Mental Patients Overload County Emergency System : Health care: Service cutbacks squeeze about 30,000 out of clinics and into ‘revolving door’ facilities.

A violently psychotic woman kept two Los Angeles police officers busy for three hours recently, but not in the way one normally thinks of police work. Their task consisted of driving from one county hospital to another in search of a psychiatric emergency room with space for her.

She was finally admitted to Martin Luther King Jr./Drew Medical Center, but only after a police supervisor was sent to remind hospital administrators that, full or not, state law required them to take the patient, said Detective Walter DeCuir, head of the Los Angeles Police Department’s Mental Evaluation Unit.

State law, however, has become something of a grim joke in Los Angeles County’s overloaded mental health system, according to interviews with county officials, doctors and hospital administrators.

Nowhere are the consequences of overload more vividly illustrated than in the county’s psychiatric emergency rooms.

“Near riot” conditions is how Dr. John Ray, associate medical director of Psychiatric Hospital at Los Angeles County-USC Medical Center, recently described his facility, where an emergency area designed for eight has an average of 15 seriously ill patients at any time. On some weekends this year, it has been crammed with as many as 23.

About 10% of patients receive only “Band-Aid” treatment, Ray said, and some “go back into the community dangerous.”

Moreover, because of cutbacks in outpatient mental health services, many of these severely disturbed people receive no follow-up care. This is reflected in police statistics that show a 50% increase during 1991 in calls for help with the disruptive mentally ill--up to 30,750 such calls last year, compared to 20,568 in 1990.

County officials say they are trying to alleviate the worst pressure points. But unexpectedly low state sales tax revenues--the county mental health system’s sole funding source--suggest these problems could worsen.

“We are looking at a number of options, but none of them look too good without more money,” said Areta Crowell, county mental health director since January.

Crises have defined the mental health system in Los Angeles County in recent years. More than a decade of inadequate funding has led to clinic closures and widespread staff reductions. Twelve of 31 county mental health clinics have closed in the last three years, and services have been slashed, mental health officials say.

These service reductions have squeezed an estimated 30,000 mentally ill people out of the clinic system and into what Ray calls the “revolving doors” of the county’s psychiatric emergency rooms.

There, overcrowding and inadequate resources have combined to erode the quality of treatment, violating, in some cases, federal and state standards of care, said Dr. Rod N. Burgoyne, medical director for the county Department of Mental Health. Thousands of others who should be in the mental health system have been sent to jails.

“If there isn’t a place to put the patient, there isn’t a place to put the patient and you can write laws till hell freezes over,” said Burgoyne.

The problem is not new. In a 1987 “Declaration of Conscience,” doctors at the county’s four psychiatric emergency facilities described conditions in gruesome detail:

“A desperate level of overcrowding exists night after night in each of our emergency units,” the doctors wrote to the Board of Supervisors. “Sick people are sleeping on mattresses on the floor. . . . Dazed, deluded and endangered people are returned to the streets.”

Today, benumbed doctors say things are getting worse.

“If it was tragedy to any other group of people, we would be spending all of our time in the courts. . . .” said Dr. Milton H. Miller, chief of psychiatry at Harbor-UCLA Medical Center and a signer of the 1987 declaration. “The mentally ill are simply a forgotten constituency.”

At King/Drew Medical Center, the pressure of too many patients has forced doctors to turn away potentially dangerous psychotics, said Dr. Claudewell S. Thomas, chief of psychiatry. Priority is given to those who clearly pose a threat.

“If someone who is hallucinating is not threatening someone, they may be released,” Thomas said. “But the nature of that delusional system could change. At best it is gambling.”

There have been some improvements in recent years--notably, the addition of beds and isolation units to the emergency rooms at Harbor-UCLA and Olive View Medical Center. Doctors there say patients at least do not sleep on the floor.

But many mentally ill people cannot get in, said Dr. Frank De Leon-Jones, an Olive View psychiatrist. Psychiatric Hospital is increasingly unable to accept patients brought in by relatives or who arrive on their own seeking help.

“We are mostly serving police cases,” Ray said.

The ones turned away are often those who could benefit most from psychiatric treatment, doctors say.

“When you walk into the emergency room and have 15 patients who need hospitalization and you have only one bed . . . you have to decide who marginally is capable of surviving on the outside,” said Dr. Ricardo Mendoza, chief of emergency psychiatry at Harbor-UCLA.

Mendoza recalls a 36-year-old woman who walked into the emergency room in tears. The recession had driven her small business into bankruptcy. To pay off debts, she sold her home. When Mendoza saw her, she was living in a garage and giving up on herself.

“She was not psychotic, not even clinically depressed,” he said. “Ten or 15 sessions of psychotherapy would have helped her get back into a productive life.”

Mendoza referred her to a private community mental health center with a sliding fee scale, but doubted that she had the money to pay even a minimal fee.

“You hope to God they are going to get seen somewhere,” Mendoza said of this woman and other patients “who have the greatest potential for being helped.”

The mental health system lacks even the resources to follow up on those sick enough to be hospitalized, said Crowell, the county mental health director. Doctors report a six- to eight-week average wait for follow-up appointments.

Psychiatric Hospital, the largest and hardest-pressed of the four hospitals, still has patients sitting or lying on the floor, many of them sedated and on mattresses for days before a bed becomes available, Ray said.

The hospital’s administrator, Raul Caro, said conditions in the emergency room have deteriorated in the last two months. The number of police-escorted patients surged in January, he said, when County-USC’s General Hospital stopped taking Psychiatric Hospital’s overflow.

Harbor-UCLA and King/Drew are similarly overcrowded, said LAPD’s DeCuir. And Olive View’s psychiatric unit is so jammed that it rarely can assist the harder-pressed inner-city hospitals, administrators at the Sylmar facility said.

“What do you do with 20 patients when at most you can properly care for 10?” Ray of Psychiatric Hospital said. “This is what I ask myself when I get called at home and there are 20 patients and the possibility of someone getting seriously injured.”

Between 40% and 60% of the patients, doctors say, have drug or alcohol problems and others are hallucinating. Packing such volatile patients into a 500-square-foot emergency area has created the conditions Ray describes as “near riot,” although so far there has not been one.

The mental health department’s Burgoyne says doctors in these emergency rooms worry daily about violating medical standards and ethics.

“Everything is strained to the max,” Burgoyne said. Especially worrisome are patients with physical ailments--drug intoxication or malnutrition, for example--in addition to psychosis.

“In Psychiatric Hospital, there is no space even to do an adequate physical work-up. . . ,” he said.

Faced with such dilemmas, doctors are understandably reluctant to admit new patients--even those brought in by police, Burgoyne said.

“Which law do you break?” he asked, referring to federal and state hospital regulations governing patient admissions and treatment.

Jim Preis, director of the Los Angeles-based watchdog group Mental Health Advocacy Services, said: “I think this is a huge malpractice suit waiting to happen.”

Since The Times reported last month that the solution to the overcrowding at County-USC’s General Hospital had worsened conditions at Psychiatric Hospital, county health officials have given the facility’s emergency patients top priority for vacant psychiatric beds at any county facility.

“This priority status helped to reduce patients in the emergency room,” Richard B. Dixon, the county’s chief administrative officer, told the Board of Supervisors last month.

County officials also are considering these measures:

* Contracts with private hospital psychiatric units to take the overflow from the county hospitals. This sort of public-private partnership in 1990 helped relieve severe overcrowding in county obstetrical units. But adult psychiatric patients have limited coverage under the state’s Medi-Cal insurance program compared to mothers and babies, and would require significant additional funding.

* Greater coordination between the mental health system and social services so hospitalized psychiatric patients with additional problems--such as drug addiction or homelessness--can be discharged into follow-up programs.

* New county taxes, including a possible “tippler” tax on alcoholic beverages served in restaurants and lounges, to supplement sales tax revenues dedicated to mental health services.

This is the first year mental health programs in California are financed entirely by county sales tax collections. The recession, however, has dashed hopes that the sales tax would provide at least as much as last year’s state budget.

Projections by the state Department of Finance show all counties receiving less than in fiscal 1990-91.

Los Angeles County’s loss is projected at $15.3 million, or 6.4% of the $237.8 million in state General Fund money mental health programs got last year.

“It will be ghastly this year and it will be ghastly next year,” said Assemblyman Bruce Bronzan (D-Fresno), who authored the 1991 law tying mental health funding to county sales tax revenues.

Without the new funding arrangement, however, many believe that mental health would have continued to be a loser in state budget battles. When the economy rebounds--as some expect it will by 1994--so will mental health’s fortunes, Bronzan predicted.

“It is not much comfort when you are in a crisis situation,” he acknowledged.

Mentally Ill in L.A. County

The reduction of public clinic and hospital services for the mentally ill in Los Angeles County has led to increasing work in recent years for the Los Angeles Police Department’s Mental Evaluation Unit. The unit handles all calls to LAPD from patrol officers, community agencies and citizens about potential suicides, dangerous psychotics or mentally unstable individuals involved in public disturbances.

Number of Calls to Police

Source: Detective Walter DeCuir, LAPD Mental Evaluation Unit.

County mental health programs will get even less state money this fiscal year than in 1990-1991, when a state budget shortfall forced clinic closures and severe program cuts. This year, funding for county mental health programs is tied to the sales tax. Since the recession has depressed sales, the programs are projecting 6.4% less this year than the county received in fiscal year 1990-91.

Decreasing State Funds

(projected) COUNTY 1990-91 1991-92 Los Angeles $237.8 million $222.5 million Orange 40.0 million Riverside 21.9 20.5 San Bernardino 27.9 26.0 San Diego 48.1 45.0 Ventura 11.8 11.1

Source: State Department of Finance and the California State Association of Counties.