Mental Healthcare in Virginia

By Jerome Blackman, MD, FIPA,
Professor of Clinical Psychiatry,
EVMS, Norfolk, VA.

The Main Problems

We can break the psychiatric problems in Virginia into a few groups:

 1) overcrowding of emergency rooms with people who have acute psychiatric problems, mainly psychoses, because either the patients have no insurance to cover private hospitalization, or there are no beds available. Such patients often wind up in jail, with poor psychiatric care at best.

2) mentally ill people making up the vast majority of the homeless, who may not be acutely, “substantially“ dangerous anyone, and therefore cannot be committed under the current criteria for involuntary commitment.

3) lack of public psychiatric beds for both standard mentally ill people and mentally ill people who have committed serious crimes (“forensic psychiatric” patients). One of the solutions to this has been to try to force private hospitals to accept such patients, but Medicare and in particular Medicaid  do not cover the cost of such. 

4)  commitment laws that tried to protect the civil rights of patients but hamstring psychiatrists in hospitalizing acutely mentally ill or even chronically mentally ill people who need help. 

5) a peculiar “pre-screening“ process by relatively untrained people at community service boards, who are trying to keep people out of the hospitals. These prescreeners blame psychiatrists as being greedy and crooked , and generally interfere with the process of getting severely mentally ill people hospitalized on an involuntary basis. 

The basis for these decisions, which  defy common sense, is long and complicated, and involves, mostly, problems that existed prior to 1987, when a small number of corrupt private hospitals and corrupt psychiatrists kept people in the hospital too long in order to make money for the hospitals and the psychiatrist. Another problem existed in some state mental hospitals in Alabama and Georgia, as I recall, where some patients were found rotting in old age, in the back wards in psychiatric hospitals. Both of these problems have been rectified, but the laws enacted to try to prevent and correct such reprehensible professional behavior are still around. In other words, our current commitment laws are anachronistic, meant to address problems from 40 years ago.  Today, unethical physicians can certainly be disciplined by their medical boards, and most certainly would be.

Recommendations

My recommendations are my own. They derive from my experiences in teaching, having worked in mental hospitals for many years, and my understanding of what is currently going on legally.

1) Allocate money to open new state - funded psychiatric beds, and pay psychiatrists well to work there. This would recognize that schizophrenia and bipolar psychosis are both chronic, recurrent illnesses, where people need to be hospitalized periodically. “A least restrictive environment“ is a remnant from the late 60s  civil rights concerns, and actually interferes with the proper care of severely ill people.  This may be expensive, but the cost to our cities of homeless people and psychotic people breaking laws and committing crimes may be higher. Severely mentally ill people are also using up a lot of time for police officers, who could be spending their time watching out for more serious crimes.

2) To handle the severe problem of homelessness, such people could be picked up by police and evaluated by a psychiatrist.  Most homeless people will only go to a shelter briefly, and not stay there, because most of them are severely paranoid. If the commitment procedure only required that the psychiatrist state that the patient is severely mentally ill, instead of trying to make the psychiatrist into a lawyer and a judge who determines whether something is dangerous or not, a psychiatrist could write a letter outlining the nature of the illness, and the reason for commitment.  More about this below.   

A further note is that all the studies in the past 60 years demonstrate that mental health professionals cannot predict with any accuracy a patient’s dangerousness to self or others. Therefore, making that a criterion of commitment is not logical. The finding that a patient is severely mentally ill and requires treatment leaves the question of hospitalization to the psychiatrist to evaluate the patient. A well-trained, board-certified psychiatrist should be able to do this, without making firm predictions about anything. I also think that law should be passed to relieve any psychiatrist of malpractice liability for making a recommendation of commitment. Also, the psychiatrist should be relieved of any liability for false imprisonment charges, which generally are not covered by malpractice insurance policies. The question of keeping people in the hospital is something else. No doubt, after 30 days, a second opinion from a different psychiatrist, who is not connected with the first psychiatrist’s practice group, should be sought, if the patient needs further hospitalization.

3). In my opinion, it is fruitless to try to force psychiatric private hospitals to accept indigent patients or patients who are severely ill, because the private hospitals will not be able to sustain these patients without losing a tremendous amount of money. It would be more propitious for the state to establish its own beds, hire its own psychiatrists, and make these beds available to severely ill people. Trying to coerce private hospitals to accept such patients is destined to fail.

4 & 5). Regarding commitment, it is my opinion that the prescreening process should be eliminated. Any board-certified psychiatrist should be able to write a report delineating the nature of the mental illness. If that psychiatrist feels hospitalization is necessary for treatment, a period of 30 days or so might be set aside for the initial treatment of patients. 

The legal rights of patients could still be respected by having a hearing within three days,where the judge makes a decision based on the psychiatrist’s report. If the patient would like to challenge the psychiatrist, the patient and the patient’s attorney can hire a second psychiatrist to offer an opinion, which can be offered at the trial, and the judge can make a decision based on those opinions.  If the first psychiatrist involved works for community service board, that’s fine. However, involving the community service board as an immediate adjunct and controlling factor regarding commitment has been a thorn in the side of most psychiatrists (and patients’ families) for the past 30 or 40 years. Most of the “pre-screeners“ have not been to medical school or had a psychiatry residency, and certainly are not board-certified in psychiatry. 

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