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Steps Toward Evidence-Based Practices for Parents
with Mental Illness and their Families
San Francisco General Hospital: Women's Issues Psychiatric Program
San Francisco, CA
Program Description
The Women's Issues Psychiatric Program is a specialized team on the inpatient service of the Department of Psychiatry at the San Francisco General Hospital (San Francisco, California). The program focuses on women's issues including pregnancy and parenting, among women with serious mental illness. Program participants receive both psychiatric and obstetrical services from a multidisciplinary team trained to address issues at the interface of psychiatry and obstetrics/gynecology (OB/GYN). Women participants can also continue joint psychiatric/OB care after discharge at the outpatient high-risk clinic (see below). The program is also a training site for students and interns in medicine, nursing, social work, and psychiatry.
Program History
The Women's Issues program began in 1985. It was originally developed "in reaction" to treatment practices for pregnant women with mental illness. According to the program's founding psychiatrist, it was common practice to stop use of all psychotropic medications for pregnant women in order to prevent any risk to the fetus. Without medication, women decompensated, needed to be "locked up," and attempted suicide at much higher rates. Women so-"treated" also complied more poorly with prenatal O/B care. The Women's Issues program was founded upon the premise that women should be educated about the risks and benefits of treatment during pregnancy, and allowed to make treatment decisions that included medication, taking into account the risk of "no treatment."
The program began as a consultation service to the OB service. Staff were recruited from both psychiatry and OB to learn about the relevant issues and develop appropriate and collaborative treatment protocols. In 1986, the program became fully integrated into the inpatient psychiatric service. In more recent years, changes in inpatient psychiatric practice driven by de-institutionalization and healthcare funding, have changed the population served by the program. This change in population has been followed by changes in focus and content. For example, referrals that originally included patients from state mental hospitals or residential facilities administered by the county Department of Mental Health, now include admissions from acute psychiatric emergency rooms, and a variety of community-based mental health providers. As a result, a larger proportion of the women referred to the program are not pregnant, and the population served by the program has shifted from primarily women with schizophrenia to women with varied diagnoses (e.g., acute psychosis, PTSD, Major Depression, Bipolar Disorder), and/or substance abuse.
The focus of the program has similarly expanded from managing pregnancy in the context of a serious mental illness to include multiple women's issues such as parenting, relationships, history of trauma, and domestic violence. At present, women are admitted to the Women's Issues Team if they are pregnant, experiencing other reproductive issues, or have a history of trauma. Many of these women are diagnosed with Borderline Personality Disorder, and the providers have developed expertise in this area. Finally, length of stay in hospital has decreased considerably since the beginning of the Women's Issues Program. Acuity on the unit has increased as a result, and follow-up care and referral to appropriate community resources have become critical components of care.
Funding History
The San Francisco General Hospital is a public hospital whose services are available to all residing in San Francisco County, California. It provides a full range of inpatient and outpatient medical services, including psychiatry, for both insured and uninsured individuals. The Department of Psychiatry is funded through the County Department of Mental Health (DMH) and reimbursement from the state health insurance program (MediCal). The Women's Issues program, as part of the Department of Psychiatry, is funded though reimbursement from public (MediCal) and private insurance, and subsidized by DMH money to serve those without insurance.
Target Population
The Women's Issues Program serves women 18 years and older with Serious Mental Illness (SMI) who are admitted to an acute inpatient psychiatric unit during a psychiatric crisis. Many women receive case-management services from the Department of Mental Health.
Theory and Assumptions
Mission. The Women's Issues Program does not have an explicit mission statement, distinct from that of the Department of Psychiatry, which includes a commitment to gender and culture specific treatment. As noted above, the program was developed "in reaction" to highly objectionable practices and poor outcomes for women with mental illness who were pregnant. One of the program's founders defined the original mission of the program as "providing reproductive choice" and improving reproductive health for women with serious mental illness. Currently, that mission has expanded to encompass the more generalized empowerment of women with mental illness to have choice in all areas of life, including their reproductive health. For example, a weekly clinic run by a nurse practitioner for routine OB/GYN examinations is available for hospitalized women.
Program Goals. The primary goal of the program is to improve the quality psychiatric and medical services available for women with serious mental illness. This includes the central goal of providing adequate information and support so that women can identify priorities and be empowered to participate in the decision-making process about their own treatment and life-course. The program also aspires to enhance the relationship between psychiatry and OB services, and provide specialized training in the interface of OB and psychiatry, so that the care of women with serious mental illness is improved.
Theoretical Orientation. The program is founded upon a feminist psychodynamic approach that strives to demystify treatment, and encourage empowerment and collaboration. However, patients are sometimes treated against their will when providers deem it necessary for safety. The program is also eclectic in practice as needed. Treatment modalities include psychopharmocology, and cognitive behavioral models in addition to feminist principles.
Community Context
California Mental Health System. The California Mental Health System is organized and funded at the county level. Consumers are eligible for case-management services only after they have used over $100,000 in mental health services. Consistent, preventive care is generally non-existent. According to providers, this practice "trains people to be in crisis" (and use costly inpatient services) because resources are not available until there is a crisis. In addition, it allows potentially manageable conditions to progress to more chronic and entrenched disorders that can not be well managed even with case-management that becomes available after high-end service use.
Community Strengths and Weaknesses. San Francisco is rich in resources. However, organization of mental health services at the county level obscures this wealth with respect to those in need. The city of San Francisco is a both a city and a county. As a city, it attracts a large population, including mental health consumers seeking increased resources. As a county, however, San Francisco is small relative to the population it must support. The proportion of poor, inner-city neighborhoods to middle class and affluent ones is high. Thus, although relatively rich in resources, supply does not meet demand.
Mental Health Resources. According to providers and consumers, mental health issues are deeply embedded in local economic and social issues. San Francisco has one of the highest standards of living in the United States. There is little affordable housing available. Adults with mental illness are therefore at high risk for homelessness and substandard housing in crime-ridden neighborhoods. Substance abuse is a major local issue, and there are limited treatment facilities available. San Francisco reportedly has the highest rate of substance related Emergency Room visits in the United States.
Community Collaborators
Providers on the Women's Team are familiar with community resources and the Women's Issues program has strong collaborative relationships with the High Risk OB Clinic described later in this volume, the Community Crisis Resolution Team, and the Community Case Management program. The availability of these resources in the community and the long-standing collaboration among providers allow for continuity of care and enhanced follow-up, and stability for women seen by the Women's Team in psychiatry.
Agency Context
The Women's Issues Program is located on an inpatient psychiatric unit at a public teaching hospital in San Francisco. The program is fully integrated into the larger unit. Staffing consists of a multi-disciplinary team of psychiatrists, psychiatric nurses, psychiatric social workers, a psychiatric occupational therapist, a psycho-pharmacologist, and trainees across all disciplines. Pregnant women can receive both psychiatric and prenatal care during an admission. Consultation is available from all services in the hospital.
Program Model: Services and Interventions
Program participants are offered all services available to patients on the inpatient psychiatric units at the hospital. They receive a comprehensive assessment and evaluation of immediate, short-term, and long-term needs, medication consultation, neuropsychological testing if needed, group therapies as offered on the unit, and discharge and follow-up planning (referral to and contact with community resources). These services are delivered on a unit that houses mostly women patients, and are provided by predominantly women providers who are trained in and sensitive to the interface of women's issues (e.g. oppression, poverty, trauma) and psychiatry. Because the hospital is a public hospital, there may be men present on the unit, and the Women's Team may work with men admitted for general psychiatric problems. Specialized groups can be arranged to address specific women's issues (e.g., parenting, domestic violence) as requested by patients. As noted above, an OB/GYN consult is often provided as women with SMI are less likely to receive adequate GYN care in the community.
Evaluation
The Women's Issues Program does not collect any formal outcome data. Client progress is monitored during the inpatient stay. Individualized goals are established for the period of hospitalization and discharge. As goals are achieved, women are discharged from the program and unit. The program does aggregate data on participants' characteristics.
Demographics. Approximately one-third of the women are African American one-third Latino, 20% Caucasian, and 15% Asian.
Diagnoses. The most frequent diagnoses among the women admitted to the Women's Issues Program are Schizophrenia, Bipolar Disorder, and Major Depressive Disorder.
Co-occurring Disorders and Issues. Substance abuse is a very common co-occurring disorder among the women involved in the program. All women experience some co-occurring issues such as poverty, homelessness, or history of trauma or abuse.
A Success Story
The Program has been very successful in raising awareness about reproductive health issues among psychiatric providers, and about mental illness among OB providers. The relationship between Psychiatry and OB/GYN at San Francisco General Hospital has been enhanced through the program's existence and cross-training of both senior providers and trainees. Providers in psychiatry and OB have become more knowledgeable about the diverse and intersecting needs of women with SMI, and are eager for collaboration across disciplines. Ultimately, this collaboration has resulted in improved care for women with SMI.
For example, a middle-aged woman of Japanese origin with schizophrenia was hospitalized after she was widowed. She initially refused a GYN exam offered by the Women's Team. However, after building trust with her providers who provided encouragement and education about the importance of reproductive healthcare, she agreed to the exam. Cervical cancer was diagnosed and treated successfully with chemotherapy and radiation. Without the diligence of the Women's Team and the availability of GYN healthcare for women admitted to psychiatry, this woman would most likely have died.
Challenges
Numerous challenges confront psychiatric care for women in San Francisco. From the perspective of the Women's Issues program, providers point to a lack of case-management services for women with SMI, and poor follow-up in the community as primary barriers to success. Case-management is only provided to women after they have already become "high-end" consumers of mental health services. According to providers, this explicitly non-preventative approach increases the likelihood of psychiatric crises, and contributes to the creation of chronic mental illnesses and high-end service utilization. In addition, there is a lack of inpatient and outpatient care for women with co-occurring SMI and substance abuse disorders (i.e., duel-diagnosis), and for parenting women with their children. Programs for women with SMI who wish to retain custody of their children are "essentially non-existent." Finally, a shortage of affordable housing and other community resources add obstacles to women's mental health. All of these dynamics contribute to increased likelihood of poor mental health for women, psychiatric crises, and loss of child custody.
Next Steps
Changes in the program are currently contingent on changes in funding structures. Providers agree that case-management services are inadequate and available only after a chronic illness has been established, and custody loss highly likely. Funding for preventive services and increased community-based services is critical for this population.
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