Thursday, July 3, 2008

A Hard Day's Night for the Mentally Ill: Psych Patients Waiting In Emergency Rooms

In centuries past, the mentally ill were neatly locked away from public view, along with society’s other smelly unmentionables; the homeless, the unemployed, the criminally insane, and the drunkards among them. They would be herded onto ships of fools and sent out to sea, to land at some unsuspecting port, or to simply die in the blue beyond.

Many years later they were hidden behind tightly locked doors of forbidding sanitariums. In any case, society was more than happy to “treat” these unfortunates because that meant shrouding their cockeyed faces, shrill screams and endless gibberish from plain view. We as a society have a well-honed ability to simply tune them out, at least until they’re in our face.

Now they’re in our emergency rooms, as they have been since Ronnie Raygun put it to the mental health system. Every now and again a news organization will run a story about all these psych patients clogging up the ERs. Today’s AP story offered a new twist: Patients are clogging psychiatric ERs because there simply aren’t enough services. This notable, albeit subtle, shift has been a long time coming. No longer are we only concerned that mentally ill patients are occupying beds that should be reserved for the “truly sick” people. In a moment of clarity, someone in the press is finally declaring the mental health system itself is sick. And it is-- severely, chronically so-- and cannot be treated with a standard regimen.

I have spent the better part of the last ten years holed up in California emergency rooms assessing, detaining, admitting and discharging psychiatric patients. Some are schizophrenics, pleasantly insane and otherwise. Some are malevolent sociopaths who wouldn’t, or didn’t, hesitate to butcher their own mother. Others are depressed and bipolar who see no recourse other than to kill themselves. And there are the kids who tried meth or some designer drug and triggered a chemical reaction unleashing heretofore dormant psychoses. There are the older drug addicts whose trips, like their dependence, won’t stop. Then, as always, you have the handful of players who come in looking for three hots and a cot and will feign absolutely any symptom for their price of admission.

During this tenure, advocating for, not just serving, the mentally ill in our society has become something of a personal mission for me. The solution is not to throw some more money at the problem, put some more services out there and hope everyone will shut up. Instead, a fundamental paradigm shift is what we need.

As with the individual, our society’s collective thought creates reality. The underfunded, broken mental health system is only an expression of our mutual fear and loathing of mental illness and, consequently, those who it affects. Change the belief and we’ll change the reality.

It wasn’t that long ago that a mysterious illness swept like a wildfire through a freewheeling slice of the gay community and a hodgepodge of IV drug abusers, two of the most marginalized populations in society. No one really cared about the carnage of AIDS until it struck middle America’s nerve when Rock Hudson sickened and died. Then Liberace. Then Freddie Mercury. The face of AIDS changed and services and funding grew accordingly. The same must be and can be done for mental illness.

Efforts like Joe Pantoliano’s Efforts like Joe Pantoliano’s No Kidding, Me Too! which seeks to remove the stigma of mental illness using star power, are on the right track. We just need more of them.

Raising awareness can raise funding. But improved policing of where the money is spent would be well worth the effort. The group I mentioned earlier, the impostors who feign mental illness for a free place to stay need to be redirected elsewhere, such as homeless shelters and case management services. This cannot be accomplished, though, until there is adequate liability protection for physicians and other professionals who dare to just say no to a malingerer, only to have the person walk out and knife themselves, just to prove a point, but unexpectedly die. It may smell of sweet justice, but it reeks in the courtroom when family members suddenly emerge from the woodwork to sue the unlucky physician.

Then there are the politicians and other stakeholders. One look at the internecine dealings behind distribution of California’s “millionaire tax” for mental health services is an embarrassing look at bureaucrats and technocrats gone wild. How long before grabby government hands are dipping into this till to fund everything but mental health in this cash-strapped state? Accountability cuts all ways.

The political will for treatment is another key issue. States like California have created legislation such as Laura’s Law, which provides for mandated outpatient treatment, but without any funding source. We can all do that kind of math: Good law+ no money=hot air. Meanwhile, many patients continue to wind through the system’s Great Revolving Door on a monthly basis, noncompliant with treatment, penniless after spending their SSI checks on drugs, and carrying “insurance” like Medicaid, which doesn’t even pay the direct costs of their care. A dollar reimbursement for $5 worth of care is a great way to devolve to no services.

Until we as a society decide if the mentally ill are really worth treating, we will continue to see ERs, general and psychiatric alike, overflowing with insanity.
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