How Hospitals Respond When Mentally Ill People Come in From the Streets

The most famous homeless person in New York in 1987 went by the name Billie Boggs. For a time, she lived on the sidewalk at 65th Street and Second Avenue, where she lay on an air vent for warmth and screamed racial epithets at passers-by. She was observed barefoot in winter and sometimes twirled an umbrella to keep people at a distance.

Ms. Boggs, whose real name was Joyce Brown, was taken to Bellevue after Mayor Ed Koch announced a plan to clear the sidewalks of homeless people with severe mental illness.Her initial treatment involved a shot of Haldol, an antipsychotic drug. When she demanded to be released, she emerged as a test case exploring the limits of involuntary psychiatric hospitalizations.

This week, Mayor Eric Adams announced his own initiative to bring more people with severe mental illness to hospitals for evaluations against their will. He said it would apply to homeless people who, because of their illness, were unable to meet their basic needs and were therefore a danger to themselves — a standard the Boggs case set.

In some respects not much has changed in the intervening years in how hospitals respond to schizophrenia and street homelessness.

Haldol is still commonly administered at Bellevue and other hospitals today. And just as they have for decades, psychiatrists still wrestle with whether someone is a danger to themselves, and what factors to consider, when deciding to admit someone involuntarily.

“If it’s someone sleeping in a subway car and yelling at people — even if not necessarily violent — that might be ‘danger to self’ because they’re putting themselves in a position where they may inevitably get hurt,” Dr. Gaddy Noy, a psychiatrist who works in the emergency room at NewYork-Presbyterian/Columbia said, considering some of the same factors that psychiatrists and social workers did some 35 years ago when considering Ms. Boggs. “If someone is staying outside and they’re coming in with frostbite that’s ‘danger to self.’”

In interviews some hospital psychiatrists said Mayor Adams’s plan to increase hospitalizations would not come close to solving the problem of untreated mental illness among those living on society’s margins. But some also said that the plan would help many homeless people receive more treatment than they currently get.

Short-term hospital stays can be critical for stabilizing people with severe mental illness, such as schizophrenia, and determining which medication might work for them — a process that can involve trial-and-error. “It’s about stabilization and setting people up for ongoing care,” said Dr. Michael Zingman, a psychiatry resident at Bellevue Hospital, which has the largest inpatient psychiatric division of any general hospital in New York City.

But, he added, the city needs more psychiatrists working with the street homeless population in between hospital stays. “You can get people to a certain point of wellness and stability while they’re in the hospital, but the real work is outpatient — bringing services to people where they need them.”

For some people with severe mental illness, a hospitalization can pave the way for years of stability following a psychotic episode. But others cycle between hospital and street. Homelessness — with its stress and danger — increases the odds of another psychotic episode followed by another hospitalization.

“It doesn’t make sense to take people who are homeless and just discharge that person back to the street,” said Dr. Mitch Katz, the president of the city’s public hospital system, which operates some of New York City’s largest psychiatric wards. “All that’s going to happen is they’re going to be subjected to the same stress of life on the street, medicines are going to get lost, they’re going to miss their appointments, and they will cycle back into psychosis and at some point they will be brought back to the psychiatric emergency room where the process will start again.”

Already each day homeless people land in city emergency rooms, brought by the police and paramedics after their behavior crossed a line. Sometimes, this process begins with a 911 call. Or it may start when a shelter director learns that one resident, gripped by paranoid delusions, had started arguing with other shelter residents.

Some major hospitals have a separate psychiatric emergency room where patients are held for observation for several days. At Columbia’s, for instance, there might be 30 or so patients at a time, with most staying for three to five days.

It’s here that psychiatrists evaluate who requires a longer hospitalization in a psychiatric ward. Patients whose psychotic episode was brought on by drugs, such as the cheap synthetic cannabinoid known as K2, often appear more lucid after a day or two and are discharged. Others too are soon deemed fit enough to be released. “Sometimes someone after 16 hours later after being in our psychiatric emergency room will look and sound completely different,” Dr. Katz said, at which point they are discharged.

But for many patients with unmanaged schizophrenia, psychiatrists try to find a bed in an inpatient psychiatric unit. That can involve a lot of phone calls and rejection.

Psychiatric beds are scarce, as many hospitals have closed in-patient psychiatric units over the years. The reasons include the low financial returns of providing psychiatric care to the poor and a national movement to reduce psychiatric hospitalizations in favor of outpatient treatment. The number of inpatient psychiatric beds dropped even lower when the deadly first wave of the pandemic in spring 2020 forced some hospitals to close their psychiatric units to make room for Covid patients.

But more than two years later not all of those units have reopened, including a 30-bed facility at NewYork-Presbyterian’s Allen Hospital, at the northern tip of Manhattan. That psychiatric unit in particular used to be filled with homeless and undocumented patients who lacked the insurance necessary for many other facilities, according to nurses and doctors.

Dr. Katz has expressed concern that private hospitals used the pandemic as cover to downsize psychiatric units. “Private sector hospitals are saying this might be a good time to get out of this business,” he said in an interview last year.

Now, there are some 2,800 psychiatric beds at hospitals in New York City, not including a smaller number of beds run by the state’s Office of Mental Health. Those state beds, whose number has declined dramatically as a result of deinstitutionalization, are mainly occupied by two groups of patients. Some were defendants in criminal cases while the others are psychiatric patients who did not improve after short-term stays at other hospitals.

Dr. Noy said that some days he and his colleagues might only find a single inpatient psychiatric bed available at hospitals nearby willing to admit someone from the emergency room. Insurance status can play a role in whom hospitals will accept. And without more inpatient beds, the mayor’s policy was likely to cause more crowding in emergency rooms, Dr. Noy predicted.

About 50 percent of inpatient psychiatric stays in New York City are for schizophrenia, according to city statistics. For homeless psychiatric patients, schizophrenia makes up an even larger share of hospitalizations, doctors said.

The search for the right medication for schizophrenia also often bumps up against legal timelines. Though some involuntary admissions have a 60-day limit, others are limited to 15 days by state law. It can take more than a week to assess whether a particular antipsychotic drug is working, and doctors have more than a dozen to choose from. Finding the right one for a specific patient can involve luck and trial-and-error.

“If somebody comes in and they’re already on a medication, we’ll sometimes titrate it” — adjust the dose _ “and go up on the dose,” Dr. Zingman said. “If they’re not responding, we’ll switch them to something else.” But there is rarely time to try more than one new antipsychotic medication during a single hospitalization.

One medication, Clozapine, can be quite effective in patients whose illness hasn’t responded well to others. But doctors are sometimes hesitant to prescribe it to homeless patients because it requires regular blood work to monitor against side effects that include blood disorders. Dr. Zingman said that he often hears colleagues express concern about prescribing it to homeless people with schizophrenia, because “we’re not sure if they’ll follow up or what care they’ll get in the shelter.”

Deciding when to discharge someone is also a judgment call. Some patients will still exhibit a baseline level of paranoia or delusions when they are discharged, but are in far better shape than when they arrived. “We’re not necessarily aiming to make it all go away, but to get them to the point where they can go back into the community,” Dr. Zingman said.