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Addressing psychiatric "bus therapy" and its underlying problems

4756317503_2afb86be75In the current issue of JAMA Psychiatry, Stanford's Smita Das, MD, PhD, MPH, a researcher in psychiatry and behavioral sciences, and Judith Prochaska, PhD, MPH, an associate professor of medicine with the Stanford Prevention Research Center, have an editorial (subscription required) on the resurgence of "bus therapy" - the practice of under-resourced state psychiatric hospitals handing patients a one-way ticket out of town to become another state's responsibility.

Das and Prochaska write that the problem of patient dumping isn't new; rather, it gained attention during the 1970s after mental health disorders were deinstitutionalized but measures weren't established to meet the needs of displaced people seeking care.

The piece notes that the problem has been exacerbated by cuts to non-Medicaid state mental health spending in 29 states and Washington, D.C. during 2009-2012, and that one particularly struggling state - Nevada - has bused more than 1,500 patients in the last five years to California, most of them to San Francisco or Los Angeles. (The New York Times also recently reported on this issue.)

The authors set the scene with a typical case of a psychiatric patient relegated to bus therapy and sent to San Francisco:

He is brought to the county psychiatric emergency service, which, hectic and often over capacity, treats nearly 6000 patients annually (of which 39% are not San Francisco residents). The patient needs housing, a psychiatrist, case manager, primary care provider, and transfer of Medicaid or general assistance—a package known colloquially as the San Francisco Special. Placements are challenging—the county hospital reduced its acute in-patient psychiatry capacity 50% in the last 5 years owing to budget shortfalls—yet out-of-state visitors are not turned away.

In the editorial, Das and Prochaska argue that current reshaping of health care spending and guidelines makes for an ideal time to address patient dumping and find solutions to the practice's underlying causes, and she suggests increasing mental health budgets, transitional interventions, and proven methods of health-care delivery such as telemedicine and group therapy to serve patients and reduce provider burnout.

"This is a relevant and timely issue as the country is experiencing healthcare changes and feeling the impact of low resources in mental health," Das said in an e-mail. "We hope more providers, administrators and policy makers take note of 'bus therapy' as an example of one of the many signs that we need to pay more attention to mental health."

Photo by Vincent Desjardins

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