Neglect of the Severely Mentally Ill Is the Real COVID-19 Mental Health Crisis
By: James C. Coyne
Tags: California, Mental Health, Psychiatry, Covid 19, Severe Mental Illness

The public needs stories of heroic success, not the stories of people with mental illness whom the system has crushed and made it impossible for them to succeed. We block such patients out of awareness. We preserve our sense of a just world by believing that they deserve their plight because they brought it on themselves.

Governor Gavin Newsom has been described as having the worst job in politics. Even before the ongoing surge in COVID cases, he had to contend with climate change, wildfires, severe air pollution, social unrest, and an antagonistic relationship with President Donald Trump. The thankfully soon-to-be-gone president has featured Newsom as a villain in ads on cable TV and in tweets during his contesting of the results of the election he lost. Trump has tried lots of ways to withhold the federal funds that California desperately needs.

Last week, Governor Newsom held a press conference to announce the worst surge in cases and deaths yet in the pandemic.

The crisis was more acute in Southern California than in some other portions of the state. To cope with the effects of the ICUs approaching capacity in Southern California, Newsom ordered the distribution of 5,000 extra body bags. He also put 60 refrigerated trucks on standby to be ready as makeshift morgues.

The good news was the federal health officials had authorized the release of the first vaccine for distribution, and authorization of a second vaccine came before the week had ended.

The impending availability of the vaccine was bad news for patients at Patton State Hospital who are seeking safety from a virus that already stricken so many patients and staff at the hospital. The prior week, the California Department of State Hospitals (DSH) moved 43 women patients to a “surge capacity” facility elsewhere. However, DSH was balking at further removal of patients, citing the opportunity for the rest to be vaccinated by the end of January.

With 1,527 beds and 2,380 employees, Patton is one of the largest psychiatric hospitals in the US. The majority of people are involuntarily confined to the facility because they were found by a judge to be incompetent to stand trial or not guilty by reason of insanity.

Patton patients often stay in the facility for a decade or more, sometimes longer than the time they would have served had they been convicted and served their time in state prison.

Patton Hospital has remained grossly overcrowded, despite many patients no longer being considered to be dangerous or needing treatment in a locked facility.

The problems getting patients out of the hospital and into more appropriate placements are longstanding and need to be viewed as part of the intersection of the public mental health sector and the criminal justice system.

Finding a solution had been thwarted by state authorities’ indifference to violations of the human rights and the basic dignity of the patients, as well as federal policies that long predate Trump, like inadequate Medicaid reimbursement for public inpatient psychiatric care.

These patients in the Patton state psychiatric facility do not attract many advocates. Inmates incarcerated in prisons who have been found guilty of a crime inspire more sympathy and more asking of questions if it is just for them to remain there.

Most mental health advocates are not enthusiastic about raising awareness of the plight of the severely and chronically mentally ill. The “bad people” of Patton Hospital are not there because they are guilty of a crime, but mostly because they have been found legally incapable of committing a crime because of their mental illness.

You won’t see marches or candlelit vigils for people like the patients of Patton Hospital or even their plight mentioned at such events. Organizers want to focus on examples of likable more persons with mental disorders who are similar enough to win empathy.

Mental health organizations want the public to think about mental disorder as it is represented by champion celebrities telling narratives of how they got to be rich and famous despite professing to have had a mental disorder. You can too if you are sad or blue.

The public needs stories of heroic success, not the stories of people with mental illness whom the system has crushed and made it impossible for them to succeed. We block such patients out of awareness. We preserve our sense of a just world by believing that they deserve their plight because they brought it on themselves.

You won’t see Prince Harry and Meghan Markle lighting candles and declaring “We are one with the mentally ill of Patton State Hospital.” Don’t expect the Royal couple to make up holiday dinners for the patients to consume back in their cramped, isolated common dining areas.

The hospital becoming an epicenter of COVID transmission risks imposing death sentences on these patients who are stuck there.

Sidestepping pre-existing problems of the facility, the immediate transferring out of Patton, or releasing of some patients would have allowed social distancing of the rest. Friends and family in the community already had been identified to receive them. Negotiations had broken down and no action was taken until the release of the small number of women patients the prior week. Now, no further action was being taken to move any more patients out because the vaccine was coming.

A Sacramento-based advocacy group that provides legal support for people with disabilities had filed a class-action suit back in August on behalf of five named patients, as well as others who were at similar high risk from COVID-19 because of age or medical co-morbidity.

The August legal filing is a compelling read if you just dodge the legalese. You need little imagination to construct what is being described and grasp the humanity of the patients who are suing to get safer from the virus.

The accusations laid out against the DHS officials:

Defendants confine patients to locked units that consist of approximately fifty (50) people, all of whom share one bathroom, one eating area, one communal lounge area, and a few telephones. Patients report that, contrary to DSH protocols, Defendants do not routinely sanitize high-touch common surfaces, including tables, chairs, and telephones, between use by different patients. Staff rotate through the units constantly, and do not wear masks consistently when interacting with patients.

And

“Defendants have taken no meaningful steps to modify their policies and procedures to facilitate the release or transfer of Plaintiffs and others similarly situated to safer settings, despite the serious threat that the COVID-19 outbreak poses to their lives. On information and belief, Defendants have denied every request made by Plaintiffs and other high-risk patients to be moved to a safer, non-congregate setting. Among those Defendants have refused to move are patients who have completed or are close to completing their treatment goals at DSH, and patients who have identified community placements where they can safely shelter in place and receive treatment in a non-congregate setting. Even for patients who do not meet the current criteria for discharge to the community, it is inhumane and unconscionable to keep them in a setting where they are unable to protect themselves from infection”.

The DHS had promised further action but balked when the impending arrival of the vaccine was announced.

“Defendants have failed to conduct an adequate systematic review of high-risk patients in order to identify who can be safely discharged to a less dangerous setting; facilitate the release or transfer of such high-risk patients to safer, non- or less-congregate settings; or otherwise reduce the patient population to allow for anything close to adequate social distancing.”

The relief that the August filing sought seems eminently reasonable if only there were a sane, humane system in place. Namely, the patients sought the DHS to identify all members of the class action suit and provide a systematic assessment of their COVID risk status according to CDC guidelines. The DHS should then:

Conduct expedited individualized assessments of all members of the Class to effectuate their safe discharge or transfer from DSH-Patton to a safe, non-congregate setting. In conducting these assessments… Consider the full range of alternative treatment options, including discharge or transfer to a community setting, a family member’s home, temporary leave, conditional release, permanent or temporary housing accommodations, tele-medicine, and intensive case management services. Under no circumstances should an individual be transferred to another congregate setting with a heightened risk for COVID-19 infection.

Little progress was made to implement these remedies. The patients’ plight became direr in late November 2020. As described in the emergency filing:

In the past two weeks, 113 patients have tested positive for COVID-19. Eighty-nine of these patients tested positive for COVID-19 in the last seven days. Three of the named plaintiffs in this lawsuit tested positive for COVID-19 since the status conference on December 7, 2020. Numerous putative class members have also tested positive for COVID-19 within the last week, and at least 11 DSH-Patton patients have required acute hospitalization due to severe COVID-19 symptoms

The emergency decree that was filed on their behalf again makes fascinating reading. The DHS is accused of ailing to:

Take necessary steps to discharge or transfer high-risk patients to less congregate settings.

Enact adequate depopulation efforts.

Take appropriate measures to mitigate the risk of transmission within the hospital.

The decree seeks relief by having half of all Patton immediately released or transferred.

Good luck with that.

Last I checked, the virus continues to surge in the surrounding community and some hospitals are reporting no available ICU beds.

The decree acknowledges that some prior options are being closed, repurposed and that the virus is ripping through patients and staff. But immediate action is still needed to save lives.

We are told by public health authorities to brace for worse days in the pandemic are ahead. But eventually, the virus will ebb. Lots of basic mental health, substance abuse, and social services will be devastated and will need to be constructed. There will be more people left homeless in the interim.

We need to plan now so that the default solution after COVID is not the rebooting a decripit public mental health system that has gotten us where we were before the pandemic.

A false narrative of another kind of mental health crisis associated with COVID-19

Some researchers and journalists have attracted attention to themselves in social media by dramatizing another kind of mental health crisis associated with COVID, a surge in new mental illness, portrayed as a second pandemic and even a tsunami.

Maybe the researchers were naïve or became careless in attempting to get a quick bit of attention when everyone wants to hear from experts.

The research group, mainly based at Oxford University, purchased access to a large administrative data set from American. They interpreted their analyses as indicating that a recording of a diagnosis of COVID-19 in electronic health records (EHRsin earlier days of the pandemic was associated with six times the rate of mental illness associated with other physical health diagnoses or events.

However, when I checked, I found this alleged excess was almost entirely due to a recording of an adjustment disorder. Patients were more upset by a diagnosis by COVID than other reasons for coming into contact with major care, but their depressive and anxious symptoms did not meet the threshold for a diagnosis of major depression or PTSD or more severe mental illness.

That prospect is reassuring.

So, we can expect that the main effect of COVID on the mental health care system will be people whom we can relate to developing mental health problems from which they can recover, often without formal treatment or maybe a little support and understanding? I doubt it.

That vision leaves out mentally ill persons like the patients contracting COVID-19 at Patton and other inpatient psychiatric facilities, whether currently trapped in those facilities or cycling through community facilities or falling into homelessness. We would be left comfortable not having to give them a second thought.