The history of public institutional psychiatric care since the 1050s has been a story of deinstitutionalization and treatment with new drugs for schizophrenia (Thorazine), depression (tricyclics), bipolar disorder (lithium and valproic acid), and numerous other mental disorders for which the only treatment had previously been involuntary confinement, too often under inhumane and squalid conditions. It has also involved policy decisions by Federal and state governments as to Medicare and Medicaid funding (patients in public hospitals not eligible) and a series of civil rights lawsuits that restricted the ability of states to confine the mentally ill indefinitely without due process or treatment.
The 15 experts consulted by the Center consistently estimated that 50 (range 40 to 60) public psychiatric beds per 100,000 population are needed for hospitalization for individuals with serious psychiatric disorders. This assumes the availability of good outpatient programs and outpatient commitment.
Mississippi, at 49.7 beds per 100,000, barely meets that minimum (at least within a margin of error), but it is the only state to do so, followed by South Dakota at 40.3.
The consequences of this negligence are not speculative:
1. Marked increase of persons who are homeless.
The effect of mentally ill homeless persons on the quality of life on nation’s sidewalks and in parks and public libraries are known by all who live in cities. According to one observer: “A simple visit to the local elementary school, post office or grocery store . . . can be a Dantean journey through the dark underside of our society. Violence, harassment and an astonishing list of antisocial behavior are commonplace.” These social costs are matched by fiscal costs. In Los Angeles it was estimated that the cost of “arrests, incarcerations, emergency medical care and other crisis interventions” runs between $35,000 and $150,000 per person per year for individuals who are chronically homeless. In Reno “a chronically homeless mentally ill man . . . cost the county at least $1 million during his 10 years on the streets before he died in 2005.” Fiscal conservatives thought that they would save money by emptying state mental hospitals, but they in fact only shifted the fiscal burden from the department of mental health to departments of corrections and social services and to the courts.
2. Massive increase in severely mentally persons in jails and prisons:
The three largest de facto psychiatric institutions in the United States are the Los Angeles County Jail, Chicago’s Cook County Jail, and New York’s Riker Island Jail. We have been unable to identify a single county in the nation where the county psychiatric inpatient facility is holding as many mentally ill individuals as the county jail. And once a person is in jail, it is almost impossible to find them a bed in a psychiatric hospital. In Virginia, for example, Sheriff Paul Lanteigne of Virginia Beach “estimates that it typically takes at least six months to find an available bed for a deranged inmate.”
3. Concentration of mentally ill persons in emergency rooms, waiting for psychiatric beds to be found:
4. Violent crime:In North Carolina, for example, Doug Trantham at the Smoky Mountain Mental Health Center described “an inpatient crisis so bad that what it does is backup the entire system.” Officers there have sometimes had to drive patients across the entire state—a seven- to eight-hour drive one way—to a hospital with a bed. Emergency rooms are said to have mentally ill people waiting “four or five days in our ICU just waiting for a place to go. . . . You may have somebody in there all weekend, screaming for 12 or 18 hours,” said a nurse. It is the same in every state; in Arlington, Virginia, county officials had to call 31 hospitals before finding one that would accept a patient. The impact of overburdening the ERs with patients needing hospital beds goes far beyond psychiatric patients; rather, it interferes with all medical and surgical care in the ER.
Because there are so few beds available, individuals with severe psychiatric disorders who need to be hospitalized are often unable to get admitted, and those who are admitted are often discharged prematurely. Fred Markowitz, in his 2006 study of 81 American cities, reported a statistically significant correlation between the number of public psychiatric beds available in that city and the prevalence of violent crimes, defined as murder, robbery, assault, and rape.11 This is not surprising, since studies have shown that between 5 to 10 percent of seriously mentally ill persons living in the community will commit a violent act each year, almost all because they are not receiving treatment. Such individual are responsible for at least 5 percent of all homicides.
Many readers will recall the death on April 18, 1993 of Matt Devenney, shot by a mentally ill man in front of the Community Stewpot where Devenney was the director. What most people did not know was that a Hinds County Chancery judge had previously found the killer to be insane and dangerous, but could not convince the powers-that-were to keep him confined at Whitfield. Each time, while the judge watched helplessly, they released him after a short stay. Eventually, he killed somebody.
It ought not to take a murder to convince a shrink that a patient is dangerous.
I suspect, however, that they did know that he was dangerous, but just didn't have a long-term bed or a cell. Now he does.
So while we may be ahead of the rest of the nation in the statistical tables, what we are doing is still inadequate.