Why are there so many psychotic people on the streets of San Francisco?

Guest Contributor: John Brim,  M.D., Diplomate, American Board of Psychiatry and Neurology


I am a psychiatrist working with a non-profit agency that exclusively serves the homeless population.  It will come as no surprise that many of the people we serve are mentally ill; a large number have schizophrenia.  This devastating disease, untreated, can leave an individual helpless to deal with the challenges of everyday life, much less the challenges of being homeless on the dangerous streets of San Francisco.

Without medication, unable to distinguish the real from the unreal, street-dwelling schizophrenics frequently reject the services offered them and fall easy prey to street predators.  Lacking the ability to distinguish innocent strangers from those who are out to do them harm, some become severely agitated.  With medication, many homeless individuals with schizophrenia can be restored to a level of functioning that will enable them both to survive on the street and to cooperate with those who are working to house them.  Why, then are there so many psychotic people on the streets?  One major reason–they can’t get the type of medicine that is most likely to help them?

San Francisco’s county health plan covers some of the modern (“second generation”) antipsychotics but only provides them in the short-acting form—tablets or capsules.   Treating homeless schizophrenics with oral medications is a recipe for failure.  The nature of life on the street makes pills virtually useless.  Our patients routinely have their medications stolen while they sleep.  They have no place to securely store things, hence they lose their pills.  They simply don’t have the means to take their pills on a day in day out basis, as they must in order to recover.

It doesn’t have to be this way.  We now have modern (second generation) antipsychotic drugs that don’t need to be taken on a daily or even weekly basis.  These medications can be given in an injection that lasts a month.  Unfortunately San Francisco’s health plan for the poor won’t cover these modern long acting antipsychotics.

The problem, I suspect, is that the modern long acting antipsychotic medications have a higher initial cost.  Pills seem a cheaper option, even though they usually aren’t effective for our homeless patients.  In reality, county officials are wrong if they believe pills are cheaper.  There is mounting evidence that long acting medications can actually save money.  They may cost more “up front” but they offset their higher cost by reducing the need for police, ambulance, and hospital services.  Our neighbor, Alameda County, has made long acting antipsychotics available to the poor and homeless through its county health plan.  Unfortunately San Francisco has not.  The sad fact is that far from leading the way in helping the homeless, the government of San Francisco lags behind and fails to provide even the basic standard of mental health care for these, its most vulnerable, residents.




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