Closing the Revolving Door of Severe Mental Illness

Bipin Subedi, MD, explores how health systems can better care for patients with severe mental illness who cycle between hospitals, homelessness, addiction, and the justice system. He argues that acute inpatient treatment, while essential, is rarely sufficient on its own. Preventing the revolving door of repeated hospitalizations requires psychiatry to extend beyond hospital walls and build integrated systems that follow patients into the community.

Drawing on his leadership at NYU Bellevue and his background in forensic psychiatry, Dr. Subedi describes a model of care built on sustained relationships, flexibility, and continuity. He reflects on how programs like transitional housing and mobile post-discharge support can provide the “scaffolding” patients need when insight and executive function are impaired by psychosis. The conversation closes with practical guidance on strengthening medication adherence—particularly through thoughtful use of long-acting injectables—and on meeting patients where they are to advance more humane, effective care.

Bipin Subedi, MD, is Associate Professor of Psychiatry at NYU Grossman School of Medicine and Chief of Psychiatry at NYU Bellevue Hospital. He is a forensic psychiatrist with prior leadership experience in New York City’s jail system.

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01:36 Bellevue’s Mission and Rising Clinical Complexity
04:43 Extending Care Beyond the Hospital Walls
05:15 Bridge to Home and Transitional Stabilization
10:44 Forensic Psychiatry and the Justice System
14:17 Psychosis and Impaired Insight
15:53 Post-Discharge Scaffolding and Critical Time Intervention
18:47 Preventing Relapse with Long-Acting Injectables
22:36 Meeting Patients Where They Are

This episode is intended for psychiatrists, mental health clinicians, and health system leaders interested in serious mental illness and innovative models of integrated community care.

This discussion is for educational purposes and does not substitute for individual clinical judgment or patient care.

Senior Producer: Jon Earle

Transcript

[00:00:00] BIPIN SUBEDI, MD: What's interesting about a jail setting—kind of sad about it too—is that it's one of the few settings in our country where someone has a constitutional right to healthcare. In addition, there's nowhere else for me to discharge someone. It's a cohesive ecosystem of care. It's helped me realize that our role has to go beyond just the four walls of the hospital and really include stepping into the community and seeing ourselves as partners and support for individuals and for systems who are caring for those who are ill.

[00:00:35] CHARLES MARMAR, MD: Welcome to Insights on Psychiatry. I'm Charlie Marmar, the chair of the Department of Psychiatry at NYU Grossman School of Medicine and Langone Health network, and it's my great privilege and pleasure today on our podcast to be in conversation with Dr. Bipin Subedi, who is an Associate Professor in our department and is Chief of Psychiatry at NYU Bellevue Hospital. I would love to have a conversation with you today about how you are thinking about advancing the understanding and empathic care for the most complex psychiatric patients, including, unfortunately, those with homelessness and severe addiction and often either treatment-refractory psychosis or who are not compliant with treatments that might be effective for them. So welcome, Bipin.

[00:01:35] BIPIN SUBEDI, MD: Thank you.

[00:01:36] CHARLES MARMAR, MD: Tell us a little bit about Bellevue, its historic mission, and how we're thinking about next-generation care for our NYU Bellevue patients.

[00:01:48] BIPIN SUBEDI, MD: Yeah, absolutely. At NYU Bellevue a high proportion of our patients suffer from homelessness, don't have family supports, have histories of trauma and abuse, as well as substance use and complex medical needs. So when treating complex patients, we really don't have a choice. We have to evolve to meet the needs of the patients that we have. And in our emergency room, we've seen over the last year a significant increase in presentations of complex patients, but just volume overall. So the work that we do starts in the emergency room, ensuring that we have a proper evaluation, that we're integrating someone's substance treatment needs, medical needs, and are liaising with their treatment teams in the community to provide an appropriate assessment and putting a robust treatment plan in place. I think also a lot of times hospitals focus mostly on medication. What's even more important is that the care we provide is integrated into the community so that the work that we do in the hospital can persist once the patient is discharged.

[00:02:53] CHARLES MARMAR, MD: You and I have had many conversations about the challenges we face in the care of the most complex psychotic patients with homelessness and addiction and, unfortunately, violence potential at times—many, many problems. Also, very, very difficult to care for these patients medically as well as psychiatrically, and they, tragically, often suffer very poor general medical cardiometabolic health, even dental health. It's very, very difficult. And of course, as a field in psychiatry, we were all challenged by these patients. But as you think about it, I think about several levels to the problem. One level is these patients used to be cared for in institutional settings long-term, some of which were not very good or humanistic, some of which were quite good and provided a humanistic environment for their care. But with the deinstitutionalization of the seriously mentally ill in the 1960s and 1970s, have we ever met our social contract for providing an alternative structure for those patients?

[00:04:09] BIPIN SUBEDI, MD: I don't think so. And I think to this day there's still a lot of emphasis on the acute hospitalization solving all the problems for a patient who's hospitalized. And again, that's why I think it's important that we not only think about what the community resources are, but the hospital itself builds itself out into the community to provide support for patients, and that's the work that we're doing at NYU Bellevue.

[00:04:32] CHARLES MARMAR, MD: Tell us a little bit about the innovative work NYU Bellevue is doing to break down the silo between acute care and community care.

[00:04:43] BIPIN SUBEDI, MD: Absolutely. So we have our existing programs in place that provide mobile, flexible care for patients in the community. That includes our Assertive Community Treatment teams, or ACT teams. These are teams of psychiatrists, social work, nursing staff, case workers who can meet patients in the community as well as in the office setting. The key here is flexibility and where they can meet the patient, how they support the patient, and connect them eventually to housing if needed, but also to more stable long-term care. We have a really exciting program at NYU Bellevue that launched in September. Charlie, as you know, Bridge to Home—it's a collaboration with NYC Health + Hospitals Central Office and NYU Bellevue. It's a facility in Midtown West where we provide transitional housing with the plan to connect people to supportive housing who are SMI and are homeless. So we opened in September. We have a psychiatrist on-site, social workers on-site, case management on-site, so we can provide integrative, holistic care and also look to housing to maintain stability for patients.

[00:05:50] CHARLES MARMAR, MD: In order to protect patient privacy, we'll use a kind of fictional composite case. A 48-year-old person comes in with a chronic schizophreniform illness, stimulant abuse, homelessness, and a history of some involvement with the judicial system for violence-related activity, mostly the product of their serious mental illness. They come in, they come through our Comprehensive Psychiatric Emergency Program. They're carefully assessed. They're admitted, and they are treated well within the time limits we have. And then they move to that program. How long can they be in that program? And I love the name "Bridge to Home." How does it function as a gateway or bridge to stable long-term care so that we won't see that patient again in three weeks in the CPEP?

[00:06:44] BIPIN SUBEDI, MD: Sure. So there's a lot of things that we're doing to maintain stability. So first of all, having Bridge to Home be part of the hospital footprint or continuing care is extremely important. So we have relationships with not only the providers at Bridge to Home, but they know our providers in CPEP, they know our providers on the inpatient units. There's communication and then coordination of care that can occur. We then have robust treatment on-site, too. So we're providing groups, providing individual therapy. We're providing psychiatric treatment. But since the care is also in the same facility where people are living, we can have lower-amplitude, high-frequency interactions with our patients. So we can build real relationships that are outside of just the office setting, which goes a long way in building rapport as well as compliance and engagement with treatment, too. And we've seen a tremendous amount of success, actually, in the early days—and we're still evolving and filling in terms of our census—but we're seeing upwards of 90 to 100 percent compliance with outpatient visits, with medications. So it's a truly remarkable model. In terms of length of stay—and I'll keep on bringing up flexibility because I think flexibility is key—we shoot for about six to nine months, but really we anticipate patients can stay up to a year. But we will keep patients on-site and work with them until we can connect them to supportive housing, because that is the final outcome that we're looking for.

[00:08:05] CHARLES MARMAR, MD: How do we select patients from among our very large number of complexly ill patients? How do we select those that might preferentially benefit from this program as opposed to a more standard continuum of care?

[00:08:23] BIPIN SUBEDI, MD: Yeah. Well, that's a great question because I think one of the main limitations in outpatient care—there's often barriers and restrictions for patients, and there's a real reluctance to accept and work with high-risk patients. So I think with Bridge to Home, we really worked hard to balance that, to feel that we have the capacity to treat patients with increased needs and maybe higher risk, but also have to be mindful that it's a community setting. The first category I would say is an individual needs to be able to be safely managed in the community. So if someone needs inpatient level of care, that is not the right place—Bridge to Home is not the right place for them. And so if they need longer care, they would go to a state facility or stay at one of our longer-care units in the hospital. And an individual also has to be willing to go to Bridge to Home. So the voluntariness is important, too. But outside of that, it's serious mental illness, being an adult over 18. And then also right now it's only open to men, and we hope to have a female facility soon.

[00:09:22] CHARLES MARMAR, MD: And are we prioritizing patients who otherwise might experience a revolving-door system of care where they get excellent care on the acute side of Bellevue or somewhere and then quickly relapse in the community?

[00:09:38] BIPIN SUBEDI, MD: Yes, so those with a history of homelessness and also inconsistent access to care and engagement in care.

[00:09:44] CHARLES MARMAR, MD: Another component to the difficulty our patients experience is because of their illness and because of their psychotic symptoms and their paranoia, for example, and because of their use of drugs, they can be impulsively violent, and they can end up entangled with the judicial system. One of the things that I think is so fortunate for us is that we have you as our chief of service at Bellevue and vice chair for Bellevue. You are a distinguished forensic psychiatrist and you have experience of being a leader at Rikers, one of the largest jail systems in the country. Tell us how, as a forensic psychiatrist who has been the head of medical care at Rikers, how do you think about the care of psychotic patients who move in and out of the justice system?

[00:10:44] BIPIN SUBEDI, MD: I can go back and talk about my interest in forensic psychiatry and where that came from. As you know, I started my career on the civil inpatient units at Bellevue, where the focus a lot of times is length of stay and patients wanting to leave. When I moved to the inpatient forensic unit at Bellevue, what I noticed was that a lot of patients wanted to stay, and they asked me to not discharge them back to Rikers. And so I was able to build a relationship with them in a way that I felt like I could not on the civilian units. And that really kind of carried forward with me even when I went to Rikers. And what's interesting about a jail setting—kind of sad about it too—is that it's one of the few settings in our country where someone has a constitutional right to healthcare. In addition, there's nowhere else for me to discharge someone out of our system. So it really forced us as a healthcare agency to evolve to meet the needs of our patients. So a lot of these problems we see in the community have to do with systems fragmentation and lack of integration. So in the jail system, it's a cohesive ecosystem of care. And so I could see the benefit of being able to have integration under one system. So I think I've taken that with me to Bellevue, and it's helped me realize that our role has to go beyond just the four walls of the hospital and really include stepping into the community and seeing ourselves as partners and support for individuals and for systems who are caring for those who are ill in New York City.

[00:12:11] CHARLES MARMAR, MD: Bipin, one of the things that you and I also have talked about, and I think every psychiatrist in practice is very appreciative of this, is that the care of psychiatric patients generally is somewhat different from the care of general medical patients. In the case of psychiatric patients with non-psychotic illnesses—stress, anxiety, depression, and related illnesses—often the issue is reasonably good executive function and reasonably good insight and judgment about their own illness, but a deep sense of shame and stigma about it and a reluctance to see themselves as psychiatrically ill, resulting in delayed treatment-seeking and sometimes difficulty with compliance with treatment, also for reasons of shame and other concerns—concerns about career and family standing and so on. In the case of psychotic illness, those who suffer with schizophreniform illnesses, bipolar psychosis, and other psychotic illnesses, they have an additional complexity, which is that the organs of insight and judgment themselves are directly damaged or impaired in the illness, making it difficult or sometimes impossible for the person to assume responsibility for the care of their own illness. That is a unique thing. A patient has a complex cancer—they're desperate to get the best care. Someone with a schizophrenic illness may be desperate not to get any care based on their delusional thinking or otherwise. How do you think about how do we develop a system of care which takes into account the problems in insight and judgment and executive dysfunction in psychotic illness?

[00:14:17] BIPIN SUBEDI, MD: I think the first step is ensuring that we have maximized our medication interventions and ensure that someone is in as close to remission as possible in the hospital. I think that's key, because sometimes residual symptoms are unrecognized and contribute to functioning and insight. I think then beyond that, what's important is that we provide individuals with additional support again when they transition out. When you're in the hospital, you have nurses on-site 24/7, we give you your food, we give you your medications, we have a structure for you during the day, and then we often discharge people out into the ether without these day-to-day and frequent supports. So at Bellevue, in addition to thinking about programs like Bridge to Home, where there's all that support on-site—again, that's only available for a small portion of individuals in the hospital—so for those who are going into settings where there isn't an integrated treatment team on-site, there's other interventions that we can utilize, too. So a big one that we're actually starting in January of next year, hopefully, is Critical Time Intervention. So this is a team of social workers, nurse case managers that will work for people who are discharged from either a psychiatric emergency room or inpatient units for up to six to nine months and provide them with any support that they need. So that's going to appointments, whether that's getting connected to housing, whether that's getting an ID—it's a holistic support that they provide rather than one that's just focused on treatment.

[00:15:53] CHARLES MARMAR, MD: So in essence, what those teams are doing—from the framework I'm discussing with you now—what you might think of what those teams are doing, or what Bridge to Home is doing, or what the better state facilities used to do, is provide an external organ of insight and judgment.

[00:16:15] BIPIN SUBEDI, MD: Absolutely.

[00:16:16] CHARLES MARMAR, MD: To compensate for the patient's deficit until they're able to do that.

[00:16:22] BIPIN SUBEDI, MD: That's absolutely right. To provide that scaffolding. And I'll also say that we are utilizing peers more and more in our setting.

[00:16:29] CHARLES MARMAR, MD: Peer-to-peer support.

[00:16:30] BIPIN SUBEDI, MD: Correct. So peers with lived experience, because oftentimes it can be difficult for patients and even for doctors to relate to those who have mental illness. So utilizing peers who've had the experiences of being in the hospital, who know what it's like to be involuntarily hospitalized, to be working with individuals as they leave to help improve the relationship and then connection to the treatment teams, so they serve as that bridge.

[00:16:54] CHARLES MARMAR, MD: I've had the challenge at times of consulting on patients from NYU Bellevue and other patients suffering with psychotic illnesses in our department or that I consult on, where the patient has fallen ill, has come into one of our psychiatric inpatient units—and our department is unusual because we have four university hospitals and we have three city hospitals and three or four state hospitals. We have over 700 inpatient psychiatric beds in the NYU Department of Psychiatry family of care. So therefore we treat an enormous number of very ill patients. Most get excellent—I think we're very proud—they get excellent care while they're in the hospital. But, you know, and we've talked about this, some of them will have a successful hospitalization, decline long-acting injectable medication, and it's difficult to require them to do that. They'll be given their discharge medications, and as they're walking out of Bellevue Hospital, they'll take the prescription they've been given of their neuroleptics or their Clozaril or whatever they're given and throw it in the garbage can as they're leaving the hospital. And two weeks later, they're picked up by the NYPD in the subway system because they've been threatening somebody on a platform. And without the medication and without the value of long-acting injectables, their executive functioning quickly degrades and their symptoms rapidly recur. What are your thoughts about that challenge?

[00:18:47] BIPIN SUBEDI, MD: First of all, I want to reinforce the extreme importance of maximizing long-acting injectables on inpatient units. And because of the patients that we treat and because we recognize the importance of long-actings. A significant number of our patients who are discharged are on these medications. But of course, not everyone is appropriate for long-acting. They may not also accept these medications. So for those on oral medications who are leaving, where there's a high risk of non-compliance, I think the key, going back to what we said earlier, is making sure there's a scaffolding in place to support them, to try to continue to build their insight, to monitor them frequently so that we can have a lower threshold to provide them with support, bring them back to the hospital if needed, and then recognize that it's a process. For some patients it's going to take several hospitalizations in order to recover, but that there can't be gaps in care—that we have to make sure that there's a scaffolding in place throughout that time, working with the hospital, so that it's a system where we are supporting them both out and in the hospital and working them towards having insight and stability.

[00:19:52] CHARLES MARMAR, MD: And you said here today and elsewhere that one should never underestimate the importance of long-acting injectable medications where possible. As someone with more experience in engaging patients who need LAIs and struggling with their reluctance to take them, what have you learned from that experience and what advice do you have to us in practice about how can we gain the trust of our patients to actually take a course of LAIs, which could actually make an enormous difference in their life?

[00:20:32] BIPIN SUBEDI, MD: I think there's several things that I'd recommend. First of all, it helps to first stabilize an individual on oral medication. Sometimes people are a little quick to start the long-acting injectable, and so if someone's symptoms and insight has more fully improved, they may be more willing to accept a long-acting injectable. So just being really thoughtful about the timing of when the medication is offered. I think also people assume patients won't want to take long-acting injectables, so don't even bring it up. But I think there's ways to frame it to improve buy-in. So, you know, reminding patients that they won't have to take a medication every day, won't have to go to the pharmacy. I think sometimes that also works in terms of getting buy-in, too. And then I would also suggest using the longer longer-acting forms of medication. So, as you know, many of our listeners may be aware, some long-acting injectables are for one month, for several months at a time. So I think if we can maximize or minimize the frequency of the dosing, that also makes a big difference to patients.

[00:21:37] CHARLES MARMAR, MD: That's great advice. I was reading recently about an innovative program in LA County where they have teams of mental health clinicians go in a van and engage with patients of the most severe, most treatment-refractory, most addicted, psychotic patients living under bridges and so on. And it's a huge problem—homelessness, of course, in both New York and LA—and engaging with these patients and just taking time to get to know them, where they are, living where they are—on the street, under the bridge—and over time building trust to the point where the patient would accept an injection, which might be given right there in that setting, on the street or in a van. And then over time, moving them into more traditional outpatient care. What are your thoughts about that kind of program?

[00:22:36] BIPIN SUBEDI, MD: I think they're wonderful. We have similar programs in New York City. So Intensive Mobile Treatment teams, or IMT teams, are heavily utilized by Bellevue. We refer often into these teams, and they work similarly. So they're like an ACT team, but have a bit more flexibility, and they can work with patients in the community longitudinally, evaluate them over time and build the relationship, like you said, and offer actually long-acting injectables in the community. It may not be under a bridge, like you mentioned, I think there may be some restrictions. But the key is that they're flexible in how they offer the treatment. And rather than expecting a patient to conform to our system, they are built around a recognition that we need to meet a patient where they're at, and that may include also giving a medication outside the traditional clinical setting.

[00:23:21] CHARLES MARMAR, MD: I think that's an enormous advance and very hopeful for the future, and I'm very excited about all the innovative things you're doing. So thank you for your wonderful contributions and it's been great talking with you this morning.

[00:23:36] BIPIN SUBEDI, MD: Thank you so much for having me.