Dr. George Keepers has served as Chair of the Department of Psychiatry at Oregon Health & Science University for more than 20 years, and has worked at a high level in Oregon's mental health field for twice that amount of time.
He was the founding medical director of what is now Cascadia Mental Health, served as a consultant psychiatrist on the Warm Springs Reservation, and served as chief of inpatient psychiatry at the Portland VA Medical Center.
Keepers, 73 years old, speaks softly and with a twinkle in his eye, much like his grandfather. But in an interview last week about his views on Oregon's mental health service delivery system, he dropped a bombshell on Oregon in the form of a simple comparison.
Zookeepers noted that Oregon spends more per capita on mental health care than most states, but its results are among the worst in the nation. Specifically, Keepers noted that Oregon spends $234.87 per person, compared to $113.27 in Massachusetts. But Keepers said the city ranks 46th in the nation for access to care and positive outcomes, while Massachusetts ranks in the top five.
And Keepers added that while the explanation isn't a mystery, it also doesn't seem like Oregon is moving toward solving the problem.
In an hour-long interview, Keepers talked about why so many mentally ill people roam the streets without receiving treatment, whether 911 is good policy, and how people with serious mental illnesses… He also shared his thoughts on whether it is time to put people who are suffering back into institutions. His remarks have been edited for brevity and clarity.
WW: Are there generally accepted principles for how to build a behavioral health system?
George Keepers: yes, I have. Compared to a place like Massachusetts, which has a very good mental health system, we spend about twice as much per person in Oregon. But while Massachusetts ranks in the top five for mental health care, the state ranks near the bottom of the nation.
Why do you think there is such a contradiction?
Well, in Oregon, multiple government agencies are trying to create different systems without much coordination. The mental health system has always been described here as a partnership between the state and county. The county is Oregon's mental health authority. What happens is the county decides what happens within its jurisdiction. It can vary greatly depending on location.
Why do we get better results in Massachusetts?
Massachusetts controls health care delivery within the state. In addition to directly delivering the program, they designed the standards for other institutions' programs offered in the state. And because they can control insurance reimbursement, they can require insurance companies to cover certain types of treatments. As a result of the authority they have, they are able to create highly efficient, effective, and coordinated systems of care.
This is very different from the Oregon Health Authority, which does not have the ability to create plans or manage reimbursement for plans. Instead, we have a decentralized system of governance through counties, coordinated care organizations, and more.
Oregon is a pretty enlightened state, and leaders say they care a lot about mental health. Are there other reasons why the results are so poor?
I don't know if there is an answer. Oregon is another place that does not fluoridate its water.
What do you say about Oregon when you talk to colleagues from other states?
Oregon State is not leveraging its expertise. For example, schizophrenia is a condition that we know how to treat. We can't cure it, but we know how to treat it. The same goes for drug abuse. Treatment is very effective. For example, when we look at physicians who become disabled due to substance abuse, over 90% of them return to practice after receiving effective treatment. With proper treatment, people get better. However, I think the state of Oregon is underutilizing its expertise in treating mental illness and substance abuse.
Multnomah County has received more than $200 million as part of Oregon's Community Mental Health Program. What do you think about the investments made in the last three years?
I don't have the ability to make those decisions. I can say that the results were not good enough. But I'm not going to exclude that prefecture. The explanation for why things went sour is more complex.
First, let me say that Portland's homelessness problem is not new. When I first started working with him in the 1980s, there were a large number of homeless mentally ill people in what is now the Pearl District. As Paarl developed, there was no longer any housing available for these people. And the number of homeless and mentally ill people has increased significantly. Meanwhile, the number of beds at Oregon State Hospital has been drastically reduced.
We are told that not only are we short of beds, but we are also short of trained mental health providers.
There is certainly a shortage of psychiatrists. There is also a shortage of child psychiatrists. There is a severe shortage of master's level social workers. And we don't have a strategy to grow that workforce. In Washington, we have established an integrated training center for all types of mental health professionals. We've been advocating for that in Oregon as well. In fact, the Unity Center for Behavioral Health is an ideal location for this type of training facility. We can build similar types of programs with far less investment than Washington.
OHSU plays an important role in the Unity Center. But Unity had a rocky start. What about now?
Unity provides superior patient care. But there are some things we didn't expect. One is the significant impact that increased use of opiates and methamphetamines has had on patient populations. Second, I never expected to care for so many dedicated patients at Unity. In fact, state hospitals cannot admit most civil patients. Instead, they are subject to the legal system of patients who are hospitalized to restore their ability to assist and assist with legal defense, or who are hospitalized with convictions other than insanity. They are expected to care for patients.
How does Oregon's process for civilly executing people who may pose a danger to themselves or others compare to other states?
It's much more difficult than most states, and in my opinion too difficult.
But even if civil commitment laws were more generous, there would be no place to put people.
exactly. The committed patients currently being treated are in the Unity Center and Providence psychiatric wards, but some committed patients are in general hospital beds, and some committed patients spend significant periods in the emergency room. I have seen him receiving treatment for many years. That's not good for anyone.
What do you think about Measure 110?
That's a difficult question. There is no doubt that the drug war has been a disaster. Therefore, the premise of this measure was correct. The idea of getting people into treatment is sound. But we can't convert people into treatment until treatment facilities exist. And they weren't in place at the time the 110 number went into effect. Another thing: 35 states (Oregon is not one of them) have committed people who are addicted to drugs, use them in an uncontrolled manner, and have no autonomy or ability to choose treatment. There is a kind of commitment method that allows you to do that.
But again, even if you could fuck people like that, there's nowhere for them to go.
correct. Additional treatment facilities for drug addiction are needed.
Methamphetamine psychosis was a big problem a few years ago, but it has been overshadowed by fentanyl. Has it calmed down?
Stimulants remain a big problem. In some ways, methamphetamine is a bigger problem than fentanyl when it comes to treating patients. Because those patients are much more likely to be very violent and agitated than those on fentanyl.
You painted a vivid picture of Oregon's disjointed non-system. Could reintegration be part of the answer?
No, I won't say that.
Why not?
We need more beds and higher levels of care and treatment. But why not put everyone in the hospital? Because it's not the correct treatment. The vast majority of people with severe mental illness are able to live successfully in the community and lead far more fulfilling lives than if they were institutionalized. It would be inhumane to put them all in the hospital.
