HOSPITAL emergency departments are among the least appropriate and most expensive places in Massachusetts for patients in psychiatric crisis. Yet these departments are where police, families, group homes, nursing homes, and others routinely take people who are agitated, panicked, or threatening to hurt themselves. Emergency departments are also where people go at the end of the month when their medications run out, when their primary physicians can't see them for two weeks, when they are frightened or desperate and have nowhere to turn after 5 p.m. and their therapist's answering machine tells them to go to the emergency room.
Emergency departments and these patients in crisis are both victims of a healthcare system that increasingly relies on emergency care to cover gaps in basic mental health and social services. Once at the emergency department, psychiatric patients wait twice as long for help as other patients, often in escalating frustration. Their interactions with harried staff, who often have little mental-health training and resent the long-term occupation of emergency beds, can make matters worse. Emergency departments don't have much time to provide reassurance, and often resort to restraint and seclusion - sometimes even handcuffs and pepper spray. Many psychiatric patients recount harrowing and traumatic experiences: As the Globe reported this summer, psychiatric patients sometimes die and have bones broken in emergency departments. They are often stripped of clothing and left for hours.
This has to stop, for all our sakes: the emergency departments, people with psychiatric disabilities, and taxpayers who pick up the tab.
This problem isn't restricted to Massachusetts. Recently, Rhode Island's mental-health advocate sued the state, arguing that involuntary detention in nontherapeutic emergency rooms for days without treatment violated state constitutional and statutory obligations. A few months earlier, advocates in New York filed a far-reaching lawsuit to end emergency department overcrowding and mistreatment at King's County Hospital Center.
In Massachusetts, advocates and patients have sought help from the Legislature. In September, Massachusetts lawmakers heard witnesses tell horror stories of their experiences in emergency departments, sometimes after going there just for medical care. Bills filed by Representatives Ruth Balser and Peter Koutoujian would authorize regulations to protect people with psychiatric disabilities in Massachusetts emergency departments.
This legislation is desperately needed. Currently, there are no state rules limiting or even regulating the use of restraint, seclusion, handcuffs, or forced stripping in emergency departments. The public health and mental health departments, however, opposed the legislation, stating they would instead work with hospitals to voluntarily improve the treatment that people with psychiatric disabilities receive in emergency departments. We hope that these promises will yield concrete improvements; publicly available statistics about restraints of psychiatric patients in emergency departments (as is required of all inpatient psychiatric units) would be a good first step.
Yet while changing emergency department practices toward psychiatric patients is essential, it is equally essential to prevent as many of these emergency department visits as possible.
Yet the state could well take a step in the wrong direction. Proposed regulations by the Department of Mental Health would allow people who need psychiatric evaluations to be sent to emergency departments. A better option would be to increase mental-health services for people with psychiatric disabilities. This could include emergency service workers who provide crisis evaluation in the community; nighttime crisis services; and crisis beds outside emergency departments. Helping patients get to medical appointments, find primary-care doctors, and pay for medication would be more cost-effective and less traumatizing for patients than a visit to an emergency room.
Emergency departments were never meant to be a home for the most difficult clients of exhausted and underfunded social service agencies. People with psychiatric disabilities need a better option. The answers are out there; the question is whether the will to implement them exists.
Susan Stefan is director of the National Emergency Department Project at the Center for Public Representation.
