MARTINEZ — The vast majority of patients who arrive at California hospitals with a psychiatric emergency are not admitted, a situation that has prompted some mental health advocates to ask whether enough is being done to help those who may pose a threat to themselves or others.
The number of psychiatric beds in California hospitals has steadily shrunk over the years as the focus in treating mental illness has shifted toward less restrictive outpatient care. Many mental health professionals have argued that forced hospitalization in many cases can do more harm than good.
But the decision to send a patient with a psychiatric emergency home can also have tragic consequences, as occurred in Contra Costa County in April when a 9-year-old Discovery Bay boy was stabbed to death in his bed just hours after his admitted killer was taken to Contra Costa Regional Medical Center in Martinez. After speaking for a couple hours with a psychiatrist, William Shultz said in a jailhouse interview that he was diagnosed as being delusional, discharged from the Martinez hospital and sent home in a cab.
The hospital’s handling of Shultz’s case was not unusual. In 2014, the Contra Costa Regional Medical Center’s psychiatric emergency services — a locked facility separate from its general medical emergency room — handled 10,566 visits, admitting 874 of those patients (8.3 percent) to its inpatient hospital with 23 beds. In 2013, the hospital admitted 947 of 9,860 visits (9.6 percent) to its inpatient facility. That percentage is only slightly below the statewide average of 11.1 percent, based on 2013 data, though other county hospitals in the Bay Area have higher admittance rates (15.8 percent at Alameda County’s John George Psychiatric Hospital and 12.5 percent at Santa Clara Valley Medical Center’s inpatient psychiatric care).
In addition to the 874 emergency patients admitted to its own facility last year, the Martinez hospital also sent a similar number to other hospitals for inpatient services, an official said, but most patients receive outpatient services.
Once in those Contra Costa Regional beds, mentally ill patients stayed an average of 8.6 days, compared with 13.9 days in Alameda County with its 80 psychiatric beds and 13.3 days in Santa Clara in its 50 beds, according to 2013 state data collected by the California Office of Statewide Health Planning and Development.
John Snook, executive director of Virginia-based Treatment Advocacy Center, said that only the most severe and dangerous cases are hospitalized because California has so few psychiatric beds.
“What you see is predictable. If there are only a few beds, facilities have to triage, and take only the most severe cases,” Snook said. “People aren’t very good at predicting when someone is imminently dangerous, and so they are let out and what happens is people continue to deteriorate.
“Those folks then find themselves in a much less therapeutic facility — they’re in jail.”
In one of his agency’s studies, researchers could not identify a single county in the nation where the county inpatient psychiatric hospital was holding as many mentally ill individuals as the county jail.
Family members of mental health patients have complained of the revolving door at Contra Costa’s psychiatric emergency services department, where, they say, many mentally ill patients are seen but too few are admitted for short- or long-term care.
Dr. Kristine Girard, chief psychiatrist at the Contra Costa facility, said she understands families’ frustrations but stressed that determining whether someone is a danger to themselves or others, which would provide the option to involuntarily hospitalize a patient, is not an exact science.
“That is a challenge. It’s very difficult,” she said. “No one with a professional kind of lens … can accurately predict the future.”
The Martinez hospital is conducting an analysis of Shultz’s care the day before he stabbed to death 9-year-old Jordon Almgren, according to Contra Costa County Supervisor Mary Piepho, who lives in Discovery Bay. However, what exactly happened during Shultz’s brief stay there is a mystery due to patient-confidentiality laws.
Piepho has also proposed a report on how other county law enforcement and medical teams handle similar cases compared with Contra Costa.
Shultz’s attorney and the Almgren family lawyer declined to comment for this story. Shultz recently pleaded not guilty to murder.
One 49-year-old Antioch mother, whose 30-year-old son has been diagnosed with delusional psychosis, said Shultz’s quick exit from the hospital is the norm. She said she struggled unsuccessfully to get her son hospitalized care for years.
During one period, she said, her son stopped eating, dropping from 210 to 135 pounds. Police took him to the Martinez facility, only to be sent home hours later, she said.
“He was killing himself, gravely disabled, a failure to thrive, and he was sent home in a cab,” she said, asking for anonymity to protect her son’s identity. Her son was eventually hospitalized, and she said that once inside the inpatient portion of the Martinez facility, he received great care.
Girard emphasized that “patients are entitled to the least-restrictive environment.”
“We are committed to hospitalizing based on critical need and do that on a case-by-case basis,” she said.
Public psychiatric beds in California have dropped from 6,285 in 2005 to 5,283 in 2010, down 16 percent, according to a Treatment Advocacy Center report. The state averages 14.2 beds per 100,000 population, ranking 22nd in the country. The study recommends 50 beds for every 100,000.
The dismantling of inpatient psychiatric care in favor of outpatient facilities began to catch hold in the 1960s in a “deinstitutionalization” movement. In 2010, there were 43,318 patients in psychiatric hospitals in the United States, down from 535,540 in 1960, and 135,134 in 1980.
The mass exodus from public mental hospitals was driven, according to a Treatment Advocacy Center report, by media reports on overcrowded facilities post-World War II, civil libertarian lawyers working to free patients, reductions in federal fiscal support, introduction of antipsychotic drugs, and literature and movies such as “One Flew Over the Cuckoo’s Nest” that portrayed hospitalization as part of the problem.
Santa Clara County Supervisor Joe Simitian is pushing for more psychiatric beds for juveniles in his county, which has none dedicated to minors. That causes nearly 20 minors per day to seek or be sent for treatment at hospitals outside the area for acute inpatient care, according to his office’s recent report.
“There’s a tension between need and desire to ensure beds are available, and concerns of overinstitutionalizing,” Simitian said.
Pat McConahay, a spokeswoman for Disability Rights California, said there are alternatives to hospitalization, and outpatient care also needs funding.
“Situations like this are a major problem statewide in California; however, the answer is not hospital inpatient treatment necessarily,” McConahay said. “What these people need is a crisis team to work with them, certainly not being sent home alone in a cab.”
Staff writer Danny Willis contributed to this report. Contact Matthias Gafni at 925-952-5026. Follow him at Twitter.com/mgafni.
