Psych Bed Shortage Threatens Public Safety
www.medpagetoday.com/ Published: Jan 28, 2014 |
By Ben Hartman, MD, Contributing Writer, MedPage Today
Last November, Austin Deeds, son of Virginia state Sen. Creigh Deeds, left a Virginia hospital emergency room, went home, stabbed his father, and then killed himself.
The ER attending physician had wanted to admit him, but wasn't able to do so because of Virginia's civil commitment laws. In Virginia, physicians who want to admit a psychiatric patient have 4 hours to draft a treatment plan, have it approved by a judge magistrate, and then find the patient a psychiatric bed. The physician can petition the court for an extra 2 hours.
In Deeds' case, the ER failed to locate an open psychiatric bed in its own hospital or elsewhere, so the younger Deeds was released.
When the media learned of the subsequent horrific events, a hospital spokesperson first claimed there were no beds available in the area. Later, nearby hospitals said they did indeed have beds but were never contacted.
Tip of the Iceberg
Regardless of what exactly happened, the incident exposed a nationwide problem: a shortage of psychiatric beds in every state, which makes psychiatric patient transfers a cumbersome, if not impossible, option. (The term "psychiatric bed" means a bed specifically located in a hospital's locked-down psychiatric unit.)
In a 2008 report Treatment Advocacy Center (TAC), a national nonprofit organization dedicated to eliminating barriers to timely and effective treatment of severe mental illness, found 17 public psychiatric beds per 100,000 U.S. citizens, down from 340 beds per 100,000 in 1955.
Doris Fuller, executive director of TAC, said the primary cause of the problem was the passage of The Community Health Center Act in 1963. The law's goal, according to Fuller, was to shift psychiatric treatment of severely mentally ill patients from in-patient psychiatric hospitals to community health centers, where they could live at home and receive treatment in a familiar environment.
Most psychiatric hospitals closed, but few health centers were built, according to Fuller.
The ones that were built didn't have the resources to treat those with severe mental health disorders: schizophrenia, bipolar disorder, major depression, homicidal/suicidal ideation.
By the 1980s thousands of newly deinstitutionalized patients had returned to the streets often to be returned to institutionalized care -- but now it would be in prison. According to Fuller, in the 1950s, only 3% of American prisoners were mentally ill; today it's 40%.
This patient population also overwhelms ERs, especially in urban settings.
Congress Acts, ERs Struggle
The problem is exacerbated by the Emergency Medical Treatment and Labor Act (EMTALA), Congress' 30-year-old attempt to mandate "good Samaritans." EMTALA requires ERs to stabilize and treat all patients who enter the ER, regardless of their ability to pay.
Rules vary by state, but generally physicians have 48 to 72 hours to evaluate the patient and decide to admit or discharge. If they fail to meet that deadline, and don't obtain a court order, the patient is legally permitted to leave the hospital against medical advice.
If the patient is evaluated within the required time frame, but the hospital has no psychiatric beds, the physician will try to transfer the patient to a hospital with bed space. But, according to Mark Reiter, MD, vice president of the American Academy of Emergency Medicine, physicians can't transfer psychiatric patients to another facility unless the facility agrees to accept them.
Most private facilities will refuse patients without insurance, even if they have beds available. Financial reimbursement for treating psychiatric patients is scant and often nonexistent.
ERs often handle these situations by "boarding" patients -- keeping them until a bed is found, they are cleared for discharge, or they choose to leave.
Said Reiter, "Since most hospitals do not have any psychiatric beds, patients needing psychiatric hospitalization typically need to be transferred. Private psychiatric facilities commonly refuse to accept many of the psychiatric patients that do not have commercial insurance. This creates difficulty for the emergency department, which has an EMTALA obligation to place the patient in a secure setting for inpatient psychiatric care, while many of the private psychiatric facilities do not feel they have an EMTALA obligation to accept the patient, perhaps because they do not consider themselves a hospital."
Reiter added that even if the emergency room physician finds placement for a patient, they usually are not placed long enough to resolve their psychiatric needs. Or they don't have adequate outpatient follow-up to prevent an immediate return to the ER.
According to Sandra Schneider, M.D., president of the American College of Emergency Physicians (ACEP), these "boarded" patients are not getting any care, or if they are getting care, it's minimal (e.g., tranquilizers). They are not receiving psychotherapy and may eventually be released back into the community in severe condition.
"With medical illness, we have tests to tell if you are, for example, having a heart attack. If you are, I will know within a couple of hours," she said. "We don't have these tests with mental illness. That's why you see so many people with mental illness, who committed these atrocities. We don't always know who's a little difficult to deal with and who's going to go get a gun and go to an elementary school and kill everybody."
This is especially tragic because many of the mass killings could have been prevented had the patients received the needed mental healthcare, according to Kristina Ragosta, director of advocacy at TAC: "I've never seen any evidence that people with severe mental illnesses, schizophrenia and bipolar disorder, undergoing appropriate treatment, have committed any of these mass casualty acts."
A New Plan
To help prevent these tragedies, and ensure psychiatric patients continue treatment, 45 states have instituted Assisted Outpatient Treatment (AOT) programs. The only states without the program are Maryland, Connecticut, Massachusetts, Tennessee, and New Mexico.
Through AOT, a patient with severe mental illness and a history of medical noncompliance is released into the community -- but with a court-ordered treatment plan, created by an evaluating psychiatrist.
These patients receive case management, medication management, individual or group therapy, day programs, and substance abuse treatment. Case managers, Assertive Community Treatment (ACT) team members, patient advocates, and family members work with and monitor the patient. "Typically, violation of the court-ordered conditions can result in the individual being hospitalized for further treatment," according to TAC's website.
A recently published study examined New York state's experience with its AOT program. The study concluded that the programs saved the state money by preventing costly psychiatric crises interventions. The programs also benefited the patients.
According to a survey commissioned by the state, 75% of the participants reported the program helped them stay well, and 90% reported the program made them more likely to keep appointments and take their medications.
For the past 10 years, the U.S. Department of Justice has conducted before-and-after research studies on AOT participants. They found a drastic reduction in participants' arrests for all crimes, and a sharp decline in arrests for violent crimes.
A recent examination of an AOT program in Nevada County, Calif., analyzed the costs associated with 17 individuals during the first 2½ years of the program and found that AOT saved more than $500,000 -- most due to decreased hospitalizations and jail time. The authors concluded that for every $1 invested in AOT in Nevada County, $1.81 was saved.
Schneider, of ACEP, agrees with the AOT concept, but thinks it's essential that new psychiatric hospitals be built.
"The idea of providing psychiatric care in the community is a good one, it would keep psychiatric patients in the community instead of the hospital ... I think the idea of ramping up community resources is a really good idea, but I don't think it's a good idea to take away the institutional resources before you have the community resources," she said.
Unfortunately, there are no plans for a major investment in the nation's mental health system, according to Schneider. Until the nation spends money for psychiatric care, this "travesty" will only worsen.