In spite of the valiant continuing efforts to improve state mental care in North Carolina, surprisingly the North Carolina Hospital Association has recently weighed in a recent member and openly called the mental health system in North Carolina “broken.” In a January 9th article the small town newspaper, the Laurinburg Exchange, written by J.L. Pate (jpate@civitasmedia.com) entitled : “Mental Health Broken,” a very small newspaper, in a very small town southwest of Fayetteville NC less 100 miles from the Raleigh Durham corridor, reported on the state of mental health deficiencies at apparently a local meeting in Scotland County concerning the bursting needs and demands placed upon small community hospitals in the area.

Mr. Hugh Tilson told state Rep. Garland Pierce of Wagram NC and Ken Goodman of Rockingham NC at a presentation sponsored by the Scotland (County) Health Care System (the local consolidated hospital and clinic system) at its own Dulin (meeting) Center, that, “our behavioral health care system is broken,” and that “the best I can say is that we can learn a lot of good lesson from the state’s system what not to do.” Pretty strong statements for such usually cautions figures and organization.

This statement in context is all the stronger when one realizes North Carolina has been in now over a 14 year effort of overhaul and drastically change the method of service mental health care delivery from a county by county local mental health center (MHC) based system which in large part worked quite well to a largely privatized, larger entity based system. In the new LME” (Local Management Entity) was the new code word to replace MHC, population “service areas,” arbitrarily had to have at least 200,000 citizens. It was conceived in keeping with still in vogue business principles that ‘economies of scale’ would save large amounts of monies. MHC’s were looked on a small and inefficient, and another belief was that each duplicated administrative bodies with ‘too much bodies’ (workers and salaries) in each county. So adjoining counties were clumped together into service areas each with at least 200,000 persons. Administrations and offices in local counties were reduced or closed outright. The joke was in some areas of the state that all that was left for citizens to contact “portals of entry” were solitary pay phone booths that linked straight to the biggest county in each LME’s district that displaced patients could walk up to and call for services, routine or emergent. Behind such waggish humor was the sentiment that the roll out was done hastily, with much to inadequate and poor informing of the MHC patient cohort and the smaller counties in such LMEs were left literally with empty MHC buildings. And for new patients who suddenly had crises or a new depression, or a child with school phobia in September knew not where to go. Further patients all over the state learned that they had to commute to the ‘big city’ in the LME for services. North Carolinians are not Texans who are accustomed and undeterred by driving long distances. [My sister in Houston thinks nothing of driving hundreds of miles within big ol’ Texas to see her daughter]. The scale of the world of the North Carolinian like many non western states is much smaller as are many other states where the world is not so incredibly routinely distant to basic needs and family.

The local painful lesson imparted to the local Scotland County (Laurinburg NC area) was that the burden of caring for the mentally ill would start to fall much more heavily upon the local governments and the nature and location of MH resources were undecided. The article noted that the local hospital had of course already felt the start of the trend that is now a full blown multi-year crisis in the state that is felt all over the country. Local hospital ERs all over this state and all over the country are having to shoulder the acute psychiatric care of the mentally ill. Scotland Memorial Hospital is now in the midst of painfully and expensively re-doing its ER so that it can have an emergency “four bed lockdown unit” for persons with psychiatric needs and crises. As Dr. Doug Nederostek was reported in the article to have said in August of 2014, “We average two to five involuntary commitment patients daily who stay an average of two to five days, limiting acute care space.”

Many years ago I used to consult weekly to a small town a couple of counties north of Laurinburg. Its hospital did not have a psychiatrist nor did the entire county. Many of us faculty psychiatrists at the Depts. of Psychiatry at Duke and UNC-Chapel Hill medical schools were encouraged to do this to help cover areas of the state with no psychiatric services to speak of. The other medical schools at the time, the newly openly East Carolina Brody School of Medicine in Greenville NC (quite eastern NC) and the Wake Forest-Bowman Gray School of Medicine in Winsto-Salem did the very same thing. As well the medical schools worked hard to encourage newly graduated residents in psychiatry to settle in areas of NC without psychiatrists. I recall with great pride over 30 years ago when one of my first supervisees in adult psychiatry elected to set up a practice in the Kannapolis area of NC north of Charlotte and was literally the first psychiatrist there.

To further explain the reason why this sort of issue is now a universal problem, the Scotland Healthcare Service President and CEO Mr. Greg Wood stated to the meeting that first week in January that “the state’s deficiencies in behavioral health care create a growing financial burden on the cost of operating Scotland Memorial Hospital.” This statement would have been much more forgivable and understanding 14 years ago when the state’s reform effort started in 1999-2000, but it is now 2015, over 14 years into this initiative.

I will quote the article’s author’s words that explain this state of persisting disgrace far better than can I:

“Most patients with symptoms of mental illness need specilized and sometimes extended treatment not available at Soctland Memorial, Wood said, whichincurs the additinal problem of having mental health patients occupy beds needed for the vast majority of people suffering from physical illness.

Prior to 2001, the state had 39 local mental health authorities that, along with state-run institutions, provided care to those with mental health and substance abuse problems. In an initial effort at reforming the state’s mental health system, the General Assembly passed a law manding that local mental health agencies stop providing services themselves and act as administrators who coordinated a group of contractors to service clients.

Audit reports documented substandard conditions and poor management in state-run hospital, prompting the state to summarily close many treatment facilities, including the Dorothea Dix Hospital in Raleigh [which serviced the Scotland County area]. In addition, legislators determined that the state wasted millions of dollars, particularly on community support programs that were over-used and poorly monitored. Some contractors who ran group home for local mental health agencies were reportedly unqualified to do so.

Despite the state’s efforts at mental health reform, hospital administrators agree that the problem has only worsened in the last decade. Public policy studies since then have documented the migration of the mentally ill from these shuttered treatment facilities to community hospitals, jails and prisons.”

In my next series of articles, I will write of other states that are having the same problems, largely from the same ill planned causes, explain from a clinician’s viewpoint the causes, and also contest some of the above author’s own explanations that have become woven into the long evolving story/explanation of WHY this happened, why the states have felt the need to undo the MHC system etc. I will also try to weave in a more realistic history of the views of the mentally ill and the state psychiatric hospital system in this country. I will intentionally look at, detail and “story tell” the dark and darkest sides of abuses in the state psychiatric hospitals as they existed for over a hundred years. I will compare those to the manner in which Native Americans were treated especially in the 1800’s and early 1900’s when they too were sequestered away in their own version of sight, out of mind state psychiatric holding pens, the forced migration off their historical tribal lands to the abominable reservations. I will highlight the recent historical interest in the cultural history of the state psychiatric hospitals that have appeared in the form of wonderfully honest and fascinating books in the last several years that help to portray this movement honestly, even handedly without apology in all its positives [and there were some…] and negatives.