No Room at the Inn

Many of us are now gathering, or will soon gather, with our family for the winter holiday break. Regardless of our religious affiliation, or lack thereof, this time of darkness broken by traditional celebrations of light is a moment for gratitude, renewal, and reaching out to others in need.

Among the many stories of this season is that of a poor family, tired from their travels during a time of upheaval and unable to find a secure place to rest. While this story has come down to us through the ages, it is not a unique or outdated story. For far too many of our patients, or those who should be our patients, there is indeed no room at the inn, and instead only a gurney in the emergency department (ED) or a jail cell.

Recently the Supreme Court of Washington state in the case In re the Detention of D.W., et. al., found that under Washington’s involuntary treatment act, the boarding of psychiatric patients in the ED due to overcrowding of the appropriate evaluation and treatment facilities is unlawful.

Since 2007 the number of psychiatric beds of all types in Washington has decreased by almost 15 percent, with the single largest decline in state hospital beds—25 percent—and a more modest 6 percent decline in general hospital beds. These same trends have occurred across the country, although few, if any, other states have seen a legal ruling as definitive as that of the Washington Supreme Court.

It is a tragedy that access to beds on psychiatric units, whether in general, private, or state hospitals, has become so difficult. Few areas of clinical medicine have been as “managed” as psychiatric care, and because state and local governments and Medicaid are the largest payers of psychiatric care, these costs are highly visible to legislators, especially in difficult financial times. When combined with a misunderstanding of the nature of psychiatric illness that tends to view hospitalization as a failure of community-based care, the lengthy boarding of psychiatric patients in hospital EDs is seemingly inevitable. It is also fair to say that in few other areas of clinical medicine would long ED waits for needed care be tolerated. The important goal in all of clinical medicine of preventing unneeded hospitalization should not make necessary hospitalizations impossible.

The scope of the problem has been highlighted in two essential reports from E. Fuller Torrey, M.D.’s Treatment Advocacy Center. In 2012 the center published “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals 2005–2010.” Among the key findings:

In addition, there has been a decline in the number of psychiatric beds in general hospital units over the same period, exacerbating the lack of access in the very institutions whose EDs are boarding patients awaiting services.

In its 2014 report, “Treatment of Persons With Mental Illness in Prisons and Jails,” the Treatment Advocacy Center stated, “In 2012, there were estimated to be 356,268 inmates with severe mental illness in prisons and jails. There were also approximately 35,000 patients with severe mental illness in state psychiatric hospitals.”

These patterns—disturbing as they are—also reverse a century or more of attempts to move individuals with severe mental illness from the streets and out of prisons and jails and provide humane and medically appropriate care. With such circumstances occurring in tandem with the collapse of the community-based system of care, which has the evidence-based capacity to help patients sustain improvement and recovery, tragic and inhumane outcomes are inevitable.

In October 1963, President Kennedy said at the signing of the Community Mental Health Act (the last bill he signed prior to his assassination), “The mentally ill ... need no longer be alien to the affections or beyond the help of our communities.”

Would that we all, especially those who are fortunate to have a roof over our heads and food on our tables, open our hearts to make that promise true for the most vulnerable in our communities. ■