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Milton Miller: L.A.'s Mental Health Woes

July 15, 2001|GALE HOLLAND | Gale Holland is a Los Angeles journalist."There is a crisis each week in mental health. You try to decide which of the impossible crises to tackle first."

Dr. Milton H. Miller, professor of psychiatry and chairman of the department of psychiatry at Harbor-UCLA Medical Center, also deputy medical director of the Los Angeles County Mental Health Department, met in his office with Gale Holland to discuss L.A.'s mental-health-care system. Miller, who is also vice chair of UCLA's Department of Psychiatry and Biobehavioral Sciences, has seen the county's ups and downs over more than 20 years at Harbor-UCLA.

Question: Your hospital's counterpart in East Los Angeles, County-USC Medical Center, was recently in the news because of appalling patient conditions in it's psychiatric emergency room. Are the problems limited to that unit, or are they part of a broader crisis in mental health care?

Answer: They are part of the very big and complex problem in mental health care: We've got a growing population, a growing indigent population, more drug and alcohol use. At the same time, the situation at County-USC has the elements of a tragedy, in the sense that if you look back you can see the coming together of seemingly unconnected forces to create a terrible situation. First and foremost, there was the 1994 Northridge earthquake, which destroyed the psychiatric building there, the largest mental health structure in any of our public hospitals. And then for some years USC has not had a permanent psychiatry chairman, a big loss, because in the mental-health world you need advocacy.

Q: Why hasn't County-USC made an appointment?

A: Well, they have been trying to decide whether a laboratory scientist or a clinician would be the better choice. Also, it's hard to attract a chairperson to a hospital that's been largely destroyed.

Q: Is the problem for indigents that they can't pay for treatment, or does poverty cause mental illness?

A: Trouble comes in twos and threes and fours. The connection between not enough money, no place to stay and mental illness is well established.

Q: It seems like every few years, like clockwork, there's a crisis in a county psychiatric unit or department. What could be done to interrupt that cycle?

A: The cycle is not every two years, the cycle is each week. You try to decide which of the impossible crises totackle first. Do you address the concerns of the group that is picketing a mental-health clinic and saying it represents a danger to children? Or the angry group that claims it is not getting the resources it needs? Do you build community programs or deal with emergency rooms that are jammed?

Q: Why have the problems erupted at County-USC but not at your unit?

A: The USC hospital is situated in the middle of an intense inner-city area. Also, for the past five to six years, the county has evaluated every one of the people who come into the jail system. Of the 180,000 jail visitors, we actively treat 30,000 for psychiatric illness. Half have illness of such magnitude they might as well be hospitalized. Also there is the soft landings program. For the last two years, we have been bringing thousands of mentally ill people leaving the jail into the system for treatment. USC has received a large share of those people.

Q: What order of magnitude does this new jailhouse burden represent for the county?

A: It's as if the lost continent of Atlantis suddenly erupted before us. At least 20% of the people the county treats are from the jail.

Q: Wouldn't it be wiser and more cost-effective to treat people in community settings before they end up hospitalized or jailed?

A: Strong scientific data say if you do what we know should be done for people who are profoundly sick, you can diminish hospitalization by 70% to 80%.

Q: Why aren't we doing it then?

A: We probably start out with about one-third to one-half of the resources it would take to do a reasonable job. Compared with New York or other large metropolitan areas, we have maybe 75% of their resources.

Q: Who, or what, is to blame for that?

A: Funding is largely driven by the governor and Legislature.

Q: And have politicians been supportive?

A: To the amount necessary, absolutely not. But they have been touched and moved and cajoled and pushed by the advocacy of the family movement. Resources for the soft landing program came from the legislature two years ago. The governor is quite involved. So we're not out of the game, but we're not big winners in terms of resources.

Q: Drugs likes Clozaril and Risperdal were said to be giving schizophrenic patients their lives back. But they haven't proved to be the panaceas we hoped for. What happened, and are there new drugs on the horizon?

A: It is a small truth that the new drugs do not automatically bring stunning cures. But the big truth is that the new armament of drugs has helped people in ways that have never been possible before. For a certain number of patients, 10%, the new drugs have meant something approaching a cure, a miracle. For another 25% to 30%, their comfort in the world is greatly enhanced.

Q: And for the other 60%?

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