Richard Davis: A crisis without a fix
When a crisis appears to only affect a small number of people and when those people are among the most disenfranchised among, us guess how fast that crisis is dealt with? This is what is happening when it comes to providing appropriate care for people suffering from mental health crises.
Many states around the country, including Vermont, do not have the infrastructure or the capacity to deal with people who not only have acute mental health problems but also have no money and poor insurance coverage. As a result, people having acute psychotic episodes are being warehoused in hospital emergency rooms for days and sometimes weeks at a time until a proper placement can be found.
An acute care hospital emergency room is no place for a mentally ill person in crisis to spend so much time being treated like a prisoner. And make no mistake about it, these people are the prisoners of our non-existent mental health care system.
This country has a patchwork of places that provide mental health care. If you have the money you can find high level care. But in this age of insurance companies dictating care plans and poor Medicaid reimbursement, too many people end up with a sprinkling of treatment, if they receive any at all, and then they are soon back to the troubling place where they started.
Consider these statistics from the Centers for Disease Control and Prevention (CDC)National Hospital Ambulatory Medical Care Survey, 2009–2011: "During 2009–2011, an estimated 382,000 emergency department (ED) visits related to schizophrenia occurred each year among adults aged 18–64, with an overall ED visit rate of 20.1 per 10,000 adults. The overall rate for ED visits related to schizophrenia for men (26.5 per 10,000) was approximately double the rate for women (13.8 per 10,000). Public insurance (Medicaid, Medicare, or dual Medicare and Medicaid) was used more frequently at ED visits related to schizophrenia compared with ED visits not related to schizophrenia. About one-half of ED visits related to schizophrenia led to either a hospital admission (32.7%) or a transfer to a psychiatric hospital (16.7%); these percentages were higher than for ED visits not related to schizophrenia."
The problem with mental health care in this country is not one of quality but of capacity. And the CDC numbers indicate the problem may be bigger than politicians think it is. An institution like the Brattleboro Retreat provides a high level of care and it offers a number of programs to serve a spectrum of populations. They even have beds designated to deal with people who in past times would have been sent to the state hospital. But there are not enough of those beds and that is a problem that has been decades in the making.
In the early 1970s many states decided that the system of state run mental health hospitals was not a good way to care for the mentally ill population. Those hospitals had become warehouses for all kinds of people with problems that were not always of a mental health nature. Even in those days the hospitals resembled the snake pits and dungeons of years past.
I was working as an aid in the hospital in Northampton, MA just before the closure of many Massachusetts mental hospitals. It was a scary place to work, with it massive locked wards and the stench of decades of abuse and neglect.
I remember being given a tour of the facility as part of my orientation and I was taken to a series of underground passages connecting buildings. Along the walls were rings and shackles. The person showing me around told me that in the days before psychotropic medications were available patients were chained to those walls as a form of "treatment".
That kind of history coupled with the inhumane conditions that existed into the 70's prompted Massachusetts officials and many other mental health bureaucrats from other states to decide to close those facilities. But they never developed a realistic plan to care for all of the people they released and, as the decades passed, they continued to ignore the increasing problem they had created.
This mess we now have in many states could have been avoided if politicians and bureaucrats believed that the lives of people suffering from mental illness were as important as the lives of everyone else. But they did not, and now they continue to ignore the crisis that gets worse every day.
In a posting on the Vermont Medical Society web site it was noted by Emergency Department and UVM Medical Director, Steve Leffler, M.D. that, "It's my understanding that at any one point in time in Vermont there are about eight psychiatric patients in an ER waiting for a bed somewhere," who doesn't believe we would put any other patients through what we put the mentally ill through. He gave an example of a patient coming to an ER for an appendectomy and argued we wouldn't return them to the ER after their surgery because they had no place to go. If that happened, he said, we would fix it, but we continue to let the mentally ill suffer for weeks at a time in emergency rooms.
What will it take to even begin to work on this problem? How long can we continue to sweep it under the rug?
Richard Davis is a registered nurse. He writes from Guilford and welcomes comments at firstname.lastname@example.org. The opinions expressed by columnists do not necessarily reflect the views of the Brattleboro Reformer.
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