(The following oped was originally published in the News & Observer.)
Many people know that Gov. Mike Easley’s 2001 mental health reform was a failure, but few people realize how bad the system is today.
Over a decade after mental health reform, mentally ill people who go to an emergency room wait an average of three and a half days to get admitted to a psychiatric facility. In some cases, patients languish for weeks in hospital emergency rooms, receiving no treatment despite being in a state of psychiatric crisis. The outpatient system is little better: Severely mentally ill people rarely follow up on treatment. For many, jails and homeless shelters have become the new asylums.
Recently, the Department of Health and Human Services announced a new “Crisis Solutions Initiative” to great fanfare from state officials. Unfortunately, the plan is mostly buzzwords and platitudes that fall short of addressing the fundamental problems in the mental health system. In order to ensure care for people with severe mental illnesses, we need more crisis-oriented inpatient services and better plans to ensure the continuity of care after discharge from a psychiatric facility.
With only 10.64 inpatient beds per 100,000 people, North Carolina has an extreme shortage of crisis-oriented psychiatric services. National benchmarks suggest that 50 beds per 100,000 is the minimum. DHHS claimed in 2008 that 22 to 31 beds per 100,000 was a “more appropriate” target. But by either benchmark, North Carolina is failing miserably. The result is appallingly long waiting periods, and triage-style treatment that forces many patients out of hospitals before they are ready to be reintegrated in the community. However, inpatient beds are expensive, making it unlikely that we can afford to fully meet either benchmark in the state’s present financial environment.
This makes it imperative for the state to ensure that treatment continues after discharge from a mental hospital. All too often, people with severe mental illnesses fail to continue treatment after a psychiatric crisis because they believe they are not sick. In the absence of continued treatment, people with severe mental illnesses are caught in a “revolving door.” Without medication, their conditions further deteriorate. Eventually, they end up back in the hospital – or in prison or homeless shelters. For many people with severe mental illness, the system creates a devastating cycle of crisis, hospitalization, discharge, regression, and another crisis.
In order to stop this cycle, the state should move to ensure better care coordination between state facilities, local management entities, and outpatient providers. If it does so, severely mentally ill people who are willing to adhere to treatment can be directed to outpatient resources.
For those patients who refuse to take medication or adhere to treatment, assisted outpatient treatment (AOT) may be the best option. In AOT, a judge orders a person to get treatment if it is necessary to prevent dangerous psychological deterioration. Once assigned to AOT, participants receive intensive outpatient services that are designed to foster recovery and stability. Clinical studies at Duke University and Columbia University show that AOT is an evidence-based practice that effectively reduces the rates of re-hospitalization, arrest, and victimization. Assisted outpatient treatment also saves money in the long term, because emergency rooms and incarceration are extremely costly to taxpayers. Those savings are significant: A study by Duke researchers found that the average annual cost declined by 50 percent in one sample, and 62 percent in another.
There are some who may balk at the idea of court-ordered mental health treatment. Dave Richard, director of mental health for DHHS, recently described assisted outpatient treatment as a “pretty restrictive model,” and expressed concerns that court-ordered outpatient treatment takes away patients’ ability to make decisions for themselves. For some people with severe mental illnesses like paranoid schizophrenia, however, that decision-making capacity may already be compromised. Certainly voluntary treatment is always preferable to assisted outpatient treatment. But when people’s conditions cause them to repeatedly devolve into psychotic crisis, court-ordered treatment may be the only way to secure a good outcome for patients, families, and the public as a whole.
Last week, Gov. Pat McCrory stated that “improving mental health … is a top priority of our administration.” If that is true, then the governor might ask why his administration’s Department of Health and Human Services is still timidly nibbling at the edges of the broken system. DHHS’ new “Crisis Solutions Initiative” offers plenty of slogans, but few solutions.
It’s time to get serious about severe mental illness.