Magazine article Clinical Psychiatry News

State Budget Cuts Gut Public Mental Health System: Some Advocates Want the APA to Lend a More Public Voice against Budget Cuts. (Budget Shortfalls in 40 States)

Magazine article Clinical Psychiatry News

State Budget Cuts Gut Public Mental Health System: Some Advocates Want the APA to Lend a More Public Voice against Budget Cuts. (Budget Shortfalls in 40 States)

Article excerpt

It is like a vision out of Dickens: Madmen in rags on street corners, with nowhere to turn, waiting to be picked up by police constables and pitched into the darkness of prison cells. Individuals wild-eyed with delusions or trembling with anxiety, stumbling into understaffed hospitals that have little to offer other than long waits. Horrific acts of violence committed in the blur of psychosis, leaving loved ones or total strangers maimed or killed.

Such scenarios, or something not far from them, are occurring with increasing frequency all over the country as states throughout the union cut their Medicaid and social service budgets. Fiscally fragile community mental health clinics providing outpatient care to Medicaid patients are particularly vulnerable, and an increasing number are barring their doors and turning out the lights. Inpatient facilities are feeling the knife as well.

In short, the nation's mental health infrastructure is being decimated (see accompanying article on pg. 8), and many people it once served are being left to their own devices--without their medications.

According to Charles Ray, director of the National Council for Community Behavioral Healthcare, 35 of the Council's 1,000-plus member organizations have reported clinic mergers or shutdowns in the last year.

"These are only the ones we hear about," Mr. Ray said. "Most are small neighborhood [Internal Revenue Service] 501c3 organizations barely able to [continue] operating in the first place." New budget cuts of 15%-20%, coupled with increased demand for services, drive them out of business.

Those that survive face staff turnover of 25%-30% per year. They simply cannot afford to keep qualified personnel for long. "If Ford or GM bad greater than 5% or 6% turnover on their production lines, they would be blowing whistles," he said. "In my 31 years in the mental health profession, I can tell you I've never seen this level of distress nationwide."

Things are no rosier on the inpatient side, with major facility closures in both private and public sectors. Mark Covall, executive director of the National Association of Psychiatric Health Systems, told CLINICAL. PSYCHIATRY NEWS that psychiatric hospitals are closing their doors or reducing bed counts. In 1992, there were 437 privately owned, freestanding inpatient hospitals; the number dropped to 315 in 2000. In 1992, there were 273 state mental hospitals, which dropped to 250 in 1998. "I know it is less today at least in terms of the number of beds," he added.

Data show there were 1,500 psychiatric units at general hospitals in 1998, which dropped by 14% to 1,275 in 2000. "Overall, we've seen a combined reduction in total inpatient beds, somewhere between 5,000 and 10,000 over the past few years," he said.

This means fuller houses and maximal-capacity operations at those remaining facilities. According to a survey of administrators at 120 NAPHS member hospitals, occupancy increased 11% from 1999 to 2000, with a total occupancy increase of 24% over the past 5 years.

Lengths of stay were halved in the 1990's, from an average of 23 days in 1991 to 10 days in 2000. This, however, was predicated on relatively firm outpatient community mental health center (CMHC) infrastructures into which patients could be discharged. Clearly, that has changed.

"The situation is getting worse when it should be getting better. CMHC services have never been built up to the level they needed to be. Now, all sectors of behavioral health care are being pressured, and funding has declined, while demand has remained the same or increased. We're at a point where, no question, things could get much worse," Mr. Covall said.

Not that things were especially cheery before the current wave of cuts. According to a recent analysis of National Comorbidity Survey and Epidemiological Catchment Area Study data, only 40% of individuals with disabling mental illnesses received treatment of any sort between 1990 and 1992, and of these, only 39% received care at the "minimally adequate" level. …

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