A soft-spoken homeless woman who primarily stays in Honolulu’s Chinatown calmly welcomed the second dose of her medication from Dr. Chad Koyanagi, a psychiatrist with the Institute for Human Services.

The 59-year-old has been homeless for at least a decade, and the story she tells about herself changes frequently. On this Thursday afternoon, she says she grew up across the street from Hell’s Kitchen, a neighborhood in New York, and graduated from Kaimuki High School.

But she very clearly recalls the name of the medication Koyanagi gives her: Invega Sustenna, an injection used to treat schizophrenia.

Koyanagi, David Warman, an IHS program coordinator, and his assistant, Shona Cobb, have been providing outpatient medical treatment for a little over a year, as part of IHS’ Outreach Navigation Program, which has seen increasing success after recent changes to state laws.

Psychiatrist Dr. Chad Koyanagi gives Cynthia an injection in Maunakea Marketplace. Dr. Koyanagi worked with IHS Outreach Navigation Coordinator David Warman and Shona Cobb to track down patients that needed medicine.
Psychiatrist Dr. Chad Koyanagi gives an injection to a woman in Maunakea Marketplace after he and the outreach team spent almost an hour searching for her. Cory Lum/Civil Beat/2022

Last week, Civil Beat joined the outreach team at IHS, a local nonprofit working toward ending and preventing homelessness, to observe their work.

“Does it help with depression?” the woman asked. She explained that she felt sad because her purse was recently stolen and that she’s been dealing with lice for months and doesn’t want to lose her hair.

Typically, the medical treatment provided is in the form of an extended-release injection, such as Invega, and while it doesn’t help depression, it does suppress psychotic symptoms.

There are about 12 different kinds of injections, and Koyanagi said it can take weeks and sometimes months to diagnose an individual to provide them with the correct type. Though one of the biggest challenges after is locating people when it’s time for their next injection.

Other than variations of Invega, Abilify Maintena, which is used to treat bipolar disorder, is the most commonly prescribed.

IHS Assistant Outreach Navigation Program Coordinator Shona Cobb assists David Warman in cases along with Psychiatrist Dr. Chad Koyanagi MD in administering medicines to homeless with mental health concerns.
IHS Assistant Outreach Navigation Program Coordinator Shona Cobb, who experienced both substance abuse and homelessness for several years in the past, feels a duty to help others who are now in that position. Cory Lum/Civil Beat/2022

There are three pathways for people to get medication through the program. Some accept treatment without involvement of a court. Over two years, seven people were helped through this method, but that increased to 23 in the last 14 months.

The second route, guardianship, usually involves a family member or a public guardian if the person has no relatives or friends able to step in.

The last resort, Assisted Community Treatment, is for those whose mental illness or substance use disorders impair cognitive function, leading them to refuse treatment, which results in IHS stepping in to advocate in court for doctor-prescribed treatment management.

Warman, Cobb and Koyanagi work as a team to build trust with each person, as court involvement can delay people getting help and is more costly.

His status as a psychiatrist, Koyanagi said, allows the team to conduct assessments, provide treatment on the spot and do more technically involved referrals.

Each of the three has their own qualifications for the work. Warman was a special education teacher for over two decades, and Cobb experienced homelessness both as a child living on the beach with her mother on the Big Island and at least six times as an adult.

“That’s why I do what I do. I connect so much with all the people I meet and it breaks my heart every time I leave them,” Cobb said. “There are so many barriers … everything is a revolving door and I wish there were more resources for them. I wish I could do more.”

Koyanagi, who has been a psychiatrist for over 20 years and with IHS for 12 years, started working with homeless people at the beginning of his career at Kalihi-Palama Health Center.

“I’ve known some of these people for years and years,” Koyanagi said. “I have a soft spot for them because they go the longest without getting any help, and they quietly wither away, faster, year after year.”

IHS Outreach Navigation Program Coordinator David Warman, Dr. Chad Koyanagi and right, IHS Assistant Outreach Navigation Program Coordinator Shona Cobb stop to assist a man that said he felt sick and needed help.
IHS Outreach Navigation Program Coordinator David Warman, left, Dr. Chad Koyanagi, center, and IHS Assistant Outreach Navigation Program Coordinator Shona Cobb stop to assist a man who said he felt sick and needed help. Cory Lum/Civil Beat/2022

In the last 14 months, IHS has been better able to reach people as the result of a change in Hawaii’s Assisted Community Treatment law in 2019, which lets a judge order an individual to receive outpatient mental health treatment.

Previously, people who were facing ACT petitions were provided a public defender if they refused treatment. The change in state law replaced public defenders with court-appointed guardians ad litem last year. Unlike a public defender, a GAL is not legally obligated to advocate for what their clients want. Instead, they determine and advocate for what’s in the client’s best interest.

IHS Executive Director Connie Mitchell said the decision to petition for guardianship or an ACT hinges on the person’s vulnerability and whether they have a medical condition causing them to deteriorate rapidly.

Mitchell said since the change in the law in 2021, IHS was granted nine guardianships and nine ACTs in a little over a year. In the first two years of its outreach program, IHS was only granted six guardianships and six ACTs.

The most recent annual census of people experiencing homelessness counted almost 6,000 in the state, with almost 4,000 on Oahu. IHS is the largest homeless shelter operator in the state, with 420 emergency shelter beds spread across multiple shelters. Currently, five of the 18 people under court orders for ACT or guardianship are housed in its shelters.

Warman said despite being granted nine ACTs, which legally allows the provision of medication in a hospital to an individual who refuses it, IHS has never had to “hold someone down and force them to accept medical treatment.”

Mitchell, who previously served as the director of nursing at the Hawaii State Hospital and led the largest department in a 178-bed state psychiatric hospital, said she wishes IHS could help people faster. A main cause of delays, she said, is that ACT cases require a judge to weigh evidence to make the decision, which can take months.

“I think as a clinician, I wish that it was a clinical decision, not necessarily a decision that had to be legally made by a judge,” Mitchell said, adding that she understands some people have concerns about civil rights being violated.

“We don’t want to make it easy for somebody to say: ‘Oh, that person’s crazy, I’m just going to take them to the emergency room and tell them to give them a shot,'” she said. “But I think clinicians, because they have access to information right away, they can make that decision better.”

For example, clinicians can use the Hawaii Health Information Exchange to see how often a person has visited an emergency room, or if they have demonstrated a potential danger to themselves or others.

Shopping carts and tents located on Sumner Street near the Institute for Human Services. Cory Lum/Civil Beat/2022

Civil rights concerns about the ACT law have been expressed in the past, including written testimony by the Hawaii Department of Health, the Attorney General’s Office, and Louis Erteschik, executive director of the Hawaii Disability Rights Center, who said he previously testified against the removal of public defenders in ACT cases but whose position has since “evolved.”

Erteschik, an attorney since 1974, said he was very much against the idea of involuntary medication, along the lines of what’s being done in a new program in New York.

“What you don’t want, obviously, is some totalitarian society where some shrink is running around telling you you need a little shot of this or that,” Erteschik said. “So that’s the nightmare scenario that we want to avoid, and I used to assume that’s all that ACT was.”

Since his testimony on a bill amending state law in 2021, Erteschik said he has encountered many homeless people during his commute to work on the bus, and seeing the symptoms of their mental states was a revelation. He has come to appreciate the type of work IHS is doing.

Chris Thomas, the attorney who handles all of IHS’s guardian and ACT cases, said he believes having a GAL to support each person through the process provides adequate protection.

“We’re seeking to treat the worst of the worst in terms of mental health,” Thomas said. “Those who don’t have the capacity to understand what’s happening to them in terms of their mental illness, and obviously the legal processes are foreign to them.”

Thomas said the prior involvement of public defenders delayed treatment.

“If it takes six, eight, 12 months to treat somebody because the attorneys are busy arguing, it seems to me to be contradictory to the purpose of the law — which is to treat people,” he said.

IHS received $500,000 in county funding for its Outreach Navigation Program, but after June it would need more money to continue.

Mitchell said the program has allowed IHS to help people make sense of their psychoses.

“Just like when someone has diabetes and their pancreas is not releasing enough insulin to digest sugars, we help them understand their brain isn’t working right now because there’s an imbalance of certain neurotransmitters — and that’s why they’re hearing the voices, feeling really anxious,” Mitchell said. “And that’s not their fault.”

Civil Beat’s health coverage is supported by the Atherton Family Foundation, Swayne Family Fund of Hawaii Community Foundation, Cooke Foundation and Papa Ola Lokahi.

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