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A psychiatrist’s prescription for addressing homelessness

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Bobby Johnson, a man currently living in a youth shelter, gets his eyes examined during a Project Homeless Connect event providing homeless persons with medical, legal and personal services (Jessica Christian/S.F. Examiner)
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In the psychiatric unit of the newly named Zuckerberg San Francisco General Hospital, mental health care providers see the most acute cases of mental illness. The burden of mental illness manifests with each visit to the psychiatric emergency room for a psychotic break, each admission to the medicine ward for skin infection from intravenous drug use, each stay in the ICU for a failed suicide attempt.

In therapeutic terms, the purpose of psychiatric hospitalizations is to “hold and contain” patients in a safe space until the crisis eases with medication and therapy, at which point they can be discharged to a less acute, less restrictive environment. Yet ZSFG has seen, over the past year, an increase in the number of psychiatric patients who cannot be discharged to a safe environment due to the dwindling number of beds in available facilities. Because of this, the average length-of-stay in the inpatient psychiatric ward has increased, with an overflow of psychiatric patients into other medical services, psychiatric emergency room or, worse, County Jail.

Serious mental illness is unique in that its disease course involves a complex of factors that may start as trauma during childhood and often involves a terrible cycle of poverty, social exclusion and addiction that is exacerbated by homelessness. Without treatment and support, these insidious factors push the most vulnerable into a slow, downward trajectory away from mainstream society.

The current housing crisis is directly linked to the acute rise in homeless populations on the streets of San Francisco. As housing prices and cost of living increase, those at the bottom who were tenuously housed are now being squeezed out.

For vulnerable populations — in particular, the mentally ill with poor social supports — there are few alternatives to the streets. I have met multiple female patients who prefer to stay in the streets rather than go to shelters, where their only belongings may be stolen, and who have been previously traumatized by physical or sexual assault. In addition, privately owned facilities, which provide respite such as board-and-care facilities, are being closed down and sold due to the high prices they can now command.

The result of this is an increase in the number of homeless people, as well as decreased access to services, and poor utilization of limited resources for the most vulnerable. What can be done to improve this situation?

As a society, we must first rid ourselves of inherent biases against mental illness. A dangerous prejudice remains against the mentally ill. Like medical ills, psychiatric disease happens to patients, and depression, anxiety or psychotic thoughts cannot be simply willed away.

More concretely, we must recognize destabilizing effects of homelessness on those with existing mental illness. We must safeguard and expand low-income housing and safe shelters for the most vulnerable, including single-room occupancies, board-and-care facilities, acute diversion units and sub-acute locked facilities for those who cannot otherwise live independently in society.

It’s time to increase our city’s capacity to provide free mental healthcare for the many patients who want treatment for their psychiatric illnesses but are turned away because all the appointment slots are full. Let’s educate and incentivize healthcare providers to work in the public sphere and fund scientific research to improve our current treatments for these devastating diseases.

The goal is to allow patients to return to a productive and meaningful life unencumbered by illness as much as possible. The end result will be a decongestion of our streets and our jails, and more importantly, basic justice for those who cannot unite and advocate for themselves.

Jennifer Guo, MD, Ph.D., is a psychiatry intern at Zuckerberg San Francisco General and a member of the Committee of Interns and Residents/SEIU Healthcare.

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