As state legislatures continue to slash budgets for mental health services at the same time that the worst economic downturn since the Great Depression continues to take a toll on the population, emergency departments (EDs) across the U.S. are confronting a drastic increase in psychiatric emergencies. Already overburdened with uninsured patients whose deteriorating conditions force them to seek medical care, EDs are being inundated with mentally ill patients who have nowhere else to turn.
When the economy spirals downward, psychiatric patients are among the first to lose access to proper medical care. Further compounding this problem are patients who were not previously seeking emergency care: those with no documented history of mental illness who present in an acute psychiatric state. Typically, these patients have lost their jobs, their homes, and their health insurance. Unable to support their families, they are deeply depressed, in some cases suicidal, and have come to the ED as a last resort. But emergency nurses and doctors have neither the appropriate training nor the capacity to handle the influx.
A Look at the Numbers
Consider a few examples: North Carolina’s legislature has cut the state’s inpatient psychiatric capacity by half since 2005. Pennsylvania Governor Tom Corbett has proposed a 20% reduction in social service spending, with the major portion impacting people with mental disabilities. Washington State has lost a third of its inpatient psychiatric beds in the past decade. California cut $587 million in state-funded mental health services in the past two years, the most of any state. Alabama is debating plans to close its last four state hospitals for the mentally ill. The state has shut down 10 mental health treatment centers since the 1990s. In addition, financing for Alabama’s mental health services has been cut by 36%, and additional cuts of up to 25% are planned for 2013.
In terms of numbers of people using psychiatric services, the Centers for Disease Control and Prevention, the National Institutes of Mental Health, and the Substance Abuse and Mental Health Services Administration have little or no recent data. But mental health advocacy groups and state-funded agencies as well as physicians from a dozen or more hospitals across the country have reported significant increases in psychiatric emergencies, according to Reuters. Various reports claim that ED visits caused by psychiatric emergencies having risen 20 percent in the past three years. When you consider that the Institute of Medicine had released a report in 2006 that found EDs were already overtaxed and overcrowded, the picture darkens even further.
The National Association of State Mental Health Program Directors (NASMHPD) estimates that in the past three years state legislatures have cut $3.4 billion in mental health services, while an additional 400,000 people sought help at public mental health facilities. Demand for community-based services has risen 56 percent, and demand for emergency room, state hospital, and emergency psychiatric care has risen 18 percent.
Impact on the ED
The increased demand means that emergency nurses, doctors, and social workers spend hours, sometimes days, trying to arrange care for psychiatric patients who remain in EDs taking up beds typically used for trauma cases.
More than 70 percent of emergency administrators report that they have kept patients waiting in the ED for 24 hours, according to a survey of 600 hospital emergency department administrators by the Schumacher Group, which manages EDs across the U.S. Ten percent reported that they had boarded patients for a week or longer.
Most EDs do not have secure holding rooms. Nor do they have quiet spaces that are better suited for dealing with patients in acute psychiatric distress. As a result, a patient in such a state might be strapped to a gurney in a hallway while a social worker searches for an available bed.
Meanwhile, EDs across the country continue to struggle under increasingly difficult circumstances with no solution in sight.
More information on caring for patients with psychiatric emergencies is available through Mosby’s partnership with the ENA and the newly published ENA: Handling Psychiatric Emergencies.