Mental health conservatorships led to lengthy inpatient stays among homeless people with mental illness

At a time when public and private agencies and the legal system are grappling with how to best assist people who live at the intersection of homelessness and mental illness during a global pandemic, UCLA researchers have found mental health conservatorships for people with disabling, severe mental illness who are also homeless can result in lengthy psychiatric hospitalizations.

"Our study found that mental health conservatorships resulted in very lengthy inpatient stays for those who were homeless when conserved, sometimes as long as months or even a year," said Dr. Kristen Choi, UCLA Fielding School of Public Health assistant professor of health policy and management. "We observed a 'bottleneck' effect in this study. There are very few long-term housing options for people who are disabled by mental illness and in need of supportive housing in Los Angeles. When these individuals are stabilized and ready for a lower level of community-based care, there is no place for them to go."

Choi, a psychiatric nurse who is also an assistant professor with the UCLA School of Nursing, led the current study, "Mental Health Conservatorship Among Homeless People With Serious Mental Illness." Mental health conservatorships, known as a Lanterman-Petris-Short Act (LPS) Conservatorship in California, are highly restrictive and thus reserved only for individuals with severe, ongoing disability from mental illness who cannot accept voluntary treatment. There is a strict legal process for initiating such conservatorships that involves review and monitoring by the courts.

"It is important to note that the majority of people experiencing homelessness do not have mental illness," said Dr. Enrico Castillo, a psychiatrist with the UCLA Center for Social Medicine and Humanities. "Homelessness is not the same thing as mental illness and as such, the solution to homelessness is housing, not psychiatric treatment."

The most recent measurement, the 2020 Greater Los Angeles Homeless Count, found 66,436 people in Los Angeles County experiencing homelessness; the 2021 survey was suspended because of the COVID-19 pandemic. At the same time, across the United States, the best available estimate of homelessness is some 580,466 people, according to the U.S. Department of Housing and Urban Development. Twenty-one percent of individuals who are homeless have serious mental illness, compared with 5 percent in the general U.S. population. Mental illness among people who are homeless is associated with higher risk for mortality, disability, substance use disorders, and suicide.

Publication of the study is pending in an upcoming edition of the peer-reviewed journal Psychiatric Services, published by the American Psychiatric Association. It is currently available on-line. The researchers from the UCLA Fielding School and the UCLA Center for Social Medicine and Humanities examined a sample of 795 adults, 18 years of age or older, who were hospitalized on an involuntary psychiatric hold in Los Angeles between 2016 and 2018. They examined discharge and mental health conservatorship outcomes for patients who were homeless. The researchers found that inpatient stays were almost four weeks longer for individuals who were homeless when admitted compared to those who were housed.

For the minority of people experiencing homelessness who also have severe and disabling mental illness, such as those in our study, supportive housing options that combine treatment with housing are greatly needed in Los Angeles."

Dr Marissa Seamans, Study Co-Author and Assistant Professor of Epidemiology, UCLA Fielding School of Public Health

The study was conducted in partnership with Gateways Hospital and Mental Health Center, a safety net mental health system in Echo Park that aims provides mental health care to all people regardless of their ability to pay. In response to their growing homeless patient population and the results of this study, Gateways Hospital has formed a new partnership with the Homeless Outreach and Mobile Engagement (HOME) Team pilot program to link street-based psychiatric treatment with inpatient, outpatient, and residential treatment in the Gateways system.

"This partnership will enable us to better meet the needs of homeless individuals who are living in the streets due to their mental health related impairments," said Dr. Shayan Rab, a street psychiatrist with the HOME Team. "Street-based mental health services can be a first step in addressing long-term treatment needs. At the same time, more residential treatment options in Los Angeles is ultimately the solution we need most."