Mental health care in Ohio shifts from hospitals to jails

RELATED: Mental health professionals say local treatment networks work

By PETER H. MILLIKEN

milliken@vindy.com

YOUNGSTOWN

In the aftermath of highly publicized issues, such as mass shootings and skyrocketing drug addiction, more scrutiny has been placed on services for those with mental health and recovery issues.

In the past five decades, state-run psychiatric hospitals have been phased out with funds shifted into each community to create outpatient care and support services for those afflicted with any of a number of mental illnesses.

As in all complicated cases, the result has been a complicated stream of causes and effects.

The 112-bed Woodside Hospital was shuttered 19 years ago. Today, the Mahoning County jail handles an inordinate number of inmates who oftentimes find themselves incarcerated because there is no other facility available to help them balance their mental health needs.

“One of the biggest providers of mental health services in the state are the jails, and we have to fix that,” said Duane Piccirilli, executive director of the county mental health and recovery board.

Mahoning County officials find themselves focused on ensuring that jail inmates with mental illness have stable housing and mental health services when they’re released.

bed shortage

“Because of the [state psychiatric] hospitals not being around and that not being addressed for so many years, the end result is a lot of this is in the jail,” said county Commissioner Carol Rimedio-Righetti.

“It’s not fair to that person, nor is it fair to the sheriff or any policing agency to have to deal with that,” the commissioner added.

“We’re sort of in a crisis for state hospitals,” Piccirilli said. “We have days when there are no hospital beds for our clients.”

“I think it really does stem from the state’s decision over time to get out of the housing of those folks with mental-health challenges,” said Mayor John A. McNally, who also is a former county commissioner.

One- to three-day psychiatric hospital stays are sometimes available, when needed, “but, a lot of times, they end up going to the county jail, either through city or county intervention,” the mayor said of people with mental illness.

“Offenders will be diagnosed [with a mental illness] while they’re in jail, and that requires more treatment dollars and more treatment staff,” McNally observed.

Sheriff Jerry Greene said at least one-third of county jail inmates here take psychotropic medications to manage their mental illness.

The sheriff said a high percentage of jail inmates “has some form or tie to their crime to either mental illness, drugs or alcohol.”

The county jail houses an average of about 500 inmates.

When Woodside was open, police had the option of taking a mentally disabled person there, rather than criminally charging and jailing that person, said Maj. Alki Santamas, jail administrator with the county sheriff’s office.

Today, 24 hours of individual and group mental health counseling and an additional 24 hours of substance-abuse counseling are provided weekly in the jail by agencies of the county mental health and recovery board.

Four hours a week of psychiatric services are also provided there.

“We’ll pass the baton from the jail to those local community agencies and have a smooth transition,” through planning in advance for each inmate’s release, said Santamas. “Hopefully, when they do get released from custody, their chances of returning to the [jail] facility will be diminished.”

Despite the mental-health screenings and services the jail provides to its inmates, two inmates committed suicide by hanging themselves in the jail in recent months, one Aug. 25 and the other Oct. 4.

They were the first suicides there in more than 12 years.

State system

In 1980, Ohio had 19 state psychiatric hospitals, including Woodside, located on the city’s South Side, with a combined average daily resident population of 5,129 patients.

Today, the state operates only six psychiatric hospitals, including Heartland Behavioral Healthcare in Massillon and Northcoast Behavioral Healthcare in Northfield.

Those six hospitals, all for adults, have a combined total of 1,043 beds, of which 1,002 were occupied recently.

“It takes two [police] officers all day to go to Massillon to bring a person over there,” said Judge Robert Milich of Youngstown Municipal Court. “We just don’t have the facilities available.”

Sixty percent of the patients in the state hospitals were committed there or sent there for evaluation by criminal courts, said Eric R. Wandersleben, director of media relations and outreach for the Ohio Department of Mental Health and Addiction Services, which operates the hospitals.

“The role of the state hospital has changed dramatically in the last 30 years,” said Tracy Plouck, director of that department.

“If you entered a state hospital in the ’60s, ’70s or early ‘80s, you may have been there for years at a time,” she said. Today, hospitals follow an acute-care model with stays now averaging 10.5 days for patients not placed there by judges, she said.

“We focus on stabilization and connection to community services,” she said.

“Our capacity is generally pretty tight with the state hospitals, but we do not have plans to build another facility,” Plouck said. “We are not going back to the days where we’re going to be a long-standing residential center.”

The psychiatric unit at St. Elizabeth Youngstown Hospital contains Mahoning County’s only adult inpatient psychiatric hospital beds. Within the next few weeks, that unit will expand from 18 to 38 beds.

“I get a lot of people [who] are in jail. I want to get them into treatment. There’s no place to put them. You don’t have the facilities available,” Judge Milich said.

If someone presents a danger to himself or herself or potentially to others, the judge said he sometimes finds himself with no choice but to jail that person, even if a psychiatric hospital placement would be a better choice for that individual.

“The overriding thing in the state now appears to be: ‘Save money’,” in the mental health and prison systems, he said. “The whole thing has to be reviewed.”

There’s also a shortage of residential alcohol and drug-abuse treatment availability for poor people in Mahoning County, the judge said.

MENTAL ILLNESS

Mahoning commissioners unanimously approved a resolution this fall launching the county’s participation in the national Stepping Up Initiative designed to reduce the number of mentally ill people in jails.

Stepping Up’s housing- planning effort is designed to reduce homelessness,

Piccirilli said.

The county has just received a $150,000-per year, two-year state grant that will help county jail inmates and Community Corrections Association halfway house clients with mental illness and substance abuse conditions re-enter the community.

The commissioners’ resolution says the prevalence rates of serious mental illnesses in jails are three to six times higher than in the general population.

Many mentally ill people remain jailed because their low incomes make them unable to afford to post bond, Piccirilli explained.

Another likely explanation for the high numbers of reported mentally ill jail and prison inmates is that professionals have improved their ability to diagnose mental illness, said William Carbonell, the county mental health and recovery board’s director of clinical programs and evaluations.

“We’re actually assessing those people with mental health issues more in the recent years than we ever have” in the past, as jail standards have evolved, and diagnosing more mental illnesses as a result, Santamas said.

Twenty percent of Ohio’s 50,521 state prison inmates are seriously mentally ill, said Gary Mohr, director of the Ohio Department of Rehabilitation and Correction, which operates state prisons.

“We’re the largest mental health provider in our state,” Mohr said in a 20-minute video titled “Sick, Tired and Behind Bars in Ohio.”

The video was produced this year by the National Alliance for the Mentally Ill and funded by the Ohio Attorney General’s Office.

“There are 10 times more people with mental illness in Ohio prisons than in our state’s mental health hospitals,” Ohio Attorney General Mike DeWine said in the video.

CONSEQUENCE

A 2008 study by the Treatment Advocacy Center of Arlington, Va., concluded that a “consequence of the radical reduction in public psychiatric hospital beds has been a massive increase in severely mentally disabled person in jails and prisons.”

That study by psychiatrist E. Fuller Torrey, center founder, is titled: “The Shortage of Public Hospital Beds for Mentally Ill Persons.”

Calling for restoration of public psychiatric hospital beds, the Treatment Advocacy Center recently observed on its website: “By 2010, [the latest year for which data are available], only 14.1 public hospital beds remained for every 100,000 U.S. residents – the lowest total since 1850, when construction of state psychiatric hospital beds began.”

In Northeast Ohio, the 2014 numbers are 9.8 per 100,000 for Heartland’s 11-county primary service area, and 9.6 per 100,000 for Northcoast’s seven-county primary service area, which put these areas well below the national average.

TAC said the goal should be to have at least 50 such beds per 100,000 people.

After a 1988 Ohio Department of Mental Health study found 36 percent of those released from Ohio state psychiatric hospitals were homeless within six months after discharge, Ohio rapidly developed an array of community-based services for mentally disabled people during the 1990s.

In a 2010 update on the “Crisis in Ohio’s Acute Mental Health Care,” ODMH concluded: “The question remains open as to whether there is a causal relationship between homelessness and a reduction in state psychiatric beds.”

BED shortage accelerates

Between 1989 and 2008, the combined census of Ohio’s state psychiatric hospitals, taken each June 30, dropped 72 percent from 3,600 to 1,000, with most of that decline occurring between 1989 and 1999.

As local mental health boards gradually reduced the number of bed days they bought in state psychiatric hospitals and used the savings to expand community care, state hospital closings and consolidations became inevitable, ODMH said in its 2010 report.

Among the casualties was Woodside Hospital in Youngstown, which closed in September 1996 in a state budget-cutting move.

Another issue affecting access to mental health care is the shortage of mental health professionals, including psychiatrists, psychologists, counselors and social workers, Piccirilli said.

“People aren’t going into that specialty in public mental health,” he said of psychiatry, adding that the shortage may be due to some psychiatrists preferring more financially rewarding private practice.

“The average age of a psychiatrist is nearing retirement,” Plouck observed.

Due to the psychiatrist shortage, Mahoning County patients have recently been diverted from Heartland to Northcoast hospital, Piccirilli said. The shortage of psychologists, counselors and social workers is mostly due to their low pay, he said.

In the video, Mohr lamented that a state prison releasee often has to wait up to three months from the date of discharge to see a psychiatrist.

MEDICAID EXPANSION

Wandersleben and Piccirilli said Ohio’s expansion of Medicaid eligibility to cover people with incomes up to 138 percent of the federal poverty level is allowing county mental health and recovery boards to stretch their state subsidy and local levy dollars to cover needs, such as re-entry assistance for those leaving jails and prisons and returning to the community and substance- abuse prevention education, which Medicaid does not pay for.

Piccirilli estimated that Medicaid expansion under the Affordable Care Act has stretched public funding for mental health services in Mahoning County by about $1 million annually.

Wandersleben gave a higher estimate that put the county figure at just under $1.5 million for 2014, and he gave estimates of $1.3 million for Trumbull County and $690,000 for Columbiana County.

“We are providing more prevention, intervention and outreach than we ever have because of Medicaid expansion,” Piccirilli said.

He said his board spends about $10 million a year on mental health and substance abuse recovery services for county residents.

The local board coordinates taxpayer-funded mental health and recovery services in Mahoning County and funds the agencies that provide them. These services are paid for by a combination of federal and state tax money, local real-estate tax levy dollars and grants.