Georgia continues to face the threat that it could lose control of its public mental hospitals to the federal government after a judge rejected a reform plan by the state.
On September 30 U.S. District Judge Charles Pannell rejected Georgia's settlement agreement that aims to fix the state's ailing mental health network over five years. The court had initially accepted the settlement agreement in January as part of an effort to address problems identified by the U.S. Department of Justice and patient advocacy groups. But the judge rejected the settlement agreement after the Justice Department raised fresh allegations of neglect, abuse, and substandard medical care in the state psychiatric system.
"The judge recognized that these problems are endemic," said Ron Honberg, J.D., legal director of the National Alliance on Mental Illness, in an interview with Psychiatric News.
In an October court filing in response to the judge's decision, state officials wrote that the state has made improvements and that it is in "significant compliance" with the January settlement.
The voluntary settlement agreement stems from a Justice Department lawsuit (also filed last January) over allegations that the state was failing to prevent needless suffering and death at Georgia's state psychiatric hospitals.
Advocates and now the Justice Department objected to the settlement agreement because it lacked details and timelines, as well as ways to improve Georgia's community-based mental health services. Under-funded community psychiatric programs result in unnecessarily lengthy stays as well as frequent rehospitalization in state psychiatric hospitals, said the critics.
"For many, the only barrier to discharge is that they have nowhere to go," said Alison Barkoff, a senior staff attorney at the Bazelon Center for Mental Health Law and an attorney in the case, in an interview with Psychiatric News.
The lack of community-based treatment has led psychiatric hospitals to discharge patients directly to jails, homeless shelters, or motels instead of community treatment programs.
The state will now have until January to continue its reform efforts before it must again report to the judge on its progress. If the judge is not satisfied, he could order vast, costly changes to the state's mental health network, and Georgia could lose control of its psychiatric hospitals.
The judge's September decision came after also hearing from a group of patient advocates, including the Carter Center, which criticized the state's mental health reform plans as lacking specific details to improve the system.
"The agreement [reached in January] amounts to little more than a promise by Georgia to do better," wrote advocates in a letter to the judge.
The advocates' concerns were echoed by the Justice Department, which alleged both "significant risks of harm" to patients in a state psychiatric hospital and failure to ensure that patients "are adequately evaluated for placement in the most integrated setting." Such evaluations are required by the Supreme Court's 1999 Olmstead decision—also focused on the Georgia state psychiatric system—which requires states to develop appropriate community-based services for people with disabilities who are institutionalized but are capable of living independently with support services.
"Regularly, the hospitalized individual is kept in the hospital unnecessarily and/or discharged to a personal care home without necessary services and supports," wrote Susan Jamieson, director of the Mental Health and Disability Rights Unit at the Atlanta Legal Aid Society, to the court.
William McDonald, M.D., president-elect of the Georgia Psychiatric Physicians Association and an advisor to the state on implementing the reforms, told Psychiatric News that the state has made progress in making reforms that were not fully under way until July. In that short time, he said, Georgia has taken "real strides" in improving both psychiatric hospitals and community-based care.
Among the improvements are additions to available community-based supportive housing and an agreement by the Medical College of Georgia to assume leadership of one state psychiatric hospital, McDonald said.
Barkoff challenged that assessment and noted that her clients have reported no improvements in community-based mental health services around the state.
McDonald maintained that the state will provide enough changes to address issues raised by the lawsuit and settlement; however, the degree of success could depend on legislators' willingness to provide additional funding increases soon.
"Like a lot of states, with mental health [funding], you have to fight for it," McDonald said. Mental health care "is not always first in line."
Barkoff countered that many improvements could come with little or no additional funding. "What we're talking about is downsizing the hospitals and allocating that money to the community setting," Barkoff said.
The court also is considering holding a "status conference" that could be used to expand the settlement agreement to explicitly order improvements to the Georgia community-based treatment system.
The settlement agreement reached in January is posted at <www.bazelon.org/pdf/Georgia_settlement.pdf>.