The Everyman Psychiatrist

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San Francisco's Homeless Mentally Ill: Still Neglected

Psychiatry's Sickest of the Sick: Abandoned by Public Health Officials

The homeless mentally ill in the city of San Francisco have been so visible for so long they've become almost part of the landscape to us city dwellers--essentially invisible people who, for all intents and purposes, have disappeared.

But for visitors, who flock to neighborhoods such as North Beach, the Embarcadero, South of Market, and the Haight in search of a little urban adventure, they can't help but notice both the numbers of mentally ill and the intensity of psychiatric illness on display.

I still see these people. Time and again when I am out and about in San Francisco, I observe many of the "frequent flyers," many of whom I know by name, that I've assessed in the psychiatric ER of San Francisco General Hospital, where I've worked as a physician and psychiatrist for more than 20 years. I've had to discharge many of them back out to the streets because there is no will on the part of the city or the state of California to provide appropriate care to these patients.

In my opinion, this is tantamount to discrimination.

There is no will on the part of the politicians or public health officials to provide them appropriate care. The wish is for "out-of-sight, out-of-mind." Cut services enough and maybe they'll leave town. These people don't vote. They don't donate to political campaigns. They don't show up at meetings of the San Francisco Health Commission. They don't live in Pacific Heights or Noe Valley.

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These patients are people. Each one of them is someone's son or sister or father or daughter or brother or mother. Nearly all have been lost to their loved ones and find themselves abandoned--swirling around the streets and the jail cells and the emergency rooms of the city, not taking their psych meds because they don't believe they are sick and smoking marijuana and crack cocaine or drinking alcohol to deal with their psychiatric symptoms and emotional pain. Their staunchest advocates are family members who've lost loved ones to suicide, homicide, accidental death, victimization, homelessness, or incarceration.

The number of acute care psychiatric beds are being rapidly downsized in both the public and private sector. Lengths of stay in the acute care psychiatric units are dropping. 

The word has long been out in the circles of health care economics: inpatient psychiatry is a money loser. And it's not as if we're talking about taking care of babies or young mothers or old folks. We're talking about "crazy" people here.  Not a warm and fuzzy bunch.  Who is going to advocate for these people, who are disenfranchised, disempowered, and forgotten.

So when the public health leaders of San Francisco have an opportunity to address this imbalance by supporting the implementation of a tangible assisted outpatient treatment program for psychiatry's "sickest of the sick," what do they do? They stall, they obfuscate, they run away.

Laura's Law is California's version of assisted outpatient treatment.  Passed in 2001, in the wake of the murder of Laura Wilcox by a severely psychiatrically ill person in Nevada County, it was designed to provide an administrative structure and guidelines for getting the sickest of the sick into outpatient treatment and making them, yes making them, go to their appointments, and very strongly encouraging them to take their psychiatric medications. 

On the agenda for the San Francisco Board of Supervisors twice this summer, the vote has been sent back to committee, the matter stalled.

The success of a similar law in New York called "Kendra's Law" in improving the physical and mental health of the "sickest of the sick" in that state has been very well-documented.

Dr. Mitch Katz, chief of San Francisco's Department of Public Health (DPH), is an HIV specialist. He knows little about psychiatry and sadly does not get advice from any clinically based psychiatrist or other mental health professional engaged on the front lines of treating psychiatry's sickest of the sick. His mental health advisors tend to be career bureaucrats.

He treats the subject from a theoretical and overly medicalized perspective. He ignores reams of research showing that mental health case management and outpatient substance and mental health treatment is effective in managing chronic mental illness. He doesn't understand that many of these patients will begin to accept treatment voluntarily after just a few days back on psychiatric medications as long as they are supported by a functional and pragmatic system of care.

His stance is akin to having me as a psychiatrist (or a radiologist or a pathologist, for that matter) dictate HIV care without consulting an HIV specialist. It is, of course, an absurd way to generate public mental health policy.

San Francisco used to be the city that "knew how" and took bold, innovative steps to address civic problems.

But if San Francisco's politicians and public health leaders are not willing to support Laura's Law, then chances are the city's downtown and tourist areas will continue to look like open-air asylums.

copyright, 2010, Paul R. Linde, M.D.

Paul R. Linde, M.D., is a San Francisco-based author and clinical professor of psychiatry at the UCSF School of Medicine.

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