For all the angst over the scarcity of treatment for the mentally ill, Western State Hospital recently experienced a surprising surplus: more empty beds than patients to put in them.
It wasn’t a sign of progress, though – it was yet another symptom of scarcity. The hospital is short on staff psychiatrists, who evaluate threatening or suicidal patients and commit them to involuntary treatment if necessary. The Legislature is finally trying to expand treatment, but the shortage of doctors is a serious bottleneck.
Understaffing recently forced Western State to halt 90-day civil (not criminal) admissions for almost three weeks; it resumed them a week ago Wednesday. At one point, more than 40 patients were backlogged, most in desperate need of care. Yet the hospital briefly had more than 20 open beds.
The Lakewood psychiatric hospital is budgeted for 46 staff psychiatrists, but seven of those positions are vacant. The story’s the same at Eastern State Hospital near Spokane: It is budgeted for 14 doctors, but five positions are unfilled. When the doctor’s not in, people go untreated.
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This bad trend is driven in part by a good trend. Congress and the U.S. Department of Veterans Affairs have been expanding treatment for veterans who suffer psychological wounds, such as post-traumatic stress disorder. The VA has been aggressively recruiting psychiatrists – including doctors who work for Western State and Eastern State. The state’s loss is the military’s gain.
The far bigger problem, though, is that there aren’t enough psychiatrists, period, across the United States.
U.S. medical students tend to shy away from psychiatry. The reasons aren’t entirely clear, but psychiatry is one of medicine’s lower paying specialties. Health insurance tends to reward doctors for either fixing people or doing procedures. Neither approach works well with psychiatry. Severe mental illness can be managed but not normally cured.
As a specialty, psychiatry is underpaid. Average compensation is less than $200,000 a year, compared to well over $300,000 a year for some other specialties. Orthopedic surgeons, at the very top, average more than $400,000 a year.
Washington has its own compensation gap. The doctors at Western State and Eastern State top out at $164,000, though DSHS is moving to bump that up to $188,000. But the VA is offering up to $250,000. Medical school grads can do math.
Aside from the money, practicing psychiatry at the two hospitals can be harrowing. Forensic patients are often dangerous people. Other patients facing involuntary commitment are gravely impaired, or pose an immediate threat to themselves or others. Western State is one of Washington’s most dangerous places to work, and most doctors prefer private practices.
To make mental health dollars stretch further, some of the things psychiatrists have traditionally done might be handled by less expensive professionals, such as nurse practitioners and social workers. But no gimmicks will solve this problem. The Legislature may well have to offer doctors higher salaries and other incentives, such as loan repayment or bonuses for staying in the system.
After the Great Recession hit, the Legislature closed hospital beds and otherwise bled the mental health system. The results were dire. Jails became psychiatric hospitals. Patients were warehoused in emergency rooms. On occasion, the severely ill committed acts of violence that could have been prevented with early treatment.
Western State and Eastern State need proper staffing. As Washington has learned to its sorrow, mental health can’t be done on the cheap.