Sidewalk Injections of Antipsychotics — NYTimes

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

sloh

Full Member
15+ Year Member
Joined
Mar 31, 2008
Messages
1,859
Reaction score
2,706

Street psychiatry offers a radical solution: that for the most acutely mentally ill, psychiatric medication given outdoors could be a critical step toward housing. Dr. Rab, a medical director of Los Angeles County’s Homeless Outreach & Mobile Engagement program, describes the system his team has built as an outdoor hospital, or sometimes as a “DoorDash for meds.”

Every weekday morning, 18 teams fan out across the county, making rounds with about 1,700 patients in tents and vehicles and alleyways. The teams try to persuade them to accept medication, sometimes in an injectable form that remains in the bloodstream for weeks. If clients say no, the teams return, sometimes for months, until they say yes; if they still refuse, the team can petition a court to order involuntary treatment.


He understood their caution. Prescribing psychiatric medication on the street often means working without a definitive diagnosis, medical records or laboratory tests. And because clinical trials are conducted in controlled settings, Dr. Jones said, there was no research to support using injectable antipsychotics in a homeless population.

But for Dr. Jones, this was “the perfect setup” for injections, which research suggests sharply reduce the risk of relapse. Six months after receiving her first shot, “less paranoid, less chaotic, less delusional,” the woman had moved into housing and was receiving disability benefits, he said. After that happened a few times, county officials took notice.

“Once we got them on” a long-acting injectable antipsychotic, “we could get them into housing, and once they were in housing, they would cost the county a lot less,” Dr. Jones said. While living on the street, acutely ill patients can cycle in and out of emergency departments scores or even hundreds of times a year, at a cost to the county of $6,000 per visit, county officials said. Over the course of a year, services for one person can add up to more than $1 million.

Dr. Curley Bonds, the chief medical officer of Los Angeles County’s Department of Mental Health, said his confidence had grown as he watched those patients move indoors after accepting treatment on the street. In a field preoccupied with evidence-based practices, he said, there is also room for “practice-based evidence.”


Street teams have been expanding their role in homeless outreach for years, but there is little published research about what they do, so it is difficult to track negative outcomes, or say what works.

This absence of data, critics say, is a red flag in the field of psychiatry, whose history is marked by unproven treatments imposed on vulnerable people without their consent.

Samuel Jain, the senior attorney at Disability Rights California, said he had become aware of the rising use of injectable antipsychotics among homeless people this summer, when street physicians interviewed by the news site CalMatters declared it “an absolute game-changer.”

That claim, he said, “feeds the fiction that if you just take your meds, the societal problem will go away.”


“Fifty years ago, psychiatrists would have found it inhumane to allow their patients to live without shelter,” said Dr. Braslow, a professor of psychiatry at the Columbia University Irving Medical Center.

Dr. Enrico Castillo, an associate professor of clinical psychiatry at U.C.L.A., said he worried that the hundreds of millions of dollars being used to provide street treatment would be better spent building housing. There is, he said, a strong base of evidencesupporting “housing first,” in which individuals receive permanent housing with no strings attached, and treatment is offered thereafter; no such evidence exists for street psychiatry.

“It’s a lot of money being spent before we have evidence,” he said.
 
So they pretty much had me until "practice-based evidence.” I get how in medicine effectively we are forced to do this in practice quite often. But it's not a quip and it shouldn't be an aspiration.

Probably this is a net good for these folks, but that fact is pretty gross, because there ARE other ways to try to manage these patients that is more respectful of rights/consent, safer, more monitoring, and it just isn't being done, so this is what we are left with.
 
I think this is a great idea. People will come up with very beautiful, expensive and undoable plans, but this is simple and although it does not fix the whole problem, it is something. Building great houses for everyone would be beautiful and unreachable.
 
Sometimes the solution is worse than the problem itself? Yes? Over in LA, lots of SNF’s end up taking in these psych patients. Covered by Medicare and surveyors are increasingly accepting of this bc it does save the county more money overall compared to these psych patients recycling through the ER. Institutionalized if you will. Housing, food, shelter, and psych meds all under 1 roof.
 
Probably this is a net good for these folks, but that fact is pretty gross, because there ARE other ways to try to manage these patients that is more respectful of rights/consent, safer, more monitoring, and it just isn't being done, so this is what we are left with.
I mean, it sounds like, with the exception of rare court-ordered treatment, the patients are consenting and being followed frequently. I agree on the other half though--they should be collecting data on the program and outcomes for those who accept and don't accept treatment. It's not something that can be easily/usefully randomized, but it is something that can be studied with some degree of useful data generation.
 
I mean, it sounds like, with the exception of rare court-ordered treatment, the patients are consenting and being followed frequently. I agree on the other half though--they should be collecting data on the program and outcomes for those who accept and don't accept treatment. It's not something that can be easily/usefully randomized, but it is something that can be studied with some degree of useful data generation.
Are they though? I haven't read the article yet but just this blurb makes this whole process seem much more manipulative and paternalistic:

"Every weekday morning, 18 teams fan out across the county, making rounds with about 1,700 patients in tents and vehicles and alleyways. The teams try to persuade them to accept medication, sometimes in an injectable form that remains in the bloodstream for weeks. If clients say no, the teams return, sometimes for months, until they say yes; if they still refuse, the team can petition a court to order involuntary treatment."

I get that there can be a fine line between convincing and coercing, but this really feels like the latter. Sounds like, "we're going to keep coming back until you accept this, and if you don't we'll eventually force it". Reading the initial post makes this feel like a strong argument for reinstating unlocked institutionalization where patients can have a place to stay, a base for these teams where they can ensure patients are compliant with meds they're willing to take, providing social stability until they can have more permanent housing, and frankly ensuring a safer environment for both the patients and staff seeking these people out. Otherwise, how is this any different from ACT teams that already exist?
 
Are they though? I haven't read the article yet but just this blurb makes this whole process seem much more manipulative and paternalistic:

"Every weekday morning, 18 teams fan out across the county, making rounds with about 1,700 patients in tents and vehicles and alleyways. The teams try to persuade them to accept medication, sometimes in an injectable form that remains in the bloodstream for weeks. If clients say no, the teams return, sometimes for months, until they say yes; if they still refuse, the team can petition a court to order involuntary treatment."

I get that there can be a fine line between convincing and coercing, but this really feels like the latter. Sounds like, "we're going to keep coming back until you accept this, and if you don't we'll eventually force it". Reading the initial post makes this feel like a strong argument for reinstating unlocked institutionalization where patients can have a place to stay, a base for these teams where they can ensure patients are compliant with meds they're willing to take, providing social stability until they can have more permanent housing, and frankly ensuring a safer environment for both the patients and staff seeking these people out. Otherwise, how is this any different from ACT teams that already exist?

What’s your stance on unlocked institutionalization?
 
Are they though? I haven't read the article yet but just this blurb makes this whole process seem much more manipulative and paternalistic:

"Every weekday morning, 18 teams fan out across the county, making rounds with about 1,700 patients in tents and vehicles and alleyways. The teams try to persuade them to accept medication, sometimes in an injectable form that remains in the bloodstream for weeks. If clients say no, the teams return, sometimes for months, until they say yes; if they still refuse, the team can petition a court to order involuntary treatment."

I get that there can be a fine line between convincing and coercing, but this really feels like the latter. Sounds like, "we're going to keep coming back until you accept this, and if you don't we'll eventually force it". Reading the initial post makes this feel like a strong argument for reinstating unlocked institutionalization where patients can have a place to stay, a base for these teams where they can ensure patients are compliant with meds they're willing to take, providing social stability until they can have more permanent housing, and frankly ensuring a safer environment for both the patients and staff seeking these people out. Otherwise, how is this any different from ACT teams that already exist?
It sounds to me like ACT teams that are able to do LAI. I understand how the journalist wrote the sentence. They conveniently left out how often they return, which leads the reader to assume daily. They may well come back once a week or once a month. I doubt they're resourced enough to visit thousands of people every single day.

And I already mentioned obviously the court ordered stuff does explicitly become coercive. But the journalist also omitted detail as to who is chosen for that process--again leading the reader to assume it's all patients who refuse after a few months. It's probably a more selected group who the team thinks are seriously impaired and truly in need of treatment.

Let us not forget this is NYT which seems to have some sort of weird bias against psychiatry/psychiatric treatment.
 
Top