Imagine losing your grip on reality; your only place to turn is the local hospital. Once there, you give up your personal effects, your clothes, and often, your right to leave. You wear paper scrubs in a sparse room, lay on an uncomfortable bed, and have a guard nearby preventing your escape. In seeking help, you have become a prisoner. This is done for your and for the hospital personnel’s protection, but nevertheless, it is a distinct loss of freedom. But it is all for a greater good, to get you, the patient, transferred to a psychiatric facility where you can get the help you need. Except the wait can be excruciatingly long; from a few hours to multiple days. This is not a humane way to help those in greatest need of immediate intervention. But it is our present reality.
There is a mental health crisis in America. As an emergency physician, nearly every day I see a patient declaring they are suicidal or are psychotic and in need of legally required treatment and evaluation by a psychiatrist. But they are waiting longer and longer to find a psychiatric bed at a psych hospital. Waits of six to sixteen hours have become the norm. Already crowded emergency departments get more crowded when patients wait an unconscionable length of time taking up space, time and resources just to sit there without any real treatment.
This is not just anecdotal. There is clear and incontrovertible evidence of the erosion of psychiatric beds with 524,878 in 1970 to 211,199 in 2002, and the beds in state mental health hospitals had an even steeper decline. These are the critical access beds for those without insurance and funds to seek private care. Those beds have been reduced from 340 per 100,000 in 1955 to 14 per 100,000 in 2010. This is a 96 percent decline, despite recommendations by experts that there be 50 beds per 100,000 civilians.
Where did everybody go? Is there less mental health disease? Of course not. They have been displaced to the streets and to the prisons. Approximately two-thirds of the homeless are mentally ill. In 2012, there were 350,000 mentally ill inmates in American jails and prisons, but only 45,000 mental health patients in public psychiatric hospitals due to the bed shortage. And when people who are in the most acute distress go to seek help, they are pushed through a revolving door, with many returning again and again.
As an emergency physician who has a degree in psychology, I am frustrated by my inability to truly help a significant portion of my patient population. This desire to help those most disenfranchised in the health care system is mimicked by my main character and med student Dan Greenberg in my novel Schizo: Hidden in Plain Sight. His compassion towards his schizoaffective patient drove him to listen and respond to her plight as no other student or physician had before, and of course, no good deed goes unpunished, and it puts him in grave peril.
Schizophrenia and related schizoaffective disorders are very difficult diseases to treat and are chronic and severe; affecting how a person thinks, feels and behaves. People with schizophrenia may seem like they have lost touch with reality. There are antipsychotics that can help calm the voices and the disconnected thoughts, but they can be poorly tolerated both physically and mentally. Schizophrenics usually have above average intelligence, and so, the more the medication works, the more insight the patient gets into their disease and the more they wish to feel normal. They recognize the Catch-22 that they are left with: Take the medicine and function sluggishly and realize the strain you put on yourself and others, or do not take the medicines and be blissfully unaware of your own psychosis. Those on meds often become depressed and suicidal, and frequently discontinue their medicines to avoid those feelings.
Managing schizophrenia, bipolar disorder, clinical depression, and substance abuse requires psychological as well as medicinal care. The current dilapidated state of the mental health system does not lend to the intensive outpatient and sometimes inpatient care that is required to function optimally. The solutions will be expensive and require a commitment to a complete overhaul of our legal and mental health systems. Politicians need to support a return to the pre-1980s method of distributing money for mental health and eliminate the block grant as a method of funding. However, it can be done if we all make a choice to do what is right for individuals and society as a whole.
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