I am a older child, adult, geriatric teaching psychiatrist with over 30 years' practice experience in North Carolina, first at Duke as clnical teaching faculty, then in Western NC as a primary child psychiatry specialist. I have taught and supervised child psychiatrists and psychiatrists in training and many other mental health professionals and taught at two medical schools. I have served in many public and private practice settings. My primary interest is in observing and documenting the ongoing mental health reform efforts in the State of North Carolina and documenting its sucessess and failures at all levels. My favorite pastime among many others is spoofing my friends and kids with my deadpan sense of humor.
In a recent editorial, the Virginia News & Advance newspaper published on May 29, 2016, entitled “Trying to Remake State’s Mental Health System,” Virginia’s commendable mental health reform efforts were enumerated in a concise fashion. Virginia’s efforts are somewhat unique in the country’s landscape concerning this issue which now dominating many American state legislatures.
Virginia’s efforts, similar to a few others states’ efforts, have been singularly prompted by a highly publicized tragedy, that of the death of a young adult, Gus Deeds. What is very different is that his father is a mental health professional, and a Virginia state legislator.
This young man while psychotic tried to stab the father, Craige Deeds. He was held in a local hospital emergency room for several days while awaiting a referral and placement in either a private or public state psychiatric hospital. There was no bed to be had and he was released a few days later. Shortly thereafter, he suicided. His father, state senator Deeds Ph.D. has made this a personal and public service legislative cause and mission to author and see enacted to address the deficits in Virginia’s mental health system to prevent another tragedy.
State Senator Deeds’ efforts have been very well placed and appropriate. However, even he has had difficulty in seeing this well crafted and reasonable legislation passed as the above-cited editorial, unfortunately points out. This is emblematic of many state’s efforts. The limiting factors are budgetary and many state legislatures, governors, and legislators are finding it very hard to find and devote the long needed monies to mental health reform. Some states have made creditable progress such as my home and practice state of North Carolina. But it remains quite hard to address the funding issues in many states that have permitted the development of state mental health system crises that we see presently almost everywhere. One can only hope that these difficulties can be overcome as efforts continue.
In a very recent article, “Mississippi budget cuts to close psychiatric beds,” published in the Clarion-Ledger newspaper on may 10, 2016, it is reported that Mississippi will close a number of treatment units and beds in the state’s public mental health and substance abuse facilities.
The article details that this has come about as a result of the state’s legislature deciding to cut funding by some 4.4% or $8.3M imposed by the current governor Phil Bryant’s yardstick, something called”performance- based budgeting process.”
The article goes on to detail a number of state-funded services that will be cut or reduced in size. Such targeted/designated services include inpatient mental health services and residential and community-based substance abuse treatment programs. The reader may follow the link above to read exactly what services will be trimmed or shut down altogether.
This is a rare opportunity for the concerned mental health/substance abuse services policy wonk, observer of both the national and regional scenes in such matters, to monitor what happens in the coming few years in this locale, the state of Mississippi.
Further, it affords almost an experimental laboratory, to watch the consequences unfold. One will be able to see if this has a positive influence on the overall “mental health of the state,” or negative consequences. To reveal this writer’s own bias from having watched many other states do the same since the early 1990’s, it will test the hypothesis that this action likely will repeat the past history of such efforts , namely to cause predictable negative results.
These results in other states have included: 1) increase in the mentally ill populations in local jails; 2) increased waiting lists in ERs around the state of acutely disturbed public psychiatric patients in crisis who need inpatient hospital services; 3) perhaps an increase in public incidents involving the chronically mentally ill of both a minor nuisance variety or major ones of tragic proportions; 4) increase in deaths of the mentally ill through suicide; 5) increase in the deaths of mentally ill persons through extreme public law enforcement actions due to the more disturbed and the communities not having a timely access to treatment; 6) more grieving families and tales in the local media as time goes on of possibly preventable tragedies; 7) increased strain on private treatment facilities ranging from private hospital based psychiatric units to hospital ERs, to the university medical school based psychiatric services.
The reader is invited to watch Mississippi as this made for observation stage in the ongoing struggle with provisioning public mental health services plays out in the media and locales of Mississippi to see how this turns out. I know this observer will watching with keen interest and growing concern and foreboding.
I became aware of Bridgewater State Hospital during my college and medical school years in Ann Arbor, Michigan through two events in my student life back then.
First, I was able to see the famous documentary movie, “Titicut Follies,” almost accidentally at a university sponsored film festival in 1970 or so. The film was all the rage since it had been “banned in Boston” by the Supreme Court of Massachusetts. It was filmed in 1967 by the now acclaimed filmmaker Frederick Wiseman. I remember not knowing really anything about the movie, but going with friends to see this controversial movie. At that time, I had not settled on a future career in psychiatry. I was stunned at the content of the movie which showed deplorable conditions at a correctional center division of the state hospital located at Bridgewater Massachusted. After I finished medical school, I was
After I finished medical school, I was fortunate enough to land a six-month externship in forensic psychiatry at the Center for Forensic Psychiatry located on the grounds of Ypsilanti State Hospital south of Ann Arbor. This was a state hospital that had become famous in its own right. It was the subject and setting of a famous book, The Three Christs of Ypsilanti, by Milton Rokeach.
The Three Christs of Ypsilanti
The book was ahead of its time, portraying the irony of three psychotic inpatients who shared a unit as well as the common delusion that each was Christ. The book was hit for years and required reading almost in every university in first-year classes in psychology. I had read the book as well and was fascinated by the premise of how these patients handled the dilemma of their common and contradictory claims.
Little did I know that my externship would bring me into contact with the late forensic psychiatrist, Dr. Ames Robey. Dr. Robey astutely had realized and discovered the identity of the “Boston Strangler” as one of the psychiatric inpatients at Bridgewater, Albert DiSalvo.
Albert Desalvo, The Boston Strangler
This brought Dr. Robey national fame and publicity though he had no interests in all media attention. As an aside, I also was able to work under Dr. Elissa Benedek MD, an early female forensic psychiatrist, who was also a child psychiatrist, and a few years later, became President of the American Academy of Child and Adolescent Psychiatry. She was a small bespectacled woman, calm, supportive and incredible teacher, and clinician.
So, these two experiences acquainted me serendipitously with Bridgewater State Hospital. Late last year, Bridgewater State hit the headlines again as stories of abuse, poor treatment, a group of deaths of three men in 2015 were reported in the Boston media. Within months, three guards at the facility were indicted of involuntary manslaughter and the Boston Globe had a documentary series of articles on the all too familiar, decades-old tale of sandals and substandard levels of care. I had actually assumed that Bridgewater State, by this time, had long been closed. Silly me. Like so many state psychiatric facilities, it was very much needed and like an old battleship kept in service for decades. The news about the hospital by April of this year just kept getting worse. To me, it was like somehow seeing an eerie reprise of the movie “Titicut Follies.” That goofy and weird feeling kept me following the news stories that have emerged in the last two months in the Boston Globe newspaper.
How did this hideous story come to be repeated nearly 45 years later? The Boston Globe reported on the slowly evolving, yet almost inevitable conditions that brought this tragic replay back to life in an article in April 2016, this past month at the time of this writing. The usual culprits of legislative neglect through decades of inadequate funding, lack of oversight and installation of a poor level of care, and a herculean task demanded of an institution not properly fueled for its job.
A once famous historical psychiatric institution forced into repeating its own tragic failings because of legislative “neglect” forced into a Kafka-esque re-run reinforcing all the negative stereotypes of a psychiatric institution. This has almost a psychotic quality, all its own, in which the observer, cannot tell reality from unreality…
A very recent article, Colorado Still Lacks Inpatient Psychiatric Care by Ms. Elizabeth Drew published May 10, 2016 documents the same kinds of problems with psychiatric acute inpatient treatment resources that many other states have faced around the USA for the last 15 to 20 years.
Ms. Drew highlights the backdrop that started the mental health reform effort in Colorado so suddenly and starkly. Colorado suffered the misfortune to have the two double tragedies of mass shootings, the Columbine High School tragedy a number of years ago and the more recent Aurora CO theater shootings of 2012 committed by the then clearly psychotic James Holmes, whose trial riveted the nation. The James Holmes shooting caused a huge outcry from the public in that state for major and thoroughgoing changes in mental health services’ delivery.
Colorado has closed two state hospitals due to aging facilities being shut down and not being replaced. Colorado ranks now well below the current statistical average of 14 or so (13.9 in the previous blog posting’s article) per 100,000 beds for public inpatient psychiatric care in the state. Like many other states, its public mental health system has suffered greatly in the past two decades with inadequate funding and lack of growth of services commensurate with its higher than national average population growth. And like many other states, tragedies have begun to ramp up in severity, frequency and publicity as the “chickens have come home to roost.”
This article describes the very ambitious and quite rapid changes in point of fact, that Colorado put into place just last year, only about three years or so after the Aurora theater shooting. A massive state-wide system of acute outpatient crisis centers and much more rapid access to mental health contact, screenings and referrals to treatment resources was put in place. This clearly had a positive effect. Admirably, Colorado has begun a serious open effort to evaluate only one year into the operation of its new system. The results have been mixed and no matter what criticisms or kudos one may choose to endorse. Colorado, in my opinion as a long-time observer of mental health reform efforts nationwide, had commendable courage to permit and undertake this open review process. This review effort, documented in Ms. Drew’s article appears to show two results if I may condense and categorize them: 1) positive results in the delivery of acute mostly outpatient services, and 2) the common bugaboo of the yet unaddressed shortage of acute inpatient hospital beds seen now almost everywhere. Ms. Drew succinctly summarizes the reasons for this as relating to loss and closure of state hospital psychiatric beds and facilities, and, inadequate funding at the state and federal levels of the riddle of the expense of inpatient psychiatric hospital based treatment. [In a coming post I will try my psychiatric hand at explaining why inpatient psychiatric treatment is always expensive].
In coming posts, I will try my psychiatric hand at enumerating other issues common to all states beyond hospital beds that make the current mental health delivery crisis so severe. These issues will include the shortage of mental health professionals especially psychiatrists and the history of some more discrete and largely unknown to the public, mental health training fund losses that have caused our current severe practitioner shortages.
Texas, like many states, has been struggling for the better part of the last two decades with its public mental health system’s needs. Like almost all other states in the United States, it has seen its share of declining state funding for state-wide mental health services. Ageing state hospitals for the acutely mentally ill, chronically mentally ill and developmentally disabled have been closed or downsized. Short-falls have gradually appeared in the provision of outpatient services recommended and hoped for, to supplement or replace those reduced state hospital beds.
Texas for a number of years has begun to experience the enormous increase in jail populations of the mentally ill, mirroring many other states, especially New York with its travails at Rikers Island, perhaps the country’s most famous metropolitan jail facility, serving New York City. Rikers Island has lamentably been in the tragedy borne headlines in the last few years with repeated suicides of mentally ill inmates, and lawsuits by families and repeated efforts at reform and improvement, recently occurring again by necessity under the mayoralty of Bill DeBlasio.
Harris County Jail, of Houston Texas, has become known as one of the largest “psychiatric” facilities in the country. Several years ago I recall that the Harris County Jail had to increase its psychiatrist staff roster from three psychiatrists to fifteen and add a number of psychiatric physician extenders and other staff to serve the needs of this swelling psychiatric segment of the inmate population. What happened in Harris County, encompassing metropolitan Houston, was not unique to the country’s correctional systems at all, but became known readily nationwide as one of the first such settings recognized for this tell-tale barometer of the deficiencies in any area’s public mental health service system. Harris County, on a personal note, is known quite well to me, as that extended area was where my father came from and is where I have my only sibling living all our adult lives.
A very recent article online written by Stephen M. Glazier, one of the nation’s leading mental health care executives and head of UTHealth Harris County Psychiatric Center of Houston, outlined one of the best-written definitions of the concept of psychiatric “continuum of care,” that I have ever read. His article appearing at TribTalk.org, “Bridging the Mental Health Treatment Gap,” on May 9, 2016, provided insight into Texas’ progressive efforts in just the last 1-2 years on improving the state’s mental health reform and care delivery efforts which have not received the recognition they deserve.
Mr. Glazier pointed out the common issue seen in many states who have had to face the need to close or replace aging state hospitals, and the multifaceted dilemmas of what to replace them with. He eloquently wrote of the concept of providing what he termed the middle range of less intensive residential and non-hospital based psychiatric services in the overall continuum from hospital to home or ultimate living placement for the mentally ill person. He delineated some key concepts and facts: 1) that Texas’ state psychiatric bed ratio has declined since 2001 from 13.4 beds per 100,000 persons to 10.9; and that, 2) even if Texas had ‘kept up’ with the growing mental health needs, the rapid growth population growth in the state of Texas, which has always been in the top five states in the US, the state’s level of services would still have fallen behind previous levels of beds per 100,000 population.
His idea is not a new one, that increased and nuanced provision of these middle ground “residential,” transitional psychiatric services, would to at least some degree, not only replace some state hospital beds, but reduce the spill-over, or “trans-institutionalizations,” (the new buzzword) that we are seeing as ever more rapidly increasing numbers of the seriously mentally ill, shift from non-existent state psychiatric hospital beds to jails, hospital ERs, and the streets and shelters, all never intended to serve this population. But Mr. Glazier’s description of what is needed in filling in the gaps in the continuum of care of the mentally ill is well worth reading.
This subject and set of events is dated, and I offer my apologies to the reader. But this offering will serve to remind what can go wrong when in the course of the mental health reform process, things can go very wrong when the health care sector succumbs to criminal insufficiencies in their immediate continuum of care system, gives in ethically to a dishonest set of circumstances, does not fight back and falls back upon devising equally criminal ways of coping and inventiveness instead of advocating at any cost for their powerless patients who are dependent upon them for everything and anything they need to start over and begin the recovery process outside life in the hospital.
Over two years ago the Los Angles Times reported on a story that I thought I would never see again in my practicing lifetime, that of “dumping patients.” I practiced in Arizonaover 15 years ago and saw the now extinct Charter hospitals do this when a patient’s health insurances would be exhausted after a month or long stay in the free-standing hospital and then be “discharged to the street” literally and abruptly. I was witness to this process as our hosptal system having a rather compassionate approach to psychiatric care would willingly accept these unfortunate and truly traumatized persons when their desperate families brought to our admission doorsteps, those of the Camelback hospitals, once a group of psychiatric hospitals in the Phoenix and Scottsdale areas, started in the 1940’s and in the days of affordable psychiatric healthcare, a nationally recognized system for its superb quality of care. These dumped persons from the for-profit hospitals, still suffering acute symptoms such as severe unremitting depressions, suicidal impulses or pressing urges and thoughts, would be admitted no questions asked–at a loss to the hospital and to us attendings who took them on as inpatients, not expecting to be paid at all, and saw this as part of our responsibilities and part of universe of care we should offer out of our senses of service and ethics. I saw no practitioner at the Camelback system of hospitals ever turn down such a patient or take on their care resentfully.
The process of discharge in modern inpatients psychiatric care literally begins with a day or two of admission, not so that we can hurry up the process, but so that we can get a head start in lining up the needed outpatient resources, financial support, sometimes a place to live for a homeless person, sometimes family resources for a homeless minor, but always for a “best fit” between the patient and the all important team of team of therapist and psychiatrist. Often during the patient’s inpatient “do-over,” we would have the prospective therapist and future psychiatric come to visit the patient in person to have a get-acquainted session to make sure there was a good personality fit and rapport among them all, thereby giving often these persons brutalized by the “for profit” systems genuine hope that after discharge, whenver all arrived at a consensus decision made together, there would be the help ready in place to support them, giving them genuine hope instead of another trauma.
The article I came across recently in my constantly Google searchbot curating system for developments and trends inthe massive nationwide effort at changing our mental health care delivery system for all for the better was in the Los Angeles Times, entitled “S.F. sues to recoup costs for patients ‘dumped’ by Nevada hospital,” published ‘way back” in September 10, 2013. Its dated historical time of occurrence does not make it any less timely and happens to follow up on my previous post, which documented the emerging and alleged corruption of a privatized (read also for profit but sanctioned by the state who handled over inpatient psychiatric care to a national money making hospital system, to deliver service and make profit like the experiment with privatization of state prison systems who crowed about saving money to state legislatures, and of course pocketing the difference.) Well that did not go so well in a number of instances and the practice is still be re-examined in states who went in this direction.
The LA Times article though documented simply horrendous new heights of patient care callousness in patients at hospitals in Nevada, at discharge, from the Rawson-Neal Psychiatric Hospital in Las Vegas, often by bus with no resources, not provision at all for any outpatient care or personnel to San Francisco. The investigation by the newspaper the Sacremento Bee, started small but uncovered a scam/scandal of monstrous proportions and scale. It was found that about FIFTEEN HUNDRED patients had been shipped off to cities and towns in California over the previous five years. The investigation at that time was headed up by San Francisco City Attorney Dennis Herrera.
Those days were a unique confluence of corporate greed, and the growing appearance in the 1980’s of the seeds of the crisis we now face: the national shortage of adequate outpatient resources to replace which that hospital, especially the state public psychiatric hospitals could furnish even if at times, it bordered on “institutionalization.”
The solution is obvious and in everyone’s sight and radar. Outpatient resources and its infrastructure must be constructed nationwide, and governors and the no more taxes ideology of the present day and last 0 years must confront the reality that this costs money. Period. Good luck all you politicians trapped by your ideologies that do not square with reality. You need a paradigm shift in the biggest way and it will painful for your as you have to rethink your dearly held assumptions and shibboleths.
This will be a full post but a ‘sidebar’ type as mentioned a few posts ago. This concerns one of the other states suddenly having a different type of problem in mental health reform service delivery. This involves what can happen when there is an attempt to privatize andsplit off the tasks of mental health care delivery by the mantra popular in certain political and business circles.
The enthralling idea behind privatization for traditionally “government services,” such as municipal water supply, trash collection, mass transit, public health care and mass pandemic protection, to cite an extreme example, is that governments cannot do the work as well, efficiently or cheaply as can the “private sector.” The political machines of the past century such as Tammany Hall and its decades of corruption and cronyism, the Daley political machine of Chicago where everything that got done, “got done,” often as a result of greasing the palm of your local alderman.
The ideological faith and belief that capitalistic, corporate business could always do a better job took strong hold of the political imagination of many in this country by the middle of this past century, emerging fully in the Reagan years largely in the form of “de-regulation,” and unfettering the business world from choking restraints of governmental rules, over-regulation that stifled innovation, efficiency and the free market and its potential productivity. Much of this was indeed true in certain sectors and up to a point. But the non-psychologically minded politicians who could not live in the world of ambiguity and human nature, would behave as if humannature and all its foibles and inherent sense of self interest would sacrifice for the betterment of the greater good of the Almighty Economy. A huge ideiological boo-boo in this paradigm shiftwas committed under this belief system, that began perhaps with President Reagan’s breaking the air controllers’ strike in the earliest years of his first term. But human nature asserted itself and those years came to be known as the “Age of Greed” years before our Wall Street crooks in nice looking suits broke the economy with hedge funds that were worthless, the housing mortgage bubble, insider trading and greed on a scale never seen or achieved in history.
So now we are witnessing states who have either given up
I apologize for this dated article and reference, but it reminds us all again of a problem linked to the overall policy and planning malfeaseance committed by mental health planners, bureaucrats, policty wonks, legistlators from the state to federal levels, in pursuing the idiotic policy of closure of psychiatric inpatient treatment beds and resources in the publich AND private areans. That error, is of course, one of the triads of haunting reminders of our big “boo-boo” of turning mentally ill out of treatment facilities too early, not having beds for them and not providing even a fraction of the known needed “community based resources,” and that is patients stuck in ERs around the country for days. This article came from the online edition of WXYZ News of Detroit MI, a state that was one of the earlies states to undertake “mental health reforom” under then Gov. John Engler in the decade of the 1990’s. This aticle was published in June, 2015 and showed that nearly 15 years after the start of mental health refrom in Michigan, children were STILL waiting indeterminate periods of time for a child psychiatric bed to open up for their needed attention. In crisis, mentally ill boys and girls are waiting days for a hospital bed.
This post will be a fact-based overview of the prevalence of mental health illness conditions and the burden nationally in the United States according to the National Alliance for the Mentally Ill and the National Institute of Mental Health on an annual basis.
I am writing this post at this point in time to also contribute to setting the stage for delving into the many complex issues that this blog will address in its future postas and tasks. These issues will range from the staggering seeming increase in demand for mental health services all sectors of our American healthcare system, and many sectors in which we have neglected and actually delayed or even faced the necessity to institute regular and proximately closely situated competent mental health services such as school based clinics and for adults in the workplaces. Currently in the last 10 to 15 years we have had continuing bitter reminders of the needs for mental health services in the schools by the occurrence of mass shootings both by students and by adults in school schools. Prior to that in the 1980s and 1990s we had so many incidents of mass shootings by disgruntled employees of the US postal system that it became a national meme and joke to say that someone had “gone postal.”
Approximately 3 weeks ago I read one of the most distressing that most informative articles I have seen in over 20 years. It was published in the Oklahoma City newspaper on January 2, 2015 and written by Jaclyn Cosgrove. It was entitled “‘Epidemic ignored’: Oklahoma treats its mental health system without care.” It was described as: “a yearlong investigation into Oklahoma’s mental health system.’
It had the usual now almost obligatory saddened startling photographs of dilapidated antiquated hospital facilities with patients in threadbare clothing without shoes crowded into dining halls or sitting hopelessly in empty hallways.
Much more startling to me the reader of such articles now spanning nearly 30 years since I have made it special interest of mine, were reading quotes from legislators, treatment advocates, and mental health professionals from time periods ranging from 40 to 100 years ago. The statements that were discovered and published in this article were quite riveting and unsettling because they could have been uttered in the last few years and without there being identified in the context of the years long past when they were first uttered, I would’ve had no idea if these were statements made by people long deceased. It was like reading the history of our present dilemma in mental health care system delivery and its failures nationwide, that existed in a parallel almost identical universe of similar mistakes, failures to adequately fund mental health programs, many of whom had forms and objectives and methods similar to the “new” massive programmatic renovations proposed in almost all states in this country today
For instance in 1895 the governor at that time of Oklahoma William C Renfro began proposing a novel idea that residents should be treated for their mental illness closer to their homes. This arose out of the unbelievable practice in that time in Oklahoma when the territory was sending mentally ill residents away by train to the state of Illinois. A second example is the fact that this newspaper article reported, “almost 80 years ago, the national mental hospital survey committee published a report that noted that air Oklahoma would save money if it invested in its mental health system.’ Whatever the future may bring,’ the report concluded,’ Oklahoma cannot look on itself with pride until provision is made for adequate care of its mentally helpless citizens. The year of that statement was 1937. It was recognized even then that the few state-funded inpatient hospitals then supported by the state of Oklahoma were only the first part of the treatment continuum that had to include community placement for the chronically mentally ill
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One of the fundamental hypotheses of this newspaper article was that Oklahoma has been far behind in most other states in this country in providing mental health services. For instance the news purple article noted that in the year is surrounding World War II, Oklahoma had one of the worst doctor to patient ratios ranking it number 43 in the United States for care of the mentally ill. One other telling statistic was cited that each of the doctors at Central State Hospital in approximately 1947 had a caseload of 700 people, one of the highest psychiatric physician caseloads in the United States. It also had one nurse for every 45 patients in the hospital. The problems with safety of the psychiatric hospitals and facilities began very early in the history of treatment of the mentally ill in Oklahoma. For instance Western State Hospital at Fort Supply was overcrowded by nearly 500 patients and had building buildings which had already by the 1880s been repeatedly condemned by fire marshals as fire hazards and there were only four doctors to treat 1603 patients and no nurses or social worker
This is the historical backdrop to the looming mental health serivce crisis in Oklahoma today. This beginning examination of the mental health crisis in Oklahoma will be examined further in the coming weeks in a series of posts that will sketch the usual elements that have already beeen seen to operate in so many other states the last 20 years. These all too well known factors include: economic shortfalls in the state’s budget that suddenly jeopardize everything except football program at the state universities, poor foresight and plannnining, shortage of mental health professionals and delaying for still years the easy to have been seen to explore still further the outpatient agenices, facilities, physicial plants and staff cohorts of the world of public outpatient mental health services.
Further I will go on to document in following posts the same kind of story in another state with very unique twists and hardships of its own in meeting lesser mental health care needs in that state, Alaska which is slowly grinding toward a large crisis of its own.
The Mental Health Reform Blog 