Homelessness is difficult enough, but when it's compounded by serious mental health issues the result can be an inability to function at even the most basic level.
Sometimes that leads to round-the-clock involuntary hospitalization, and when that happens a state-appointed psychiatric conservator can take over, making critical health care decisions for a person deemed mentally unstable.
But new research conducted in California warns that once a conservatorship is set up, there's a very real risk that a homeless individual will end up stuck in a psychiatric hospital for weeks or months -- far exceeding what's needed and much longer than inpatient care provided to patients who aren't homeless.
The bottom line, according to lead researcher Kristen Choi, is that "our mental health care systems are falling short in meeting the needs of individuals who are homeless at every level." She's assistant professor in the schools of nursing and public health at the University of California, Los Angeles (UCLA).
Taxpayers also pay a hefty price: Choi's team estimates that it costs $767 per day (nearly $280,000 per year) to care for a homeless person on a psychiatric ward in California, compared to less than $14,000 to provide them with year-round housing. Most of the patients in the study were uninsured.
In their research, the UCLA team tracked the progress of nearly 800 Los Angeles residents, aged 18 to 56, who were involuntarily hospitalized within a non-profit "safety net" psychiatric facility sometime between 2016 and 2018.
A little more than half of the patients did have housing and never ended up being placed in a conservatorship. In these cases if they were hospitalized it was typically for less than two weeks, Choi's team found.
But nearly half of admittees to psychiatric care were homeless. Among that group, about one in every seven were placed under a mental health conservatorship, according to the report.
Once that step was taken, these patients often faced "very lengthy hospital stays," averaging about five months, although some went even longer, Choi said.
A mental health conservatorship is "a strict legal process," she added. In California, it's a kind of highly restricted last-resort option, intended for limited durations in order to protect mentally impaired patients for whom "all other treatment options have been exhausted," Choi explained.
"Mental health conservatorships are for individuals who are 'gravely disabled' by serious mental health illness, such as schizophrenia, bipolar disorder, or other mental health disorders," she said. If unable to feed, clothe or house themselves, such patients can be deemed in need of a guardian who can step in to make mental health treatment decisions.
(As such, this arrangement is not to be confused with the much-publicized case of Britney Spears, whose conservatorship was of the financial affairs/probate variety; the pop star never lost her ability to make her own health care decisions.)
Once patients become stable enough, mental health conservatorships are meant to end, with patients shifting from an involuntary psychiatric hospital setting to a voluntary, community-based care model instead.
But housing is crucial to that transition.
"It is difficult, if not impossible, to stabilize mental illness for individuals who do not have their basic needs met, including housing," Choi explained.
And even if psychiatric stability is achieved, all patients face "a very long waitlist for beds at lower levels of care, such as in psychiatric step-down facilities, psychiatric rehabilitation facilities, and group homes," she added.
That means that patients under conservatorship often "have no choice but to wait in the hospital" after stabilization, Choi noted, sometimes for weeks or months.
Too few options
That wait ends up being a particularly heavy burden for homeless patients, given that 14% of the study's homeless patients were placed in a conservatorship compared to just 3% of patients with housing.
Overall, even though homeless admittees to psychiatric care under conservatorships made up just 6% of all the patients in the study, they ended up accounting for more than 40% of the total time spent hospitalized over the study period, the researchers found.
None of this is good for anyone, said Choi. But she believes that "hospitals have few options" when it comes to handling such patients, because there's been so little progress in improving access to either housing or community-based mental health services.
"It is important to note that the vast majority of people experiencing homelessness do not have mental illness," Choi stressed. "Homelessness is ultimately a problem of lack of housing, not lack of mental health care, and we must be cautious to not conflate homelessness and mental illness."
But she believes that "conservatorships are not appropriate or humane for the majority of people with mental illness," homeless or otherwise.
Hoping to address the situation in Los Angeles, Choi said she and her colleagues are linking street-based homeless outreach teams -- such as L.A.'s Homeless Outreach and Mobile Engagement (HOME) program -- with inpatient psychiatric services at facilities such as Gateways Hospital and Mental Health Center.
Housing and health care
The problem isn't confined to California, of course. Alleviating mental illness among the homeless is an uphill battle everywhere, according to child and adolescent psychiatrist Dr. Nicole Kozloff.
"A lack of stable housing makes managing a serious mental illness a near-impossible task," said Kozloff, who is associate director of the Slaight Family Centre for Youth in Transition at the Campbell Family Mental Health Research Institute in Toronto.
In a perfect world, mental health treatment involves psychotherapy appointments, daily medication regimens, bloodwork, and medical check-ups, Kozloff said. But life on the streets is far from a perfect world.
"It is very difficult to maintain this routine if you have to prioritize your basic needs, don't have a private place to store your belongings, (and) can't afford transportation," Kozloff said. "Furthermore, the stress of being homeless can exacerbate existing mental health problems."
Kozloff agreed with Choi that solutions lie in improved access to permanent affordable housing, coupled with a wider availability of "mental health supports geared to a person's needs and choices."
Choi's team published their findings recently in the online issue of Psychiatric Services.
There's more on conservatorships at the Family Caregiver Alliance.
SOURCES: Kristen R. Choi, PhD, RN, assistant professor, school of nursing and UCLA Fielding School of Public Health, department of health policy and management, University of California, Los Angeles; Nicole Kozloff, MD, child and adolescent psychiatrist, clinician scientist, and associate director, Slaight Family Centre for Youth in Transition in the Child, Youth and Emerging Adult Program, Campbell Family Mental Health Research Institute, Toronto, Ontario, Canada; Psychiatric Services, October, 2021