No one's saying Western State Hospital's aged psychiatric wards are shining examples of mental-health care. The 130-year-old, 1,000-bed Lakewood hospital has often been under threat of losing its federal funding, has been repeatedly found in violation of treatment procedures, and had to be told by a court to stop abusing developmentally disabled patients. If anything, its budget should be expanded, says Dr. Richard Ries, a Harborview psychiatrist. "Washington state already hospitalizes fewer psychiatric patients than almost anywhere in the U.S. In King County alone," he says, "we spend a third of what other comparable large urban areas spend on mental health. How much more can you downsize before putting patients and the public at extreme risk?"
But driven by budget cuts, the state once again is downsizing its biggest mental hospital. At least 120 mentally ill patients are being sent to residential settings where, state officials claim, care will be as good or better. But Martha Thiry of Bellevue worries that she has already seen the future of that downsizing plan. When she recently visited her mentally ill brother, a longtime Western patient conditionally released more than a year ago to an Eastside congregate care facility, she had to hold her nose as she entered his room. His long-unchanged linens were filthy, and the room was ripe. It was a scene similar to an earlier visit, she says, when "I pulled back the covers and had the shock of my life. His linens were covered with crawling, slimy black mold." The understaffed home's supervisor, Thiry recalls, said residents were expected to do their own linens, period. Thiry ended up performing the chore herself.
People should "see the level of sedation the clientele are obviously under and what could happen to them if these vulnerable individuals were to fend for themselves," Thiry said last week. "Closing wards at Western will just compound the huge social problems that already exist."
The cutbacks may ultimately affect as many as 150 patients and 212 full-time employees, saving $6 million a year. And so far, so good, says the state. "In May and June, 30 long-term patients who had been in the state hospital 10 years or longer were moved to community settings," notes Andy Toulon, who is overseeing the transitions for the Department of Social and Health Services (DSHS). "And the word we get is they're doing very well, thriving, and are generally much happier than they were in the state hospital."
Yet local officials and mental-health advocates worry that the ward closures planned for this fall and early next year—demanded by Gov. Gary Locke's social-services slashings—will cost more than they save and ultimately leave some patients on the streets. "The initial bastardized plan has been modified repeatedly in the face of criticism from providers and folks like me," says Tom Richardson, state director of the National Alliance for the Mentally Ill (NAMI), whose son is schizophrenic. "But I am not convinced that it will be anything more than a gradual disaster for many of the people."
The mental hospital downsizing plan of past decades essentially dumped the ill on Seattle streets and strained the resources of Harborview Medical Center and the King County Jail—the latter is unofficially the state's second-largest psychiatric hospital. "Whatever the problems were in the past, they'll be compounded as they try to pull this off in the middle of budget cuts," says Dr. Ries. "King County is already pulling funding here, in the middle of its own crunch." Dr. Alonzo Plough, director of Public Health-Seattle & King County, says Western's move will disproportionately affect the Seattle area. "I fully expect this will increase the number of individuals who will face incarceration as a default pathway for mental-heath treatment," he says. Jail health services are already at capacity—an average of 60 psychiatric patients are seen daily.
Though in prior downsizings, patients were essentially plopped into the community and told to take their medication, the difference this time, says DSHS' Toulon, "is we have a much better community infrastructure now." Certified home operators will provide 24-hour care and receive from $140 to $165 per patient per day (the in-hospital cost is more than twice that). Counters Dr. Ries: "No one's lining up at the door to take those contracts. Many of these patients are people who have already failed community living. The money's just not enough to care for them."
That will be tested as the state moves out at least 90 more Western patients in installments, beginning in October (30 from Eastern State in Medical Lake will also be moved). Locke has tried to portray the cuts as humane, but, says Michael Rynes of NAMI Eastside, whose own mentally ill daughter has been living on the streets for three years, "It is most always about cost in this state, rarely about best treatment practices."
At crowded Harborview, Dr. Ries says the move further shrinks the lifeline of the region's mentally ill. "You need facilities like Western to back up the community hospitals, once a patient has flunked the other interventions—medications, aggressive treatment, and the like. At Harborview, we basically clean up the pieces of what's broken out there. There will be more pieces now. Cutting budgets doesn't make problems go away."