the sting of increasing costs and happily assumed the behemoths in the healthcare ‘industry’ that we no longer comprehended would duke it out and protect us.

I cited the year 2014 above as a sentinel boundary because in that year the first big anti-price fixing lawsuit came to be brought against the real culprits, our former friends, and beneficiaries, the generic drug manufacturers and marketers.

It turned out that those companies had morphed into the typical monopolistically large company. It seems that often when companies reach a certain enormous critical mass in their particular marketplace, they start to take advantage of their size and try, and often succeed, in controlling their marketplace. They eat up more of their competition and eliminate their rivals, removing that usual checks and balances set of economic controls attendant to free-market competition. And they can do so, since if they in the class of company Death Stars, they usually possess enormous cash reserves and can dominate the forces in their marketplace, such as advertising, opening large numbers of stores, etc.

And, then they start to look for other means of expanding their economic dominance outside the application of ordinary marketing and production. They start to work with the few remaining equally dominant rivals in their industry by working to set the prices of their goods MUTUALLY. In other words, price-fixing. And this started to happen in the generic drug industry. And by 2014 the lawsuits by states and the Federal government’s corrective enforcement bodies started.

And the depth of price-fixing was bold, audacious and as bad as the scandals around the price of Epi-Pens and other medications that lit up the ire of the public in the past several years. Expect that it involved hundreds of generic medications and dozens of generic manufacturers. The cost to the public began to be conservatively calculated as running into the many, many billions of dollars.

An explanatory article from a litigation firm offers just about as good an explanation as I have found regarding this whole mess. It also defines for readers not familiar with the generic drug world, the in’s and out’s of the terms and the relationship of brand name drugs, their patent lives, and the generic drugs.  Generic Drug Price-Fixing Lawsuit, from the firm NastLaw.

A listing of many of the firms involved in the price-fixing include several well-known names that are indeed giants in generic medicine pharmaceutical constellation:


  • Mylan Pharmaceuticals
  • Teva Pharmaceuticals
  • Actavis
  • Heritage Pharmaceuticals
  • Impax Laboratories
  • West-Ward Pharmaceuticals
  • Par Pharmaceuticals
  • Aurobindo Pharma
  • Mayne Pharma
  • Lannett
  • Sun Pharma
  • Upsher Smith Laboratories
  • Mutual Pharmaceuticals
  • Sandoz
  • Perrigo
  • Fougera Pharmaceuticals
  • Taro Pharmaceuticals
  • Dr. Reddy’s Laboratories
  • Zydus Pharmaceuticals

As usual, I like to offer the reader-selected news pieces that report on the trends and phenomenon that I ardently discuss. One recent article, Price of an OCD drug jumped 1,200%. State attorneys general blame price-fixing focuses on an old psychiatric drug, clomipramine. When it came out it was moderately costly but then it went generic relatively early in its life as it had been an old drug on the research shelf of forgotten drugs [a fascinating story by the way]. Then it was caught up in this national price-fixing orgy by the generics. This report cited above, very aptly illustrates what happened in many instances of recent generic price-fixing.

A notable issue is that this drug was not tossed on the heap of many other old generics and lost in a puddle of several look-alike drugs. Clomprpamin had special, money magnetizing features. It was one of only a few drugs that worked on its condition, OCD, or obsessive-compulsive disorder. It had a large target patient cohort, millions. It had proven itself and a huge number of patient-consumers were already happily taking this prescribed drug that was a miracle in their lives, freeing them from the truly ghastly confines and disabling, total life-disrupting clutches of OCD. And their psychiatrists utilized this drug in confidence and medical subscription of it was not universal but very very high, as good old Prozac also helped a minority percentage of OCD patients.

Currently, the investigations [such as: EXCESSIVE PRICING OF OFF-PATENT PHARMACEUTICALS: HATCH IT OR RATCHET? by JENNIFER L. GRABER, New York University Law Review, Volume 92, Number 4, October 2019; and In the United States District Court for the District of … –] attendant to these various gargantuan anti-trust, price-fixing lawsuits are completed and their fascinating reports are easily available online for any curious reader. The suits are starting to draw to their conclusions. Some of the investigations were aided by some high-level drug company executives involved in these massive fraudulent conspiracies, have turned “state’s evidence,” and cooperated with the plaintiffs.

So now, several dozen generic drug companies, stand apparently close to receiving severe penalties. Judges sound ready to affix verdicts that in anyone’s view, have to emerge as GUILTY as hell in my view. Fines should be in the hundreds of millions, if not billions of dollars for the biggest. Executives should be fined right down to their golden umbrellas stands and go the jail for years. In my view, their sentences should last through their remaining ‘prime’ years of earning power as business moguls and they should be barred from every business and manufacturing-related type of employment except fast food grill production or manning/personing the picker line of recycling computer components for precious metals [to lend their ‘positions of penalty’ some glamour].

So, stick around your favorite business news sources. In the not too distant months to come, we shall likely hear the verdicts that I hope will inject marketplace competitive corrections into the not so level playing field of generic medication pricing for the last 15 years or so of price-fixing tricksterism.

Another correction that needs to be reinserted into our national marketplace of commerce, must/should be the resurrection of anti-trust and anti=price fixing regulatory and law enforcement bodies. We have worshipped at the false idol of total de-regulation for nearly 40 years and it has cost us dearly.


Continue reading “Generic Drug Houses Face Price-Fixing Lawsuits”

judge Frank M. Johnson of Alabama Federal Court
Judge Frank M. Johnson, Pioneering Alabama Federal Judge in Civil Rights and Right to Treatment Case Law



Recently I became aware of the pioneering legal decisions concerning mental health reform that began in the 1950s and 1960s continuing really through the end of his very long legal career on the federal bench of Judge Frank M Johnson of Alabama. He was a pioneer most well-known for his decisions in the field of civil rights. In the decades since his name pioneering legal decisions and forward-thinking ideas that basically led to the basis for federal interventions and sweeping of desegregation across the self especially in the 1960s. Some people still remember the difficulties in the Kennedy administration and integrating both public high schools elementary schools and perhaps most famously the state university systems in Alabama and Georgia. Many people remember Gov. George see Wallace’s famous stands on the steps the University of Alabama buildings in which he proclaimed to television in the world beyond his stance of, “Segregation now, Segregation tomorrow,  Segregation forever.” Judge Johnson’s decisions in the 1950s, and for decades later throughout his long federal judicial career, virtually quashed the legal and institutional resistance in the South and correspondingly nationwide, to public school and university level segregation practices. However, I became aware a few months ago, demonstrating a hole in my grasp of psychiatric – legal histories, of the role of this jurist in the very famous initial decisions regarding mental health hospitalization and more tellingly the right to treatment. In one decision the most famous of all, Wyatt versus Stickney he went on to write the standards for the first time of the delivery of mental health care in state hospital institutions.

Career of Judge Frank M. Johnson and His Legal Opinions
The career of Judge Frank M. Johnson and His Legal Opinions

Note: for more information on these two pictured books, please click through to Amazon [note I do NOT receive any remunerative ‘kickbacks’ from Amazon if you purchase; these are for your educational edification only]



The Wyatt order of 1971 defined adequate care and treatment as comprised of three areas: a humane psychological and physical environment; a certain number of qualified staff; and individual attention.

One reference that is a good explication of the then newly emerging concept of the “right to treatment” by Kathryn Glass of the University of Michigan Dept. of Social Work is the following:  An Examination of “Right to Treatment” Standards: Mental Health Policy within the Context of the State Hospital System by Kathryn Glass

The Wyatt standards were designed to meet what the district court called the three “fundamental conditions for adequate and effective treatment”: “(1) a humane psychological and physical environment, (2) qualified staff in numbers sufficient to administer adequate treatment and (3) individualized treatment plans.” See Wyatt v. Stickney, 334 F. Supp. 1341, 1343 (M.D. Ala. 1971)

This case began on October 23, 1970, when patients at Bryce Hospital, a state-run institution for the mentally ill in Tuscaloosa, Alabama, filed suit in the United States District Court for the Middle District of Alabama against the commissioner and deputy commissioner of the Alabama Department of Mental Health and Mental Retardation (“DMH/MR”), the members of the Alabama Mental Health Board, the governor of Alabama, and Alabama’s probate judges.1  These patients alleged that the conditions at Bryce Hospital were such that they had been deprived of their rights under the United States Constitution.2

On March 12, 1971, following a hearing on the plaintiffs’ application for preliminary injunctive relief, the district court found that patients at Bryce Hospital were being denied their “constitutional right to receive such individual treatment as will give each of them a realistic opportunity to be cured or to improve his or her mental condition.”3  Wyatt v. Stickney, 325 F. Supp. 781, 784 (M.D. Ala. 1971). The court ordered the defendants to devise and to submit to the court for approval, a plan to bring the hospital into compliance with constitutional standards of care.

Several months after the district court’s decision, the plaintiffs were given leave to amend their complaint to include allegations of constitutionally inadequate treatment at a second state-run hospital for the mentally ill, Searcy Hospital, in Mt. Vernon, Alabama, and at Partlow State School and Hospital, a state-run institution for mentally retarded persons in Partlow, Alabama.4  Following this amendment, the court’s order of March 12, 1971, was made applicable to the Searcy and Partlow facilities.

After the defendants failed to formulate “minimum medical and constitutional standards” for the operation of the three institutions, the district court, on April 13, 1972, established what would become known as the “Wyatt standards,” which set forth several specific requirements for the adequate treatment of both mentally ill and mentally retarded individuals.5  The court enjoined the defendants to implement the standards. See Wyatt v. Stickney, 344 F. Supp. 373, 378-86 (M.D. Ala. 1972) (Bryce and Searcy Hospitals); Wyatt v. Stickney, 344 F. Supp. 387, 394-407 (M.D. Ala. 1972) (Partlow State School and Hospital).6  The former Fifth Circuit affirmed the district court’s injunctions in 1974. Wyatt v. Aderholt, 503 F.2d 1305 (5th Cir. 1974). It upheld under the Due Process Clause of the Fourteenth Amendment the plaintiffs’ constitutional right to treatment and affirmed the standards that were promulgated by the district court. In 1975, the district court, with the agreement of the parties, amended its 1972 injunctions to apply the Wyatt standards to all DMH/MR facilities.7

Judge Johnson’s own cobbled together standards for minimum staffing numbers for a group of 250 patients in a state hospital [did not apply to private psychiatric hospitals]  was as listed below:

Classification                                                 Number of Employees


Unit Director 1
Psychiatrist (3 years’ residency            2
training in psychiatry)
MD (Registered physicians)                   4
Nurses (RN)                                                   12
Licensed Practical Nurses                       6
Aide III                                                             6
Aide II                                                               16
Aide I                                                                70
Hospital Orderly                                          10
Clerk-Stenographer II                              3
Clerk-Typist II                                             3
Unit Administrator                                     1
Administrative Clerk                                  1
Psychologist (Ph.D.) (doctoral
degree from accredited
program)                                                         1
Psychologist (M.A.)                                     1
Psychologist (B.S.)                                      2
Social Worker (MSW)                                 2
Social Worker (B.A.)                                    S
Patient Activity Therapist (M.S.)           1
Patient Activity Aide                                   10
Mental Health Technician                        10
Dental Hygienist                                           1
Chaplain                                                           5
Vocational Rehabilitation Counselor   1
Mental Health Field Representative     1
Dietitian                                                            1
Food Service Supervisor                            1
Cook II                                                               2
Cook I                                                                 3
Food Service Worker                                   15
Vehicle Driver                                                 1
Housekeeper                                                   10
Messenger                                                        1
Maintenance Repairman                           2

It is easy to realize that judge Johnson’s enumerating of the minimal staffing numbers of clinical and nonclinical employees needed to staff a treatment center of 250 patients was unbelievably revolutionary for its time. No one had ever done this before in quite such detail.  judge Johnson did on his own with almost no experience or knowledge of inpatient psychiatric hospital treatment. He had a few sources to draw upon including those of Judge David Bazelon of the Federal District Court in Washington DC. Judge Bazelon had begun to also formulate standards of care in lawsuits coming out of the St. Elizabeth’s (state hospital) just preceding the filing of the Wyatt versus Stickney case.

Judge Johnson also formulated in this ground breading decision a number of  general standards of care:

1. Patients have a right to privacy and dignity.
2. Patients have a right to the least restrictive conditions necessary
to achieve the purposes of commitment.
3. No person shall be deemed incompetent to manage his affairs . . .
solely by reason of his admission or commitment to the hospital.
4. Patients shall have the same rights to visitation and telephone
communications as patients at other public hospitals. …
5. Patients shall have an unrestricted right to send sealed mail. …
6. Patients have a right to be free from unnecessary or excessive
medication. .
7. Patients have a right to be free from physical restraint and isolation. …
8. Patients shall have a right not to be subjected to experimental
research. …
9. Patients have a right not to be subjected to treatment procedures
such as lobotomy, electro-convulsive treatment, adversive [more modern term would be: aversive] reinforcement
conditioning or other unusual or hazardous treatment. …
10. Patients have a right to receive prompt and adequate medical
treatment. …
11. Patients have a right to wear their own clothes and to keep and use
their own personal possessions. …
12. The hospital has an obligation to supply an adequate allowance of clothing to any patients who do not have suitable clothing of
their own. . . . Such clothing shall be considered the patient’s throughout his stay in the hospital.
13. The hospital shall make provision for the laundering of patient
14. Patients shall have a right to regular physical exercise several
times a week.
15. Patients have a right to be outdoors at regular and frequent
intervals. . ..
16. The right to religious worship shall be accorded to each patient
who desires such opportunities. . ..
17. The institution shall provide, with adequate supervision,
suitable opportunities for the patient’s interaction with members of
the opposite sex.

These standards of care are now part of the national lexicon and taken for granted in all mental health treatment circles. They came to be incorporated by national accreditation bodies such as the joint commission for the accreditation of hospital organizations or JCAHO as it is known. Judge Johnson single-handedly changed the landscape of inpatient psychiatric treatment forever in the United States and his contributions cannot be overestimated.

Judge Carlton Reeves
Justice Carlton Reeves, Current Pioneering Federal Justice in Mississippi

More recently I’ve become aware of another jurist on a federal appeals court in the state of Mississippi, Judge Carlton Reeves. This man has continued these kinds of decisions on the mental health front in the state of Mississippi, virtually having to revisit decisions of 50 and 60 years ago by Judge Johnson and continue to require the state of Mississippi to live up to those original standards. Most recently earlier this year he had to fine-tune and bore down on the requirements to deliver adequate,  good enough mental health treatment by quashing a legal maneuver by the state of Mississippi to avoid implementing these basic rules and to end up having to spend more money on the state public mental health system.

Judge Reeves currently is more known for his civil rights decisions and he is very recent decisions striking down discriminatory laws against LGBTQ persons and most especially, is striking down in the last few years and at the time of this writing, the third week of May 2019, Mississippi’s extremely strict post six week abortion ban.

Judge Steven Leifman
Judge Steven Leifman of the Florida Eleventh Circuit

Yet another judge who is even less well-known is judge Stephen Liefman of the Eleventh Judicial Circuit of Florida, mainly in the Miami-Southern Florida area. Judge Fleishman’s most unique in that he is also trained and former practicing psychiatrist. In his career as a state circuit level judge, he has been uncomfortably faced with the enormous numbers of mentally ill in the homeless and incarcerated populations in the modern United States. He has publicly estimated in years past that in his judicial area of assignment over 20, 000 people at any one time who are in the jails are mentally ill. He has begun a court-based intervention program, the Eleventh Circuit Criminal Mental Health Project. This program was begun in 2000. It now provides mental health assessments and diversion from the jail settings, treatment through community mental health centers, and a continuum of care that ranges from inpatient to community housing placements. This program has been another model for the nation trying to divert mentally ill persons away from the sinkhole of jails and prisons at all levels.

It is still disheartening to realize that since the 1950s and 1960s this country still has had to rely on brave jurists like these three examples, to compel states to provide minimum standards of care for the severely mentally ill. This does not speak well of the concept of states’ rights and has forced the continued imposition of federal mandates to ensure humane efforts in public mental health care.




Credit to the Cherokee, Doing Everything Right

Secrecy Surrounding Proposed Maine Private Psychiatric Facility

A recent newspaper article from the Associated Press of August 13, 2018, just a week prior to the posting of this article by Marina Villeneuve, highlighted an interesting development in the state of Maine. This psychiatric commentator felt this was worthy of attention on a larger stage as it illustrates several issues regarding the continuing struggles in this country to try to come to terms with our three decades old national mental health service delivery crisis.

The article entitled, “Company fights to keep details of Bangor psychiatric home a secret,” concern the efforts of the Republican governor of Maine Mr. LePage and a Florida-based company, Correct Care Solutions, to keep secret the disclosure of its contracts, legal arrangements, staffing patterns and cost proposals surrounding the construction and operation of a 21 bed “residential psychiatric home” apparently for less acute psychiatric adult patients. This psychiatric residential home is to be operated by this private corporation for at least 10 years. It is to be located on the state campus of the Dorothea Dix Psychiatric Center in Bangor Maine for “some psychiatric patients who no longer need hospital care.” It appears as though there had been openly shared cordial agreement among the “Governor, lawmakers and (mental health) advocates” that the “secure residence could shorten waiting lists and ensure millions in jeopardized federal funding for a state psychiatric center that had lost federal certification” (in the recent past).

However apparently in the recent past, the previously shared intentions aims and objectives among the parties in Maine had run afoul of Correct Care’s wish to keep many of its issues, past history and proposals surrounding the construction of this facility secret. In spite of the fact that the company was notified by state agencies that all its proposals would be public documents, the company submitted many of its proposals amid expected secrecy or ‘confidence’ as the company termed it. But it did claim publicly is that its facility would cost taxpayers less in day-to-day per patient cost than the state’s two inpatient psychiatric centers. This is not a startling proposal as inpatient care is always much more expensive than non-hospital-based nonacute level care.


Continue reading “Secrecy Surrounding Proposed Maine Private Psychiatric Facility”

National Shortage of Mental Health Providers

The national mental health provider shortage, especially of psychiatrists, continues unabated. More and more large mental health organizations are now joining the national vocal chorus highlighting this decade and a half (in my own estimate) crisis.

The article I read of August 15, 2019, by Brent Johnson, which stimulated my thoughts on this shortage,”More people know they need mental health services, but facilities cannot find staff to treat them,” was published in a regional business-oriented periodical “ROI” (I guess for Return on Investment). The article featured thoughts from the CEO of a local, regional New Jersey mental health provider agency, Robin’s Nest, Mr. Anthony DiFabio.


Mr. DiFabio is well positioned to speak authoritatively on these issues. He is also board president of the New Jersey Association of Mental Health and Addiction Agencies.

He details that all types of agencies in all service sectors are having enormous troubles recruiting and maintaining practitioners at all levels of expertise, training and professionals. This goes beyond the all too well known national shortage of psychiatrists. Psychologists, social workers, and counselors-therapists at all levels of training from bachelors to master’s level are increasingly hard to recruit and retain. One issue he highlighted I was less aware of, was that agencies now have significant retaining practitioners due to staffers leaving for other positions in other areas of work. Salaries again are touted as causing losses of staff on a continuing basis. I have this as social workers and psychologists, especially the younger ones to their professions, leave public mental health jobs for more lucrative positions, especially in federal systems.

Continue reading “National Shortage of Mental Health Providers”

The Largest Psych Hospital in America, Psst. It’s A Jail…

A couple of years ago I wrote a post in another blog about the incongruity that the Harris Co. Jail in Houston TX was the country’s largest inpatient public psychiatric hospital in disguise. This week an article in the local Houston press reminded me of Houston’s Harris Co. Jail ‘claim to fame:’Houston’s biggest jail wants to shed its reputation as a mental health treatment center
Ever the trickster brother even in my elder years, at that time, I actually brought this to the attention of my non-mental-health-issues-aware sister who lives there. I would tease her and ask her to arrange a tour for me there when I had an upcoming visit. I laid the teasing on thick, adding a hint, dear to her heart, that I might consider moving there since Harris County Jail was advertising for psychiatrists to work there, and a large number, FIFTEEN back then.


Everyone seems to have heard about Rikers Island prison in New York City and its horrors, overcrowding, deaths etc. I suppose it does not help Rikers’ public image much since it has been mentioned in every episode of Law and Order for over 20 years on television. And I further suppose Harris County Jail has been happy to fly well under Rikers’ blip on the national consciousness radar.

Another acquaintance of mine in the Houston who is in government tells me the officials in the area governments are very sensitive to stories like this about their county jail and do not want it lumped together with other infamous jails such as Cook County (Chicago), Los Angeles, Phoenix, etc. And who can blame them? A quote from the article brought to me by my trusty Google Search New Bots hinted at this sensitivity: ” The Harris County sheriff’s office doesn’t want its jail to be the largest mental health facility in Texas anymore.”I must preface my coming complimentary remarks about Texas’ efforts in the state’s jail systems by stating that in my estimation, Texas is one of the several states in the country that is making huge and creditworthy reform efforts on many fronts in their entire state’s mental health care delivery system.  The legislature formed a task force on mental health in 2014-5, and it actually DID something. It issued a very comprehensive report in a year’s time. It is a piece of landmark analysis and goals. And, to top it off, the state legislature in Texas started drafting and passing concrete reform legislation. They started talking about spending up to $500M initially in a few years to get the massive, multifaceted statewide effort underway. It was all the more amazing since the Texas state legislature was the same body that had a number of its legislators hide in motels across state lines in another state to avoid a politically contentious vote several years ago. It was the laughing stock of the country for a week or so as all kinds of media and Internet games and memes started about where the missing lawmakers were. Pseudo rewards were offered. Petitions were started by wags and satirists to rename the missing officials “Waldo.” Kinky Friedman the inimitable  Texas satirist and sometime candidate for the Governorship had a field day. Molly Ivins, the late great political satirist of Texas, was said to have been sighted in the Legislature and her newspaper’s offices. It was great theater.

The Harris Co. Jail has a triaging setup that is situated RIGHT AT the front intake booking desk. A trained officer with a communicating wireless tablet can consult with a nearby consulting psychiatrist to start the referral process form evaluation and treatment within the jail complex. Harris Co. Jail has decided that it will not pursue a mental health “diversion” program like many other judicial systems have started. In point of fact, Texas has started dozens of pilot diversion programs in counties elsewhere in the state. This model is felt to fit better in smaller counties with much smaller local jail populations.

So rather than having the ‘diversion-referral process start in the courtroom, this process is situated at the receiving desk of the jail. The model is structured so that the staff, from the trained deputies to the consulting mental health providers (from counselors to psychiatric social workers and psychologists to the close-by psychiatrist) on down, have a more vertically integrated and functional system that makes sense. It can be activated for any arriving inmate right at the first contact within the jail. It is certainly a novel approach and should be studied and likely tried elsewhere.

The jail has its own inpatient unit, the Harris County Psychiatric Center, which has nearly 300 beds. This is filled all the time and has a waiting list from the rest of the jail’s population. The jail as a whole, has long known that 1 in 4 or its total population have mental illness and need medication based psychiatric treatment and management. Nationally, over 400,00 inmates have psychiatric illnesses needing ongoing treatment, a staggering number.

Texas’s and Harris County’s efforts are to be applauded, followed closely and studied. Hopefully, it is a sign of things to come.


The Crusade of Virginia Legislator Dr. Craige Deeds PhD

Mental Health Crusader, Dr. Craige Deeds PhD
State Senator Craige Deeds PhD

Modern life, it seems, may bring to us at times, more than our share of tragedies. A person who has suffered and endured what I consider the most painful such loss in recent memory, is Dr. Craige Deeds Ph.D., a clinical psychologist in Virginia. He is also a Virginia state legislator who has dedicated himself more than ever, to the cause of reforming and improving mental health care delivery in Virginia. He lost his son in 2013 when his then schizophrenic son, committed suicide after trying to stab his father Dr. Deeds. Dr. Deeds had endeavored to hospitalize his son after that incident but somehow in the whole state, there were no beds for his sons, a circumstance I cast a very skeptical eye upon, with my own suspicions as to why none could be found at all. His son was treated for four days with medications in an ER and then had to be released when he had calmed and was no longer deemed dangerous. Four days later, he suicided.
Dr. Deeds faced this tragedy and turned his tragedy and sorrow into something positive which is about the only thing one can do. He redoubled his previous efforts in mental health legislation and singlehandedly almost has nudged the state of Virginia into enacting and putting into place several well thought out reforms, changes and additions to the state’s public mental health system. The first reform was a long needed statewide registry database of open psychiatric beds. This enabled mental health professionals and law enforcement officials and courts to place quickly acutely ill persons needing urgent inpatient psychiatric care, into hospital beds. One radical aspect of this law and change was that private psychiatric beds were mandated to be included. This prevented private psychiatric units from refusing involuntarily committed patients or unruly persons from being rejected out of hand for admission.
The reader is referred to a very recent article on the website of a CBS tv affiliate in middle southwestern Virginia, Bath County, “Lawmaker, nearly killed by son, works to improve mental health care in Virginia.”
Dr. (State Senator for his second title) Deeds has labored mightily to take one broad, large, unwieldy state-wide system issue in Virginia’s broken system of public mental health services delivery after another. It can be easily said that he has done what no one else has done, and accomplished as a result of these efforts, more than any other single person in this country. I regard him personally with utmost respect as our present modern day personification of the great reformer, Dorothea Dix. One of the things that Dr. Deeds has done, has been to cross the political aisles in his state. He has brought the two feuding political parties together in a common effort and fashioned a new alliance that has passed a set of legislative advances for over 3 years since his efforts began to take off in 2014.

Continue reading “The Crusade of Virginia Legislator Dr. Craige Deeds PhD”

A State Hospital Loses Accreditation

In a recent article entitled, “US: Care lacking at troubled Washington psychiatric hospital,” that appeared in many Northwest and national USA news sites and sources, the continuing troubles at Washington state’s Western State (psychiatric) Hospital were documented. Speaking as a psychiatrist that recognizes both the still present need for inpatient psychiatric beds and treatment, as well as the past history of state hospital abuses, I am again troubled by the travails of this hospital.


Western State Hospital in Lakeland Washington state, USA

For the reader, I wish to add a little background. This hospital is very large, over 800 beds and serves a rather large if not huge area as big as some countries. It has had all kinds of troubles over the last several years. It almost lost its federal hospital accreditation a few years ago. Loss of such endorsement in the USA means that a hospital is not able to bill for services rendered to patients through the American-federal insurance entities of Medicare (for American elderly) and Medicaid (for the American poor, those on “welfare,” the derogatory term in the USA for aid to the poor).

The news detailed that this hospital will lose up to $53M in the coming financial year which runs from July 2018 until the end of June 2019. That, in turn, means that Washington State will have to make up that money to the hospital to keep it running. And for the wondering reader not well acquainted with the American health care system, such a public hospital can NOT close. Services of psychiatric care cannot stop for obvious reasons.

The article referenced above gives a good deal of the history behind this unfortunate development which I will not go into. I wish to give the reader some semblance of explanation of why this has happened. The reader will need to have a historical viewpoint. The problems of this hospital did not start a year or two back…They have been longstanding to say the least.

Like many state hospitals in the USA, Western is located out in the countryside, quite a distance, meaning usually up to a hundred or more miles from the nearest urban area. This means that the labor pool un its area, including its home city, has a quite small metropolitan area from which to draw employees for hire. And this state hospital like most, has to employ hundreds of health workers. My own state hospital of my employ has 1,200 employees!

As a corollary in our modern society that now is overwhelmingly city based with all the ‘amenities’ thereof, is a harder sell to prospective employees. Few persons want to uproot themselves and move to a much smaller city or town and give up the modern shopping centers and such.

Currently, salaries for the professional working class are moderately lower in state psychiatric hospital settings than comparable urban areas. For nurses, physicians, physician-psychiatrists, across the economic board. Western State Hospital has long had psychiatrist shortages and nurse shortages. A few years ago the hospital had to suddenly close wards totally a hundred beds or so. No psychiatrists to see the patients…The salary issues had prompted several, ?seven or so, to move themselves and their skills to a VA (Veteran’s Administration) hospital in another part of the state because the VA hospital pay was SO MUCH HIGHER. Western State could not compete.

Another issue that has hurt Western is that the hospital structure itself is housed in a building that is many decades old, some dating back to the late 1800’s. This circumstance is actually NOT all that unusual in the USA. Most of the American state hospitals originated in the state hospital building boom after 1870 or so. [My own state hospital’s main building just a connecting walkway away from the building I work in, was built in1875. It is a gorgeous building that fortunately has been masterfully maintained].

Washington state’s governor, Jay Inslee, has labored mightily for several years to help correct the situation. He has worked with the previously reluctant legislature to increase funding which still needs far more generosity on a permanent basis. Implicit in this last sentence is a hint. Psychiatric state hospitals in the USA have long been underfunded.

Worsening this chronic pattern has been that in the last 20 years or so since the first ‘recession’ of the dot com era’s origin in 1999, states’ tax intake has shrunk. With each wave of recession in the American economy, states in the federal union that is called the United States, have had to drastically tighten their budgets. Public healthcare including state psychiatric hospitals, highway construction funding, financial initiatives in public transit, and education have taken very significant hits.

The results have been the kinds of delayed consequences that are exemplified in Western State Hospital’s evolving plight resulting in its delayed de-accreditation. This slow train wreck in public state hospitals is developing at a number of other state psychiatric hospital systems. Few states are doing what it takes to rebuild, revamp and replaces their aging, falling down facilities. The solution in the majority of states especially in the Northeastern United States has been to close many facilities. This has had the predictable result of throwing hundreds of essential inpatient psychiatric beds into thin air. And this is where the huge increase in mentally ill came from that now occupy jails and are homeless on cities’ streets.

So another basis for the de-accreditation has been that the physical plant of Western is so old and faulty that buildings are not safe and are hazards to residents and employees’ well being.