In 1994, Amy B came to the Emergency Room. She had become more depressed and was cutting her arms and legs after a break-up. After an evaluation in the ER, she was admitted within the hour to the psych unit, in a specialized program for Borderline patients. She participated in cognitive-behavioral groups, Art and Music therapy, and Psychodrama exercises. After 4 days in the hospital, Amy was discharged to an intensive outpatient therapy.
For the next 17 years, Amy prospered in her profession and established new, supportive friendships. However, following several significant losses, she experienced desolating depression with suicidal thoughts and presented herself once again to the ER. After several hours, Amy was informed that no psych beds were available, but staff was trying to find an opening at another hospital. Although she had informed the nursing staff about her medicines, no orders were received, and Amy spent the night without her medications encased in the too-bright cubicle, surrounded by flimsy cloth curtains and the writhing sounds of sick patients. The next morning Amy was informed there were no beds available at this hospital or any facility within 200 miles. After another night in the ER she was finally admitted to the hospital psychiatric facility, where now patients were mixed together, and group therapies consisted mostly of complaining about the food. After finally receiving appropriate medication and rest, Amy was discharged after 5 more days.
Leo G was brought by his family to a different ER. He had previously been treated for Bipolar Disorder and Substance Abuse, and had recently been cited for a third DUI. In the ER he was combative and aggressive. He had refused his medicine for several weeks and had stopped seeing his therapist. Leo and his family were informed that there were no psych beds available in this hospital or any other within a 300 mile radius. Waiting for hours in the ER, he became increasingly agitated and threatening. He attacked a nurse. Hospital security could not contain him and police were called. Leo was taken to jail, where he remained for 6 days, without medication or any treatment. Two weeks after his release Leo committed suicide.
Whatever happened to acute psychiatric care? In our community, two hospitals a block apart formerly offered psychiatric facilities with a capacity of 100 beds each. Now, fifteen years later, one hospital closed its psychiatric center, and the other decreased capacity to less than half. Both hospitals now provide similar, sophisticated cancer centers. Where arguably there was once duplication of mental health services, there is now duplication of malignancy treatment. Reimbursement is generous for treatment of sarcoma, but not for treatment of schizophrenia. This dilemma is reminiscent of the re-evaluation of psychiatric treatment fifty years ago, when the promise of reallocation of funding for institutional care was to be directed to outpatient treatment. Instead, psychiatric hospitals were closed, and moneys were directed elsewhere. Thus, today, we see patients with severe psychiatric illnesses homeless, on the streets, responding not to treatment, but to the voices in their heads.
