It’s time to treat mental illness in the ER with dignity

We doctors who specialize in psychiatry have a sacred trust. We are given the opportunity to talk to people who are hurting every day, people who trust that we will listen to them, try to understand them, not laugh at them, and not think that they are stupid, crazy, or horrible. A tall order, granted, given that we hear stories that sometimes border on the unimaginable, bizarre and otherworldly. This is a privilege. I believe that with all my heart, even on the days that I am the most busy and bone-tired and wondering why I chose to do what I do. My interaction with my patients, that sacred emotional bond between the hurting and the helping, is paramount. If we forfeit that, what do we really have to offer?

That being said, there is a horrendous breakdown in this trust between the hurting and the healing in the emergency departments where many mental health patients are forced by default to go for acute and  chronic care. We make jokes about the TSA and the indignity of passing through the obligatory minefield of airports large and small since 9-11, but the same indignities are being visited on the mentally ill of America every day.

When a person is picked up by the local sheriff’s department executing a probate court order for transport for mental health evaluation, one of the first things that often happens is that the patient is handcuffed. Keep in mind that this person has not been arrested or charged with any crime. They are simply being transported for a medical evaluation. I have heard patients with trauma histories talk about how they are triggered to the point of hysteria by this practice, as some of them have been bound, assaulted, even tortured in the past.

Can you imagine? You are scared, maybe strung out on drugs, already paranoid, and the police come to your front porch, seize you bodily, handcuff you, and put you in the back of a cruiser. This very first step, the very first contact with a system designed to help the mentally ill, scares some of these patients so badly that they never go back for treatment again.

This is only the beginning. When patients arrive at the ED, they are stripped of all personal possessions, clothing, jewelry, money, everything. No keeping an iPod that might be playing the very music that calms you and makes the voices fade into the background just enough to make them manageable. No keeping a Timex that might help you stay oriented during the next few days when you will be held in a nondescript room with no windows or clocks to help you know what time of day it is.

In some hospital EDs, personal health information is gathered and discussed in open cubicles or behind flimsy curtains that do little to address HIPAA regulations. The person next to you is having belly pain and is likely to have an appendectomy presently. You are hearing voices that tell you to kill yourself. Now everybody knows about both of you.

Security guards are used as sitters outside your door once you are committed for treatment. You can’t take walk down the hall to stretch your legs. You can only take a shower when allowed, and no razors are given to shave beards or legs. You can’t smoke, something that may not be in your best interest but that has strong implications among psychiatric patients. As my patient said last week, “this feels worse than prison, Doc”.

We talk about treating people with mental illnesses with compassion and gentleness. We talk about people being more than a diagnosis, more than a diagnostic code. More than just another case or “the bipolar in Bed 2”.

It’s time we start doing instead of talking. It’s time we start treating people who come to the emergency department for help with mental illness with dignity.

Greg Smith is a psychiatrist who blogs at gregsmithmd.

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  • Michael Chen, MD

    Thank you so much for this post. As physicians (as well as our communities that interact with those that have mental illness..literally everyone) we need to think of our approach to working with this population in a trauma-informed framework. The work by Bruce Perry, MD is a good starting point (it focuses on children, but very much applies to adults as well). The examples you provide are salient to uncovering the processes we take for granted, not realizing the harm and further trauma we inflict unknowningly to our most vulnerable. We need to re-conceptualize our approach to health care for the mentally ill and think through how we can be helpful rather than being harmful to our patients as soon as they walk into the hospital. First, do no harm…

    • DavidBehar

      Dr. Chen. Are you a “No Restraint” wackos?

      • Duane Sherry


        On this Memorial Day, I’m reminded of those who gave the ultimate sacrifice to protect freedom.

        And here you are, David….

        With such little respect for freedom.

        Ready to take it away from folks who have been arbitrarily labeled; people who are in emotional distress; misunderstood; marginalized.

        You’re ready to make certain they lose their freedom, without due process…. full of rage and vitriol…

        Here you are, David…

        Exercising your 1st amendment rights in a free country.

        Let me take a moment to exercise mine:

        May God have mercy on your soul, David.


  • DavidBehar

    I do not understand what this doctor is complaining about. Many patients are “stupid, crazy, and horrible,” especially in the ER. The doctor lives in some kind of self deluding state. Or else, he is an adherent of the Recovery Model, a sicko model that is far more stupid, crazy and horrible than any patient. There should be zero tolerance for the political correctness garbage on display in this article. I remind this doctor, these patients murder 2000 people a year. They destroy $billions in real estate value by just being somewhere. They refuse treatment, and prefer their selfish addictions over all other people and values in their lives. They are a blight on our society and most of their problems are from their lifestyle choices, even in biologically based disorders such as schizophrenia. For example, they could take a short break from the crack pipe and try some medication sometimes. They are not victims are represented in this misleading left wing propaganda. They are a pox on the culture.

    • Nancy

      I am flabbergasted at your rant, Mr. Behar. I have never considered murder, and I have even managed to raise a very fine young man, even with my (at times) severe mental illness. I certainly never ‘chose’ this lifestyle of mental anguish and pain. I have never been addicted to drugs or alcohol, and I was constructively self-supporting during high school onwards. The mental patients you see in the ER, no matter how aggressive and annoying, all would probably trade their mental pain for a better life if they were emotionally strong enough. They have been either damaged and /or have the misfortune to have the wrong genes!

      • DavidBehar

        Nancy: I accept and respect your views. Go in peace.

        What must be resisted to the utmost are traitors to clinical care like Dr. Smith and his politically correct little Caesars in Government. I want to see them utterly crushed.

        • Patricia

          I hope you are not a physician or anyone in the medical field.

    • md140871

      I don’t get the sense that the author is arguing that every single patient not be restrained. Use clinical judgment! I have seen numerous patients who have brought themselves to the ED because they were suicidal, only to have every ounce of dignity stripped away from them even as they show that they are no longer a danger to themselves (and were never a danger to others). Point is, we treat every psychiatric patient the same when they are all clearly very different!

      • azmd

        The problem is that the typical ED does not have the staffing or the infrastructure to address the needs of the 20-50% of psychiatric patients who will be in some way disruptive to staff and to other patients while they are there, frequently for periods of time that are much more extended compared to medical patients who can generally be relatively quickly admitted to a bed on the medical floor.

        Most EDs do not have separate secure areas in which psychiatric patients can be held, they typically don’t have a psychiatrist immediately available to evaluate the patient and provide guidance on management, and they do not have extra nursing staff to monitor often unpredictable patients. Even the quietest voluntary patient can sometimes become unexpectedly agitated. And so the ED staff takes precautions, sometimes unneccessary and sometimes draconian, to prevent harm.

        The real solution is for there to be a more appropriate place for psychiatric patients to go for triage, evaluation and transfer for admission than a community ED.

        • Patricia

          Of course that is the solution; but don’t blame the patients because of the way our culture does not value people who are not mentally well. Why not rail against the systemic structural problems that have created this?

          • azmd

            Where did I blame the patients for anything? The fact that the system does not serve their needs well does not equate to blaming them. I could say that the healthcare system has not served my needs as a patient particularly well, but I don’t feel that I am being blamed for having needs that cannot be met given the current model of healthcare delivery.

          • Patricia

            Yes, of course there should be more appropriate places for mentally ill aggressive patients to be taken. Your word choice and statistics are what seem to be blaming. I have no idea what the “statistics” say, nor do I have time to research right now, but how do we know that the practices used against them are not the very things that cause the aggressiveness? Do the studies measure how these people have been treated by those who picked them up or placed them in the EDs?

          • azmd

            I am sorry if, by citing statistics based on valid scientific research, I seem to you to be blaming anyone. I am also sorry if somehow my word choice offended you. However, just because you didn’t like what I had to say does not mean that it’s not true, or that we should not rationally consider facts as we try to make decisions about healthcare for everyone.

            I would encourage you to look at the data for yourself. The statistics I cited were based on the Epidemiological Catchment Area Study. Additionally, a study done in Sweden (Fazel, Langstrom, et. al., 2009) which looked at 80,000 schizophrenia patients, found that 13% of them had at least one arrest for a violent criminal offense, compared with 5.3% of the general population.

            Anecdotally, I would also say that I work in a hospital where we go to tremendous lengths to avoid secluding and restraining patients. We rarely use mechanical restraints at all, although 100% of our population consists of severely mentally ill involuntary patients. We have a staff of specially trained psychologists who work closely with us to create personalized behavioral plans in order to enable us to avoid overmedicating our patients or having to restrain them. It’s a well-organized, well-staffed, well-run and very humane hospital. However, we have staff assaulted by patients approximately once a week. I am talking about serious assaults, with resulting injuries.

            The fact is that some psychiatric patients are vulnerable to behaving aggressively towards others when they are ill. This fact needs to be considered when policies on how to treat such patients are created. Calling people names because they point this reality out does not do anything to help the mentally ill. Ignoring facts about our patient population likewise does not do them any good.

          • Patricia

            I’m glad you cited your sources; I think that’s important. Did those studies validate causality? What causes schizophrenics to be violent? Had they been treated before? Etc Etc. And of course I would never say that someone with a mental disturbance is *never* violent. However, not *all* mentally disturbed patients are of the sort you mentioned. I do know that statistical studies have limitations including biased reporting. (Sorry I don’t have time to do this literary research on this right now as I am doing different research).

            Your place of employment sounds great, and wouldn’t it be good to promote and study these practices and how they can be used in other settings? Don’t you think that this is the way to go? I do.

          • azmd

            I will have to let you do your own research on the methodology of the studies I have cited. I will however mention that the citations are from a recent book on schizophrenia which was edited by a very prominent worker in the field, someone I personally trained under and know to be meticulous in his attention to methodology. So I doubt that sloppily done studies would have found a way into his book.

            As for promoting and studying our practices, I would encourage you to contact your legislators. They are the ones who are in charge of determining which resources for the mentally ill get funded. You might also consider getting involved with the National Alliance for the Mentally Ill, which does some very important advocacy work, if you are interested in helping.

          • Patricia

            Don’t worry I was not asking you to provide validity for the studies. I was merely pointing out that those are elements. So, perhaps if you had just put out your information earlier on, like your original posting, it would have been more clear as to what you were exactly saying.

            Also, some practices don’t necessarily need big funds; my suggestion to you is that if you care about this, you could start to write about it (maybe you do, but you haven’t said) and start to change opinions. Or enlighten others.


        • querywoman

          It’s a pity that different standards have developed for different classes of patients. The answer is to up staffing for psychiatric emergencies.
          Cardiac patients get lots of attention.
          As I stated elsewhere, Parkland Hospital in Dallas got in trouble with the feds for not provided beds for psychiatric ER patients. Meanwhile, Parkland had stockpiled lots of money. And, as I pointed out already, not provide beds violates equal opportunity laws.
          Legally, it’s not easy to prove discrimination in am employment situation, for example. If you are a dark brown American, and your boss doesn’t like your skin color, it’s very hard to prove mistreatment. The legal standard is usually being able to show different treatment to a certain class of people. Denying psych patients, who routinely get shot up with heavily sedating drugs, beds is blatant discrimination! It shows the system does not value these people enough to give them soft beds, pillows, and covers.

          Just because something has always been is no reason to continue it.

          • Guest

            “It’s a pity that different standards have developed for different classes of patients.”

            In a regular ER, psychiatric patients (especially those who are substance abusers) are much more likely to be aggressive and violent than patients with broken arms or stroke.

            It’s important to protect staff and other patients.

            You simply cannot treat a strong, vocal, aggressive and potentially violent mentally ill young man the same way you would a six-year-old girl with a broken arm.

          • querywoman

            That’s true. However, most psych patients are not violent.
            So how about using some common sense?
            Parkland has had to provide beds, but now there psych Mrgency room is temporarily closed down, courtesy of the feds.

      • LG

        Thank you md140871, I was exactly the patient you describe and was treated horribly. It was the diagnosis of a very painful, debilitating, and incurable disease that caused my depression. I wasn’t a danger to anyone else and I called for help. Because of the deplorable way I was treated I will never again make that call. The best I can do now is not let myself get to that point again- calling the ED is no longer an option.

    • hmontaigne

      Ignorant and bigoted too. You lose.

  • azmd

    It is certainly deplorable that any patient, particularly a vulnerable psychiatric patient, be forced to languish in the ED for extended periods of time. The ED is uncomfortable for any ill person and our lack of inpatient beds for psychiatric patients is a chronic problem which badly needs to be rectified.

    However, we should not let our compassion for our patients and our wish to ensure that they are treated humanely, blind us to the need to take appropriate precautions. Psychiatric patients are at an increased risk for aggression to others as well as to themselves. Studies have shown that patients with schizophrenia are twice as likely to commit violent acts as people with no mental illness. Schizophrenia patients with comorbid substance use disorders are ten times more likely to be aggressive than than an unaffected individual.

    Psychiatric patients who are being picked up by law enforcement officers are handcuffed for the same reason that individuals who have been arrested are: to protect the officers from the small but significant percentage of detainees who may be assaultive.

    Of course it is regrettable that some percentage of psychiatric patients will be traumatized by this practice just as it is regrettable that some percentage of non-violent, innocent citizens will be similarly traumatized by being mistakenly arrested. However, to deplore a necessary precaution as inhumane creates the impression that we psychiatrists are out of touch with the fact that our patients, at times, present a risk to the community.

    • DavidBehar

      These are not certainly not victims. They are predators and parasites protected and privileged by the lawyer profession. Thank the lawyer for the recent spate of mass murders. Now these murdering paranoid maniacs qualify for involuntary treatment. Doctors should not be collaborating or sympathizers with these horrors, as Dr. Smith seems to be.

      • Patricia

        You are a troll and not offering anything more than spiteful inflammatory comments. It’s a bit frightening that so many people are approving your comments on a medical blog.

    • Guest

      “The ED is uncomfortable for any ill person”

      Especially when there are unstable, sometimes aggressive patients, either mentally ill or on drugs or both, allowed to roam freely, scaring other medically ill and vulnerable patients including children and the elderly. When you’re a parent trying to comfort a child who is vomiting uncontrollably, for instance, it’s less than nice when there is a loud, demented person stalking the halls and peering into others’ treatment areas and shouting obscenities at them or in one case, exposing himself to them.

      Staff and other patients have “rights” too.

    • Nancy

      40 years ago, I suffered from mental illness severe enough to take myself to the county ER in the middle of the night more than once. I still remember the overworked, tired intern/resident who spoke to me so kindly and who really tried to help me, even though he didn’t understand the BPD I displayed. Also, in those days the hospital would give you a hot breakfast if you had to wait all night. It was a bright spot in an otherwise dark time for me. Today, I am much better thanks to clinicians who cared enough to learn what it is to have mental illness and how to treat it, and to take the time to be kind, even in an ER setting.

      • SBornfeld

        Kindness gets 4 down arrows. I’m glad you were treated humanely. I think some of the comments make it absolutely clear that simple kindness is now considered “left wing”.
        This kind of willful misrepresentation of Dr. Smith’s essay is just one more illustration (if one were needed) that rights are only right when they belong to me, me, me.

        • EE Smith

          Kindness and consideration towards a vulnerable patient, and warm gratitude from the patient towards those who cared for her, ending u in a positive outcome for all concerned, is the way most medical providers and most patients wish things could be all the time. Or at least I would have thought so. No one has ever accused me of being “left wing”, but I don’t understand the down votes either.

          • SBornfeld

            Full disclosure: I AM an unapologetic lefty. And in fairness, there are other obvious ways to frame this argument than political.
            I’ll admit to viewing this discussion with a jaundiced eye–based on some of the conversations on more explicitly politically-charged discussions on this blog (esp. regarding guns). I don’t view the medical profession as being particularly conservative, but if I didn’t know better just from these blogs I’d think the profession is populated by frothing-at-the-mouth gun totin’ mountain men.
            That would be a better description of my own profession (dentistry).

    • Patricia

      I think if you could address the issue rather than just denounce it; come up with some thoughtful solutions, would be helpful. Just because you can come up with statistics doesn’t mean that what happens to psych patients *now* is the only way we can go. You have to admit, that’s lazy thinking for a scientist.

      • azmd

        Well, I did suggest a solution below, to which you replied by accusing me of “blaming patients.” I am happy to elaborate on what the solution would look like, if that would interest you.

  • Michelle

    After reading the whole article I still don’t see exactly how the rights of mentally ill patients are being violated. Handcuffs – unpleasant but necessary most of the time. Security guard – no patients are allowed, or are physically able, to walk around the ED freely. This is just an extra measure that costs taxpayers. Personal possessions taken away – Most regular patients have their personal possessions taken away during testing. Flimsy curtains – Regular patients are behind those same flimsy curtains. I never got a razor in a hospital, have you?
    What psychiatric patients don’t have is maniacs yelling in their faces, which regular patients would have if Dr. Smith had his way.

    • Patricia

      I don’t think Dr. Smith’s article was a “prescription” meant to cure the problems he describes, but to open the door and discuss these issues with an open mind and compassion towards mentally ill. However some of these response, especially yours, are out of line. You exactly prove his point about discrimination, calling mentally ill people “maniacs”. How could you? If you had one ounce of knowledge surrounding the issue of mental illness you could never say such a thing or describe someone in that way. You make a valid point, but your point does not dismiss Dr. Smith’s.
      It’s hard for me to believe that people reading medical blogs would be so ignorant on what exactly costs taxpayers the most. And it is not mentally ill people. Your post here is offensive and not helpful at all.

    • PollyPocket

      I have been assaulted (one patient in particular attempted to strangle me) by surgical patients. Not patients being treated for acute exacerbation of mental illness.

      To say all patients being treated for mental health issues should be restrained is inappropriate.

      They are certainly no greater risk to me than surgical patients and no one is proposing universal restraints postoperatively.

  • DavidBehar

    The soft on criminals, soft on dangerous mental patients results in 35,000 suicides, and 2000 murders a year. Those are the hard outcomes of under treated psychiatric illness. What is less evident are the drops in real estate values by having a disruptive, ultra-violent mental patient in the neighborhood, injuries to the families and to strangers, and general degradation of the environment.

    Why does the left empower these mental patients to the detriment of everyone else? They generate massive government make work jobs for left wing government dependent workers. That makes the arguments of Dr. Smith in bad faith, because he is really promoting his economic self interest without disclosing that to the reader.

    The Recovery Movement, the No Restraint movement, and other puzzling anomalous, wacked movements have government worker economic self interest as explanations. That conflict of interest makes the advocates thieves of tax money, and ordinary criminals, just slick. I may begin a legal campaign against officials for corruption. Dr. Smith’s wrongful views in this article are immunized by the First Amendment Free Press clause.

    • Patricia

      Your slide into politically ideology makes you sound like the typical trolls found on news-blogs. Why does the issue of how we treat the mentally ill have to become a liberal or conservative issue? You worry about tax payer money; well then look to the immense theft of tax payer money done by gargantuan corporations. Including the medical ones. And yet there at the bottom of heap are the mentally ill and those who end up in jail. You show your ignorance of SDOH and effects of low SES.

      I have had mental illness in my family. And guess what…those practices Dr. Smith mentioned led to them not getting the treatments they not only needed but deserved, and their lives were cut short and miserable. Did you know that prisons are the repository of the mentally ill? Is that the best treatment for them? Does that treatment cost the tax payer? (Although it does line the pockets of private corporate prison owners).

      Your thinking is backwards. And offensive, just like Ms. Michelle’s post below illustrates. If a person has a broken leg, she gets treatment and consideration. But if a person has schizophrenia or BPD they get treated as a criminal. We can’t afford, as a nation (or global citizen) to think downstream in this discriminatory way. Those days are hopefully going to end. But not thanks to people like you.

      • DavidBehar

        Patricia: Thank you for you for your perspective. I agree with most of it. I do not believe the room should be cleared while an agitated person destroys it for three hours, nor is pounding another patient. I do not believe the mental patient should be tlhe leader of his treatment t

        • Patricia

          I disagree; to say that a ‘mental patient’ doesn’t know much is just wrong. Some do, some don’t. Mental illness comes in all forms and hits all levels of intellect. And of course no one should be allowed to beat apart an ED; or disturb others. But in my opinion you are going against the wrong end of the problem. Plus you have an intense bias. Why? This bias is what creates problems for mentally ill people in the first place. And I am guessing it promotes the very behaviors you disparage. Is a mentally ill person less deserving of respectful care, than you know a “regular” sick person? Stop throwing out these cases of violence and destruction because I am willing to guess those are not the predominant cases.

  • querywoman

    How about expecting “mental” patients to use a pay phone for calls when
    most”physical” patients have free phones at their bedsides? How about
    psychiatrists in hospitals who consider having “group” sessions as their
    patient contact okay? A “physical” doctor visits hospitalized
    “physical” patients every day! It might also help “physical” patients to have social contact with other patients.
    Group sessions in psychiatric hospitals violate privacy laws. Take everything sensibly, please. It’s okay for “mental” patients to share and discuss their problems, but when a psychiatric drills a patient about symptoms in a group session, it’s a privacy violation. Psychiatrists know they should meet one-on-one with a patient, but lots of them get out of it!
    Parkland Hospital in Dallas finally got in trouble for not even providing
    psychiatric ER patients with a bed for the night! They had plenty of money to buy them. Patients got shot all the time with usually heavy sedating drugs and had to lie on benches or sleep in chairs all night. Luckily, their psychiatric ER unit has been at least temporarily shut down. Psych patients are routed elsewhere now.
    The practices listed above are blatantly discriminatory. Hospitals have committed these abuses whereas non-medical entities have repeatedly been sued under equal opportunity laws for disparate treatment of various groups of people.
    The medical profession is long overdue for paying attention to laws that apply to everyone else.

    • Guest

      “How about expecting “mental” patients to use a pay phone for calls when most”physical” patients have free phones at their bedsides? ”

      Most ER patients do not have free phones at their bedsides.

      Get Obama to issue them another Obamaphone.

      • querywoman

        I’ve checked ER’s and found that free phones are usually available. About 15 years ago, I sat with a friend in a regular medical ER after she made a suicide attempt and found a free phone to you.
        FYI, the nurses were glad that I stayed with her while I let my parking meter expire. It was their job to monitor.
        There is no such thing as an Obamaphone. Cellphones are taken away from psych patients.

        • querywoman

          Last year, when I had pneumonia, I know there was a free phone in the ER cubicle where I was stashed. Then also in my regular hospital room. I think I had to get the nurse to dial my ICU phone, but they may not have wanted me to be disturbed.
          I was allowed my cell phone at all times, whereas psych patients are not.
          Before my mama passed, at various times when she was hospitalized and reaching for her cell, I’d remind her that patients get free bedside phones and always found one.
          Perhaps you folks dislike my saying there is no such thing as an Obamaphone. The phone discount was started during Reagan’s term and now people can ever get a discount on a landline or get a cell with limited mins per month.

  • azmd

    So, as I said above: “Studies have shown that patients with schizophrenia are twice as likely to commit violent acts as people with no mental illness. Schizophrenia patients with comorbid substance use disorders are ten times more likely to be aggressive than than an unaffected individual.”

    • hmontaigne

      Sources, please.

      • azmd

        See my reply below from yesterday which provides specific citations and more expanded statistics.

  • Rob Burnside

    My perspective may be unique here. Early on in my working life, I was a firefighter/paramedic and pulled a weekly ER shift to keep my skills up. Following retirement to care for a parent in home hospice, I worked as a state park ranger, sworn and armed. Then, two years as a psych aide in a state hospital. A half-dozen or so years after that, in the throes of a PTSD related crisis, I attempted suicide and was committed (voluntarily) to a psychiatric hospital for three days, released ultimately in the custody of my son, who saved my life.

    I’ve restrained patients. I’ve handcuffed and transported patients. I’ve been assaulted by patients. As a patient, I’ve been restrained and transported, though handcuffed and pepper-sprayed only in ranger training, which was bad enough. The only thing I can offer at this point (lucky to be alive and fairly well at 65) is this: though we might learn and practice more compassion for everyone in our daily lives–what Dr. Smith is really suggesting at baseline–there is no drive-thru “one size fits all” solution to the problem he addresses.

    But awareness is improving and that’s a good thing. I can easily recall a time when hyperglycemic diabetics were routinely locked-up in “drunk tanks” and sometimes died as a result. This doesn’t happen much anymore, thank God. There’s good reason to expect, in our lifetime, better ER treatment of and for the mentally ill. Blogs like this one help immensely. Keep up the good work, everyone! Kudos to Dr. Smith.

    • EE Smith

      Thank you so much for taking the time to share your perspective. Some of the comments on these blog posts are almost as valuable as the posts themselves. Yours is a good example.

    • Greg Smith MD

      Thank you for that excellent comment. Helps very much to hear from someone who is well trained and has seen the problem from both sides of the gurney, as it were.

      I do not want to work for twenty more years and have this status quo be what is expected when someone with mental illness comes to the ED for help, whether voluntarily or involuntarily.

      I understand full well that we must operate under rules or privacy, safety, and minimal risk to staff and patients, but I still maintain that this can be done while treating the patient himself in a more humane manner.

      • Rob Burnside

        I share your concern Dr. Smith, and I wonder if a better future might be derived from both a careful study of the past and improvement/adjustment in chemical restraint meds and regs.

        Working at a state hospital, especially on the Male Aggressive Ward, I would occasionally hear a wizened, compassionate coworker speak longingly of the “old days, when every patient, regardless of diagnosis, received a ‘blue cocktail’ (Thorazine) at bedtime…” There were fewer assaults, apparently, and everyone–including my friend–got “a good night’s sleep.” Of course, this led to many patients remaining there much longer than necessary.

        Perhaps, ultimately, we’ll need a new, more easily but judiciously administered “blue cocktail,” if this isn’t a contradiction in terms, and, like trauma centers and burn centers, regional psychiatric emergency centers for the more seriously ill. The same compassionate coworker told me the old state hospital admitting ward was “head and shoulders better for psych patients than any contemporary ER.” They must have been doing something right!

        Beyond this, or better still, in anticipation of positive change–heightened awareness is key. You and those who share your passion must be the standard bearers. Status Quo has got to go. Never give up and best wishes to you.

        • Greg Smith MD


          Thanks for that.

          Although I do remember those days of Blue Cocktails and the thick blue haze of cigarette smoke that hung at the top of every room in the state hospital, I would not want to go back there, not exactly.

          I do agree that we have to take the lessons of the treatment we provided in the past (and there were some things we did right, I think) and apply them to the future as we can see it now and as we would like to see it.

          The thing that worries and bothers me the most is that another twenty years will go by, I will have worked long hours and seen thousands more patients, and I will have done nothing to leave the system in better shape that when I entered it.

          I don’t want that to be my personal legacy.

          • Rob Burnside

            Greg, I suspect that most of the good you’re doing on a daily, even hourly basis may be obscured by the sheer volume of patients in need. As we know, it’s a big problem in all of medicine today–for consumers and providers alike– but especially in mental health. If this keeps up, it seems, time will eventually be “value-engineered” out of the healing equation altogether. I don’t know where psych patients and their caregivers will turn for relief from this, should it come to pass.

            But that’s “worst case” and it doesn’t have to be. I think the ACA may help, because it’s a work in progress, subject to modification and thoughtful improvement, which you and others who care, who have not given in to cynicism, dismay, and sheer exhaustion, will no doubt help to bring about. Now, we could be talking “best case.”

            Finally, though I don’t claim to possess any special insight or “wisdom of the ages,” I’ve observed this about life: there’s a great, often imperceptible, leavening effect at work almost continuously, though sometimes so slowly that, like “soil creep,” we fail to see it at a glance. But it’s there, in force, regardless.

            What I’m getting at is the probability (a “given” in my book) that: the good you do won’t be “interred with your bones” or even your patients’ bones, but will remain in one form or another for untold generations to come. Like Moses, you might not enter the Promised Land, but I’ll bet my bottom dollar you’ll see it. And that alone may be worth working and waiting for. Again, my very best wishes. Rob

          • Rob Burnside

            Doc-(Which I’ve never called a physician I didn’t have a great deal of respect for, by the way) There’s one more thing. And this time I WILL channel Methusulah: The Oath doesn’t require you to go down with the ship.

            After twenty years in the trenches of emergency medicine, followed by a fifteen year break, I’m back teaching first aid and CPR and I love it. I’m getting around, meeting the next generation of EMT/Paramedics/Nurses/Doctors/Whatever. They think I’m old, wise, and know everything. So, they listen raptly while I “tell it like it is, was, and should be.” I’m getting through to them and it may make a difference.

            How about you? You’ve more than paid you dues. You’d make a damn fine teacher yourself. Just a little 4 a.m. tobacco for your pipe…All the best, Rob

          • Greg Smith MD


            Thank you again.

            I too have taught before and really enjoyed it. Funny you should mention that now. Just this morning, I checked on the status of my application for a clinical teaching appointment at the USC School of Medicine.

            We already have psychiatry residents rotating for eight weeks at a time with us to learn the nuts and bolts of telepsychiatry. We should also begin to take fellows in the coming academic year. I will be helping to supervise these ladies and gents as they learn the ins and outs of electronic assessment.

            I’m glad you are making a difference with the next generation.

            Erikson got it right I think. I’d much rather have the integrity that follows generativity than the despair that comes from stagnation.

            Cheers, professor.

          • Rob Burnside

            A great quote, Doc, and when I see “Erickson” I think immediately of the “Clairmont,” which reminds me of the old mariner’s charge: “One hand for the ship, and one for yourself.”

            If I’d known you were from California, I wouldn’t have mentioned soil creep in my previous post, but I trust you’ll forgive me for that.

            Time to carp the day, got a class to teach. Fair winds and following seas to you!


  • LG

    After being diagnosed with rheumatoid arthritis I had ever worsening depression which led to a suicide attempt with pain meds. I was admitted to the ED after a voluntary phone call to 911. I was made to strip completely while two girls held up a sheet for privacy from the rest of the ED but watched my every move. I asked why I couldn’t keep my underwear and socks on and was told because I could hang myself with my clothing- although they gave me a gown with ties that would have been much more useful if that was my plan. I was not allowed to see or call my husband and he was not allowed any info on me even though he had followed the ambulance in. Although I had an iv, I was not medically monitered in anyway, no O2 saturation, blood pressure, etc. The ED room I was in had a huge clear window and there were non medical people wandering by and looking in.

    They gave me an iv push of promethazine in my hand which caused severe phlebitis- I only found out later how dangerous administrating this drug is when used as an iv push into an extremity. I was given the charcoal treatment which I guess is pretty standard.

    I was held for 8 hours before anyone came to talk to me. A sitter staring at me the whole time and the lights blazing.

    The counsler that finally came told me that she herself had a positive blood test for rheumatoid arthritis and was just fine…. great, I think- one more person that has no clue about this horrible life changing disease. A disease that is not diagnosed by a blood test but can only be diagnosed clinically.
    She told me that it was she that would recommend what was done with me; she was very proud of this fact. So I told her what she wanted to hear which wasn’t hard to do with this type of person and I ended up being released eventually.

    That was a year and a half ago and I see a resident psychiatrist regularly, I’m doing much better. The meds helped a lot. At my last appointment I mentioned to my doctor that if I wanted to do myself in again I would never call for help- the way I was treated in that ED was condescending and cruel. I was stripped of all dignity and I will not ever ask for help through this channel again. This all happened at Renown Medical Center in Reno, NV- a big flashy hospital.

    When a patient is admitted for suicide ideation that is secondary to chronic illness and is treated like I was, it is just wrong.

    • Guest

      I have come to the conclusion that seeking help for mental health issues may be hazardous to one’s mental health.

      I’m sorry that happened to you, but I’m glad you are telling people about it.

    • querywoman

      Abuses in psych ER’s often boomerang in that they cause patients to be determined not to do it again.
      Did unlicensed people see you naked?
      Psychiatric ER’s and hospitals “warehouse” patients. The medical neglect is inexcusable. I don’t need to hear about, “staffing shortages,” either!
      Google “100 dollar handshake” to see how psychiatrists briefly visit hospitalized patients.
      Psychiatric patients should have nurses checking on them regularly, just like hospitalized “physical” patients. Also, free phones at their bedsides along with mandatory beds for each patient!

  • Rules4Radicals

    The largest psychiatric “hospitals” in the US are the LA County Jail and Rickers Island Prison of New York City. The ACLU and the political ruling class have dumped the chronically mentally ill on to the streets by shutting down any meaningful treatment options 40 years ago.

    These homeless and/or untreated psychotics are the ones who so often terrorize the overburdened EDs with their offensive demeanors. Until the emergent care staff and police departments of America have proper places to sent these lost souls for long term treatment, the practice of emergency room psychiatry will remain a nightmare.

    • Rob Burnside

      This is all unfortunately true, in my opinion. I believe “de-instutionalization” was a good concept initially, though poorly carried-out in the long run. It depended heavily on the capability and intent of organizations operating CLAs. (community living arrangements). At first, operators were well-qualified and compassionate. Then, “connected” individuals got into the act purely for profit and began to get referrals based on political affiliation rather than the ability to function as intended. Gradually, they edged out the original operators. At this point, the CLAs became not much more than revenue-generating, revolving door caricatures of what they were supposed to be. These operations were sold, and re-sold, until they morphed into what we have today–mysterious, entrenched corporate entities, responsible primarily to their own boards. Whether or not treatment is actually any better than the old state hospital systems is a debatable matter, and of course there are exceptions here and there, where good care is the norm. However, from a law enforcement point of view, what we have now must seem confusing and nearly inaccessible, at least in comparison to what we once had (though few in law enforcement or ER work today actually know anything good about the old state systems–that has all been “interred with their bones.”

  • WhiteCoatRants

    This post may be well-intentioned, but it has little basis in reality.

    Psychiatric patients are “forced” to go to the emergency department for acute and chronic care where their care is indignified?

    First of all, less psychiatric patients would be “forced” to go to emergency departments if their psychiatrists or the on-call psychiatrists were more available. But your article fails to mention how little mental health treatment is available for patients in need. Psychiatric patients routinely sit in some emergency departments for days waiting for a psychiatrist to provide them with care. When’s the last time you made yourself available to immediately evaluate a patient for an emergency detention order? I suppose the answer to that question doesn’t matter much. It makes you look so much more compassionate when you express your heartfelt feelings for patients in need and then vilify another specialty you apparently know little about.

    Go to my blog and do a search for “patients gone wild.” I specifically use that tag for all the assaults that occur in the emergency department so that they are easily searchable. In the past couple of years I’m up to almost 60 episodes – and those are just the ones that are reported and that make the news.

    When patients are brought to the emergency department, you express shock that they are stripped of their belongings. This is known as a “contraband check.” I have witnessed patients set fire to their beds, patients cut themselves with hidden blades, patients attack staff with makeshift shanks, and have seen one patient attempt to hang himself with a belt. Yet you, as a professional specialist, seem to think that these are small prices to pay so that patients can listen to music to assuage the voices in their heads. Some Chopin, perhaps? Wrong. Try Megadeath. And maybe when the music pushes their buttons enough, the patients can wrap the headphone cords around their necks and try to kill themselves. Or perhaps they can use the headphone cords to try to strangle a nurse. I’ve witnessed the whole patient strangling staff thing happen before as well.

    “Can you imagine?”

    You insinuate that hospital emergency departments routinely violate HIPAA regulations, but from the tone of your post, you know very little about HIPAA regulations or their requirements. For starters, try Googling “incidental disclosure.”
    “Now everybody knows about both of you”? Are you engaging in hyperbole or do you really think that the private conversations between physician and patient are broadcast over the intercom for the entire department to hear? If the former, you’re vilifying emergency department staff in order to try to make your feeble point. If the latter, you have no idea what you’re talking about. Either way, you need to back off.
    If “everyone” knows about a patient’s psychiatric problems, usually it is because the patient is screaming at the staff to go “f**k their mother” or expressing their desire to “blow up this f**king hospital.” But maybe we can play some Chopin real loud over the intercom to drown out those yells so that no one else can hear those threats and the patient’s HIPAA rights wouldn’t be “violated.” Why didn’t I think of that?

    You question the need for security guards as sitters. That blows my mind. Acutely agitated patients frequently attack staff members. Would you rather have a 90 year old nun watching over the room while she knits a hat? Maybe as the suicidal patient knocks her over while trying to escape into the street, we can let her use the patient’s iPod for comfort as we send her to surgery because she is “likely to have a burr hole presently” or “likely to have a hip replacement presently.”

    You assert that “It’s time we start treating people who come to the emergency department for help with mental illness with dignity.” Again, you use an overgeneralization to imply that no emergency department ever treats patients with mental illness with dignity. What a bunch of tripe.

    You say that “it’s time we start doing instead of talking.” I agree. Let’s require psychiatrists to respond like all other on-call specialists to hospital emergency departments. Most surgeons show up in 15 minutes when I call about a patient “likely to have an appendectomy presently”. The last time I saw a psychiatrist come to the emergency department to evaluate a patient having a psychiatric emergency was … ummm … never.

    So why don’t you lead by example? You go to your emergency department the next time a psychiatric patient is having an acutely psychotic episode. Let the patient have all of his belongings, including the switchblade and lighter in his pocket, tell security guards they can leave because their presence would only irritate the patient more.
    When the patient is beating the hell out of you and setting you on fire, the emergency department staff can all stand around and sing Kumbaya to see if the soothing tones will get him to stop. Have the emergency department physician e-mail me what happens and I’ll post it on my blog.
    I’m sure that the staff will be sure to treat you with dignity when you’re “likely to have an intubation presently” or “likely to have a skin graft presently”.

    Before you talk the talk, Dr. Smith, it would serve your readers well if you had actually walked the walk a time or two.

    • Greg Smith MD

      White Coat,

      I do not disagree that there is a woeful shortage of mental health professionals across the country, making access to timely treatment difficult at best.

      The last time I made myself available to evaluate a patient for an emergency detention order was Monday night, at the close of my regular sixteen hour shift doing telepsychiatry consults for twenty one hospital emergency departments in South Carolina. I work doing that job, my primary one, one hundred and fifty hours per four week schedule, plus I see patients including emergency evaluations in a local mental health center two to three days per week in addition to that.

      I understand the concept of contraband check and it is quite obvious that hidden blades, shanks, and belts are not items that would remain with patients after such a check. However, many of the psychiatric patients that I am asked to see in consultation are not imminently dangerous to themselves or anyone else, and might at the least be allowed to wear clothing and not paper scrubs, especially if there is adequate supervision available.

      Again, I can only speak to the response time of the service I work with now in seeing the patients that you mention variously in this comment. While not perfect because we also do not have enough psychiatrists to cover the full twenty four hour day at this point, we are able to have one and most of the time two telepsychiatrists working for sixteen hours per day. Except for the times that the consult queue contains fifteen to twenty patients or more, we are able to respond in a reasonable time to provided consultation, medication recommendations, or evaluation for commitment if needed.

      After twenty six years in the field, I am certainly doing my best to lead by example, having just worked one hundred forty hours the past two weeks seeing psychiatric patients in the emergency departments we cover as well as the clinic.

      While I welcome insightful and congenial and constructive discussion and even criticism, the last two paragraphs of your comment were none of these.

      By last count, the psychiatrists I work with in the SC telepsychiatry program had walked the walk over 14,000 times in over two dozen hospitals over the last four years.

      We’re not perfect, but we are trying to make a difference.

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