As Dr. Rishi Patel鈥檚 street medicine van bounces over dirt roads and empty fields in rural Kern County, he鈥檚 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 鈥� a long-acting antipsychotic 鈥� 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鈥檚 intertwined homelessness and mental health crises. Typically administered into a patient鈥檚 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鈥檚 oral medication 鈥� no more taking a pill every day. For people who are homeless and routinely have their pills stolen, can鈥檛 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.
鈥淭hey鈥檝e been an absolute game-changer,鈥� Patel said.
Street medicine teams bring the shots directly to their patients wherever they are 鈥� whether it鈥檚 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 鈥� or sometimes even more quickly 鈥� and with minimal paperwork and red tape. They don鈥檛 need a psychiatrist鈥檚 sign-off.
It鈥檚 estimated that California is home to more than 180,000 homeless residents. the sickest of them 鈥� people with severe, untreated psychosis who might wander into traffic or otherwise put themselves in danger 鈥� has become a , with Gov. Gavin Newsom and state lawmakers creating new and sometimes controversial ways to get people into treatment. In a recent of homeless Californians, 12% reported experiencing hallucinations in the past 30 days, and more than a quarter said they鈥檇 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鈥檚 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.
鈥淚t鈥檚 been pretty common that that鈥檚 the initiation of, 鈥榃e鈥檙e going indoors,鈥欌�� said Dr. Coley King, director of homeless health care for the Venice Family Clinic in Los Angeles. He said he鈥檚 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鈥檝e been given a shot, they have no choice but to wait a month for the drug to wear off.
Despite some street doctors鈥� rave reviews, injectable antipsychotics still aren鈥檛 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鈥檚 team in Los Angeles has about two dozen). Some patients don鈥檛 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 鈥� 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鈥檛 seen the woman he鈥檚 looking for since his team gave her first antipsychotic shot almost two months ago. Now she鈥檚 past due for another dose.
It鈥檚 worrying, Patel said, 鈥渂ecause I don鈥檛 know how she did on it.鈥�
The last place they saw her was at an encampment known as 鈥淭he Sump鈥� 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鈥檚 team doesn鈥檛 have a phone number or any other way to contact her.
The first place they look is another encampment known as 鈥渢he Shrine,鈥� 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鈥檝e 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鈥檚 not there, so the team hands out sack lunches and bottles of water, then gets back in the van and leaves.
鈥淲e鈥檝e seen results,鈥� said Kirk McGowan, a street medicine nurse with Akido. 鈥淏ut we鈥檝e seen more failures than successes. That鈥檚 just kind of the nature of the situation.鈥�
Who should prescribe antipsychotic injections?
In most cases, the people prescribing and administering antipsychotic shots in homeless encampments are general practice doctors 鈥� not specially trained psychiatrists. That鈥檚 because despite the growing prevalence of street medicine, street psychiatrists are still rare, according to a recent .
鈥淵ou look over your shoulder and there鈥檚 not a psychiatrist there helping you out,鈥� King said. 鈥淎nd we want to meet the need. We want to take care of these patients. They鈥檙e really, really ill, they鈥檙e really disorganized, and suffering and dying on the streets.鈥�
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.
鈥淭hese medications are in there for an extended period of time,鈥� said Keri Weinstock, a psychiatric nurse practitioner who practices street medicine in Shasta County. 鈥淭hey do come with risks. There are specialty things that come along with some of these specialty meds, and it鈥檚 a lot to learn when you have to know everything else, too.鈥�
Some street doctors who give these shots seek out additional psychiatric training, while others learn on the job 鈥� often with a psychiatrist on speed dial, just in case.
鈥淚 don鈥檛 think it鈥檚 rocket science to diagnose schizophrenia, as long as we鈥檝e done it with some thoughtfulness,鈥� King said.
In-the-field diagnoses aren鈥檛 always clear-cut, Patel said. Sometimes, people do such a good job of hiding their symptoms that it鈥檚 hard to tell they鈥檙e dealing with psychosis. Or, instead of experiencing obvious hallucinations or other symptoms commonly associated with schizophrenia, patients experience 鈥渘egative symptoms,鈥� 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鈥檚 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.
鈥淚t鈥檚 a very serious kind of action that鈥檚 being taken and a lot of time needs to be spent before you say, 鈥楬ey, this individual is safe for a long-acting injection,鈥欌�� he said.
To make sure a patient doesn鈥檛 have an adverse reaction, doctors typically give them an oral dose of the same medication for a few days before administering the shot.
There鈥檚 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.
鈥淵ou have to be sure you really know the correct diagnosis,鈥� 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鈥檚 an 鈥渁ntiquated way of thinking.鈥� When someone is experiencing psychosis, it鈥檚 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 鈥� 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 鈥淩icky,鈥� 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.
鈥淚t was getting to the point where I just felt like killing myself,鈥� Fonseca said.
Two months ago, Fonseca started taking a monthly shot of the antipsychotic drug Abilify. Since then, 鈥渆verything鈥檚 changed,鈥� he said.
Now, Fonseca is staying at a friend鈥檚 house and considering going to school. He says he鈥檚 stopped using meth.
鈥淚 can finally hear the birds and the crickets,鈥� he said. 鈥淚 couldn鈥檛 hear them before.鈥�
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