A Prescription for Mayhem

How shrinking psych wards spell trouble

Before Stephen Miles killed his stepmother, he tried to check himself into the hospital.

According to a criminal complaint filed last week in Dakota County District Court, the 23-year-old Eagan man killed his stepmother, Maris Jo Miles, with a hatchet blow to the head and then decapitated her with a knife. Miles's behavior had concerned his parents for days, according to newspaper accounts. He has a lifelong history of mental illness and had recently tried to strangle his father. But earlier that same day, December 30, Miles's parents had driven him to Fairview Southdale hospital in Edina, where he was seen and turned away by a doctor in the emergency room. The criminal complaint adds that his father, Roland Miles, told police the doctor said there were no beds available, "and if he needed to take his son somewhere he should go to the Cedar Riverside Hospital."

Stephen Miles refused to go, however, and eventually father and son wound up at the Burnsville home of Roland and Maris Miles. There, Stephen Miles told police, his stepmother got angry at the two for having gone to the home of Miles's mother in Eagan, and asked them to leave. Roland Miles decided to snowblow the driveway first. That was when Stephen Miles got a hatchet from the garage and killed his stepmother.

Miles is charged with second-degree murder. His attorney, Marsh Halberg, says Miles is being held for 60 days at a state psychiatric hospital while his mental fitness to stand trial is assessed.

Miles is not the first person involved in a violent death after being denied psychiatric care in the Twin Cities in recent years. In October of 2000, Larry Dame killed his sister and brother-in-law and three of their children hours after being turned away from Mercy Hospital in Coon Rapids. Two weeks later, police shot a man named Alfred Sanders, who appeared to be trying to run them down in his car; the day before, relatives had tried and failed to have him hospitalized at Hennepin County Medical Center.

In June of 2003, a Maple Grove teen who had been hospitalized repeatedly for threatening violence killed his mother. Court records later revealed that Jason Molacek was repeatedly denied care. (See "Voices and Silence," City Pages, May 5, 2004.) A month later a St. Paul mother threw her twin toddlers off the Wabasha Street Bridge during a Fourth of July celebration, also after being denied help. ("Falling," CP, August 27, 2003.)

Fairview representatives say they are unable to discuss the case, but are conducting an internal investigation. "However, we can share that any patient who presents for care at our emergency department receives medical evaluation and treatment," explains a news release. "In the event admission is necessary, we make those arrangements regardless of bed availability. No one is turned away."

It may take months to learn whether Fairview staff in fact should have placed Miles on a psychiatric hold until a bed and a secure method of transport could be found. In the meantime, the case has provoked the exact same outcry as the earlier tragedies: There's a desperate shortage of hospital psychiatric beds in Minnesota, and little is being done to address the situation. Indeed, those familiar with the situation say, things have grown markedly worse in the last year.

"It's a very large problem we're been trying to deal with for the last three years that in the last six to eight months has become particularly bad," says Dr. Janet Andrews, medical director of acute psychiatric services for HCMC. "Structured housing has really disappeared in the last year. Many Rule 36 facilities became board and lodge facilities. They have a 90-day maximum stay. Some of the more persistently mentally ill have nowhere to go.

"HCMC's psychiatric beds run at 100 percent occupancy almost all the time," she adds. "In Acute Psychiatric Services [the psychiatric emergency room], we are often in the position of sending patients out of the area to Duluth, St. Cloud, as far as Fargo, North Dakota." An expansion scheduled for completion next summer will nearly triple the number of acute beds at HCMC, from five to fourteen.

In HCMC's case, Andrews attributes the current crisis to three things: the near-disappearance of stable housing for the mentally ill; three-to-five-month waiting periods for outpatient services; and the closing of state psychiatric hospitals, which has filled beds earmarked for crisis care with chronically mentally ill people who have nowhere else to go.

Public health officials have hoped that a still-undeveloped network of community group homes would make up for the closing of state hospitals. The change would shift much of the cost of caring for people with persistent mental illnesses from the state to the federal government and to Minnesota's counties, already as cash-strapped as the state.

At the root of the crisis is an economic climate that makes caring for psychiatric patients far more difficult for hospitals than providing bypasses, angioplasties, and stomach-staplings. According to the National Association of Psychiatric Health Systems, the number of private psychiatric hospitals nationwide fell to 265 in 2002 from 460 in 1995. From 1970 to 2000, the number of psychiatric beds in state, county, and VA facilities fell from nearly half a million to less than 100,000, according to federal records.

In 2002, a Minnesota Psychiatric Society task force cited low reimbursement rates by health insurers as one reason for the lack of beds. Minnesota Hospital and Healthcare Partnership statistics show that the average cost of hospital treatment of a psychiatric patient was $1,388 in 2000, but insurers covered an average of just $678.

"The truth is, mental health beds are compensated far less than, say, cardiac beds," says Minnesota Attorney General Mike Hatch. "And so every hospital is expert in cardiac care." The Fairview hospital system, he adds, has worked harder than most to continue providing quality psychiatric services.

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