Author: Frank

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.

Research Shows NC Still Needs More State Hospital Beds

On December 12, 2015 the newspaper, the major newspapers in North Caroline, Winston-Salem Journal p, The Durham Morning Herald, and the Raleigh News and Observer, all published as article, ” Researchers measure NC psychiatric bed shortage.” In this article, hard data confirmed what has been known for a number of years, the North Carolina, in spite of its unique and laudatory efforts, almost head and shoulders above most states in the US, still needs many more psychiatric beds. North Carolina is unique and to be regarded positively in its almost singular effort to spend hundreds of millions of dollars upgradings its entire state hospital physical plants over the last several years. Almost no other state in the Union is doing this in this time of tight state fiscal budgets, and the lingering slow recovery of the now nearly 10 years banking and housing bubble scandal-induced Great Recession. NC has closed one old hospital, the former John Umsted state hospital in the “institutional” town of Butner NC, just 20 miles or so NE of Durham and replaced it and the now closed famous Dorothea Dix Hospital of Raleigh named after the 19th century’s more famous mental health reformer, Dorothea Dix, with a new nearly 400 bed state hospital , Central Regional Hospital. NC has also nearly finished completing replacing the old “Cherry State Hospital,” in Goldsboro serving the eastern third of the state with another completely new facility.

As an historical and “tourist guide” type aside, the town of Butner is tiny and sprang up in the rattlesnake-infested pine forests north of Durham in WWII when Camp Butner was built by the Army as a major military training center and was the site of a 4000 bed Army hospital for wounded veterans from the ongoing War in Europe. It was the second largest such hospital during WWII on the East Coast. After the war, in 1947, the year I was born it was sold to NC for $1 on the condition it be utilized as a state hospital for the mentally ill. On a persona note, my own training psychoanalyst, who came to NC to help state psychiatry at UNC Medical School, was named its first psychiatric superintendent. Butner is currently also the 30 year site for the famous or infamous “Federal Correctional Facity” where some of the worst federal psychiatrically insane criminals have been housed and evaluated such as Ted Kazsinski, The “Unibombers,” Mark Chapman, John Hinkley and many others.

Continue reading “Research Shows NC Still Needs More State Hospital Beds”

Private Psych Units Close and Open

As the number of state hospital inpatient psychiatric beds continue to decline across in the country in an now well known ill advised and foolish move, private psychiatric units are also both closing and opening as the “market” struggles to either stay profitable in the face of continually declining incomes and reimbursements and higher costs, or, to take a commendable stand in seeing their “mission” as providing a heartfelt mission to serve their local communities in need of inpatient psychiatric beds. This is especially true in non “big U”, big university medical center cities, ordinary cities where the private sector is now beginning to inherit the burden of psychiatric care crisis around the country. Almost always these services (no surprise) are “loss leaders,” like sales a groceries stories that are money loser but get grocery shoppers in the door to buy other items that are profitable. But in inpatient mental health there are no heart bypass surgeries or such that are such gross moneymakers in the rest of American medicine.

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Private Psychiatric Sector is Re-Awakening

One of the unspoken “white elephant in the room’ disturbing trends in the long slow 20 year disintegration of intensive, vitally needed, inpatient, hospital based psychiatric care delivery system has been the inexorable closure of beds everywhere. I do not honestly know that statistics of the percentage of private psychiatric beds that have closed since the early 1990’s when the trend accelerated, but it has been very substantial.

As they say in trite stories designed to bore the listener, “it all began in…” the early 1990’s when the bandit organization called Charter Hospitals [read the book BEDLAM by New York Times long time investigative reporter who is still writing, Mr. Joe Sharkey, for an expose of how a few national private for profit psychiatric mills like Charter operated in those days. Instead of “pump and dump,” those outfits operated on the financial principal of “vacuum and dump,” meaning keep the patient inpatient till their insurance benefits ran out, and then arrange a discharge–quickly. Charter went bankrupt as most of us ethical practitioners knew it eventually would in the early 1990’s. In the few other locales that I have practiced, other than Durham NC and western North Carolina, I always knew the refrain “never have Charter on your CV.” Among ethical practitioners it was a blight. I recall a personal incident where in one pra1930e Southwestern resident sister, did much more than I could to help them, I was approach my first week in my relocated and family driven need to work there, by a Charter “professional relations representative.” He came at the end of my long working days in the evening hours and was obviously irritated at having to wait so long as he was not accustomed to shrinks who worked past 6 p.m. I was puzzled as he carried a brand new bag of a complete set of golf clubs.{Disclaimer: I do NOT play golf]. He started his preamble and then launched into his pitch that I would be deserving of a shady sounding financial arrangement if I referred inpatients to the two then local Charter facilities. I would also be given an all expenses cruise for my wife and myself and have my staff credentials all done in a week or so. As it dawned on me nature of the arrangements being offered me and their inherent dishonesty, my Texas temper began to boil. Knowing me from years of analysis I knew I had to keep it under control or I would repeat my father’s mining engineering WWII approach to leadership in the mines he oversaw when I was growing up: throw the guy THROUGH the wall [my father was a true giant of of a man and one of the true “Four Horseman of Texas” high school football named after the Four Horseman of Notre Dame. I remember exercizing every bit of self control I ad and coldly as possibly with the most moral opprobrium, I could muster, telling him in civil but no uncertain terms to “get out” and take his bribes with him. I remember he was flabbergasted, never expecting than any greedy practitioner would turn down such a wonderful offer. As a final addendum, there was a salary offer couched in all this that would supplemented by an undisclosed sum with every referral. Such were the operations of Charter and at least some other national psychiatric chains, such as “NME” written about by Joe Sharkey.

But the bad news about Charter cratering all in a week or two in the 1991 or so [that year may wrong] was than a few thousand private psychiatric beds were lost the country over. And that started the trend of private psychiatric beds closing and private units downsizing all over the country as the reimbursements from private insurance companies cratered also. And that is the largely forgotten co-contributing cause to our present day mental health care crisis.

My next blog post in a week or two, I hope will address that legislation moving through Congress that will seek t redress the coverage inequities that still plague private hospitals who still, God Bless Their Souls, who operate inpatient psychiatric units. They ALL do so at a loss. Like a loss leader at a grocery store except in health care you cannot refer every psych inpatient for expensive surgery and make up the loss like you can at the steak counter in a grocery store. These hospitals do so out a sense of mission to the communities and because nobody else will.

But finally the psychiatric, bean counter, local legislative world is waking up partly due to the overcrowding of jails everywhere with the severely mentally ill who cost gobs of money to house, care for and treat well enough to retain accreditation of correctional review bodies, the rise of the mentally ill homeless even in small towns, as they said in the old movie “The Music Man,” ‘right here in River City! And the never ending now weekly spate of mass shootings at least enough of which are perpetrated by a particular brand of mentally ill for the most part that is fast becoming the shameful distinguishing news feature of American around the world. But debate is for another post…

A recent article, “Centra applies to add beds to psychiatric unit at Virgina Baptist,” in Lynchburg VA, published at NewsAdvance.com, is a good example of a relatively novel and much needed trend in the slow turn-around in the re-construction of mental health care in this country. Centra Health, a private hospital holding corporation is doing what I hope and assume is a brave thing, entering into the world of inpatient psychiatric care, likely in the hopes of better things, i.e., financial support, to come. Wake up Congress, this effort starting to happen elsewhere is bourne of desperation as states and local regional health care entities try to start filling a gap that is now upon us that imperils us and patients in many ways. I am not a dyed in the wool free market Republican but this is an example the market doing the right thing, seeing a need, and entering to fill it. But it needs support at a large level. And attention legislators: IT IS GOING TO COST REAL MONEY.

Centra hopes to add 8 to its existing psychiatric 37 beds which is impressive. It is clear from the article they saw the need locally and responded.

And why did this happen? Ask State Senator Craige Deeds now well known to the nation as one of our most well placed mental health advocates, whose son Gus suffered the ultimate price of unavailability of local mental health care too late, suicide, after having stabbing his father nearly two years and highlighting in a personally tragic way our current mental health care delivery crisis plight.

The answer is simply that states across the country since the 1990’s have sought to save monies in the multiple economic bubble busts, and recession, by slashing mental health budgets, closing state hospital psychiatric beds and neglecting the decades long disparities in mental health insurance reimbursement that have drive the private psychiatric care sector into a shadow of its former self nationally. My own training university, a powerhouse and truly deserving prestigious care and research organization, now has far fewer private inpatient psychiatric beds than when I trained there in the 1970’s and depends upon a local private hospital with a far larger private psychiatric inpatient service to meet those needs. Most of the university’s now few inpatient psychiatric beds are funded by research grants and funds that is the reality facing many such prestigious university medical centers that one would assume are rich and powerful beyond belief. Not so anymore.

Shift of Mental Health Care to Jails

Once again the author finds himself balefully writing about the continuing appalling trends in mental health inpatient care nationally. However, I am moved to do only when I see a very good reference that I feel the reader interested in this vital topic, should be alerted to.

A recent article in the news blog, Vindy.com of November 24th, 2015 showed that it does not take a nationally prestigious paper or news sources to put out a superb summary and analysis of a subject pertinent to this topic. In an article entitled, “Mental health care in Ohio shifts from hospitals to jails,” written by Peter H. Milliken [milliken@vindy.com] in Youngstown Ohio, the issues were as clearly spelled out as I have ever seen.

That author started that “”in the past five decades, state-run psychiatric hospitals have been phased out with funds shifted into each community cereate outpatient care and support services for those afflicted with any of a number of mental illnesses.” He adds tellingly: “As in all complicated cases, the result has been a complicated stream of causes and effects,” and I would add ‘unintended effects’ that have marked ill conceived mental health reform efforts nationwide over the last 15-20 years. The three basic mistakes were 1) way too rapid closing of albeit aging state mental health hospitals and beds, 2) grossly inadequate replacement of those inpatient beds, the thinking being in the minds of frankly ignorant and misinformed ideology on the part of state level mental health planners and legislators, that the beds were not needed and should be “liberated” [my term] bourne out of the “de-institutionalization” misguided ideology arising in the 1950’s and 1960’s, and 3) the totally insufficient of funds to cover the community based needs as a result of the closure of inpatient, BOTH public and private.

The author gives an example of a state hospital closing 19 years before, the Woodside Hospital, and its surrounding county gradually absorbing what sounds like an inordinate number of extreme mental patients who had no place else to go. He states tellingly, “We’re in a crisis for state hospitals,…we have days when there are no hospital beds for our clients,” quoting Duane Piccririlli, executive director of Mahoning County, whose jail had to pick up the slack.

The article goes on to describe what happened in stark broad overview terms. The state of Ohio previously had 19 state hospitals but now has only six. Patient shifting as it is sometimes, called has occurred in a massive way from non-existent state hospital beds to jail beds. And it costs the state more in most studies to house such patients in jails than even so called “expensive” or “labor intensive care,” and the care if far poorer and more and more marked by preventable tragedies.

Mental health cuts increase emergencies

It is now accepted social truth in this country that the last 20 years or more of funding cuts, so unwisely effected for ALL the wrong reasons, have resulted in longer waiting times in community hospital ERs and the huge shifting by the hundreds of thousands of mentally ill patients to the local and state correctional systems, that it is almost trite to write about this. But as the saying goes, “the beat goes on,” due to the still misguided policies underlying mental health funding policies in this country.

It is so bad that this writer cannot refrain from penning a bastardization (sorry for the language momma…), “destroy them [inpatient psychiatric beds] and they will come…to the ERs and jails.”

Continue reading “Mental health cuts increase emergencies”

More States Paying the Price of Cuts

One of the sadly recurring, and enduring themes of so-called “mental health reform” in this country, is the inevitability of a number of problems as state hospital beds are foolishly cut in this country and staff positions are cut as well.

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The Difficulties of Funding Improved Delivery of Mental Health Care

Today, September 22, 2015, the Raleigh News and Observer newspaper revealed and published some very disheartening and totally surprising news that illustrates yet another dilemma in the ever more difficult tasks in improving mental health care public services in this state, and, likely reflects the kinds of dilemmas that other states are and will be struggling with in facing up to their obligations in this area. The article is entitled: “NC budget cuts $110 million from regional mental health,” and can be read here.

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Contrarian Thoughts on the State Mental Hospital System: We Still Need Them

The state hospital system in this country began as an attempt in various of the early 13 colonies and later the early states as humane, for the most part, attempts to house the mentally ill. Williamsburg VA, now the site of Eastern Virginia State Hospital and a similar facility established by the Quakers in Philadelphia were two of the earliest efforts. There was no effective treatment until the advent of ECT (electroconvulsive therapy in the 1940’s and 1050’s with its own then shortcomings and crude, barbaric techniques till refined later, and the advent of psychiatric medications starting with Thorazine, Valium Elavil etc., in the 1950’s.

By this time even the best efforts of Clifford Beers a man who had recurrent psychotic mental illness and wrote in the early 1900’s the first widely read autobiographical account of his onw psychosis which was a national sensation as it described basically for the first time for the public, the pain of being mentally ill, and Dorothea Dix the great crusader for the mentally ill the lattter half of the 1800’s, fell short of preventing the average state hospital from turning into a facility for containment, incarcertion, etc., of the mentally ill. The famous book ASYLUM was published in the fifties and cranked up the debate over “institutionalization” and debasing treatment of the patients in the average state hospital. This fueled, the movement to get patients out of state hospitals, then beginning to be thought of as cruel institutions and less as places of possible treatment or early rehabilitation. This book came on the national scene at the “right” time, caught the attention of the public, politicians, advocates and helped to state the partial dismantling of state hospitals nearly every where. Bed numbers were reduced from averages of a few thousand beds per hospital, as many state hospitals were indeed massive. Smaller was thought to be better and bed numbers through the second half of the 20th century over time came down to the hundreds. And this does not include the dozens of institutions that were outright closed, because of revelations of abuse, mistreatment, no treatment, subhuman conditions, and “warehousing.” The Comprehensive Mental Health Center Act of 1963 was enacted as one of the last major pieces of legislation of the JFK Presidency. Smaller treatment-oriented facilities were to be built all over the country by the hundreds, often to be linked up with major medical centers. One of the earliest community psychiatric hospitals so built was Marshall I. Pickens Hospital in Greenville SC next to Greenville Memorial Hospital. They both still exist today; GMH is the major teaching hospital because of its size and faculty, of the University of South Carolina at Columbia. The opening of Marshall Pickens Hospital was graced by the presence of no less than Hubert Humphrey in the early years of Lyndon Johnson’s administration after the assassination of President Kennedy.

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Maldistribution and Shortage of Psychiatrists and Child Psychiatrists

This is a reprise of a recent post on my other site “Pen and Psychiatrist.” I apologize to the the reader if you have already read this topic at the other site which deals in more cultural and social issues. But after I posted that entry not too long ago, I realized it more properly belonged on this site, since it deals with one aspect of the mental health reform puzzle in this country.

In my previous life some two decades ago as a young Turk clinical teaching and supervising faculty of psychiatric and child psychiatric residents and fellows in training at Duke Medical Center, I became interested in “manpower” (the vernacular then) or more properly speaking practitioner distribution and training issues of psychiatrists. This was in the so called Golden Age of mental health practice, even though the service delivery system in all disciplines, had serious issues, I and many many others could see the troublesome issue of maldistribution of mental health care professionals that was emerging three decades ago and worsening year by year. Basically what was evolving was a situation in which desirable places to live, urban areas with urban amenities such as the symphonies, ballet and performing arts companies, university centers, and above all many colleagues around for support and lively continuing education meetings of regional psychology, social work and psychiatry societies, kept graduates of advanced training programs in the regions in which they trained. So over time, it evolved that areas like Boston/Cambridge MA, Raleigh-Durham-Chapel Hill NC (the Triangle Area), Ann Arbor MI, Dartmouth, New York City especially Manhattan, Stony Brooke, Long Island, Houston, Los Angeles, San Francisco, Seattle, Eugene OR, San Diego, Davis CA, Charleston SC, Atlanta GA, Birmingham AL, Albuquerque, Tucson AZ, and many other urban areas became the landing places where psychiatrists trained and often stayed to practice, in the university medical center cities. A good friend and colleague, now passed on Bruce Neeley MD of Duke and Emery, used to give lectures to residents nearing the penultimate stages of their training careers and were a year away from the decision of where to settle to practice. By then the 1980’s the trend had become set in concrete, only a minority of graduating psychiatrists left the training centers and set up practice in under-served areas.

Bruce Neeley and I separately in turn would give almost off the records seminars to the ‘senior residents,’ telling them in so many words, almost like the famous newspaper editor of the 1800’s, “Go West Young Psychiatrist,” In North Carolina we first meant go literally to western North Carolina which I knew very well because of my wife’s origin from Cherokee NC. But we also meant “get out of the urban centers, there are too many of us here already.”

WNC then and sadly still is vastly under-served by psychiatry with a chronic shortage that is almost criminal. I can count on the fingers of one hand the number of child psychiatrists in practice west of Asheville and that is a lot of territory. I used to tell senior residents to “Get out of the RTP [Research Triangle Park, another term used to denote the entire Raleigh-Durham-Chapel Hill area since each of those cities incredibly are only 8 to 15 miles from each other!

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Closing State Psychiatric HosptalAs: Consequences, Good and Not So Good

As usual I always bow to my internal ethics and try to be as open and transparent as possible about the subject at hand, revealing attitudes, biases, views based on long term experience, and an almost “historical view” of the galloping phenomenon of “mental health care delivery reform” thankfully occupying the attention of the country finally. I am old enough to have practiced in the so called mental health age of oodles of resources, and have watched them atrophy, became extinct, go corrupt and get themselves prosecuted out of existence, lose funding for many many understandable reasons, lose their place of importance, watch the ever decreasing number of bright talented younger generations of “would have been social workers, psychiatrists, and psychologists” shy away from the training programs, and our numbers go down especially in child psychiatry. One could take an inflammatory demagogic view and see is as necessary to prevent th abuse and horrors that indeed happened for decades shuttered away out of the light of public review and knowledge and responsible accountability and oversight. But that approach has nearly led to the old saw of “throwing the baby out with the bathwater because something was wrong with the bathwater, too dirty, too hot, whatever. I have seen the inhumane past and still in more restricted corners, inhumane treatment of patients in poorly run state hospitals that made me so mad I thought i would bomb them into the ground they were so bad, but of course after evacuating the helpless patients. I have helped to de-accredite the abominations of such hospitals, a few but enough to see first hand the decades old cultures of isolated facilities with poor faculty, psychiatrists who could work no where else due to histories of alcoholism, just plain bad practitioners and all the rest. I have had close colleagues since my residency days who presided over the deserved federally mandated dismantling of closure of famous hellholes permitted to exist far too long and heard their stories of generations of horror stories.

But in the midst of all this, or in my case in the last quarter of my career, I still know and hold to the somewhat unpopular certitude that state psychiatric hospitals are needed, good ones and now more than every. One simply statistic is that out country’s population and mental health treatment burden has at least doubled if now tripled since World War II. And we have had new mental health phenomenon syndromes, traumatic brain injuries of unforeseen overwhelming magnitude outstripping the abilities of public and private psychiatric-neurological treatment worlds to receive, treat and comprehensively help them out of our IED head rattling new genre of injuries in the Middle Eastern conflicts we have had to enter, police and try to stabilize at little thanks from much of the rest of the concerned world with some exceptions.

State hospitals across the country have been marked for closure and destructions for decades with the trend accelerating greatly in the last 2o years or so. It was thought and expected the the monies saved from funding these “dinosaurs” would be responsibly shifted to the long known need for massive outpatient services for the CMI, chronically mentally ill for which the state hospitals had long existed and served, and served well in a surprising high number of hospitals. Remember the famous Meninnger family of three generations of nationally recognized humane psychiatrists practiced in a state public hospital, Topeka State in Kansas a venerable training and research facility itself.

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