Iowa's mental health institutes are last resort for patients

INDEPENDENCE - Hard cases justify the existence of Iowa's mental health institutes, say staff at the Independence facility.

“We are the providers of last resort for those with the most severe and often most dangerous cases,” said Dr. Bhasker Dave, superintendent of the Mental Health Institute in Independence.

The needs of hard-case patients - those likely to hurt themselves or others, to engage in inappropriate sexual behavior or to start fires - won't be met if the state, in an effort to balance its budget, reduces its capacity to care for them, Dave said.

A similar opinion inspired a Legislature-appointed task force's recent recommendation that none of the state's four mental health institutes be closed until community-based clinics and wards can provide comparable care.

The mental health institutes are “the safety net when there's no place else for patients to go,” said task force Chairman Ro Foege of Mount Vernon, a former state legislator.

Foege said the task force's research has convinced its 12 members that public hospitals and community-based clinics lack the infrastructure to duplicate the services provided by state institutes to the so-called hard cases.

Sen. Jack Hatch, D-Des Moines, chairman of the Senate Health and Human Services Appropriations Subcommittee, said he agrees that institutional care of the mentally ill - including the round-the-clock, one-on-one care often provided at the state institutes - remains essential.

Hatch also said he believes that the Legislature in its next session will order the closing of one of the four facilities in Independence, Cherokee, Clarinda or Mount Pleasant, and that the closure will occur in 2011.

Hatch said he expects Charles Krogmeier, director of the Iowa Department of Human Services, to recommend a specific closure this week.

“We're not talking about getting rid of institutional care. We're talking about making it more efficient” by reorganizing the service and closing one of the state's four aging and oversized facilities, Hatch said.

Given the state's financial crisis - an impending $1 billion shortfall in next year's budget - the Legislature has no choice but to increase the efficiency of its mental health services, Hatch said.

“Before anything is closed, replacement infrastructure will have to be in place to care for the hard cases,” the senator said.

Patients come to the state institutes after repeated failures in community-based wards and clinics, said Tim Main, director of social services at the Independence facility.

“They have used up all the less restrictive resources and options,” he said.

Almost all of them suffer from more than one mental illness - for example, depression plus psychosis, psychosis plus personality disorder, Dave said. The mental illnesses are often complicated by substance abuse, mental retardation and medical conditions such as diabetes or heart disease, he said.

One current patient, he said, suffers from such severe diabetes that she needs constant one-on-one attention to counteract rapid blood-sugar fluctuations that could plunge her into insulin shock or diabetic coma.

The female ward also has two patients who need round-the-clock, one-on-one care to prevent them from harming themselves or others, Dave said.

For many patients, mental illness is complicated by social disadvantages such as abandonment or abuse by family members.

Besides treating their illnesses, “we sort of become their family, providing support and helping them develop social skills,” said Linda Hamadani, a senior administrator in the adolescent unit at Independence

Consistent with the precepts of modern psychiatry, the use of physical restraints, once a staple in the management of unruly patients, has declined 97 percent in the past decade, said Dave.

“The staff does have to occasionally manage aggressive behavior with humane holds or restraints, but we release them as soon as they calm down,” he said.

Among the most troublesome of the patients prone to injure themselves are the compulsive swallowers. Pens, forks, spoons, toothbrushes, even the bows of spectacles have been ingested by patients, say staff members.

“They look you over head to toe to see what objects you might have on you,” said Sally Slife, a nurse in the adult female service.

After a female patient broke a hard plastic switch plate and swallowed the pieces, staff members, trying to duplicate the feat, were unable to even bend an identical switch plate, they said.