A friend of mine who also worked with me as an RN on an acute care psychiatric unit sent me this newspaper clip from 1989. It is from the St. Paul Pioneer Press. At that time I had just started working on an acute care inpatient unit at St. Paul-Ramsey Medical Center (SPRMC) after working in a community mental health center (CMHC) for three years. The CMHC was in northern Wisconsin and SPRMC is in St. Paul, Minnesota. In this brief letter to the editor, I was listing the style points between both systems. Wisconsin was known to be an innovator in community mental health essentially inventing active outreach, providing meaningful crisis intervention services, and active case management with a goal of keeping people with severe mental illnesses in their own apartments in the community and out of hospitals. Anyone with any experience at all realizes that this is the best approach to the problem. We did not worry about it at the time, but it also kept people out of jail. We had working relationships with law enforcement and would often see people in jail and facilitate their treatment there and transition back to the community.
As the medical director of a CMHC in Wisconsin in those days, I had a team meeting with case mangers and nursing staff every morning. We discussed crises and treatment plans for the 100 to 110 individuals under our care. After that meeting everyone (except me) was driving off to meet our patients in the community. We had an exemplary record of helping these folks stay out of the hospital and our case managers would go to the hospital and help get them discharged if they were at baseline. We knew the resources, landlords, relatives, doctors, and local crisis housing. We worked within a system that had a single-minded focus of supporting people in the community and at the administrative level we had state support mandated that the "money follows the client". That did involve an incredible amount of paper work on the part of our case managers and needing to deal with a county bureaucrat but there were clear significant advantages over other systems.
Flashing forward 30 years has there been much progress? I can say with certainly there has been absolutely no progress on the Minnesota side. They have funded some assertive community treatment (ACT) teams but there is still a rationing mentality. I heard the rationing mentality recently restated by the current head of the state hospital system. Minnesota currently has a large steady state population of chronically mentally ill patients circulating through emergency departments, available beds, jails, and homelessness. There is limited bed availability to the point that outpatient psychiatrists have to send their patients to the emergency department (ED) rather than referring them directly to affiliated hospital because they know there are no beds. That is also true for patients who need electroconvulsive therapy. The constant stream of people to the ED creates a backlog there and getting patients out occurs only if they are held long enough for an inpatient bed to open, discharged untreated, or transferred to another hospital often several counties away. In the meantime, the state hospital system has been reduced.
In a November meeting of the Minnesota Psychiatric Society (MPS), Kylee Ann Stevens, MD the Executive Director Direct Care and Treatment of the state hospital system provided some numbers for mental illness treatment but not addiction resources. Those numbers are summarized in the graphic below.
There is also a chronic unanswered question that has been hanging in the air for the last 20 years. Did Minnesota intend to just shut down the state hospital system entirely? Certainly the trajectory of bed closures was on track to do that. In the MPS meeting we never learned what the absolute minimum number of beds was. In talking with doctors and nurses who worked in that system they certainly thought that was the goal. The current minimalist system may be in place by default rather than design - the end product of a failed attempt to close down all of the state hospital beds.
So Minnesota continues to flounder. What about Wisconsin? I don't think that their inpatient bed capacity is much better but I don't have the exact number. The community mental health movement is still alive and well but I am aware of no significant innovation. The Wisconsin Mental Health Statutes appear to have expanded significantly and law enforcement seems to have assumed more of a gatekeeper role in emergency treatment. I can't comment on whether the Wisconsin system is more cost effective and patient centered than Minnesota but I invite clinicians to comment on that.
Relative to the initial news clip - progress in general in the treatment of psychiatric disorders is not a word that can be used. Politicians run these systems and not physicians. As long as that is true we can depend on no progress.
George Dawson, MD, DFAPA