Mind over madness

The psychiatrist was mad. Maybe not shouting, spitting mad. But upset, agitated, discontent in a big way.

I didn’t have a couch in my office, so he sat on a chair next to my desk to tell his story. I typed.

“The damn place is run by a bunch of unlicensed pumpkins,” he began. “You can build a state-of-the-art hospital and have every organization in town except the Salvation Army Marching Band asking for a tour, but the place has never opened!”

The state-of-the-art hospital he referred to is the Nevada Mental Health Institute and its new $10 million inpatient hospital. The building was finished months ago, but the halls remain empty. The doctor had already been fired. But he didn’t want me to use his name—he doesn’t want to “burn bridges” in the state, he said.

So I’ll call him Dr. Andy.

“If you really have some cojones, why don’t you ask why the place hasn’t opened?” Dr. Andy demanded.

About six months ago, the new state-funded mental hospital building opened for media tours and plenty of hoo-ha. The hospital itself was supposed to open in early February, but patients still spend their days and nights in the old NMHI building.

But that wasn’t Dr. Andy’s only issue. He said he’d like it if the people in charge of NMHI were licensed psychiatrists. The director of the institute, Dr. Harold Cook, has a doctorate in psychology, but he did not go to medical school and is not licensed to practice psychology in Nevada.

Dr. Andy also worried about plans to release long-time criminally insane patients into the community via the Program for Assertive Community Treatment.

“So this guy comes here to create PACT teams for the criminally insane,” the doctor said. “He picks up the files of seven of our most violent inpatients and says, ‘I’d like to see these patients released.’ He’s probably never opened their files, or he’d see that they are in here because they’re, pardon my French, fucking dangerous.”

He described one such patient.

“The woman will scream—as she’s bashing your head into the pavement repeatedly—'Cracker!’ “

Dr. Andy talked, and my mind reeled. Maybe the doctor’s right—the institute is messed up and the public is in danger. Or maybe he’s just mad.

“Thanks for listening,” he said, standing to leave. “It’s been therapeutic.”

Diagnosing problems
To be fair, one worker complaining about his job does not a story make. But many of Dr. Andy’s claims checked out. And Dr. Andy wasn’t the only NMHI physician to question practices at NMHI—and then lose his job. Another disgruntled psychiatrist had been in touch for weeks. I’ll call him Dr. Ben, because he’d recently received a job opportunity, and he didn’t want to jeopardize it by having his name publicized as an NMHI whistleblower.

Last fall, Dr. Ben circulated a petition complaining about staff turnover and calling for new hiring policies. The majority of the staff psychiatrists signed it. Shortly after presenting the petition, Dr. Ben received word from the administration that his contract, which ended in June, would not be renewed. Later, he was put on administrative leave and barred from returning to NMHI or seeing his patients.

“NMHI functions under a cloud of intimidation with the threat of termination constantly present,” he wrote to the RN&R in November.

Some of NMHI’s troubles are well-documented.

While I was making phone calls, state auditors from the Nevada Legislature released an audit critical of NMHI’s failure to bill Medicare for about $650,000. Auditors were critical of the institute’s lax billing and collection procedures, which were ultimately costing taxpayers.

Other records show that leadership has been a problem at NMHI for years. The year before Harold Cook became director, the Joint Commission for Accreditation of Healthcare Organizations gave NMHI some of the lowest possible scores in medical leadership. In 1998, NMHI bottomed out in the “strategic planning” category, receiving the lowest possible rating. Though the score was upgraded before the end of 1998, it dropped again after a follow-up visit by an accreditation team in 2000.

NMHI’s overall hospital score in 1998, even after adjustments and corrections raised the number, was 81. The score placed the hospital in the lowest 20 percent of the nation’s accredited hospitals. Other local hospitals fared much better. The Veterans Affairs Sierra Nevada Health Care scored 97, Washoe Medical Center scored 96 and Saint Mary’s Regional Medical Center rated 98. All received “accreditation with commendation.” NMHI is still listed with JCAHO as “accreditation with recommendations for improvement.”

NMHI seemed to be ailing. Putting a finger on the exact cause of the illness would be the problem.

It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.”

—Senator Hubert Humphrey, on a plaque in the foyer of the new Hospital, the new, unopened inpatient hospital

Quiet halls
The vaulted ceiling is 38 feet above the floor of the new hospital’s reception area. Our voices echoed in the emptiness, as NMHI Director Harold Cook took photographer David Robert and me on a tour of the new facility.

In September, many members of the media toured the building. In January, not much had changed. Desks wrapped in plastic are still stacked in one lounge area. It won’t be ready for months.

“We’re looking at May,” Cook said, citing furniture orders from Prison Industries that seem to be holding up the process. “You know how these things go.”

To get to the new building, we’d walked past the inpatient hospital still in use, stopping to read the “AWOL risk” sign on the door of 8 North, the acute unit, where patients are held on an involuntary basis.

The older hospital has 72 beds. During any given month, an average of 50 patients are treated there. The average length of stay is 15 days. In its 1999 session, the Nevada Legislature funded $10 million for the new 90-bed hospital. Construction began in October 1999. It was finished less than a year later, months ahead of schedule, Cook said.

Before the building can be opened, it has to be approved by state authorities. If any details don’t pass muster, the opening can be held off even longer. Even if approved by state inspectors, only about half the hospital will actually open—one 40-bed pod and the Psychiatric Emergency Service unit with its 10-bed pod. A second 40-bed pod isn’t scheduled to open any time in the near future. Cook wouldn’t specify when the unit might be open, though some staff may use the area for office space.

Cook said that money is not a problem. Nor is a lack of staff. Except for a medical director to run the hospital—two medical directors quit in 2000—the staff for the facility already exists. Cook said they’re eager to move into the new hospital. Others back him up.

“We’re just finalized ordering furniture,” said Carlos Brandenburg, the head of Nevada’s Division of Mental Health & Development, who is also Cook’s boss. “We’re waiting on Prison Industries and private vendors.”

“My understanding is that they’re just waiting for furniture,” said Sen. Randolph Townsend, R-Reno, whose support for the new hospital helped win state legislative approval for the project.

“We have really picky staff here,” Cook joked. “They demand a place to sit.”

But a Reno advocate for the mentally ill refuses to check “new hospital” off the to-do list for the state. Elizabeth Francis handles grants and legislative matters for the National Alliance for the Mentally Ill of Northern Nevada and is a member of the Community Unity Coalition. She testified at past sessions of the Nevada Legislature in support of three improvements to the mental health system: a hospital that’s not antiquated, state-of-the-art medication and the establishment of working conditions at NMHI that would attract qualified, professional doctors—and encourage them to stay.

The first and third goals remain essentially unmet.

“The new hospital is standing, but it’s unused,” Francis said. Efforts to do more “community-based” services are needed, she said, but they need to be integrated with the hospital project.

And doing more community outreach to the mentally ill doesn’t “invalidate the concern to get the hospital running,” Francis said.

“The services [the new hospital] offers are critical to the needs of the mentally ill in Nevada.”

Unlicensed leader
As a college student, Harold Cook toured NMHI in 1972. Things were different then, he said. He’s proud of the changes.

“Hundreds of people were locked up in these buildings,” he said, gesturing across the NMHI campus. “It looked pretty bad. People were warehoused, locked in behind bars, sitting in their own feces and urine.”

A call to the Nevada Board of Medical Examiners confirmed that Cook doesn’t have a license to practice psychology in Nevada.

Cook’s own background isn’t in mental health, but in mental retardation. Before coming to NMHI in 1999, he spent 11 years as director of the Sierra Development Center, which works with developmentally disabled children. Cook’s doctorate in psychology doesn’t impress some psychiatrists, who’ve gone the extra grueling mile of medical school but work under him. Psychiatric hospitals need to be run by psychiatrists, Dr. Ben said.

Brandenburg disagreed.

“Licensure or certification has nothing to do with being able to administrate a program,” Brandenburg said during a phone interview. “The issues of productivity, maximizing resources, handling the budget and developing a service that is community-friendly, those don’t require a license.”

When discussing the 1998 accreditation, Brandenburg said the institute “passed with flying colors.” He said he didn’t know about receiving a score of 81 or the accreditation breakdown available to the public on the JCAHO Web site.

“I don’t think they give out a score,” he said.

“I have the report printed out and sitting in front of me,” I said.

“Then you know more than I do about that.”

Dr. Ben charged that Cook’s lack of psychiatric knowledge has led to the loss of six psychiatrists and two medical directors last year.

Francis won’t comment on the qualifications of specific individuals at NMHI. She sums up her view carefully:

“Leadership should be medically driven. And dedicated to the well-being of clients.”

Rent-a-docs
Young people studying to be psychiatrists at the University of Nevada, Reno, seem to enjoy residencies at NMHI, said Ole Theinhaus, chair of the Department of Psychiatry.

“It’s one of our favorite places for students to learn treatment and the nature of the clinic environment,” Theinhaus said. “There’s a variety of patients and settings—inpatient, outpatient, emergency room—they get the whole gamut.”

In fact, he’s so impressed with the facility, Theinhaus said, that he wouldn’t hesitate to send a family member there, or go there himself, if the need arose.

But even Theinhaus was bugged by staff problems.

“I have been worried about their physician coverage and the number of ‘locum tenens’ doctors they rely on,” he said. “That’s a function of how unable they are to hire and retain good psychiatrists.”

Staff psychiatrists at NMHI are furious over the proliferation of part-time psychiatrists working flexible schedules on a temporary basis. These critics replace the official term “locum tenens” doctors with the label “rent-a-docs.”

They believe the temporary nature of part-time psychiatrists, many of whom are retired and looking to pull in some extra income, doesn’t lend itself to quality care in a hospital like NMHI, which cares for some of Nevada’s sickest patients. Patients shouldn’t have to frequently see different doctors, who aren’t familiar with their cases. They should have a chance to develop a relationship with their therapist.

“They should not have [locum tenens doctors] at all,” Theinhaus said. “And the fact that they do shows something is wrong.”

Cook said he sees nothing essentially wrong with locum tenens doctors. While he agrees that staff psychiatrists are ideal, many “rent-a-docs"—he uses my word as he smiles—are qualified, experienced and enjoy getting the work.

Money troubles
The billing troubles, especially $650,000 in funds that could have been collected from Medicare, are another symptom of what Theinhaus said he sees as a larger problem.

“That is an incredible deficiency,” Theinhaus said. “They [receive most of their] money from the state Legislature. No privately run hospital would get away with it.”

An audit published by the Nevada Legislature in December shows that costs have gone up at NMHI each of the past three years. In 1997, NMHI spent less than $13 million. In 1998, more than $14 million was spent. In 1999, the figure rose to $15.5 million. Most of that money, 80 percent, came out of the state’s general fund.

During the same time, the amount of money NMHI has been collecting from outside sources, such as Medicare, has decreased. NMHI failed to collect some $650,000 that was billable from Medicare, the audit reported. Auditors attributed the mistake to a weak accounts-receivable process and a limited understanding of Medicare hospital reimbursement rules. NMHI also wasn’t charging clients based on their ability to pay.

Townsend, though also a big supporter of NMHI’s many programs, doesn’t have much sympathy for financial oversights.

“That’s because I’m a car guy,” Townsend said from his office at an automobile dealership. “If I don’t get your money, you don’t get your car.”

Brandenburg and Cook both say the $650,000 in uncollected Medicare claims can be recovered.

“The business people said we’ve not lost that,” Brandenburg said. “I reported that to the Legislature last week. We have a period of time [in which to make claims] with Medicare. We can get that [money] back over a period of three or four years.”

One of the biggest struggles, Brandenburg said, is getting psychiatrists to bill for their services. Recent efforts to maximize resources have forced administrators, he said, to take a new look at the institute’s state employee culture.

“They say, ‘I work for the state. Why should I be billing patients?’ “ Brandenburg said. “That was part of the mentality of the old culture. But we need to bill. There’s not a horn of plenty out there. … Running a psychiatric hospital is like running a business.”

Brandenburg said that even patients with insurance or Medicare are not often billed by the psychiatrists. And for lower-income patients, sliding scale fees and payment plans are being implemented.

“You, as a taxpayer, want to make sure people who can afford services … actually receive a bill,” Brandenburg said.

Patience, patients
Instead of my office, I first met Dr. Ben at a casino. He told his story.

He had worked as a psychiatrist in California. He came to Reno last spring. He applied at NMHI, he said, because he was attracted to the area. He loves to ski and play 21 at local casinos.

Though most psychiatrists don’t covet jobs at state hospitals, the NMHI position came with a university role.

“It’s been a dream of mine to teach in medical school,” he said.

The hospital job turned out to be worse than he could have imagined. He was scheduled to see 24 patients a day. That’s three an hour, barely enough time to open a file and review a patient’s history, he said, let alone assess a patient’s present state and make any changes or adjustments in medications. A copy of the doctor’s schedule, minus the names of actual patients, confirmed that Dr. Ben saw three patients an hour. Two patients received 15 minutes of care. A third received 30 minutes.

“NMHI gets the sickest people in town,” he said. “These are social drifters. Some can’t work, can’t even manage payments on the Social Security they get.”

Brandenburg defended the hospitals’ new policies, which have been in place for several months. In his view, doctors had been coasting at NMHI for years, spending an hour with each patient and taking 90-minute lunch breaks.

“I need to hold [doctors] accountable,” he said. “We expect them to see so many folks a day, and if there’s a cancellation, we ask them to see walk-in clients.”

The physicians are upset, Brandenburg said, because they’re caught up in “the old days and can’t get used to the newer paradigm.”

“I’d be less than candid with you if I said there hasn’t been some resistance,” Brandenburg said.

In fact, in the past month, the institute made a further change, giving the psychiatrists instructions to triage patients, assess their condition and send them for therapy to social workers, psychologists and nurses.

Dr. Ben called this unprofessional.

Brandenburg raved over the benefits. Psychiatrists won’t be wasted doing run-of-the-mill therapy when they could be spending their time tracking patients’ medications.

“It doesn’t make a whole lot of sense to have the psychiatrists doing therapy when they’re the only ones who can do medications,” Brandenburg said.

Inconsistency of care is another complaint shared by psychiatrists and local mental-health advocates. Dr. Ben told of one woman who came in for treatment. As she left, she asked if she could see him again for her next appointment.

“She said she’d been here four times and had seen four different doctors,” he said. “That’s 50 years behind the times. It shouldn’t be that, every time, you see a different doctor who doesn’t know your history. And who has only 15 minutes to find it out, mind you. It cannot be done.”

Brandenburg agreed that continuity of care has been a problem.

“One of the biggest criticisms I’d get is, ‘Carlos, I’m seeing five or six doctors,’ “ Brandenburg said. “That’s not good. It develops fragmentation. Dr. Cook is developing a change in outpatient services so that patients are seen in a more timely manner and see the same doctor.”

Doctors, what doctors?
Plans to provide continuity of care sound good. But for patients to see the same doctor first requires that NMHI be able to recruit and keep staff psychiatrists. It’s not looking too good. Nevada doesn’t pay its doctors as much as other Western states, say advocacy groups who’ve done wage comparisons. But even if doctors do come here, keeping them here is another challenge.

That’s why Dr. Ben circulated the petition asking for change. The petition noted that NMHI had lost six psychiatrists in six months, that the institute had gone through 25 medical directors in 20 years and was having trouble recruiting new psychiatrists. Perhaps, Dr. Ben wrote in the petition, if the medical director were also a vice chairman in UNR’s Department of Psychiatry, it would be easier to attract a qualified professional to the job. Then, under excellent leadership, other psychiatrists might be recruited for staff positions.

Seven others signed the petition, including a majority of the staff psychiatrists.

In November, Dr. Ben received the memo from Cook telling him his contract wouldn’t be renewed.

“I was told, ‘You’ve annoyed a lot of people. You don’t fit in,'” he said.

Cook said he couldn’t address Dr. Ben’s situation, as it is a personnel issue.

“You have one side of the story,” he said. “But I’m forbidden to tell you my side of the story.”

When patients found out that Dr. Ben would be leaving, they circulated a petition of their own in support of their doctor. Thirty-nine patients signed the document, which called the doctor a “well-liked and trusted member of the staff.” The patients’ petition stated that the loss of the doctor “could be detrimental to clients, a great loss in treatment and recovery.”

Cook said he’ll meet with the patients and listen to their concerns. But he couldn’t say whether anything might come of their input.

At least twice, I asked Dr. Ben if he knew any patients who’d like to chat about the care they’d received at NMHI. He repeatedly told me that giving me a patient’s name would be a breach of confidentiality. Finally, he told me that the woman in charge of circulating the petition defending Dr. Ben had requested that I call her or stop by for a visit.

But when I came by during visiting hours one Sunday afternoon, a nurse paged Cook. Cook came out and told me I could see patients only if they asked to see me. I told him Dr. Ben’s patient had asked to see me and that Dr. Ben had only given me her first name. Cook said that Dr. Ben’s patient was no longer at NMHI. He took a handful of my business cards, he said, to pass out to patients who might want to talk to me.

No patients ever called.

The next day, Cook placed Dr. Ben on administrative leave on allegations of “breach of client confidentiality.” Dr. Ben was ordered to “refrain from having contact with clients and employees of this facility” for having “divulged the name of a current patient to a newspaper reporter who attempted to interview the patient in the hospital.”

Road to recovery
Yes, Dr. Andy’s concern about releasing long-time patients with violent pasts into the community had me worried. Meeting Joe Tyler, a NMHI peer counselor, alleviated much of my fear.

Tyler called himself “blessed.”

“I may have had hallucinations and heard things in my head,” he said. “At one point, I thought I was Jesus Christ walking under the stars going to Bethlehem. And the next day, I wanted to commit suicide.”

Tyler, president of the National Alliance for the Mentally Ill’s Northern Nevada chapter, was in and out of the hospital for 12 years. Though most of his hospitalizations were at the VA hospital, at one time doctors feared a violent outbreak and brought him to NMHI.

Now, after years of therapy and medication adjustments, Tyler works at NMHI. He’s worked there for about two months. Tyler also leads NAMI support groups and has his own SNCAT television show, Erasing the Stigma, which airs at 7 p.m. Thursdays on Channel 16.

Tyler introduced me to mutan white tea during an interview at his NMHI office.

“White tea is full of antioxidants,” Tyler told me, adding some leaves to the infusion basket in a mug. “It’s much better than coffee, really.”

Before I came, Tyler approved my visit with his boss, Harold Cook. And Tyler doesn’t have a lot to say about the staff and administration at NMHI.

“The staff here really cares,” he said. “There are a lot of caring individuals here. We give a lot more than our jobs.”

Tyler spent time in the army and received his master’s degree in public health during the period of his life he calls BMBD—"before my brain disorder.”

His breakdown came during a time when he was driving back and forth between a job in Los Angeles and a home in Reno. He talks of a time when he “thought Nagasaki went off” in his head and went streaking through the neighborhood. He quotes a poem he wrote:

“Seeing unreal scary things, being outside one’s own beings,

Having a time-warped reality, and nonsensical proclivity,

Words racing through my mind so fast I can’t unwind—

Recovery seemed distant, impossible, resistant.”

Tyler hasn’t returned to the hospital for nearly eight years. He credits therapy and a new medication, Risperdal, an atypical anti-psychotic that, for once, doesn’t make him tired.

“Thorazine, Haldol … all those terrible medications sedated you,” he said. “I was tired for 12 years. … I wouldn’t feel like a human being. I’d take my meds as early as I could at night, but I’d still be wiped out in the morning.

“Now I practically bounce out of bed,” he said, stirring honey into his mug. “It’s like the fog has lifted. And the tea doesn’t hurt, either.”

A hospital without walls
Tyler’s story encouraged me. But even Tyler acknowledged that not all patients are as lucky or as strong-willed as he is.

Brandenburg said he believes that even the most chronically ill person at NMHI, even the criminally insane, could be in the community and remain stable through the PACT program.

“You hear people in the community saying, ‘This person needs to be kept in the hospital forever,'” he said. “Nobody needs to be kept in the hospital forever.”

The PACT program allows individuals to live in the “least restrictive environment” as recently dictated by the passage of the Olmstead Act. Teams consisting of a psychiatrist, psychologist, case managers, nurses, a vocational rehabilitation counselor and a social worker offer therapy, job training and medication monitoring through home visits.

It’s called a “hospital without walls.”

It costs about $1 million to set up a PACT team. But the program ends up costing 70 percent less than hospitalization or incarceration and can help reduce chronic homelessness.

But even supporters of PACT, like Francis, don’t want to see NMHI begin to rely too much on community-based services.

“It’s great, but it can only serve a very few,” said Francis, a member of the Community Unity Coalition.

Francis said that the public attachment to the PACT program needs to be balanced with support for other critical components of a strong mental health system.

Francis is one of several pushing for a mental health court in Washoe County. The court would provide a full array of mental health services to eligible defendants, many of whom have been “in and out of jails and hospitals for years,” according to a Community Unity Coalition position paper.

Such a court would be served well by a mental health institute that strove “for excellence and nothing less,” Francis said.

Change
State legislators say they’re betting that the opening of the new hospital will usher in an era of change for NMHI. And the recent hiring of Dr. David Rosen, a former NMHI medical director and psychiatrist, as the Nevada Mental Health Division’s statewide medical director bodes well for change, said Assemblywoman Sheila Leslie, D-Reno.

“I have a lot of confidence in Dr. Rosen,” Leslie said. “I still think that it’s been very difficult to recruit and retain psychiatrists—that’s just an unfortunate reality.”

If the state legislature approves Gov. Guinn’s proposed $2 million budget increase for NMHI, Cook said the money will go a long way to keeping the institute staffed. Pay raises for state workers would also help the facility compete for qualified employees.

The paradox of the NMHI problem, Dr. Ben said, is that the institute will eventually have one of the nicest facilities in the nation. But a building by itself won’t do much to help those in need.

“As far as I’m concerned, give me an old house with a properly trained staff—caring, competent people who know what they’re doing," he said. "Nobody remembers the building. They remember the nurse or doctor who cared for them."