Advertisement - Click to support our sponsors.
Saturday, October 14, 2000
In February of this year, Senate President Norman Mizuguchi and House Speaker Calvin Say commissioned a review of mental health services in Hawaii with an emphasis on the state Department of Health's plan to downsize Hawaii State Hospital (HSH) and how that may impact the severely mentally ill. Kalaupapa revisited
Severely mentally ill people
are being grossly underserved
by state Health DepartmentBy Andrew J. Weaver and
The Rev. Barbara Grace Ripple
Special to the Star-BulletinUnder the authority of the Legislature, Dr. H. Richard Lamb, professor of psychiatry at the University of Southern California, and others met with key personnel in the Department of Health and HSH, the Department of Corrections, Honolulu homeless shelters, the Hawaii Psychiatric Medical Association, and other professionals who work with the severely mentally ill.
The report concluded that the severely mentally ill were being grossly underserved by the Health Department and that a reduction in the number of beds at HSH would significantly compound the problems now facing the severely mentally ill.
In the United States there are on average 22 state mental hospital beds per 100,000 people. With a population of 1.2 million, Hawaii needs 264 beds to be at the national average, yet HSH is currently licensed for only 168 beds. If the number of beds are reduced to the Health Department's projected 108, Hawaii will have only nine beds per 100,000 -- among the fewest in the nation.
To complicate matters, hospital superintendent Wayne Law stated in February that 85 to 90 percent of the patients at HSH are there under court orders -- among the highest rate in the nation. The intent when the census reaches 108 beds is to have virtually zero non-court-ordered HSH beds. Hawaii is rapidly becoming the only state in the union in which a person will need to commit a crime in order to receive treatment at HSH.
One way to understand how underserved Hawaii's mentally ill are is to examine the number of homeless mentally ill. The Institute for Human Services (IHS), a major Honolulu agency serving the homeless, stated in February that approximately 60 percent of homeless persons seen there have severe mental illness, primarily schizophrenia, bipolar disorder or major depression.
According to the National Law Center on Homelessness and Poverty, this figure represents more than twice the average number of homeless mentally ill found in other parts of the United States. The directors of IHS expressed grave concern about a lack of psychiatric hospital beds, reporting that a number of acutely mentally ill persons had been taken to area hospitals and released after a few hours, despite the opinion of IHS staff that longer periods of hospitalization were needed.
Another way to understand how the mentally ill are not getting appropriate care in Hawaii is to look at the number of severely mentally ill in prison. The investigators visited the Oahu Community Correctional Center (OCCC) where medical and administrative personnel estimated that there are more than 200 severely mentally persons in jails on Oahu and the neighbor islands.
They said that at least half the severely mentally ill misdemeanants at OCCC should have been sent to a hospital. They were convinced that 100 to 150 additional state hospital beds are needed to permit a meaningful diversion from the criminal justice system to the mental-health system.
Their concerns are supported by a 1992 national study by the National Alliance for the Mentally Ill and the Public Citizen Health Research Group. In this survey of 3,353 directors of county and city jails, it was discovered that Hawaii was one of three states that had the highest number of acutely mentally ill in their prisons -- about one in nine.*
Other studies have shown that delaying treatment for mental illnesses can result in permanent harm, including increased treatment resistance and worsening severity of symptoms. When young persons do not receive treatment for severe mental illnesses, they are more likely to end up in prison. There are now far more mentally ill in the nation's prisons (200,000 to 250,000) than in state mental hospitals (57,716).
A meeting with the Hawaiian Psychiatric Medical Association was held with psychiatrists from the public sector, the private sector and the University of Hawaii.
Clearly, the Department of Health has alienated the psychiatric community on Oahu. There was strong criticism of the downsizing of HSH and of the difficulty in getting patients accepted by the hospital. There seemed to be a consensus that there is a group of severely mentally ill patients who need a locked, highly-structured facility and that the current downsizing is leading to homelessness and criminalization.
There was concern that long-term severely mentally ill patients are backing up at private hospitals. Those from the university felt that faculty are not welcome at HSH because they like to look at all sides of the issues.
Dr. Margaret Copi, a psychiatrist who has worked with the homeless for several years, indicated that there are thousands of severely mentally ill homeless persons in Hawaii living on the streets. There have been no good studies, however, to determine the exact number.
Recommendations and conclusions
Dr. Lamb's report to the Legislature recommended that HSH not be downsized and that it be utilized to its full capacity of 168 licensed beds. Even if that is done, 168 beds is still an inadequate number for Hawaii's population.Clinical experience everywhere with persons with severe mental illness has taught us that there is a minority of this population who need locked highly-structured care for a period of time in order to adequately treat them and to protect the community.
We have seen throughout the nation and in other countries that as the amount of highly structured care decreases, the number of severely mentally ill persons who are criminalized and/or become homeless increases. We believe that this has been the case in Hawaii.
Dr. Lamb observed that it was his belief that the issue of downsizing the state hospital played a major role in determining several negative comments by the Department of Justice's experts in its December 1999 report to Federal District Judge David Ezra.
For instance, the nationally recognized psychiatrist Dr. Jeffery Geller wrote, "While I believe it appropriate to divert potential Hawaii State Hospital patients to community-based services if those settings are adequate to meet their needs, and to transition Hawaii State Hospital patients who no longer need hospital level of care to community sites, I believe that the downsizing of the hospital is resulting in patients being prematurely or inappropriately discharged from the hospital."
The report highly recommended that a concerted effort be made to identify, evaluate and provide appropriate services to the more than 200 severely mentally ill persons in the jails of the state and the very large numbers of severely mentally ill persons who are homeless.
Finally, it recommend that a comprehensive statewide plan be developed to show how the needs of all persons with severe mental illness in Hawaii will be met.
The severely mentally ill are often treated as "lepers" in our society. In much the same way that Hawaii abandoned victims of Hansen's Disease in the 19th century to Kalaupapa, the Health Department is abdicating its responsibility to care for the severely mentally ill in the Land of Aloha today. Father Damien would be grieved and very displeased.
Dr. Andrew J. Weaver is a United Methodist minister and clinical psychologist who until August worked for six years as a staff psychologist at Hawaii State Hospital. He is now co-director of research at The HealthCare Chaplaincy in New York City. The Rev. Barbara Grace Ripple is Hawaii district superintendent of the California-Pacific Conference of the United Methodist Church.
| | |
* Torrey, E. F. (1998). "Out of the Shadows: Confronting America's Mental Illness Crisis." New York, NY: John Wiley & Sons (page 29).