Based on a consultant's study that commends Montgomery County's $7 million-a-year commitment to programs for the mentally ill but criticizes its administrative disarray, County Executive Charles Gilchrist says he plans to propose legislation soon to create a cabinet-level Department of Mental Health -- the first such independent county agency in the state.
"We're going to have to face up to what is apparently a serious deficiency" in delivering services and funds intended for the mentally ill, Gilchrist said.
"We have programs in too many departments, a lack of coordination, fragmented funding, and people are suffering as a result of it," Gilchrist said. "We need to go from a passive approach . . . to an outreach system."
Current programs for the mentally ill are divided among three county agencies -- the departments of Health, Social Services and Family Resources -- and overlapping services are administered by other departments as well.
The Mobile Crisis Team, for example, which assists the county police and rescue workers, comes under the Department of Social Services, which also oversees the state-funded group residences and foster homes. Family Resources runs the county hotline and shelters for the homeless, while the Department of Corrections has responsibility for the mentally ill in its custody.
The new department would be staffed primarily by combining these other sections, with an additional five to 20 employes, according to the consultants.
Consolidation of services is "what we've been waiting for, working for, hoping and praying for a very long time," said Dr. Ernest deMoss, president of the Alliance for the Mentally Ill of Montgomery County, an independent lobbying organization.
"You'll hear people in the advocacy movement disparage Montgomery County's mental health 'non-system,'" deMoss said. "This document speaks to unification and integration . . . and I hope the council has the gumption to pass this legislation as quickly as possible."
In the past, according to deMoss, mentally ill patients too often have fallen through the administrative cracks because of the county's failure to follow through on treatment.
You have a guy who comes out of Springfield State Hospital in Sykesville, Md. ; he's given an appointment to go to XYZ mental clinic, he never shows up and nobody goes looking for him," deMoss said. "And that happens to be the guy who's going to wind up on the street somewhere because nobody took the time to get his phone number or his address.
That doesn't speak badly of Montgomery County; that's the way it is in most places," deMoss continued. "In fact, with this study, Montgomery County has taken the initiative to rectify the problem . . . that's the whole meaning of 'outreach.'"
The $65,000 study, commissioned in February to an organization called Health Consulting Inc. of Dallas, reflects the national shift in psychiatric theory away from institutionalization and toward rehabilitation.
Institutionalizing, or what county authorities refer to as warehousing the mentally ill, has been less of a factor in Montgomery County than elsewhere because the county does not own a public hospital, and has relied on local private hospitals for short-term or involuntary care.
Ten years ago, mental health advocates frequently complained of the absence of a central facility for treatment: deMoss says private facilities such as Bethesda's St. Luke's House Inc. had waiting lists of up to three years.
Now, however, county officials think the absence of such an institution may make implementing the study easier because there is "no standing army" of psychiatric patients to assimilate, as one county official put it.
"For years, the hospital was the treatment model," the repository for the disoriented and displaced, according to Harriet Herrman, director of the social services department.
"Psychiatry was geared to the 50-minute hour," the usual length of private therapy sessions, she said. "But that worked best for the highly motivated people who knew they needed help and could afford it. From the government point of view, the place to put them was the hospital."
"Now we want to put them in situations that inhibit them as little as possible," deMoss agreed, "but they still need all the treatment they used to get in institutions."
The county's new policy on the mentally ill may affect a number of other county studies; on the frail elderly, for example, substance abusers and street people. Family Resources director Charles L. Short said the study had disclosed, among other things, that half the homeless in the county's 137-bed shelters have mental problems.
"Now we can look forward to helping people by doing something other than wringing our hands and just opening another shelter in the winter," Short said.
According to the study, using accepted population formulas, Montgomery County could expect at any given time to have 80 to 100 acutely ill persons in crisis who need immediate assistance from public agencies, as many as 1,000 who require daily care, though not institutionalization; and 3,000 more who need treatment and someone at an agency to guide them through the various levels of treatment.
The lack of case management is, in fact, one of the major criticisms leveled by the study.
"These people are expected to wander from one agency to another," deMoss said. "You need housing, you go to one place; day care somewhere else, treatment somebody else. And you've got a guy who can't take care of himself? He needs a case manager to help him through the system."
"These are our kids: For the most part, we are the parents and family and friends of the long-term mentally ill, and we have a stake in this study. I can well afford to take care of my son . . . but when I'm dead and gone I want someone to take care of him, and the others."