Steve Gold, The Disability Odyssey continues

July 30, 2007

In 1987 when Congress enacted the Nursing Home Reform Act, it recognized that mentally ill residents required "specialized services." The Act stated that "the State mental health authority must review and determine" if each resident in nursing homes "requires specialized services for mental illness." If a person does not require nursing facility services but does require specialized services for mental illness, the State is supposed to arrange for both a safe and orderly discharge from the nursing facility and for provision of the specialized services.

Two points, thus, are critical. First, it is not the nursing home or Medicaid offices that must conduct the review and make the determination, but "the State mental health authority" that is responsible. Second, Congress acknowledged that residents with mental illness need specialized services b not necessarily regular or typical nursing home services.

In 2005, 19.7% of all nursing home residents had psychiatric conditions, such as schizophrenia and mood disorders. This is a substantial increase from 1999 when 13.8% of all nursing home residents had psychiatric conditions. These percentages do not include persons who have dementia.

In terms of the totals, in 1999, there were 179,720 persons with mental illness in nursing facilities, and in 2005 there were 263,542 persons with mental illness in nursing homes. This represents an increase of nearly 84,000 persons.

Nursing facilities must provide for or arrange for the provision of specialized services. Congress meant appropriate "specialized services" and intended the "State mental health authority" to determine which services for which resident was necessary.

"Specialized services" apparently is only or primarily psychoactive medication. Such drugs include anti-depressants, anti-anxiety medications, sedatives, hypnotics and anti-psychotics.

What is amazing is the percentage of residents who receive these psychoactive medications. One might naively think they would be limited to the 19.7% of the residents who were mentally ill. Not so.

In 2005, 63.9% of all nursing home residents received psychoactive drugs, up from 50.3% in 1999. Nursing homes are places that appear to freely administer such drugs.

We surmise the reasons for such widespread use of psychoactive drugs are not mental illness, but "behavioral control." People doped up are easier for nursing facility staffs to control. Widespread use of sedatives causes lots of residents to just sit around the nursing facility and appear "out of it," whether or not without the drugs they would be more active and responsive.

Disability advocates should ask their State mental health authority:

• Are all the 19.7% receiving appropriate specialized services?
  
  
• Do they even meet the nursing home level of care requirements, separately from their mental illness?
  
  
• How often does your State mental health authority visit and evaluate each resident? When was the last time?
  
  
• What does your State mental health authority think about the high use of psychoactive drugs, and has anyone determined if the residents need them or if specific drugs are appropriate for each resident?
  
  
• Is there an overuse of anti-psychotic medications in the nursing homes? Is there an overuse of sedatives?
  
  
• Who is prescribing 63.9% of the residents with psychoactive drugs? Psychiatrists? Geriatric psychiatrists who are familiar with the medically appropriate use of these drugs? Doctors who may have no familiarity, training or experience with these? How often are residents medically reevaluated regarding continued use of these drugs?

Below are the statewide percentages of residents in nursing homes who in 2005 had a psychological diagnosis other than dementia:

Special thanks to Charlene Harrington and her colleagues at University of California San Francisco.