A Spatial Needs Assessment of Indigent Acute Psychiatric Discharges in California

Review of Banta, J., Wiafe, S., Soret, S. & Holzer, C. (2008).  “A Spatial Needs Assessment of Indigent Acute Psychiatric Discharges in California.”  J. Behavioral Health Services and Research, 35(2), 1556 – 3308.

California’s basic mental health law is the Lanterman-Petris-Short Act (the “Act”), Cal. Welfare & Institutions C. §5000 et seq. A person may be designated as “gravely disabled” under the Act if unable to take care of basic personal needs such as food, clothing and shelter.  As a consequence the person may be deprived of various civil liberties and may be forcibly medicated or involuntarily committed.  The Act is enforced on a county-by-county basis.

This article reviews data from various California counties during the period 1999 – 2003 to identify those with a greater relative proportion of indigent psychiatric hospitalizations.  There is a well-established relationship between homelessness and mental illness.  Homelessness increases utilization of public mental health facilities.  Using a (poorly-explained) “geocoding” technique the authors found the rate of indigent acute psychiatric hospitalizations varies significantly by county.  They did not correlate the county-by-county data they developed with each county’s population, which would have yielded a more accurate per capita assessment.  Nor did they offer an explanation for this variance.  Their polemical conclusion was the increase in uninsured psychiatric caseload misapplies scarce economic resources and limits access to psychiatric facilities.  However they also could have concluded the Act is a poor proxy for the actual incidence of mental illness.  A person classified as gravely disabled in one county may elude such classification in another or vice versa.  It is absurd to think the population of one county has greater per capita incidence of mental illness than the population of any other county.  These anomalies suggest political factors rather than epidemiological ones underlie the Act’s implementation and raise fundamental questions about the state-wide consistency of criteria for admission to psychiatric facilities, how these criteria are applied, and whether these disparities present equitable issues.