Fund Reductions Imperil Mental Health System, Officials Say

Twenty-one-year-old Clifford Graham, suffering from hallucinations and acute psychosis, waited 12 days in a downtown emergency room bed until nurses finally found space for him last week at the County-USC Psychiatric Hospital.

The case has appalled even those mental health advocates who are keeping track of a growing list of instances in which psychiatric care for needy patients has been delayed or denied.

“Twelve days sounds ridiculous, even with the system as bad as it is,” said Dr. J. Richard Elpers, professor of psychiatry at Harbor-UCLA Medical Center and former head of the Los Angeles County Department of Mental Health.

The case, which hospital officials described last week, illustrates the inadequacies of the county mental health system, which serves largely the poor and is now threatened with devastation due to pending cuts in state mental health funds, health officials say.

The escalating demand for treatment coupled with diminishing resources has created “just a horrible situation,” said Dr. Marvin Marsh, the mental health department’s assistant medical director.

County psychiatric hospitals are so full that patients awaiting a bed often linger for days, sleeping on the floor, according to the recent public testimony of mental health advocates and county doctors. A 12-day wait for a bed is “unusual,” Marsh said, but often patients wait “more like four or five days” before they can be assigned a bed for treatment.

Problems are likely to worsen, county officials warn, due to looming budget cuts of $18.1 million in local mental health programs.

Unless the state Legislature, which returns from summer break this week, restores some of the $25 million in mental health funds that were recently struck from the budget by Gov. George Deukmejian, about one-third of the county’s outpatient clinics will close this month, promising to trigger an even greater logjam at the hospitals. In addition to those seven clinics, which are slated to close by Sept. 1, six other centers will be curtailed, affecting about 20,000 mentally disturbed people seeking care there annually, according to county officials.

As of now, prospects for restoring some of those funds are dim, county officials say.

The outpatient clinics targeted for cutbacks and closure are scattered through the county, mostly in lower-income neighborhoods. They are considered to be a crucial link in a long chain of treatment designed to re-integrate mentally disturbed adults and children back into society. Typically, patients go to them for daily medication and therapy after being released from mental hospitals.

Their closure will put additional stress on psychiatric hospitals whose beds are already in a state of “medical gridlock,” said Bryan Jones of the Los Angeles Advocates for Mental Health--a broad coalition of health professionals, clients and policy-makers.

Beds will turn over even less frequently than they do now, he said because “the clinics won’t be there for the hospitals to discharge their patients to.”

During the last six months, the coalition has waged a campaign for additional state aid, asserting that “California’s mental health situation is especially stark” compared with other states. New York, with 6 million fewer people, has more than twice as big a budget for mental health, the coalition asserts.

Roberto Quiroz, the county’s mental health director, called the pending budget cuts “a major disaster” that will create an intolerable backup of patients--many of whom will have to seek care in the private sector or go without.

For Clifford Graham, the wait for a bed lasted 12 days. It began July 14, when paramedics rushed him to California Medical Center, a nonprofit hospital in downtown Los Angeles. Hospital officials said he was having severe hallucinations and needed to be restrained. Doctors diagnosed him as suffering from acute psychosis.

“His mind, it just went out,” his mother, Olive Draine, said.

Doctors and a special medical team from the county--the Psychiatric Mobile Response Team--determined that Graham needed acute psychiatric care, which is not available at the medical center.

The team requested a bed for Graham at the closest county hospital, the 120-bed Psychiatric Hospital at County-USC. But team member Sharen Reed said the hospital “kept telling us they don’t have a bed open.”

Meanwhile, Graham lingered 12 days in the emergency room, requiring 24-hour supervision from a nursing aide whom he ultimately “kicked in the head,” said Jill Nuttall, administrative director of emergency services at the medical center.

In frustration, Nuttall said she finally called County Supervisor Deane Dana’s office for help last Monday. And on Tuesday July 26, Graham was finally transferred by ambulance to the Psychiatric Hospital.

‘At Least Not on Floor’

Marsh said, “The fact of the matter is that there are not enough acute-care psychiatric beds” in the county mental health system. He said that when a bed opens up, hospital officials have to consider who needs it the most.

In the case of Graham, he said, they probably figured that “at least he was not on the floor.”

Dr. Richard Lamb, director of the emergency room at County-USC Psychiatric Hospital, declined to comment on the Graham case but said the hospital’s 88 adult beds were “100% full” while Graham awaited treatment.

“We’re always swamped,” he said. When a bed opens up, he added, doctors usually give priority to patients who are physically on the premises waiting in line. Frequently, he said, they are sleeping on the floor while they wait.

“When they’re physically here, we have to do something about it,” he said.

An unusual “Declaration of Conscience” signed last year and publicly released by the psychiatry chiefs at four county hospitals asserted that “a desperate level of overcrowding exists night after night in each of our emergency units.” The dilemma facing physicians, according to the declaration, is “whether to place acutely psychotic patients--helpless, dazed, deluded--in a dangerous and inhumane environment or turn them away, often back onto the streets.”

With so many outpatient mental health clinics slated for closure, mental health officials say, acute psychiatric services offered by four county medical centers--County-USC, Martin Luther King Jr./Drew, Harbor-UCLA and Olive View--will be overrun with additional patients seeking care. Also, the remaining outpatient mental health clinics will be swamped and probably able to accommodate only about half of the 20,000 patients who would be affected each year, Quiroz said.

Even now, before the cutbacks, the line for treatment at outpatient clinics is long. Mental health coalition members have testified that suicidal children and adolescents wait for up to three weeks for treatment and that at some places people wait as long as seven weeks.

Targeted for closure this month are the following outpatient clinics: East San Fernando Valley Mental Health Services in North Hollywood; West San Fernando Valley Mental Health Services in Canoga Park; San Pedro Mental Health Center; Wilmington Mental Health Center; Arcadia Mental Health Center; Coastal Community Mental Health Center in Carson, and Hubert H. Humphrey Comprehensive Health Center’s mental health outpatient service in Los Angeles.

In addition, drastic cutbacks in mental health outpatient services are expected at the county’s public hospitals and at St. John’s Hospital in Santa Monica, as well as at La Puente Comprehensive Mental Health Center.

The South Bay is expected to be especially hard hit by a cluster of clinic closures, shifting a huge patient load onto the already overcrowded acute psychiatric services of Harbor-UCLA Medical Center.

One of the first outpatient clinics targeted for closure is Wilmington, where nearly 75% of the clients are Spanish-speaking. A sister facility in San Pedro, which serves mostly low-income people, also is slated to close this month, as is a nearby clinic in Carson.

‘Everything in Limbo’

Quiroz said that he expects the closures to begin in mid-August and that he will begin notifying the clinics this week.

“If there is no money coming, by Sept. 1 every single (targeted) clinic will be closed and will be locked,” he said, adding that layoffs among the estimated 170 county workers may be inevitable. The most severely mentally disabled peopled will be referred to other county clinics, he said.

“Everything is in limbo,” said one mental health worker who asked not to be identified. “We know we’re going to close, we just don’t know when it will be. But already, some clients have stopped coming. I just hope they’re getting helped somewhere else.”

Staff psychiatrists and social workers are not the only ones concerned.

“It is going to be horrendous when those clinics close,” said Dolly Read, co-president of the South Bay Chapter of the Alliance for the Mentally Ill, a group composed of parents and friends of the mentally disabled.

“These people frequently don’t have cars or money. They’ll be told to go somewhere else but some won’t make it. They just won’t go for treatment,” she said.

During last month’s budget hearings, the Los Angeles County supervisors scrambled to find enough funds to temporarily save some mental health programs in their districts. Tapping their reserve funds, the board members came up with $1.5 million to keep several endangered outpatient clinics alive for at least three more months.

In one case, Supervisor Kenneth Hahn also earmarked enough money to extend the outpatient program at Kedren Community Mental Health Center in his district for a full year.

But for the most part, due to limited state and county funds, neither the supervisors nor the mental health department could squeeze enough dollars to rescue the remaining outpatient clinics. Last year, when some of the same clinics were threatened, the supervisors were able to scrape up $8.1 million, including $6.1 million from the state, but they are less optimistic about state assistance this time.

“There is no indication that there is any rescue money around,” said Board Chairman Deane Dana.

While they are free to cut other county services to raise money for mental health programs, county officials insist that any additional funds for mental health must come from the state.

Quiroz said $18 million is needed to just “tread water” and maintain already strapped services. He added that $8.5 million would stave off a major disaster by keeping some of the outpatient clinics open.