Unintended Consequences of Mental Health Care Delivery Reform

A small town newspaper can often offer a startlingly accurate portrayal of policy governmental changes not noticed, or reported upon by the mega-media in many locales. One such North Carolina very small regional newspaper is the Laurinburg NC Exchange. This town is likely unknown to 99% of my readers unless you are from northeastern NC, an area to the east of Interstate 85 as it curves north from Durham “The City Of Medicine” toward the state border with Virginia. It has a proud heritage of being a center of Scot (not “Scottish”) culture with an annual festival with the wearing of clan tartans and kilts.

The Laurinburg NC Tartans
The Laurinburg NC Tartans

Just three weeks ago, one of its weekly lady columnists that all Southern papers worth their while seem to have to comment on the higher ordinations of life, Ms. Mary Katherine Murphy, published a most perceptive piece of analysis entitled, “State of Mental Health: Barriers Impede Treatment.” As this is what I blog about in large part, this piece caught the ever roving eye of one of now well trained roving Google searchbots, and snagged this piece for persual. Ms. Murphy may be from a small town area and culture but her piece is well worth reading for anyone interested in this 15-20 year crisis in the  social fabric of our country. I would most strongly recommend it if I had the power to do so, to policy wonks and governmental planners, scholars in research and “think tanks” of all political stripes in this country for thorough pondering. It is that good in its brief but very on target two pages.

Continue reading “Unintended Consequences of Mental Health Care Delivery Reform”

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Progress in Washington State in Obtaining Emergency Access to Psychiatric Care

Big Strides for mental health reform, but work remains,” published originally May 16, 2015 as an editorial in the Seattle Times, provides some encouraging news in the national efforts, state by state, to improve incrementally mental health services delivery approaches.

This editorial provides a concise summary and history of the development of the current crisis in that state’s public mental health services that have long been coming. Like so many other states, the economic hits suffered especially since the great housing bubble and “Great Recession” hit the funding of public services ranging from state’s higher education university and public education funding to public mental health care resources, mandated huge budgetary cuts nationwide.

Washington state’s Governor Jay Inslee signed “Joel’s Law,” nearly two weeks ago a bill named for Joel Reuter, a bright, young software engineer whose illness made him believe he was shooting zombies when he was killed in 2013 by Seattle police.

Joel’s Law for the first time gives parents or guardians in Washington state finally, the right to directly appeal to judges for involuntary commitment of a loved one, a power previously reserved for mental-health evaluators. As I had commented in another post concerning Wisconsin’s surprising and highly tragic, misguided laws which permits only police to initiate involuntary commitment petitions for emergently needed psychiatric care, Washington had a very restrictive process to allow commencement of emergency psychiatric care.

The Washington Legislature has moved in exemplary fashion to adapt helpful legislation from other states such as New York and California in creating  new programs to allow judges to mandate outpatient treatment in House Bill 1450 for people with serious mental illness. This sort of program has been utilized to great benefit in many states in the last 10 years or so, including my home state of practice, North Carolina involving “ACT” teams which operate on a public health model of providing follow up and on site, meaning in the patient’s place of residence to supervise compliance with reliable of taking of psychiatric medications to prevent relapse into psychosis, and many kinds of social supports, entree’ into day programs, educational pursuits and keeping up even with their routine medical health maintenance.

This kind of proactive assisted outpatient treatment program can overcome the endemic lack of recognition that many of the chronically mentally ill that they indeed have their condition, which causes them to not take their medications, relapse into psychosis over and over, ending up needing otherwise needless expensive re-hospitalizations. These kinds of programs are from the public health model utilized over decades ago in ensuring tuberculosis patients took their daily curative anti-TB medications. Similarly syphilis was reduced from an all too common scourge to a relatively uncommon sexually transmitted infection by use of public health workers who not only tracked down carriers but also were able to utilize legally supported powers of enforced treatment. Somehow these massively protective and effective treatment approaches were lost in the anti-institutionalization fervor that held sway decades ago with the unintended consequences of not providing for effective outpatient public health like treatment models that would have prevented much of the national mental health crisis we confront daily.

But these kinds of programs are expensive as it takes serious money to pay for these outreach workers, frequent health care worker contact etc. Unfortunately the editorial cited above, are not yet budgeted to their needed levels. The Seattle Times pointed out sadly that perhaps only less than half of the projected $9M cost has been budgeted to date.

Joel Reuter’s father, himself notably, a former Republican Minnesota state lawmaker, was quoted concerning the ongoing reform efforts as stating: “It’s a monumental accomplishment to get both parties and both (legislative) bodies on board for this large of a change,” and that “the system here was so broken.”

My sad comment is that in the past year or so, we have had two legislator or former legislator families suffer the deaths of their sons, one due to his psychotic behaviors forcing lethal intervention, and the other to suicide. It took the grief driven but enormously selfless dedicated efforts of these two men, fathers who lost their sons to psychosis, to prod, shame and lead their states toward enlightened action on the behalf of the severely mentally ill and their families to facilitate securing even emergency psychiatric intervention. This goes against the political ethos and ideology that this country has suffered under for the last 30 years; that of cutting taxes no matter the human costs. Hopefully the public is finally catching on to these nationwide mistakes that this cruel approach has cost us in many areas, slashing teachers’ salaries, cutting our investments and support of our stellar state educational systems. All this has been under the banner of the self proclaimed boasting of resisting “raising taxes.” I submit that the time for this cruel shortsighted approach is approaching the end of the time when this was true and needed. But even now in this slow recovery, novel revenue streams are waiting to be enacted and tapped that would not be as onerous as our dogmatic politicians would have use believe. This ideology itself is becoming too costly to maintain for the health of our country in multiple arenas of essential functioning.

It is time for more enlightened leadership that politicians love to espouse but few are able to demonstrate in times of our need.

 

A State Hospital for Sale

 

Dorothea Dix Hospital
View of Dorothea Dix Hospital, Raleigh NC

One of the former three truly old, historical state hospitals in North Carolina, Dorothea Dix Hospital in the state’s capital, Raleigh, is now cleared for completion of its sale to the city of Raleigh. The huge, many hundred acre site, established in the late 1800’s, and named after one of the early American crusaders for improvement in custodial (institutional) mental health care, Dorothea Dix, will proceed with its long debated and fought over sale. The sale will total somewhere around $52 million according to a very recent news story by WRAL ABC Channel 11, of Raleigh.

Why is this of note in the world of mental health reform in this country?

1. There are literally many dozens of old languishing state hospital properties and campuses in this country; many are almost unbelievably operating after perhaps an average lifespan of nearly 150 years, while many others are abandoned ghostly properties. If you are curiious about these architectural gems, or, monstrous relics of bygone eras of ghastly cruel inhumane care, depending upon your beliefs and attitudes toward the always controversial history of mental health care, please search on my favorite bookseller and go to reading search site, Amazon.com and look for books on asylums and state hospitals in America. Fascinating reading for those interested in this sector of esoteric social history if ever there was one.

So many of these properties need to be sold, preserved or whatever, now and in the future as the still active facilities gradually are “phased out,” and replaced by more modern facilities or closed altogether, depending on the need for inpatient public psychiatric beds in each state.

2. They represent a real source of monies, for state and regional/municipal coffers that could be put to good use.

I have been aware that very few of these properties around the country have been sold and converted to helpful assets or capital. There are a number, though honestly speaking, not many, websites that catalog the numbers of abandoned former state mental hospitals slowly proceeding to ruin through abandonment and fiscal and physical neglect. One website through the genealogy organization of RootsWeb, lists perhaps most of the former and current American state psychiatric hospitals state by state. And it unbelievably it offers information on the phenomenon of the “Asylum Tourist.” Sheesh. I appreciate historic sites and beautiful woodwork, antique furniture as much as a geek can. My late father was a master woodworker and proud owner of a “ShopSmith” all his adult life. [If you do not know what that is, well, Google it, or, don’t bother, it really is information will not make you stand out anywhere except at a woodworker’s convention, or in perhaps a Trivia Pursuit championship. But then again, I doubt even the latter.

State hospitals always have and had fantastic craftsmanship, furniture, architecture, woodwork etc. Much has been salvaged from closed state hospitals. If you are a “preservationist” like Europe seems to have been in their cultures for hundreds of years, this stuff matters. That’s why we go to Rome, to Paris, to Prague, to see the incomparable buildings, art, statues, gardens and on and on. But if you are a modern, [wasteful?] devotee of the disposable, rapidly obsolescent approach to “things,” then all this is likely drivel and unimportant. I certainly am in the former camp, the older I get.

Another historical website devoted to this kind of history, details the history of the “Kirkbride” architecture of state hospitals that totally dominated such institutions for nearly 3/4 of a century. Students of architecture and architectural history still study these, visit them and even go on “tours” of these sites around the country. [I know that sounds perhaps very weird to most, but bear with me].

So I have pondered in recent years, what could old state hospitals be converted to? This is my partial list of charitable causes I could see some of these grand and incredibly sturdy structures devoted to:

  • community college facilities
  • public school educational facilities
  • subsidized housing especially for the elderly, as there are bathrooms galore, and these places were hospitals for goodness sake
  • public governmental offices [don’t laugh, check out the connection between the former St. Elizabeth’s Hospital in Washington DC and the Department of Homeland Security…
  • public museums

Now marketing a state hospital even in the best of condition is not an easy task. They are often located in not the most economically active metropolitan centers; they are mostly located out in the boondocks, the isolated countryside, as part of their raison de etre, was to get the disturbed and disturbing mental patient, the insane, out of the public eye. Who wants a facility with many buildings, and hundreds of rooms out of the middle of nowhere? Raleigh, North Carolina’s Dorothea Dix Hospital is one of the fairly rare exceptions, being located in a major modern city.

They are all truly ageing physical plants. Most of the inactive hospitals, if not almost all, have deteriorated markedly through neglect for a few years to decades. They would take huge amounts of money to rehabilitate and bring up to modern building codes.

Though all of them were really sturdily built, they were never the most energy efficient structures even with their three feet thick walls and no wood in their make-up to attract the pest control companies’ best friend, the termite. It is not unusual for an operating state hospital to have utility bills of hundreds of thousands of dollars a month, even in the scaled down facilities. Thier heating plants are aged, and almost always belong to the steam non-electrical eras of heating.

I now am witness to a state’s dilemma of what to do, at a hoped for helpful profit, with a soon to be closed ageing state hospital. How does one market such a huge property that is not a brand spanking new outlet mall on a busy inter-metropolitan interstate highway, that will mint money the week it opens?

At least in Raleigh, Dorothea Dix herself, I think would be pleased with the coming sale of her namesake institution. It will become property of Raleigh, the state will gain a sizeable amount of monies that can be put to good use, and the city of Raleigh will receive a new very large regional mixed use business park out of the deal. That appears to be far better than the site becoming a huge, slowly deteriorating eyesore and environmental blight. A good deal all around.

 

 

Typical Example of a mental health system crisis

The first newspaper series I recall reading about a state’s then system wide mental health crisis was in the 1990’s in the venerable Detroit Free Press. It is no longer available online unfortunately; it fell victim I guess, to the declining fortunes of that paper a number of years ago when it nearly went out of existence and went to publishing only three weekdays during the week. The series came after the governorship of John Engler who had to cope with the decline of the economic fortunes of that state in the 1990’s when the Big Three automakers fell on hard times and the state of Michigan suffered tremendously as much as any “Rust Belt” state at that time of disappearing manufacturing jobs. Governor Engler was one of the first governors who took a severe economic axe to human services, as well as many other state funded services, in order to keep the state going. Michigan was dear to my heart as I had attended college and medical school there and I had close friends there. One friend kept me in the loop by sending me paper cut-outs of articles from the Free Press documenting the devastating effect upon mental health services. Institutions, both academic and public state hospitals were closed that I had worked in. I found it all very hard to believe and it stimulated then my interest in “mental health reform,” that later hit my home state beginning only a few years later.  As an historical, geek aside, this was early in the days of newspapers going online and during the series on that state’s mental healthcare revolution; later the series was online but now no longer available. But this series was almost prescient as it foretold the crises other states were likely to face and how the severe but likely economically inescapable wrecking ball approach to funding in mental healthcare delivery, would affect patients, soceity, hospitals, law enforcement, jails, courts and practitioners.

A more current and still available online newspaper series on this same topic, is from the Milwaukee Journal-Sentinel, a wonderful paper. It is entitled: “Chronic Crisis: A System That Doesn’t Heal.” This series appeared in 2013 but if the reader follows the above link, you will find articles referenced also in the same newspaper that go back to 2006. I highly recommend this first lead article and its successors also found linked at the above site for further reading. It has the all too familiar stories of human tragedies, patients not helped for various systemic reasons, who died, their grieving families, analyses of the circumstances and cases, etc. If one has read any of these genre of series that are now appearing in the media now for the last several years, one has seen too many of these accounts already.

This series however, has a few features that make it exemplary and worth reading if you are interested in this social issue. It has presented a fascinating portrait of how local circumstances and even local legislation and lawsuits, one referenced in particular, that have either hamstrung systems, approaches and practitioners, or local differences in approaches to emergency services that surprised me and were new and issues I had not conceived of. I am like everyone else, still primarily local and parochial in my views and unconsciously, assuming that laws regarding, for example, involuntary commitments for mental patients urgently-emergently needing mandated care, worked the same. This series disabused me of my naive stance in a hurry.

As a “spoiler” to the reader, I will highlight the one issues that surprised me the most of all. In Wisconsin, only police can initiate an involuntary mental health petition process. In my state, any adult can initiate a psychiatric “petition.” To quote the article referenced above: 1) “Wisconsin is one of only five states that require police officers to detain a patient in an emergency;” 2) “It is a system built in reaction to state laws drafted by public defenders in the mid-1970’s that stressed the need to ‘avoid commitment at all costs’–laws that put the focus on the right to refuse treatment, not how best to provide it.'”

To afford the reader some helpful contrast, in my home and practice state, any adult who has first hand knowledge of the imminent danger to self or others on the part of the petitioned person, can initiate a mental health petition. This means that family who witness a valid and deserving need for emergency treatment, such as a credible suicide threat or act by their family member, can initiate a petition and quickly mobilize an evaluation and possible treatment. In such states’ statutory process, there is still a very strong check and balance system reviewing the evaluation, commitment and certification of treatment process that is mandated, open and transparent, and, provides for appointment of responsible and skilled counsel for every petitioned individual. A court proceeding for review of all these steps is mandated routinely. So petitioned persons are not “railroaded” as one could infer or fear. Just the opposite in fact and practice.

In future installments, I will go on to review other articles and sources of the now 15-20 years of mental health reform efforts. One will come to appreciate that even with the local variations that is unique in Wisconsin as so well documented by the Milwaukee Journal-Sentinel, many of the issues are the same from state to state.

 

Introduction to Mental Health Reform in North Carolina

Mental Health Reform began in North Carolina partially out of economic necessity. Other states had had to do so in the Midwest during the decade of the 1990’s for similar reasons, the decline of manufacturing in the so-called “Rust Belt,” but one example used mental health reform undeniably as a nearly vindictive budget slashing measure, singling out more than any other major expenditure category of a state budget for drastic cuts.

North Carolina’s impetus was truly largely driven by a perfect storm [no pun intended but it is one unfortunately nonetheless as the reader will quickly see below] confluence of unexpected and massive budgetary hits to the NC state coffers. In 1999-2000 along with a number of other segments of the economy, the “Dot Com” bubble burst nationally. This affected NC severely as North Carolina had long been building an information economic powerhouse through especially the Triangle area’s [Durham, Chapel Hill and Raleigh which are all within 8 or 15 miles of each depending on which leg of the triangle connecting the three cities you measure] universities, Duke, UNC-Chapel Hill, and North Carolina State University, respectively. NC State at the time and still is the most technically driven of the three and is now beginning to rival Rensselaer, MIT, Georgia Tech and Cal Poly in terms of research, award winning faculty, technical centers and spin off high tech companies. In fact, NC State had already established a new technical campus, the Centennial Campus adjacent to NC State’s campus and on the way to Research Triangle Park toward Durham. That campus has continued to massively grow in the years since the dot com recovery, for instance now housing the headquarters of Red Hat, the world’s leading commercial Linux distribution. This illustrates how much of an economic vortex the RTP {Research Triangle Park) is, generating hundreds of millions of dollars into the state economy. When the Dot Com bubble burst in those days when idiotic Internet companies were starting up, having no real product but promising getting groceries delivered to your house (now perhaps closer to reality), being overvalued in the stock market by unimaginably inflated multiples, the RTP of North Carolina suffered greatly, more so than Silicon Valley which was older, more established, larger and deeper. Jobs by the thousands were lost which were very high paying. High tech personnel left the state, state income tax revenues took a substantial hit. All this was a preview on a mini-scale of what was to come in the 2008 mortgage housing and financial derivatives scandal and bubble/Great Recession, partially still with us.

Continue reading “Introduction to Mental Health Reform in North Carolina”

Mental Health Reform–The Beginnings of It All

A State Hospital Dome
A Typical State Hospital Skyline

 

 

 

 

 

 

 

Since this is the very first entry into this site devoted to the contemporary history of one of the states’ efforts at “mental health reform’ since the late 1990’s, I should preview what will the be the ongoing thrust and intent of this effort.

  • This author will endeavor to focus primarily on my state’s mental health reform efforts since the late 1990’s
  • I will also in these early posts draw upon my knowledge of some of the first efforts in the United States to begin to grapple with the long dormant tasks, needs and dilemmas of the public mental health services sectors, long neglected and unchanged since the 1963 ‘Comprehensive Mental Health Center Act’
  • I will trace the many steps and changes that the effort in North Carolina has undergone, from incremental changes, improvements and commendable efforts at correction, the fits and starts, the usual “unintended consequences,” tough lessons learned since 1999-2001 when this started
  • I intend to also give credit where credit is due to the state of North Carolina, its leaders, political structure and veteran Department of Health and Human Services, to reach recently now consolidating improvements, and recent commendable achievements wrought under difficult circumstances when many were harsh and vocal critics of this uncertain reform effort, myself included in past years
  • And finally, I will try to observe a personal tenet of mine, to give credit and ‘compliments, as the positive fruits begin to take unmistakable and firm footing, that were long doubted by many especially the sector of mental health professionals [again including this humble observer; I believe that in our currently polarized and argumentative public climate, we have just about lost the sense of fairness in complimenting each other, looking past philosophical differences and vilify or deny the worth of others’ ideas; and a fitting compliment goes a long way to forging partnerships needed for fashioning corrective steps and improvements, when taking on such complex and overwhelming social problems that this blog attempts to describe, educate and promote a better grasp of where we have been and where we are hopefully headed in our efforts of promoting the common weal and good for all our citizens in need.
  • Along the way I hope to show how North Carolina, in my view is one of the nation’s leaders in devoting impressively large and comprehensive resources in addressing the effort of mental health reform even in these times of a lasting and lingering economic slowdown, where the temptation could be understable to stint on budgeting sufficient resources, and end up repeating the decades or even centuries old practice of giving short shrift to the mentally ill and cutting their budgets since they by and large, do not have powerful lobbying groups on a level with labor unions, huge corporations, nationally based special interest groups, with a few exceptions that serve special groups among the mentally ill populations.
  • Finally I pledge to the readers of this commentary observational effort, to present as even handed a presentation and historical accounting as this practitioner can, given I am not a trained historian, reporter or writer; similarly I must make “full disclosure” particular to this effort and my position: I am a psychiatrist and subject to the views and educational, clinical ethos or bias that goes along with and arises out of my four decades of practice and experiences, that I have practiced in many settings from private, academic, public state hospital and local mental health centers, HMO clinics, Native American populations, correctional facilities for adults and adolescents, outpatient and inpatient settings of all stripes from acute to residential. Mostly, I must respect the ethical expectations of my current employer, a state hospital of the state of North Carolina, and will not abuse this position and knowledge I have of this institution, its staff, leadership and especially its clients, all of whom I owe a debt of gratitude for permitting to practice and do what I love best, treat and help patients, and teach trainees and participate in a care organization that puts its efforts where its mission statements vows, to be an aid to all, operate with respect and be honestly transparent, and to constantly self-monitor and improve. I am in the twilight of my career in some ways, and realized when I came to work here, that I had come full circle, from my first years out of residency at Duke when I took a state hospital staff psychiatrist position at the then but no longer existing John Umstead Hospital north of Durham, to help start an acute inpatient adolescent unit and a comprehensive multidisciplinary family therapy training program. I was green, inexperienced, eager and did not know my own limits but always itching to contribute. Now I work with, in many ways, the most challenging clients of my career, and think in a karma kind of way, that venue I have worked in heretofore, no matter how different, has prepared me for what I do now, and I am ever grateful to be here, at a time of great change and challenge. I hope the reader will enjoy the story I will attempt to tell.

Respectfully yours,

 

Frank Black Miller MD DFAPA

 

We Need the “Asylums” Again Believe It Or Not

On January 16, 2015 the American Medical Association issued a press release giving notice of an article that asserted the current model fo treating the mentally ill as “ethically unacceptable and financially costly.” It was walking about the decades old failure of “de-institutionalization” that in in its second or third cycle of failure, being re-enacted in states all over the country once again, with similar and predictably disastrous results. I have the feeling that its title and byline in the press release was a little bit intentionally inflammatory to call attention to the importance of this issue.

This article was startlingly timely in that this author had just this week launched this blog on the broad topic of “mental health reform” and the state by state and national debacle it has become since the 19990’s in Michigan and since 1999-2000 since the same dishonest cruel blueprint was foisted upon the naive and desperate legislators in those states to save monies. Michigan by the 1990’s was in accelerating economic swandive mode because of the near bankruptcy of the Big Three American auto makers at the end of the second George W. Bush Presidency, forcing the surprisingly opposition to the bail out first of the two USA life saving bailouts that were left to the the new Obama administration. One would think that the Republicans would remember the satirical but emblematic motto of the character of “General Bullmoose,” in the old “Lil’ Abner” cartoon series by the great satirist Al Capp, “What’s Good for General Bullmoose is Good for the USA!” General Bullmoose was a character who represented the auto (GM–get it?) and military interests that dominated the country in those decades from the 1950’s onward. Business was supreme and has always been the organizing ideological center of the Republican Party. Michigan was one of the Rust Belt States losing population by the thousands yearly as families fled the loss of jobs in the auto and allied industries foretelling a trend that continues to this day.

Meanwhile North Carolina in the late 19990’s suffered enormously from the precipitous “Dot .com” bust of overvalued darling companies of stock hucksters on Wall Street that were innovative but made no money and somehow a free Internet based serviced equalled or guaranteed riches in the future. Conservative economists and stock experts who warned in ever darker tones in those years about that folly were lampooned unwisely by the upstarts of the New Economy that no one could define as old fuddy duddies with their economic heads in the sands of progress. North Carolina was perhaps the third most important “Dot .com” economic engine in the country after Silicon Valley and the Boston Corridor because of North Carolina State University’s technical powers and the graduation of the RTP (Research Triangle Park”) into the tech Big Leagues with dozens of start up tech companies who went bust as funding vaporized when results never appeared and tight money clamped down. Then North Carolina got hit with Hurricane Floyd which devastated an Eastern part of the state and cost the state in short order between one and two Billion dollars to helps its citizens rebuild. Then North Carolina lost a very important legal economic case in the early 1990’s that went all the way to the Supreme Court and cost the state over $900B in one year. North Carolina lost its contention that it could, as it had been for 9 or 10 year years, taxing the federal retirement pensions and benefits of retired federal workers living in the state. The loss meant the state had to refund almost a billion dollars swiftly as NC is a state that requires by its own Constitution that its annual state budget always be balanced, no matter what, no funky borrowing or issuing junk bonds as a way out. So the General Assembly was desperately looking for a way to save approximately two billion dollars quickly and fell sucker to the pitchmen from Michigan and before that Massachusetts in the 1980’s who had saved those states huge amounts of monies but slashing the budgets and costs of the mental health systems with a new plan that was called euphemistically “Mental Health Reform.”

Its basic tenet was to close ‘expensive’ out dated state hospitals and their beds, since everyone knew by that time that being in the state hospital environment was bad for your because of the three decade long promulgation of the modern fallacy of “institutionalization.”

The four state hospitals in Nor Carolina, Dorothea Dix Hospital in Raleigh, Cherry Hospital in Goldsboro, John Umstead Hospital in Butner outside of Durham, and Brougthon Hospital in Morganton in the western third of the state and the largest, had their beds reduced by roughly two-thirds each. The bogus reform plan, a several hundred spreadsheet program utilized in other states notably Michigan, promised the building of comprehensive outpatient services as it dismantled and destrroyed the well functioning local county by county mentalh health services. It was also suppposed to build for a start, sixteen smaller, more regionalized (read local and closer to families) less “isntitutional” smaller “mni” state hospitals. None were built for years by the state except one which was placed in the outskirts of the western town of Sylva without a large enough supportive psychiatric cohort staff of practtioners in an old, converted, rennovated nursing home and one unit housed in a small community hospital in Linville NC.

And the results were predictable, patients lost their long trusted psychiatrists and clinicians by the droves and it took years to replace those. Crises with patient ended up in the ERs of small hospitals all over the state, many with any psychiatrists on their staffs OR any inpatient psychiatric units. Patients also ended up in even greater numbers in the jails, at the country and state levels. Counties suddenly had to find staff, resources and medication budgets to care for at least 10-20 times more mental patients than they had ever had, Jail suicides dramatically increased. And the mental health reform took years to try to catch up.  A prominent then Duke faculty psychiatrist in the mid 2000’s stated publicly for the media in an interview that it would “take 10 years for the state to replace what we had [in state mental health capabilities] ten years ago. A more damning indictment of the the state’s mental health reform effort could not have been verbalized except the description by a Dr. Steve Crane MD a teaching physician for the family practice residency program in Hendersonville and Asheville as “the disaster that just keeps on giving,” which was a satirical take-off on the then current circulating satirical description of Hurricane Katrina and the failure of the Bush Administration to respond to it in a timely fashion which is now a classical study in government and business schools on how NOT to handle a crisis.

To quote the article in the Journal of the American Medical Association published January 20, 2015, “As the United States population has doubled since 1955, the number of inpatient psychiatric beds the United States has been cut by nearly 95 percent to just 45,000, a wholly inadequate equation when considering that there are currently 10 million U.S. resident with serious mental illness.

Continuing, the authors of the article, Dominic Sisti Ph.D., Andreas Segal MS, and Exekiel Emanuel MD Ph.D, wrote “For the past 60 years or more, social political and economic forces coalescent to ove severely mentally patients out of psychiatric hospitals.” They went on to say that the psychological civil rights movement propelled deinstitutionalization and resulted in “transinstitutionalization” which meant the severely mentally ill hit the ERs, jails and homeless shelters and streets around the country in huge numbers.  To further quote, “…most disturbingly, U.S. jails and prisons have become the nation’s largest mental health facilities. Half of all in mates have a mental illness or substance abuse disorder; 15 per cent of state inmates are diagnosed with a psychotic disorder.”

Instead, to quote the press release itself, “the authors suggest that a better option for the severely and chronically mentally ill, and the most ‘financially sensible and morally appropriate way forward includes a return to psychiatric asylum that are safe, modern and humane. They argue the term ‘asylum’ should be understood in its original sense–a place of safety, sanctuary and healing,” and I would add long term care, and long term rehabilitation to permit development of the current mantra ideal goal of “recovery.”