The Issue of Managing Mental Illness in Emergency Departments
The discussion surrounding the Texas church shooter has increased the stigma surrounding mental illness. It is true that the shooter suffered from a mental illness. However, with words like “crazy people” swirling in news headlines, we are at risk of further stigmatizing an already vulnerable population. Stigma is something that changes the way we view a certain population, and in healthcare, particularly the emergency department (ED), it can even change the way we treat it.
The rates of people using EDs for mental health reasons are on the rise. An estimated one in eight ED visits is for a mental health reason. As the nation experiences a shortage in psychiatric providers many individuals with mental illness find themselves in EDs more and more often. ED providers are then expected to provide care to a high volume of individuals with mental illness while not understanding or empathizing with them. And this can lead to subpar treatment.
Individuals with mental illness typically come to the ED in crisis. However, the crisis can easily become escalated instead of alleviated. ED staff members with mental health training are limited in numbers. As a result, patients often end up sitting alone with a security guard or other nontherapeutic staff members watching them with minimal interaction. In these situations, patients have reported feeling as though they were treated more like prisoners than hospital patients.
The very environment of EDs can be overwhelming, further contributing to patients’ symptoms. Patients can quickly end up receiving medication to calm them down instead of other de-escalation strategies being tried first. Often times patients would prefer not having these medications. Even worse, patients can quickly end up in restraints which again can escalate the situation.
Patients have voiced feeling as though there is no one to talk to and that care is not patient centered. They feel their case is not appropriately triaged and that all mental health conditions are treated the same even though they are very different. The lack of concern and consideration is interpreted by patients as them being disrespected.
Patients with primary issues involving mental illness can spend many hours in the ED waiting to be transferred to an inpatient psychiatric unit. This is called “boarding” and this issue has been increasing in frequency. Studies have found that patients with mental illness typically end up being boarded in EDs hours longer than patients with medical conditions. It is not uncommon for a patient to wait up to a few days for a bed in a psychiatric unit.
This issue is multifaceted though. Low reimbursement rates from insurance companies and a shortage in psychiatric providers have caused many inpatient units to close down. This in turn decreases the number of available psychiatric beds.
In arguing that mental health disorders are no different than medical ones, patients also mention that if they were having chest pains or their blood sugars were high they would not be met with the same attitude as they are with a mental health condition. After all, both are linked to biology. It’s just that mental illness is less understood than many of the medical illnesses. This is also where the stigma comes in.
Providers, especially those in EDs, can argue that they were not meant to be mental health care providers. After all, they are trained to manage significant traumas and save people’s lives from acute medical emergencies. And no one is taking that away from them. But when will we start seeing mental illness as any other illness that deserves equal consideration? When will medical providers start to embrace the need to provide quality care to mental health patients? With the future of mental health coverage looking bleak, we must have empathy for those who feel they have no other option than to go to the ED. Who really wants to spend several hours to days in an ED anyways? If a better option existed, assuredly it would be utilized.
Stigma surrounding mental illness is a pervasive part of our news. This already vulnerable population faces even more struggles as these stigmatizing headlines are published more and more. And the stigma bleeds over from the community into other settings, such as the healthcare setting. With people with mental illness requiring more frequent visits to EDs, the issue is now being faced head-on with providers who may experience similar stigma themselves. Changing the language we use to talk about mental illness is a start. But initiatives rolled out as part of Trumpcare may cut funding of mental health resources which will in turn lead to even more people with mental illness going to EDs for stabilization. It is time we shifted the conversation on mental illness. It’s time we give people with mental illness a fighting chance at recovery, whether it’s through the words we use or by improving policy on healthcare to enhance mental health resources. If not feasible, the least we can do is improve care once they make it to their option of last resort: the ED.