MHIs still 'safety net' for severely mentally ill, state officials say

Oct. 09--INDEPENDENCE -- In one of the many buildings tucked away on the verdant 276-acre campus of the Iowa Mental Health Institute in Independence, there are two long hallways.

Pacing in each hallway, locked away from the other wards, is a lone psychiatric patient.

Turned away by the justice system and other mental health care providers across the state, these two have ended up where they are because of what Dr. Bhasker Dave, superintendent of the Independence Mental Health Institute, describes as uniquely psychotic behavior.

Resistant to modern-day medications and psychiatric treatments, the two have assaulted staff members and fellow patients enough times to warrant their separation from the general inpatient population.

"In Independence we hardly every use seclusion" or constraints, Dr. Dave said. "Yet there are some patients who cannot be controlled or managed safely without intervention.

"We are the provider of last resort and the safety net for some of the most vulnerable mental ill," Dr. Dave told the Iowa Council on Human Services during its meeting Wednesday.

One patient has assaulted eight staff members and will attack unprovoked if someone so much as glances at him askance.

"He exercises poor frustration and impulse control," Dr. Dave said. "He's easily agitated, has bizarre beliefs and behaviors and acts out without warning or any identifiable cause."

The other patient once struck his favorite residential treatment worker in the face after politely asking for a cup of water.

"He drinks water wherever, whenever." Dr. Dave said. "You have to watch him so he doesn't drink the toilet water. When he takes a bath, he drinks the bath water. He drinks so much water his sodium levels are lowered. So we have to do weekly draws for the sodium."

Each of these patients requires constant observation and supervision by one to two of the institute's staff members. They are extreme cases among a population of extreme cases that no one besides the state's mental health institutes can or wants to deal with.

For the last 10 years, the providers of last resort have been beleaguered by budget cuts, faced with a reduction in psychiatric beds and challenged by a shrinking professional workforce pool.

A changing landscape

There are four mental health institutes in the state besides the facility in Independence: one in Cherokee, one in Clarinda and one in Mount Pleasant.

Built in 1873, the Independence Mental Health Institute serves the residents of 28 counties in Northeast Iowa.

Each institute has different specialties, but all act primarily as providers of inpatient psychiatric care to Iowa's most extreme cases of mental illness. Roughly 80 percent of the patients in Independence are committed into inpatient care by the court system against their will, according to Dr. Dave.

The goal is to rehabilitate a patient in as short a time as possible so they can be discharged back into the community.

Among all four mental health institutes, there are only 139 inpatient beds, about 32 of which are reserved for children, according to Rick Shults, mental health and disability service director for the Iowa Department of Human Services.

That number has been shrinking since the early 2000s, when budget cuts reduced the available inpatient psychiatric beds by about 40 percent statewide.

In Independence, that meant a reduction from 170 beds to 95 and the creation of a waiting list for inpatient services. Then came the recession in 2008. Inpatient psych beds shrank from 95 in Independence to 75.

"The question of how many beds are needed is a dynamic question in relation to the whole service system," Shults said. "We often hear, 'We don't have enough inpatient psychiatric beds,' because that's what we see as the solution to the problem. I'm reminded of the idea that if you have a hammer, every problem is a nail."

A new tool the state has gained over the last two years is the Integrated Health Home program, providing constant health care coordination, medication tracking and peer support services for persons suffering from serious mental illness.

"As these develop, I would expect to see a change in the perceived need for inpatient psychiatric beds," Shults said.

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