County Faces Tough Choices on Mental Health

Like the battlefield doctors on “MASH,” San Diego County’s mental health clinics will have to treat only the most severe cases under a budget-cutting plan announced Friday by the Department of Health Services.

The triage plan would remove $7.5 million from the budget and eliminate more than 4,600 people from free or reduced-price mental health care in outpatient facilities--about half of the number now served each year.

The county mental health hospital in Hillcrest, which houses emergency and chronic mental patients, will not suffer directly from the cuts.

A Cascade Effect

But the proposal’s indirect effects will cascade through the mental health system and into the community, critics were predicting within hours of the plan’s release.

More patients will need hospitalization at Hillcrest and the streets will probably house more homeless mentally ill, they said.

“These are not people for whom mental health care is optional, and yet that’s what essentially this budget is going to be saying,” said Dr. Stephen Shuchter, director of a UCSD Medical Center clinic that would lose funding for 833 clients under the plan. “These are people with severe depression, suicidal, psychotic--these are not people with just problems in living.”

County mental health officials, who prepared the cuts under direction of Chief Administrative Officer Norman Hickey, agree that the effects will be drastic, and they doubt that there is any way to avoid them. A statement that will be sent to the Board of Supervisors lists 13 probable negative effects of the cuts.

Dr. Harold Mavritte, clinical director for the county, said some people who are “screened out” under the plan might even become dangerous. He noted that James Huberty, the man who killed 21 people in a San Ysidro McDonald’s in 1984, had unsuccessfully sought help from an outpatient mental health clinic before the massacre.

He emphasized that such a tragedy would be a “worst case”--but is still something to consider.

Potential Tragedies

“A lot of people, when they come in or even call for services, they don’t approach you by calling in and saying, ‘Hey, I’m getting ready to blow up downtown.’ They might call and ask for a little bit of information,” Mavritte said. The triage system the clinics will be adopting would immediately eliminate such callers from potential treatment.

Over the last several weeks, the health department has been contemplating how to accomplish $6 million in cuts ordered by Hickey because of the county’s push to shift discretionary spending to jails and courts. Included in the total was a $1-million state cut in the money it will provide for the mentally ill who are not indigent but who can’t pay for their care.

The other $5 million represented money that the county had been putting into mental health out of its discretionary fund to solve chronic problems at the Hillcrest hospital, said Patrick Stalnaker, spokesman for the department.

“So now when they take the money away we are not going to pull it away from the hospital, because our priorities say we’re going to take care of the sickest first,” Stalnaker said.

But $6 million in cuts will also result in reduced income from treatment services, bringing the total revenue decrease to $7.5 million.

The plan calls for allocating outpatient mental health services throughout the county roughly proportional to population. However, North County inland area will not receive any cuts in its outpatient facilities because two residential treatment centers will be closed.

And the southern part of the county, although it will suffer cuts overall, will receive a proportionately higher share of funding because it has a higher concentration of mentally ill people in group homes than do other county regions, Stalnaker said.

Outpatient Services Curtailed

The day-care unit at East County Mental Health Center in El Cajon would be closed, as would the Lemon Grove Socialization Center.

Most outpatient clinics would see their services reduced by about half. The remaining money would pay mainly for providing medication and associated care to the severely mentally ill.

Dr. Sidney Bolter, medical director of Vista Hill Hospital, which runs two clinics for the county, was especially critical of the timing of the announcement. Contract providers such as Vista Hill should have been given advance notice, he said.

“I think it’s very unwise to come out with this at 4 o’clock on a Friday afternoon. Patients . . . will read about it for the first time before we have had a chance to tell them,” he said. “It can really send people into a much more severe illness, into some kind of crisis that we cannot predict the end point of.”

The plan was sent Friday to mental health care providers as well as the Mental Health Advisory Board, which will consider it on Wednesday. The providers were invited to comment on it at that meeting and during county budget hearings June 13-26.