This is the first of two articles that will examine mental-health care in Sonoma County in the wake of Santa Rosa Memorial's decision to close its inpatient psychiatric unit.

With the decision by Santa Rosa Memorial Hospital to close the last inpatient psychiatric unit in the county, psychiatry professionals across Sonoma County are feeling the strain from too few beds and too little resources for their patients.

"The competition for bed space will be fierce," said Art Ewart, Sonoma County's mental health services director. "There are likely many reasons. First, it's a sellers market, the hospitals can be very choosy about who they take. Often times they will find reasons to not admit very difficult clients. Also, they expect comprehensive and full insurance coverage before accepting clients."

Last July the Norton Center, the last non-emergency psychiatric unit run by the county, closed. In February, Memorial Hospital announced plans to close its 18-bed inpatient psychiatric service after the unit reportedly lost $22 million over the last three years. Now, the county can only operate emergency care through the Psychiatric Emergency Services in Santa Rosa, which does not hold clients for more than 23 hours.

With nowhere to turn within the county, more and more patients are being sent to facilities in Marin County, San Francisco and Vallejo for long-term psychiatric treatment. Critics say the county is passing its responsibility on to other areas.

"What makes folks in Sonoma County think San Francisco makes money on serving people with mental health-

care needs? Of course we don't," wrote Ed Harrington, controller of the city and county of San Francisco in a letter to the Press Democrat. "We just happen to believe it is our responsibility to take care of our family members, friends and neighbors who are in need. We make the tough decisions to raise local taxes to pay these bills and we get a lot of grief for it."

Ewart said, however, that the county never sends a patient out of the area without picking up the bill. "Taxpayers from other counties do not pick up the cost of these clients," he said.

Even though the county contracts with other hospitals to provide care for Sonoma County residents, that does not mean a bed is always available. Sonoma-based psychiatrist Dr. Dick Kirk said he has spent countless hours calling hospitals in a vain search for somewhere to send his patients. And he has found it increasingly difficult to place his patients since Norton closed.

"I used to call up and people knew who I was," he said, indicating personal relationships made it easier to find a bed. "It's nobody's fault, it's the insanity of the system."

But if a well-known psychiatrist like Kirk cannot find a bed, what chance does the average mental health patient have? The Sonoma Index-Tribune decided to find out what would happen if an average person called area hospitals seeking advice for how to deal with a mental health crisis.

The following is an actual conversation with the county's Psychiatric Emergency Services. The situation, while fictional, still represents a very real issue.

I-T: "I'm worried about my neighbor, I'm really worried he's having some serious mental health issues..."

PES: "Could you please hold?" (On hold for three minutes). "Can I help you?"

I-T: "Yes, it's my neighbor. I know he has mental health issues, but he's just been freaking out lately and I'm..."

PES: "Please hold." (On hold for two minutes) "Yes?"

I-T: "I have this neighbor who I look out for. I believe he's schizophrenic but I'm not really sure. I think he's gone off his medication. He's been talking to himself and acting really paranoid. He's really not acting right and I am worried. What should I do? How can I help him?"

PES: "Is he a danger to himself or others?"

I-T: "I don't know. Definitely not to others, and I don't think himself. I know he has a history of..."

PES: "It doesn't sound like an emergency. Call his primary psychiatrist."

I-T: "He doesn't have a primary psychiatrist, he doesn't have insurance."

PES: "Well, it doesn't sound like an emergency and so we can't treat him here."

The official with Psychiatric Emergency Services proceeded by giving the names and numbers of some local psychiatry clinics.

The I-T made similar inquiries to Santa Rosa Memorial Hospital, Sutter Medical Center of Santa Rosa, Queen of the Valley Medical Center in Napa, St. Helena Hospital's Center for Behavioral Health in Vallejo, Marin General Hospital and Sonoma Valley Hospital. Most of the hospitals said they could not give medical advice over the phone, and said to contact the patient's psychiatrist. After learning he had no psychiatrist, most offered suggestions on local clinics and services that provide free or discounted psychiatric care.

"If it gets worse, you can bring him to an emergency room, they can help get him back on medication," said a nurse from Sonoma Valley Hospital.

It became obvious after spending literally hours on hold with different hospitals that it takes a lot of patience to find advice on dealing with a mental health crisis.

Kirk said it is so difficult to get patients placed that many smaller clinics, such as the Sonoma Valley Community Health Center, try to fix the problem in house rather than spend the time searching for a hospital bed.

"It's just too frustrating to try to get people to emergency treatment elsewhere," Kirk said.

Inpatient psychiatric units have been closing up and down the state for years. State and federal reimbursement for mental-health care is so low that hospitals treating the indigent population get reimbursed on average for only three days of a nine-day stay. With rising health-care costs, hospitals like Memorial do not have incentive to keep these units open.

"Without a national health-care policy and universal health-care, mental health treatment will increasingly default to the public sector," Ewart said.