Only Most Severe Cases to Receive Care : County Cuts Treatment for the Mentally Ill

In a continuing policy shift said to be based on a lack of money, San Diego County mental health officials are taking major new steps toward restricting public treatment for mentally ill people, The Times has learned.

Mental health officials this month began telling their contract outpatient clinics to reduce the number of moderately ill patients being counseled and instead make room for more seriously ill persons, who will no longer be treated by county-employed psychiatrists.

Because of what officials say is a lack of funds for the county’s entire public mental health system, the trend ultimately could mean that public care will be available only for the most severely ill patients who need round-the-clock supervision to prevent them from hurting themselves or others.

“You’ve got to take care of the sickest of the sick,” Dr. Harold Mavritte, clinical director for the county’s mental health system, said in an interview. “Those who are less sick will get by on their own resources.”

Mavritte was the prime mover in a decision last year to cut the number of beds at the county’s troubled Hillcrest hospital by one-third, in order to improve patient care by restricting services to fewer people. While that move has resulted in better treatment, according to county and state officials, it has forced patients who previously would have been seen at Hillcrest to either seek hard-to-find care elsewhere or to go without.

Now Mavritte has issued a memo to his staff ordering them to make no new referrals of patients to the county’s extended care program, which is being cut back, and instead to send those patients to the contract clinics. The effect of this decision is that the contract clinics will no longer be able to provide care for hundreds or even thousands of less seriously ill people who have been getting counseling.

The county’s extended care program handles seriously ill patients who, while not needing hospitalization, have chronic problems that must be handled mainly through long-term medication. Many patients discharged from Hillcrest in the past have been sent to the extended care program, where county-employed psychiatrists and nurses see the patients regularly to prescribe medicines and provide brief counseling.

The immediate reason for the memo was an inability of the county to fill several psychiatrist positions for the extended care program, Steve Harmon, assistant deputy director of mental health, said Wednesday.

“They are hard to recruit, and with the need for us to prescribe for and monitor (extended care patients), rather than for us to get into a situation where we don’t have sufficient coverage, we are now making referrals to our (contract) outpatient clinics,” Harmon said.

But in more general terms, he added, “We are going to tell our contract providers (at an Oct. 20 meeting) that they must now emphasize the most chronic, the most acute, the most dangerous, and they can no longer take care of the lady who is afraid to leave her apartment, that she is not one of the priorities.”

The outpatient clinics are not set up mainly to handle such seriously ill patients, according to directors of two major center-city clinics.

“We have had effects throughout our clinics,” said Dr. Stephen R. Shuchter, director of the UC San Diego Gifford Clinic, the county’s largest contractor. “We now are forced to prioritize for those in the category of most disturbed, and we have cut back on the amount of conference services, on the frequency and intensity with which we can treat (all) people.

“We are at the point where the quality of mental health services is diminishing, where we can’t offer services to people we used to offer services to . . . so people with less severe disorders are not being seen.

“We are constantly in flux, on the verge of being overwhelmed, and it is a very stressful system” for employees and patients, Shuchter said.

Arlen Versteeg, director of the Downtown Mental Health Center, said that his clinic already has more moderately ill patients that it can handle under its county contract without the new flood of persons referred from the extended care program.

“We’re trying to fit them in as we can, but that means longer waiting lists and having to adjust the threshold of whom can get into our clinics based on severity,” Versteeg said.

Versteeg said that patients who are not chronically ill will find it more difficult to get treatment. Those people include individuals who suffer depression after the death of a child or other trauma who can be discharged after six months to a year of counseling and support, perhaps augmented with occasional medication.

“And if psychiatrists only see those chronic people in a maintenance state,” Versteeg said, “it takes much of the enjoyment out of their work because a mental health professional generally wants to reverse a pathology through therapies, etc.”

Harmon said that such clinics are going to have to decide what type of care they wish to provide.

“I expect some lively discussion” at the Oct. 20 meeting, he said. “I know some will say that if we don’t treat the lady in the apartment, she will get worse and end up in the hospital anyhow and that we could have prevented that. That’s a good argument, but when you have limited money, and some people are a danger to themselves or others, you have to make hard choices, and the contractors and people who work for them will have to decide whether they want to be part of the public system and do such work.

“In 1986, the reality is that the caseload of patients will have to be the chronic and difficult to handle people, who never will get completely well.”

Mavritte admitted that the situation is not ideal, and that the problem of too high a demand for limited resources puts the county in a terrible bind.

“It’s like running a public health department,” he said. “You’re never going to get anywhere treating all the victims of malaria, you’ve got to eradicate mosquitoes, too.”

But Mavritte said the “mosquito eradication” cannot take place unless more money is provided for county mental health.

“San Diego does not have near enough funds,” Shuchter said. “We have seen a cut in funding in central San Diego of well over 50% for services.”

Shuchter said that county mental health officials should be more outspoken before their bosses, the Board of Supervisors, in demanding better funding. “For the last 10 years, the county (officials) should have been screaming at the board, instead of just accepting whatever the supervisors said,” Shuchter said.

Although the county Board of Supervisors has ordered a reorganization of the health and mental health services, the most recent policy changes have been made by mental health officials without public discussion before the board.