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, 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.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, Rab had persuaded Yoh to start an oral antipsychotic medication. Now the doctor wanted to go further.

“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,” Yoh said, dreamily. His hair was matted, his ankles caked with dirt.

“OK,” 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. “That was a huge milestone,” he said.

About 75,000 people are homeless in Los Angeles County on any given night; in 2022, 2,374 of them died while homeless. 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 crucial step toward housing. 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 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.

But street psychiatrists say they are seeing transformations. When he gives presentations on the team’s work, Rab likes to display photographs of patients as his team first encountered them: inert, disheveled, barely visible in mounds of trash. And then, later, scrubbed clean, sitting on a bed in a group home.

Rab thought Yoh could be one of those stories. Case workers had been visiting him in the underpass for five months, bringing him hamburgers and bottled water, gingerly building trust. It was leading up to this moment. Rab wanted to see what “this magical injection,” as he put it, would do.

‘Practice-based evidence’

It was 2018 when Dr. James Rodney Jones, then the medical director of a Los Angeles County mental health clinic on Skid Row, first injected a dose of long-acting antipsychotic medication into the arm of a homeless woman.

The woman was in her late 20s. Jones often saw her passed out in front of a 7-Eleven or arguing with security guards. She acknowledged “bipolar ups and downs” and alcoholism but refused medical appointments or shelter beds.

Jones devised a plan. First, daily visits, bringing her bottled water and snacks. Then, as she became more trusting, he added an oral dose of the antipsychotic Zyprexa, which he told her would help her sleep. Jones led her behind a telephone pole for privacy and gave her an injection of Zyprexa that would stay in her system for a full month.

“You can’t just go out and hand out medicine like that,” he recalled officials as saying. “Do they even have an open chart?”

He understood their caution. Prescribing psychiatric medication on the street often means working without a definitive diagnosis, medical records or laboratory tests. And because clinical trials are conducted in controlled settings, Jones said, there was no research to support using injectable antipsychotics in a homeless population.

But for Jones, this was “the perfect setup” for injections, which research suggests sharply reduce the risk of relapse. Six months after receiving her first shot, “less paranoid, less chaotic, less delusional,” the woman had moved into housing and was receiving disability benefits, he said. After that happened a few times, county officials took notice.

“Once we got them on” a long-acting injectable antipsychotic, “we could get them into housing, and once they were in housing, they would cost the county a lot less,” Jones said.

Over the years that followed, Jones’ Skid Row experiment expanded into one of the largest street psychiatry efforts in the nation. Of the 1,919 people the team served last year, 22% ended the year housed; about 10% were treated involuntarily.

Talking them into it

Street teams have been expanding their role in homeless outreach for years, but there is little published research about what they do, so it is difficult to track negative outcomes or say what works.

This absence of data, critics say, is a red flag in the field of psychiatry, whose history is marked by unproven treatments imposed on vulnerable people without their consent.

Samuel Jain, the senior attorney at Disability Rights California, said he had become aware of the rising use of injectable antipsychotics among homeless people this summer, when street physicians interviewed by the news site CalMatters declared it “an absolute game-changer.”

That claim, he said, “feeds the fiction that if you just take your meds, the societal problem will go away.” On an individual level, he worried about consent: Antipsychotics are “extremely powerful,” and patients must be fully informed of their risks and benefits. Is that possible, he asked, in a doctor-patient relationship conducted on the sidewalk?

Dr. Enrico Castillo, an associate professor of clinical psychiatry at UCLA, said he worried that the hundreds of millions of dollars being used to provide street treatment would be better spent building housing.

There is, he said, a strong base of evidence supporting “housing first,” in which individuals receive permanent housing with no strings attached, and treatment is offered thereafter; no such evidence exists for street psychiatry.

‘A gathering of my senses’

Yoh had agreed to take an injection of Abilify. From that point forward, his medication adherence was assured, and the outreach teams were released from the burden of delivering pills to him every day. But they were also bound together now, Rab said, because the team would need to monitor him closely for side effects.

In a tiny room in Hollywood, Yoh then began a new life. He moved into a small hotel that had been taken over by the county for interim housing, where nurses delivered meds and meals were distributed three times a day.

He had agreed to provide his fingerprints, which Allen Ziegler, a psychiatric social worker, ran through a criminal justice database. The database recorded a brief stint in prison. Now Yoh had an age: 44. And a name: Eric Covington.

With no warning, during one of Ziegler’s visits, he blurted out these facts: He had been working in a call center in Colorado Springs when God spoke to him, telling him to quit his job. After that, he bought a bus ticket to Los Angeles, a place where he knew he could survive the winter outdoors. He thought this had happened 20 years ago.

One way or another, though, this mission had come to an end. God still spoke to him, but his head was clearer now.

“I felt a gathering of my senses,” he said. “Like, if you want to live, this is what you need to do.”