View Point

By Andrew J. Weaver

Tuesday, April 27, 1999

Closing State Hospital
needs public debate

I have worked at the Hawaii State Hospital for almost five years and am concerned about plans to close it. My colleagues there are honorable and highly professional people who are devoted to the work of caring for their patients, who often suffer profound anguish as a result of their mental illness.

My co-workers and I are proud that, in 1996, the Hawaii State Hospital was fully accredited (and remains so) for the first time in over 20 years by the Joint Commission on Accreditation of Healthcare Organizations. It had a 93 percent compliance standard compared to other hospitals in the nation.

One in 100 people in our islands has schizophrenia, a disease caused by a chemical imbalance in the brain that grossly impairs reality-based thinking. It is often the source of despair, which can be seen in the fact that one in 10 individuals with the illness commits suicide.

Schizophrenia is an inherited disease about about which people have no more choice than the color of their eyes. Imagine that you "hear" angry voices day and night saying that you are a terrible person, or that you have repeated terrifying thoughts that others want to hurt you.

These kinds of symptoms are not unusual among those we serve at the hospital. Unfortunately, even with state-of-the-art medications, about one in five persons suffering these severe symptoms receives only limited relief.

Many patients in state hospitals have multiple problems such as poor self-care and community living skills, demoralization, substance-abuse problems, limited family support, aggressive behavior and physical health problems. Historically, state hospitals have acted as the place of last resort for those who could not find care in the private sector.

Closing mental hospitals and increasing community-based treatment are a national trend, and they should be developed in Hawaii as much as possible.

In 1993, there were 256 state hospitals in this country, down from 278 in 1980, according to the U.S. Department of Health and Human Services. However, it is not the national trend to remove all state hospital beds from the array of services offered to mental patients in a state.

A 1998 article in the Harvard Review of Psychiatry reported that, in the U.S., there were 29 state hospital beds per 100,000 people. With our population of 1.2 million, Hawaii would need 348 beds to be at the national level. But we have 168 beds at the Hawaii State Hospital.

Currently, every state has at least one state hospital. However, one state has tried to close its only state hospital for more than a decade.

According to a recent article in the prestigious journal, Psychiatric Services, Vermont has been examining the feasibility of closing its only state hospital since 1987. After 10 years of planning, study and coordinated efforts among public and private agencies to create a totally community-based treatment model, it continued to maintain 68 state hospital beds -- and Vermont has less than half the population of Hawaii.

Eighty-three percent of the patients at the Hawaii State Hospital are there by court order, while only a minority were in Vermont. Also, the Vermont study found that privatized treatment for the remaining patients "is believed to be equally as or more expensive than keeping them in the hospital."

Dr. William Spalding, a noted advocate for and expert in community-based treatment for the mentally ill, recently wrote that "there are serious adverse consequences of deinstitutionalizing people without first having adequate rehabilitation and support services in place in the community, including higher levels of violence and mortality, overuse of medical, emergency psychiatric and correctional resources, and public reaction."

He concluded that, after several years of developing a comprehensive mental health system in Nebraska, 15-20 percent of people with severe and persistent mental illness "are not successful in even the best community treatment programs." He further found that deinstitutionalization was accompanied by large reductions in resources for the most severely disabled individuals.

A statue of Father Damien stands at the front of our state Capitol as an eternal reminder to never again abandon the suffering and vulnerable in our ohana. It is imperative that we take deliberative care in any plan to close the Hawaii State Hospital.

We must have a full public debate to make certain that we continue to give the best care possible to the seriously mentally ill.

Andrew J. Weaver is a staff psychologist at
Hawaii State Hospital and the author of books and numerous
articles on mental health care.

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