The Largest Psychiatric Hospitals in the USA

In about 2012, I read an article that described the largest psychiatric hospitals in the USA as

1.  LA County Jail
2.  Riker's Island
3.  Cook County Jail

In the past month there is good evidence that in Minnesota, one of the most liberal states in the country - the situation is no different.  A recent study estimated that 25-30% of the jail population had a mental illness and 11% were on maintenance antipsychotic medications.  The  Hennepin County Sheriff Rich Stanek is quoted:

“What we’re seeing is crisis levels of mental illness among our inmates. This is solid evidence that our jails continue to serve as the largest mental health facilities in the state.” (1)

That same article refers to a Legislative Auditor's report describing the problem as widespread throughout Minnesota.  There is an alarming statistic that since the year 2000 there have been 770 suicide attempts and 50 suicides in Minnesota jails.  The article does outline some helpful measures.  Inmates will be screened by psychologists and psychiatric nurses.  The screening by psychologists is focused on low level offenders who can possible be released earlier,  although the offenses of the mentally ill were not substantially different from the non-mentally ill population.   The mentally ill inmates had a higher recidivism rate and were 30% more  likely to have 10 or more bookings at the jail. In a separate opinion piece (2), Sheriff Stanek reports that jail personnel are all going through 32 hours of crisis intervention training (CIT) to learn about the specific problems that mental illness causes and how to interact with people experiencing those symptoms.  The Barbara Schneider Foundation - a non-profit organization dedicated to end the criminalization of the mentally ill through positive training and education -  provides the training.  In his opinion piece the following quote is instructive:

"The urgent need for this training is a direct consequence of federal action requiring states to close our state psychiatric hospitals with no immediately viable community alternative. Our county jails should never have become the largest mental health facilities in the country."

I have previously written many times about the abysmal system of care that is available for people with severe mental illnesses.  In my experience, the people rationed out of the system include many of those who end up homeless and in jail.  If you have severe problems with mental illness that affect your decision-making, your social behavior, and your ability to assess the impact of your decisions you are at much higher risk  of an adverse interaction with the police or incarceration.  If incarcerated you are less like to have the resources to make bail, obtain and cooperate with an attorney, or follow the conditions of release. 

 These impairments combined with severely rationed resources accounts for the explosion of mentally ill in jails and this is not an acute problem.  It has been progressively worse over the past 20 years.  Stanek also call on the Governor and the legislators to provide finding for adequate placements (and hopefully supervision) and funding for CIT.  So far legislators have passed a law that allows Sheriffs to transfer mentally ill offenders to the limited beds at Anoka Metro Regional Treatment Center (AMRTC).  That has resulted in an increasing backlog of admissions of committed patients and increasing violence at the hospital.  Nobody in any of this controversy has spoken to the needs of the antisocial or career criminal with severe mental illness.  The issue of addiction and how that creates mental illness, criminal offenses, and leads to recidivism and worsening mental illness is also not addressed. 

In these articles and most, the families are left out of the equation.  The families I have seen are typically parents who have been dealing with the severe mental illness of their children for years.  They are shocked to find out that their children have been incarcerated instead of being hospitalized.  They are shocked that their children are not receiving any care for their mental illness while incarcerated especially that their medications have been acutely discontinued.  I have talked with many of these patients who were on methadone or buprenorphine for opioid addiction who had these medications acutely discontinued and went into opioid withdrawal until that resolved.  Psychiatrists everywhere have heard the pleas of these parents and their request to assist them in getting their child out of jail.  There is generally noting that can be done.     

 An associated issue is how government systems are managed at all levels.  In recent times, the idea that government systems can be managed like for-profit businesses that much show a profit for shareholders is all the rage.  It was one of the reasons that scientific and humane treatment of mental illness could be rationed out of existence.  Suddenly there was no longer a concern that a patient with mental illness was disruptive and might end up in jail or homeless if that behavior continued.  Now they had to be "dangerous" or the hospital asked them to leave.  When there were still too many demands on rationed beds they had to be "imminently dangerous" or they were asked to leave.  Sheriff Stanek and sheriffs across the country are dealing with the fallout of this managerial practice.  If people can't be treated in a cost effective manner (defined as getting them out in a defined number of days that are paid for)  they are not admitted.  Many of these patients are brought to hospitals by the police and not admitted because the hospital knows they will be taken to jail.       

The other problem of course is that jails are not really hospitals.  In today's political climate - even saying that out loud can set a dangerous precedent.  Even though Sheriff Stanek is doing what he can and he has a mandate by the Minnesota legislature allowing him to hospitalize patients on a priority basis at a state hospital, minimal to non-existent standards of care in jails do not make them hospitals.  The clear evidence from the editorial is the sparse medical coverage (1 RN very 12 hours for over a hundred mentally ill inmates), lack of adequate medical training (provided in this case by a not-for-profit foundation), and a lack of discharge resources for continuity of care.    

There are no psychiatric hospitals that can function or legally operate with that level of care.


George Dawson, MD, DFAPA



References:

1.  Chris Serres.  Mental illness in Hennepin County jail far higher than previous estimates, new study finds.  Star Tribune September 22, 2016.

2.  Rich Stanek.  Commentary:  Addressing the mental health crisis in our jails.  Star Tribune October 14, 2016.

Attribution:

1.  The photo is Hennepin County Jail from Wikimedia Commons.  The source information is by Micah (Transferred from en.wikipedia by SreeBot) [Public domain], via Wikimedia Commons.  The page URL is: https://commons.wikimedia.org/wiki/File%3AHennepin_County_jail.JPG

Shut Down The Psychiatric Gulags - Don't Build More!

On my drive home from work yesterday, I heard an outrageous story about a judge ordering LA County jail to build 3,200 psychiatric beds to treat mentally ill inmates in that facility.  As is typical of MPR, I could not find the link today but I did find the link to this LA Weekly story , that basically brings people up to speed.  It is a typical journalistic approach with the human interest component.  In this case the human interest portion was interesting to me, because I have heard these stories hundreds of times from people I have treated who have been incarcerated with a few variations.  The most significant variations have to do with suffering acute alcohol or drug withdrawal and not being assessed or treated for that problem and not having access to maintenance medications that have proven effective for the specific mental illness.  The current plight of the mentally ill in the LA County jail system and increasing judicial pressure on the basis of rights violations for the lack of treatment led county supervisors to vote to build what was called the most expensive building project in county history.  From the article:

"That day, county supervisors ........ voted to spend nearly $2 billion on a long-sought jail to replace notorious Men's Central, a facility that federal investigators say is plagued by suicides, abusive conditions and violence. The funds will build a two-tower compound given the ungainly name "Consolidated Correctional Treatment Facility."

According to the article it will be a 4,860 bed facility,  3,260 (67%) beds of which will be dedicated to treating prisoners with mental illness.  My most recent post on the matter includes information that LA County jail has 19,386 inmates and that recent epidemiological surveys suggest that 30-45% of inmates have problems due to severe mental illness and impaired functional capacity.   That suggests that unless public policy changes, the most expensive building project in LA County could be overwhelmed by demand before it gets started.  The author in this case points out the folly of building this tower.  It is basically the folly of building any large psychiatric facility in the absence of any other infrastructure, but in this case compounded by the fact that this is in fact a jail and not a treatment facility.  There is really no evidence that the problematic aggressive or suicidal behavior will be any better in a new "two-tower compound" with the same jail atmosphere and mentality.

I have previously posted about the plight of the mentally ill being incarcerated in America and the fact that county jails are currently our largest mental institutions.  It is a basic collusion between governments at all levels and the business community to enrich corporations that have been set up to "manage" the American healthcare system.  As usual, the most vulnerable people are "cost shifted" out.  Cost shifting refers to cost center accounting that basically leads divisions within the same organization to try to save money on their budget by shifting the costs to somebody else.  In managed care systems it can lead to all kinds of distortions in care.  It also happens with outside agencies.  I was told about a situation where workers in one county actually dragged an  intoxicated patient over the county line and into another county so that patient would no longer be their  financial responsibility!  Cost shifting is the end result of these perverse incentives.

There is perhaps no better example than incarceration rather than hospitalization.  There are estimates as recent as from a few days ago that treatment and possible hospitalization may cost $20,000/year as opposed to incarceration costing $60,000/year.  In both cases the taxpayers pick up most of the tab.  The cost shifting has occurred from insurance companies and health care systems to the correctional system.  If an insurance company can dump a patient with a severe mental illness into jail, it doesn't cost them a thing.   If that same patient is hospitalized they may receive a one-time DRG (Diagnosis Related Group) payment of about $5,000 irrespective of how long the patient stays.  The hospital incentive is to get them out in 5 days whether they are stable or not to maximize profit.  When they are discharged, the patients are generally expected to go to appointments to discuss their medications.  Clinic profits on these visits are minimal but the main problem is that many of these appointments are missed - in some cases up to 50-60%.  Many of these patients lack stable housing and they frequently end up back in the emergency department and back in the hospital.  Hospitals now have bottlenecks in the emergency department and many people are discharged back to the street.  The cycle of ineffective care continues.

I can attempt a brief analysis of the problem as I watched it unfold during 23 years of inpatient practice.  I will demonstrate how things have changed to the detriment of patients with severe mental illness.  Consider the hypothetical case of Mr. A.  He has diagnoses of depression, schizophrenia and alcohol dependence.   He recently ran out of his usual medications and started drinking.  He became progressively depressed and stopped talking with his family members.  They went over to see him and noticed he has a loaded handgun on his table and was talking about shooting himself.   They called the police who came, confiscated his handgun, noted that he was acutely intoxicated and sent him to the local hospital emergency department.  How has the management of this scenario changed over the past 30 years and why?

In the early 1980s, Mr. A would have been assessed as a person who was high risk for ongoing suicidal behavior (depression, schizophrenia, alcoholism and acute intoxication) and admitted to a psychiatric unit.  The psychiatrist there would have done everything possible to stabilize all three conditions even if it meant civil commitment to a long term care institution.  The length of stay (LOS) would have been on the order of 20-30 days comparable to many current psychiatric LOS in the European Union.

By the late 1980s, a managed care company would have called the hospital or psychiatrist in charge.  They would initially demanded that the patient be discharged to a county detox facility.  They would claim that alcohol withdrawal detoxification was not a psychiatric problem, and therefore the patient does not meet their "medical necessity criteria" for inpatient hospitalization.  If that was ineffective they might say that he was no longer "acutely suicidal" or "imminently dangerous" two additional medical necessity criteria.  In the end they always win, because they just stop paying and the administrators force the clinicians to discharge the patient.  The length of stay is now down to less than 1 week and the patient may not be stable at all at the time of discharge.

By the 1990s, the patient might not even make it to the inpatient unit.  By now psychiatric departments are continuously burned by managed care companies, especially in the case of any patient who is acutely intoxicated at the time of admission.  Many have closed their doors.  Many departments have strongly suggested that the emergency departments send any intoxicated patients directly to county detox units if they are available.  The counties respond by refusing to take any patients on any intoxicants than than alcohol and even then the patient has to blow a number on a breathalyzer consistent with acute alcohol intoxication.   At any point in this process a decision can be made to just send the patient home.  There are various ways the patient can access more firearms at that point or even get the original firearm that was confiscated.  There are also various ways that the patient can end up incarcerated including going back home, drinking and getting arrested for disorderly conduct or public intoxication.  A more complicated situation occurs if the patient is intoxicated and wanders into a neighbor's home or place of business.  I have seen people end up in jail for months on trespassing charges in these situations.   And that brings us in to the 2000s where it is much more likely that a person with severe mental illness will be incarcerated than even make it to the emergency department.  In the 2000s the patient may end up stranded in the emergency department for days or sent home with a bottle of benzodiazepines to handle their own detox if they can deny that the are "suicidal" consistently enough.  There is also the mater of inpatient bed capacity.  Fewer beds are full constantly because bed capacity has been shut down due to managed care rationing and people are often released because there will be no open beds in the foreseeable future.  The LOS in many cases is now zero days, even for people with severe problems.

How did all of this happen?  How did the care of mental illness and addictions fall to such a miserable standard?  It is documented in many posts on this blog.  Professional guidelines were compromised and treatment infrastructure was destroyed by the managed care industry and the politicians who actively supported and continue to support it.  Professional organizations don't stand a chance against pro business state statutes,  commissions stacked with industry insiders, and federal legislation that protects these companies from lawsuits for interference with care.  Even a travesty as basic as prior authorization for generic drugs is unassailable.  I don't understand why these basic facts are so incomprehensible to people in the field.  Just a few hours ago, 1BOM posted a Hall of Shame of entities the original authors claim are failing people with severe mental illness.  This list completely misses the mark and is probably a good example of how deeply entrenched the mechanisms are to prevent treatment  and shift costs away from states and health care companies.

There are countless easy solutions to the problems, but the companies in power literally do not want to spend a dime.  The patient with severe mental illness can receive comprehensive community services and be maintained in their own housing at a cost of $10, 000 to $20, 000/year for clinical services.  That same patient costs corrections departments $60,000 per year.  That patient currently costs managed care companies nothing if they can transfer their care to a local state-funded Assertive Community Treatment (ACT) team.  Managed care companies incur the same cost if the patient is transferred to the correctional system.  If ACOs come to fruition and all of the chronically mentally ill are enrolled, it should be an easy matter to make the managed care companies responsible for both the costs and the patient.  A simple court order to pick up the patient from jail and stabilize them in the community could suffice.

Erecting more gulags won't work.  They are effective only for enriching health care companies that profit by denying care for those with severe mental illnesses and addictions.  They are also another hidden health care tax on the taxpayers who are already paying far too much in hidden health care taxes.




George Dawson, MD, DFAPA

Graphics Credit:  ConceptDraw Pro - this graphic was included as an example with this software.