Bold plan to tackle SF’s crisis on the streets . . . mental health treatment

[Pedestrian]

Heather Knight May 28, 2019 Updated: May 28, 2019 4 a.m.

San Franciscans will almost certainly be asked a groundbreaking question on the November ballot: Should all city residents be guaranteed the right to quick, effective mental health care?

. . . every San Franciscan . . . would be covered under a proposed program called Mental Health SF. It’s a twist on the 12-year-old Healthy San Francisco program, the first of its kind in the country, that ensured medical care for nearly every city resident. The proposal would . . . likely be the most comprehensive approach to mental health care in any American city . . . .

(Operating costs would be funded) with a new gross receipts tax on those companies that pay their CEOs upward of 100 times more than the median compensation paid to employees . . . .

Mental Health SF would center around the construction of a new treatment center, probably on the campus of San Francisco General Hospital, that would be open every day, around-the-clock. It would open by June 1, 2022 (and be paid for by) half of the revenue from (the proposed) IPO tax . . . . (It has been) estimated the tax would raise between $100 million to $200 million in the first two years.

Any city resident needing mental health or substance abuse treatment could walk in and receive quick access to psychiatrists, nurse practitioners, case managers and a pharmacy. There would be an acute crisis wing with beds for those who are so ill that they can’t safely be released.

Patients would be divided into two categories. “Bridge patients” would be those with private insurance or Medi-Cal who are having a hard time getting an appointment with a psychiatrist or a prescription written. The treatment center would help them and seek reimbursement from their insurance company.

“Core patients” would be those newly released from jail, uninsured people or others who need longer-term care provided by the city. Both sets of patients would be paired with a “navigator” who would help them obtain the care they need . . . .

The plan’s backers say it would cost the city an estimated $40 million to $60 million annually (but could) actually save money in the long term, which isn’t too far-fetched considering the Department of Public Health spends $370 million annually on mental health care and substance abuse treatment . . . .

https://www.sfchronicle.com/bayarea/...s-13899585.php

This is the latest and perhaps the best idea to come along to actually do something about the plague of homeless people, many (nearly all the long-term ones) of whom are mentally ill or substance addicted, on SF's streets and their attendant litter, bodily evacuations and drug paraphenalia discarded in the gutters.

As the article mentions, the city already spends hundreds of millions on the problem and already has a program of guaranteed health care for all (known as Health SF), but what it lacks is (a) a single place anyone can go--or be taken by the police--to receive both immediate and long term care and (b) the ability to provide compulsory treatment when necessary.

The latter of these needs would be taken care of by an initiative backed by the Mayor to expand legal conservatorships for the mentally ill and substance addicted.

I think San Francisco isn't the only city needing something like this. LA and Seattle and maybe Portland all probably do. I'm less familiar with the current state of eastern and midwestern cities but it's hard to believe at least some don't have a problem (in spite of less hospitable weather to living on the streets). And by reputation, some Canadian cities do as well (I've seen reports of a similar problem in Vancouver).

[JManc]

It sounds nice in theory but I don't see this really working out in the long run other than saving a few bucks consolidating treatment centers but it's not going to address or reduce SF's or any other cities' homeless problem. Long term care for someone who is paranoid schizophrenic for example often would require non-voluntary commitment to a psych facility which opens a whole other can of worms.

[Pedestrian]

Originally Posted by JManc

It sounds nice in theory but I don't see this really working out in the long run other than saving a few bucks consolidating treatment centers but it's not going to address or reduce SF's or any other cities' homeless problem. Long term care for someone who is paranoid schizophrenic for example often would require non-voluntary commitment to a psych facility which opens a whole other can of worms.

This is where the new mental health conservatorships come in. To repeat, SF's new mayor is trying to boost that program:

An LPS conservatorship gives legal authority to one adult (called a conservator) to make certain decisions for a seriously mentally ill person (called a conservatee) who is unable to take care of him/ herself.

If asked, the Court can give LPS conservator the duty to take care of and protect the seriously mentally ill person (conservator of the person) and also the power to handle the financial matters of the seriously mentally ill person (conservator of the estate). The conservator can give consent to mental health treatment, even if the conservatee objects. S/he can legally agree to the use of psychotropic (mind-altering) drugs (but the conservatee may physically refuse to take them).

Also, the conservator can agree to place the mentally ill person in a locked facility if a psychiatrist says it is needed and the hospital agrees to take the person, whether or not the conservatee agrees. The conservator can also decide where the mentally ill person will live when s/he is not in a locked psychiatric facility.

An LPS conservator must have enough medical and social information before making decisions for the conservatee. And, the conservator must only take actions that are best for the mentally ill person. The LPS conservator can also make financial decisions for the seriously mentally ill person, like paying the bills and collecting a person’s income.

. . . LPS conservatorships often begin when the person’s symptoms become so severe that they interfere with self-care and safety, and s/he is placed in a locked facility.

http://www.scscourt.org/self_help/pr...ship_lps.shtml

[Tom In Chicago]

Originally Posted by JManc

It sounds nice in theory but I don't see this really working out in the long run other than saving a few bucks consolidating treatment centers but it's not going to address or reduce SF's or any other cities' homeless problem. Long term care for someone who is paranoid schizophrenic for example often would require non-voluntary commitment to a psych facility which opens a whole other can of worms.

Isn't the homeless problem in San Francisco, California - and across the country for that matter - something that /started/ with the shuttering of mental health care facilities in the first place?

. . .

[Sun Belt]

Originally Posted by Tom In Chicago

Isn't the homeless problem in San Francisco, California - and across the country for that matter - something that /started/ with the shuttering of mental health care facilities in the first place?

. . .

Maybe, but unlikely because that was over 30 years ago and not too many homeless people have a very long life expectancy.

-----

A lot of the current homeless are opioid addicts. Just be glad you don't reside in California, where the homeless are everywhere.

Oklahoma has filed a lawsuit against Johnson & Johnson and a few other drug manufacturers.

These drugs have really F'd people up, some were innocent and some abused them, but the end result has been catastrophic.

https://www.latimes.com/nation/la-na...527-story.html

[Chef]

Mentally ill people you see on the street and the homeless are not necessarily the same group of people although there is overlap. They, and hard core addicts may have been the first group to become homeless but the pool is expanding as cities have become more expensive. Some of the temps we have at my work are homeless, they are mostly young people who didn't go to college and left homes in rural areas to find jobs but haven't found anywhere to live that they can afford. Most are living in their cars, some are living in shelters. If you saw them on the street you wouldn't think they were homeless.

I think it important to realize that it isn't just a mental health issue anymore, it is also an economic issue. The sort of people who used to live in cheap studio apartments a generation ago are now often living on the streets as the rising cost of rental housing is knocking all renters down a peg or two.

We don't have more addiction now than we did in the '80s or '90s. Probably less if anything. The social conditions of America are no different now than they were when there was less homelessness. What we are seeing are manifestations of an economic problem. The poor make less money than they used to and housing has gotten more expensive.

[jd3189]

^^^ I would also agree with that. Goes back to the similar debates in previous threads.

[Pedestrian]

Originally Posted by Chef

Mentally ill people you see on the street and the homeless are not necessarily the same group of people although there is overlap. They, and hard core addicts may have been the first group to become homeless but the pool is expanding as cities have become more expensive. Some of the temps we have at my work are homeless, they are mostly young people who didn't go to college and left homes in rural areas to find jobs but haven't found anywhere to live that they can afford. Most are living in their cars, some are living in shelters. If you saw them on the street you wouldn't think they were homeless.

I think it important to realize that it isn't just a mental health issue anymore, it is also an economic issue. The sort of people who used to live in cheap studio apartments a generation ago are now often living on the streets as the rising cost of rental housing is knocking all renters down a peg or two.

We don't have more addiction now than we did in the '80s or '90s. Probably less if anything. The social conditions of America are no different now than they were when there was less homelessness. What we are seeing are manifestations of an economic problem. The poor make less money than they used to and housing has gotten more expensive.

There are essentially 2 distinct groups of homeless people: The chronically homeless and the short term homeless. Most of the former are addicted or mentally ill. Most of the latter are not. They should be distinguished. The short-term homeless sometimes become chronically homeless but usually, because they are capable of accessing services and/or acting to relieve their situation by moving away to someplace they can find work or afford housing or otherwise respond, they don't stay homeless. I don't consider people living in cars or camper vans to be "homeless". They may not have a home you or I would want, but they have shelter and are doing something appropriate to survive.

It's the ones who ARE mentally ill of addicted and who therefore cannot access services or care for themselves whom one sees huddled in doorways all over San Francisco and many other cities today. They are the primary problem and the problem the new plan is intended to address.

As to whether we have more addiction now, I used to agree with you. I don't really any more--and once again, I worked for 12 years in a San Francisco opiate addiction clinic as a physician. This graphic neatly sums up the problem:



As most people now recognize, the increased prescription of opioids, chiefly Oxycontin (chiefly because of the marketing campaign of its producer, Perdue Pharma in the 1990s), drove a consequent rise in use of illegal opiates and ultimately dangerous illegal synthetic opiates. But there really has been a rise in the use of, addiction to and death from all 3.

[Pedestrian]

Originally Posted by Tom In Chicago

Isn't the homeless problem in San Francisco, California - and across the country for that matter - something that /started/ with the shuttering of mental health care facilities in the first place?

. . .

Not really. IMHO that is an urban myth and I was around to see what was happening in those years.

Most locked state mental facilities were closed in the 1970s. I (a) worked briefly in a state mental hospital in North Carolina in 1971 when they were still operating just about everywhere, and (b) moved to San Francisco in 1982 when no one really felt "homelessness" (or mentally ill/addicted people taking over the streets) was an issue in any way comparable to today.

In CA many people blame Ronald Reagan, who was Governor from 1967 to 1975 with the closing of the mental hospitals in that state and say it was to save money. But really, the action was supported by a wide range of political groups from liberals concerned about "human rights" to libertarians with similar concerns to conservatives who, yes, were happy to save some money.

What also was happening in those years that made the closure seem justifiable was the proliferation and wide use of anti-psychotic drugs. Here is an interesting article on the invention and beginning use of chlorpromazine (Thorazine), the first such drug. To quote Wikipedia, "In 1955 it was approved in the United States for the treatment of emesis (vomiting) (and later for treatment of psychosis). The effect of this drug in emptying psychiatric hospitals has been compared to that of penicillin and infectious diseases".

But by the time I was on the scene to observe, in the late 1960s and early 1970s, there was beginning to be a proliferation of these drugs. Notable in 1971, besides Thorazine, there were in common use Mellaril, Stelazine and Haldol. A real breakthrough was a form of these drugs, fluphenazine decanoate (Prolixin) that could be given by injection once every 2 weeks so there was no need to depend on mentally ill people to take a pill every few hours--they could be seen every 2 weeks and given a shot. That, as much as anything, made it seem as if forced confinement of schizophrenics was unnecessary and even barbarous.

Of course as we all know, once the mental wards were closed, the clinics to give those Prolixin shots or any other form of treatment were, for the most part, never funded or opened, although that's not entirely true in San Francisco. Here the Dept. of Public Health has always run facilities capable and wiling to provide treatment. The problem is getting those needing it to present themselves. The typical raving lunatic on the streets is taken to the psychiatric emergency ward at SF General Hospital, given acute treatment that may well incldue anti-psychotic medication, perhaps even kept for up to 3 days observation, and then released, with followup in the DPH's clinics up to them.

[Tom In Chicago]

Originally Posted by Pedestrian

Not really. IMHO that is an urban myth and I was around to see what was happening in those years.

Most locked state mental facilities were closed in the 1970s. I (a) worked briefly in a state mental hospital in North Carolina in 1971 when they were still operating just about everywhere, and (b) moved to San Francisco in 1982 when no one really felt "homelessness" (or mentally ill/addicted people taking over the streets) was an issue in any way comparable to today.

In CA many people blame Ronald Reagan, who was Governor from 1967 to 1975 with the closing of the mental hospitals in that state and say it was to save money. But really, the action was supported by a wide range of political groups from liberals concerned about "human rights" to libertarians with similar concerns to conservatives who, yes, were happy to save some money.

What also was happening in those years that made the closure seem justifiable was the proliferation and wide use of anti-psychotic drugs. Here is an interesting article on the invention and beginning use of chlorpromazine (Thorazine), the first such drug. To quote Wikipedia, "In 1955 it was approved in the United States for the treatment of emesis (vomiting) (and later for treatment of psychosis). The effect of this drug in emptying psychiatric hospitals has been compared to that of penicillin and infectious diseases".

But by the time I was on the scene to observe, in the late 1960s and early 1970s, there was beginning to be a proliferation of these drugs. Notable in 1971, besides Thorazine, there were in common use Mellaril, Stelazine and Haldol. A real breakthrough was a form of these drugs, fluphenazine decanoate (Prolixin) that could be given by injection once every 2 weeks so there was no need to depend on mentally ill people to take a pill every few hours--they could be seen every 2 weeks and given a shot. That, as much as anything, made it seem as if forced confinement of schizophrenics was unnecessary and even barbarous.

Of course as we all know, once the mental wards were closed, the clinics to give those Prolixin shots or any other form of treatment were, for the most part, never funded or opened, although that's not entirely true in San Francisco. Here the Dept. of Public Health has always run facilities capable and wiling to provide treatment. The problem is getting those needing it to present themselves. The typical raving lunatic on the streets is taken to the psychiatric emergency ward at SF General Hospital, given acute treatment that may well incldue anti-psychotic medication, perhaps even kept for up to 3 days observation, and then released, with followup in the DPH's clinics up to them.

Very interesting. . . my aunt used to work at Kaiser back in the 60's and 70's and (a staunch Republican) has blamed the mess on Reagan. . . I suppose it's an easy narrative to parrot. . . thanks for the clarification. . .

. . .

[JManc]

Originally Posted by Tom In Chicago

Very interesting. . . my aunt used to work at Kaiser back in the 60's and 70's and (a staunch Republican) has blamed the mess on Reagan. . . I suppose it's an easy narrative to parrot. . . thanks for the clarification. . .

. . .

My mom works/worked in mental health and social services and also blamed Reagan. She cited changes in patient rights' laws.

[CherryCreek]

Great news. This sort of treatment option is definitely needed. Other cities may want to pay to send to homeless to SF where at least some treatment will be available.

[mhays]

Washington State just passed a biennial capital budget with, iirc, $180,000,000 to start a new behavioral health treatment center and teaching facility to be operated by the University of Washington. That's just the capital budget, not the operations budget.

Maybe we're finally seeing some progress on this front.