A Plan for Rescuing the Mentally Ill : Health economics: These Californians face a terrible fate as the state shifts responsibility to financially strapped counties.

For more than 100 years, California and most other states took responsibility for the most seriously mentally ill citizens by sheltering and treating them in large state hospitals. During the past 30 years, the care of the mentally ill has been shifted to the community, in small and large boarding homes, locked nursing facilities and shelters, or to families, whose emotional and financial resources have become stretched to the limit. Eventually, many end up homeless on the streets where they are exposed to privation, disease and predation by others. Brushes with the law often result in imprisonment in jails where tolerance, care and treatment are lacking.

With the recent realignment of the mental health system from the state to the counties, the state hospitals’ census is rapidly dwindling, and these hospitals may soon cease to exist. This must not be allowed to happen.

The reason for the emptying of the state hospitals is money, or rather the lack of it. Given the prolonged economic recession in California and the state and local budget debacle, county mental health programs cannot afford to provide the quality care that the state hospitals have offered the mentally ill. And so counties are being forced to relocate these patients to inferior institutions for the mentally disabled, which are cheaper, employ minimum-wage and poorly trained attendants and have no full-time psychiatrists on staff.

The savings are illusory. Costs are simply transferred from the state and county mental health departments to the correctional and welfare systems. The Los Angeles County jail system is now the largest “mental institution” in the country, with more than 5,000 mentally ill inmates. The criminalization of the seriously mentally ill is a disgrace and a mockery of our pretense of being a civilized society.

What, then, is to be done? Taking fiscal constraints into account, we recommend three paths of action.

* Maintain our state hospitals, which are now providing excellent care to those who need higher levels of supervision and rehabilitation. The State Department of Mental Health should conduct a survey to evaluate what actually has happened to the thousands of severely mentally ill persons who have been discharged during recent years: How are they functioning? What are their symptoms like? Where are they living? How much is it costing for their support? A similar survey of patients released from New York state hospitals found that 40% were unable to secure adequate community services and were rehospitalized within six months, at an average cost of $36,750 per patient. One in 10 suffered homelessness and 90% who abused drugs or alcohol received no services for their dual afflictions.

* Create integrated state hospital and local mental-health programs; this partnership would result in a single system of care that would monitor the clinical status of patients wherever they reside. Services need to be redesigned with adequate community resources for the seriously mentally ill still residing in state hospitals, including a sufficient number of residential settings with varying degrees of supervision and support, and assertive case-management services that include outreach, rehabilitation and crisis intervention. State hospitals, in conjunction with county mental health programs, can serve as regional resources for larger groups that are not easily served in the community: the elderly mentally ill, for example, and the dually disabled--those with mental illness and mental retardation or substance abuse.

* Continue the support of clinical and applied research that has been advancing new treatments and better understanding of the brain and behavior mechanisms that cause mental illness or impede its effective treatment. We have learned much from research in the last few years about schizophrenia, manic-depressive disorder and major depression--the illnesses responsible for the suffering in most of those we call mentally ill. Diagnostic techniques have advanced to the point where they are as reliable as those used in other medical specialties, and it is now possible to identify the estimated 800,000 Californians who have serious mental disorders.

Brain imaging and other research advances have documented that these disorders are biomedical: They are caused by abnormalities in the functioning of the brain where neurotransmitters (chemical messengers) are poorly regulated and cause symptoms such as depression, mania, delusions and hallucinations. Anti-psychotic medications have been developed to correct the biochemical imbalances and control distressing symptoms.

Research has found that symptoms get worse when stress is experienced. This has led to the crafting of rehabilitation techniques that equip patients and their care-givers with coping skills and supported employment and housing options. Simply applying what already has been discovered through research can cut relapse rates in half, reduce disability and the enormous burden of the mentally ill on social services and even promote recovery.

World-class researchers have established collaborations at Metropolitan, Napa and Camarillo state hospitals, where new drugs are being tested and experiments are being conducted to “train the brain” to overcome neuro-developmental deficits. These research centers also attract millions in federal and pharmaceutical company grant funds to California, ameliorating the state’s fiscal stagnation. With the state Department of Mental Health redefining its responsibilities and mission for the future, it is essential that priority be given to the support of research at state hospitals, where the most disabled and severely afflicted of the mentally ill are treated.

The strength and quality of a society can be measured by the type of care it gives to its disabled citizens. We Californians must and can do better than we are doing now.