Arizona provides a clarion call to California: cuts to acute mental health services in San Francisco must be reversed.
By Hetty Beth Eisenberg
OPINION The massacre in Tucson is a tragic wake-up call for the public mental health system of our own county. Among the many pressing angles to the story, it is vital to consider the severe cuts to mental health services in Pima County last year.
Although only a small fraction of the mentally ill commit acts of violence, we must contemplate the larger issue of what happens when a community fails to prioritize mental health. Acute mental health services are such an essential tool for caring for the severely mentally ill that one is staggered by the low priority they've been given by our forward-thinking community in San Francisco.
Throughout the nation, the mentally ill are among our most disenfranchised constituents. In San Francisco, a considerable fraction of our severely mentally ill populations are indigent, homeless, and without health insurance. Acute care services for the mentally ill therefore lose money. In these hard financial times, city officials, like those in Pima County, are making painful decisions. Over the past three years, mental health services in San Francisco have been cut to austerity levels.
To see the short-sightedness of these cuts, one must consider not only the most drastic scenarios. For every Jared Loughner, there are thousands of individuals whose profound burdens could be alleviated with the help of these services. Inpatient psychiatry at San Francisco General Hospital provides the highest level of mental health care in our county. Unlike private hospitals, SFGH takes all patients, regardless of their insurance, and regardless of the risk of violence. The inpatient service at SFGH provides the only safety net for those patients who are the most extreme danger to themselves and others.
From 2008 to 2010, the number of acute psychiatry beds at SFGH was cut from 84 to 42. The consequences of the cuts were palpable. They led to the disintegration of the Cultural Focus Program, a nationally-recognized model of ethical inpatient psychiatric care. The most ill patients were crowded onto two remaining acute units. The staff was then put in the position of having to move patients to understaffed units, so-called subacute, before they were clinically ready.
In January, one of two remaining acute psychiatry units at SFGH was cut. This leaves 21 acute beds available to the entire city. It's now impossible to separate the most violent patients. The unit has become hyperacute, with an increasingly agitated population amplifying itself. Staff feel unsafe and cannot provide adequate care for their patients. As they grapple with understaffing, many cite what happened at Napa State Hospital recently when a psychiatric worker was murdered — an incident attributed to understaffing.
Meanwhile, there is considerable pressure to discharge these patients quickly. A vast number end up on the streets, in jails, overwhelming outpatient programs, or bouncing back to the emergency room — racking up even higher costs.
Due to budgetary pressures, the Department of Public Health insists that our unstable patients should be funneled into outpatient services. While outpatient programs provide vital means for supporting the chronically mentally ill when they are stable, they are also being cut — and are insufficient to protect acute patients.
These budget cuts make it plain that we are dealing with a clumsy model of mental health — one that lacks essential mechanisms. Such a model reflects a poor understanding of mental illness.
Arizona provides a clarion call to California: we must hear the implicit warning. These cuts to acute mental health services in San Francisco, a city with a large mentally ill population, must be reversed. Each day that they persist heightens the very real tragedy for our patients, our healthcare workers, and our entire community. *
Hetty Beth Eisenberg, MD, MPH, is a resident physician in psychiatry at San Francisco General Hospital.