Emergency Care of the Mentally Ill

Pat Salber

First published 4/17/11 on The Doctor Weighs In

Say you are grappling with a chronic mental illness….bipolar disease or schizophrenia.  You have been told you need to take your medications as prescribed, but you can’t… or you won’t… or you do… but on your own timetable.  Your symptoms get worse and your family gets nervous.  You are doing things that scare them.  It is the middle of the night, so they do the logical thing.   They take you to the closest emergency department.

Emergency Departments are pretty wild places a lot of the time.  Thanks to ED overcrowding, chances are there is a full waiting room with people in various states of disarray (some are bleeding, some are vomiting, some are squeaky clean and others are disheveled and reeking of (pick one):  alcohol, urine, cigarettes, vomit, “Aroma of Street,” or dried blood.  You are freaking out…but you are told you have to wait until they can get to you.

At some point, you and your family make it out of the waiting room and into the treatment area.  It is chaos.  The nurses want you to undress and put on a gown.  They want to take your blood pressure, maybe take your blood, and they don’t really have time to talk to you.  Eventually, the doc arrives.  He thinks  you need a couple of days in a psych facility (the good news), but there are no available psych beds in the entire state (the bad news)!

Don’t worry, the doc tells the family, we will keep an eye on you until a bed opens up.  It could be an hour, a day, a few days…or a week!  Can you believe that??

Here are some factoids from a  2010 survey conducted by the Schumacher Group, a Louisiana based ED management company, that support that statement:

  • The great majority of ED administrators (86%) indicated they are often or sometimes unable to transfer mental/behavioral patients to inpatient facilities in a timely manner.
  • Over 70% of ED administrators report mental/behavioral patients boarding for 24 hours or longer. 10% said they have boarding times for mental/behavioral patients as long as one week or more.
  • 60% of ED administrators believe patient care at their EDs has been compromised due to delays in transferring mental/behavioral patients to inpatient facilities.

Lots of the information in this post comes from a recent story by Jenny Gold a Kaiser Health News Staff Writer.  In that article, she lays out the sorry state of affairs by telling the story of a patient named Erik who got stuck in an ED in Rhode Island for two days.  He has a diagnosis of schizoaffective disorder and PTSD.  He is insured (both Medicaid and Medicare), but he has nowhere to go because there is simply no room at the inn.

Gold, referring to a 2010 report by the National Association of State Mental Health Program Directors Research Institute (NASMHPDRI), writes that states have closed or are planning to close nearly 4,000 state psychiatric beds, about 8% of capacity.  This is at the same time that psychiatric visits to emergency departments have increased dramatically (~27% in Rhode Island alone between 2005 and 2009).

We long ago closed large mental health hospitals that warehoused the mentally ill but we did so without ensuring adequate outpatient services for these folks.  This led to large numbers of chronically mentally ill joining the ranks of the homeless.  And as if that is not bad enough, we continue to see a shrinking of  services available to folks with Mental Health diagnoses.

According to the National Alliance on Mental Illness (NAMI,) 32 states have had to cut mental health budgets since 2009.  [Yeah, I know, we need to cut out the waste in government….of course it is always easier to define services to the most vulnerable as “waste” – these folks usually have a hard time getting to the polls on election day.]

Now, let’s take a look at a page from the NASMHPDRI report to see what they are cutting:

State Acute Inpatient services, State Long Term Inpatient, Clinic Services, Day Services, Crisis Services, Prescriptions….doesn’t look like waste to me.  But I guess the rationale of the cutters and our country is that you can always get your care in the ER.  Right George?

[President George W. Bush in 2008I mean, people have access to health care in America,” he said. “After all, you just go to an emergency room.”

Pat Salber MD MBA, now a Principal in Zolo Health Solutions, is a former Emergency Physician.

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