BY MARISA KENDALL | CalMaters
Doctors on the front lines of California’s homelessness and mental health crises are using monthly injections to treat psychosis in their most vulnerable patients.
As Dr. Rishi Patel’s street medicine van bounces over dirt roads and empty fields in rural Kern County, he’s looking for a particular patient he knows is overdue for her shot.
The woman, who has schizophrenia and has been living outside for five years, has several goals for herself: Start thinking more clearly, stop using meth and get an ID so she can visit her son in jail. Patel hopes the shot — a long-acting antipsychotic — will help her meet all of them.
Patel, medical director of Akido Street Medicine, is one of many street doctors throughout California using these injections as an increasingly common tool to help combat the state’s intertwined homelessness and mental health crises. Typically administered into a patient’s shoulder muscle, the medication slowly releases into the bloodstream over time, providing relief from symptoms of psychosis for a month or longer. The shots replace a patient’s oral medication — no more taking a pill every day. For people who are homeless and routinely have their pills stolen, can’t make it to a pharmacy for a refill or simply forget to take them, the shots can mean the difference between staying on their medication, or not.
“They’ve been an absolute game-changer,” Patel said.
Street medicine teams bring the shots directly to their patients wherever they are — whether it’s in a tent along Skid Row in Los Angeles, in a dugout in the middle of a field in the Central Valley, or along the bank of a stream in Shasta County. Doctors can diagnose someone, prescribe the medication, get their consent and give the shot within a matter of days — or sometimes even more quickly — and with minimal paperwork and red tape. They don’t need a psychiatrist’s sign-off.
It’s estimated that California is home to more than 180,000 homeless residents. How to help the sickest of them — people with severe, untreated psychosis who might wander into traffic or otherwise put themselves in danger — has become a hot-button issue, with Gov. Gavin Newsom and state lawmakers creating new and sometimes controversial ways to get people into treatment. In a recent UCSF survey of homeless Californians, 12% reported experiencing hallucinations in the past 30 days, and more than a quarter said they’d ever been hospitalized for a mental health condition.
Doctors say the goal of giving an antipsychotic shot to someone living in an encampment is to get them thinking clearly, so that they can start engaging with social workers, sign up for benefits and get on housing waitlists. While Newsom’s new CARE Court allows judges to order people into mental health treatment, and other recent legislation makes it easier to put people with a serious mental illness into conservatorships, doctors administering street injections take a different approach. The treatment is voluntary, and people can get help where they are, instead of in a locked facility.
Some success stories are dramatic. Doctors talk about patients who one day are babbling incoherently, and a week after a shot, are having conversations.
“It’s been pretty common that that’s the initiation of, ‘We’re going indoors,’” said Dr. Coley King, director of homeless health care for the Venice Family Clinic in Los Angeles. He said he’s seen dozens of patients get off the street after taking these shots.
As with any medication, the shots can have side effects. And while a patient can stop taking a pill and generally put a stop to a negative reaction, once they’ve been given a shot, they have no choice but to wait a month for the drug to wear off.
Despite some street doctors’ rave reviews, injectable antipsychotics still aren’t reaching everyone who experts say they could help. Street medicine teams report having just a handful of patients on these medications at any one time (King’s team in Los Angeles has about two dozen). Some patients don’t want the shots, balking at the idea of having a drug in their system for an entire month, especially if they have feelings of paranoia related to health care.
And street doctors complain that hospitals still seem to prefer discharging patients from temporary psychiatric holds with a bottle of pills they may or may not take – instead of giving them a long-acting shot.
Losing track of patients
One of the biggest challenges street doctors face in administering these shots is following up with patients.
In Kern County, Patel hasn’t seen the woman he’s looking for since his team gave her first antipsychotic shot almost two months ago. Now she’s past due for another dose.
It’s worrying, Patel said, “because I don’t know how she did on it.”
The last place they saw her was at an encampment known as “The Sump” in the Central Valley farming community of Lamont, where she lived in a plywood shack along a muddy ditch behind a farm. But code enforcement recently cleared everyone out of that area, and Patel’s team doesn’t have a phone number or any other way to contact her.
The first place they look is another encampment known as “the Shrine,” because it once held a shrine to Santa Muerte, a Mexican saint of death often prayed to by drug dealers. The team drives the van through an empty field of dead, yellow grass. Several people are living in room-sized pits they’ve dug into the dirt and covered with tarps and sheets of metal. Next to the vacant land is a vineyard, with rows of vines dotted with small, green grapes.
She’s not there, so the team hands out sack lunches and bottles of water, then gets back in the van and leaves.
“We’ve seen results,” said Kirk McGowan, a street medicine nurse with Akido. “But we’ve seen more failures than successes. That’s just kind of the nature of the situation.”
Who should prescribe antipsychotic injections?
In most cases, the people prescribing and administering antipsychotic shots in homeless encampments are general practice doctors — not specially trained psychiatrists. That’s because despite the growing prevalence of street medicine, street psychiatrists are still rare, according to a recent USC report.
“You look over your shoulder and there’s not a psychiatrist there helping you out,” King said. “And we want to meet the need. We want to take care of these patients. They’re really, really ill, they’re really disorganized, and suffering and dying on the streets.”
There are no legal restrictions preventing a general practice doctor from administering these injections. But some practitioners think the responsibility should be reserved for psychiatric providers.
“These medications are in there for an extended period of time,” said Keri Weinstock, a psychiatric nurse practitioner who practices street medicine in Shasta County. “They do come with risks. There are specialty things that come along with some of these specialty meds, and it’s a lot to learn when you have to know everything else, too.”
Some street doctors who give these shots seek out additional psychiatric training, while others learn on the job — often with a psychiatrist on speed dial, just in case.
“I don’t think it’s rocket science to diagnose schizophrenia, as long as we’ve done it with some thoughtfulness,” King said.
In-the-field diagnoses aren’t always clear-cut, Patel said. Sometimes, people do such a good job of hiding their symptoms that it’s hard to tell they’re dealing with psychosis. Or, instead of experiencing obvious hallucinations or other symptoms commonly associated with schizophrenia, patients experience “negative symptoms,” such as extreme social withdrawal.
When those types of cases arise, Patel calls a psychologist for a second opinion.
While these drugs are generally considered safe, they do come with a risk of side effects that can include dizziness, sedation, stiffness and decreased mobility. Those symptoms might be no big deal for someone living in a house, but for someone on the street, could be catastrophic, said Dr. Shayan Rab, a street psychiatrist with Los Angeles County’s Homeless Outreach and Mobile Engagement team. It could make someone more vulnerable to being attacked or robbed, or prevent them from accessing food or shelter.
“It’s a very serious kind of action that’s being taken and a lot of time needs to be spent before you say, ‘Hey, this individual is safe for a long-acting injection,’” he said.
To make sure a patient doesn’t have an adverse reaction, doctors typically give them an oral dose of the same medication for a few days before administering the shot.
There’s also a risk that after a street doctor gives someone a shot, that patient could later get sent to the hospital on a temporary psychiatric hold. Doctors there might not know the patient already has a long-acting dose of antipsychotic medication in their body, and might give them another dose.
Before giving someone a shot, Dr. Aislinn Bird wants to be 100% sure their symptoms are actually caused by psychotic disorder, such as schizophrenia, and not complex PTSD, major depressive disorder, methamphetamine use, or something else. Overdiagnosis of psychotic disorders is rampant, especially in the African American community, Bird said.
“You have to be sure you really know the correct diagnosis,” said Bird, who serves as director of Integrated Care at Health Care for the Homeless in Alameda County.
But Dr. Susan Partovi, who practices street medicine on Skid Row in Los Angeles, said that’s an “antiquated way of thinking.” When someone is experiencing psychosis, it’s an emergency that needs to be treated as soon as possible, no matter the cause, she said. Her preference is to treat the symptoms first, and then see if the patient wants to work on other issues, such as substance use.
Antipsychotic injectables, such as Abilify and Invega, tend to be most prevalent in street medicine practices. But street doctors also administer long-acting injectable HIV medication, as well as medication for addiction such as Vivitrol — an injectable, long-acting medication that can help reduce cravings for opioids and alcohol, and protect against overdose.
Silencing the voices in his head
Ricardo Fonseca Jr., who goes by “Ricky,” has been homeless for two years, living in a tent behind a Dollar Tree, then in a park in rural Kern County. The 31-year-old said he was working as a welder until he had a sudden mental breakdown and started hearing voices.
The voices said horrible things to him. Sometimes they yelled, and he yelled back, scaring those around him. He used methamphetamine to cope.
“It was getting to the point where I just felt like killing myself,” Fonseca said.
Two months ago, Fonseca started taking a monthly shot of the antipsychotic drug Abilify. Since then, “everything’s changed,” he said.
Now, Fonseca is staying at a friend’s house and considering going to school. He says he’s stopped using meth.
“I can finally hear the birds and the crickets,” he said. “I couldn’t hear them before.”