By Tom Jackman and Chris L. Jenkins
Washington Post Staff Writers
Friday, December 14, 2007
Gov. Timothy M. Kaine (D) is expected to propose spending more than $40 million today to begin overhauling the state's mental health system, which has come under intense scrutiny since 32 people were killed this year at Virginia Tech by a gunman with a history of psychiatric problems, according to government sources.
Kaine's proposal will closely parallel the recommendations of the independent panel that investigated the April 16 shootings by Seung Hui Cho and will focus primarily on getting people help in crisis situations, the sources said.
The new money will increase the number of "crisis stabilization units" designed to offer brief psychiatric intervention instead of immediate hospitalization. Kaine also is expected to recommend more money to allow local community services boards to provide better monitoring of the mentally ill, including those who have been ordered into outpatient treatment, as Cho was 16 months before the Virginia Tech shootings.
Kaine's proposal will be the first indication of how serious Virginia is about changing its mental health system, advocates say. It is unclear how far he and the legislature will go in changing longstanding policy, such as the state's imminent-danger standard. Judges and magistrates cannot order people into a treatment facility unless they are "an imminent danger to [themselves] or others as a result of mental illness" or so seriously mentally ill as to be substantially unable to care for [themselves]." Virginia is one of only five states that have such a high bar for commitment.
Some experts believe changing the imminent-danger standard could be costly if it results in more people being hospitalized and treated. But states that have abandoned the standard have not seen a substantial rise in costs, officials said. One study of seven states that made the change in the late 1980s found that five had fewer inpatient admissions a year later.
A separate study examining commitment laws around the world, including the United States, found that schizophrenics went without treatment for six months longer in states or countries requiring a "dangerousness" standard.
"The problems of judging dangerousness in mental illness were one of the key points revealed in the inquiry into the Virginia Tech shootings," said Christopher Ryan, a psychiatrist at the University of Sydney in Australia and one of the study's authors. "It would be better if people with these illnesses could receive the treatment they need before dangerousness becomes an issue."
Experts say that mentally ill people often do not recognize that they need help. To be involuntarily committed in Virginia, an initial judgment is made by a magistrate and then a special justice holds a commitment hearing.
Family members of mentally ill patients and mental health workers said Virginia's standard is too strict and results in the denial of treatment for people who need it. Those decisions then reverberate through the mental health chain, participants say, as emergency room doctors and mental health workers try to anticipate how a person will be judged.
Eighteen states have revised their standards since 1999, according to the Treatment Advocacy Center in Arlington County. Maryland amended its criteria for emergency evaluation in 2003 but did not notice a difference in involuntary commitments, an official with the state Department of Health and Mental Hygiene said, and the state does not keep statistics on commitments.
Minnesota deleted the word "imminent" from its law in 2001 and added criteria to prevent "significant psychiatric deterioration." It also didn't see an increase in treatment, state Rep. Mindy Greiling said. Greiling sponsored the legislation changing the criteria but said her state mental health agency opposed the change and has not actively educated people on the new law.
"I haven't noticed that it's being used enough," Greiling said. "It gets quite frustrating."
Utah changed its law in 2003 to remove the "immediate" criterion and allow judges to consider a person's mental history. There was an initial increase in people being ordered to treatment, said Jed Erickson, an associate director of Valley Mental Health in Salt Lake City, but that dropped off. Erickson said the publicity concerning the law's change increased awareness of the issue but didn't affect the mental health system itself.
The problem comes back to money, said Paul S. Appelbaum, a psychiatrist at Columbia University and past president of the American Psychiatric Association. The shortage of psychiatric hospital beds -- the number of beds in Northern Virginia dropped to 196 from 402 from 1990 to 2006 -- plays into the real-life consideration of where to put a person who needs help.
"In the absence of sufficient inpatient resources to meet the likely demand," Appelbaum said, "it doesn't matter how much you loosen the standards for commitment if there are no beds. Clinicians standing at the metaphorical front door have to ratchet up the standards they apply, regardless of the state's law."
So how much will it cost Virginia? The mental health department has not begun its calculations, officials said, but will do so when legislators file bills that require fiscal-impact statements.
The Virginia Supreme Court appointed a commission on mental health law reform that is about to make a series of recommendations to the General Assembly. Commission Chairman Richard J. Bonnie, a law and psychiatry professor at the University of Virginia, said the report will try to assess the costs of changing the commitment standard. He said the commission will recommend spreading the costs over six years.
Phillip A. Hamilton (R-Newport News), chairman of the Health, Welfare and Institutions Committee in the House of Delegates, said that any cost increase incurred by the state will depend on how broad lawmakers make the new standard. He said his committee had not tried to determine what any changes might cost.
"With going to 'substantial likelihood' as a commitment criterion, a case could be made that that broadens the pool [of patients] and therefore you increase the cost," he said. But he added that potential language could also include stipulations that ensure that concrete evidence is presented before someone is committed. "You have to have some evidentiary standard," he said.
Del. Robert Bell (R-Charlottesville) will head a House subcommittee on the commitment standard. He said he recognizes the need for change but also wants the state to be wary of forcing too many unwilling people into treatment. He said there would be costs, and "I don't know any way around it if we're going to keep you safe."