Mental Health Reform Legislation Coming?

After several years, much needed mental health reform legislation at the Federal level may finally be coming our way.

I must state at the outset, the gnawing sentiment that at least some of the suddenly growing and politically fashionable reason for pols to jump on this now aged, creaky bandwagon stems from the recent years of increasingly frequent mass shooting we have experienced in this country. And the growing heart-rending and hard to shout down with caustic political rhetoric often based on hysterical fears of somehow losing “our” guns rabid pushback that seems to instantly spring from the same blusterers of certain quarters because, surprise, surprise, these atrocities are committed with guns instead of Nerf toys.

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Mississippi budget cuts to close psychiatric beds

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.

 

 

Colorado Has Same State Wide Problem

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.

 

A Good Idea from a Texas Mental Health Leader

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.

 

Corporate Psychiatry, and Greed Back Again?

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

Continue reading “Corporate Psychiatry, and Greed Back Again?”

Oklahoma Joins List of “Distressed” Mental Health States

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.

 

 

 

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.”

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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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