South Dakota Illustrates the Shortage of Psychiatrists

A recent and typical article in the South Dakota newspaper, the Argus Leader, “Psychiatrist shortage worsens court bottleneck,,” sadly but truthfully illustrates one of the worst reasons for one sector or causative reason for one aspect of the mental health crisis of delivery of services in this country in all sectors, public and private, inpatient and outpatient whether clinic or private office based. There is a tremendous shortage of shortage of psychiatrists in this country. This issue has been building for over 30 years!

It started when the ability of hospitals and training centers for many kinds of residencies in subspecialties in all aspects of training of “residents,” who are doctors in training in specialties such as family medicine, pediatrics, OB=Gyn, general surgery, psychiatry, internal medicine, and even the subspecialties such as all kinds of cardiology (interventional, electrophysiologic), pediatric surgeries (orthopedic, neurosurgical) dermatology, endocrinology, all the subspecialties in radiology etc. This obviously stupid development came about when during the Reagan administration, Congress in its misplaced attempt to do something about Medicare and Medicaid fraud, thought that training centers should be allowed to transfer (divert was pejorative condemning word that was  back then to convey some kind of behind the the scenes skullduggery in money manipulation) those revenues to help fund training programs.

Now it must be understood that ALL training programs in medical residencies are expensive. Residents have to have salaries to live on, though they have always been just enough to make ends meet especially if you have a family…and residents are NOT paid wild, glorious fantastic salaries and live the good life, driving Benz’s, Beemers and Lexus’es. They drive used cars (I sure did for years, but the truth being I do anyway as my motto became with bunches of daughters in 2 different cohorts and one later adopted son, “Never Buy Retail.” Buyin Easter shoes for all the girls annually was something we saved for after the Christmas-Hanukkah holidays and even then we shopped at place called “Discount Shoes,” which was almost a 200 drive away from our home in Durham so we could afford the Easter “pony shoes,” as I jokingly called them for the feminine horde.

Residents in training also generate very little revenue from their clinical work. In the old days (imagine old man reminiscing vocal sounds and harrumphs in the background), residents at least in surgery could be billed to insurers including Medicare and Medicaid as “assistant surgeons,” and generate some lower fees which helped. This disappeared under the new punitive regulations until residents in the surgeries and other specialties that had procedures they could charge full rates for. That circumstance would typically come legally at the end of their training when they were “chief residents,” could function autonomously and ran the lower level residents and interns’ services, scheduling, teaching, assigning patients, reviewing work-ups, approving studies, in other word, the junior attendings. In this way the essential supervision of all residents lower than the chief, was handled and parcelled out at different levels and handled as appropriate to the training of the resident, by the resident one year ahead of the next resident. It worked for deacdes since the aftermath of the “Flexner” report which occurred in 1910 or so. It catalogued the incredibly sad state of medical training then in the USA and proposed virtually the entire modern training system we have today. It was a masterful work of presience with Dr. Flexner foreseeing what would be needed to train doctors to high standards, generally how to involve modern developments not even dremaed of then and legislate firm, universal standards of training at all training centerss. For instance courses were standardized and required, and another telling example is that surgery residents started to have to keep verified surgical diaries listing all the procedures they had performed, assissted in, and observed throughout their residencies. Even now these have to be reviewed and presented at the time being considered for board certification.

In psychiatry things were different as they always were. With the exception of psychological testing, psychiatry had no expensive, bodily invasive medical or surgical procedures that could be charged for with nice high fees. Psychiatry residents in training even in wealthy settings such as Cambridge, San Francisco, Westword in LA, the tony areas of New York City bordering Central Park, Ann Arbor, Chicago, Georgetown in DC, mostly had patients who were poor, had little or no insurance, even Medicaid especially in the early days of Medicaid. And when insurers began to pay for psychiatric services, they were paid for at the discriminatory rate of half, 50%, of medical/surgical rates. And so the residents in psychiatry did not generate enough monies to pay their own expenses to their training programs, office, staff, salaries and especially the time of their superising psychiatrists. Although youger pscyhiatrists in training always had psych resident mentors above that offered peripheral supervision, formal superision was conducted by one’s supervising faculty psychiatrist. It was very expensive, given the nature of what the psych trainee did, which was an interview. The supervision onsisted of the faculty psychiatrist who followed the case as long as the trainee treated the adult, teen or child, heard all the “material,” and then taught, offering advice how to interpret, how to supportively interview, how to form all alliance, how to foster self insight, how to help the person effect and move to real points of change in their lives, how to see them through crises in their lives. And of course, all the ancillary social issues were handled and learned as well, what to do with substance abuse, dysfuntional families and marriages, deaths and losses and on and on.

The point is that training of psychiatry and psychological Ph.D. level mental health clinicians was and still is tremendouls costly. Some experts estimate that until recently with the coming monies from the former Congressman Patrick Kennedy’s and other’s reparative training fund bills for the mental health professions, that some 80% of training funds nationally disappeared.

So what happened; by the end of the 1980’s training programs closed, not many but a fair number. Most reduced staffs and residents, especially the latter by half or more. My own program reduced the number of residents by 2/3.

All the big cheese observers of the “psychiatry scene,” especially but also all the other mental health discipline began to complain, then warn, then project the coming crisis of shortage of mental health provider crisis with astounding statistics and then starting to scream from the national battlements (a la the battlements of the French Bastille in my fertile imagination). We were not replacing the measley 6,500 or so child psychiatrists we used to have TOTAL in this country by the 2000’s. Those that died or retired were lost to service and most of the time communities did not have replacements.

My own experience with this was telling. In 2006 i lost my psyhiatry partner to a terminal diagnosis of cancer in a close member of his family. He was in his mid 70’s and decided to retire, moved with his wife to be near their family. This was an unexpected and rapid necessary exit from our practice but it left me in the veritable “lurch.” Our practice was an almost half child oriented practice. At the time mental health reform in NC was a true disaster mostly because it was in the middle of its development, little was finished or formed or ready in the new outpatient service delivery structures across the state. Long term employee professional of the local county or combined several county mental health centers were told they had to re0\-apply for their positions, including the Ph.D.’s and MD’s. So what happened in our town was typical; all three lady child psychiatrists left within two months and there were no practitioners other than me for the entire country. I worked for two years trying to recruit another child psychiatrist to come to my practice. I thought the prospect of the magnitude of the immediate need would surely attract someone. I recall telling several visiting candidates, ‘Don’t worry, you’ll be full in one or two weeks. guaranteed.” They all had better offers elsewhere in the medical centers or big cities. I worked two years on Saturdays and Sundays seeing and caring for the public mental health center county kids, and finally truly “burned out,” something I thought would never, ever happen to me! I finally had to face reality and closed my practice of many years and took a salaried job, but a wonderful one working as the first psychiatrist on the Cherokee Qualla Boundary Indian Reservation, my wife’s ancestral home. It was wonderful for both of us and my wife was able to return to her childhood home and be with all her relatives especially her elders. I worked my contract and helped to find a Native American replacement psychiatrist finishing psychiatric training (there was only one in the entire country) and persuaded him to come and after nearly five years’ development work there, my work was done and I then faced my now olde rage ‘category-status’ and decided to return to my original first rotation at my training residency and become a state hospital psychiatrist and “give something back.” However, slightly selfishly this state hospital offered a full range of psychiatric residency teaching opportunities that made me “teaching self” water with great anticipation since it took residents in psych rotations from several medical schools. But it so doing I in effect contributed to the growing shortage myself of psychiatrists in the country.

So what does all this have to do with South Dakota? South Dakota has a smaller population and only one state hospital. It has had even FAR worse problems staffing their one hospital with psychiatrists and has had to close beds the last one or two years because of lack of coverage or clinicians to treat them.

But as in the rest of the country the huge new influx of “legal patients,” has swamped the hospital, doing as this near tsunami of “incompetent to proceed” to trial patients has done is almost ALL the other state hospital hospitals [including my own], taken beds always for ordinary psychiatric patients in crisis.

The result as this article typically reports patients have been stranded for days to weeks in ill equipped small community hospital ERs, waiting for an acute admission bed to ‘open up.’ This practice is so widespread in the country that it has acquired a convenient name, “psychiatric boarding,” or just plain “boarding.” In some states, advocacy organizations have sued states and their hospitals for such practices. It is a widespread problem with presently no real solutions. Most state legislatures are not willing to fund and construct the many dozens or hundreds of beds that would accommodate these legal patients so they are treated and accepted first by the admissions units of the state psychiatric hospitals who have NO choice but to do so because these patients are court ordered.

I will take the liberty and quote three paragraphs from the above referenced article to illustrate the problem as it currently bottlenecks both the inpatient psychiatric hospital’s mission and obligation to treat its patients and the legal system that must observe and uphold the constitutional right for a defendant to be able to understand and participate in a capable manner in their court proceedings and to fully cooperate with their counsel.

From the Argus Leader, “A shortage of psychiatrists in South Dakota is hampering efforts to address a bottleneck for court-ordered mental health evaluations in the state.

An Argus Leader Media investigation found mentally ill defendants were jailed for half a year or more as they waited for exams to determine whether they are competent to stand trial.

The state’s mental health hospital says it is not responsible and does not have the resources to conduct all of the exams, and that’s forced counties to seek out private psychiatrists to help manage a surge in criminal cases involving defendants with mental illnesses.

The problem is that few private practitioners in the state are qualified…”

Finally, to close out this long winded treatise on the shortage of psychiatrists, I will further take the liberty to quote the Argus Leader’s data in this article which gives startlingly information on how understaffed the entire state is with (or if you prefer from a pessimistic standpoint) without psychiatrists, the following passages will delineate the dimensions of the shortage that exists NOW:

“A Kaiser Family Foundation analysis this year found South Dakota has enough mental health professionals to meet only about 15 percent of the need for services in the state. There were an estimated 30 psychiatrists statewide in 2014, according to the U.S. Bureau of Labor Statistics.

The South Dakota Department of Labor and Regulations puts its estimate at just 20 psychiatrists statewide.

Based on BLS and Census data, South Dakota has fewer than one psychiatrist for every 30,000 people, one of the lowest ratios in the region.”

At the end of the article, the author listed the relative ratio’s of psychiatrists per 100,000 persons in 2014 that last year for which such data was fully available. These statistics are woeful as one accepted statistic commonly accepted for urban areas is ONE psychiatrist per only 3,000 people to 30,000 persons at most. The Midwest illustrates its serious shortage more than almost any area of the country. But all areas have them, except by and large cities in which there are one of more medical schools and concentrations and availability of specialty training programs.

Psychiatrists per 100,000 people, 2014

Nebraska   3.2

South Dakota  3.5

Iowa  4.8

Minnesota  6.6

Wyoming  6.8

Montana  11.7

North Dakota  Data not available

Sources: Bureau of Labor Statistics, U.S. Census Bureau

 

Were State Psychiatric Hospitals Better 100 Years Ago?

A fundamental intellectual tenet of mine is that to have a comprehensive and ‘honest with oneself’ grasp of historical and social long term processes, history of the subject being studied should be included. George Santayana’ famous quote that those who ignore history are ‘doomed’ to repeat, seems to hold more and more power of truth the older I become.

The history modern mental health care began in almshouses, shelters for the developmentally disabled and intellectually disabled, earliest perhaps by the Quakers of the early 1700’s in Pennsylvania. Theirs was an extraordinary (and still is) ethos of charity, helping those in need and one of the original origins of the philosophy of “non-violence,” embodied in conscientious objects in our wars and taking on the needs of the shunned, ‘repugnant,’ disabled persons who frightened the average person. It is no new concept that state hospitals were built intentionally out of the ‘boondocks,’ the countryside, away from towns so delicate sensibilities of citizens were not disturbed by the sight of unpredictable persons, that in reality before the era of modern treatment in the middle half of the 1900’s NO ONE really understood beyond crude empirical approaches, i.e., “we do not know how but this medicine works on hallucinations so let’s give it for that.”

There are many, many articles, books, some films from the earliest days of the then miraculous, wondrous Brownie 8 movie camera, that record the abysmal conditions of many state psychiatric hospitals in the Western world and the US, Latin America, Scandinavia, Europe and a few other regions and countries where modest efforts at housing the chronically mentally ill occurred. For instance, it is not well known that the famous country singer, Johnny Cash, established and supported an orphanage for children in Jamaica and did so very quietly as a true philanthropist.

If it were not for Google’s miraculous search bots, I would never have come across or read the article to which I wish wholeheartedly to refer the reader. It is from this week’s edition of the English newspaper, The Daily Mail. In the usual British brutal journalistic tradition it has simply ghastly title: “EXCLUSIVE: Chained to their beds with no heat or water, and left to lie in their own excrement: How the 19th century mentally ill were sent to hide away in grisly insane asylums and categorized as ‘idiots’, ‘imbeciles’ or ‘lunatics,’

This article itself is based on what appears to be a singularly striking book with lots of old pictures of life and patients in state psychiatric hospitals in Scotland and England, entitled, ” Lunatics, Imbeciles, and Idiots: A History of Insanity in Nineteenth Century Britain & Ireland, by Kathryn Burtinshaw and Dr. John Burt.

Continue reading “Were State Psychiatric Hospitals Better 100 Years Ago?”

Discharging Patients to Bleak Destinations

May 11, 2017

In today’s AJC Online publication of the Atlanta Journal-Constitution, entitled: “Deaths, delays paint grim picture of Georgia mental health reformState still discharging patients to extended-stay motels, homeless shelter” authored by Allan Judd of the AJC, a despicable, but tried and true shameful expedient method of discharging and placing discharged psychiatric patients has come to light once again. Before I identify it, I would like to cite a few of its historical predecessors that were also once ‘standard practice,’ that tried to make one segment of our long “broken mental health system” work.

Several years ago, a private psychiatric hospital in Nevada gained notoriety in the news by the discovery that for two years or so, it had been discharging chronically mentally ill patients to the ‘foreign’ territory of California. Patients would be given a starter set of clothes and belongings in a suitcase, an amount of cash money whose exact amount I can not at this moment recall, and plunked down after a short plane flight from Henderson NV I believe to the airport and streets of San Francisco as a means of “placement.” This is of course set off much moralizing, scandal, and opprobrium, corrective and punitive action was taken and the practice stopped.

Now a story emerges from Georgia that it is doing something close to that by discharging “mental patients” from its state hospitals to makeshift former motels and shelters with just a bus fare token and little else,…like follow up, a ready and waiting clinical post-discharge treatment team and program? Perhaps, perhaps not.

This also reminds me of the practice of New York approximately two decades ago, in which such patients were discharged to welfare hotels; these were abandoned, closed, bankrupted, foreclosed, gone out of business hotels from another era who could not compete anymore in the glitzy market of tony New York hotels. These places would be filled with ‘dischargees’ from prisons and psychiatric hospitals with no other suitable resources, families or homes they could turn to. New York as I recall was indeed treating these unfortunate folks with outreach mental health, public health and social work teams struggling to help keep them stable in such grim and lonely settings, but these ‘placements’ quickly became cesspools of crime and corruption as the predatory types, the criminal wolves of society learned to prey upon these defenseless persons at the first of every month when their benefits checks would arrive. [In the days before automatic electronic deposit had taken hold].

New York City Police had to deal with this and it was a nightmare and a number of deaths and tragedies brought this practice to the corrective glare of the light of investigative focus.

Those detestable practices likely had to be employed since states, as they closed aging, falling down, decrepit state hospitals without funding adequate decent housing on a massive social scale for this displaced population.

The ironic similarity to refugee camps in the Middle East sprang easily again to my mind. Any person without stable resources, a supportive surrounding community of “friends and neighbors,” an adequate income and food supply, medical care and all the ordinary trappings of a life in a familiar community that most of us take for granted, and has only as many possessions as they can carry on their heads, or in a duffel bag or black plastic garbage bag or a ‘borrowed’ grocery store cart, qualifies as a “refugee,” in my mind. In fact, to stretch this wretched analogy further, we have our own internal large population of “Syrian refugees,” in our country though we largely do not realize it on a collective national consciousness. Except the “relief” workers do, who struggle valiantly to help care for these unfortunates against truly daunting odds.

As they say in real estate, “location, location, location,” I would add the phrase “funding, funding, funding,” to this national disgrace. This sector of our nation’s life and citizens needs new “infrastructure rebuilding” as much or more so than our fabled Interstate Highway System conceived and begun during President Eisenhower’s era.

 Rather than send the reader off to the article via a hyperlink I have decided to excerpt portions of the article for the reader to read and ponder first hand:

Deaths, delays paint grim picture of Georgia mental health reform

State still discharging patients to extended-stay motels, homeless shelters

Posted: 7:31 a.m. Thursday, May 11, 2017


Mentally ill patients often left Georgia’s state psychiatric hospitals with just a bus token and directions to a homeless shelter.

For people with disabilities, these same institutions became places of permanent confinement.

This is the system that Georgia, under pressure from the federal government, pledged seven years ago to radically overhaul. But with a court-enforced deadline fast approaching, the state increasingly seems unlikely to fulfill its promises.

Georgia has less than 14 months – until June 30, 2018 – to comply with a settlement it reached with the U.S. Department of Justice in 2010. The agreement followed an investigation that concluded the state had systematically violated the rights of people with mental illness and developmental disabilities.

But the state continues to discharge patients with mental illness to places where they are unlikely to get psychiatric treatment: extended-stay motels, for instance, and even the massive Peachtree-Pine homeless shelter in midtown Atlanta. All patients with disabilities are supposed to be moved into group homes or other community-based facilities, but at the current rate of progress, the state might not meet that requirement for another 10 years.

As officials try to comply with the agreement, they also are investigating an alarming number of deaths in community-based treatment: about 350 since 2014. Those apparently include five dozen suicides.

A court-appointed monitor credits the state with making many promised improvements, especially regarding crisis intervention and other services for people with mental illness.

Still, a grim picture emerges from the monitor’s most recent report, as well as from interviews and documents reviewed by The Atlanta Journal-Constitution.

It is “absolutely essential” that the Georgia Department of Behavioral Health and Developmental Disability “act with urgency to meet its obligations,” the monitor, Elizabeth Jones, wrote in late March in a report to U.S. District Judge Charles Pannell. “Although there has been noteworthy progress in certain discrete areas of implementation, the reform efforts require additional diligent and effective actions if compliance is to be achieved within the anticipated timeframe.”

Department officials declined to be interviewed.

In a statement, the agency did not say whether it expects to meet the deadlines next year. But the department said it is moving at “a reasonable pace” to move. “Transitions are carefully and individually planned to meet the unique needs and preferences of each individual and to provide the best opportunities for success in the community.”

The agency said it welcomed the monitor’s “reflections and recommendations.”

The Justice Department began investigating Georgia’s psychiatric hospitals in 2007 after a Journal-Constitution series, “A Hidden Shame,” exposed a pattern of poor medical care, abuse, neglect and bad management that had caused dozens of unnecessary deaths.

Transforming a historically troubled mental health system has been a slower process than perhaps anyone envisioned when state and federal authorities put together a plan. Already, a judge extended the deadline for compliance once, from 2015 to 2018.

The state has spent millions of dollars and reorganized the bureaucracy that oversees the hospitals and community treatment. It also closed two state hospitals, in Rome and Thomasville. All that’s left of Central State Hospital, the notorious facility in Milledgeville that once warehoused as many as 12,000 people, is a unit for people committed through the criminal justice system.

The state complied with hundreds of provisions from the settlement agreement with ease. But several issues have proved insoluble.

For instance, despite promising to provide “supported” housing to 9,000 people with mental illness, the state has managed to find such homes for fewer than 2,500 former hospital patients, according to the monitor’s report.

Vouchers that pay for the housing have been “a game changer for the people who have gotten the housing vouchers,” said Talley Wells, who runs Atlanta Legal Aid’s disability integration project. “But the reality is we still have a long way to go to complete the settlement. The state made a commitment to 9,000 people to provide this game-changing housing.”

In past years, the state hospitals, especially Georgia Regional Hospital/Atlanta, sent scores of newly discharged patients to locations where continued treatment seemed unlikely: homeless shelters, street corners, even an abandoned van on a street in Atlanta’s West End.

But from 2016 to 2017, according to the monitor’s report, the hospitals cut discharges to homeless shelters by half. At the same time, however, the number of patients placed in extended-stay motels quadrupled.

The patients typically leave state hospitals with appointments for additional mental-health treatment; in Atlanta, it’s usually at a clinic operated by Grady Memorial Hospital. But most patients discharged to shelters and motels never show up for their appointments, the monitor found. Some return to state hospitals again and again.

The lack of housing sometimes contributes to deaths and injuries, state records show.

In November 2014, records show, a staff member at a community-based mental health center promised a client she would complete paperwork to get him a housing voucher. Almost a month passed before the staff member followed through. By then, the client was homeless – and had killed himself.

Finding appropriate places for developmentally disabled patients has been just as difficult.

Since 2010, the state has moved more than 500 disabled patients out of state hospitals. But in the year ending June 30, 2016, officials managed to transfer just 26 patients and as many as 10 times that many remain in state hospitals. (The monitor’s report listed the number as 284, while the state said it is 204.)

The state has continually struggled to find high-quality community settings, especially for patients who have complex medical needs.

As the Journal-Constitution reported last month, many patients have ended up in privately run group homes where inadequate staffing, poor training, and incessant cost-control measures have put them at risk. Between 2014 and 2016, 53 people died in Georgia under the care of just two for-profit group home operators. At least 46 of the deaths were unexpected and, according to state reports, may have been preventable.

A state panel called the Community Mortality Review Committee examines each death. Minutes from the committee’s meetings show that at least two dozen disabled people choked to death on food from 2014 to 2016. Others died from bowel obstructions, a condition that is supposed to be closely monitored.

State officials redacted most details of individual deaths. But the committee’s minutes show that in one case in 2015, for example, the staff of a group home had not been trained on what foods would be too difficult for a particular patient to swallow. The state left the resident alone during breakfast with food she couldn’t swallow, and she choked to death.

The deaths show the need for better screening and more oversight as transfers from the state hospitals continue, advocates for people with developmental disabilities said.

“This is all about making sure people have the supports they need to lead meaningful lives in their communities,” said Alison Barkoff, one of the lawyers who represented advocates during the state and federal negotiations over the settlement agreement. “It’s not just moving people for the sake of moving people.”

Barkoff said the state should either fix problems immediately, if it can, or acknowledge it will need to extend the settlement agreement past the June 2018 deadline.

But what happens if the deadline passes without the state’s full compliance is not at all clear.

Under President Barack Obama’s administration, the Justice Department aggressively pushed the state to act. At one point, federal lawyers asked a judge to hold the state in contempt of court for failing to live up to its promises. That request led to the extension of the settlement agreement.

Advocates worry that President Donald Trump’s Justice Department may show little interest in enforcing Obama-era settlements such as the one with Georgia. While career attorneys in the department’s civil rights division remain on the job, the division’s top positions, which are political appointments, are unfilled.

With the state so far from complying with the settlement agreement, the matter may come to a head next year before a federal judge.

“I can’t imagine they will have met their obligations,” said Ruby Moore, executive director of the Georgia Advocacy Office, a federally mandated agency that promotes the rights of disabled and mentally ill people. “There is just too much to be done. They’re working hard, but I don’t think they have enough time.”


 

NH Governor Issues Urgent Call for More State Hospital Beds

As what I feel and predict will go from a quiet common state governmental call to action to hard pressed and at times, downright stingy state legislators, Gov. Sununu of New Hampshire has gone quite public in his urgent call for the establishment of inpatient acute state hospital psychiatric beds. This might seem like not so big a deal but I expect that this will become more and more frequent as the acuity of the public deficit in the capabilities to the now overflowing needs in many states overwhelmed by the numbers of chronically mentally ill.

In an article published of all places in the New Hampshire newspaper, The Portland Press Herald,  April 21,2017 entitled “New Hampshire Gov. Chris Sununu calls for more beds at psychiatric hospital,” the Governor publicly declared again but more emphatically the need for major figures in the state government agencies, especially the Dept. of Health and Human Services to mount a rapid effort with short-term corrections, which I guess  means “more beds please,” and a long-term realistic plan to address the mental health crises for treatment service delivery in the state. I think that this is noteworthy because it represents a growing trend that has finally burst into the open. However reluctant many governors have been in confronting this issue, I think that more will come out of their legislative closets and start trumpeting the needs for such actions. It has already started in such states as Texas and especially Washington state where Gov. Jay Inslee has been focusing on acute state public mental health issues as much or than any other state chief executive except the Governor and the Virginia’s two year old oversight committee on mental health issues with some of the most comprehensive and innovative programs in the country except perhaps my own state of North Carolina which has worked on these issues very quietly (in spite of HB2 ‘bathroom law’ distraction.

Continue reading “NH Governor Issues Urgent Call for More State Hospital Beds”

State Hospital Psychiatric National Bed Count Hits Historic Lows: Good or Bad?

A now slightly dated article published July 4, 2016 in many papers authored by Lateshia Beachum of the Washington Post that I came across in the Walla Walla Union Bulletin of Washington state recorded the magnitude of the cut backs nationally in public state hospital beds psychiatric beds. While this has long been known as a trend occurring over at least the last five decades, this article startled even this observer by how many beds have been cut by state governments in just the last several years. The article was entitled, “Psychiatric bed count hits record low in state hospitals.”

The first sentence of the article hints at two of the main themes: “The number of psychiatric beds in state hospital has dropped to a historic lows, and nearly half of the beds that are available are filled with patient from the criminal justice system.”

Continue reading “State Hospital Psychiatric National Bed Count Hits Historic Lows: Good or Bad?”

Good News for New Hampshire, Not So Good News for Vermont

This writer keeps monitoring for positive developments in the realm of mental health reform and there are more than a few beginning to materialize around the country.

Of brief note is the fact that yesterday, Congress began finally to take positive legislative forward movement on Representative Tim Murphy’s “MHealth Care for Families…” bill to move it toward the Senate and the President’s signature. It is a huge step in the right direction.

Another positive development of note is that New Hampshire, according to a news report by KSL.com, “State hospital opens 10-bed mental health crisis unit,” on its online site for the states’ KSL TV channel, of July 5, 2016, reported that “A new 10-bed mental health crisis unit is open at New Hampshire Hospital after almost a delay of years.” The unit opened in Concord NH but illustrated immediately the enormity of the need in “little ol’ New Hampshire,” as we might say here in the South. On the day after it was opened it already had a waiting list of 23 people for emergency admission.

The article also mentions quite significantly that this entire effort was prompted by the state’s need to comply with a federal lawsuit over these very issues that had been initiated in 2013.

This observer sadly notes that even noble catch-up efforts in the nation’s and states’ mental health reform effort that are need, all good, and well intentioned, often are behind even when they get started but at least we are finally going in the right direction in places now.

But in the neighboring state of Vermont, things are not good. For months there has been well-deserved focus on something one does not hear much about anymore, since President Reagan broke the air controllers’ strike in the 1980’s and the decline of “organized labor” and “unions’ began in this country. Another striking feature of this situation has been that this new labor against management movement has involved healthcare professionals and mental healthcare professionals, which is truly almost totally anState opens new mental health crisis unit unheard of this country. This story has been a gathering storm since last year. It seemed to start in this writer’s mind a few years ago when whichever torrential “Nor’easter” storm savaged its way up the East Coast and into inland New England which is a bit of a rarity. That storm wiped out the state’s only public mental health hospital. Vermont has been limping along borrowing/leasing psychiatric inpatient beds in the state’s small private psychiatric inpatient hospital world. The state has relied most heavily on the Dartmouth Medical School’s inpatient psychiatric services for temporary relief.

This seemed at the time the best solution that could be had on a sort of moment’s notice state of urgency and emergency. But there was trouble in paradise so to speak. Labor problems began within months and built to the point where psychiatric nurses and psychiatrists themselves were fed up with working conditions which I am not privy to at all and began to voice their concerns at the state political level. Apparently, not much was responded to and too little positive corrective action appeared.

So they began to talk of work stoppages, strikes and other things that this writer associated with the United Mine Workers’ and United Steelworkers’ and Teamsters’ unions of the 1960’s and 1970’s that were every few years regular events. It was like Yogi Berra summarized in his most famous quote, “Deja vue all over again.” I personally know of psychiatrists through indirect sources that the psychiatrists were not just posturing to wangle higher wages, but were so serious that they were actively looking for jobs elsewhere, so strongly did the group of them feel about the deficiencies of patient care and availability. And Dartmouth and the State were caught in the middle I suppose, trying to generous and even-handed about all this.

This is yet another symptom of how bitter and unfortunately rancorous the processs of advocating for change can be anywhere, in any system, when the vehicle being ‘recalled and repaired and retooled’ can be at present when we attempt both short term and long term fixes that neither come easily nor rapidly enough. Again this writer will follow this story closely. I for one have never been on strike, though I went through them as a child decades ago as both my parents worked in the mining industry and this a regular every so many years event. And in the spirit of transparency, I know I could not do this and abandon my own patients.

 

 

 

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.