Mental illness and the overwhelmed ER

Help me Lucy! You're our last hope!

Here’s my column from the Greenville News, yesterday, 28 September.

I remember an ad for a national chain of psychiatric hospitals that ran many years ago. It said: ‘If you don’t get help at Megahospital Inc, please, get help somewhere.’ Of course, the subtext was: ‘If you can’t afford help at Megahospital Inc., good luck.’

Capitalist that I am, I’m not opposed to private hospitals and their financial incentives. But it made me laugh. Psychiatric care in America has always been a scarce commodity, even when state and county facilities could bear some of the burden.

Fast forward to our current economic situation, and ‘get help somewhere,’ now means hospital emergency rooms. Our hospital, and hospitals all over South Carolina and the nation, are being overwhelmed with mental illness. And no, I don’t mean the staff.

Ambulances bring patients in for suicidal thoughts, for confusion, for overdose; even for anxiety and depression. The same patients come in private cars, in taxis and on buses, or walk through the doors of hospitals day after day. It used to be a weekly event (outside large urban areas). Now it’s daily and sometimes hourly.

Of course, one of the reasons these folks come to hospital emergency rooms is that they are uninsured, or have insurance with no mental health coverage. And the state and county mental health clinics and hospitals are just as financially strapped as everyone else. When we try to send patients to them, we have to navigate a series of road-blocks erected to help those facilities to ration resources as well as possible.

What usually happens is that, even if we hope to commit a psychiatric patient, we have to keep them in the general hospital anywhere from 24 hours to two weeks, waiting on beds in mental health or even more scarce drug rehab centers. During that time, and because the commitments are mostly for suicidal ideas or attempts, patients are on suicide precautions. They sit in bare rooms, being watched by staff members who are paid their salaries to sit outside the door and ensure that the patient, or patients, in the room don’t harm themselves.

Psychiatric patients in South Carolina community hospitals often receive no psychiatric care at all, except for the blessing of what we call ‘telepsych,’ a state project funded by the Duke Endowment, which allows remote psychiatric consultation via a kind of video conferencing. This is used to determine the need for commitment. It is not a form of ongoing therapy, and is not used after the decision to commit is made.

Why don’t they get care, you ask? Psychiatrists (the in-person kind) are few and far between. Most of them, oddly enough, have to make a living; current pay structures certainly offer them no incentives for hospital care. So, these patients sit, and sit. They take up space in hospitals that cannot provide definitive care. Sometimes, they get angry and try to leave. Sometimes, they get sent to a facility, then come back shortly after their discharge from psychiatric care and start the process all over.

So, we have untold numbers of depressed, anxious, suicidal, psychotic, anti-social, violent and disruptive individuals who have no options for mental health care; and we have finite numbers of psychiatric facilities, with even more finite finances.

The hospitals pay money for the care provided and receive nothing in return. And we all know the consequences of error, even in this untenable situation. Let a patient leave who subsequently kills himself, comes to harm or harms someone else, and federal and state regulators descend like hungry crows, just behind previously unknown family members with lawsuits in hand.

Hospital administrators and staff face a kind of perfect storm. Expected to help those in need, so they can ‘get help somewhere,’ hospitals don’t have the staff, space or ability to treat these patients for their psychiatric problems. Legislators or judges will never alleviate liability by saying, ‘you’ve done enough, you can let him go…you don’t have the staff or money and the state doesn’t have a psychiatric bed.’ And the state cannot fund the care needed, even if it wanted to do so.

Like it or not, the mental health crisis is a microcosm of the impending crisis of medicine as a whole. Starry eyed promises of quality, timely, low-cost care for everyone, so that we all ‘get help somewhere,’ will run into the hard wall of real shortages of staff and facilities, real costs, insufficient funds and difficult human beings.

It all makes me feel a little depressed too.