New York Times
POSTED: 1:30 a.m. HST, Dec 27, 2012
LAST UPDATED: 1:58 a.m. HST, Dec 27, 2012
NEW YORK » When a young woman in the grip of paranoid delusions threatened a neighbor with a meat cleaver one Saturday last month, the police took her by ambulance to the nearest psychiatric emergency room. Or rather, they took her to Beth Israel Medical Center, the only comprehensive psychiatric ER functioning in Lower Manhattan since Hurricane Sandy shrank and strained New York's mental health resources.
The case was one of 9,548 "emotionally disturbed person" calls that the Police Department answered in November, and one of the 2,848 that resulted in transportation to a hospital, a small increase over a year earlier. But the woman was discharged within hours, to the shock of the mental health professionals who had called the police. It took four more days, and strong protests from her psychiatrist and caseworkers, to get her admitted for two weeks of inpatient treatment, said Tony Lee, who works for Community Access, a nonprofit agency that provides supportive housing to people with mental illness, managing the Lower East Side apartment building where she lives.
Psychiatric hospital admission is always a judgment call. But in the city, according to hospital records and interviews with psychiatrists and veteran advocates of community care, the odds of securing mental health treatment in a crisis have worsened significantly since the hurricane. The storm's surge knocked out several of the city's largest psychiatric hospitals, disrupted outpatient services and flooded scores of coastal nursing homes and "adult homes" where many mentally ill people had found housing of last resort.
One of the most affected hospitals, Beth Israel, recorded a 69 percent spike in psychiatric emergency room cases last month, with its inpatient slots overflowing. Instead of admitting more than one out of three such cases, as it did in November 2011, it admitted only one out of four of the 691 emergency arrivals this November, records show. Capacity was so overtaxed that ambulances had to be diverted to other hospitals 15 times in the month, almost double the rate last year, in periods typically lasting for eight hours, officials said.
Richard Rosenthal, physician in chief of behavioral services for Continuum Health Partners, Beth Israel's parent organization, said he was proud of how much Continuum's hospitals had done to handle psychiatric overflow since storm damage shuttered Bellevue Hospital Center, the city's flagship public hospital; NYU Langone Medical Center; and the Veterans Affairs Hospital. But these days, he said, as he walks on Amsterdam Avenue between Continuum's Roosevelt hospital on West 59th Street and its St. Luke's hospital on West 114th Street, he notices more mentally ill people in the streets than he has seen in years.
"When you have the most vulnerable folks, all you need is one chink in the system and you lose them," Rosenthal said. "Whether they lost their housing, or the outpatient services they usually go to were closed and they were lost to follow-up, they have become disconnected, with predictable results."
Similar patterns are playing out in Brooklyn, where Maimonides Medical Center has been overwhelmed with mental health emergencies from Coney Island ZIP codes since Coney Island Hospital, one of the city's largest acute care psychiatric hospitals, suspended operations, hospital officials said.
"Triage has reached a different level: You have to get sicker to get in," said Dr. Andrew Kolodny, the chairman of psychiatry at Maimonides, citing a 56 percent increase in psychiatric emergency room visits there from Oct. 26 to Dec. 7, compared with the same period last year, and a 24 percent rise in admissions. The increase in admissions was possible only with emergency permission from the state to exceed licensed limits.
"Not only is there decreased capacity, because Bellevue and Coney Island are off line," Kolodny added, "but there's increased demand because the storm or the loss of their residence has been a stressor for mental illness."
The storm battered a mental health system that still relies heavily on private nursing homes and substandard adult homes to house people with mental illness. Such institutions have a sordid history of neglect and exploitation, and the courts have repeatedly found their overuse by the state isolates thousands of people in violation of the Americans With Disabilities Act.
Plans are under way to increase supportive housing — dwellings where mentally ill people can live relatively independently, with support services. But even before Hurricane Sandy, the expansion fell far short of demand.
The storm underscored the fragility of the system. Many disabled evacuees who were sent first to makeshift school shelters lost access to the psychiatric medications that kept their symptoms at bay, Kolodny said. Even those lucky enough to have the drugs they need are at greater risk of relapse as they experience crowded living conditions.
"If they're now sleeping in a gym with 100 people, that can tip them over the edge and start making them really paranoid," he said.
On Staten Island, where the chief of psychiatry at Richmond University Medical Center says psychiatric resources have been stretched to the limit, clergy members report that mentally ill people transferred to a large adult home in New Brighton from one that was washed away in Far Rockaway, Queens, are now showing up at church rectories, begging for socks and underwear.
"It's heartbreaking, because they just found us by chance," said Margaret Moschetto, a missionary at the Church of Assumption-St. Paul in New Brighton. "They were just walking around the neighborhood. They really didn't know where they were."
Ana Marengo, a spokeswoman for the Health and Hospitals Corp., which operates city's public hospitals, would not answer questions about where emotionally disturbed people were being taken for evaluation in the absence of Bellevue and Coney Island, which were not expected to reopen before February. Nor would she say where the city had transferred hundreds of psychiatric patients when the two hospitals were evacuated, or how many outpatients had been lost to follow-up.
Marengo referred inquiries to Samantha Levine, a spokeswoman in the mayor's office, who said in an email, "All the patients evacuated from Bellevue are being cared for at other facilities and new patients are being treated at other hospitals that have expanded capacity to meet the community's needs."
Watchdog groups and legal advocates for the mentally ill — including the Mental Hygiene Legal Service — filled in some of the blanks. Some painted a picture of heroic efforts by the state to help safely relocate patients, including 28 men who had been awaiting criminal arraignment in Bellevue's forensic unit and were transferred to Kirby Forensic Psychiatric Center on Wards Island, and more than 300 chronic patients who were sent from Staten Island's South Beach state mental hospital to Creedmoor in Queens and the Bronx Psychiatric Hospital.
Bellevue psychiatric patients went to private hospitals or to other city hospitals, including Metropolitan in East Harlem and Kings County in Brooklyn, where the psychiatric units are under supervision by federal court monitors after a 2009 settlement that tackled patient neglect, violence and excessive use of restraints.
In the confusion, some patients lost contact with their families and caseworkers. At Community Access, the same case managers who struggled to get hospital treatment for the young woman with the meat cleaver had to hunt for an elderly female tenant who had been taken to Bellevue by police before the storm. Police had picked up the older woman for public urination near a schoolyard. But two weeks after the storm, which knocked out Internet access and telephone service at the apartment building, neither the staff nor her sister could find her.
Dorca Rosa, the elderly woman's case manager, eventually found her at Gracie Square Hospital on the Upper East Side, behind several locked doors.
"I cried when I saw her," Rosa said. "I found her in horrible conditions. She was lying in her own feces, she had a fractured leg and the provider could not explain how her leg was fractured."
Frank Bruno, chief executive of the hospital, said he was unaware of the episode, and in any case could not comment because of patient privacy laws.
Acute psychiatric patients are rarely kept longer than 30 days; those involuntarily committed are released when they no longer pose a danger to themselves or others. The major problem is where to discharge people to make room for the next emergency cases.
"The dominoes start falling backwards," said Yves Ades, 61, a psychologist and the chief operating officer of Services for the UnderServed, which runs 36 supportive housing developments for people with mental illness across the city, including one in the Rockaways that lost 71 units to flooding. "It was always a strained system, but it was functioning. Now, it's breaking."