Reflections on a Mental Health Care System : Illness: San Diego County has reason to be proud, the system’s outgoing director says, but it also must realize that more money and resources are vital.

Q: What are some of the differences between the mental health care system in Los Angeles County and that in San Diego?

A: Los Angeles did something (last year) that was very important. They were willing to add a special tax . . . an entertainment tax. . . . It is not specifically dedicated to mental health . . . but because they put that amount of money in the general fund, then they were able to give that amount to mental health. That was a truly remarkable action and an indication of the support that that board was able to develop for mental health services.

(Also), I think the constituency (for mental health) in Los Angeles has been mobilized for some time and is stronger . . . and (county supervisors) understand that there would be tremendous political pressure (if they were) to cut mental health services any further.

The constituency here . . . has felt, and rightly so, that this board (of supervisors) understood the problem and was supportive. And so, at some level, they didn’t feel the need to get out and be political. . . . But as the board’s choices (here) get tougher and tougher, then I think that mental health constituents (clients, families and mental health care providers) will have to get active to make sure that their needs are not buried because they are they invisible.

Q: What do you consider the biggest accomplishment of your tenure in San Diego?

A: I’m very proud of getting a National Institute of Mental Health demonstration grant (to study the homeless mentally ill). It was the result of a lot of collaboration, and we are implementing it extremely well. It’s a very good project in terms of the information that will be generated by the research, and what people are learning just from doing the project. . . .

We have over 150 people who have been given permanent housing, and we are finding out what (does and) doesn’t work with that population. . . . I think that will have a tremendous impact, not just here in San Diego but all around.

The other one that I am very very proud of is the intensive-case management project. . . . (We) identified the 100 . . . patients who used the (psychiatric) hospital the most days. We randomly selected 30 people (for intensive-case management) and 30 were assigned to the regular case management group. . . . We think with intensive, assertive case management (and such things as peer counseling) we can keep those people out of the hospital.

What happens to most people who fail in the system . . . is that they don’t maintain their treatment contact . . . or they deny they have any illness. In any case, they don’t want any part of the mental health treatment system. . . . They hated what happened to them and they just want to stay as far away from it as possible.

Anyway, (we found) exactly what would be predicted. . . . (Case workers) started to make a relationship with these people. When they needed to be hospitalized, (we) put them in the hospital, but (we) also took them out fast because they only needed hospitalization for a short time to do what was needed medically.

We get stuck in our hospital with people who have no place to go and no one to take responsibility for them. And doctors are afraid of being charged with dumping patients and not following up on their medical responsibility. So (we) can’t let them go, but they really don’t need that level of treatment.

The intensive-case management staff was able to manage the movement in and out in such a way that, over a year, (these patients) used so much less (in hospital services) that we saved (an amount of money) . . . equal to the investment that we put in. . . .

So we would like to get a lot more people into that kind of health system.

Q: What percentage of the homeless are mentally ill?

A: The best estimates are that 30% of the homeless are mentally ill. That means 2,500 people on any given day (in San Diego). I think those numbers and the concentration of those numbers are what give people the conscious presence of mentally ill individuals all of the time. . . .

We tried another experimental project to try to focus on these difficult folks. Pat Shields, who is our homeless program coordinator for the central region and is also our best expert on persons with mental illness and substance abuses, (worked with) the city Police Department (on) the problems of the most visible of the homeless mentally ill downtown.

The police keep telling us we are not doing enough for these people. So we said fine, let’s identify them and see what we can do. (The police) started off thinking they had 100, and then the number dropped (to 50 or 60) as we looked at them, because many of them had only a drug or an alcohol problem and did not have a mental illness.

Pat did some screening, and a psychiatrist went out in the field. They really worked hard to try to understand these individuals and to provide appropriate services.

What she found is that she could get everyone (with mental illness or a dual diagnosis) into treatment. But they would drop out, because the system was not able to deal with all of the complexities and the ramifications of these individuals. . . .

It could be looked at as, “Gee, the system can’t work.” Or it can be looked at as how complex the problems are, and how labor-intensive it is to get all of it to fit together and to maintain contact with the person. Which brings us right back to intensive case management.

So it is clear that we need to add resources to that. Now, I don’t know how San Diego is going to do that. Nobody has enough resources, so no one is willing to put them into anything. And so you spend all your time fighting, and everybody thinks somebody else has more money.

Q: How much of the mental illness problem could be alleviated by increasing drug and alcohol abuse treatment, which is a less expensive form of care?

A: A lot of individuals who we identify as the most problematic are not going to be helped by run-of-the-mill drug and alcohol programs any more than they are helped by run-of-the-mill psychiatric programs, because those programs depend on voluntary admission to treatment. (And they are) very much reliant on peer counseling, which is tremendously effective for those that it works for. . . .

Given the very limited resources available, the more costly people end up being ignored in that system and it has pushed them into the more costly psychiatric system.

So we need as a community . . . to look at the larger interactions. We also know there are legal and court costs that come from not having intensive case management. People end up committing petty crimes and (the police) get tired of bringing them to the emergency room, so they take them to the jail eventually.

Q: There has been a lot of discussion of the problems resulting from deinstitutionalization of mentally ill patients in the 1960s. Do you think the standards for involuntary commitment should be eased?

A: Every time we have looked at that we have concluded that it’s more a resource than a legal issue. When you have enough resources, you can get the legal support you need for involuntary treatment. . . .

The National Institute of Mental Health has been doing a lot . . . of research on the issue, and that was the consensus of (mental health professionals) across the country. . . .

It may be unpopular to say that, because people would like to have a quick fix by changing the law. But if you don’t have the resources, what good is it going to do to change the law?

It’s not that anyone who is in treatment now does not need treatment. It’s (that a lot of people who need treatment) aren’t in treatment. And we can be as cost-effective as far as we want and we will still have people who are not treated. And the system will look ineffective. . . .

We figure that at best we are treating two-thirds of the seriously mentally ill in San Diego County. At best. And some of those individuals we give $1,500 worth of services. That’s all.

Q: How is mental health care being rationed?

A: Overall, we are rationing by shortage. We have (defined) the target populations as narrowly as we logically can. . . . And we have cut down (on) the amount of expensive care as much as we can. . . . I think . . . ultimately we must have an increase in overall investment. The programs that we know are effective on a per-person basis . . . the successful programs (for the seriously mentally ill), seem to (cost) out at no less than $10,000 to $18,000 a year per person . . . to maintain them in the community. And we are now spending in this county . . . about $3,600 (a year per person). . . .

Q: So are you saying that we need to triple or quadruple what we are spending now to have a reasonably adequate mental health care system?

A: Yes. It is an investment. It is not, in the larger scale of our productivity and our economy, such an exorbitant amount. Even if you (just doubled) the amount, (it would only double the) one-quarter of 1% (of the) sales tax that is currently devoted to mental health programs . . . and a half-percent would sure make a big difference.