One in a series of occasional articles

It used to be tough getting out of a state mental hospital. Today, getting in can be just as hard.

The Northern Virginia Mental Health Institute in Fairfax County, a 114-bed facility intended for short-term hospital stays, recently had 31 people on a waiting list to get in, while about 20 were well enough for release but had nowhere to go.

Western State Hospital in Staunton, the state's long-term mental hospital for Northern Virginians, had a waiting list earlier this year of more than a dozen who wanted to commit themselves. Its December ready-for-discharge list has 91 patients, including 63 who have waited for at least a year.

Despite three decades of deinstitutionalization -- a policy meant to move patients out of state hospitals and into community residences -- hospital officials find themselves unable to admit many who need attention or to release some patients eligible for discharge because there are so few neighborhood facilities where patients who need less than full hospital care can stay.

"What's happening is that patients who would have come in voluntarily are getting to the point where they get detained involuntarily" because they deteriorate and attempt suicide or act violently to get attention, said Judith Regner, the Northern Virginia institute's admissions director.

Waiting lists are only one of the challenges facing Western and the institute, the only two public psychiatric institutions for adults in Northern Virginia. The quality of care continues to be complicated by long-familiar problems.

The facilities have serious problems hiring qualified nurses, and the doctors at Western continue to carry heavy caseloads, hospital officials say. Also, the hospitals find themselves confronting security issues and more patients who have abused drugs, while the patients complain of monotony and say they do not receive the attention they think they need.

The Virginia General Assembly next month is expected to consider increased funding for all state mental health facilities. A coalition of advocates for the mentally disabled is pushing a plan, proposed by state mental health officials, to provide an additional $140 million in the next two years for community programs for the mentally ill, the mentally retarded and substance abusers.

Such a large funding increase will be difficult to obtain, they acknowledge, because of competing priorities and budget constraints.

The waiting lists resulting from a lack of community residences have put hospital administrators in a position of pressing for increased funding of community facilities, even ahead of more money for the hospitals.

"Someone can be ready to go, and get all excited about it. If they don't get out, it can cause of setback," said John Beghtol, Western's assistant director for community services. "There simply is not housing {in Northern Virginia} for the chronically mentally ill."

Officials at Western and the institute say that at any given time 15 to 20 percent of the patients could leave if there were a place for them. This would improve staff-to-patient ratios and make way for new patients' care.

On occasion, patients have forced the hospitals to admit them by creating an emergency.

A repeat patient at Western State, for example, recently took an overdose of drugs on the hospital's doorstep to make sure officials would admit him, according to social workers there. The man has lost touch with his family and should be in a supervised apartment, but none is available, they said.

His pattern has been to go to a boarding house and stay on his prescribed medication for a month or so, but then attempt to return to the security and structure of the hospital.

State policies on institutionalization of the mentally ill began to change in the 1950s, spurred by the development of drugs to control mental illness. Community mental health centers were established by federal law in the 1960s, and court cases in the 1970s established the principle that the mentally ill had to be treated in the least restrictive setting possible.

With deinstitutionalization, the state toughened its admission standards, and the huge state facilities grew smaller.

At the peak in 1963, there were 11,561 patients in Virginia's state mental institutions. That number has dropped to about 3,000 and has basically leveled off, state officials said. Western State now has about 650 patients, less than a quarter the number it had 25 years ago.

This dramatic decrease was not accompanied by a corresponding increase in community facilities, however. About half of the patients return to families that are often unable to care for them fully.

As the number of institutionalized patients fell, the staff-to- patient ratio at state hospitals rose, improving care. But officials at Western say they still need more medical staff to provide effective treatment.

Western, which takes patients from Northern Virginia, the Rappahannock area and the Shenandoah Valley, has a $36.5 million annual budget and 1,240 employes on the payroll. This amounts to about 1.9 staff members per patient overall but includes a large number of administrative and maintenance staff members who care for the hospital's buildings and extensive grounds.

In 1955, the ratio was reversed, with 688 employes for 2,785 patients, or about one staff person for every four patients. State officials today acknowledge that the state hospitals then were doing little other than warehousing the patients.

Overall, the institute has fewer staff members per patient than Western, though the institute's ratio of psychiatrists is higher. Currently, 138 of the institute's 173 positions are filled, giving the facility a ratio of about 1.2 staff members for each patient.

Western has 17 psychiatrists carrying a patient caseload now, or about one for every 38 patients, plus eight physicians, according to the hospital. At the institute, the ratio is one psychiatrist for every 16 patients.

Western started an affiliation with the University of Virginia in Charlottesville in 1979, which hospital administrators credit with a vast improvement in medical staff because older, primarily foreign-trained doctors who often did not speak fluent English were replaced.

"The quality of the medical staff, it's much better than it was. I still don't have nearly enough," said Dr. Glenn Yank, Western's medical director.

The public hospitals cannot rival private hospitals in staffing, according to private and public hospital administrators. While it is difficult to make a quantitative comparison, private hospitals are able to spend more and hire more highly trained medical and nursing staffs, they say.

Dominion Hospital, a 158-bed private psychiatric hospital in Falls Church, has 2.4 staff members per patient, most of it direct care. The patients at Dominion have private psychiatrists who go to the hospital to treat them but are not on the hospital staff.

Patients sometimes start at a private facility and are transferred to a public hospital after their insurance coverage runs out. Plans often limit coverage to 30 days of treatment or a lifetime benefits limit of $25,000 to $50,000, which can be used up in a matter of months, according to hospital administrators.

It costs about $57,000 a year to care for each patient at Western, far less than at private hospitals, largely reflecting the difference in staffing ratios.

Dominion Hospital charges an average of $490 a day for adults and $655 a day for adolescents, not including psychiatrist's charges. At Western, the average per day -- reflecting the cost of caring for each patient -- is $157. The cost at the institute is $175 a day.

The institute, which opened in 1968, was supposed to represent a trend toward smaller, regional facilities designed for people needing intensive care for no more than four months. Over time, the differences have faded between it and Western, as the institute has filled up and taken more patients who need longer stays.

About 37 percent of the institute's patients, many of them in their thirties, are substance abusers, which has become "a whopping problem, one we're just starting to get our teeth into," said Dr. Robert E. Strange, the institute's director.

While all state hospitals have difficulty in recruiting and retaining nursing staff, the problem at the institute has reached "crisis" proportions, according to Strange. He said his facility has only about 60 percent of its nursing positions filled, with 18 vacancies for registered nurses. The problem has become so serious that Strange said he fears that the hospital will be found out of compliance with Medicare standards when the facility is reviewed in January.

This could mean decertification and the loss of Medicare funds to the state as well as a loss of prestige for the facility, which could make it even more difficult to attract good staff.

Also, accreditation can influence the hospital's ability hire competent staff.

Western was accredited by the Joint Commission on Accreditation of Hospitals for the first time in January 1986, the first of the four large psychiatric hospitals to receive accreditation. Joint commission accreditation is voluntary but was important to continuing the affiliation with U-Va. as a training facility, administrators said.

The institute first got its accreditation in 1969, less than 18 months after its opening, a tribute to its quality.

Quality of life in the institutions remains one of the most difficult problems. Mental health advocates consider Western the best of the long-term state facilities, the three others being Eastern State Hospital in Williamsburg (founded in 1773, it was the first public mental hospital in America), Southwestern State Hospital in Marion, and Central State Hospital in Petersburg.

A three-hour drive from Northern Virginia in Staunton, Western is made up of 20 low, red-brick buildings on a 300-acre campus. The wards, where patients generally share rooms for two to four people, are clean but still starkly institutional. When not in therapy, patients congregate in lounges, often in front of a television set.

The institute, a one-story complex behind Fairfax Hospital, is a modern building with double rooms painted yellow or green. Each ward has a lounge with a stereo and television, and patients can walk around outside in a garden or recreation area.

As the severity of the patients' illnesses has increased, the institute has reluctantly responded to demands from the community for more security to keep patients from leaving the facility. One of its three wards now is "semilocked," meaning that the doors are locked but no major security precautions are taken, Strange said.

Some families, patients and mental health advocates say that too much of a patient's time at state hospitals is spent sleeping or watching television in large recreation rooms.

"How do I kill my day? Sleeping," said a young Alexandria man at Western. "The majority of the day is spent sitting. There is nothing to do on weekends."

The Virginia Department of Planning and Budget, in a report issued a year ago, pointed to that problem at the state's mental institutions.

"Generally, ward environments observed by the study team reinforced passive, institutionalized behavior . . . . In many instances, the predominant patient behaviors observed on wards were sleeping, television watching, smoking, pacing and arguments between patients," the report stated. It noted that the institute was an exception to this pattern.

Leslie S. Tremaine, Virginia's director of mental health, said her office is reviewing that report to see where inpatient treatment should be improved. "We are well out of the warehousing league," Tremaine said. "We're looking to solidify our commitment to make sure patients have intensive, active treatment."

Next: Community housing for the mentally ill.