A look at our broken mental health system
The complaint is frequently heard that the mental health system in California is broken. If this is true there are three main reasons. First, there are not enough hospital beds. Second there are too many mentally ill persons in prisons.
And, third, many seriously mentally ill persons in our communities are not receiving treatment.
In 1955 California State Hospitals had a total of 42,000 beds. These public psychiatric beds served both patients who had relatively short stays before being discharged and those with more severe and persistent illness who could remain at the hospital for many years. The California Hospital Association reports that there are 6,702 beds state-wide for short stay patients — a substantial reduction from 9,253 beds in 1995. There are only 1,840 beds state-wide for those patients needing long term treatment in a secure facility. Since 1955 there has been a loss of more than 33,000 psychiatric beds while during that same time the state’s population has tripled.
There are two major reasons for this severe shortage of beds. The first is the federal Medicaid law dating from 1965 that deals with Institutes for Mental Disease. The law prohibits federal funding for adult patients in psychiatric facilities which are larger than 16 beds. It has been described as discriminating against the mentally ill and is the only section of the federal Medicaid law that prohibits payment for medically necessary treatment simply because of the type of illness being treated. That section of the law should be repealed. The second reason for the shortage is hospitals changing psychiatric beds to medical-surgical beds which results in more revenue. Such proposed changes should be subject to approval.
According to the Department of Corrections there were 19,000 mentally ill persons in state prisons in 2000 accounting for 12% of the total number of inmates. In 2017 that number had increased to 39,000 accounting for 30% of the total population. The Department of Corrections offers two reasons for the increasing numbers and proportion of mentally ill inmates. The first is that they are less likely to be eligible for early release programs because they can have difficulty conforming to prison rules. Eligibility of mentally ill inmates for early release programs should be based at least in part on their response to treatment as determined by medical staff. The second reason is that mentally ill defendants receive on average 12 % longer prison sentences across all types of offenses compared to non-mentally ill defendants. Mental health courts can provide alternatives to jail or prison and should be mandated in all counties.
Many seriously mentally ill persons in our community are not receiving treatment because our laws can act as a barrier to treatment. The LantermanPetris —Short act dates back to 1967 — 53 years ago. It remains essentially as it was written. The concept of “Grave Disability” originated with the LPS Act and is the inability to provide for one’s food, clothing or shelter as a result of mental illness. It was based on the legislative finding that half of all admissions to state hospitals in the 1960’s were elderly persons many of whom may have had dementia and “physically debilitated alcoholics.”
Grave Disability was never intended to apply to younger patients with Schizophrenia or Bipolar Disorder because the legislature believed that following hospital discharge “nearly all” of those patients would voluntarily “seek out” treatment. However, experience has shown that a significant number of seriously mentally ill patients are unwilling to accept treatment. Outpatient treatment with medications can be mandated only if the court determines that a person is gravely disabled and lacks the capacity to give an informed consent.
In January 2019 the Los Angeles Board of Supervisors approved a motion to the California Legislature to expand the definition of grave disability to include persons who are unable to seek medical care because of their mental illness. The legislature should act on that motion. In addition, the level of evidence for Grave Disability should be reduced from the current “beyond a reasonable doubt” to “clear and convincing.”
If these changes were implemented California would have more psychiatric beds, fewer mentally ill persons in prison and more seriously ill persons receiving treatment. Our current broken system of mental health services would be substantially repaired.