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.
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