The lawsuit began before several of its contesting attorneys were born and outlived its first two judges, but the dispute over the Washington, D.C., mental health system finally was settled in February after 37 years.

Dixon v. Gray —its last incarnation (Vincent Gray is the current mayor)—began in 1974 as a means to compel first the federal government and then the District of Columbia (once it received home rule) to provide mental health care in the least-restrictive setting in the nation’s capital.

U.S. District Court Judge Thomas Hogan approved a settlement negotiated between the plaintiffs and the District and ordered the class-action suit dismissed.

“I am satisfied that this is a fair and orderly settlement that protects the interests of the class and satisfies the need for continuing mental health care in the District,” said Hogan from the bench.

“The settlement signals that we have made enormous progress in building a solid community mental health system and commits us to making continuing improvements,” said Gray at a press conference following the court session.

The lawsuit’s tortuous path was strewn with footdragging and broken promises for two decades, said plaintiffs’ attorney Iris Gonzales, J.D., of the law firm Covington & Burling, which handled the case pro bono, in an interview with Psychiatric News.

Much else was changing in the world of mental health care over the same decades. When the suit began, Washington’s mentally ill population was largely served by inpatient care at historic St. Elizabeths Hospital. Now, a new 300-bed psychiatric hospital stands on the grounds of St. Elizabeths, and half of its patients are forensic cases. Most patients in the District receiving public mental health care are now managed in the community.

After a change in mayoral administrations and the appointment of Steve Baron, L.C.S.W., to head the city’s Department of Mental Health in 2000, the parties agreed in 2003 on 19 provisions that, once met, would settle the case. By September 2011, the District met 14 of these “exit criteria” and was in “substantial compliance” with another.

The remaining four exit criteria covered continuity of care, supported housing, supported employment, and care for children. The two sides spent five months hammering out standards and goals to meet those last four criteria by September 2013.

“The District was having difficulty meeting those requirements, so we sat down and discussed how to get the same benefit in different ways,” said Gonzales.

For instance, length of stay for children in residential facilities was problematic, so the parties found ways to improve and expand community services to help children function better there, she said.

Housing was another critical area. Between 600 and 700 people with mental illness are on the waiting list for housing, but the parties agreed that the District will start by providing 200 new supported-housing vouchers by 2013, and offer another 100 either as vouchers or as actual housing units after that.

“The Dixon decree can’t solve all the problems of the D.C. Department of Mental Health,” said Gonzales. “It’s done what it can do and gives the best possible care in the least-restrictive setting.”

Judge Hogan mandated quarterly reports on the District’s progress to verify compliance and left open a provision for the parties to return to court, if necessary.

Outside observers praised the settlement while noting the work still remaining.

Robert Keisling, M.D., medical director of Pathways to Housing D.C., has followed the case closely, and his organization has filed briefs in support of the plaintiffs.

The agreement isn’t perfect, said Keisling in an interview. “Waiting times for appointments are still too long, and there are too many people with mental illness in the city’s criminal justice system.”

Also, the Dixon case primarily involved adults, said Judith Sandalow, J.D., executive director of the Children’s Law Center in Washington, D.C.

“Now it’s time to focus on children,” said Sandalow. “If they comply only with the exit criterion, we won’t have a functional mental health system for children. There are not enough of the right services, and it’s almost impossible for families to access them.”

However, she believes that the mayor and the Department of Mental Health want to implement reforms and is thus not contemplating additional legal action.

Settling the case represents a major step forward for Washington, D.C., said Baron.

“Since the District took over the mental health system in 1975, D.C. has never operated without court oversight,” he said in an interview. “This agreement is important symbolically because it shows that the District is at last capable of running its own public mental health system.”  

The agreement is posted at www.dmh.dc.gov/dmh/frames.asp?doc=/dmh/lib/dmh/pdf/DixonSettlementAgreement/Settlement_Agreement.pdf.