Katherine Gluck blurts out to the judge, “I’m guilty.”
Gluck, 47, is charged on this March morning with threatening her former husband with a hammer. Police who arrested her in Burlington, Vermont, know those tired eyes and stringy blond hair. In December, Gluck was charged but not jailed or hospitalized after she slammed a dead raccoon against the front door of City Hall. Her family urged her to get help for her bipolar disorder, which usually involves getting back on medication. She refused.
Now, court-appointed lawyer Sarah Reed hopes Judge Thomas Devine will send Gluck to a hospital. The odds aren’t good. Hurricane Irene wiped out the last state-operated psychiatric beds in Vermont nine months ago.
Since then, private-hospital emergency rooms have been backed up with mentally ill patients -- some handcuffed to ER beds for as long as two days. Dozens of people are turned away each month without being admitted, and calls to Burlington police about mental-health issues increased 32 percent over the prior year.
As the only U.S. state with no government-operated psychiatric beds, Vermont’s experience reflects a growing realization among mental-health experts and advocates that the decades-long trend toward outpatient care has reached its limit -- and public outcry against the latest round of cuts is beginning to change the game.
“It’s gone too far,” said Mark Covall, president of the National Association of Psychiatric Health Systems. Patients with severe schizophrenia or bipolar disorder sometimes need long-term psychiatric care “and that setting is becoming extinct,” he said.
There were 42,385 patients in U.S. state mental hospitals last year, down from 559,000 in 1955. Today, there are 14 state and county psychiatric beds in the U.S. for every 100,000 people. Fifteen experts polled in 2008 by the Arlington, Virginia-based Treatment Advocacy Center recommended at least 50.
In Vermont, Governor Peter Shumlin initially proposed to restore 36 of the 54 beds lost to flooding -- citing the expense of maintaining the beds, in part.
“We have an opportunity to provide community-based care,” Shumlin said last December when he proposed the lower number. “We believe this model will be more affordable for Vermont taxpayers and better quality care.”
A groundswell of opposition from mental-health advocates and patients’ families helped change Shumlin’s mind; the state now plans to restore 45 beds by 2015 -- still just half the U.S. per capita average in a state of 625,471 people. For now, Vermont is contracting with private hospitals to use about 25 beds.
A similar outcry in Alabama forced Governor Robert Bentley, a Republican, to moderate plans to close four state hospitals and displace 524 patients. In Massachusetts, 200 gathered in March at the statehouse to oppose the shutdown of a 169-bed psychiatric facility in Taunton. The same week, a crowd of 300 in Brooklyn, New York, rallied to preserve the 265-bed Kingsboro Psychiatric Center.
“For the first time, there is pushback against closing psychiatric hospitals,” said D.J. Jaffe, executive director of the New York-based Mental Illness Policy Org., a nonprofit policy center.
“There is a direct connection between violence and lack of hospital beds,” Jaffe said. “You can’t stabilize someone who’s psychotic anywhere other than in an inpatient setting.”
A study published in 2009 showed that suicide rates increase when the number of state psychiatric beds decreases. Researchers Jangho Yoon of Oregon State University and Tim A. Bruckner of the University of California, Irvine, studied state-level data from 1982-1998 to find that eliminating one public bed per 100,000 people was associated with an increase of 0.25 suicides each year, provided that community health funding remains constant. If such services increased, suicides could be offset, concluded the study in Health Services Research.
In Vermont, “I think we may see a rise in suicide,” said Robert Pierattini, chief psychiatrist at Fletcher Allen Health Care, a private hospital in Burlington.
States have been cutting back on psychiatric beds since the mid-1950s, when the development of powerful antipsychotics Haldol, Thorazine and others began to allow for less restrictive settings. The recent global recession pushed the process to a new level, said Ted Lutterman, senior researcher with the National Association of State Mental Health Program Directors.
The 3,144 beds lost from 2009 through last year were not eliminated simply by closing units here and there, as had been the case. Entire facilities were shut down to ease budget deficits, Lutterman said.
“It used to be difficult to close a whole hospital,” he said. “That logjam has been broken.”
New Jersey Governor Chris Christie, a Republican, is closing the 310-bed Hagedorn Psychiatric Hospital, which will become a facility for homeless veterans, despite a rally of workers and advocates in 2010. As of April 30, about 62 patients remained in the hospital, which will be empty by the end of June, said Ellen Lovejoy, a spokeswoman for the state Department of Human Services.
“New Jersey has the second-highest rate of institutionalization in America” behind only Texas, Christie said in February, when he proposed the closing in his budget address. “This is a shameful fact.” A portion of the savings from the closing -- about $5.6 million -- would be spent on community-based care for the mentally ill in the fiscal year that begins in July, said Nicole Brossoie, a spokeswoman.
A psychiatric bed costs about $658 per day, and Medicaid, the public health insurance system for the poor and disabled, won’t reimburse larger state facilities. That policy decision dates to the 1960s and was enacted to thwart the creation of larger state hospitals, perceived as grim and punitive, inspirations all for Ken Kesey’s 1962 novel, “One Flew Over the Cuckoo’s Nest.”
In Vermont, the lost beds have left the mental-health system teetering on the edge of disaster. While the state has contracted with private hospitals for about 25 beds, there frequently aren’t enough to go around.
“I worry every day,” Patrick Flood, the state’s mental health commissioner, said in a telephone interview last month. “I have on my screen right now the case of somebody we have to find a bed for tonight and there’s no apparent bed.”
Every Bed Taken
In early January, Tammy Thompson’s 22-year-old son, diagnosed with schizoaffective disorder, went to private Copley Hospital in Morrisville, Vermont, where he was involuntarily committed. Every psychiatric bed in the state was already taken.
“So he stayed in his clothes, handcuffed to an exam bed, all night and all the next day,” she said. “It was horrendous.”
Leah Hollenberger, a Copley spokeswoman, declined to comment on any specific patient’s case. She said the hospital’s emergency department, like others in Vermont, has seen an increase in the number of psychiatric patients who “are extremely violent” or suicidal. Staffers sit with such patients, one on one, at all times, she said. Some patients have made threats, requiring police intervention.
“It is a very difficult situation,” Hollenberger said in an e-mail.
After two days, Thompson’s son was sent to the private Brattleboro Retreat and he’s now home, Thompson said. She asked that her son’s name not be published.
The number of patients held in Vermont emergency rooms for want of a bed has spiked. This year through April, 49 mentally ill patients were held for as long as two days, up from 18 in the same period last year, according to the state Department of Mental Health.
When the state hospital was open, the private Fletcher Allen facility typically turned away about 15 mentally-ill patients a month, said Pierattini, the chief psychiatrist. Just after the closing, that number hit 40 a month. It peaked at 130 early this year, and has since returned to 40 or so this spring, he said.
The hospital simply doesn’t have enough room to meet the need, he said.
State hospitals have “no-reject” beds -- meaning the most difficult patients cannot be turned away. That’s not the case with private hospitals, said Ruth Grant, a retired physician whose son with schizophrenia has been rejected by two private hospitals because he can be unruly and violent.
“The privates pick and choose and that infuriates me,” she said.
In Burlington, Vermont’s largest city with 42,000 people, the impact is showing up on police logs. Calls about mental health issues, which Police Chief Michael Schirling defined as any act with an underlying mental issue, rose 32 percent to 215 calls from October 2011 to March 2012, up from 163 over the same period a year before.
“There’s no question that the closing of the state hospital had a cascade effect” that’s felt on the streets, Schirling said.
Matt Young, 62, who heads a local mental-health outreach effort, is finding more people who need his team’s help. Subsidized by the state and by local merchants, Young and others roam the city’s 19-block commercial district of dress shops, bistros and Ben & Jerry’s Ice Cream parlors, working to keep the mentally ill from landing in jail or the hospital. That might mean steering someone into detox, finding a bed for the night or simply stopping for a friendly chat to soothe overheated emotions.
On a chilly March morning, Young, a former Boston restaurateur, had to make sure a 33-year-old with schizophrenia who’d slept in a local dumpster was on a bus to New Haven, Connecticut, where he came from.
A fiftyish woman with “significant mental health issues,” had been evicted from her apartment and needed a place to live by week’s end, he said. As he discussed his efforts to find her housing -- one landlord had barred her for complaining of “bugs in the walls” before she moved in -- his cell phone rang about another patient.
“Beds that used to go to some of these individuals are now being taken up by the most acutely ill,” Young said.
Mary Hamm, a 45-year-old with schizophrenia, lives alone in St. Albans with round-the-clock caretakers covered by her veterans’ insurance benefits. She was diagnosed when she was in the Army, according to her mother, Barbara. Mary took a turn for the worse in February and had to be hospitalized.
With no beds available at the Veterans Administrations Hospital in White River Junction, she was transported 186 miles to the veterans’ hospital in Bedford, Massachusetts. There, she stayed about a week and returned, her mother said.
“We were pissed off,” said Barbara, 80. “But what are you going to do? It’s the only place they could get her into.”
Vermont officials promise a better way. Shumlin revised his plans after he received assurances from the U.S. Department of Health and Human Services that the state could get a waiver from Medicaid rules against reimbursing facilities with more than 16 beds. The state now plans a 25-bed facility, which will cost $16 million to $20 million; officials hope 90 percent of that amount will come from federal disaster funding, said Flood, the mental health commissioner.
In addition, the state will continue to contract for the use of private beds, 14 at Brattleboro and six at Rutland Regional Medical Center. The 45 total remains nine short of the 54 beds lost to flooding.
To pay for daily operations, the state legislature in March approved a 15 percent increase in mental health spending to $174 million for the fiscal year that begins in July. The increase includes $21 million for enhanced community services designed to offset the need for more beds, Flood said. Those measures include mobile teams to monitor patients at risk, new beds in transitional housing and a central computer to identify available beds around the state at any hour.
Fran Levine, a nurse manager at the old Vermont State Hospital, is skeptical. “They’re promising us magic and roses again, and we know it’s not going to last,” she said.
Wariness about such mental-health funding goes back decades, said Julie Tessler, who directs the Vermont Council of Developmental and Mental Health Services, a trade group.
“The concern is, one governor sets something up and, 10 years later, it’s a memory,” she said.
Back at Katherine Gluck’s arraignment, Judge Devine asks if everyone has seen the psychiatrist’s report.
“I haven’t seen it,” Gluck says. “But why should they show it to me after a long day’s work?”
Devine interrupts. “We don’t want you to say anything that will get you in trouble.”
Gluck is the youngest of five and has had bipolar disorder since she was 16. She graduated from high school and college and went on to become a carpenter. There’ve been “many, many” hospitalizations since, says her sister, Christine. “When she’s stable, she’s a great member of society.”
Vermont’s bed shortage weighs heavily on the proceedings. In the eight months since the state hospital was closed, Gluck’s attorney hasn’t had a mentally-ill defendant get a hospital bed right away. They’re usually sent back to jail to await a bed or released with orders to stay out of trouble. Neither option is acceptable to Gluck’s family, according to Christine.
After conferring with the state prosecutor and Reed, Judge Devine utters his decision in a low voice.
“What did he say?” Gluck asks.
“He’s sending you to Brattleboro Retreat,” Reed tells her.
A single bed has been found, paid for by the state, 117 miles south of Burlington. Her family members will have to take turns making the drive.
The assault charge against her is dropped. After two-and-a-half weeks, Gluck is released from the hospital with conditions. She’ll be monitored for 90 days to make sure she’s taking medication. If she doesn’t comply, the charge could be reinstated.
“I’m doing much better than I was before but I’m on heavy doses of medication,” Gluck said during a telephone interview in May, about a month after her release.
Reed agrees with her client. “She’s actually pretty delightful now, she’s one of the lucky ones.”