[acb-hsp] Mentally Ill Flood ER

[peter altschul]

Mentally ill flood ER as states cut services

By Julie Steenhuysen and Jilian Mincer Reuters December 24, 2011

CHICAGO/NEW YORK (Reuters) -- On a recent shift at a Chicago 
emergency department, Dr.  William Sullivan treated a newly 
homeless patient who was threatening to kill himself.

"He had been homeless for about two weeks.  He hadn't showered or 
eaten a lot.  He asked if we had a meal tray," said Sullivan, a 
physician at the University of Illinois Medical Center at Chicago 
and a past president of the Illinois College of Emergency 
Physicians.

Sullivan said the man kept repeating that he wanted to kill 
himself.  "It seemed almost as if he was interested in being 
admitted."

Across the country, doctors like Sullivan are facing a spike in 
psychiatric emergencies -- attempted suicide, severe depression, 
psychosis -- as states slash mental health services and the 
country's worst economic crisis since the Great Depression takes 
its toll.

This trend is taxing emergency rooms already overburdened by 
uninsured patients who wait until ailments become acute before 
seeking treatment.

"These are people without a previous psychiatric history who are 
coming in and telling us they've lost their jobs, they've lost 
sometimes their homes, they can't provide for their families, and 
they are becoming severely depressed," said Dr.  Felicia Smith, 
director of the acute psychiatric service at Massachusetts 
General Hospital in Boston.

State mental health budget

Visits to the hospital's psychiatric emergency department have 
climbed 20 percent in the past three years.

"We've seen actually more very serious suicide attempts in that 
population than we had in the past as well," she said.

Compounding the problem are patients with chronic mental illness 
who have been hurt by a squeeze on mental health services and 
find themselves with nowhere to go.

On top of that, doctors are seeing some cases where the patient's 
most critical need is a warm bed.

"The more I see these patients, the more I realize that if it's 
sleeting and raining outside, the emergency room is the only 
place they have," said Dr.  R.  Corey Waller, director of the 
Spectrum Health Medical Group Center for Integrative Medicine in 
Grand Rapids, Michigan.

Government agencies such as the National Institutes of Mental 
Health, the Centers for Disease Control and Prevention and the 
Substance Abuse and Mental Health Services Administration could 
not provide fresh data on use of psychiatric services in recent 
years.  But doctors from more than a dozen hospitals nationwide, 
mental health advocacy groups and state-funded agencies told 
Reuters they are all seeing a marked increase in psychiatric 
emergencies.

A WORSENING PROBLEM

The National Association of State Mental Health Program Directors 
(NASMHPAID), an organization of state mental health directors, 
estimates that in the last three years states have cut $3.4 
billion in mental health services, while an additional 400,000 
people sought help at public mental health facilities.

In that same time frame, demand for community-based services 
climbed 56 percent, and demand for emergency room, state hospital 
and emergency psychiatric care climbed 18 percent, the 
organization said.

"This wasn't one round of cuts," says Ted Lutterman, director of 
research analysis at NASMHPAID Research Institute.

"It was three or four for many states, and multiple cuts during 
the year."

If the economy doesn't improve, next year could be worse because 
many community mental health agencies are cutting programs and 
using up reserve funds, says Linda Rosenberg, president of the 
National Council for Community Behavioral Healthcare.

"It's been horrible," she said.  "Those that need it the most - 
the unemployed, those with tremendous family stress -- have no 
insurance."

In the emergency room, this increased demand has meant doctors 
and social workers are spending hours and sometimes days trying 
to arrange care for psychiatric patients languishing in the 
emergency department, taking up beds that could be used for 
traditional types of trauma.

More than 70 percent of emergency department administrators said 
they have kept patients waiting in the emergency department for 
24 hours, according to a 2010 survey of 600 hospital emergency 
department administrators by the Schumacher Group, which manages 
emergency departments across the country.

Ten percent said they had "boarded" patients for a week or more.  
And many hospitals are not prepared for the increased caseload of 
psychiatric patients, says Randall Hagar, director of government 
affairs for the California Psychiatric Association.

California cut $587 million in state-funded mental health 
services in the past two years, the most of any state, according 
to the National Alliance on Mental Illness, a patient advocacy 
group.

"They don't have secure holding rooms.  They don't have quiet 
spaces.  They don't have a lot of things you need to help calm 
down a person in an acute psychiatric crisis," Hagar said.

"Often you have a patient strapped to a gurney in a hallway 
outside of the emergency department where social workers are 
desperately trying to find an inpatient bed," he said.

FROM CITIES TO SMALL TOWNS

In North Carolina, the state has cut its inpatient psychiatric 
capacity by half since 2005, says Dr.  Bret Nicks, an emergency 
physician at Wake Forest Baptist Medical Center in Winston-Salem 
and a spokesman for the American College of Emergency Physicians.

Nicks points to a report from the Institute of Medicine released 
in 2006 that found U.S.  emergency departments were already 
overtaxed and overcrowded.

"Now you are adding in patients who are unsafe to leave but yet 
have nowhere to go," he said.  "I consider patients with acute 
psychiatric needs as really the forgotten patient population in 
the U.S.  right now."

Dr.  Stephen Anderson is an emergency department doctor at Auburn 
Regional Medical Center, a mid-size suburban hospital outside of 
Seattle.

"When the economy is hurt they are some of the first to drop off 
the healthcare rolls," he said of local residents in the largely 
blue-collar community.

Anderson, who heads the Washington Chapter of the American 
College of Emergency Physicians, said the state has lost a third 
of its inpatient psychiatric beds in the past decade.

Lately he is seeing a marked escalation in patients with 
psychiatric problems turning up in the emergency department.

In early December, a third of its beds were occupied with people 
in a psychiatric crisis who were not safe to return to the 
community.

The problem extends out to small towns.

Sullivan splits his time between the big emergency department at 
the University of Illinois Medical Center at Chicago and St.  
Margaret's Hospital, a tiny facility in Spring Valley, Illinois, 
about 100 miles southwest of the
 y.

On a recent shift, a young woman with schizophrenia arrived at 
the hospital.  She had just lost her job and apartment and was 
living with relatives.  She could not afford the medications that 
were keeping her illness in check.

The woman asked Sullivan to switch her prescriptions to drugs 
that could be found on the $4 discount list at Wal-Mart and other 
discount stores.

"I didn't feel comfortable doing that," Sullivan said, noting 
that emergency physicians are being asked to deliver specialized 
care that should be handled by a psychiatrist.

He found a healthcare facility about 25 miles away with a 
psychiatrist who could help, but even that presented a

problem for the woman, who had no way of getting to the 
appointment.

"It's almost akin to having a cardiac patient come in and say, 'I 
need someone to adjust my defibrillator.' In the emergency 
department, we can do a lot, but there are some things we have to 
leave with the specialists," he said.

(Editing by Michele Gershberg and Eric Beech)