Mental Health Care : A System on the Verge of Collapse

The 10-year-old boy had been running away from his home in the San Gabriel Valley, setting fires, scraping paint off building walls and then eating it.

In desperation, his family called county mental health workers this month when the boy, who was also hearing voices, jumped out of a moving car. A psychiatric emergency team arrived, but there was nothing it could do. The boy needed hospitalization, but there were no available beds.

“It’s a miracle if we can find a bed for a child,” says Bonnie Jones, a county mental health worker. “I’ve had times when I’ve made 30 calls and not been able to find a bed.”

Public psychiatric hospitals are so full that, night after night, patients clog emergency rooms awaiting a bed that rarely becomes available.

Sleep on Clinic Floor

At County-USC Medical Center’s Psychiatric Hospital, which houses the county’s largest psychiatric emergency room, dozens of patients nightly sleep on the floor in a big room “wall to wall with mattresses, that smells like a urinal,” says Dr. Thomas Ciesla, former president of the Southern California Psychiatric Society, about a recent visit to the facility.

“There was a sea of disheveled, malodorous bodies, some of them babbling to themselves. . . . A guy would wake up . . . and urinate on the person (on the mattress) next to him.”

The doctors, according to Ciesla, have the “sad task” of deciding “who gets admitted to a (hospital) bed, who got the floor and who got the street. Most people got the street.”

Young and old, suicidal or psychotic, tormented by inner demons or disabled by neuroses, they are the sickest of the mentally ill. In Los Angeles County, their numbers have overwhelmed a mental health system on the verge of collapse.

Every day they jam the county’s four psychiatric emergency rooms, which have become the last outpost for these troubled people who typically lack the health insurance necessary to gain admission to private hospitals. Patients routinely sleep on the floor, waiting for days to be admitted for treatment. But because of an acute shortage of hospital beds, they are often stabilized temporarily and then discharged into the street.

“Instead of hospitalizing these patients, we make arrangements we are not in any way proud of,” concedes Dr. Milton Miller, chief of psychiatry at Harbor-UCLA Medical Center.

Officials openly acknowledge that the county’s system for delivering care to the mentally ill is in a state of crisis. The latest blow came June 9, when the county, after a months-long court battle, shut down three outpatient clinics in the South Bay and San Fernando Valley. At one time these clinics served about 3,000 patients, providing medication and therapy designed to head off a psychotic collapse that is likely to land a patient in crowded psychiatric emergency rooms.

Los Angeles County has an estimated 95,000 mental patients in need of varying degrees of treatment. But, more than 20% of the staff of the Department of Mental Health has left because of layoffs, demotions or voluntary terminations in the face of looming budget cuts. The murder on Feb. 21 of social worker Robbyn Panitch by a deranged client at the county’s Santa Monica clinic decimated staff morale.

‘Worst Outpatient Services’

The county was rated as having “among the worst outpatient services for the mentally ill in the United States,” according to a 1988 survey by Ralph Nader’s Public Citizen Health Research Group and the National Alliance for Mental Health.

Compounding that problem is an acute shortage of psychiatric hospital beds. “Los Angeles is now the most deprived urban area in the country, as far as available acute care in the public sector is concerned,” says Dr. R. W. Burgoyne, medical director of the county Department of Mental Health. “An increase in acute-care in-patient psychiatric beds is our current most crucial need for the system as a whole.”

“Nearly every day,” adds county Mental Health Director Roberto Quiroz, “our emergency services have more than 60 patients awaiting acute placement” in a hospital bed.

In testimony at budget hearings earlier this year, Quiroz warned that the state’s mental health system needs a massive infusion of cash to pull it back from “the edge of disaster.”

‘History in the Making’

For at least 10 years, Quiroz said in an interview, the county’s mental system has sustained “cuts and then modest increases, cuts and then modest increases. This has been history in the making.”

As Richard Dixon, the chief administrative officer of Los Angeles County, puts it: “The crisis in mental health did not appear overnight. It has developed over numerous years.” The crunch is statewide, he adds. This year, the counties of San Diego, Monterey and El Dorado, for example, have all made significant cutbacks in outpatient mental health services.

The problem is rooted in reforms dating back nearly 25 years, when a nationwide effort was undertaken to reduce the population of state mental hospitals that had become notorious for their wretched conditions. Thousands of mentally ill people were discharged into the community with the expectation they would find comprehensive, economical and humane treatment in outpatient clinics and other settings.

In California, the census at state mental hospitals plunged from 37,489 patients in 1959 to fewer than 5,000 patients today. But the plan was a disaster, mental health officials now concede, because government money did not follow patients into the community.

The state by law funds 90% of local mental health services. But Dixon says state support for county programs last year fell about $42 million short of what was needed just to keep pace with inflation and population growth.

In recent years, the county has contributed millions to local mental health services. But county officials say they no longer can bail out mental health programs without jeopardizing other vital services.

Gov. George Deukmejian has backed away from his original plan this year to cut $200 million from mental health services. Mental health advocates, who have staged a massive Sacramento lobbying campaign, say they were encouraged by legislative efforts last week to boost funding an additional $165 million, of which Los Angeles County could expect to receive an estimated $21 million to $32 million.

No Guarantees

But because there are no guarantees, Los Angeles mental health officials are preparing for another bruising round of budget cuts, should state funding fall short of their needs. As part of a plan to save almost $15 million, six of the remaining 23 outpatient clinics would be closed and services for the elderly, minorities and children would be reduced.

Meanwhile, the mental health crunch continues, with patients filling up psychiatric emergency rooms.

The office of the county counsel denied The Times access to the county’s four psychiatric emergency rooms, but doctors there described a sense of desperation that is played out around the clock. Most of the patients are brought to the emergency rooms by police or special teams of social workers who respond to crises, such as when a person is threatening to jump off a bridge, or is wandering in and out of busy traffic, or has become so disoriented they can no longer feed or bathe themselves.

Concerted Effort by Police

Some police departments have made concerted efforts in recent years to educate their officers in detecting mental illness and routing patients to psychiatric facilities.

Detective Walt Decur says the LAPD’s mental evaluation unit received 19,000 calls in 1988, up from 12,000 calls the year before.

“But there’s a real sense of frustration,” Decur says, “because now that we’re all set up to refer people into the mental health system, we find that system is not equipped to handle them.” Increasingly, he says, the unit is picking up the same patients over and over and referring them to crowded psychiatric facilities that are forced to release rather than treat them.

The crush of mentally ill patients arriving daily at Olive View Medical Center’s six-bed psychiatric emergency room in Sylmar prompted the staff earlier this month to try to plug the dike. Under their new ad hoc policy, after 10 patients have arrived, the staff issues a “yellow alert” requesting police to hold off bringing any others, says Dr. Milton Greenblatt, chief of psychiatry. When the patient load bulges to 15, doctors declare a “red alert,” advising police again of their overload.

In May, the overflow of patients at Olive View was so heavy there were 125 instances where patients spent the night on the floor, hospital officials said.

One bright light in an otherwise abysmal picture is the newly remodeled psychiatric emergency room at Harbor-UCLA Medical Center that opened last year. “We used to have the worst E.R. this side of Africa,” says Miller, the center’s chief of psychiatry.

But the new facility is equipped for only 15 patients, and typically 20 to 35 patients a day come for treatment.

“As the system has died all around us, we have become the only place to bring patients,” Miller says. And once they arrive, there typically is no place to refer them for long-term acute hospital care.

“In the old days,” Miller recalls, “we’d refer 100 patients a month,” mainly to Metropolitan State Hospital in Norwalk. Now he says Metropolitan has room for only four to 12 monthly.

For lack of resources, physicians say they dismiss extremely ill patients every day.

“I can’t tell you how many times I’ve had clients that need to be hospitalized . . . that are out of there in a couple of hours or the next morning,” complains Edith Pollach, president of the Assn. of Psychiatric Social Workers of Los Angeles County.

But what were physicians at Martin Luther King Jr./Drew Medical Center supposed to do with a 37-year-old man, highly agitated and verbally disruptive, who arrived for treatment the night of June 15?

Dr. Anna Smith, associate director of psychiatric service at the hospital’s mental health center, says the staff kept the man for four hours, but released him to make room for other patients who were more dangerous or suicidal.

The man, with a long mental history, didn’t leave. He paced the halls, darted in and out of the hospital and screamed gibberish at hospital staff, patients and visitors. The next day he was still there. Staff kept an eye on him, according to Smith, but decided they couldn’t take him in again unless he hit someone.

“He needs to be in a hospital,” says Smith, who estimated that visits to the psych emergency room have jumped 30% to 40% over the last year.

The closure of Coastal Mental Health Center in Carson and the Wilmington Mental Health Center have heaped larger than ever workloads on the psychiatric emergency rooms at both King and Harbor-UCLA Medical Center.

The cutbacks have had “an enormous negative impact,” Dr. Claudewell Thomas, head of psychiatry at King, stated in a recent declaration submitted to the county Board of Supervisors.

“Because outpatient treatment is not readily available to keep patients stabilized, we are seeing an increase in demand for crisis treatment. Patients are being cycled and recycled through crisis hospitalizations, which means they are using more expensive resources than they would otherwise have to use if outpatient treatment were more readily available.”

Delusional Woman

That’s what happened to a delusional woman who was discharged from Camarillo State Hospital last fall, says Barbara Kessel, a county social worker in North Hollywood. After the woman’s release, Kessel called county clinics trying unsuccessfully for three months to find help for the housebound woman. In the meantime, the woman stopped taking her medications and became gravely disoriented and violent. She was returned to Camarillo after threatening her husband with a loaded rifle.

Although only three of the county’s 28 outpatient clinics were shut down entirely this month, others have been severely curtailed, largely due to demotions and voluntary terminations by junior staff members who fear further cutbacks.

“We’re down to seven clinical staffers here, compared to 15 two years ago,” says Pat Frazier, the program director at Compton-Downey Mental Health Center. “The morale here is very low.” Frazier herself was demoted and her pay was cut more than $1,000 a month, despite her 30 years of county service, including 15 years in the Department of Mental Health.

The clinic, which has been targeted for closure three times during the last two years, has won a reprieve for now. “But the staff knew they were vulnerable and many have left,” Frazier says.

Meanwhile, the demand for services has not slackened. There’s a two-month wait for an appointment. “We’ll see the emergencies more frequently, but only at the expense of those on the waiting list,” Frazier says.

One man, distraught over losing the psychiatrist he had relied upon for 15 years at the East Valley Mental Health Center in North Hollywood, was so upset when the clinic closed that he began making verbal threats against President Bush. His social worker said he ended up at Camarillo State Hospital as the target of a Secret Service investigation.

The county’s Crisis Management Center in Van Nuys has had to pick up much of the slack caused by the closure of the East Valley clinic, which handled 800 patients. The crisis center, which specializes in handling psychiatric emergencies, was so overwhelmed one day last week that by mid-afternoon, it had to shut its doors to additional patients.

“I’m not going to let the place be so overrun with patients that it is an unsafe place,” says Ron Klein, the center’s administrator who examined patients on Monday for the first time in two years. “I don’t know how long we can continue this way.”