By Steve Lopez
Originally published in the Los Angeles Times

The team gathered at 4th and Crocker streets and headed south, into the blue-tented netherworld of social collapse, armed with lifesaving drug-overdose kits and injectable, long-acting anti-psychotic medication.

“We’re trying very aggressive treatment on the streets,” said Dr. Susan Partovi. “Housing definitely saves your life, but there’s a small sub-group of people who won’t accept housing because of their mental illness.”

She figures that if she administers medication that lasts a month and can help stabilize patients — with their consent — they’ve got a chance.

“They don’t think there’s anything wrong, and they think they don’t need housing,” Partovi said. “They don’t think rationally, and so once you treat their delusions and their irrationality, they start to realize, ‘Oh, I do need resources.’ ”

Partovi, who began practicing street medicine in 2007 in Santa Monica, has never been shy about her lack of patience with the official response to the entrenched humanitarian crisis. In 2017, I shadowed her as she walked through Skid Row with county Supervisor Kathryn Barger, advocating for broader authority to assist those in obvious acute mental and physical distress, even if they refused help, and despite opposition from civil rights attorneys and others.

By administering long-acting meds, Partovi — author of the just-published “Renegade M.D.: A Doctor’s Stories From the Streets” — is once again pushing boundaries. She’s acting out of a belief that her approach is medically sound, and with frustration sharpened by her street-level view of the countless bureaucratic cracks and canyons in the system. She’s driven, too, by an uncompromising compassion for homeless people who are so sick she can sometimes predict who will die next.

Critics might say a person in the throes of impairment isn’t competent to give consent for a monthlong dose of medication, and that such meds are neither a panacea nor a substitute for intensive ongoing case management. But to Partovi, the slow pace of intervention — along with multiple daily deaths on the streets — add up to a human rights violation and a moral failure, so she’s stepping into the breach.

But she’s not a psychiatrist, and her street medicine team’s approach is not fully embraced by the L.A. County Department of Mental Health. DMH has psychiatric street medicine teams operating in several parts of the county. The Skid Row unit —which is led by Dr. Shayan Rab and in cludes psychiatric nurses, social workers and addiction counselors, and sometimes conducts sidewalk court hearings for those who resist treatment — was featured in a September 2022 article by my colleague Doug Smith.

Dr. Curley Bonds, chief medical officer of the department, says DMH psychiatrists first establish a working relationship with the client and invest time in determining a clinical history, including prescribed medications and dosage. It can be difficult, he said, to distinguish between psychosis and the effects of street drugs like methamphetamine, but trained psychiatrists have an advantage over doctors with other specialties. Treatment would ordinarily begin with short-term oral medication, Bonds said, to establish the “efficacy and tolerability of the agent.”

Only then would long-acting injectables be an option, he continued, but even then, the civil rights of the patient would have to be a consideration.

“We are more cautious about making sure there is informed consent and … we really want to respect a person’s autonomy for decision-making,” Bonds said. Despite procedural differences and quibbles over the Partovi team’s approach, Bonds added, “I don’t want to put us at odds with them … because what they are doing is important work.”

A glance at the reality on the streets of Los Angeles makes clear that far more help and substantially greater urgency are badly needed. And Partovi is not alone in practicing what she calls “low barrier bridge psychiatry.”

Dr. Coley King, director of homeless healthcare at the Venice Family Clinic, is not a psychiatrist, either. But as a street medic in L.A., the national capital of homelessness, he works in what is essentially an outdoor mental hospital, with tents instead of beds. King treats mental illness and whatever else he sees — and what, often, no one else is treating.

He told me he has used both short-term and long-term antipsychotics, depending on the situation. The risks posed by medication are not as great, he said, as the risk of being homeless, sick and untreated.

“The need is so dire, and the patients are dying at such a young age, and the lack of available psychiatry is so marked,” said King, who leads a street medicine team through Westside streets four days a week and often works with a psychiatric nurse practitioner. “We’re not doing this in any sort of cavalier fashion. We’re doing it very thoughtfully with a mind to knowing our medications and knowing our diagnosis and treatment are based on a ton of experience and a lot of exposure to working side-by-side with psychiatrists in the field.”

In 2020, I wrote about a formerly homeless Santa Monica woman whose life had been turned around after King treated her for her addiction and physical and mental ailments. The treatment included a long-acting injection the woman agreed to, and when I met her, she was living in a hotel before moving into housing arranged by the outreach team.