Dr. Milton H. Miller, professor of psychiatry and chairman of the department of psychiatry at Harbor-UCLA Medical Center, also deputy medical director of the Los Angeles County Mental Health Department, met in his office with Gale Holland to discuss L.A.'s mental-health-care system. Miller, who is also vice chair of UCLA's Department of Psychiatry and Biobehavioral Sciences, has seen the county's ups and downs over more than 20 years at Harbor-UCLA.
Question: Your hospital's counterpart in East Los Angeles, County-USC Medical Center, was recently in the news because of appalling patient conditions in it's psychiatric emergency room. Are the problems limited to that unit, or are they part of a broader crisis in mental health care?
Answer: They are part of the very big and complex problem in mental health care: We've got a growing population, a growing indigent population, more drug and alcohol use. At the same time, the situation at County-USC has the elements of a tragedy, in the sense that if you look back you can see the coming together of seemingly unconnected forces to create a terrible situation. First and foremost, there was the 1994 Northridge earthquake, which destroyed the psychiatric building there, the largest mental health structure in any of our public hospitals. And then for some years USC has not had a permanent psychiatry chairman, a big loss, because in the mental-health world you need advocacy.
Q: Why hasn't County-USC made an appointment?
A: Well, they have been trying to decide whether a laboratory scientist or a clinician would be the better choice. Also, it's hard to attract a chairperson to a hospital that's been largely destroyed.
Q: Is the problem for indigents that they can't pay for treatment, or does poverty cause mental illness?
A: Trouble comes in twos and threes and fours. The connection between not enough money, no place to stay and mental illness is well established.
Q: It seems like every few years, like clockwork, there's a crisis in a county psychiatric unit or department. What could be done to interrupt that cycle?
A: The cycle is not every two years, the cycle is each week. You try to decide which of the impossible crises totackle first. Do you address the concerns of the group that is picketing a mental-health clinic and saying it represents a danger to children? Or the angry group that claims it is not getting the resources it needs? Do you build community programs or deal with emergency rooms that are jammed?
Q: Why have the problems erupted at County-USC but not at your unit?
A: The USC hospital is situated in the middle of an intense inner-city area. Also, for the past five to six years, the county has evaluated every one of the people who come into the jail system. Of the 180,000 jail visitors, we actively treat 30,000 for psychiatric illness. Half have illness of such magnitude they might as well be hospitalized. Also there is the soft landings program. For the last two years, we have been bringing thousands of mentally ill people leaving the jail into the system for treatment. USC has received a large share of those people.
Q: What order of magnitude does this new jailhouse burden represent for the county?
A: It's as if the lost continent of Atlantis suddenly erupted before us. At least 20% of the people the county treats are from the jail.
Q: Wouldn't it be wiser and more cost-effective to treat people in community settings before they end up hospitalized or jailed?
A: Strong scientific data say if you do what we know should be done for people who are profoundly sick, you can diminish hospitalization by 70% to 80%.
Q: Why aren't we doing it then?
A: We probably start out with about one-third to one-half of the resources it would take to do a reasonable job. Compared with New York or other large metropolitan areas, we have maybe 75% of their resources.
Q: Who, or what, is to blame for that?
A: Funding is largely driven by the governor and Legislature.
Q: And have politicians been supportive?
A: To the amount necessary, absolutely not. But they have been touched and moved and cajoled and pushed by the advocacy of the family movement. Resources for the soft landing program came from the legislature two years ago. The governor is quite involved. So we're not out of the game, but we're not big winners in terms of resources.
Q: Drugs likes Clozaril and Risperdal were said to be giving schizophrenic patients their lives back. But they haven't proved to be the panaceas we hoped for. What happened, and are there new drugs on the horizon?
A: It is a small truth that the new drugs do not automatically bring stunning cures. But the big truth is that the new armament of drugs has helped people in ways that have never been possible before. For a certain number of patients, 10%, the new drugs have meant something approaching a cure, a miracle. For another 25% to 30%, their comfort in the world is greatly enhanced.
Q: And for the other 60%?
A: The big news is that we have now genetically mapped the brain, we are close to being able to predict in advance which medicines will work well with a particular patient and why, and which medicines are going to be accepted by the body of the person. One of my colleagues reads journals all the time. Still, when I asked him about a meeting he attended, he said, "Oh my God, I am a child in this field. I know nothing. From last year to this year, it has changed completely."
Q: But are the advances getting to the people who need them?
A: Dr. Marvin Southard, the relatively new director of the county's Department of Mental Health, just made an agreement with UCLA, so we now have a contract where the university's Department of Psychiatry has a responsibility for education and for clinical training in our public mental-health clinics. For me, that's hugely important because the lag time between state-of-the-art medicine and public health is often 10 to 15 years. Also, without young people to challenge you, to work you over and not believe what you say, you tend to get into a rut.
Q: AB 1421, currently before the state Legislature, would force compulsory outpatient treatment for severely disturbed patients. Is this an important step forward, or an unacceptable abridgment of civil rights?
A: I think there are two answers. One, there is a kind of involuntary treatment that takes place every day. It's called "my family stayed on top of me and made me go." What is at issue is whether the same thing would work where the authority is vested not in family and loving friends, but in some bureaucratic agency.
To love someone and to know with 99.9% certainty he would be helped by treatment, and yet to be powerless to get that treatment, is an unbearable human situation. But this law surely would not work for everyone who would be put forward as a candidate. It would probably lead to many involuntary hospitalizations. Who is going to pay for that is not clear. So I would favor the introduction of some limited testing period to see how well we could do it in California and Los Angeles. And I would be very careful about how we study it.
Q: Mental-health clients say they reject treatment because it's harsh, it's authoritarian and it's insensitive.
A: It's a huge problem. What we have in a place like Los Angeles are doctors who have patient lists of 300 to 400 that they see once every month and a half, often in rather physically unattractive structures. At times, there is little sensitivity to the lifestyle, culture, even the language of the patient.
Q: Is that changing?
A: We are desperately at it. If I go to one more cultural training program, I will begin speaking Swahili. But here in Los Angeles County, our Department of Mental Health director is a social worker. He really believes in a social-welfare, in a serve-our-communities approach. If the boss believes in the job, it has a profound impact on everybody.
Q: What does quality mental health look like?
A: Well, you have to have services available 24 hours a day. You have to have a place for patients to live with the security and safety of home. To live in dangerous neighborhoods does little for one's mental equilibrium. And then a huge issue is medication. About 75% to 80% of people get into trouble because they stop taking their medicine. So if you can get them to take their meds, even if they have no hope, that is very helpful. If you can also provide supportive employment, people can thrive.
Q: Have we as a people failed the mentally ill?
A: Yes. What we leave unfinished in one generation becomes twice the problem in the next.
Q: What would it take to turn things around?
A: We need continuity of leadership. And we haven't had our Robert Dole walk out on national television and talk about mental illness. We could yet be inspired by national leaders who try to bring out the best in us.