A State Hospital’s Troubles: Typical for the Country

Western State Hospital in Lakeland WA is undergoing troubles again. In an article published on the local tv news outlet KOMO-tv, entitled,  “Western State Hospital warned again about the loss of federal funding,” by Keith Eldrige on Friday, July 7th, 2017 the details and some of the history leading up to this sad state of affairs is enumerated in straight forward and informative fashion.

A little background is in order to be fair and honest to the reader as taking thins out of context can almost always lead to a quick and wrong impression. As state hospital go, Western was doing fairly well under very trying circumstances that have been in NO way unique to it alone. It has been besieged in recent years like all state hospitals by the new wave of “ITP” or incompetent to proceed patients that have emerged in nothing short of droves of thousands across the country. These patients are one of the most obvious results of the “trans institutionalization” of patients from the ‘under-bedded’ state and local public psychiatric hospital systems nationwide through the misguided efforts to cut inpatient psychiatric beds drastically to save monies in state budgets, in turn, themselves slammed around economically by the huge impact of the Great Housing Bubble burst [read runaway Wall Street greedy foolhardy faulty and dishonest mortgage packaging of the 2000’s]. States had to cut budgets drastically and almost universally their mental health segments had to be cut and beds cut and the hospital closed out of hand in many states. So we had the well-known issue of the chronically mentally ill appearing out in the public without almost any housing and inadequate outpatient services in almost every state. And to survive they did things that put them in jail in droves. It was perhaps a little ironic or surprising that one very conservative [I do not mean that politically at all] group nationally, the associations of country sheriffs and other such law enforcement policy groups became some of the EARLIEST non-clinical groups yelling to the rooftops along with mental health advocacy groups such as NAMI, the Judge Bazelon Center, and Dr. E. Fuller Torrey’s national advocacy group, The Treatment Advocacy Center.

Dr. E. Fuller Torrey, national psychiatric advocate for the severely mentally ill
Western still had budgetary gaps and big ones. It had deficiencies in safety, inadequate fire control measures, areas of the structure that drastically  need renovation, and still staff issues. Staff have been required to work overtime on a regular basis for many months to make up for the migrating losses of staff to other facilities as detailed about. This resulted in frank and known and identified burn out and work fatigue identified by the hospital and more staff quitting. So Western has been in a vicious cycle of I suppose almost barely keeping its head above water with respect to staff and still not being able to get back up to full capacity.
The Governor of the State is Mr. Jay Inslee, a Democrat. He has a Republican-controlled state legislature. He has worked openly and tirelessly with the legislature to craft compromise funding bills to help the state hospital system and it has been hard and slow. And, in effect, not fast enough to remedy the long-standing and recent acute problems of Western State Hospital over the last two years or so.
The importance of all this is of course money. Money to support the hospital, part of which obviously comes from the state’s legislature and the rest from usually not very large patient collections, but the rest coming from the Federal agency, the CMS. If a hospital loses accreditation, it loses CMS funding. And then the state has to make up the difference immediately often to the tune of a million dollars a month or more in most states I have followed over the past decade or so that have gone through this painful process. Often the Feds, such as CMS, give extra time, in this case, another 60 days for Washington to put in place beginning remedies, in order to give the whole process time to hold off on the “death sentence” of cutting off federal funding altogether as it usually takes a long time, like well over a year or so if not more, to make big and expensive repairs in the physical plant and recruiting psychiatrists and psychologists to the tarnished hospital.
Western State Hospital and Washington are one of several state hospital systems in the same position and there are no easy answers for any of these bodies that are ‘under the gun.’ But one answer is clear and has been in plain sight for decades and is THE root cause for all this, large and continuing sums of monies must be spent by state legislatures to correct the neglect of decades of the mental health delivery systems.
Advertisements

Millidgeville State Hospital, History & Pictures

I had a residency classmate at my training program some 40 years ago who eventually served as medical director of this huge old state hospital. I visited it once long after he had worked there for a stint and was overwhelmed by its size and vastness of its campuses. I had never seen such a massive mental hospital facility and was not prepared for its size.

It had its share, or more than its share of scandals and periodic tales of abuse for decades and did many such state hospitals especially early in their histories before the era of modern treatment with advent of effective medications, movement beyond just ECT, or electroshock therapy for out of control mania and truly treatment resistant long-standing depressions and the addition of all the behavioral and cognitive therapy, art therapy (and that really is valuable stuff speaking as someone who in my younger stupider days, thought it was not very relevant [I was a dummy young Turk type then to some extent], music therapy, DBT [Dialictal Behavioral Therapy which is wonderful stuff], psychodrama [which is sadly not practiced in enough hospitals] and so on.

What I am leading up to in my habitual meandering style is pointing the reader(s) to a post I somehow discovered one night recently, on a sort of mixed text and wonderful pictorial history of Milledgeville State Hospital [latter called Central State Hospital in recent modern days before it closed in 2016] that is so well done I had to do this post and highlight/publicize it by offering its URL so readers could read it and marvel at this institution, its history and dilapidated kind of grandeur. I know there are those that would rankle at having the term ‘grandeur’ applied to state hospital that personally represented horrors to them or their extended families, and I understand and completely accept that sentiment as all state hospitals had their sins, tragedies, and horrors to say the least and were in ways certainly ignoble chapters in our nation’s history.

But anyway, here is the URL to the extremely well-done website that shows an enormous amount of artistic photographic effort and historical research that I think many will enjoy and as I said above, marvel at. URL: Milledgeville State Hospital in Georgia.

 

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.

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”

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.