No Place To Go

There is a fantastic article up on the New York Times website, coming out in print this weekend in the NYT Magazine, called When My Crazy Father Actually Lost His Mind, by Janeen Interlandi.  The author tells the chaotic story of how her family tried to get help for her 69 year old father who was ill with a manic episode.  In it, he bounces from hospital to jail to ER, to homelessness, over and over. She talks about the catch-22's with the legal/psychiatric system with a father who is dangerous enough for a restraining order to keep him from his family, but not dangerous enough for civil commitment, and she talks about stories of others families where awful things have happened.  Her love for her father comes through, mixed in with her frustration that there is no place or mechanism to help such people.  Ah, but the story has a happy ending.  It reminded me a lot of Pete Earley's book Crazy: A Father's Search Through America's Mental Health Madness.


Interlandi writes:


And so for weeks, we had been locked in a game of chicken: waiting for my father to do something clearly dangerous; praying like hell that it would not be his suicide or accidental death or the death of someone else. In the meantime, my mother had all but stopped sleeping and had started hiding the car keys and the checkbook. She would tiptoe around their one-bedroom apartment at night, waiting for him to doze off, then call my sister or me to unload her despair in a flurry of whispers. 

Oh, I can't begin to  do this article justice in a blog post, you'll just have to read it.

Shrink Rappers Set Bar High for NAMI Walks

4/24: $250 ~ 4/25: $295 ~ 4/28: $330

Click on image to donate!
See which Shrink Rapper has attracted the most donations.
4/28 (7%): thank you, Carol!
4/25 (6%): thank you Christina, Jesse, Abhishek!

The National Alliance on Mental Illness is the nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness. They provide education and training programs for consumers, family members, providers, and the general public. Their Family-to-family and Peer-to-peer programs have won awards for providing education, insight, and support to people and families affected by mental health problems. They have hundreds of state and local affiliate organizations to provide grassroots support to communities.

NAMIWalks, NAMI's annual fundraiser, raised charitable contributions to support their work. The Shrink Rappers are working to raise money for the NAMIWalks fundraiser on May 19 at the Baltimore Inner Harbor. All of the money goes to support the Anne Arundel County NAMI affiliate. We did this last year 3 days before the event and managed to still raise $750. We're shooting for $5000 this year.

Anne Arundel county has a population of 588,000 people. Anne Arundel county has 14 psychiatric beds to treat the portion of that 588,000 who require intensive inpatient psychiatric treatment. That comes to 2.4 inpatient beds per 100,000 people. The average number of psychiatric beds in the U.S. is 36 per 100,000 (most recently available data; see other psych beds posts for details). The average number of psychiatric beds in Africa is 3.4 beds per 100,000 population. Anne Arundel county has fewer inpatient resources per capita than Africa. They need our help.

So... I'm asking our dear readers to help out and pitch in. In the last month, we've had 22,000 unique visitors. If only one-fourth of you Shrink Rap visitors gave $1 to our fund-raising campaign, we'd have $5000 for the Anne Arundel county NAMI chapter, which they can put to good use. Please consider clicking the picture above to donate to this cause. Give $1, $10, $25, $50, or even $100... whatever you can. And it's all tax-deductible. (4/25: Sarebear said it won't take less than $10.)

To really sweeten the deal, we will give an autographed copy of our book to any person or organization that donates $250 or more. (Yeah, I know, big deal. Still, it's a token of our appreciation.)

And, if we manage to get any SUPER donations of $1000 or more (!!), we will place an image of your choice (tasteful only) for one month in a prominent place on our blog to celebrate your generous donation (or to advertise your organization), including a link back to your website, as well as four signed copies of our book. Note that we get about 40,000 page views and over 20,000 unique visitors per month -- that's ~2.5 cents per impression! (If we get more than one of these donations, we'll give each one it's own month, in order of receipt of donation, starting with June.)

"Roy, you've talked me into it. Enough already; where do I click!?"

Click right HERE to take you to our team donation page.  Or click on the image at the top of the post. I will change this image daily to update the progress you are making. You will be able to choose which Shrink Rapper you want to honor with your donation (a little friendly shrink competition).

I'll throw in one more thing. Whomever donates the most will get to also have a Guest Post on Shrink Rap, and we'll bring you on as a guest on our podcast, My Three Shrinks. (Can you tell I listen to a lot of public radio?)

Thank you for considering this worthy cause.
~Roy out.

PS: You can also JOIN our Shrink Rappers Team and raise funds yourself. We have room for 27 more "walkers", and you can either walk in person on May 19, or just in spirit (you don't have to be present to raise money, but I must tell you that Clink will be out of town, and Dinah is at best a maybe).

Where Did All The Psych Beds Go?

Roy likes to write about Emergency Departments and Bed Availability for psychiatric patients, but this one came to me, so I'll borrow the topic while he's away.


In the Observer-Dispatch in NY State, Andrew Coates writes in "Guest View: Psych ward closings require public discussions":


The pell-mell closures of inpatient wards at Mohawk Valley Psychiatric Center and at other Office of Mental Health (OMH) facilities around the state are unfair and unwise. The cuts will shift costs to localities even as they rob the same communities, especially Utica, of much-needed jobs.

New York state law formerly required a full year of public notification when OMH planned to close or downsize inpatient services.
But last year, Gov. Cuomo wrote into the state budget a provision that authorized ward closures on 30 days’ notice and facility closures on 60 days’ notice.
 
Coates goes on to say that the Governor has chosen "expediency over community needs." 

It may be politically expedient to turn a deaf ear and a blind eye to needs of patients with serious mental illness. (Patients who are not exactly known for lavish campaign contributions!)
Yet cutting services to vulnerable patients with no serious public discussion of the impact on our communities, with no regard for the human hardship upon patients and their families, is as irresponsible as it is outrageous.


 In the next day's (2/29) Times Union, Dr. Coates then shared a patient's perspective on the bed closures.  The patient wrote:


For many individuals in Mohawk Valley, no one is really sure where they are going. But they are leaving maybe the only home they ever knew. Maybe the only place they ever felt safe.

Mohawk Valley is not perfect but it’s certainly better than the streets. And now the system has failed them – the system itself is failing. The mental health system is stretched to the breaking point already in NYS. Closings are just going to make it worse. People are going to end up on the street.

 I'll leave the comments to you.  I probably would have found the patient's opinion to be more powerful if she had been previously hospitalized in the facility that is being closed.  


Thanks to Meg for the shout out on this issue!

Running Out of Psychiatric Beds

I read today that Eastern Ontario has started a bed registry to keep track of where open psychiatric beds are available. This is something I've long advocated. The United States now has less than 10% of the beds it used to have 50 years ago. Granted, treatment has improved and community resources are enhanced. But there are still areas that often do not have a sufficient number of hospital beds for folks needing acute inpatient psychiatric care.

The Ontario story described in the Ottawa Citizen states that six of the area hospitals have been connected to a computerized "bed board" that provides real-time information on who has an appropriate bed available. This saves time in the ER and gets patients to needed treatment more quickly. Otherwise, calls need to be made to each individual hospital, which is very time-consuming.

And it is not uncommon for all the beds to be full. Last July there was an EMTALA complaint against a hospital in Maryland because a patient sat in the ER all weekend, and this hospital said they had no beds to admit the patient to. The Department of Health and Mental Hygiene investigated the complaint and found that, indeed, the hospital was full that weekend. The ER's record indicated that all the hospitals (except the state hospitals) were called that weekend and all indicated their beds were full. So, DHMH visited every hospital (about 28, I think) thinking that surely one of them had an empty bed they were hiding. What they discovered was that every single psychiatric bed in the state was full.

Unfortunately, we have no way of determining how often this happens, but we know if happens often enough. A "bed board" like this would be very helpful in (1) quickly finding beds when needed, and (2) keeping track of the extent of this problem. Having patients wait in ERs for days is unsafe and is even discriminatory. How many people with stroke or uncontrolled diabetes sit in ERs for days waiting to find a bed for treatment? I'd like to hear others' thoughts on how this problem can be addressed.

[Note: my apologies to our readers for not blogging or commenting much over the last year or so. I plan to be more engaged again in Shrink Rap going forwards. I'll never talk as much as Dinah does, but I'll get some words in :-]

Virginia Report: Not Enough Psychiatrists, Beds

The Washington Post reports today on a 230-page state report that finds Virginia "lacks experienced psychiatrists to evaluate the mentally ill, there aren't enough beds for those seeking emergency treatment in many areas and hospitals are losing money on mentally ill patients, according to a state government report."

Last year, NAMI released a Report Card for each state, grading them on things like access to care, services, and infrastructure. Virginia received a grade of D. Today's report suggests increasing funding to meet the state's need.

"Additional psychiatric beds cannot be opened unless there are psychiatrists available and willing to staff them," the report says. It adds: "On the outpatient side . . . a lack of psychiatrists affects licensed hospitals because individuals in need of psychiatric service cannot find them in the community and . . . turn to emergency departments. . .

To address these shortfalls, the report suggests that the state "examine its potential role in . . . assuring an adequate supply of beds . . . [by] increasing financial support for uninsured psychiatric patients."

NAMI's report noted the lack of culturally competent treatment, and rights abuses in some of the state hospitals.

"Additionally, Virginia's ability to serve its growing population of ethnic and racial minorities has suffered because the state has shown no initiative on the issueof cultural competency. Virginia has not conducted a cultural competency assessment or developed a plan to meet the needs of minorities, who comprise nearly 30 percent of the state's total population.

Lack of short-term acute care beds for individuals in crisis is another major problem. In Northern Virginia, the commonwealth's most populous area, approximately 24 percent of the region's private bed capacity vanished in 2005 alone, due mostly to the closure of psychiatric wards at four different hospitals. Individuals in need of beds are transported downstate, resulting in trauma for the individual and diversion of local police officers, who must spend hours transporting people to areas as far away as Hampton Roads.

State hospitals have posed a different set of issues. In the 1990s, four out of 10 were under investigation by the U.S, Department of Justice (DOJ) for egregious violations of the rights of patients."

To view the actual report, the 230-page pdf report is here, and the briefing, consisting of 60 slides, is here.

Psych beds dropping like fish

According to yesterday's Science Magazine, we may lose the availability of sustainable fisheries by 2048 (see Scientific American: Overfishing Could Take Seafood Off the Menu by 2048). The article predicts total collapse of all world fisheries by 2048. "Total collapse" is defined as 90% depletion since the 1950s.

[prepare for non sequitur]

We have also been rapidly losing the availability of psychiatric beds for folks in need of acute inpatient hospitalization for mental health problems like major depression, bipolar disorder, and schizophrenia. In Where have all the psych beds gone?, I deplored the massive loss of inpatient psychiatric beds over the past 40 years or so. We used to have 20.4 beds per 10,000 population, and it is now down to 3.6. The numbers are now at about 18% of what they were previously. Another 8% to go before the U.S. hits "total collapse." Of course, there has been an opposite trend in forensic psychiatric beds, but I'll leave that for Clink to blog about (also see Hot Potato).

"Holy mackerel!" is right. People are boarding for days at a time in Emergency Rooms all over the country, waiting for a bed to become available. So, what's the current state of affairs? Check it out...

Pennsylvania State Hospitals Cutting Beds: NAMI President, Dr. Suzanne Vogel-Scibilia, as well as other citizens, petitioned the governor to halt bed closures. "'We ask this because of current inadequacies in community resources and the lack of a statewide comprehensive plan for closure and placement,' the petition reads."

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Florida Community Loses 16 Beds: Citrus County now has no psychiatry beds. Hospital officials say the beds were not needed. "But mental health advocates say Florida faces a shortage of inpatient psychiatric beds. The state received the lowest score possible in terms of access to inpatient services, according to a recent study by the National Alliance on Mental Illness. 'There are about 3,000 more beds needed in the state,' said Sue Homant, executive director for NAMI Florida. 'My personal guess is the number is even higher than that.'" ... According to NAMI's Report Card, Florida scored an F in Infrastructure, 48 out of 50 in per capita spending on mental health (a whopping $37.99 per person), and was number 15 in suicide rank. Florida is floundering.

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Ohio Gaining Beds: "Mental health professionals say more beds are needed since a number of hospitals with psychiatric services closed or cut beds in the past decade."

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Connecticut ERs Filled to the Gills: 2-weeks in ER awaiting a bed is common [treating them in a unit takes less time than this].

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Let us know what is happening in your state (or country).

[Roy] Where have all the psych beds gone?

Since the deinstitutionalization movement in the 1950s and 60s, the number of psychiatric beds in the US has been dropping, coinciding with the psychopharm era, the community mental health center era, and then the managed care era.

There used to be 20.4 public and private psychiatric beds per 10,000 population in the US in 1970, and now there are only around 3.6, a drop of 82%. This compares to 465 general med-surg beds per 10,000 population in 1975, with a current staffed capacity of around 229 (51% drop). In 2003, 5.8% of folks admitted to hospitals from an ER were for mental health and substance abuse problems.

The definition of a "medically necessary" admission has been so eroded that currently you pretty much have to threaten suicide to gain inpatient psychiatric hospitalization. The result of these changes is an inadequate supply of both inpatient psychiatric beds and of community alternatives.

The ongoing debate is whether to invest money in more psychiatric beds or into community services which can prevent the need for the beds in the first place. While the debates continue, patients pile up in Emergency Departments (ED) throughout the country, waiting for a bed to open up somewhere in the state. In Maryland, it is not uncommon for folks to wait in an ED for 3-5 days before being transferred out. It is particularly problematic for kids, seniors, developmentally disabled folks, and the uninsured.

In Louisiana, their previous shortage has grown worse since Katrina, resulting in serious backups in the ED.

Times-Picayune: "The problem is not confined to the New Orleans area. Joseph Miciotto, administrator of the LSU Hospital in Shreveport, said the emergency room there has had up to 21 psychiatric patients awaiting admission at the same time, creating potential safety problems for patients and health workers."

USA Today: "And estimates also suggest that only 22 of 196 psychiatrists continue to practice in New Orleans, while the number of psychiatric hospital beds has been sharply reduced: as of June 14, the authors said, there were only two psychiatric beds within a 25-mile radius of New Orleans."

I have noted a reversal of this trend in the last few years. States are starting to add beds, mostly because of outcries from mental health advocates about long waits in EDs.

Kansas City Nursing News: "Over the last 15 years, the number of adult psychiatric beds has steadily decreased in the Kansas City area. Today, there are about 450 beds in the community, a 65 percent decrease from 1990. Based on national and regional data, the Kansas City area should have 600 psychiatric beds."

If you have info to share about what is happening in your state, we welcome your comments.