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Georgia Struggles with Nationwide Problem of Housing for Chronically Mentally Ill

Finding housing for the chronically mentally ill after discharge from psychiatric inpatient services has come to be one of the most vexing problems that all states continue to struggle with. In brief, this has risen to be one of the paramount issues facing every state’s public mental health service delivery system due primarily to two factors: 1) decades of “de-institutionalization,” phasing out the practice and philosophy of housing the chronically mentally for decades or lifetimes, coupled with cutting back in every state of the numbers of state hospital psychiatric beds, and, 2) the rise of legal decisions and enforcement measures since the 1970’s emphasizing transferring patients to “less restrictive” levels of care, which is most clearly spelled out and embodied by the Olmstead Supreme Court decision.

An earlier post described the revelation that in Nevada in this past decade or less, that state had been discharging patients on planes to San Francisco, California! Patients were apparently given a suitcase of a supply of clothes and supposedly some amount of money to help them set down roots in the neighboring state. By report, this practice had been utilized for about two years before it was revealed and a brouhaha resulted. New York state’s practice of turning out of use old hotels turned into “welfare hotels,” for housing not only persons or families on welfare but also the chronically mentally ill and paroled ex-convicts has long been known.

This past week or so, an article entitled: “Deaths, delays paint grim picture of Georgia mental health reform: State still discharging patients to extended-stay motels, homeless shelters, by veteran reporter Alan Judd was published May 11, in the Atlanta Journal-Constitution newspaper. that shows the huge problems states face in completing the long heralded de-institutionalization process, that of moving the “CMI” [chronically mentally ill] populations from hospitals to safe housing with adequate outpatient treatment, supervisory and rehabilitation services.

Georgia has been contending with this issue for at least 7 years since the federal government began to monitor and require positive changes in finding housing for the discharged patients, instead of releasing them as the article put it: “with just a bus token and directions to a homeless shelter.” Now Georgia apparently faces the imposition of a looming deadline of June 30, 2018, to comply with a legal settlement and pledge Georgia entered into with the federal U. S. Department of Justice back in 2010. 

The article even-handedly notes the many steps of progress that have been undertaken and implemented by the state and gives credit for notable and partial improvements.

But this article illustrates the Herculean tasks that states face in transitioning themselves from the traditional custodial role utilizing large massive hospitals and viewing treatment as often lifelong or at least so long that it may as well be lifelong, to a system aiming at re-integrating the chronically mentally ill safe enough to be returned to the communities and constructing complete new and entirely different systems of housing and care for literally thousands of persons within spans of a relatively few years. There are no simple answers in any quarter and the task which may have been viewed as achievable within approximate task-timer periods clearly is proving to be greater, harder, more coslty and complicated than likely almost anyone could have imagined.At the least, enforcement by the “feds,” may have to consist of extending time periods of effort to the states and partnerships that help with costs and perhaps even approaches not yet widely appreciated by any of us.

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.

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New Hampshire’s MH Reform Efforts Show Difficulties

An article published in the online edition of NH tv station WCAX on April 18, 2017, summarized and quoted below shows the daunting hurdles that states around the country are typically facing when trying to confront mental health service services and to construct interim reasonable working solutions.

In his article, “How potential reform could impact ongoing mental health crisis in NH,” author Adam Sullivan adeptly and succinctly outlines many of the huge state legislative, implementation and funding issues that must be dealt with, seemingly all simultaneously in confronting mental health service delivery deficits that have, to put it simply, festering for decades nationwide, not just New Hampshire by any means.

First, like almost all, if not all states, NH has the shared problem of not nearly enough public or private inpatient high acuity beds. Second, this state with a small population and with a correspondingly small number of large major medical centers has few resources other than local smaller community emergency rooms to handle acutely psychotic, sometimes violent, patients. Often these good community hospitals have NO consultant psychiatrists, no hospitalist psychiatrists and no psychiatric units to transfers these patients to internally within the hospital after a prompt psychiatric/mental health evaluation.

On a rare personal, I am in my sixties and working in a state hospital because in the waning years of my career (although I truly wish and intend to work at least another 10 years), I receive an average of three snail mail brochures and glowing offers to work in community hospital ERS as a psychiatric hospitalist. And by email, I receive AT LEAST 2 to 6 a day! This ought to quickly make clear one of the problems; as one one psychiatrist recruiter who was also a personal social friend for other reasons, told me ominously and presciently almost 20 years ago, “there is no product.” Meaning the supply of psychiatrists and psychologists, even back then far outstripped the demand. And from the ever increasing headhunter inquiries I receive, it is not yet improving.

A very telling quote from the article is that of Mr. Ken Norton of the NH chapter of NAMI one of my two most respected advocacy organizations nationally for national mental health reform. Mr. Norton states the obvious which bears repeating, The challenge is multifaceted and some of it is longstanding.” The other is Dr. E. Fuller Torrey’s organization, “Treatment Advocacy Center,”

The author of this telling article states that “On any given day last month in New Hampshire, there were 44 adults and four kids being boarded in emergency rooms while they waited to receive care for mental illness. There is a lack of inpatient capacity. There is a lack of community resources, there is a lack of step down or step up receiving facility beds or partial hospital day-treatment programs.”

Mr. Norton is a well-informed writer as he addresses that very long term economic conditions nationwide that have crushed the budgeting at the states’ levels for maintaining past levels of both outpatient and inpatient public psychiatric care. “Norton says the recession of 2008, the stigma around mental health and inadequate insurance coverage have all contributed to the problem.”

Mr. Norton notes that “ultimately, the level of services, hospital involvement, the level of private inpatient psychiatric beds, some of the other step down things all just kind of went away.” I think this is an apt manner of describing of what happened nationally in national psychiatric public and private service care delivery. It ‘went away’ quietly because other than the national advocacy organizations who did not have the national clout that they have worked hard to earn nowadays, almost no one outside of the mental health world (I refuse to call it an ‘industry,’) was stirring a faint racket on national stage compared to the overwhelming economic crises we were undergoing.

But Mr. Norton raises another dilemma if I may take some liberty with his remarks and reframe them. In the last several years, mental health reform has indeed reached the highest level of concern and national awareness yet. But as he states truthfully, “he worries that health care reform in Washington could exacerbate the crisis if, for example, caps on mental health coverage are imposed.”

Norton updates lawmakers in Concord and the governor on a regular basis. He says the crisis in New Hampshire can be turned around but it will take time and money.

And there is the big key, the bugaboo that legislators nationwide do not want to talk about, REVENUE to pay for the reconstruction of local, and state mental health delivery systems. We still operate under the nationwide ethos of the supposed curse or mentioning “new revenue streams,” or the most dreaded work of all: “taxes.”

Unfortunately, none of the static funding shuffling from one local or state level service need to another is going to do the trick.

“We have been advocating for statewide mobile crisis response. When somebody is in crisis, a team comes to them which includes peer support. We have been advocating for increased reimbursement rates for services for the community mental health centers to address the workforce development issue. And we have been advocating for more beds,” said Norton.

Related Story:

Special Report: Emergency Rooms in Crisis

ITP Ordered Inmates Continue to Take up Needed State Hospital Psychiatric Beds

In a very recent newspaper article “State hospital sees increase in court-ordered mental health evaluations, extending wait times ,” published in the| Wyoming News, on March 25, 2107 all too familiar story is unfolding and is typical of such issues nationwide.

State hospitals around the country are being flooded with referrals from local and state criminal courts. These patients are almost always chronically mentally ill who have committed mostly minor crimes including breaking and entering, theft, trafficking in stolen goods, assaults, trespassing etc. They are often not being actively followed by area mental health agencies and kept on their (usually antipsychotic and/or antimanic medications for a variety of reasons. Many of them have the characteristic of disbelieving they have mental illness and go off their medications rapidly This is a discussion for another day but it shows perhaps the most glaring deficiency in the outpatient care of the mentally ill today. We have no true old-fashioned public health organized outreach for these patients as we did in past eras, legislatively mandated (read court ordered) means of tracking these patients with mobile public health workers who make sure they take and stay on their long-acting injectable antipsychotics and stay symptom-controlled. We did this in the age of Typhoid March and in the era of getting syphilis under control as well as the national such treatment approaches to tuberculosis.
Nowadays “outpatient patient commitment” for such enforced treatment is at best limited and indeed laughable. Most such outpatient commitments, legal orders to comply with receiving their needed “LAI’s” last only 90 days and then patient in the majority of this population nationwide, absent themselves from follow-up, ending up back in state hospitals, in the jails where they become symptomatic. Jails are not in any shape or form psychiatric treatment facilities. Smaller jails in small counties and towns, have no psychiatric practitioners of any level of training, nor almost always a local community hospital with an inpatient psychiatric service.
So what happens is that these inmate patients gets petitioned by their defense attorneys or presiding judges to be sent to the local state hospitals, which often in the case in the big sparsely populated western states, the only state psychiatric hospitals, and invariably hundreds of miles from their communities of origin. They are called in most states, “ITP’s,” or “incompetent to proceed,” since they are mostly psychotic and cannot rationally aid their own defense attorneys.
The article in the Casper newspaper details succinctly that almost logarithmic meteoric rise in the number of ITP service requests the hospital has had to content within the last 115-17 years.
I will depart from my usual style and quote the author of the article since it deftly summarizes the ever escalating numbers of mentally ill in jails now requiring these services all across the country.

“Between fiscal years 2000 and 2004, the hospital completed an average of 131 forensic evaluations per year. Between fiscal years 2011 and 2015, the hospital performed an average of 193 annually.

The most recent figures show that between March 2016 and March 2017 the hospital completed 261 exams.”

“In the fiscal year 2015, the hospital performed 232 competency evaluations for the courts — more than double the amount in 2000, according to data from the hospital. Between fiscal years 2000 and 2004, the hospital completed an average of 131 forensic evaluations per year. Between fiscal years 2011 and 2015, the hospital performed an average of 193 annually.

The most recent figures show that between March 2016 and March 2017 the hospital completed 261 exams.”

State hospitals now are variously estimated to have approximately 25% of their public inpatient state hospital beds occupied by the ITP population. It often takes months to both treat in conventional manner these persons’ active psychosis and then months longer to put them through standardized curriculum to fully educate them about the in’s and out’s of the legal system, their charges, how to deport themselves in court and above all the actively participate in their own defense when they return to trial.

 

Reform Is Heating Up In Mississippi

Mental health reform has lagged unconscionably in Mississippi for years. Now things are really heating up in Mississippi, and it is not even spring yet.

A little background is in order first. Mississippi has an uncomfortable political situation that my state of North Carolina had for the last four years and made reform and budgetary cooperation almost impossible. The governor and attorney general of North Carolina before this past November’s election were from opposing political parties and were political rivals. I shall not go into a political review or rant over this, as we all have had too much of that sort of thing over the last year and a half at the national level and everywhere else. In any case, the governor of NC was voted out and the attorney general took his place as governor. While Mississippi may not have quite the same political situation [and I hope they do not, I would not wish what we in NC went through the last 2 years on anyone, it was awful], the two top political officials of the state are sniping, are not friends it sounds like and certainly not working together on many matters including mental health reform.

Things have apparently gotten worse in Mississippi in late February when MS Governor Phil Bryant made a demeaning pseudo-Huey Long colloquialism, to “Gimme some of that mental health reform.” Had I been present in the governor’s audience, I likely have muttered under my breath, that this is not ‘ol time religion,’ nor is it the movie ‘Oh brother, where art thou.’

The attorney general Jim Hood had even stronger reactions than I, in his newspaper opinion piece in the Jackson Free Press newspaper of the capital of Mississippi, “Governor Obfuscates with Call for ‘Gimme some of that mental health reform.’ The attorney did himself no favors either as he excoriated the governor literally charging that the governor was taking monies of the Missisissipi taxpayers for noble causes such as mental health reform [this was implied in the article] and giving them to “his” “huge corporate benefactors.” Whew, as I stated in my title, things really are heating up, down there…

But it turns out that the attorney general Mr. Hood may know more of which he speaks and has likely a compelling motive for supporting genuine mental health reform in MS. He states in the above-referenced article that he is defending the state of Mississippi against a number of lawsuits regarding mental health reform. Many observers of the national mental health reform movement have been observing the travails of MS as lawsuit after has been brought against the state for huge and serious lapses, gaps and just plain inadequate state and local level mental health services. As another article, “Mississippi Still Faces Merged Mental-health Lawsuits,” and detailed in “In the Statehouse and the Courtroom, Mental Health is Embattled,” also published in the Jackson Free Press, MS now faces a consolidated federal lawsuit by the Department of Justice and many other parties including the Southern Poverty Law Center. The second article gives a great deal of background on the new lawsuit, Troupe vs. Barbour [as in the former governor, Haley Barbour of a few years ago]. It also details the difficulties that are preventing the politicians from coalescing into a working coalition to get something done. [Gee, where have I seen that before in some august legislative body?]

Things are so bad that the Jackson Free Press editors have weighed in on the process in their call for positive action and an end to the political paralysis, “Stop the Mental Health Politicking.” In reading through the editors’ exhortation to stop the infighting and to get to work on the issues, I was struck by the similarities in the MS logjam with many others in states who have or are still struggling to come to terms with mental health reform. The editors angrily state outrights that MS’s mental health programs have been “shrouded in secrecy,” and that the deficiencies have been known and ignored by the state’s legislature “for decades.” Not ringing endorsement of the past or present efforts.

And the editors, as the voice of reality, [when did politicians ever pay attention to that? Answer: only when they have to, as one anonymous wag stated eons ago], reform will take large efforts, closing some institutions [angering workers, local economies etc.], and a lot of money. And when one gets to the stage of “talking serious money,” as the saying goes, the specter of taxes, new revenue streams, cutting other vested interests, all come into play. And especially in the South sometimes, the code is to try to be polite and not offend anyone. [I speak as a transplanted pseudo Southerner from the South(west) who has spent more than 3/4 of my adult life in the American South].

So it will be interesting to watch in the coming legislative session or sessions, whether the government of Mississippi can collectively come together for the benefit of patients, providers and all the other groups and peoples with interests in mental health care delivery, and construct something that works. If they do not, I am sure the “feds,” will help them get motivated to do so. But solutions are borne out of compulsion often do not have the self-generated altruism and pride to do something positive, and fall apart as soon as the “occupying force,” leaves, whether it is Iraq in our time, or Reconstruction in the American South after the Civil War, or the Gaza Strip in the Middle East. So stay tuned to the coming jockeying, political horse trading, and whatever else it takes to enact and implement mental health reform in Mississippi. It will be interesting.

 

Washingston State Hospital System Fined

IN a very recent story of less than a week ago, entitled: “Washington accrues almost $7.5 million in contempt fines,” written by Martha Bellislea of the Associated Press published in many major newspapers across the country, the sad story of the travails of Washington’s Western State Hospital continues to showcase the plight of a number state public psychiatric hospitals.

 

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Solitary Confiment: New Data and Food for Thought

In an intriguing article/newsletter/blog post, “REPORT OFFERS RARE DATA ON SOLITARY CONFINEMENT IN UNITED STATES” real data is offered on solitary confinement in the American prison system. The numbers are impressive. This article took its information from a report, “Aiming To Reduce Time-In-Cell.” published by “The Association of State Correctional Administrators, of The Arthur Liman Public Interest Program, Yale Law School in November 2016.

The report noted that “In the fall of 2015, 67,442 people were locked in a cell for at least 22 hours a day, for 15 continuous days or more.” The data was collected from 45 of the 50 state prison systems, and, 48 of the 53 federal prison jurisdictions.

Texas, one of my ancestral home states, that has the highest number of death row inmates in a county jail in the country, Harris County of Houston, was second only to California in the total number of inmates in solitary.

As far as the mentally ill population is concerned, the article states, “Just over 54,000 incarcerated men are reported to have serious mental health issues in general population. A little more than 5,000 incarcerated men with serious mental health issues are in isolation.”

As a final note, the percentages of inmates in solitary confinement is quite striking in some states that have relatively small comparable total state populations.