Psychotic Reaction

Larry Newton knows firsthand that psychiatric crisis care in Harris County is a tragic mess. With a 12-year history of manic depression, the 35-year-old Newton routinely depends on the public health care system for emergency mental health care, often with miserable results.

Late last year, Newton was in a manic phase, a recurring period of excitation that alternates with moods of emotional dejection, when he decided he was in urgent need of psychiatric help. He took a cab to the Mental Health and Mental Retardation Authority's crisis clinic on Caroline Street near downtown, arriving around 3 a.m. There, he found just one nurse on duty, who told him to sit and wait. He did so until 5:30 a.m., "when the buses started running again," and was told to take a Metro bus home and then go to a MHMRA clinic that keeps daytime hours. The crisis clinic had seemed like a better bet for Newton that night than the emergency room at the county's Ben Taub Hospital, since, he says, "the line is too long at Ben Taub" and psychiatric patients end up "waiting hours and hours before seeing a doctor."

Newton's previous trips seeking emergency care at Ben Taub's eight-bed psychiatric unit had yielded mixed results. Once he was given a voucher for a cab ride home; two other times he was forced to stay through the entire weekend in the emergency room before he was admitted to the Harris County Psychiatric Center. During another visit, he bolted as he was being led to a cab to be sent home. He ran all the way to a washateria on lower Westheimer, where he passed out and later was picked up by an ambulance and returned to Ben Taub.

Such experiences are the norm rather than the exception for some of the estimated 20,000 Harris County residents who are in need of public mental health services. The eight beds in Ben Taub's psychiatric unit are simply not enough to meet the emergency mental health needs of the county's three million residents.

The Texas Department of Health said as much in June when it cited Ben Taub for deficiencies in its psychiatric unit, warning that the hospital could lose millions in Medicare reimbursements if corrective measures weren't pursued. That seemingly dark threat was in fact good news of a sort for county hospital district officials, who were keenly aware that something needed to be done to improve a situation that on weekends had patients sleeping on gurneys and reclining chairs in the psychiatric unit's hallway.

"They told us, 'You're trying to do too much.' I got told in June that was it," says Ben Taub administrator Mike Bullard. The state's report, which instructed Ben Taub to quit taking so many patients and stop putting them in a locked ward without their proper consent, is being used as leverage by hospital district officials trying to dislodge the inter-agency logjam that for years has crippled the county's psychiatric crisis care services.

"I think we all welcomed this," says Dr. Timothy Bayer, head of psychiatry at Ben Taub. "We knew it was a problem and we thought if we had the state on our side saying something had to be done, people's attention would be gotten."

An additional attention-getter occurred over the busy Labor Day weekend when Bullard, in part because of the state's warning, decided to divert psychiatric patients away from Ben Taub. The hospital district years ago had created a stir by resorting to a similar "drive-by" maneuver when Ben Taub's emergency room overflowed with trauma patients. Such "drive-bys" of psychiatric patients may be more frequent in the future if short-term solutions aren't found for crisis care.

Ben Taub, a familiar choice for the longtime uninsured and a last resort for newly uninsured, ceased to be an option for those in need of emergency psychiatric care on the night of Monday, September 5. Earlier that weekend, Bullard had told the Houston Police Department to take mental patients elsewhere, and close to midnight on that Monday, he gave the same directive to the city's Emergency Medical Services ambulances.

But there is no "elsewhere," at least not in the public sector. The county's MHMRA runs a crisis care clinic, but it has no inpatient beds, no general medicine backup and is unable to hold patients if they refuse treatment and want to leave. The 250-bed Harris County Psychiatric Center is usually full, and even if it isn't, it has no emergency room and is closed on nights and weekends.

Consumer activist Mike Harvey says it's "unconscionable" that the HCPC's admitting doors are open only during weekday working hours.

Harvey has a manic depressive disorder and has been a consumer of mental health services in Harris County for more than 30 years. "Whenever I had an emotional break and had to go to the hospital it was on the weekends, it was after hours or it was on holidays. It never failed. If people out there think we get sick between 9 and 5, Monday through Friday, that's horsefeathers. It does not work out that way. Most people do not get sick in that time frame. Nighttime is very bad for mental patients."

Betty Cobb of the West Houston Alliance for the Mentally Ill says much of the problem the county faces in providing emergency psychiatric care stems from inadequate funding and poor organization, not a lack of effort.

"We admit that everything stinks, but there are good people trying to do their jobs. That's what is sad -- those good people get their names bloodied," Cobb says. "I only know good things about Ben Taub. You can't blame them if they don't have

a bed."
Cobb recalls the story of one mother whose son did not seek the psychiatric care he urgently needed because of his past experiences with the crisis care network. One day he left home and disappeared. His parents notified the authorities, posted fliers and did everything that parents in such a

desperate situation would do. Cobb saw the mother several days later. She was smiling "I said, 'How's your son?' She said, 'Oh, I'm so thankful. He's in jail.' That's how sick it is."

A mental health worker employed by one of the agencies says the system gives patients only cruel choices. "It's a Catch-22. If you're in the midst of psychosis, you might have to wait two hours. But if you can sit still two hours, you're probably not in the midst of psychosis."

Harvey says the problem, if not the solution, is simple: "Basically, you can't get timely service. You can't get relief for your episode within time to do any good. It just exacerbates the problem."

The desperation of Ben Taub's resort to the Labor Day "drive-by" has led to a heightened awareness of the problem. The Mental Health Needs Council, composed of officials from the county agencies that deal with mental health, will meet this week to discuss crisis care, and representatives of MHMRA and the hospital district already have met with County Judge Jon Lindsay to discuss ways to improve the situation. They hope to have a plan ready by the end of this month that will include interim improvements. The long-range goal is to have an expanded outpatient crisis center, possibly in leased space at West Oaks Hospital, a private facility.

But insufficient state funding will remain a problem. Texas ranks among the bottom five states in per capita spending on mental health, and Harris County is below average for the state's counties, receiving $22.13 per capita from the state compared to an average of $27.56. Harris County MHMRA director Steven Schnee says he's not "terribly optimistic" about more funding. Others speculate the MHMRA budget statewide will take a big hit during next year's legislative session.

MHMRA has responsibility for most of the county's public sector outpatient psychiatric services, while the county hospital district runs Ben Taub and the 24-bed psychiatric unit at Quentin Mease Hospital. The Harris County Psychiatric Center, funded by the state and county and staffed by the University of Texas Health Science Center at Houston, provides inpatient care.

"You have these agencies, each of whom have some mandate to provide some mental health care but it's not clear who is supposed to be doing what," Bayer says.

As MHMRA and the hospital district negotiate solutions, officials hope the Harris County Psychiatric Center can find ways to admit patients during off-hours and to free up beds. That won't be easy, partly because of the opposition the HCPC faced when it first opened on South Macgregor. Concerns by residents of nearby neighborhoods over the type of facility it would be led to an agreement that the HCPC would not have an emergency room and would only admit patients during something akin to normal business hours.

"When the hospital was proposed, the community was in an uproar about the possibility of the hospital having an emergency and [outpatient] setting and having problems accepting [that] there might be mentally disturbed individuals at all hours of the night walking around the neighborhood," says David Small, the center's administrator.

These concerns are still perceived to exist, to the degree that when a patient is transferred to the HCPC from Ben Taub at a relatively unusual hour, a "stealth admission" is conducted by sending the patient over in a cab rather than an ambulance.

It is also argued that opening the center to night admissions will be futile if it's already full. "What's the point of being open at night if we're full at 4 p.m.?" asks one HCPC psychiatrist.

In addition to expanding the HCPC's hours, another proposal being considered calls for county patients in need of longer-term psychiatric treatment to be shipped to the state hospital at Rusk in East Texas. The intent would be to free local beds for patients needing shorter stays, but Small thinks the benefit would be marginal and short-lived. The move would create a few bed openings the first time it was done, but they would soon be filled by the overwhelming demand. "It would be a one-time gain that would be quickly used up and you'd never see it again," he says.

Shipping more patients to Rusk also would result in a reduction of state funding to Harris County for psychiatric care. "Rusk wouldn't be anxious to start many more patients from Harris County, since we are their largest supplier of patients," Small says. "And every patient at Rusk, those funds are counted against funding that would come to the county."

Small believes reducing the length of stays, moving patients into community settings and acquiring funding so that the time constraints on admissions could be relaxed a bit are more realistic approaches. Like the county's other mental health care providers, HCPC officials complain of not having enough funding. Since the center opened in 1987, its budget has been a flat $31 million per year.

Ben Taub, meanwhile, still must deal with patients dropped off by the police and city EMS ambulances. Bullard says closing Ben Taub's psychiatric unit on a weekend or holiday remains a possibility. Another, more unlikely option would be to divert emergency psychiatric patients to private hospitals. Bullard says he told the city's emergency ambulance service over the Labor Day weekend that "the treatment we could offer would not exceed the capabilities of any emergency room in the private sector," suggesting that the ambulances could take the patients to private hospitals. But since mentally ill patients who arrive escorted by police or in the back of a city ambulance are seldom lucrative prospects for private hospitals, few expect that to happen.

So Ben Taub adjusts. The deficiencies found by the state have been acted upon, with an emergency room holding area for pregnant women having been transformed into an a holding area for psychiatric patients on gurneys, and overflow patients now being placed in the holding area for non-psychiatric patients. Those two moves allow the "locked down" unit to be freed of excess patients, which Bayer says is an improvement, since "the more people who are in there, the more agitated they become." But mixing overflow psychiatric patients with patients in need of emergency medical care in the same holding area may just be a recipe for more problems.

Larry Newton, who has received treatment from all three of the county's main mental health care providers, questions whether the hastily implemented changes at Ben Taub will have more than a short-term effect. "It's understandable," he says, "but what are you going to do with all the people who go through Ben Taub if the main room can only hold eight people?"

Maybe just tell them to keep their seats.


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