No easy answers for mentally ill homeless
A five-minute stroll around downtown San Francisco makes it obvious the city has a huge number of people with mental health problems. And it’s not unusual to see homeless people who appear mentally ill wearing hospital gowns or identification bracelets, signaling they’ve just been released from the hospi- tal and are back on the streets.
What’s going on? I sat down with Dr. paul Linde, who for a quarter-century worked in the psychiatric emergency room at San Francisco General Hospital before leaving to work part-time as a primary care psychiatrist. He described San Francisco’s revolving door for mentally ill homeless people, the shortage of treatment beds and how California’s newly passed law strengthening the conservatorship program might help.
Answers have been edited for length and clarity. To hear our entire exchange, listen to the latest episode of my podcast, San Francisco City Insider, at sfchronicle.com/ insider.
Question: You were an emer-
gency room psychiatrist at S.F. General for 25 years. That must have been a really stressful job. Can you describe what a typical day was like?
Answer: There would usually just be one other psychiatrist on duty. I would say on an average day there might be 20 patients waiting for us. Some of those folks had been there for already 24 hours, so when you get there you have to already begin to look at where do people need to go? What should we do with individual patients? But of course, as soon as the clock starts ticking, you can have new patients being brought in. There would be times when that would be four or five coming in a half hour.
Q: Did any particular patient stand out for you? What were some of the behaviors you saw?
A: Unfortunately, a typical patient would be someone who’d been brought in by police who’d been assaultive or aggressive in public. One day, someone was swinging a pipe, someone was swinging a bat, someone was swinging a bicycle, and I was waiting for the next person to be swinging a baby. These are often people who are intoxicated on intravenous methamphetamine or are psychotic from untreated bipolar or untreated schizophrenia or both.
Q: You describe some neighborhoods in San Francisco being like open-air insane asylums. Why has the problem gotten so bad? A: There are multiple variables. San Francisco is a draw, and part of the burden for the city is really: What do you do with so many people who are coming from elsewhere? This is a regional and national problem. There’s also a relative lack of access to drug treatment in San Francisco. I know there’s hope to be had in terms of treating addiction and that we need to catch people when they’re ready. There are places in the city where people can get help, but we need to make it more accessible. The last thing is, honestly, the ways the civil rights laws are written in California, it’s difficult to make people accept treatment against their will. It’s difficult to take those people off the street.
Q: How does the process work now? If someone is acting violently and insanely on the street, a police officer can take them to S.F. General. Then what happens?
A: It’s a 72-hour hold and the criteria is suicidal, homicidal or being unable to take care of yourself due to psychiatric illness. So basically those patients are brought in — we take their vital signs, we try to get their history. Immediately they’re evaluated for their safety. We decide whether to keep them or whether to try to admit them to the inpatient unit or whether they can go. The average length of stay has gone down over the years. In the psych emergency, it’s close to eight to 12 hours now. When I started, it was 24 hours or more. The inpatient beds are usually full, so if you think someone needs to be inpatient they often have to wait a day or two to be admitted. So the people who are less acute but still needing admission, they may have to wait three or four days, so the reality is you have to discharge those people because you can’t keep them that long.
Q: You likened it to being like a car wash. Can you explain that metaphor?
A: You’ve got your chow, you’ve got your shower, you’ve got your medication, you’ve got some sleep and now it’s time to get out the door. What happens is I think a lot of these people get discharged and they end up bouncing back in a week and repeating the process.
Q: You argue there just aren’t enough places to send these people to, other than back on the streets. What would we need to make a dent in this problem?
A: We need more of the expensive acute inpatient beds. We don’t have enough of them, and we don’t keep patients long enough to stabilize them. Medi-Cal will stop paying for the admission on day four, so if you’re going to keep them on day six, seven and eight, the hospital will be losing money. The question is: Does the whole system need to change? We also need places to send people from the hospital that are less expensive, places like long-term residential care facilities.
Q: Can you talk about conservatorship programs (when patients may be held without their consent) and whether our current state law is good enough on that?
A: I welcome the efforts of Scott Wiener and the mayor. I do think it will be helpful. Part of what they’re focusing on is getting the sickest of the sick off the street and into a safe, structured environment. It’s a very humane thing to do. But it’s a lot to take away someone’s right to move about freely for six months to a year. What I’m thinking is, if you can keep people 10 days instead of three days, we could do that on a much more widespread basis and help more people.
Q: Has there ever been a time when City Hall was on top of these issues?
A: The programs change, the acronyms change, the priorities change. I don’t really think City Hall has ever had a handle on this problem. It’s going to be harder now than ever, just because of the numbers.
Q: If you were mayor for six months, what would you do to make a real impact on these issues?
A: I’m almost positive I can’t take it. I hate meetings with a passion. But I would double the number of inpatient beds, and I would keep people longer. I would reinstate some form of the state hospital system. What I find fascinating is that 90 percent of the patients at Napa State Hospital are penitentiary patients. People have to get deep into the criminal justice system to get that long-term psychiatric care. Isn’t that crazy? And those patients are twice as expensive as the civilly committed. The bureaucratic challenges are unbelievable. I don’t ever want to be mayor.