Saturday, February 12, 2005
ENEWS - TREATMENT ADVOCACY CENTER 2/11/05
ENEWS - TREATMENT ADVOCACY CENTER
TREATMENT ADVOCACY CENTER
Visit our web site www.psychlaws.org
February 11, 2005
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1. MORE HOMELESS MENTALLY ILL THAN EXPECTED ACCORDING TO UCSD STUDY - University of California, San Diego News, February 1, 2005
2. LOST ASYLUM - Worcester Magazine, January 20-26, 2005
3. SPOKANE GROUP HOME SHUTTING DOWN - The Spokesman-Review, January 27, 2005
4. SISTER'S HOPE IS HOME - Raleigh News & Observer, January 10, 2005
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UNIVERSITY OF CALIFORNIA, SAN DIEGO NEWS, February 1, 2005
[Editor's Note: A new study from the School of Medicine of University of California, San Diego (UCSD) gives stark perspective to the inextricable meld between severe psychiatric disorders and homelessness. Many studies have documented the prevalence of people with severe mental illness among those who are homeless; the findings vary somewhat but approximately one-third of those living on our streets are afflicted with mostly treatable psychiatric illnesses.
The USCD researchers took a converse approach, determining the percentage of people with serious mental illness in San Diego County who are without a place to live. They found that 15% are, or about one in seven. Over all, about only one out of every 500 Americans is homeless.]
MORE HOMELESS MENTALLY ILL THAN EXPECTED ACCORDING TO UCSD STUDY;
Interventions Urged
By Sue Pondrom
The prevalence of homelessness in persons with serious mental illness in San Diego County, the nation's sixth largest metropolitan area, is 15 percent - a higher percentage than suggested in previous studies, according to new research by investigators at the UCSD School of Medicine.
Published in the February 2005 issue of the American Journal of Psychiatry, the study noted that homelessness in this population might potentially be reduced or prevented with substance abuse treatment and help in obtaining public-funded health benefits (Medicaid, or MediCal in California). Because homeless mentally ill were more than twice as likely to be hospitalized as non-homeless patients, the investigators said improved care for homeless persons with serious mental illness may be cost effective or at least result in improved patient outcomes with only moderate increases in total costs.
The research was conducted among an ethnically diverse population of 10,340 San Diegans with serious mental illness (both homeless and those with housing) who were treated by San Diego County Adult Mental Health Services (AMHS). While one-fourth to one-third of homeless persons are estimated to have a serious mental illness, this is one of the first studies to document and describe the other side of the picture - the number of mentally ill who are homeless.
"Homelessness is more common in patients with serious mental illness than I would have guessed," said the study's first author, David Folsom, M.D., co-director of the UCSD Combined Family Medicine-Psychiatry Residency Program and the assistant medical director of St. Vincent de Paul Village's Family Health Center, a free medical clinic located in one of San Diego's largest homeless service agencies.
According to the UCSD researchers, homelessness was most frequently associated with people who were diagnosed with schizophrenia or bipolar disorder, who were substance abusers, and who had no public-funded health care. Men were also more likely to be homeless than women, as were African Americans. Latinos and Asian Americans were less likely to be homeless.*
"Homelessness is an increasingly important public health issue, with seriously mentally ill persons most at risk for homelessness," said the study's senior author, Dilip Jeste, M.D., UCSD Estelle and Edgar Levi Chair in Aging, professor of psychiatry and neurosciences, director of the UCSD Sam and Rose Stein Institute for Research on Aging, and a geriatric psychiatrist at the VA San Diego Healthcare System. "In addition to the trauma experienced by these individuals, there is also a cost to society. Homeless persons have a significantly more-frequent use of expensive emergency services** and are more likely to spend more time in jail."
The study noted that in San Diego, African Americans comprise 5 percent of the general population, 11 percent of the AMHS population with serious mental illness, and 16 percent of the homeless patients with serious mental illness treated in AMHS. Latinos contribute 23 percent of the general population, 19 percent of the AMHS patients, and 12 percent of the homeless.
"It is possible that the higher rate of homelessness among African Americans may be in part due to fewer community resources for this group of patients, whereas the larger Latino community may be able to provide more resources to protect against homelessness," the study said. "However, African Americans have been found to be at higher risk of homelessness in other cities with larger African American populations, such as New York and Philadelphia***."
The authors also said that an investigation of homeless persons in Los Angeles, only some of whom had mental illness, found lower rates of homelessness in Caucasians and Latinos than in African Americans.
Noting that treatment for substance abuse has been reported to improve outcomes, the researchers said "access to substance abuse treatment is more difficult for homeless persons with serious mental illness than for other homeless persons. Similarly, patients who did not have MediCal insurance were twice as likely to be homeless as patients with MediCal; homeless persons with psychotic disorders have been reported to have greater difficulty obtaining and maintaining entitlement benefits than non-psychotic homeless persons."
The authors concluded that "although it would be naïve to assume that treatment for substance use disorders and provision of MediCal insurance could solve the problem of homelessness among persons with serious mental illness, further research is warranted to test the effect of interventions designed to treat dually diagnosed patients and to assist homeless persons with SMI obtain and maintain entitlement benefits."
The study was funded by the National Institute of Mental Health and by the Department of Veterans Affairs. Additional authors were William Hawthorne, Ph.D., Laurie Lindamer, Ph.D., Todd Gilmer, Ph.D., Anne Bailey, M.S., Shahrokh Golshan, Ph.D., Piedad Garcia, Ed.D., Jurgen Unutzer, M.D., and Richard Hough, Ph.D.
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WORCESTER MAGAZINE (MA), January 20-26, 2005
[Editor's Note: One major contributor to the ranks of people with severe mental illness among the homeless is a lack of sufficient inpatient facilities to provide treatment, support, and an avenue to recovery. We hope not, but chances are that some Worcester State Hospital patients may soon be living in shelters and lining up at food kitchens.]
LOST ASYLUM
More Mentally Ill Patients Will Face Life on the Outside When State Replaces Worcester State Hospital
By Charlene Arsenault
In the sticky-hot summer of 1989, Rick LaFortune decided he was the Messiah. As Jesus, he descended on a park in downtown Leominster, where, to begin saving the world, he stripped naked and folded his clothes neatly in a pile. The police grabbed him, throwing him into a blanket and a cell, in that order.
LaFortune had been coaching at the Special Olympics and was getting sloppy about the small dose of medication he was supposed to take. Over the years, that formula -- stress and med changes -- preceded many of his breakdowns, beginning in 1968, when he was 16 and a high school student in Fitchburg.
He doesn't elaborate on what precipitated that first episode (sometimes he does elaborate, sometimes he veers off the question), but just says he wasn't adjusting well in school. He was institutionalized in Jamaica Plain, where they diagnosed him as paranoid schizophrenic. "I wound up in a hospital that was, quite frankly, brutal," says LaFortune. "It was something that made One Flew Over the Cuckoo's Nest look like a picnic. And I got electric shock treatments there. I was terrified."
After landing in facilities every few years or so, including Worcester State and Gardner State hospitals, he knows what makes for a good hospital. He speaks highly of both and attributes much of his wellness to the staff there; to him, state hospital care beats private hospital care hands down.
LaFortune is now one of the de-institutionalized. It's been seven years now since he was committed to a hospital. He lives by himself in a subsidized apartment in Fitchburg, one of many countless mentally ill people who cope in the community.
He is luckier than a lot. He's had a family structure to assist him in getting the right help when he was going off the deep end. He's also found the right programs, had caseworkers to negotiate his insurance (now Mass. Health) and psychologists to tinker with his meds. Not everyone has that, argue advocates for the mentally ill, a situation which indirectly contributes to the homeless and jail population.
LaFortune credits state facilities like Worcester State Hospital for helping him. He liked the care. He liked the structure and familiarity. It provides a sense of security that can't be felt elsewhere, especially to the mentally ill.
"There is a part of the population, myself included," says LaFortune, "that when I become very sick or very manic and psychotic, I need a safe place to be and for me that is usually a locked unit where they can be forceful with me, but in a gentle way. You need a place like Worcester State for that. You need a place where people can be safe and you need a place where they can get tough love. One of the biggest things Worcester State did for me was give me discipline. There are two or three people I know who are still at the state hospital who've told me that they would rather live there than in the general community because people accept them there."
Gov. Mitt Romney's administration has been hot to shut Worcester State down practically from the day he took office. (The facility, which houses 156 inpatient beds, was built in 1833 and celebrated its anniversary yesterday.) In his very first February budget speech, Romney unveiled a plan to close Worcester State Hospital and wipe its $24 million budget off the books. There was an immediate backlash from advocates for the mentally ill.
"He wanted to take all the people and move them out here, there and everywhere," says state Sen. Harriette Chandler (D-Worcester), who battled the closing. "The largest number would have gone into community services. There was no question in anybody's mind that there weren't appropriate services. There wasn't careful thought given to what the whole movement meant. It sounds good on paper, but these are human beings who are very sick people."
The fear is that when institutions close, the needy are cast to community services that can't take care of them. "We just don't do a good job," says James McDonald, longtime advocate for the mentally ill and vice president of the Central Alliance for the Mentally Ill (part of NAMI). "In the hospital, you have nurses, you have doctors, you have your meals served and social workers. You must have the same thing in the community. We don't have that. We did at one time. We did have enough case managers. We did have enough apartments, but there are more and more people. You're almost unable to get into the services of the DMH unless you're very seriously ill."
Once Romney announced his intentions to close Worcester State, the Legislature responded quickly, requiring a study from the state Department of mental Health to justify closing the hospital. DMH Commissioner Elizabeth Childs expanded the study to examine the entire department and its inpatient capacity needs. A year later, rumors flew that the Romney administration was looking to shut down Worcester State Hospital as well as Westboro State Hospital to make room for a new hospital, reducing the total number of beds and placing discharged patients in community facilities and treatment.
The administration says shutting the two suffering hospitals would streamline the budget. We'd get a nice, new, state-of-the-art-facility, but one that would leave fewer beds for the mentally ill in the state. The money saved could be pumped into the community to buffer the wave of de-institutionalization that has already begun and would have to continue.
Much like what occurred in the '80s when then-Gov. Michael Dukakis instigated de-institutionalization, 268 of the 900 mental health patients in the state will be discharged this year. The Department of Mental Health thinks it's a great idea. You get a different view when you talk to people who care for the mentally ill.
After two date extensions, in March, 2004, the DMH delivered that feasibility study that was demanded of them in March. It favored the idea of building the new hospital and recommended "community placements of 268 adult continuing care inpatient clients who are ready to leave." It was critical of the efficiency of both the Worcester and Westboro facilities, too, pointing out ancient heating systems, lack of cooling systems and old electrical units. It estimates that $59 million in capital costs would be needed to keep both facilities in operation over the next 10 years. "Existing facilities at either Worcester State Hospital or Westboro State Hospital do not provide a sound option for consolidated impatient capacity in Central Massachusetts over the long term," reads the report.
According to Lester Blumberg, DMH's chief of staff, "The existing infrastructures at either Worcester or Westboro are insufficient to sustain a capacity of 270 beds, which is the number we have estimated we need for the Central Massachusetts facility. Not only is the physical plan inadequate, but we have learned so much more about the environment of care in the decades since these buildings were built. They are institutional in look and feel and they therefore promote institutionalization."
A commission of 15 people, chosen to study Romney's plan, met for the first time on Monday, Jan. 10, when it was announced that the state Designer Selection Board brought on Ellenzweig Associates Inc. to study where -- and how -- to build the new 320-bed hospital. The plan for a new facility has real momentum.
In the meantime, the discharges have already started to occur. A MHW (mental health worker) at Westboro State Hospital, speaking on the condition of anonymity, says they've already felt the movement. "I talked to my supervisor about this," he says, "and she said that although it may mean that some people may lose their jobs, she thinks it'll be beneficial for the patients because the conditions at the hospitals are deplorable."
The discharge rate, he explains, seems to have sped up so much that the units are getting cleaned out far earlier than they used to be. "In the past, we'd get residents from the locked units and then put them into residential settings," he says. "They had much more time to follow their treatment plan and cope with their problems. They're now sending people through so fast that they're not confident in these [residential] houses. I think in the long run, the patients are going to suffer in a sense that they have deadlines to meet. They'll get into the community when they're not ready to go into the community, and end up homeless."
Blumberg argues that no one is left behind, and references as an example the closing of Medfield State Hospital, where of the 255 patients discharged, only 7% have required hospitalization again. The DMH's discharge plan, he says, is being timed to allow for development of these services to support those clients.
"Each person who is discharged has an individually developed community treatment plan that is designed to meet their needs," says Blumberg. "We are enhancing existing community residential services to provide these individuals with the support they need. For the most part, they are moving into existing residential settings that have vacancies created by other clients who are ready to move through the continuum of care to less-intensive services." He points toward visiting nurse services, supported living services (where staff visits the home), day treatment and clubhouses.
"I feel that it would be a good idea to build a new hospital," says an RN who currently works at Worcester State Hospital. "Both buildings are quite old and do need to be updated, so a new hospital would be in the best interests of the patients."
Yet among advocates, the fear is that in its rush to complete the project, the DMH and the Romney administration is failing to grasp the depths of care that some mentally ill people need. Jo Masserelli, who directs a training project to teach human service workers in conjunction with Catholic Charities and also offers a few beds to those in need, says, "I would say people need more than just programs. They need more than just service involvement. Another presumption is that just because a human service exists that it takes care of everything. I think families need some assistance to become competent to help other family members. I think there are a lot of troubled people. Mental health services can address some of those troubles, but certainly not all. I would say I'm highly in favor of a responsive and well-done de-institutionalization, and that's been the bulk of my work."
"I know that the patients being discharged are ready from what I see," says the Worcester State RN. "They're ready to go into the community. But to some, [the hospital] is almost like a home."
Phil Hadley, president of the National Association of the Mentally Ill/Massachusetts chapter, staunchly maintains improvements need to be made before de-institutionalization is even considered. There are 3,000 families among NAMI members who are affected by mental illness and he says they struggle with a large degree of stigma and inability to get proper help. "They limit people from 10 to 14 days and they're not much better than when they went in," says Hadley. "There is no follow-up after they get out of the hospital. When the patient is in the hospital and is seen by a psychiatrist and then when they're discharged, if they have a psychiatrist on the outside -- that's important. There is no communication between the in-house doctor and out-house doctor. They don't talk. It's very frustrating. Unless they have a person who is an advocate for them, by nature of the disease, these people aren't thinking correctly and they need an advocate. They don't know what to do. They end up on the street."
Chandler walked away from that first commission meeting last Monday with a positive vibe, but with many questions, including not only where the money will come from to build it, but the issue of siting, which Chandler and others say will prove to be one of the hot buttons. NIMBY (not in my backyard) always plays a part in such moves.
"I've been led to believe by Commissioner Childs, who is a psychiatrist who researched this carefully, that what she is talking about constructing is a state-of-the-art building that will use the synergy of our neighboring institutions, like UMass or Tufts Veterinary School," says Chandler. "We have a lot of things going on, but we can't close it down in sort of a thoughtless manner as we did 10 years ago."
State Rep. James Leary (D-Worcester), also on the commission, says, "I'm cautiously optimistic that we'll get a consensus on this. I think there are two major issues -- one is the siting, and the second is we have to get an answer: Is the Romney administration really ready to spear the cost on this? The bottom line has to be to take care of these patients. It has to be done in a humanitarian way. I don't know that we always have the services. It varies. It's something we have to address, and it often depends on year-to-year funding."
"People need social workers, occupational training and, at the simplest level, they need to be reminded to take their medication," continues Chandler. "The people who are able to leave Worcester State are people for who modern medicines have made a difference, but it makes no difference if they can't remember to take them. The need will never go away. Where are these social services? Can we have an inventory, please?"
So here's what happens next: At the feasibility commission's meeting, they rejected the Legislature's deadline date and voted to submit the final synopsis on April 1, 2006. The previous deadline would have given the commission only two and a half months to report. Unworkable, they said. They also delayed their next meeting for 60 days in order to have a chance to tour two newer state hospitals and the New Hampshire State Hospital as models.
It's been seven years since LaFortune had a big slip, starting to hallucinate while living alone in his apartment in Clinton. "I was seeing bugs," says LaFortune. "Nobody else could see bugs, but I could. I could see them crawling all over me and all over my bed. So I got two cans of Raid. I sprayed the whole apartment with it and sprayed myself with it. I had a meeting with a nurse for my shot, and they smelled it. They said, 'You're not leaving.'"
Today, he's fairly well adjusted and spends his days taking care of his dad, who needs him now. He's also licked smoking, cut down on sweets and works out at the Y a couple of hours a day. It's still tough to keep the weight down: years of mood-altering drugs took a toll and sparked diabetes. He takes 13 pills a day and some make him very tired.
"There are two meds that I'm taking now that haven't changed in seven years," says LaFortune, who says the "older" drugs work much better for him. "I'm feeling better than I've ever felt. Things are going great. I've weaned myself off being dependent on therapists and doctors. I don't see a psychiatrist as often as I used to. I have a therapist I see frequently. I have my own network now."
LaFortune is one of the lucky ones. "For the mentally ill we have very little," says McDonald. "Mental illness is a medical illness. We don't take a person who has cancer and say you can't stay in the hospital, we're going to put you in an apartment down in the Main South area. Why do we, or why does this administration, do this? This administration has been brutal."
Even if there are unforeseen obstacles, it'll take five to eight years to build a new hospital. Already, though, the wave of de-institutionalization -- the transfer of patients to the neighborhoods of our cities and towns -- is here. Advocates pray we're ready.
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THE SPOKESMAN-REVIEW (WA), January 27, 2005
[Editor's Note: State hospitals are not the only endangered venues of intensive treatment. Often the most supportive type of care for a patient being released from a hospital is a group home. Yet in many communities, apparently including Spokane, the use of these facilities is being discouraged, perhaps inappropriately so. Independent living is always the ultimate goal for a person with mental illness but being prematurely thrust into it can be nothing more than a guarantee of rehospitalization.]
SPOKANE GROUP HOME SHUTTING DOWN
Jan. 27--Craig Ferguson lives in a tiny room in a sprawling group home in south Spokane. A small television sits atop a record player that no longer spins. A cloth picture of two elk, horns interlocked in battle, hangs above his bed.
On Wednesday, Ferguson stood under the door frame leading to his room, and stared at the plastic bags filled with his clothes. After 14 years at the Hilltop Center, Ferguson is moving.
"I'll be all right, I guess," said Ferguson, 47. "It's been a good place to be."
This week, the Hilltop Center announced that it would close its 21 beds for the mentally ill, blaming a decrease in referrals from mental health systems and a restructured county payment system.
"I've been in this business for 40 years," said Elaine Charon, operator of Hilltop and two other homes, which will remain open. "I feel like it just isn't feasible anymore."
Once cornerstones of the support network for mentally ill people trying to live in the community, the group homes have watched the number of beds gradually dwindle, as county officials have publicly encouraged more independent living arrangements. Spokane's Regional Support Network, which provides public mental health care in the county, said it will subsidize 193 beds in group homes this year, down from 209 beds two years ago.
County officials did not immediately respond to requests for interviews on Wednesday.
In an e-mail message to providers last week, an RSN official said, "Everyone has openings, but we cannot afford to fill beds at a rate that is not financially sound for us." The official said the county is "constantly over budget" on its residential spending.
At Sunshine Terrace, residential care coordinator Ken Niccolls said he has noticed a decline in referrals but said the home has survived in part because of its size; the home operates 60 beds in Spokane Valley.
"I understand that there are not as many referrals," Niccolls said. "We might be better off than most people because we have a larger (facility)."
Kathy Weiss, administrator at Valley View Living Center in Spokane Valley, said the home has several vacancies but said she was confident her numbers would bounce back.
"It's kind of the nature of the business," Weiss said. "You see that ebb and flow."
At Hilltop Center, 605 S. Bernard St., several of the residents said they have tried living independently but struggled to stay on their medications, off the streets and out of jail.
Steve Adams, a 39-year-old former dishwasher who has schizophrenia, said when he lived on his own, he stayed up all night drinking cup after cup of coffee. He has lived at the group home for two years, where staff members monitor his medications.
"I went off my medication a few weeks ago, and I just started falling to pieces after about seven or eight days," Adams said. "I couldn't even water my plants."
Pam Brault, the home's operator, said that for years the home has responded to personal emergencies -- both minor and serious -- from former clients.
"Usually within a month of a client moving out, they are back at the front door wanting a meal," Brault said. "Of course you aren't going to say no to a hungry person."
Brault said the home will close Feb. 18. The home's operators are working with case managers to find housing for the residents, Brault said.
On Wednesday, several residents packed their clothing and belongings, even though it may be several weeks before they leave. On the second floor, a man who has lived at the home for two years filled a bag with cigarettes and packets of sugar that he had hidden in his sock drawer. He said he had previously lived in group homes, on the streets and in shelters.
This, he said, was just another move.
"Just got to keep on moving," he said.
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RALEIGH NEWS & OBSERVER (NC), January 10, 2005
[Editor's Note: Below is another episode in Ruth Sheehan's chronicling of the release of Phil Wiggins into the community after decades in state hospitals. It appears that the efforts of his sister, and perhaps the spotlight provided by this series, have secured Mr. Wiggins with a facility well-suited to the task of easing his transition into the community - a group home.]
SISTER'S HOPE IS HOME
By Ruth Sheehan, Staff Writer
On a quiet cul-de-sac in Zebulon sits Phil Wiggins' future.
The group home is a pale gray Cape Cod with a varnished front door. It is indistinguishable from the other homes in the neighborhood; if anything, it's nicer.
The interior is airy and bright. Couches and chairs surrounding a fireplace make the living room homey. Above the mantel is a painting of a black Jesus.
The bedrooms are simply furnished; the shared bathroom gleams. The entire place is spotless.
Louise Jordan, Wiggins' sister, approves.
I have been following Wiggins' journey from state psychiatric hospitals back into the community for eight months. Wiggins, 61, who suffers from schizophrenia, has spent the past 44 years in Dorothea Dix or, more recently, Cherry Hospital in Goldsboro. But now the state, to comply with a federal mandate, is shifting even the most severely mentally ill into neighborhoods and houses like this.
Last spring, it looked like Wiggins was on a fast track for his move. The hospital planned to release him to Wilson County, even though Jordan lives in Raleigh, and Wiggins hasn't lived anywhere but a psychiatric hospital since he was 17.
Jordan's concerns about his fascinations with fire and chemicals were largely ignored. She feared that in this move, as in a previous attempt two years earlier, he wouldn't receive the services or attention he needs.
Since then, though, the process has slowed dramatically. The hospital agreed to release Wiggins to Wake County. Jordan finally feels like the state is paying attention.
On the day we visited the group home last week, Jordan eyed the other residents, wondering how her brother would fare in this world.
It is an open question. But the group home gives her hope.
This home is owned and run by a registered nurse who operates several group homes for the mentally ill in the area. She asked not to be named or have the exact location of the homes disclosed because many of her neighbors have no idea what goes on in the tidy houses.
This home seems as near to perfect as Jordan expects to find. The owner promises round-the-clock care. One attendant sleeps at the house; another is on hand, awake, all night, too.
Jordan is impressed with the supervision -- Wiggins has a history of wandering.
She is relieved that the home's chemicals, cleaning supplies and such, are kept in a locked closet. Even the food is locked up. The residents are given smoking breaks every two hours, and Wiggins will not have his own lighter or matches.
Jordan still worries about the smoking but marvels at how things have changed since last summer, when Wiggins' caseworker at Cherry Hospital suggested that Jordan consider placing Wiggins at Oliver House, a rest home described in The News & Observer weeks earlier.
"What a journey it's been from Oliver House to here," Jordan said.
But the real journey lies in the weeks ahead, when a bed comes open. In the next few weeks, Wiggins will visit the group home himself. If he likes it, it will be his new address.
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Treatment Advocacy Center E-NEWS is a publication of the Treatment Advocacy Center.
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Visit our web site www.psychlaws.org
February 11, 2005
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1. MORE HOMELESS MENTALLY ILL THAN EXPECTED ACCORDING TO UCSD STUDY - University of California, San Diego News, February 1, 2005
2. LOST ASYLUM - Worcester Magazine, January 20-26, 2005
3. SPOKANE GROUP HOME SHUTTING DOWN - The Spokesman-Review, January 27, 2005
4. SISTER'S HOPE IS HOME - Raleigh News & Observer, January 10, 2005
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UNIVERSITY OF CALIFORNIA, SAN DIEGO NEWS, February 1, 2005
[Editor's Note: A new study from the School of Medicine of University of California, San Diego (UCSD) gives stark perspective to the inextricable meld between severe psychiatric disorders and homelessness. Many studies have documented the prevalence of people with severe mental illness among those who are homeless; the findings vary somewhat but approximately one-third of those living on our streets are afflicted with mostly treatable psychiatric illnesses.
The USCD researchers took a converse approach, determining the percentage of people with serious mental illness in San Diego County who are without a place to live. They found that 15% are, or about one in seven. Over all, about only one out of every 500 Americans is homeless.]
MORE HOMELESS MENTALLY ILL THAN EXPECTED ACCORDING TO UCSD STUDY;
Interventions Urged
By Sue Pondrom
The prevalence of homelessness in persons with serious mental illness in San Diego County, the nation's sixth largest metropolitan area, is 15 percent - a higher percentage than suggested in previous studies, according to new research by investigators at the UCSD School of Medicine.
Published in the February 2005 issue of the American Journal of Psychiatry, the study noted that homelessness in this population might potentially be reduced or prevented with substance abuse treatment and help in obtaining public-funded health benefits (Medicaid, or MediCal in California). Because homeless mentally ill were more than twice as likely to be hospitalized as non-homeless patients, the investigators said improved care for homeless persons with serious mental illness may be cost effective or at least result in improved patient outcomes with only moderate increases in total costs.
The research was conducted among an ethnically diverse population of 10,340 San Diegans with serious mental illness (both homeless and those with housing) who were treated by San Diego County Adult Mental Health Services (AMHS). While one-fourth to one-third of homeless persons are estimated to have a serious mental illness, this is one of the first studies to document and describe the other side of the picture - the number of mentally ill who are homeless.
"Homelessness is more common in patients with serious mental illness than I would have guessed," said the study's first author, David Folsom, M.D., co-director of the UCSD Combined Family Medicine-Psychiatry Residency Program and the assistant medical director of St. Vincent de Paul Village's Family Health Center, a free medical clinic located in one of San Diego's largest homeless service agencies.
According to the UCSD researchers, homelessness was most frequently associated with people who were diagnosed with schizophrenia or bipolar disorder, who were substance abusers, and who had no public-funded health care. Men were also more likely to be homeless than women, as were African Americans. Latinos and Asian Americans were less likely to be homeless.*
"Homelessness is an increasingly important public health issue, with seriously mentally ill persons most at risk for homelessness," said the study's senior author, Dilip Jeste, M.D., UCSD Estelle and Edgar Levi Chair in Aging, professor of psychiatry and neurosciences, director of the UCSD Sam and Rose Stein Institute for Research on Aging, and a geriatric psychiatrist at the VA San Diego Healthcare System. "In addition to the trauma experienced by these individuals, there is also a cost to society. Homeless persons have a significantly more-frequent use of expensive emergency services** and are more likely to spend more time in jail."
The study noted that in San Diego, African Americans comprise 5 percent of the general population, 11 percent of the AMHS population with serious mental illness, and 16 percent of the homeless patients with serious mental illness treated in AMHS. Latinos contribute 23 percent of the general population, 19 percent of the AMHS patients, and 12 percent of the homeless.
"It is possible that the higher rate of homelessness among African Americans may be in part due to fewer community resources for this group of patients, whereas the larger Latino community may be able to provide more resources to protect against homelessness," the study said. "However, African Americans have been found to be at higher risk of homelessness in other cities with larger African American populations, such as New York and Philadelphia***."
The authors also said that an investigation of homeless persons in Los Angeles, only some of whom had mental illness, found lower rates of homelessness in Caucasians and Latinos than in African Americans.
Noting that treatment for substance abuse has been reported to improve outcomes, the researchers said "access to substance abuse treatment is more difficult for homeless persons with serious mental illness than for other homeless persons. Similarly, patients who did not have MediCal insurance were twice as likely to be homeless as patients with MediCal; homeless persons with psychotic disorders have been reported to have greater difficulty obtaining and maintaining entitlement benefits than non-psychotic homeless persons."
The authors concluded that "although it would be naïve to assume that treatment for substance use disorders and provision of MediCal insurance could solve the problem of homelessness among persons with serious mental illness, further research is warranted to test the effect of interventions designed to treat dually diagnosed patients and to assist homeless persons with SMI obtain and maintain entitlement benefits."
The study was funded by the National Institute of Mental Health and by the Department of Veterans Affairs. Additional authors were William Hawthorne, Ph.D., Laurie Lindamer, Ph.D., Todd Gilmer, Ph.D., Anne Bailey, M.S., Shahrokh Golshan, Ph.D., Piedad Garcia, Ed.D., Jurgen Unutzer, M.D., and Richard Hough, Ph.D.
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WORCESTER MAGAZINE (MA), January 20-26, 2005
[Editor's Note: One major contributor to the ranks of people with severe mental illness among the homeless is a lack of sufficient inpatient facilities to provide treatment, support, and an avenue to recovery. We hope not, but chances are that some Worcester State Hospital patients may soon be living in shelters and lining up at food kitchens.]
LOST ASYLUM
More Mentally Ill Patients Will Face Life on the Outside When State Replaces Worcester State Hospital
By Charlene Arsenault
In the sticky-hot summer of 1989, Rick LaFortune decided he was the Messiah. As Jesus, he descended on a park in downtown Leominster, where, to begin saving the world, he stripped naked and folded his clothes neatly in a pile. The police grabbed him, throwing him into a blanket and a cell, in that order.
LaFortune had been coaching at the Special Olympics and was getting sloppy about the small dose of medication he was supposed to take. Over the years, that formula -- stress and med changes -- preceded many of his breakdowns, beginning in 1968, when he was 16 and a high school student in Fitchburg.
He doesn't elaborate on what precipitated that first episode (sometimes he does elaborate, sometimes he veers off the question), but just says he wasn't adjusting well in school. He was institutionalized in Jamaica Plain, where they diagnosed him as paranoid schizophrenic. "I wound up in a hospital that was, quite frankly, brutal," says LaFortune. "It was something that made One Flew Over the Cuckoo's Nest look like a picnic. And I got electric shock treatments there. I was terrified."
After landing in facilities every few years or so, including Worcester State and Gardner State hospitals, he knows what makes for a good hospital. He speaks highly of both and attributes much of his wellness to the staff there; to him, state hospital care beats private hospital care hands down.
LaFortune is now one of the de-institutionalized. It's been seven years now since he was committed to a hospital. He lives by himself in a subsidized apartment in Fitchburg, one of many countless mentally ill people who cope in the community.
He is luckier than a lot. He's had a family structure to assist him in getting the right help when he was going off the deep end. He's also found the right programs, had caseworkers to negotiate his insurance (now Mass. Health) and psychologists to tinker with his meds. Not everyone has that, argue advocates for the mentally ill, a situation which indirectly contributes to the homeless and jail population.
LaFortune credits state facilities like Worcester State Hospital for helping him. He liked the care. He liked the structure and familiarity. It provides a sense of security that can't be felt elsewhere, especially to the mentally ill.
"There is a part of the population, myself included," says LaFortune, "that when I become very sick or very manic and psychotic, I need a safe place to be and for me that is usually a locked unit where they can be forceful with me, but in a gentle way. You need a place like Worcester State for that. You need a place where people can be safe and you need a place where they can get tough love. One of the biggest things Worcester State did for me was give me discipline. There are two or three people I know who are still at the state hospital who've told me that they would rather live there than in the general community because people accept them there."
Gov. Mitt Romney's administration has been hot to shut Worcester State down practically from the day he took office. (The facility, which houses 156 inpatient beds, was built in 1833 and celebrated its anniversary yesterday.) In his very first February budget speech, Romney unveiled a plan to close Worcester State Hospital and wipe its $24 million budget off the books. There was an immediate backlash from advocates for the mentally ill.
"He wanted to take all the people and move them out here, there and everywhere," says state Sen. Harriette Chandler (D-Worcester), who battled the closing. "The largest number would have gone into community services. There was no question in anybody's mind that there weren't appropriate services. There wasn't careful thought given to what the whole movement meant. It sounds good on paper, but these are human beings who are very sick people."
The fear is that when institutions close, the needy are cast to community services that can't take care of them. "We just don't do a good job," says James McDonald, longtime advocate for the mentally ill and vice president of the Central Alliance for the Mentally Ill (part of NAMI). "In the hospital, you have nurses, you have doctors, you have your meals served and social workers. You must have the same thing in the community. We don't have that. We did at one time. We did have enough case managers. We did have enough apartments, but there are more and more people. You're almost unable to get into the services of the DMH unless you're very seriously ill."
Once Romney announced his intentions to close Worcester State, the Legislature responded quickly, requiring a study from the state Department of mental Health to justify closing the hospital. DMH Commissioner Elizabeth Childs expanded the study to examine the entire department and its inpatient capacity needs. A year later, rumors flew that the Romney administration was looking to shut down Worcester State Hospital as well as Westboro State Hospital to make room for a new hospital, reducing the total number of beds and placing discharged patients in community facilities and treatment.
The administration says shutting the two suffering hospitals would streamline the budget. We'd get a nice, new, state-of-the-art-facility, but one that would leave fewer beds for the mentally ill in the state. The money saved could be pumped into the community to buffer the wave of de-institutionalization that has already begun and would have to continue.
Much like what occurred in the '80s when then-Gov. Michael Dukakis instigated de-institutionalization, 268 of the 900 mental health patients in the state will be discharged this year. The Department of Mental Health thinks it's a great idea. You get a different view when you talk to people who care for the mentally ill.
After two date extensions, in March, 2004, the DMH delivered that feasibility study that was demanded of them in March. It favored the idea of building the new hospital and recommended "community placements of 268 adult continuing care inpatient clients who are ready to leave." It was critical of the efficiency of both the Worcester and Westboro facilities, too, pointing out ancient heating systems, lack of cooling systems and old electrical units. It estimates that $59 million in capital costs would be needed to keep both facilities in operation over the next 10 years. "Existing facilities at either Worcester State Hospital or Westboro State Hospital do not provide a sound option for consolidated impatient capacity in Central Massachusetts over the long term," reads the report.
According to Lester Blumberg, DMH's chief of staff, "The existing infrastructures at either Worcester or Westboro are insufficient to sustain a capacity of 270 beds, which is the number we have estimated we need for the Central Massachusetts facility. Not only is the physical plan inadequate, but we have learned so much more about the environment of care in the decades since these buildings were built. They are institutional in look and feel and they therefore promote institutionalization."
A commission of 15 people, chosen to study Romney's plan, met for the first time on Monday, Jan. 10, when it was announced that the state Designer Selection Board brought on Ellenzweig Associates Inc. to study where -- and how -- to build the new 320-bed hospital. The plan for a new facility has real momentum.
In the meantime, the discharges have already started to occur. A MHW (mental health worker) at Westboro State Hospital, speaking on the condition of anonymity, says they've already felt the movement. "I talked to my supervisor about this," he says, "and she said that although it may mean that some people may lose their jobs, she thinks it'll be beneficial for the patients because the conditions at the hospitals are deplorable."
The discharge rate, he explains, seems to have sped up so much that the units are getting cleaned out far earlier than they used to be. "In the past, we'd get residents from the locked units and then put them into residential settings," he says. "They had much more time to follow their treatment plan and cope with their problems. They're now sending people through so fast that they're not confident in these [residential] houses. I think in the long run, the patients are going to suffer in a sense that they have deadlines to meet. They'll get into the community when they're not ready to go into the community, and end up homeless."
Blumberg argues that no one is left behind, and references as an example the closing of Medfield State Hospital, where of the 255 patients discharged, only 7% have required hospitalization again. The DMH's discharge plan, he says, is being timed to allow for development of these services to support those clients.
"Each person who is discharged has an individually developed community treatment plan that is designed to meet their needs," says Blumberg. "We are enhancing existing community residential services to provide these individuals with the support they need. For the most part, they are moving into existing residential settings that have vacancies created by other clients who are ready to move through the continuum of care to less-intensive services." He points toward visiting nurse services, supported living services (where staff visits the home), day treatment and clubhouses.
"I feel that it would be a good idea to build a new hospital," says an RN who currently works at Worcester State Hospital. "Both buildings are quite old and do need to be updated, so a new hospital would be in the best interests of the patients."
Yet among advocates, the fear is that in its rush to complete the project, the DMH and the Romney administration is failing to grasp the depths of care that some mentally ill people need. Jo Masserelli, who directs a training project to teach human service workers in conjunction with Catholic Charities and also offers a few beds to those in need, says, "I would say people need more than just programs. They need more than just service involvement. Another presumption is that just because a human service exists that it takes care of everything. I think families need some assistance to become competent to help other family members. I think there are a lot of troubled people. Mental health services can address some of those troubles, but certainly not all. I would say I'm highly in favor of a responsive and well-done de-institutionalization, and that's been the bulk of my work."
"I know that the patients being discharged are ready from what I see," says the Worcester State RN. "They're ready to go into the community. But to some, [the hospital] is almost like a home."
Phil Hadley, president of the National Association of the Mentally Ill/Massachusetts chapter, staunchly maintains improvements need to be made before de-institutionalization is even considered. There are 3,000 families among NAMI members who are affected by mental illness and he says they struggle with a large degree of stigma and inability to get proper help. "They limit people from 10 to 14 days and they're not much better than when they went in," says Hadley. "There is no follow-up after they get out of the hospital. When the patient is in the hospital and is seen by a psychiatrist and then when they're discharged, if they have a psychiatrist on the outside -- that's important. There is no communication between the in-house doctor and out-house doctor. They don't talk. It's very frustrating. Unless they have a person who is an advocate for them, by nature of the disease, these people aren't thinking correctly and they need an advocate. They don't know what to do. They end up on the street."
Chandler walked away from that first commission meeting last Monday with a positive vibe, but with many questions, including not only where the money will come from to build it, but the issue of siting, which Chandler and others say will prove to be one of the hot buttons. NIMBY (not in my backyard) always plays a part in such moves.
"I've been led to believe by Commissioner Childs, who is a psychiatrist who researched this carefully, that what she is talking about constructing is a state-of-the-art building that will use the synergy of our neighboring institutions, like UMass or Tufts Veterinary School," says Chandler. "We have a lot of things going on, but we can't close it down in sort of a thoughtless manner as we did 10 years ago."
State Rep. James Leary (D-Worcester), also on the commission, says, "I'm cautiously optimistic that we'll get a consensus on this. I think there are two major issues -- one is the siting, and the second is we have to get an answer: Is the Romney administration really ready to spear the cost on this? The bottom line has to be to take care of these patients. It has to be done in a humanitarian way. I don't know that we always have the services. It varies. It's something we have to address, and it often depends on year-to-year funding."
"People need social workers, occupational training and, at the simplest level, they need to be reminded to take their medication," continues Chandler. "The people who are able to leave Worcester State are people for who modern medicines have made a difference, but it makes no difference if they can't remember to take them. The need will never go away. Where are these social services? Can we have an inventory, please?"
So here's what happens next: At the feasibility commission's meeting, they rejected the Legislature's deadline date and voted to submit the final synopsis on April 1, 2006. The previous deadline would have given the commission only two and a half months to report. Unworkable, they said. They also delayed their next meeting for 60 days in order to have a chance to tour two newer state hospitals and the New Hampshire State Hospital as models.
It's been seven years since LaFortune had a big slip, starting to hallucinate while living alone in his apartment in Clinton. "I was seeing bugs," says LaFortune. "Nobody else could see bugs, but I could. I could see them crawling all over me and all over my bed. So I got two cans of Raid. I sprayed the whole apartment with it and sprayed myself with it. I had a meeting with a nurse for my shot, and they smelled it. They said, 'You're not leaving.'"
Today, he's fairly well adjusted and spends his days taking care of his dad, who needs him now. He's also licked smoking, cut down on sweets and works out at the Y a couple of hours a day. It's still tough to keep the weight down: years of mood-altering drugs took a toll and sparked diabetes. He takes 13 pills a day and some make him very tired.
"There are two meds that I'm taking now that haven't changed in seven years," says LaFortune, who says the "older" drugs work much better for him. "I'm feeling better than I've ever felt. Things are going great. I've weaned myself off being dependent on therapists and doctors. I don't see a psychiatrist as often as I used to. I have a therapist I see frequently. I have my own network now."
LaFortune is one of the lucky ones. "For the mentally ill we have very little," says McDonald. "Mental illness is a medical illness. We don't take a person who has cancer and say you can't stay in the hospital, we're going to put you in an apartment down in the Main South area. Why do we, or why does this administration, do this? This administration has been brutal."
Even if there are unforeseen obstacles, it'll take five to eight years to build a new hospital. Already, though, the wave of de-institutionalization -- the transfer of patients to the neighborhoods of our cities and towns -- is here. Advocates pray we're ready.
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THE SPOKESMAN-REVIEW (WA), January 27, 2005
[Editor's Note: State hospitals are not the only endangered venues of intensive treatment. Often the most supportive type of care for a patient being released from a hospital is a group home. Yet in many communities, apparently including Spokane, the use of these facilities is being discouraged, perhaps inappropriately so. Independent living is always the ultimate goal for a person with mental illness but being prematurely thrust into it can be nothing more than a guarantee of rehospitalization.]
SPOKANE GROUP HOME SHUTTING DOWN
Jan. 27--Craig Ferguson lives in a tiny room in a sprawling group home in south Spokane. A small television sits atop a record player that no longer spins. A cloth picture of two elk, horns interlocked in battle, hangs above his bed.
On Wednesday, Ferguson stood under the door frame leading to his room, and stared at the plastic bags filled with his clothes. After 14 years at the Hilltop Center, Ferguson is moving.
"I'll be all right, I guess," said Ferguson, 47. "It's been a good place to be."
This week, the Hilltop Center announced that it would close its 21 beds for the mentally ill, blaming a decrease in referrals from mental health systems and a restructured county payment system.
"I've been in this business for 40 years," said Elaine Charon, operator of Hilltop and two other homes, which will remain open. "I feel like it just isn't feasible anymore."
Once cornerstones of the support network for mentally ill people trying to live in the community, the group homes have watched the number of beds gradually dwindle, as county officials have publicly encouraged more independent living arrangements. Spokane's Regional Support Network, which provides public mental health care in the county, said it will subsidize 193 beds in group homes this year, down from 209 beds two years ago.
County officials did not immediately respond to requests for interviews on Wednesday.
In an e-mail message to providers last week, an RSN official said, "Everyone has openings, but we cannot afford to fill beds at a rate that is not financially sound for us." The official said the county is "constantly over budget" on its residential spending.
At Sunshine Terrace, residential care coordinator Ken Niccolls said he has noticed a decline in referrals but said the home has survived in part because of its size; the home operates 60 beds in Spokane Valley.
"I understand that there are not as many referrals," Niccolls said. "We might be better off than most people because we have a larger (facility)."
Kathy Weiss, administrator at Valley View Living Center in Spokane Valley, said the home has several vacancies but said she was confident her numbers would bounce back.
"It's kind of the nature of the business," Weiss said. "You see that ebb and flow."
At Hilltop Center, 605 S. Bernard St., several of the residents said they have tried living independently but struggled to stay on their medications, off the streets and out of jail.
Steve Adams, a 39-year-old former dishwasher who has schizophrenia, said when he lived on his own, he stayed up all night drinking cup after cup of coffee. He has lived at the group home for two years, where staff members monitor his medications.
"I went off my medication a few weeks ago, and I just started falling to pieces after about seven or eight days," Adams said. "I couldn't even water my plants."
Pam Brault, the home's operator, said that for years the home has responded to personal emergencies -- both minor and serious -- from former clients.
"Usually within a month of a client moving out, they are back at the front door wanting a meal," Brault said. "Of course you aren't going to say no to a hungry person."
Brault said the home will close Feb. 18. The home's operators are working with case managers to find housing for the residents, Brault said.
On Wednesday, several residents packed their clothing and belongings, even though it may be several weeks before they leave. On the second floor, a man who has lived at the home for two years filled a bag with cigarettes and packets of sugar that he had hidden in his sock drawer. He said he had previously lived in group homes, on the streets and in shelters.
This, he said, was just another move.
"Just got to keep on moving," he said.
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RALEIGH NEWS & OBSERVER (NC), January 10, 2005
[Editor's Note: Below is another episode in Ruth Sheehan's chronicling of the release of Phil Wiggins into the community after decades in state hospitals. It appears that the efforts of his sister, and perhaps the spotlight provided by this series, have secured Mr. Wiggins with a facility well-suited to the task of easing his transition into the community - a group home.]
SISTER'S HOPE IS HOME
By Ruth Sheehan, Staff Writer
On a quiet cul-de-sac in Zebulon sits Phil Wiggins' future.
The group home is a pale gray Cape Cod with a varnished front door. It is indistinguishable from the other homes in the neighborhood; if anything, it's nicer.
The interior is airy and bright. Couches and chairs surrounding a fireplace make the living room homey. Above the mantel is a painting of a black Jesus.
The bedrooms are simply furnished; the shared bathroom gleams. The entire place is spotless.
Louise Jordan, Wiggins' sister, approves.
I have been following Wiggins' journey from state psychiatric hospitals back into the community for eight months. Wiggins, 61, who suffers from schizophrenia, has spent the past 44 years in Dorothea Dix or, more recently, Cherry Hospital in Goldsboro. But now the state, to comply with a federal mandate, is shifting even the most severely mentally ill into neighborhoods and houses like this.
Last spring, it looked like Wiggins was on a fast track for his move. The hospital planned to release him to Wilson County, even though Jordan lives in Raleigh, and Wiggins hasn't lived anywhere but a psychiatric hospital since he was 17.
Jordan's concerns about his fascinations with fire and chemicals were largely ignored. She feared that in this move, as in a previous attempt two years earlier, he wouldn't receive the services or attention he needs.
Since then, though, the process has slowed dramatically. The hospital agreed to release Wiggins to Wake County. Jordan finally feels like the state is paying attention.
On the day we visited the group home last week, Jordan eyed the other residents, wondering how her brother would fare in this world.
It is an open question. But the group home gives her hope.
This home is owned and run by a registered nurse who operates several group homes for the mentally ill in the area. She asked not to be named or have the exact location of the homes disclosed because many of her neighbors have no idea what goes on in the tidy houses.
This home seems as near to perfect as Jordan expects to find. The owner promises round-the-clock care. One attendant sleeps at the house; another is on hand, awake, all night, too.
Jordan is impressed with the supervision -- Wiggins has a history of wandering.
She is relieved that the home's chemicals, cleaning supplies and such, are kept in a locked closet. Even the food is locked up. The residents are given smoking breaks every two hours, and Wiggins will not have his own lighter or matches.
Jordan still worries about the smoking but marvels at how things have changed since last summer, when Wiggins' caseworker at Cherry Hospital suggested that Jordan consider placing Wiggins at Oliver House, a rest home described in The News & Observer weeks earlier.
"What a journey it's been from Oliver House to here," Jordan said.
But the real journey lies in the weeks ahead, when a bed comes open. In the next few weeks, Wiggins will visit the group home himself. If he likes it, it will be his new address.
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