[humanser] Mentally ill flood ER as states cut services

[Mary Ann Robinson]

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)