Maryland's psychiatric backlog

There has long been a tension between the state's judiciary and the Maryland Department of Health and Mental Hygiene over how best to deal with individuals who are mentally ill and have been charged with crimes. The latest "crisis," as recently detailed by The Sun's Michael Dresser, is a chronic shortage of inpatient beds in the state's public psychiatric hospitals.

That's not a small problem. If someone is charged with a crime but there are doubts about that individual's mental competency, he or she will need treatment as well as a psychiatric evaluation. State-run psychiatric hospitals handle such cases. But increasingly, they are turning away court-ordered patients because their 960 or so beds are full. The result is that more of the mentally ill end up housed in local jails that lack the capacity to adequately deal with them. That, in turn, means judges may have to dismiss more such cases or risk overloading those jails or denying appropriate medical treatment to patients.


What happened? The easy answer is that the state dramatically reduced the number of inpatient beds that once totaled 3,000. That includes the decision to close Baltimore's only public psychiatric hospital, the 51-bed Walter P. Carter Center, in 2009 to save money and direct more patients into community-based care. And that decision came on top of the closing of the 200-bed Crownsville Hospital Center in Anne Arundel County five years earlier.

And while increasing the number of beds might alleviate the current backup — as recently as 2012 a consultant suggested adding 216 beds — it would cost the state millions of dollars (chiefly to pay the salaries of around-the-clock medical and security staff) that might better be spent elsewhere. That's because the backup isn't just about the number of beds available but about a system that doesn't use existing resources efficiently.


First, a brief history. Maryland closed facilities like Crownsville and the Carter Center not only to save money but because medical best practices had evolved (enabled in no small part by the rise of psychopharmacology) and it was determined that the typical patient would be better served in a community-based setting rather than warehoused in a state hospital. That's still true today. There has been a dramatic decline in the need for such costly beds for individuals outside of the court system. Today, those psychiatric patients are far more likely to live in group homes or similar circumstances. That same trend has been experienced in every other state.

Meanwhile, the demand for "forensic" beds to accommodate court-ordered patients has not particularly grown. The problem is more like a traffic jam. As much as 10 percent of those now housed in state psychiatric hospitals could likely be released tomorrow — particularly if group homes, adult day care programs or other community providers had the capacity to absorb them, which, unfortunately, they don't.

And there are other issues, too, including certain judges who insist that defendants be evaluated immediately when that's not medically necessary and state law that requires individuals found not competent to stand trial be housed in a state hospital when community-based care might be better. The net effect is that DHMH too often has its hands tied while the most cost-effective solution requires a cooperative effort and real reform involving the courts, local jail administrators, community-based providers and the state hospitals.

That's why the Hogan administration's decision to organize a broadly representative work group to recommend a solution is the correct response. Ultimately, there may be a need to add beds in state hospitals but there are other potential solutions, too, such as offering inpatient psychiatric care in the largest jails or allowing for a higher Medicaid reimbursement for providers willing to care for forensic patients, all of which deserve to be explored.

Gov. Larry Hogan didn't create this problem. It is, as they say in medicine, a preexisting condition. But it's certainly within his capacity to fix it.

This isn't an issue that is likely to win the governor great favor, of course. Politicians aren't elected based on how well they treat people arrested on assault charges because they heard a voice in their head telling them to hit somebody. But Mr. Hogan speaks frequently of wanting state government to be more efficient and effective and, in that regard, this is clearly an opportunity to outperform his predecessors who have failed to address a longstanding and complex problem involving a truly powerless group of people.