Can you imagine what would happen if a newspaper reported that a hospital refused to treat someone suffering a heart attack? What would the public think if a car accident victim was turned away from an emergency room? Yet, according to a recent report by the Virginia Office of Inspector General for Behavioral Health and Developmental Services, at least 200 persons who were having a mental health crisis and met Virginia’s involuntary civil commitment standard because they were dangerous were refused treatment in the Hampton Roads area between April 2010 and March 2011. 
The practice of turning away psychiatric patients in Virginia has become so common that there is a word for it — “Streeting.”
The IG’s report cited an example of a 66-year-old Virginia woman who needed immediate care but was turned away by 15 private hospitals. She then was driven a hundred miles away to a crisis stablization unit only to be turned away there because she did not make it through the unit’s medical clearance process due to lethargy, a medication side effect. Forty-eight hours later she was finally admitted to a hospital emergency room.
She was lucky. At least she finally found a bed.
Where is the community outrage? Why are doctors, mental health professionals, community leaders and elected officials not alarmed?
Unfortunately, the IG’s report was not a surprise to most of us who are familiar with Virginia’s mental health system. More than two years ago, a University of Virginia professor warned a special panel charged with suggesting improvements to state legislators that an estimated 2,400 Virginians would be streeted each year unless something was done to improve crisis care services. That’s 2,400 psychotic people who are suffering and need help.
On Sunday, the executive director of the National Alliance on Mental Illness in Virginia, Mira Signer, published an editorial in the Washington Post that explained several reasons why “streeting” has become so commonplace in her state. Under pressure from the U.S Justice Department, the state has been gradually reducing beds at its state hospitals.
In 2010, the number of beds at the Northern Virginia Mental Health Institute in Falls Church was reduced from 129 to 123. By July 1, an additional 13 beds will be lost. Eastern State Hospital in Williamsburg had its beds cut from 250 to 150. Despite protests by mental health groups, a specialized children’s unit in Marion in southwest Virginia was shuttered and next month the Chesapeake Regional Medical Center will close a 24-bed mental health unit for older people.
The Justice Department wants Virginia to follow other states in closing down state hospitals. This practice dates back to 1963 when President John F. Kennedy signed into law the Mental Retardation Facilities and Community Mental Health Centers Construction Act, which led to the establishment of more than 750 comprehensive community mental health centers throughout the country. The development of more effective psychotropic medications and new approaches to psychotherapy made community-based care for the mentally ill a more feasible alternative. The feeling was that most people with mental illnesses could be treated more effectively and in a more cost-effective manner in community settings than in traditional psychiatric hospitals. This “deinstitutionalization” movement has led to the populations in state inpatient hospitals to drop steadily from nearly 600,000 in 1955 to fewer than 70,000 today.
Community based treatment is a wonderful practice.
But neither our federal or state governments have ever adequately financed community based services. Instead, they have continued to close state facilities to save money, abandoning thousands of ill persons to live in substandard assisted liviing facilities, nursing homes and sending more than a million a year into our criminal justice system, with 360,000 of those unfortunate souls ending up being incarcerated in jails and prisons.
Regular readers of this blog or those of you who have read CRAZY: A Father’s Search Through America’s Mental Health Madness are familiar with how deinstitutionalization has become a cruel joke. The fact that the U.S. Justice Department continues to push states, such as Virginia, to empty their hospitals without also demanding that states provide adequate community services is short-sighed and heartless.
But there are more reasons for “streeting” than simply the closing of state hospitals.
The last time that I visited the Northern Virginia Mental Health Institute in Falls Church, there were more than a dozen patients who were ready to move out on their own. They had the symptoms of their illnesses under control. They were ready and eager to return to life in our community. But there was no where for them to go because of a serious lack of affordable housing in Fairfax County. This meant there were twelve beds that could have been filled with new patients – if community housing had been available.
This is why in my speeches, I explain that you can’t talk about fixing our mental health system unless you talk about affordable housing. You can’t talk about mental health reform unless you talk about jobs. You can’t talk about it without talking about transportation – and drug and alcohol treatment programs and other wrap around services that persons who are sick need to be well in a community setting.
Housing is just as much a mental health necessity as is medication or access to case managers and psychiatrists.
Private hospitals and HMOs are also to blame for ‘streeting.” They have been closing their psychiatric units as quickly as they can because they lose money. I recently heard a hospital administrator explain how each time his hospital hired a psychiatrist, it lost money. Insurance companies that dodge their responsibility to care for mental health services also are too blame. When my older son was stricken with pneumonia and hospitilized in New York, he was kept there for four weeks without anyone trying to discharge him. Yet the moment my son with a mental illness enters an emergency room, the hospital, doctors and insurance company are trying to get him discharged ASAP, often by stuffing a pill in his mouth and shoving him out the door.
Shame on them!
In his report, Inspector General G. Douglas Bevelacqua cites another reason for “streeting.” Much like other states, Virginia doesn’t know what to do with sexual offenders after they finish serving their prison sentences. States have been using involuntary civil commitment statutes to transfer sexual offenders directly from prisons into locked mental health facilities because they are considered dangerous. They are being kept there indefinately. This further reduces the beds available to persons who need help recoverying from severe mental disorders.
IG Bevelacqua notes that the sex offender population has grown from 14 in 2004 to over 260 today and it is projected to increae by 7 individuals each month through 2016 at a cost per person of $91,000 per year.
I salute Inspector General Bevelacqua for having the courage to shine a spotlight on “streeting.”
The question now is — is anyone out there listening to his warnings?
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