“just a mental health patient living on the street”…

Posted on Friday 27 December 2013

New York Times
December 25, 2013

As darkness fell on a Friday evening over downtown Raleigh, N.C., Michael Lyons, a paramedic supervisor for Wake County Emergency Medical Services, slowly approached the tall, lanky man who was swaying back and forth in a gentle rhythm. In answer to Mr. Lyons’s questions, the man, wearing a red shirt that dwarfed his thin frame, said he was bipolar, schizophrenic and homeless. He was looking for help because he did not think his prescribed medication was working. In the past, paramedics would have taken the man to the closest hospital emergency room — most likely the nearby WakeMed Health and Hospitals, one of the largest centers in the region. But instead, under a pilot program, paramedics ushered him through the doors of Holly Hill Hospital, a commercial psychiatric facility. “He doesn’t have a medical complaint, he’s just a mental health patient living on the street who is looking for some help,” said Mr. Lyons, pulling his van back into traffic. “The good news is that he’s not going to an E.R. That’s saving the hospital money and getting the patient to the most appropriate place for him,” he added.

The experiment in Raleigh is being closely watched by other cities desperate to find a way to help mentally ill patients without admitting them to emergency rooms, where the cost of treatment is high — and unnecessary. While there is evidence that other types of health care costs might be declining slightly, the cost of emergency room care for the mentally ill shows no sign of ebbing. Nationally, more than 6.4 million visits to emergency rooms in 2010, or about 5 percent of total visits, involved patients whose primary diagnosis was a mental health condition or substance abuse. That is up 28 percent from just four years earlier, according to the latest figures available from the Agency for Healthcare Research and Quality in Rockville, Md. By one federal estimate, spending by general hospitals to care for these patients is expected to nearly double to $38.5 billion in 2014, from $20.3 billion in 2003.

The problem has been building for decades as mental health systems have been largely decentralized, pushing oversight and responsibility for psychiatric care into overwhelmed communities and, often, to hospitals, like WakeMed. In North Carolina, the problem is becoming particularly acute. A recent study said that the number of mental patients entering emergency rooms in the state was double the nation’s average in 2010. More than 10 years after overhauling its own state mental health system, North Carolina is grappling with the consequences of a lost number of beds and a reduction in funding amid a growing outcry that the state’s mentally ill need more help.

In Raleigh, where the Dorothea Dix Hospital — a state psychiatric institution that served the area for more than 150 years — was closed in 2012, mentally ill patients began trickling into hospital emergency rooms. Hospitals, which cannot legally turn away any patient seeking care, say the influx of psychiatric patients is straining already busy E.R.’s and creating dangerous conditions. This spring, University Medical Center of Southern Nevada in Las Vegas declared an “internal disaster,” shutting its doors to arriving ambulances for 12 hours, after mental patients filled up more than half of its emergency room beds. A suicidal patient took out a gun and shot herself in the head while in a hospital emergency room in New Mexico in January…
This was so in the cards back in the end of the 1970s when I was a resident. We date a lot of things in psychiatry from that time. It’s when the DSM-III came out and produced a cataclysmic change in the specialty. But it was also when Reagan was elected President and the funding shifts escalated. I remember it as the time when "the homeless" began to appear on our streets, and the disappearing bed space in the hospitals dwindled below a critical level. Psychiatry proper turned to drugs and away from most other things, including mental health advocacy. Since then, the responsibility for public mental health increasingly fell to the States, and that support began a long creeping dwindle with each budget cycle. So now a person with the most predictable and debilitating mental illnesses of them all became "just a mental health patient living on the street." The ERs are choked with mental health patients, so they’re going to send them somewhere else – until that next somewhere else is choked with mental health patients and starts looking for a new somewhere else to send them. This is a problem currently lacking a solution – and a national tragedy…
    December 27, 2013 | 6:04 PM

    Don’t expect Obamacare to fix this. Deinstitutionalization has and always will be a tragedy for the 5% we cannot help in community settings.

    But, politicians, just like the courts, aren’t interested in truth and responsible boundaries out there, beyond their sheltered lives so well insulated from reality.

    You would think after the Giffords shooting in Arizona almost 3 years ago now would have made DC politicians a bit more sensitive and attentive.

    But, it wasn’t an entrenched incumbent shot. Pity.

    Bernard Carroll
    December 27, 2013 | 10:01 PM

    If you think about other incurable diseases in their day – polio, say, or tuberculosis – we didn’t stop funding for the special hospitals needed to care for patients afflicted by such conditions. It was a social responsibility, period. We scaled back the facilities only after genuine therapeutic or preventive paradigm shifts occurred in the form of streptomycin and the Salk/Sabin vaccines. The major mental illnesses that one sees among the homeless and the prison population are just as incurable as those earlier examples were back then. If their conditions were not incurable they wouldn’t be on the streets or in prisons or warehoused in nursing homes that lack therapeutic programs and trained staff.

    We sold those patients short by grandiose social engineering at the expense of humane medical care and asylum protection. Thorazine and its cousins controlled and mitigated symptoms but didn’t cure. And it is quite wrong, by the way, to say that none ever left the old asylums. Many did, thanks to the good fortune of a benign natural history, and they were protected as long as they needed to be given asylum.

    I used to work in the public mental health sector in North Carolina. For 7 years I directed a 100-bed geriatric psychiatry program at John Umstead Hospital in Butner, NC. If any readers bristle at my use of the term incurable mental illness, I would just invite them to spend a little time in such a program. Sure, a state psychiatric hospital isn’t where you would want to go for a vacation, but it beats the street or the prison or the warehouse nursing home.

    Our politically correct American Psychiatric Association doesn’t talk about incurable mental illness. Everything has to be upbeat, positive, and forward-looking. Their public relations output is mostly pabulum about inconsequential preliminary research near-breakthroughs and infomercials in journals like JAMA. The incurably mentally ill do not make for attractive PR.

    Since I retired the number of beds in my former program was drastically reduced, and who knows where the patients are nowadays? I understand the impulse to divert patients away from emergency rooms, but when I read the story yesterday I had to wonder about the wisdom of training EMTs to make assessments of psychiatric versus medical needs. As the saying goes, life is a series of tradeoffs.

    Remember the incurables!

    December 27, 2013 | 11:28 PM

    Amen to the above comments by Dr Carroll! Unfortunately, he is completely correct, and having recently worked for an ACT team program, I saw patients who were incensed we held them to their conditional release conditions that some judge administered without any psychiatric input by us, and then, quite literally mind you, dumped this patient on the program to handle the patient without any input or opinion by treatment staff.

    And who do you think this one patient raged at as the person was becoming non compliant and violating the terms of this “contract” such patient agreed to in court? Not the f—–g judge, and I use that descriptive adjective there because these judges get alleged input only from forensic mental health staff who work solely for the court, and never talk to any outpatient treating staff to get realistic and responsible input what we can do with such patients!

    So, this “grand” experiment and ongoing effort to keep chronically ill patients and other non complaint individuals on the backs of primary care psychiatric staff in simple outpatient clinics, or even somewhat more specialized programs like ACT, is nice in theory, but, theory is only as effective as the realities of the environments we offer to patients who are willing to accept the boundaries of our efforts and abilities.

    Frankly, after 3 years in clinical training of residency and now 20 plus more years on my own, these conditional release and other court ordered patient care referrals, over 80% who have basically been a waste of my f—–g time, well, when I finally get that call from a really invested and respectful judge, once I recover from the fainting spell of realizing the judge actually called, I will say exactly what I said above in the first comment here on this thread, and then add in so many words:

    “so if the patient does not cooperate with a fair and appropriate treatment plan regimen for the issues brought into care, can I tell such patient in so many words “tell the judge you aren’t interested in the care plan, don’t piss on me” and then let them come into your court room to bitch and moan!”

    Yeah, I really look forward to the response from said judge at that moment!!!

    December 28, 2013 | 8:57 AM

    I live this reality (albeit from the safe confines of professional life not as one who is on the streets) and although I agree that there are individuals in our community who do not have the wherewithal to care for themselves I also know that there are many who lead full lives in our community and do so because of the support offered to them. In another era, they may have lived out their lives in a state hospital and rather than have the discussion we are having today, we would be talking about our overcrowded and under funded facilities.

    I see this as a multifaceted problem as follows with several forces coming together in ways not entirely intended:

    1. Psychiatry: the prevailing view is that these are medical problems that can be treated as easily as we treat bacterial pneumonia. In EVERY branch of medicine we have pushed to reduce hospital days. Once psychiatry put itself in with everyone else we were subject to the same criteria and the same cost cutting. This created a situation where if you were not engaged in “active treatment” typically defined as changing medications or increasing doses, then you needed to move the person out. This became embedded as good clinical care. this has impacted outpatient treatment as well. Fifteen minute “med checks” keep us in line with our colleagues in other specialties. Yeah for us!
    2. Advocates: There has been a steady push against hospitals, especially involuntary treatment. Although, I agree with some of this, in that it helps to push states and communities to develop programs and to avoid warehousing, the question arises as to when we have pushed too far. It also sometimes leads to just shifting people to just another place where people are receiving long term chronic care.
    3. Politicians: These two groups, who often disagree, both give a rationale for politicians to cut costs. What happens is that it is easy to ignore the inconvenient fact that we do not know how to help some people.

    Fuller Torrey wrote a book about this. Since I often disagree with him, I was surprised that I found much of it interesting. I reviewed it here:


    Ann Van Regan
    December 28, 2013 | 3:55 PM

    The way to get homeless mentally ill folks off the street and out of jails is to make affordable housing available. Even supportive housing costs less than expensive psychiatric care and offers a quality of life not available from medically based care.

    I live in a mixed income co-op with about 100 members,many with mental illnesses. Pot-luck dinners and having neighbours around has saved many hospitalizations.

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