This week, the New York Times ran an article highlighting the pioneering work of street psychiatrists on the Los Angeles County Department of Mental Health (DMH) HOME Team, including Yelena Koldobskaya, MD, who is an active member of the SCPS Unhoused Workgroup. She has been instrumental in developing several SCPS-suggested 2025 high-priority advocacy projects for CSAP. This article highlights some of the extraordinary clinical work of California street psychiatrists on behalf of patients, as well as their active involvement in APA advocacy efforts.
Dr. Koldobskaya completed her undergraduate education at Cornell University, followed by a PhD in organic chemistry and an MD at the University of Chicago. She trained at the UCLA Westwood residency program in psychiatry and served as an inpatient chief resident in her last year of training. From 2017 to 2022, she worked as a correctional health staff psychiatrist in Los Angeles. Since 2022, she has been working with a multidisciplinary field-based outreach team in Los Angeles County. Dr. Koldobskaya’s work focuses on street-based treatment of chronically mentally ill unhoused individuals, with a focus on the development of long-term care plans and alternatives to incarceration. Dr. Koldobskaya is an early-career psychiatrist representative on the council of the Southern California Psychiatric Society (SCPS) and is co-chair of the SCPS Unhoused Workgroup.
Under a L.A. Freeway, a Psychiatric Rescue Mission
The crisis of homelessness is pushing American psychiatry to places it has not gone before — like sidewalk injections of antipsychotics.
Yoh lived under an overpass in Los Angeles, absorbed by an inner world that featured space travel, the C.I.A. and a journey to Eden. A street psychiatry team thought they could bring him inside. In a downtown Los Angeles parking lot, a stretch of asphalt tucked between gleaming hotels and the 110 freeway, a psychiatrist named Shayan Rab was seeing his third patient of the day, a man he knew only as Yoh. Yoh lived in the underpass, his back pressed against the wall, a few feet from the rush of cars exiting the freeway. He made little effort to fend for himself, even to find food or water. When outreach workers dropped off supplies, he often let people walk away with them. He could barely converse, absorbed by an inner world that he described in fragments: a journey to Eden, a supersonic train, a slab of concrete hanging in space. But here he was, seated on a stool in the parking lot, talking to his psychiatrist. Two weeks earlier, Dr. Rab had persuaded Yoh to start an oral antipsychotic medication. Now the doctor wanted to go further.
“One thing that can make your life a little bit easier,” he said. “We have the same medication that comes as a monthly injection, so you only have to take it once. Is that something you’d be interested in? It’s better for you.” “Yeah,” said Yoh, dreamily. His hair was matted, his ankles caked with dirt. He hadn’t slept well, he said, because he had been visited by a poltergeist. “OK,” Dr. Rab said. “We’ll get that organized for you.” Yoh wandered back to his spot in the underpass, and the doctor climbed into his car, off to the next appointment. He was pleased. “That was a huge milestone,” he said.
Driving away, Dr. Rab passed tent after tent after tent. Around 75,000 people are homeless in Los Angeles County on any given night; in 2022, 2,374 of them died while homeless, mostly because they overdosed, or their hearts failed, or they were hit by cars. Officials are desperate to move them inside.
Street psychiatry offers a radical solution: that for the most acutely mentally ill, psychiatric medication given outdoors could be a critical step toward housing. Dr. Rab, a medical director of Los Angeles County’s Homeless Outreach & Mobile Engagement program, describes the system his team has built as an outdoor hospital, or sometimes as a “DoorDash for meds.”
Every weekday morning, 18 teams fan out across the county, making rounds with about 1,700 patients in tents and vehicles and alleyways. The teams try to persuade them to accept medication, sometimes in an injectable form that remains in the bloodstream for weeks. If clients say no, the teams return, sometimes for months, until they say yes; if they still refuse, the team can petition a court to order involuntary treatment.
This is a major departure for the field of psychiatry, which long discouraged clinicians from tracking down patients in the chaotic conditions where they live. It alarms patients’ rights activists, who say people living on the street may not be in a position to give consent. And critics question whether state resources should go to expensive curbside medical treatment when what people really need is housing. Read more.
Also, here’s a recent study on the same subject you may find of interest: Addressing Mental Health Disability in Unsheltered Homelessness: Outpatient Conservatorships in Los Angeles, and please see below for a piece on housing as a Medi-Cal benefit as well as addressing behavioral health needs in encampments.