Dismemberment of Dane County Mental Health.

Decline in Mental Health Services and destabilization in mental health

Introduction

My intention in writing this blog is to share the experiences that I went through with my son, starting with the first manifestation of his illness and our journey through numerous subsequent episodes. Also to provide commentary as a parent and psychiatrist on issues that these experiences bring up, such as how the diagnostic process works in mental health, how to work with treatment providers and medication issues. My hope is that reading this may be helpful for people with mental health issues and also their families and friends.

Dismemberment of Dane County Mental Health. Decline in Mental Health Services and destabilization in mental health

While this is story is about one particular patient in one particular county, the connections between availability of services and health stability are important to consider more broadly and apply to patients more generally. During Scott Walker's tenure as governor of Wisconsin from 2011 to 2019, significant changes to mental health services were implemented, many of which sparked controversy due to perceived cuts and reallocations in funding. These changes occurred in the broader context of Walker’s efforts to reduce government spending and limit the state’s budget deficit. Early in his administration, there were reductions in funding for community-based mental health programs, which provide critical support for individuals with severe mental illnesses. These cuts strained county-run programs and forced many to reduce services or implement waitlists. Simultaneously, Walker emphasized privatization and sought to shift some mental health services to private providers, which critics argue created gaps in coverage, particularly in rural areas where private providers were less accessible.

Winnebago

Over a period of a couple of years in 2015-2016 Bill had recurrent psychotic episodes and had to be hospitalized. His final state hospital encounter occurred when Bill was hospitalized at a private community hospital but because he was clearly psychotic, with repeated hospitalizations, they decided it would be best to transfer him to a state hospital to facilitate recovery. Winnebago Mental Health Institute was now the only state facility where longer term stays were available for people with psychiatric illness, since Mendota was closed to psychiatric hospitalization except for the criminally mentally ill. It was two hours north of Madison in the middle of the state, away from friends. I was worried about the quality of care since I had no experience with that hospital. When I called I rarely could get Bill on the phone because of the way their phone system was set up. Patients answered the hall phone and didn’t know who Bill was. When I reached staff they were reluctant to provide information about his status in the hospital citing privacy concerns. I decided I would fly up to Madison and stay for a couple of days so that I could visit him during visiting hours. It had the typical state hospital institutional look, with long wards in different wings. I met with his doctor and then with his doctor together with Bill. Asked about events leading to hospitalization Bill insisted “no I was taking all my meds.”

His doctor replied “then how do you explain that you became so ill that you had to be hospitalized and that with the medicine that you are now taking that you are slowly recovering?”

The doctor was foreign trained but had been working in the US for the past decade. He was knowledgeable about medication and seemed able to establish good rapport with Bill. The second day I visited I could see a tiny incremental improvement. I left back for St Louis feeling glad that he was in good hands and would be hospitalized for long enough to stabilize him. I reflected on the reversal from the usual way of seeing things, that state hospitals were inferior whereas private hospitals offered better care. In Bill’s case he clearly needed the longer stay that a state hospital could provide and treatment from a psychiatrist with experience in treating seriously mentally ill.

Short term hospitalizations

There are a number of years that passed between Bill’s accounts of his illness and when he wrote again at the end of his life. Following his release from mandatory medication compliance he remined intermittently compliant with his medication. The mental health care system changed significantly over this period of time. When he needed longer term hospitalization it was no longer available in Madison at Mendota Mental Health Institute, which had been converted to a hospital for the criminally mentally ill. In order to be admitted to Mendota a person had to have had criminal charges brought against them and to be considered dangerous. Thus his hospitalizations were short stays at community hospitals, usually a week or less, other than his one admission to Winnebago State Hospital. Typically he would be admitted and his care would be managed by a resident supervised by an attending physician. It was often quite frustrating to interact with his team. As is always the case with hospitals it was hard to get in touch and hard to get information about what the plan was. For me as a psychiatrist it was frustrating how hard it was to get them to listen to what I had to say. It didn’t seem to matter that I had been through countless illness episodes with Bill and could tell them what his experiences had been with different medications and different doses. Or that I was a tenured professor of psychiatry at a major university. They always wanted to start at a low dose and slowly increase—which meant that at discharge he was still under-dosed, let alone having had sufficient time for the medicine to stabilize him. I tried to be patient. I arranged phone conferences, which helped a little bit but the time in hospital was so short that in the end it didn’t make much difference. He was discharged home to his apartment, still quietly psychotic. It was less common that he was discharged first to a step-down facility than in previous years. The number of transitional beds had decreased and it was harder to get a place there.