Since mid-October, 40 involuntarily detained, acutely mentally ill patients were transferred to Fairbanks or Juneau, mostly on commercial airliners, because the Alaska Psychiatric Institute in Anchorage didn't have enough doctors to evaluate them.
API's psychiatric staff is down from 10 to 5, said CEO Melissa Ring, short two psychiatrists and three psychiatric health practitioners who can prescribe drugs. Unable to hire even temporary doctors, in November she closed one of two large units used for the 72-hour detention and evaluation of patients, removing use of 24 beds from the 80-bed state mental hospital.
Since then, with API frequently full, many patients ruled gravely disabled or likely to cause serious harm to themselves or others have been held in hospital beds waiting for a turn at API, or have been flown to Fairbanks or Juneau. Of the 40 transferred, 15 were coming from other places lacking an evaluation facility, and so would have been traveling anyway.
Asked if moving patients around the state could pose a public safety risk, Ring said, "Yes, there could be concerns about that." But she said doctors work to choose patients for transport most likely to do well on a flight. A transport contractor sends an escort with each transferred patient and hospitals may also medicate patients before they fly.
Ring hopes to have API's closed Katmai Unit operating by the end of the month when new doctors and practitioners are on staff. But to make those hires, she may need the ability to offer higher salaries.
On Tuesday, Ring met with state officials, including Commissioner of Health and Social Services Valerie Davidson, and private hospital leaders, to discuss a new salary schedule. On the same day, Gov. Bill Walker announced a state hiring freeze for noncritical workers to address Alaska's massive budget deficit. Ring said Walker's order would not affect API's situation.
Ring would not disclose the current salary of doctors at API, as each is negotiated separately. She hopes to increase salaries and place them on a standard scale. She said transferring patients around the state is expensive, but could not give figures.
A worsening national shortage of psychiatrists has affected many states. Unlike psychologists, who cannot prescribe drugs, psychiatrists need degrees like other medical specialists, but on average earn less than many doctors. According to a recent article in Modern Healthcare, psychiatrists averaged $226,000 a year, while cardiologists and orthopedic surgeons made an average of $525,000 a year.
Every day, police or family members bring patients in severe mental distress to the Providence Psychiatric Emergency Department, which is funded as part of the state mental health system. Under Alaska law, police or physicians can hold a person who is apparently mentally ill for up to 24 hours before going to a judge or magistrate to request a 72-hour detention for evaluation at a designated facility, of which there are currently three: API, Fairbanks Memorial Hospital and Bartlett Regional Hospital in Juneau.
Each year, API receives about 1,500 patients for 72-hour evaluations. Some are treated and released, but most receive further treatment, either voluntarily or through involuntary commitment ordered by a judge.
But with the system often overwhelmed, the 24 hours before sending a patient to API can stretch to two days or more, with repeated renewals of the 24-hour hold. In one case cited by the Disability Law Center in a 2011 lawsuit that is still pending, a patient was held for four days at Central Peninsula Hospital in Kenai before being transferred to API. Also, the 72-hour hold doesn't begin until the patient arrives at API, and can include weekends or holidays, so the entire detention can last much longer than three days.
"The violation of people's legal rights is principally that their entrance into the system is being delayed," said Mark Regan, director of the federally funded law center. "They're being taken into the system and being detained, but they're not being evaluated locally."
Anchorage psychiatrist Aron Wolf agreed the problem has become serious. He said, "This could morph over from a staff issue to a civil rights issue. I think we are real close to it morphing over, frankly."
Wolf, who has practiced in Anchorage for decades, said the staff problem faces all local psychiatric care facilities. He said Anchorage had more psychiatrists 15 years ago than it has now. The problem is that pay has not kept up with costs or other specialties.
"I don't think there is a bad guy in this story," he said. "This is something they need to find the money for."
In the short term, API will have to pay high wages to bring temporary doctors -- who Ring and others agree are usually less effective than permanent staff members. Making those hires is especially difficult now because the hospital is in crisis, said Jeff Jessee, CEO of the Alaska Mental Health Trust.
In the long term, Jessee said patients should be seen closer to home by creating more facilities qualified to evaluate them and by making greater use of telemedicine. That model works better and costs less than more hospital beds, he said.
The API hospital facility, built about 10 years ago, is spectacular, with high ceilings streaming with light, stained glass and extraordinary art. But in the Katmai Unit, rooms stand empty and at a nurses' station, which would normally be a center of activity, all is quiet.
Alaska faces the timely irony of having built a showplace of a mental hospital but being unable to staff it because of lagging salaries. The resulting situation is unacceptable, of detaining acutely mentally ill patients for long periods before evaluation and flying them around the state on airliners.
But besides dismay at this state of affairs, we should also think about the additional caring we need to offer these patients. Anyone can become mentally ill — severely depressed or psychotic — with the need to be protectively detained and evaluated. For ourselves and our families, we should see to it that this care happens quickly, close to home, and without a lot of bureaucratic shuffling.
Charles Wohlforth's column appears three times a week. Email him: cwohlforth@alaskadispatch.com.
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