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State of Emergency

Why we are failing patients with mental health issues in the emergency room.
(Photo: Oli Scarff/AFP/Getty Images)

(Photo: Oli Scarff/AFP/Getty Images)

This was the third time I had seen him this month alone. It was the same story as before; he was hospitalized and provided a short supply of medication at discharge. Now, he was back in the emergency department, intoxicated, talking to himself, and disheveled.

He tells us he drinks to quiet the voices, a common story. Self-medicating with drugs and alcohol to “smooth out the rough spots” or “quiet the voices,” is not uncommon for people without access to appropriate mental health services.

This is a daily occurrence in one urban emergency department where I work and is emblematic of the state of our mental health and crisis intervention system nationwide. Care for many with mental illness is now a patchwork of emergency department visits, incarcerations, and months-long waits for appointments at community mental health clinics with fewer and fewer providers available to care for this growing population.

The problem has gotten so bad that a recent survey by the American College of Emergency Physicians reveals that more than 80 percent of respondents feel the mental health system in their areas is not working.

Twenty-six percent of those living below the federal poverty line have struggled with mental illness in the previous 12 months, according to Substance Abuse and Mental Health Services.

Too often our focus turns to mental illness only in the wake of horrific and sensationalized crimes—the shootings at the Colorado Springs Planned Parenthood clinic and an Oregon community college, or the stabbings on a University of California campus. Fortunately, the number of people with mental illness committing violent crimes is low. Unfortunately, the stigma is that these individuals are violent and unstable due to their history of arrests.

According to a Substance Abuse and Mental Health Services Administration report, more than 40 million American adults over 18 years of age were living with a mental illness during the previous year. This represents 18 percent of the population. Those living with “serious mental illness” number about 10 million, or just over four percent of the population.

In Illinois, the state where I live and practice, two million people are living with mental illness and 434,000 are considered to be living with serious mental health issues, according to 2013 data from the National Alliance for Mental Illness. Still, between 2009 and 2012, Illinois cut $187 million in spending on mental health treatment.

In Illinois, two state in-patient psychiatric facilities and six public mental health clinics have closed in the last six years. Illinois ranked third—behind California and New York—in funding cuts during this period, according to NAMI. These three states, some of our most populous, cut more than $300 million combined from their mental health budgets in the 2011–12 fiscal year alone.

People living below the federal poverty line are disproportionately affected by these cuts as they have the highest rate of mental illness and are most likely to be affected by changes to mental health budgets and Medicaid services.

Twenty-six percent of those living below the federal poverty line have struggled with mental illness in the previous 12 months, according to SAMHSA. Compared to those with private insurance, those receiving Medicaid or Children’s Health Insurance Program support are almost twice as likely to have a mental illness.

Cuts to Medicaid spending and the reimbursement of providers and planned cost shifts under the Affordable Care Act have left many of our most vulnerable citizens with nowhere left to turn but the emergency department.

And now, one in every eight emergency room visits are for mental health disorders with and without concomitant substance abuse issues, according to the Agency for Healthcare Research and Quality. Yet the care provided is often inadequate.

Emergency department overcrowding, boarding, and wait times have become national concerns. Patients waiting to see a psychiatrist or to secure an in-patient psychiatric bed contribute to the bottleneck and are disproportionately affected by wait times.

With fewer providers to care for these patients, and fewer available in-patient and outpatient treatment options, it is not surprising that the emergency department length of stay for admitted psychiatric patients is three times longer than that of non-psychiatric admissions, according to a 2012 study published in Emergency Medicine International.

It is not uncommon to have patients waiting for admissions to a state hospital spend more than 12 hours in the emergency department. For some of the most severely ill and/or dangerous, the wait can be days. Many patients spend their three-day hold period in the emergency department and are cleared for discharge without ever seeing an in-patient unit.

A 2012 NAMI study found that 50 percent of patients who sought emergency department care for their mental health issues were dissatisfied with the help they received. More than 70 percent said they waited longer than 10 hours to see a mental health professional.

Many jails in large urban areas are serving as de facto mental health clinics and institutions. In Illinois, Cook County Sheriff Tom Dart has said that between 25 to 30 percent of the inmates at Cook County jail are mentally ill.

That the state of Illinois is in significant financial peril is not in dispute, but it is questionable if the additional projected 2016 cuts to Medicaid, Department of Human Services mental health services, and psychiatric leadership grants are the best way to trim the budget. These cuts alone are projected to total $1.6 billion.

But what are the costs to our citizens who live with mental illness and their families? Most importantly, do these cuts actually save money or do they shift the burden elsewhere?

We may not know the answer to those questions, but we do know that the cost of emergency department and jail care for mentally ill patients is much higher than that for a patient living—and possibly working—in the community and receiving out-patient care.

One urban emergency department reviewed the hospital record for a single patient who had presented more than 700 times in a 10-year period. The cost of care at this hospital alone was estimated at $2.5 million.

The solution to the problem of people living with mental health issues is not easy or without cost. But we can surely do better.

We need to focus on treatment and early intervention. Working to de-stigmatize mental health problems and seeking affordable mental health care, we can begin to implement compassionate—and ultimately cost-effective—care. We need more than a safety net approach that briefly saves the severely affected but does nothing for those suffering in silence every day with little to no access to care.