Virginia’s Continuing Mental Health Crisis

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by James C. Sherlock

I like government at every level to address only things it must. Then I want it to be world class in efficiency and effectiveness. It has been clear since the ’60’s that I am destined to be repeatedly frustrated on both counts.

We come to an old issue in Virginia, the shortage of appropriate treatment options for the mentally ill. The COVID-driven increase in mental illness has brought this issue back front and center.

Why is the Commonwealth so reliably awful when it comes to strategy, management and funding of state health programs? Even under federal court orders in the case of mental health?

Some of that is incompetence, but some is lack of interest — investigations and funding — by our governors and General Assemblies of both parties.

Most of us discovered the shortage in severe mental illness capacity in 2013 when Sen. Creigh Deeds’ son killed himself and injured his father. That incident that was preventable if there had been a psychiatric bed available.

That was not the first time the Commonwealth knew about it. There was that pesky federal investigation and court order.

Remember all of the Virginia government pledges to fix the problem after the Deeds tragedy? Those problems are not only with us still. They are worse.

The Virginia Department of Behavioral Health and Developmental Services (DBHDS) briefing from November 2020 shows how far behind we are. Go to slide 26 and read the rest to see what I mean. We have not yet studied how to go forward on many fronts.

Virginia ducked its responsibilities for decades. It is now trying to play catch up – with federal COVID money.

  • See the breakdown of Virginia’s spending of American Rescue Plan money on mental health by clicking on and opening that category.
  • See also the July 7, 2021 Joint Subcommittee to Study Mental Health Services recommendations for the 2022-24 biennial budget here. We’ll see what Governor Northam’s biennial budget offers in December.

But Virginia continues to shoot behind the rabbit. Way behind.

Background – Virginia’s losses in court. In August 2008, DOJ initiated an investigation of Central Virginia Training Center (CVTC) pursuant to the 1980 Civil Rights of Institutionalized Persons Act (CRIPA).

In April 2010, DOJ notified the Commonwealth that it was expanding its investigation to focus on Virginia’s compliance with the Americans with Disabilities Act (ADA) under the 1999 U.S. Supreme Court Olmstead ruling. The Olmstead decision requires that individuals be served in the most integrated settings appropriate to their needs.

Those issues centered on the treatment of persons institutionalized with severe mental illness.

On January 26, 2012, a Settlement Agreement was reached to address the twin issues. That did not mean we don’t need state mental hospitals. We do. But we need them to be compliant and we need other options.

Implementation of the requirements of the Agreement were projected to take 10 years. Going forward from 2012, Virginia’s mental health facilities and programs  continued to get worse by all applicable performance measures.

Having seen enough, the Justice Department went back to court and Virginia settled again.

In May of 2019, a federal court order tasked the parties to the 2012 Agreement with creating a document system, or “library,” to ensure that the Commonwealth will perform all provisions of the 2012 agreement.That 2019 Settlement Agreement can be found here.

The library of uncompleted actions filed 01/14/2020 contained 84 pages of descriptions of ongoing deficiencies Virginia had promised to fix in the 2012 settlement but had not yet addressed. And those were only CRIPA and ADA issues concerning institutionalization.

The problem is not just in mental health programs and facilities.

In January of this year yet another settlement was reached, this time by the Department of Corrections, in which a mentally ill Portsmouth man was held in solitary confinement for 600 days.

Where are we? Other than needing a better Attorney General — one who monitors the court-ordered settlements to which his office has agreed — where are we in the mental health system?

Virginia suffers at least two major shortages:

  • hospital beds for those with severe mental illness; and
  • mental health professionals for all levels of mental illness.

Treatment facilities for severe mental illness. The Treatment Advocacy Center (TAC) located in Arlington, VA is a go-to national resource for data and policy recommendations for mental health treatment.

To quote TAC,

Psychiatric hospitalization is the treatment option of last resort for individuals with acute or chronic serious mental illness who need intensive, inpatient care – the equivalent of the cardiac ICU for heart patients.

When people in psychiatric distress are uninsured, poor, charged with crimes or meet state criteria for civil commitment because they are violent/ dangerous to themselves or others, publicly supported state psychiatric beds are where they are admitted for treatment.

Even under Olmstead criteria, TAC recommends a minimum of 50 beds per 100,000 people is considered necessary to provide minimally adequate treatment for individuals with severe mental illness. TAC ranks Virginia 49th among the states in beds per capita at 18.2. Information on State facilities is here.

Virginia incarcerates more individuals with severe mental illness than it hospitalizes. In Virginia, the likelihood of incarceration vs. hospitalization for the mentally ill was last measured (TAC) at 3.6 to 1.

Law enforcement executing temporary detention orders (TDOs) is eager to turn people over to mental health facilities with proper security. But the state hospitals don’t have the capacity and most private facilities in Virginia do not have the security.

TAC recommends Virginia

  • Stop eliminating public psychiatric beds;
  • Restore a sufficient number of beds to create access to inpatient care for qualifying individuals in crisis;
  • Make active use of the state’s civil commitment laws to provide more timely treatment to individuals in need of treatment for symptoms of psychiatric crisis and reduce the consequences of non-treatment on them, their families and their communities.

A study of Bureau of Justice Statistics data a few years back indicated that approximately 15% of males and 30% of females booked into local jails had a serious mental illness such as schizophrenia, schizoaffective disorder, or bipolar disorder.

Virginia’s strategy to increase law enforcement diversion to the mental health system is a combination of Crisis Intervention Team Assessment Centers (CITAC) and the creation of new regional receiving centers.

The Commonwealth apparently has no intention to increase state hospital capacity. DBHDS has recommended to fix the state hospitals’ infrastructure and raise pay to add and retain staff for the current beds but not to expand the number of beds.

The 2020 Appropriations Act required a report on the feasibility of expanding the CITAC program. The report is now available.

A primary recommendation was

Establishment of up to five Crisis Receiving Centers, one in each behavioral health region, to provide opportunities to reduce the number of misdemeanants incarcerated with mental illness, reduce the number of psychiatric emergencies waiting in EDs, and provide access to a wider system of care for those in crisis.

Crisis Receiving Centers should contain, at a minimum, basic medical evaluation, immediate access to psychiatry, staffing by peer specialists with lived experience, extensive case management, 23 hour observation, and stabilization.

What happens after 23 hours to people ordered to hospitalization if there are no beds?

The Fredericksburg Free Lance-Star editorialized early this month:

“The new Central State Hospital in Petersburg will have 25 fewer psychiatric beds than the one that’s in use now. The legislature has denied a request for 56 new beds at Catawba State Hospital outside Roanoke. At Eastern State Hospital in Williamsburg, total admissions have doubled in the past four years. Only one facility, Western State in Staunton, has added to its capacity, but those beds won’t be available until hospital workers can be found and hired.”

The state is providing funding to expand bed capacity outside the state system, but the private hospitals where those beds reside aren’t equipped to provide the same kind of long-term care as state facilities, and some private hospitals are reluctant to admit patients with major mental issues.

Thus, we have a plan that calls for more intervention from community services to keep people out of mental hospitals and makes beds in those mental hospitals harder and harder to come by, but the state hasn’t funded outpatient services and other community services solutions sufficiently. So the number of people left stranded in emergency rooms and elsewhere in private hospitals grows.

Private psychiatric hospitals. In 2019, after Medicaid expansion and provider rate increases, the state’s eight private psychiatric hospitals (4 in Hampton Roads plus Falls Church, Leesburg, Petersburg and Bristol) together made only $2.5 million in profits on operating revenue of $172 million.

Of the large facilities only the single HCA facility, the one in Falls Church, made enough profit to justify the investment. The other seven together lost $7 million. Only one (Williamsburg) was non-profit.

That can’t help the prospects for expansion and modification of existing facilities to treat patients under government institutionalization orders. even if they could find the staff to do it.

Virginia law. Information about Virginia law governing behavioral health and developmental services can be found in Section 37.2 of the Code of Virginia. Section 37.2 includes statutes governing the emergency custody, temporary detention and involuntary commitment to treatment of individuals in mental health crisis.

TAC’s critique of Virginia’s laws can be found here.

Community Services Boards. Information about the eight Virginia Community Services Boards can be found here.

Not enough providers. There is a tremendous shortage of behavioral health professionals in the Commonwealth and nationwide. At last count the federal government listed 79 underserved areas in Virginia.

The Virginia Health Care Foundation reports 34% of Virginians live in those communities.

The shortages are particularly troubling in psychiatric-mental health nurse practitioners (Psych NPs) and psychiatrists, those specially trained and licensed to prescribe and manage psychotropic medications, critical to treat many mental health conditions. And, nearly 2/3 of Psych NPs and Psychiatrists nationwide are age 50 or older.

The small number of Psych NPs is particularly compelling. There are only 217 Psych NPs practicing in Virginia; 57% of Virginia localities have no Psych NPs. Psych NPs are concentrated in Northern Virginia, Richmond and Hampton Roads, with other pockets where Virginia’s Psych NP training programs are located (Charlottesville, Radford, Winchester).

The Psych NP specialty is in demand. There are employment opportunities in all sectors (primary care medical practices, university counseling centers, hospitals, Veterans’ Administration, substance abuse programs, public mental health agencies, residential treatment) and in all areas of the state. In February 2021, there were 94 Psych NP job postings in Virginia on (compared to 35 in August 2017).

The salary for Psych NP jobs in Virginia posted on averages $120,364.

So only 217 Psych NPs and 94 openings. This is a dollar-and-lifestyle bidding war, and we are not winning.

Not enough facilities. Not enough providers.

COVID made the medical community re-think telehealth. Virginia is working through new laws to expand access to telepsychiatry  to mitigate the personnel problem, but it won’t eliminate it.

The facilities issues are on us.

I wonder when we will settle with DOJ yet again.