I recently saw one of my former patients walking by Ala Moana Beach Park talking to herself, or to the voices she heard in her head.

She was 55 the last time I saw her, living on the streets, never wanting to reveal her exact locale. She hadn’t come to the office in the past three years before that, and did not have a current address.

When she was medicated by her psychiatrist, she would usually go to a shelter, and seem to be okay for a while. But part of her mental illness was so tied to hearing the voices that she would be upset when they were gone, which lead to her frequent relapses into worsening schizophrenia as soon as she stopped taking her medication regularly.

Welcome sign to the Hawaii State Hospital located in Kaneohe. Hawaii. 24 nov 2014. photo Cory Lum

We need more facilities like the Hawaii State Hospital in Kaneohe, where almost all the patients are placed by court order after getting in trouble with the law.

Cory Lum/Civil Beat

She was never a danger to herself or to society, so she wasn’t kept in a mental institution. But that didn’t leave her many options.

She wasn’t able to work, and couldn’t afford to get an apartment on her own. She didn’t have a permanent address, and that made it hard for her to collect her disability income on a regular basis. She didn’t want to stay in a shelter and wasn’t willing or able to follow the rules that were required.

So where could she go?

The days of locking such people up ended when President Ronald Reagan signed the Ominbus Budget Reconciliation Act in 1987 that ended the federal government’s role in the institutionalized care of the mentally ill.

Block grants were given to the states, and the days of the “asylum” were over. Thousands of people were released into society as mental hospitals closed, with the focus on community-based care, rather than institutionalization.

It may have seemed like a more humane way to treat the mentally ill, but was it?

Funding for mental health has not kept up with the demand, and as a result, fewer beds are available for  long-term care. We have not provided the best care for those who need it most.

In Hawaii it is estimated that a third or more of the homeless suffer from mental illness. These people are around for all to see, at the bus stops, downtown walking against the lights pushing shopping carts of all of their worldly belongings, shouting to themselves or others late at night in public places. Still others may suffer in silence, living in the shadows.

Many have been jailed, putting additional burdens on correctional facilities unequipped to handle them.

These are the people that previously would have been housed in mental health facilities. They may not be capable of seeking the help they need, or not know they have an illness that could be treated.

It’s time to bring back the idea of long-term federally funded mental health hospitals where those with serious mental disorders can live out their lives in a safe environment.

The cost would be enormous, but no greater than the current efforts to house the homeless or build new prisons.

Not everyone with a diagnosed mental illness would need to be put in long-term care, but for those who suffer severe disorders, this option is desperately needed.

Hospitals should be built to offload the current burden on the already strained mental health facilities that provide short-term care. With long-term care, acute needs could be provided and those who are able to return to the community can do so safely.

By providing better care either in the new hospitals, or in the current acute care residential settings, crimes would be averted as well, lowering the numbers of mentally ill that end up incarcerated.

The cost would be enormous, but no greater than the current efforts to house the homeless or build new prisons.

Integration with the current psychiatric hospitals would be essential, in an effort to provide a seamless transition of care should individuals need more intensive services.

This is not to say that hospitals that currently care for the mentally ill are not doing their best. Given their resources, places like Kahi Mohala, the Hawaii State Hospital (where practically all the patients are there under court order) and Kekela at Queen’s Medical Center have done incredible jobs with the resources they have. But more needs to be done, and the funding has to be restored at the federal level.

The current model of care may work for some. But walk around downtown, or even Waikiki, and you’ll soon see that better mental health services are desperately needed.

People like my former patient can’t manage on their own, but are left to wander indefinitely because they are not considered dangerous.

It’s time to provide more long-term options.

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