This examiner has been following the state of Virginia’s efforts to reform its public mental health care delivery system for a number of years. This professional and personal interest of mine was accelerated and intensified after the tragedy of Dr. Creige Deeds several years ago when his schizophrenic son had a relapse of his psychosis and stabbed his father who is both a veteran Virginia state legislature or an actively practicing clinical psychologist. By way of short review for those readers who are not familiar with the situation, I will recap it as briefly as I can. Dr. Deeds endeavored to have his son hospitalized emergently but at that time in 2013, Virginia had a very dysfunctional statewide system for ensuring timely emergency hospitalizations of people in a mental health crisis. For a variety of factors, all of which from my point of view is bad and inexcusable but are found all over the country, Dr. Deeds’ son Gus could not be emergently hospitalized for ongoing treatment. He spent several days in his local hospital emergency room and the practitioners there instituted stopgap emergency treatment resuming some sort of antipsychotic medication regimen but then had to discharge the then 23-year-old psychotic son (and to this date I still do not know specifically how much of a symptomatic remission was achieved in the son Gus at the time of his release from that hospital’s emergency room surface). In any case, the son then tragically suicided successfully a few days later. The father Dr. Deeds, to his credit, began to very responsibly undertake in his dual role as a mental health skilled practitioner and state-level legislator, a very long term bipartisan effort to spur Virginia’s state legislative body into addressing the grievous holes at all levels in Virginia’s state psychiatric mental health care delivery system.
One of his accomplishments was to help craft and see the passage of the law that instituted a statewide database registry of all empty inpatient psychiatric beds in both state and private psychiatric facilities. Further, this law mandated individuals in mental health psychiatric crises, after being evaluated and confirmed as needing emergency hospitalization, had to be accepted by private psychiatric facilities if they had available beds in any part of the state, and further to provide transportation to a facility that had an available inpatient bed for such a patient.
This mechanism has been in place for several years and by all accounts has helped a great deal. However, it cannot address the ongoing issue of the fact that Virginia still has a relative shortage and an absolute shortage of inpatient psychiatric beds both in private services and especially at the state hospital level. Private psychiatric beds have been in decline in Virginia just like in every other state in this country, for at least 20 years. Part of this is, of course, do to the fact that inpatient psychiatric hospital services lose money hand over fist for just about any private entity whether University medical center-based, community hospital-based, or large private hospital conglomerate based. Until the last very few years, private hospitals certainly have not been expanding or constructing new inpatient psychiatric units. There have been notable exceptions in a small number of states. For instance in Iowa, the four cities or Quad cities area as it is called, have seen a number of private hospital systems banding together and opening new inpatient psychiatric units in novel cooperative financial and bed-sharing arrangements. Similar efforts have begun to happen in other states that have a critical mass of population sufficient to furnish psych patients at adequate numbers. Some states have seen University medical centers renovate or open new psychiatric units in spite of the financial disincentives that still exist largely having to do with the low rate of financial reimbursements for inpatient psychiatric services. One example is the Seattle Washington area. New medical schools that have come into being in a few states, especially those that are dedicated in their missions to serve their local communities in areas, have seen fit to open new psychiatric residency training programs to begin to turn out desperately needed new psychiatrists. To become accredited nationally in order to start these psychiatric residency programs, they have had to, but also have willingly opened new inpatient psychiatric treatment services in their areas of operations which is all to the good.
Back to the state of Virginia and this discussion.
Virginia like virtually every state in the union here in the United States, overall still has too few inpatient psychiatric beds of any kind whether public or private. And the dreaded phenomenon of “psychiatric boarding” in local hospital emergency rooms has continued. For the international reader or American reader who is not quite sure what this phrase refers to, psychiatric boarding means that psychiatric patients in emergency rooms being referred for urgently needed inpatient psychiatric care may have to wait for days or weeks until there is a psychiatric bed available somewhere. In many states, state and federal level courts have outlawed this practice, declared it virtually unconstitutional, and have actually rendered statewide level judgments with rather large monetary fines because of the persistence of this practice. This is no small insoluble riddle since this is a systemic problem and in areas where sufficient inpatient psychiatric beds simply are not available, there is no immediate solution.
But two patient populations are hit especially hard by the issue of scarcity of appropriate inpatient psychiatric beds. These two populations are the elderly experiencing acute psychiatric crises, and children and adolescents. In almost all states in this country, there still are not enough beds for the elderly and youth. Within the elderly population, there is a subpopulation that is even more poorly served. This subpopulation is the demented – psychotic elderly.
The state of Virginia currently has one main geriatric psychiatric state hospital facility. As one might expect since this facility serves the entire state it runs full all the time. This is not a new phenomenon and other states share this systemic difficulty. And it is easy to see why.
One of the very large state hospital patient populations in this country since the late 1800s was that of the mentally ill and/or demented elderly. They were also a patient population who suffered some of the worst physical, medical, and civil rights abuses for decades in those facilities nationwide.
The blunt-hammered legally driven solution beginning in the 1960s with the state hospital reform movement was that of deinstitutionalization, closing of state hospital beds and trans-institutional transfer of the elderly largely into nursing homes in the last 50 years. This so-called temporary and very imperfect solution finally began to be curtailed approximately in the 1990s in this country as nursing homes began to be regulated and have their care reviewed and upgraded by legal mandate of the mentally ill – the demented elderly psychiatric patients within their settings. For instance, nursing homes came to be regulated and not permitted to cross a certain threshold of numbers of psychiatric patients within their facilities. This had the effect of reducing the numbers of mentally ill elderly who could be stuffed into nursing homes.
Similarly as a result of the Omnibus reconciliation budget act that was initially enacted under Pres. George H. W. Bush Sr. and finally fully activated in 1997, the use of psychotropic medications especially benzodiazepines and antipsychotics were severely regulated and curtailed in the nursing home setting. This had the unintended effect of making nursing homes ever poorer places for the treatment, management, and housing of the psychotic elderly patient. This was largely dependent on the treatment philosophy of the medical and nursing staff of any given nursing home. If they were particularly zealous in the beginning, to arbitrarily curtail the use of psychotropic medications, care was altered in deleterious ways. What would happen is a nurse administrator, or an independent nurse family practitioner or nursing physicians assistant or the medical physician director of the nursing home would arbitrarily begin to stop the administration of these medications because a reviewer would call attention to their utilization. These care reviews always carried with them the institutional-bureaucratic admonition to decrease their utilization. Over time without these medications, these elderly patients with a history of psychotic psychiatric illness of any sort would sooner or later become acutely psychiatrically symptomatic and of course, need discharge, and transfer to some nearby inpatient psychiatric unit.
Now I am a board-certified geriatric psychiatrist since the early 1990s. I was fortunate enough to be empathically trained during my residency years in working with elderly patients. I have consulted in nursing him settings throughout my entire career no matter where I have lived and practiced. I have to say that the following, which sounds kind of bad in certain ways and could be viewed as biased and perhaps pejorative, nonetheless reflects my honest experience in a number of nursing home settings that indeed rendered very good care.
Nursing homes who did not like working with chronic psychiatric elderly patients tellingly would permit the resumption of psychiatric psychotic symptoms in their elderly patients all too willingly through this mechanism that was always bureaucratically correct. It was not lost on me that this reflected everyone’s distaste for psychiatric issues and psychiatric patients which is a prejudice still widespread even within treatment communities. And of course, I was a firsthand witness to the fact that when these patients often were denied readmission at their previous nursing home placements.
I remember many exceptions to this rule and wish to name two of them on purpose because of their wonderful non-prejudicial commitment to their patients. One was the very first nursing home that I consulted to for approximately 15 years in Durham North Carolina after I had finished my psychiatric residency training. I was fortunate enough to be asked by the then medical director of this facilities medical services, the wonderful Dr. Eugene Stead MD the long-standing chairman of the Department of medicine at the Duke University Medical Center to be his psychiatric consultant at this nursing home facility. He had a reputation as the most exacting and fearsome medical instructor who had been recruited in the early 1960s from Johns Hopkins School of Medicine in Baltimore to put Duke Hospital’s Department of medicine on the national map competitive with Harvard, Johns Hopkins and all the other great powers in internal medicine. Duke was always nicknamed the” Harvard Medical School of the South” and it certainly achieved that in a very short period of time under the leadership of Dr. Stead and many other chairpersons of surgery, neurosurgery, pediatrics, etc. But I found Dr. Stead to be a very gentle and empathic physician in his role with the geriatric patients at this facility, the Methodist Retirement Home. This facility had a true continuum of care before this became a politically correct phrase. It had apartments, dormitory rooms with and without kitchens, assisted living dormitory rooms, and initially when I started working there, a small medical hospital which later expanded to well over 100 beds in the 1980s. Dr. Stead was very unusual for his time as he recognized and supported the need for ongoing readily available general psychiatric services for the patients in that facility. I was a new young rookie fresh out of residency training when I began my parallel work with Dr. Stead rounding with him at least two half-days a month throughout the facility providing psychiatric care and management. I learned an enormous amount from Dr. Stead even though he was not a psychiatrist. Early on I realized that this was a miraculous stroke of luck, being afforded this kind of at the elbow of the master training and mentoring. The Methodist RetirementHhome was and still is an incredibly wonderful facility and program. It had a mission of treating and being a retirement home in residence for retired Methodist ministers and their widowed spouses from all over the Southeast. Because of that institutional and wonderful commitment, this facility never showed or displayed antipathy or prejudice to any of their residents who had dementia or psychosis or a combination of both. They always accepted them back if a resident had needed out of facility inpatient psychiatric care usually of course at Duke University Hospital which was just across the road!
The other facility that I wish to name but by no means, not the only other one, was a Cherokee tribal nursing home facility “Tsali Care” of the Eastern Band of Cherokee Indians in Cherokee North Carolina on the Qualla Boundary reservation. Through my three decades plus acquaintance with the Eastern band of Cherokee Indians through my wife’s family most of whom were enrolled members of the tribe, I was fortuitously able to serve as the first full-time psychiatrist at the newly organized mental health and substance abuse service for the tribe from 2007 through 2010. As always, I requested to be able to consult at this nursing home facility and was able to do so. The nursing home there, of course, had an ironclad commitment to all members of the tribe and of course did not, and never would have, displayed any antipathy toward the Cherokee elders in the nursing home setting who had dementia and/or psychosis. The care that this facility afforded its tribal elders was second to none and always left me in appreciative awe of how well they cared for those patients and residents.
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.
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.
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:
Upsher Smith Laboratories
Dr. Reddy’s Laboratories
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.
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.
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.
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.
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
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
Vocational Rehabilitation Counselor 1
Mental Health Field Representative 1
Food Service Supervisor 1
Cook II 2
Cook I 3
Food Service Worker 15
Vehicle Driver 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
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
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
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.
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.
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.
I wish to highlight an article that appeared in the Charlotte Observer this date of publication, March 10, 2019, entitled: For the Cherokee tribe in western North Carolina, America’s drug problem hits home by Thomas McDonald. This documents through the story of a young lady, a recovered opiate user and member of the Eastern Band of Cherokee Indians, the efforts that the Tribe has undertaken for years to address their substance abuse problems. Their efforts are frankly in my view, likely the very best that have been undertaken in any Native American reservation and deserve wide recognition.
It is no secret in mental health and substance abuse treatment circles nationally and in the public mind, that the Native American population in this country has struggled in the last several decades with an enormous crippling addiction and substance abuse problem. For instance, it is long been known that in certain reservations and puts this is been highlighted, up to 50% of Native American adults are afflicted with chronic alcoholism. In the last three decades or so mirroring the invasion of prescription and illegal addicting drugs that have invaded initially larger urban areas in this country, and following the economic and recessionary collapses in the employment industries of urban areas by opiates resulting in our now well-known national opiate epidemic, Native American reservations have not been immune either.
In many ways, the Native American reservations have been incredibly more vulnerable for subtle reasons that are not well understood in majority American circles. For instance, Native American reservations are sovereign federal territories and administered in decades past or ruled over, might be the more appropriate sobriquet, by the Bureau of Indian Affairs. This unfair system started in the 1800s and resulted in the brutal colonial style of rule that prevented Native Americans by large from governing themselves and making their own best decisions in their behalf for decades. This finally began to be reversed in the latter part of the 1900s as various tribes began to restrict the power of the BIA and to rule themselves in matters of finance, economics and healthcare to mention a few. As Native American tribes began to seize upon the opportunity afforded them by almost “loopholes,” in federal law to permit the establishment of tribal-run casinos, the power of tribes began to exponentially increase on their own behalf as they gained more and more autonomous sources of funding separate from the sustenance funds afforded to them through the BIA and federal budgets. These casino funds in tribes who managed well there casino properties and revenue sources, made possible the establishment of many tribal-run agencies that began to operate solely for the benefit of the tribes and were completely administered by tribal figures and governance bodies. Over time the economic goal minds that the casinos afforded, made possible solid revenue streams for tribal improvement from everything from housing to healthcare.
But this did not protect the reservations from the onslaught and invasion of addictive drugs. From the sort of “humble” beginnings of applying and supplying destructively tribal reservations with sources of alcohol to feed and promote and sustain alcoholism for decades, the invasion of addictive drugs took on the characteristics of the entry into those poisons and the rest of American main street life. Outside drug dealers only a few decades ago began to I reservations as new and fertile territory for their goods. And without delay unscrupulous and antisocial figures within tribal populations themselves graduated from selling alcohol and marijuana to opiates and provided unwelcome bridges intertribal life for the distribution of opiates on the reservations.
Tribal reservations were quite vulnerable to these invasions from without and from within. 20 to 30 years ago tribal police forces were still somewhat small and understaffed. The FBI had dominion legally and jurisdiction over major crimes on reservations as this agency was tasked with law enforcement of major crimes. This hampered the ability of tribal police forces to undertake interdiction and law enforcement efforts regarding the opioid epidemic. Gradually tribal police forces were given greater budgets and expanded to meet the invasion of addictive drugs for sale on tribal properties.
The newspaper article that I am highlighting in this article which I commend to every reader of this post moved most highly to follow and read in the Charlotte Observer this date, weekend of March 10, 2019, makes brief mention of the next factor I wish to highlight. On reservations which have their own autonomous tribal sources of income such as casinos or entertainment venues such as the famous Hard Rock Cafe franchise etc., distribution of tribal income funds to all enrolled members takes place usually on a twice a year basis. This is called the “per capita,” or “per cap,” distribution day.
This is a unique phenomenon largely not known to the outside world. It means that every enrolled tribal member will receive so many thousands of dollars twice a year from the tribe and its autonomous revenue source such as a casino franchise. The amount may vary at every distribution date of eight dependent on the volume of business and profit from the casino for instance. Persons who are minors nowadays have their per capita funds automatically deposited in trust funds set up automatically on their behalf administered by their parental guardians. They become eligible to begin to receive these funds for instance, on the Cherokee reservation, after their 18 and graduate high school.
In years past, the per capita day began to attract an influx of illicit drug dealers twice a year for a certain period of time after the monies were distributed. I hate to use pejorative metaphors but I will go ahead in this case to give a bit of emphasis to the power of attraction that these kinds of monies being distributed could have upon vulnerable tribal members. Tribal members who were already addicts would have enormous amounts of monies, thousands of dollars, suddenly in their possession after cashing their per capita check. Illicit drug dealers would set up shop person’s homes, motels both often on the reservation properties and do a land office business selling drugs. Federal authorities, representing agencies such as the FBI and DEA, as well as tribal police began the twice a year interdiction efforts with undercover agents, often Native Americans from the reservation itself and from other tribes would not be known as law enforcement officers to the invading drug dealers. Nighttime arrests would abound and federal courts in cities near reservations would be full for weeks of newly arrested and indicted drug dealers.
The Cherokee tribe for over two decades has made enormous progress in trying to help tribal members manage their per capita funds wisely and be less vulnerable to the preying efforts of drug dealers at per capita time. The Charlotte Observer newspaper article makes mention of a huge effort that has been going on for nearly 20 years in the Cherokee tribe. Disbursements of the per capita funds were restricted and given in increments every five years after one reached the age of majority of 18 trying to help delay impulse spending on drugs by young immature tribal members. Another notable effort that has continued is the requirement of having high school students take budgeting and economic classes in high school to prepare them for the responsibilities of suddenly inheriting tens of thousands of dollars that they had earned throughout their first 18 years of life. The Charlotte Observer newspaper article makes mention of the young lady highlighted who spent tens of thousands of dollars of her per capita funds on drugs after she came of age. This story, unfortunately, has not been all that rare but the tribe has suspended enormous community-based efforts, financial education programs, and financial safeguards to help coming-of-age members manage their per capita funds wisely.
The article further documents that enormous resources that the tribe has spent in the last few decades on mental health and substance abuse treatment efforts. The young lady who is profiled in the article is an example of recovered tribal members have joined the community-based education prevention and treatment efforts of the tribe to address their outsized addiction problem. Of note is the statistic that nearly 50% of adults received some kind of substance abuse related diagnosis several years ago in an epidemiologic health study conducted to track and gauge the magnitude of the problem.
In the early 2000’s healthcare and medical leadership of the Cherokee tribe recognized the need to establish and sustain a substance abuse and mental health treatment service for the tribal members. In less than 10 years such a service was established and began operating with a full complement of substance abuse certified counselors, psychiatric social workers, school-based counselors (which had already existed for several years) clinical psychologists, an on-site clinical psychiatrist, numerous mental health and substance abuse related community-based support groups, and organized comprehensive buprenorphine anti-addiction clinic, and plans for a large residential substance abuse treatment center and plans to convert the original Cherokee hospital into a comprehensive mental health and substance abuse detox and treatment center after completion of the new Cherokee medical hospital facility accomplished a few years ago.
The Cherokee Indian tribe has literally done everything right in my view. They have established one of the most comprehensive, if not the most comprehensive and financially well-supported substance abuse and mental health services of any Native American tribe in this country. Behind the scenes, it is serving as a national example to other tribes send representatives periodically to visit and learn from its set up and accomplishments.
Not every Native American tribe and reservation, however, can be expected to duplicate the incredible set of services at the Eastern and of Cherokee have established in Western North Carolina. Only a minority of Native American tribes have the deep financial pockets that the Eastern Bdate surrounding area Band possesses.
This exists for a number of reasons that are also somewhat unique to the Eastern Band of Cherokee.
First, there existed an entrepreneurial awareness in a number of families in this tribe that started early on even before World War II, a growing tourist-based industry which capitalized on the creation of the Great Smoky Mountain Park during the New Deal era of President Franklin Roosevelt in the southeastern United States that had virtually no competition in that extended geographic region. Out of the nucleus of a number of farsighted families, and over nearly 50 years nascent development the town of Cherokee and Western North Carolina became a huge destination for tourists and their dollars from that entire region.
Second, a larger nucleus of tribal leaders who were very adept businesspeople emerged by the last quarter of the 20th century. This group of leaders forged a very astute bargain the federal government and the state of North Carolina in order to be able to establish, operate and profit from the Harrah’s casino that they started on the reservation. Because they had no casino within the entire southeastern United States, the Harrah’s casino did extremely well making possible the economic and healthcare related development that the Eastern Band of Cherokee Indians has enjoyed.
Consequently, the Eastern Band of Cherokee Indians has not suffered embarrassing public economic catastrophes that other tribes have suffered from establishing casinos in venues with not a lot enough surrounding tourist population to support such revenues or have had so many other casinos nearby that none of them were able to be successful financially.
Still, the Eastern Band of Cherokee Indians and their collective leadership deserve all the credit in the world for shepherding their financial windfalls and resources wisely and benevolently in the service of their members and their unique health care needs. In my opinion, they serve as an example and model that can and should be exported and imitated even in the non-Native American arenas where we continue to fail so miserably in addressing the social and medical problems and needs of our age.
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.
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.
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.
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.